Download Normal skin conditions

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ACOFP 53rd Annual Convention & Scientific Seminars
Dermatology for the Family
Physician
Thomas Told, DO, FACOFP dist.
3/17/2016
DERMATOLOGY FOR THE FAMILY PHYSICIAN
THOMAS N. TOLD D.O. FACOFP dist.
Professor of Family Medicine
Dean and CAO.
ROCKY VISTA UNIVERSITY COLLEGE
OF OSTEOPATHIC MEDICINE
Parker, Colorado 80134
[email protected]
COMMON SKIN CONDITIONS
Bread and Butter
Lesions.
WHY BUTTER SOMEONE ELSES BREAD!
THE SUN WILL ALWAYS KEEP US BUSY
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ACTINIC KERATOSIS (NORMAL)
Dry, flakey, can be tender, but usually don’t bleed
 No anesthesia needed
except for very large
lesions.
THE WIDER THE FROST RING THE DEEPER THE FREEZE
 Better to under freeze
than over freeze.
 Small children do not do
well with this method.
 Depth of the freeze is
equal to 1-1 ½ times the
radius of the frost ring.
 Freeze small lesions for
5-10 seconds and warts for
40 seconds
Form a frost ring that is 2-3 mm wider than the lesion.
SWABBED, TOUCHED OR SPRAYED
Liquid nitrogen is the
best, but requires storage
equipment.
Verruca Freeze is more
convenient but doesn’t
work as well.
Co2 is difficult to work
with in a solid state and
doesn’t penetrate well.
Nitrous Oxide works
better on lesions inside
the mouth or vagina and
less well on the skin.

Liquid nitrogen -346 F
Sprayed on.
Verruca Freeze -94 F
Nitrous oxide gun -129F
Swab dipped liquid
nitrogen
-320 F
CRYODISTRUCTION: “THE BIG CHILL”
CO2 -109 F
Clean procedure
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Skin turns white and starts
to swell after freezing.
Hemorrhage is common
after freezing.
 Have the patient “pop” the
blister with a sterile lancet.
 Infection is possible
 Nerve damage is the worst
complication where nerves
are shallow. (fingers, ears,
shins)
 Pigment changes in black
patients may occur at the
site.
 Recurrence is always
possible with warts.

ONCE IS NEVER ENOUGH!!!
SEBORRHEIC KERATOSIS (NORMAL)
Looks like old candle wax or a mini smashed burger on the skin
Works well on large
superficial lesions
Seborrheic KERATOSIS

Is most often used in
conjunction with
electrocautery.

Results in very little
scarring.

Lesions
can recur.
CURETTAGE
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LET’S HAVE A TALK ABOUT MOLES
NORMAL MOLES
FLAT JUNCTIONAL NEVUS
COMPOUND NEVUS
INTRADERMAL NEVUS
NORMAL MOLES?
Umbilicated can be
early cancer changes
Smooth is normal
Junctional Nevi
Interdermal Nevi
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NORMAL MOLES?
Zone of no pigment… be careful
melanoma can do this also
Compound Nevi
Halo Nevi
MELANOMAS CAN LOOSE PIGMENT IN
PORTIONS OF THE LESION. BUT USUALLY NOT IN
A HALO PATTERN
Melanomas are not symmetrical like halo nevi
MALIGNANT MELANOMAS
• A Asymmetry
• B Border Irregular like the
coast of Maine
• C Color Black, red or spotted
from loss of pigment
• D Diameter greater than 6MM
pencil eraser.
•E Elevation Gradually
gaining height
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•A
Asymmetry
Border
•C Color
•D Diameter 6mm+
•E Elevation (raising up)
•B
MALIGNANT MELANOMAS
•A Asymmetry
•B Border
•C Color
•D Diameter 6mm+
•E Elevation (raising
up)
MALIGNANT MELANOMAS
MELANONYCHIA
Moles can
be under nails and
in the mouth and other
mucus membranes.

MELANOMA
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DERMATOSCOPIC SIGNS OF
MALIGNANCY
Basel Cell carcinoma
Squamous Cell carcinoma
Melanoma
Basel Cell carcinoma
Melanoma
Squamous Cell carcinoma
TAKING A CLOSER LOOK CAN SAVE LIVES
THE MOLE PATROL
MELANOMA (oil)
PIGMENTED NEVUS (oil)
ATYPICAL NEVUS (oil)
MELANOMA (dry light)
LENTIGO (oil)
MENANOMA IN SITU (oil)
OTHER NORMAL SKIN CONDITIONS
Skin Tags Big or Little.
Acrochordon
Cherry Hemangioma
Can bleed profusely
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NOT ALL SKIN TAGS ARE HARMLESS (HIGHER
THREAT OF NEUROLOGIC AND OTHER TUMORS)
Café’au lait spots
Neurofibromatosis with pigmented skin patches Café au lait spots (coffee with cream)
color. They look like large freckles. Black arrows are café au lait spots. White arrows are
neurofibroma.
MRSA THE SPIDER BITE THAT WASN’T!!!
METHACILLIN RESISTANT STAPH AUREUS
THE REAL MC COY
EARLY MRSA
OLDER AND CHRONIC
MRSA
SPIDER BITES
ADVANCED MRSA
LICHEN SIMPLEX CHRONICUS.
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MALIGNANT SKIN CONDITIONS (BLEED EASILY)
Basal Cell Cancer
Basal Cell Cancer
MALIGNANT SKIN CONDITIONS
Squamus Cell Cancers
WHEN IN DOUBT RECOMMEND IT BE TAKEN OUT.
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May use a conventional
Double edged razor blade
May use a #15 scalpel blade
Produce a pink
scar.
Commercial
blades
SHAVE BIOPSY
Some of the dermis is left
behind. Deeper if
malignancy is suspected
Clean procedure
Size 2-10 mm
local anesthesia
Stretch the skin
perpendicular to the skin
tension lines.
 Apply steady downward
pressure with a twisting
motion till you feel a give in
the tissue.
Do not remove the punch to
check the progress this will
shred the biopsy.
 Close the wound with two
sutures.
You can undermine larger
punch sites (5-10 mm)
Stretch skin
90 degrees
To wrinkle line
Use
Wrinkle line
SKIN PUNCH BIOPSY
Clean procedure
Placing
incisions that run
perpendicular to skin tension
lines are harder to close and
produce widened scars.
Use subcutaneous
sutures for excisions on the
face or other cosmetic areas.

Try to utilize natural skin
folds as well as tension lines
to hide incisions.

Never ever!!
Let the
patients fear of needles or
threat of scarring stop you
form doing an excisional
biopsy.
“MOTHER NATURE HATES A STRAIGHT LINE”
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MORE THAN A RASH
THE HEARTBREAK OF PSORIASIS
Silver plaques on extensor surfaces
PSORIASIS IMITATORS
TINEA INFECTIONS
ECZEMA
R
I
N
G
W
O
R
M
THE WOODS LAMP WILL HELP OUT
FUNGUS GLOW GREEN
UNDER THE WOODS LAMP
WOODS LAMP CAN
FIND THE GUILTY ONE
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ONLY 20% OF FUNGUS
FLUORESCE
 MICROSPORIUM Sp.
Glow Blue-green
Corynebacterium and
psoriasis fluoresce coral
red.
Psoriasis glows pink –
red
Bathing may reduce
fluorescence.
 fibers , scale and
clothing will fluoresce

WOODS LAMP
WOODS LAMP WITH SHROUD
DERMAOTOPYTE FUNGUS
GLOWS GREEN UNDER UV LIGHT
Psoriasis glows red
From protoporphyrin IX
WOODS LAMP EXAMINATION
Clean procedure
KOH PREP FOR FUNGUS

Use a #15 scalpel blade to
scrape off some epidermis
from the skin.

Place the skin sample on a
glass slide

Add two drops of KOH and
cover with cover slip

If KOH+DMSO no heat.

KOH alone heat for 2-3
seconds before boiling

Nails let KOH sit for several
hours
DETECTING THE FUNGUS AMONG US .
10 X
power and
low light
Clean procedure
WARTS
VERRUCA VULGARIS
(COMMON WARTS)
MOLLUSCUM CONTAGIOSUM
(The POX be on you.)
BELLY BUTTON
THEY ARE UNBILICATED WARTS
(Rarely need treatment)
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DIGITAL AND PLANTAR WART TREATMENT
15 mg Bleomycin powder mixed with 5cc steril water.
Makes a 2% solution. Mix 2:1 with lidocaine yielding
1% solution and inject intralesionally.
BLEOMYCIN
CRYO WITH LIQUID
NITROGEN
DERM LASER
Must use local anesthesia
Electrocautery destroys
all of the lesion.
PYOGENIC
GRANULOMA


Good for vascular lesions,
and granulomas

SKIN TAG
Curettage works well after
cautery to remove charred
material.

Loop cautery can remove
a lesion for study, but the
heat will distort the tissue
architecture near the base.


Careful with warts!!!
ELECTRODESSICATION OF SKIN LESIONS
Clean procedure
VISUAL EXAM

What is it?
INTRADERMAL NEVUS
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VISUAL EXAM 2
Are all OK?
ALL ARE NORMAL APPEARING
VISUAL EXAM 3
What is it?
SEBORRHIC KERATOSIS
VISUAL EXAM 4
What is it?
SQUAMUS CELL
CARCINOMA
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VISUAL EXAM 5
What is it?
BASIL CELL CARCINOMA
VISUAL EXAM 6
What is it?
MELANOMA
ENJOY THE SUN SAFELY!
QUESTIONS?
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