Download Bad Rash - Wayne State University

Wow that looks Pretty
Bad!!
Jai Gilliam, M.D.
Internal medicine/Pediatrics
Noon Conference
45 yo Caucasian male is coming to
see you in clinic for a new rash
that has developed over the past 1
month. He says that the rash
itches “a lot” and that he has tried
multiple over the counter creams
but this has provided no relief. He
describes the rash as being very
dry and that it “peels” a lot. It is
localized around his nose,
forehead, and involves the lateral
aspects of his hair line
Seborrhea (Seborrheic dermatitis)
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Patient will present with generalized, fine, scaling
(flaky) rash of the scalp, ear, nose, and occasionally
lips.
Rash is puritic in nature
Treatment: Selenium sulfide shampoo, zinc pyrithione,
and Tar
What other crucial questions would you ask this
patient?
Have you ever been tested for HIV ?
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Mrs. Jackson is being seen in clinic for a
“personal matter”. She states that she is really
embarrassed about her weight and wants to try
to loss some weight. She also would like to talk
about a rash that she has had for a long time.
She says that it occurs along her skin folds and
that it “itches like crazy”. Patient tried some
Hydrocortisone cream on the rash but the rash
got worse.
On her physical exam you see this.
Intertrigo
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Contact irritant dermatitis where candida is a
common fungus that causes this rash.
Occurs along the folds where there is a lot of
moisture making it an ideal location for fungus to
grow.
Commonly seen in obese patients.
Treatment: Make sure that the area is dried
especially after showering/bathing.
Topical antifunguls and antifungal powder to
prevent moisture.
Mr. Powers is a 43 yo male who is coming to your
clinic because he is concerned about these
“Weird” circular rashes on his arm and legs. He
describes the lesion as “shiny” and almost like a
“irregular circular” pattern. He says that he has
had it for the past 6 months but he came in
because it just keeps getting worse. He denies
any itching and no trauma. You review his
medication and he is taking Lipitor, allegra-D,
accupril, Glucophage, and glipizide.
When you do your physical exam you see this
Necrobiosis lipoidica
Rash is commonly seen in diabetics
15% Precedes the onset of diabetes
25 % occur at the onset of diabetes
60% will occur in patients already diagnosed
Etiology- 3 theories
1. Diabetic microangiopathy secondary to glycoprotien
deposition.
2.Vasculitis- secondary to immunoglobulin deposition along
with complement/fibrinogen deposits
3. Abnormal Collagen- defective collagen has been seen in
other diabetic end organ damage
Treatment: Topical & intralesional steroids. ( atrophy of skin),
Aspirin & Dipyridamole (Anti-platelet therapy, platelet induced
vasocclusion disease.
Your next patient is a 28 yo male from the middle
east who speaks very little English. He’s at this
office visit with his wife who is able to translate.
She says that they are being referred to you from
another physician. Her concern is that her
husband has developed a medium size ulcer on
his ankle. It has been there for about 4 months,
but it has gotten worse. The wound is now
draining purulent discharge.
The only other medical issue is that he has
been having problems with his “bowels” for which
his wife says that he is taking a special
medication for his bowel problem.
Pyoderma Gangrenosum
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2 types: Classic PG- involving primarily the legs.
Atypical PG- involves superficial skin, effecting the
hands
Diagnosis is based on exclusion by history/biopsy- DDx
is infection, connective tissue dz, vasculitis, trauma
Cause: speculated to be related immune dysregulation
Prognosis is good, associated with other systemic dz:
IBD, rheumatoid arthritis, chronic hepatitis, Wagener's
Treatment: Mild- topical steroid. Moderate-Severe:
Oral steroid, cyclosporin, methotrexate, and tacrolimus
Mrs.Lenning is a 36 yo female who is bringing her
4month old infant in for well child check. The only
concern on this visit is about breast feeding. She
claims that she has been having some difficulty
with breast feeding. She has noticed that there is
a dry rash around her areola on her right breast.
She has tried some Hydrocortisone cream on it
because she thought it was eczema but the rash
did not improve
When you do her physical exam you see this
Paget’s disease of the breast
1.Eczematous rash is pathoneumonic for the
presence of intraepithelial breast adenocarcinoma
2.Diagnosis-confirmed by punch biopsy,showing
Paget cells-(adenocarcinoma cells).
3. Prognosis: depends on the stage of disease (+)
lymph nodes vs localized disease.
4.Treatment option:masectomy (rarely), breast
conserving surgery(nipple-areoloa resection),
Conserving surgery + whole breast irradiation
provided the lowest % with recurrence
You have been consulted to see a 67 yo female S/P
right knee replacement for a possible wound
infection of the right knee.She is complaining of
right knee swelling, tenderness, and skin
hyperpigmentation. Her surgery was approx 1 week
ago and she is being seen today in Post-op clinic.
Her entire post-op course was unremarkable and
she has never had this before. Patient denies any
trauma to this leg, no fever, no chills, no other
systemic symptoms
When you do your physical exam you see the
following?
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What questions do you want to know about her
post-op course.
Where you taking any Coumadin during her
recent hospitalization?
Coumadin Necrosis
Typically presents 7-14 days after administration of
coumadin.
Caused by Protein C deficiency: Bx will show fibrin thrombi within cutaneous
vessels leading to interstitial hemorrhage.
Clinically: Rash will develop over the trunk, arms, breast, and penis
(common symptom).
Treatment: Stop Coumadin, Protein C need to be replaced.(concentrated or
FFP), surgical debridement if rapidly progressing necrosis.
Once a patient has experienced this drug induced necrosis, Is it safe to try
the patient back on Warfarin?
Yes, Patient can be placed back on Warfarin but these patient need to be
closely monitor. If a patient has previously had a skin reaction to
coumadin there is no contraindication for subsequent doses
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Mr.Lewis is a 34 yo male with Hx of HTN is coming
to your clinic for the first time.He is concerned of a
small “bump” on his face. He says that it has been
there for the past 1 year, but the bump has
progressivley gotten worse. He denies any bleeding
from the lesion or trauma.
Overall, he says he has been healthy but says
that for the past 2 month he has really felt very
tired and that his “smokers” cough has gotten worse
over the same duration. He denies any fever, chills,
or wt loss.
When you do your physical exam you notice this on his
face?
Lupus Pernio
No relation to SLE, term Lupus= Chronic autoantibody
inflammatory disease and Pernio associated with
SARCOIDOSIS.
25% of patients with Sarcoidosis will develop some form
of skin rash.
Biopsy of skin lesion in Sarcoid reveal the classic finding
of non-necrotizing granulomas
Mimics other disease, systemic involvement: eyes, heart,
skin, muscle, CNS, kidney, spleen
Treatment: Prednisone and other immunosupresive
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Anything in the History that you should ask about
for this patient?
Have You Ever been tested for HIV?
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Bullous Pemphigoid
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Pemphigus Vulgaris
Starwars
 Episode III
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Secrets Revealed
Thank You
Sources
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1 Medstudy: Internal medicine core curriculum
section on Dermatology, 11th edition 2005/2006
2.Uptodate
3.Lawrence, Cox Physical signs in Dermatology
2nd edition chapter on hair/scalp disease. Pg 334350. copyright 2002