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The World of Dermatology Objectives Cite the advances in management as they relate to screening, diagnosis, and therapy Identify the optimal techniques in therapy with skin malignancies Assess how new data and therapeutic techniques can be incorporated in the individualized treatment Johnnie M Woodson, M.D., F.A.A.D. Assistant Professor of Dermatology University of Nevada School of Medicine Director of J. Woodson Dermatology & Associates, LTD of patients Review medical and surgical options for the management of skin diseases Describe the pathophysiology of immune-mediated chronic inflammatory diseases Outline the benefits and limitations of new and emerging immunosuppressive, anti-inflammatory, and disease-modifying treatments for immune-mediated chronic inflammatory diseases Johnnie M Woodson, M.D. Can You Identify This Condition? Johnnie M Woodson, M.D. Scabies Johnnie M Woodson, M.D. Can You Identify This Condition? Sarcoptes scabiei var hominis Eight legged mites, ovoid flat body, 100 eggs per day Intensely pruritic erythematous papules and burrows on finger\toe, web spaces, nipples, axilla, male genitalia and umbilicus Mineral oil preparation skin scrapings show mites, eggs or feces Crusted scabies, immunocompromised host such as elderly, HIV or transplant patients Can be treated with permethrin and crotamiton • Can You Identify This Condition? 30 day cycle on human host Johnnie M Woodson, M.D. Actinic keratosis UV damage leads to p53 mutation Transformation to squamous cell carcinoma .025% to 16% Atypical keratinocytes, pleomorphic and disorganized Johnnie M Woodson, M.D. Can You Identify This Condition? Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Can You Identify This Condition? Keratoacanthoma Dome-shaped firm crater lesion, rapid growth, follicular origin Controversy-nine or less aggressive malignancy associated with immunosuppression and systemic lupus erythematosus Excision, topical 5-FU, cryo- surgery, Mohs surgery Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Can You Identify This Condition? Pyoderma Gangrenosum Four types - Ulcerative, Pustular ,Bullous,Vegetative Clinical Inflammatory pustule, ulcerates at sites of trauma (pathergy), distinct rolled edges, painful ulcer, 40-60 years old lower extremities and trunk • Inflammatory bowel disease association, leukemia possible association, 1.5-5% with inflammatory bowel disease develops Associations - leukemia, polycythemia, chronic active hepatitis, HCV, HIV, SLE, pregnancy Treat for underlying condition, compresses with ointment occlusive dressings, potent topical steroids or intralesional, tacrolimus, systemic steroids, dapsone, sulfasalazine, cyclosporine, infliximab, SSKI, Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Can You Identify This Condition? Erythema Nodosum Clinical • Red, tender nodules, anterior shin's, size, lower extremities and upper extremities • Onset fever, chills, malaise, leukocytosis, arthropathy • Immunologic reaction triggered, medications, benign and malignant systemic illness, bacterial, viral , fungal infections Infections • Streptococcal, tuberculosis, Yersinia, coccidioidiomycosis, histoplasmosis, dermatophytes • Acute respiratory illness, viruses, infectious mononucleosis, cat scratch disease, hepatitis B, sarcoidosis • Sulfonamides,bromides,oral contraceptives • Enteropathies,ulcerative colitis, Crohn's disease, malignancies lymphoma, leukemia, cervical cancer • Spontaneous resolution 3 to 6 weeks, nonsteroidal anti-inflammatory's, systemic steroids, potassium iodide 400-900 mg Q day Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Cutaneous T-cell lymphoma (Mycosis Fungoides) Can You Identify This Condition? Clinical Types • Flat and raised lesions, pruritus, females, epidermotropism, increased mucin in follicles, tumor stage poor prognosis Diagnoses • Johnnie M Woodson, M.D. Patch and plaque stage, hypopigmented type, pigmented purpura, alopecia mucinosa, erythrodermas, tumor stage, granulomatous and slack skin, pagetoid reticulosis Biopsy at three month intervals, clonality assists, malignant clonal T cell populations(CD4+/CD7-),CD4/CD8 ratio expansion into blood, memory cell marker CD45RO elevation peripheral blood involvement Johnnie M Woodson, M.D. Cutaneous T-cell lymphoma (Mycosis Fungoides) Can You Identify This Condition? Sezary Cells - enlarged hyper convoluted nuclei, activated T cells, 100 cells counted to assess percentage, greater than 5% poor prognosis Pognosis - 10% or less median survival 12 years, tumors no involvement median survival 2-3 years Treatment - dapsone or sulfa pyridine, intralesional and topical high potency steroids Johnnie M Woodson, M.D. Molluscum Contagiosum Johnnie M Woodson, M.D. Can You Identify This Condition? Poxvirus, MCV-1 to 4, small children MCV-1, HIV-associated MCV-2 Young children, sexually active adults, immunosuppressed persons, skin to skin contact, swimming pools Smooth surface, firm, dome shaped pearly papules with umbilication Spontaneous resolution, light cryotherapy, topical tretinoin, topical cantharidin 4-6 hours, trichloroacidic acid 35-100% Johnnie M Woodson, M.D. Nevoid basal cell carcinoma syndrome (Gorlin syndrome) AD, patched gene (inhibits hedgehog signaling pathway) Decreased patched therefore increased smoothened gene therefore uncontrolled cell proliferation Frontal bossing, bifid ribs, calcification of falx cerebri, multiple basal cell carcinoma's, palmoplantar pits, painful odontogenic jaw cysts, medulloblastoma, hypertelorism and ovarian fibromas Johnnie M Woodson, M.D. Squamous Cell Carcinoma Johnnie M Woodson, M.D. Can You Identify This Condition? Johnnie M Woodson, M.D. Can You Identify This Condition? UVB-Related, increasing age, let it to decline, skin types I and II, immunosuppression, chemical carcinogens P 53 mutations, human papilloma virus 6,11,16,5,8 Metastatic rate 0.3 to 16%, risk increases with location on lips ears eyelids genital area, depth of invasion perineural spread immunosuppression recurrence Mohs surgery, excision, nonsurgical cryo- treatment, radiation Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Bowen’s Disease Full thickness keratinocyte atypia Transformation to SCC 5% Can You Identify This Condition? Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Can You Identify This Condition? Can You Identify This Condition? Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Can You Identify This Condition? Malignant Melanoma Lifetime risk 1 in 60 to 1 in 80, 20-45 years old, chest, upper extremities man, back, lower legs, lower extremities women CDKN2A(aka MST-1 or p16) mutation Skin, lymph nodes, lungs, liver, brain, G.I. track metastatic sites Excision, since you know node biopsy if greater than 1 mm, interferon-alpha Surgical margins-less than 1 mm-1 cm, greater than 2 mm-2 cm Johnnie M Woodson, M.D. Malignant Melanoma Johnnie M Woodson, M.D. Identify This Unknown! Sentinel node biopsy - greater than 1 mm or less than 1 mm with ulceration New biologic therapy's, interferon alpha Prognosis - Breslow depth for primary lesion, ulceration second most important, sentinel node most important predictor for overall survival Poor prognosis - head and neck, increased number of nodes, metastasis visceral, increasing age, male, acral lentiginous type Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Arsenical Keratosis Identify This Unknown! Johnnie M Woodson, M.D. Erythrasma Johnnie M Woodson, M.D. Identify This Unknown! Johnnie M Woodson, M.D. Secondary Syphilis Johnnie M Woodson, M.D. Identify This Unknown! Johnnie M Woodson, M.D. Dental Fistula Johnnie M Woodson, M.D. Identify This Unknown! Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Black Heel (Tinea Pedis) Identify This Unknown! Johnnie M Woodson, M.D. Johnnie M Woodson, M.D. Kaposi's Sarcoma (AIDS related) Summary Identified common dermatologic conditions Addressed medical and surgical options for the management of skin diseases Described how new data and therapeutic techniques can be incorporated in the individualized treatment of patients Described the pathophysiology of immune-mediated chronic inflammatory diseases Outlined the benefits and limitations of new and emerging immunosuppressive, anti-inflammatory, and disease-modifying treatments for immune-mediated chronic inflammatory diseases Johnnie M Woodson, M.D. Johnnie M Woodson, M.D.
