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Dermatology in Primary Care Eric J Milie, D.O. Objectives Understand the basic terminology used in naming dermatological conditions Recognize common dermatological conditions and implement a treatment plan for them Discuss the risk factors for skin cancer, as well as warning signs necessary for early detection Basic Terminology: Primary Lesions Macule Papule Nodule Vesicle Bulla Pustule Cyst Plaque Wheal Macule Circumscribed change in skin color without elevation or depression, less than 1-2 cm in size May be result of hyperpigmentation (brown as in lentigos), hypopigmentation (vitiligo) or vascular dilation (erythema) Macule Papule Small solid elevation of skin generally < 5 mm in diameter Majority of the papule elevation projects above the plane of the surrounding skin. Papules may be flat-topped, as in lichen planus; or dome shaped, as in xanthomas; or spicular, if related to hair follicles. Papule Nodule Palpable, solid, round, or ellipsoidal lesion Depth of involvement and/or palpability differentiate it from a papule rather than its diameter (although nodules are usually larger than papules: > 5 mm diameter) Can involve any layer of the skin and can be edematous or solid Based on the anatomical component(s) involved, there are five types of nodules: epidermal, epidermal-dermal, dermal, dermalsubdermal, and subcutaneous. Nodule Vesicle Circumscribed, elevated lesion that is < 5 mm in diameter containing serous (clear) fluid. Vesicle/bulla is the technical term for blisters Walls can be so thin that the contained serum, lymph, blood, or extracellular fluid is easily seen Fluid can be accumulated within or below the epidermis Vesicle Bulla A vesicle with a diameter > 5 mm Bulla Pustule Superficial, elevated lesion that contains pus (pus in a blister) May vary in size and shape The color may appear white, yellow, or greenishyellow depending on the color of the pus Pus is composed of leukocytes with or without cellular debris. It may also contain bacteria or may be sterile Pustule Cyst An epithelial lined cavity containing liquid or semisolid material (fluid, cells, and cell products) Most common are epidermal cysts, lined by squamous epithelium and produce keratinous material Cyst Plaque Palpable, plateau-like elevation of skin, usually more than 2 cm in diameter and rarely more than 5 mm in height Often formed by a convergence of papules, as in psoriasis. Plaque Wheal Transitory, compressible papule or plaque of dermal edema Typically intensely pruritic (result of allergic reaction) Wheal Basic Terminology: Secondary Lesions Scale Ulcer Crust Erosion Excoriation Lichenification Atrophy Scar Scale Accumulation or abnormal shedding of horny layer keratin (stratum corneum) in perceptible flakes The change may be primary or secondary Scales usually indicate inflammatory change and thickening of the epidermis The may be fine, as in pityriasis; white and silvery, as in psoriasis; or large and fish-like, as in ichtyosis. Scale Ulcer Circumscribed area of skin loss extending through the epidermis and at least part of the dermis (papillary). Ulcer Crust Dried serum, blood, or pus on the surface of skin May be thin, delicate, and friable or thick and adherent Crusts are yellow, if from serum; green or yellow-green if from pus; or brown or dark red if formed from blood Crust Erosion Moist, circumscribed, usually depressed lesion due to loss of all or part of the epidermis Often results from eruptions of vesicles and bullae Erosion Excoriation Linear or punctate superficial excavations of epidermis caused by scratching, rubbing, or picking. Excoriation Lichenification Chronic thickening of the skin along with increased skin markings Results from scratching or rubbing Lichenification Atrophy Paper-thin, wrinkled skin with easily visible vessels Results from loss of epidermis, dermis or both Seen in aged, some burns, and long-term use of highly potent topical corticosteroids Atrophy Scar Replacement of normal tissue by fibrous connective tissue at the site of injury to the dermis Scars may be hypertrophic, atrophic, sclerotic or hard due to collagen proliferation Reflects pattern of healing in the affected area Scar Basics of Therapy Topical Systemic Surgical Phototherapy Topical Therapy The advantage of direct delivery and reduced systemic toxicity make topical treatment quite attractive There is often a vehicle which then contains an active ingredient “If lesion is wet, dry it; if dry, wet it” Topical Therapy: Vehicles Cream- a semi-solid emulsion of oil-inwater; contains a preservative to prevent overgrowth of micro-organisms. Stabilized by an emulsifier. Mostly water so mostly evaporates; non-greasy so easy application and removal Gel – a semi-solid transparent non-greasy emulsion Topical Therapy: Vehicles Lotion – liquid vehicle, aqueous or alcohol based, which may contain a salt in solution. Lotions evaporate to cool the inflamed/exudative skin Ointment – a semi-solid grease/oil, sometimes also containing powder, but little or no water. The active ingredient is suspended. Usually, no preservative needed. Ointments are best suited for dry skin disorders – rehydrate and occlude. Because they are greasy, they are difficult to remove. Topical Therapy: Vehicles Paste – An ointment with a high proportion of powder which gives a stiff consistency. Pastes can be applied to well-demarcated lesions. Due to its ointment base, they are difficult to remove. Emollients - Useful in dry-skin disorders due to their ability to re-establish the surface lipid layer and enhancing rehydration of the epidermis. There are several emollient ointments, creams and oils added to baths. Topical Therapy: Quantity Needed The whole body requires 20-30 g of ointment per single dose. In an adult: - face or neck – 1 g - trunk (each side) – 3 g - arm – 1 ½ g - hand – ½ g - leg – 3 g - foot – 1 g Topical Therapy: Steroids Topical steroids are used in a variety of skin disorders and are frequently prescribed by primary care physicians. Classified by strength and fluorination High potency and fluorinated steroids should not be used in face or intertrigenous areas because of their side effect profiles Side Effects of Potent Topical Steroids Atrophy Telangiectasias Stria Ulceration Acneform Eruption Hyperpigmentation Hypopigmentation Hypertrichosis Adrenal Axis Suppression Telangiectasia Stria Hypertrichosis Low Potency Topical Steroids Hydrocortisone* Desonide * Aclomethasone dipropionate (Aclovate)* Low potency topical steroids can be used on any portion of the body * Indicates non-fluorinated topical steroid Mid Potency Topical Steroids Hydrocortisone Valerate (Westcort)* Triamcinolone (Kenalog) Betamethasone valerate Betamethasone dipropionate Prednicarvate* Hydrocortisone butyrate* Hydrocortisone probutate* Mometasone furoate (Elocon) *Non-fluorinated Mid Potency Steroids continued Note that both Triamcinalone and Elocon are fluorinated steroids Should not be used on the face! Triamcinolone frequently used because it is cheap and efficacious when used properly High Potency Topical Steroids Flucinonide (Lidex) Desoximetasone (Topicort) Amcinonide Halcinonide Diflorasone diacetate All fluorinated Super Potent Topical Steroids Betamethasone dipropionate (Diprolene) Diflorasone diacetate (Psorcon) Halobetasol propionate (Ultravate) Clobetasol (Temovate) Should only be used under supervision of dermatologist Topical Steroids: General Guidelines In general, primary care physician should familiarize themselves with one steroid in the following classes: low potency (Hydrocortisone), mid potency nonfluorinated (Westcort), mid potency fluorinated (Triamcinolone), and high potency (Lidex or Topicort) No fluorinated steroid on face or intertrigenous areas! Steroid Vehicles In general, the ointment formulation of a steroid is stronger than the cream Use ointments on dry, scaling eruptions Use creams or gels on moist, weeping eruptions Use alcohol based vehicles for the scalp What is in Lotrisone? Combination of clotrimazole (antifungal) and betamethasone, a moderate to high potency topical steroid Indicated for inflammatory tinea on palms or soles only Lotrisone should not be used in intertrigenous areas (see side effects slide) More reasonable approach is to use antifungal and Westcort or Hydrocortisone Systemic Therapy Indicated for serious dermatological conditions and infections Side effect profile not as favorable as topical treatment Some dermatological conditions may require inpatient hospitalization for intravenous antibiotics, steroids, antifungals, etc. Phototherapy and Photochemotherapy Sunlight (Ultraviolet A and Ultraviolet B) Ultraviolet B PUVA therapy Ultraviolet B UVB (290-320 nm) is given 3 times a week Initial dose is determined from the patients skin type or minimal erythema dose (MED) With each visit, the scheduled dosage is increased Commonly, 10-30 treatments are the normal course UVB can be used in children and pregnant women May be used in psoriasis, mycosis fungoides, atopic eczema, and pityriasis rosea Side effects include acute sunburn and increase risk of skin cancer. PUVA UVA alone has minimal effect, thus it is used in combination with photosensitizing psoralens given topically or systemically PUVA stand for Psoralens plus UltraViolet A Commonly, oral 8-methoxypsoralens is taken 2 hours before UVA (320-400 nm). The psoralens is photoactivated, which results in DNA cross-linking, inhibition of cell division, and suppression of cellmediated immunity Like UVB, the initial dose of UVA is determined by MED or skin type; and dosage is increased a scheduled visits PUVA is usually given 2-3 times per week for 15-25 treatments PUVA can be combined with acitretin (RePUVA) but not methotrexate Bath PUVA, bath containing a psoralen, is an alternative to systemic-side effects of oral psoralens Local PUVA, topical psoralen, may be effective in psoriasis and dermatitis involving the hands or feet. PUVA continued PUVA may be given for psoriasis, mycosis fungoides, atopic eczema, polymorphic light eruption or vitiligo Acute side effects include pruritus, nausea, erythema; long-term side-effects of premature skin ageing and skin cancer depend on the number an total dose of UVA Cataracts are possible and UVA-opaque sunglasses must be worn for 24 hours after taking psoralen. Basic Surgical Procedures Surgical removal is the treatment of choice for suspicious lesions Often times only definitive treatment for several dermatological lesions Basic Surgical Procedures continued Excisional Biopsy Excision axis depends on skin creases / Langer’s lines and its margins on the lesion. Once the skin is numbed with local anesthetic, the skin is incised vertically down to the subcutaneous fat with the scapel, in a smooth continuous manner to complete both arcs of the ellipse. Using simple interrupted skin sutures, the wound is apposed and slightly everted. Absorbable subcutaneous sutures are used for big excisions. Basic Surgical Procedures continued Incisional Biopsy Performed for diagnostic purposes. The technique is comparable to an excision, but less tissue is taken Punch Biopsy A punch (normally about 4 mm in diameter) is twisted into the skin: resulting cylinder of skin is removed and the defect cauterized or sutured. Basic Surgical Procedures continued Shave Biopsy Used for benign lesions, usually intradermal nevi or seborrheic keratosis. The lesion is shaved parallel to and slightly above the skin’s surface. Cautery may be used to achieve hemostasis. Skin tags are removed by using scissors to snip them off followed by cauterization to any bleeding points. Basic Surgical Procedures continued Curettage After local anesthetic, the lesion is removed by a gentle scooping motion with the curette. The base is then cauterized. Curettage may be used in seborrheic keratosis, pyogenic granulomas, keratoacanthomas, single facial viral warts, but not nevi. Cautery Provides hemostasis and destroys tissue. The classic cautery machine has an electrically heated wire and is self sterilizing. Silver nitrate sticks or 35% aluminum chloride in 50% isopropyl alcohol provide chemical cautery. Basic Surgical Procedures continued Cryotherapy Liquid nitrogen (- 196 °C) is delivered by cotton wool bud or spray gun and injures cells by ice formation. After immersion into liquid nitrogen, the cotton wool bud is applied to the lesion for 10-15 seconds until a thin frozen halo appears at the base. The spray gun is used at a distance of 10 mm for a similar amount of time. Longer freezing times are given for malignant tumors. Blisters may develop within 24 hours. These are punctured and a dry dressing applied. Side effect may include hypopigmentation of pigmented skin, ulceration (especially on the lower legs of the elderly). Treatment may be repeated in 4 weeks if warranted. Cryotherapy may be used for viral warts, seborrheic keratosis, molluscum contagiosum, intraepidermal carcinoma. Basic Surgical Procedures continued Mohs’ Surgery Excision of malignant tumor which is mapped and microscopically examined to define its extent and the completeness of the excision. Dermabrasion A rotating mechanical head wounds the skin down to the dermis Basic Surgical Procedures continued Laser (Light Amplification by Stimulated Emission of Radiation) High intensity light energy is applied to the tissue. Laser surgery is a rapidly changing field in which new types of lasers, as well as the conditions amenable to treatment, are continually being introduced. Lasers vary from a continuous-wave carbon dioxide laser to a short-pulsed pigment Q-switched ruby laser. Uses for lasers are equally varied and include: port wine stain nevi, telangiectasia, viral warts, some tumors, and tattoos. Common Dermatological Conditions Encountered by Primary Care Physicians Acne Eczema Seborrheic Dermatitis Psoriasis Contact Dermatitis Tinea Corporis Onychomycosis Herpes Simplex Varicella Zoster Seborrheic Keratosis Actinic Keratosis Skin Cancer Acne Vulgaris Follicular disorder that affects susceptible pilosebaceous follicles, primarily of the face, neck, and upper trunk, and is characterized by both non-inflammatory and inflammatory lesions Condition of unknown origin; however, multiple factors are known to contribute to its pathogenesis and its aggravation Acne is not limited to adolescence. 12% percent of women and 5% of men at age 25 years have acne. By age 45 years, 5% of both men and women still have acne. Primary lesion is the comedone Closed Comedone Open Comedone Treatment of Acne Vulgaris Comedones -Tretinoin (Retin A)* -Adapalene (Differin)* -Tazarotene (Tazorac) *Retinoids Treatment of Mild Papulopustular Acne Retinoids: Reverse abnormal keratinization Topical Antibiotics Benzoyl Peroxides: Caution as will bleach clothing, bed clothes, etc. Sodium Sulfacetamide Azelaic Acid Mild Papulopustular Acne Treatment of Moderate to Severe Papulonodular Acne Tetracycline: Mainstays of treatment Minocycline: Use in summer Doxycycline: Photosensitizing Sulfonamides: If tetracycline allergy Others (OCPs, spironolactone) Moderate Acne Vulgaris Treatment of Severe Cystic Acne Isotretinoin: Known teratogen, pregnancy category X. Patient must be on birth control prior to prescribing the drug, along with negative pregnancy test. ? Link between drug and depression. Severe Cystic Acne Acne Rosacea Common condition affecting skin of face Most common presentation is red “flush” appearance Usually occurs initially between 35-50 years of age, women more than men Enlargement of nose- rhinophyma No comedones May have ocular involvement Mainstay of treatment is topical metronidazole Acne Rosacea Rhinophyma Ocular Rosacea Eczema Ill defined erythematous patches with or without excoriations, lichenification, scale, hyperpigmentation Nummular eczema- round, ill defined erythematous patches Family history of allergies, asthma, or hay-fever If present at puberty, most likely life-long problem Men with nummular eczema: Alcohol abuse Eczema Nummular Eczema Treatment of Eczema Mild soaps and emoliants: No deodorant soaps Topical Steroids: emoliant base Antihistamines Pimecrolimus cream (Elidel)* Tacrolimus (Protopic)* Topical or systemic antibiotics in presence of secondary infection *Questionable Association with Lymphoma Seborrheic Dermatitis Classic lesions are ill-defined, scaling, erythematous patches in the nasolabial folds, in the ey brows, on the scalp, and behind the ears Other areas potentially affected include the chest in hairy chested men, the groin, pubic area, and axilla Seborrheic Dermatitis Seborrheic Dermatitis Seborrheic Dermatitis Treatment Ketoconazole shampoo Topical steroids (Gel or alohol based for the scalp) Non-fluorinated topical steroids for face and ears Anti-fungal or anti-yeast cream for skin involvement Tacrolimus or pimecrolimus Psoriasis Classic lesions are well defined, erythematous, thickly scaling plaques Areas of predilection include elbows, knees, gluteal cleft, sacrum, and scalp Koebner phenomenon- development of lesions in areas of trauma Nail involvement with pitting, onycholysis, subungal keratosis, and oil spots Psoriasis Psoriasis Koebner Phenomenon Psoriasis- Nail Involvement Psoriasis Treatment Topical steroids Calcipotriene (Dovonex): Associated with kidney stones Tazarotene (Tazorac) Anthralin UVB, PUVA Acitretin (Soriatane): Teratogen, liver toxicity Methotrexate, cyclosporin Tinea Corporis Superficial dermatophyte infection of the skin of the trunk and extremities A pruritic annular plaque is characteristic of a symptomatic infection Occurs in all age groups, adolescents most common Immunosuppressed population may get most severe symptomatology The most common cause of tinea corporis worldwide and in the United States is T rubrum Tinea Corporis Tinea Corporis Treatment Topical clotrimazole, itraconozole, or ketoconazole for localized infections Nystatin and mycostatin treat tinea only Consider systemic agents for more generalized infections Onychomycosis Fungal infection of the toenails or fingernails May involve any component of the nail unit, including the nail matrix, the nail bed, or the nail plate Affects men>women, adults>children 6-13% of U.S. adult population Usually asymptomatic; therefore, patients usually first present for cosmetic reasons without any physical complaints Onychomycosis Onychomycosis Treatment Document infection by culturing a true dermatophyte Consider systemic treatment with itraconazole (Sporanox) or terbinafine (Lamisil) Black box warning with Sporanox and CHF patients Beware drug interctions, liver toxicity Consider topical treatments Nails positive for candidia can be treated with topical antifungals or itraconazole Contact Dermatitis Characterized by triad of: 1. Erythema 2. Edema 3. Vesiculation • Treatment consists of removing offending agent, steroids (systemic and or topical), and antihistamines or emolians for symptomatic relief Contact Dermatitis Contact Dermatitis Contact Dermatitis Herpes Simplex Recurrent history of grouped vesicles on an erythematous base in the same general location Lesions usually preceded by a prodrome of burning or stinging Herpes Simplex Herpes Simplex Treatment of Herpes Simplex Acyclovir 200mg 5 times a day for 5 days Valacyclovir 2g BID for 1 day Famciclovir 125mg BID for 5 days Suppression of Herpes Simplex Acyclovir 200mg TID Valacyclovir 500mg-1g QD Famciclovir 250mg BID Herpes Zoster Grouped vesicles on an erythematous base following a dermatomal distribution Prodome of pain, burning, or stinging is common Complications of Herpes Zoster Infection Secondary infection Dissemination Encephalitis Pneumonitis Transverse myelitis Post-Herpetic neuralgia Motor paralysis Gangrenous zoster- immunocompromised host Herpes Zoster Complications of Herpes Zoster Involving the Face Post-herpetic neuralgia, especially with ophthalmic zoster Granulomatous angiitis of cerebral vessels Keratitis, scleritis, uveitis, glaucoma,optic neuritis, and others Ramsay-Hunt syndrome: vertigo, tinnitus, ipsilateral hearing loss, and facial paresis Herpes Zoster Ophthalmicus Treatment For Herpes Zoster Analgesics Compresses Antivirals -Acyclovir 800mg 5x/day for 7-10days -Famciclovir 500mg TID for 7 days -Valcyclovir 1g TID for 7 days *Immunocompromised patients may require inpatient treatment with IV Acyclovir Seborrheic Keratosis Raised growths on the skin Seborrheic-greasy; keratosis-growth Waxy appearance, “stuck on” No malignant potential, no relationship to sun exposure May become irritated from catching on clothing Seborrheic Keratosis Actinic Keratosis Most common premalignant lesions in humans The incidence is much higher in the Sun Belt and is directly related to light skin and sun exposure Lesions are erythematous, scaly plaques that measure 3-10 mm in diameter Incidence is much higher in individuals with fair skin and blue eyes and is lower in individuals with darker skin types Distribution of actinic keratoses is related to sun exposure and skin type Can occur in patients aged 20-30 years but are more common in patients aged 30-60 years. Actinic Keratosis Skin Cancer Basal Cell Squamous Cell Melanoma Basal Cell Carcinoma Most common form of skin cancer Arise in the basal cells, in the bottom layer of the epidermis Chronic exposure to sunlight is the major cause, and lesions arise on sun exposed areas of the body Men > women, fair skin > dark skin Slow growing and rarely metastasizes, but can cause significant local destruction Five Warning signs of BCC 1. 2. 3. 4. 5. An Open Sore that bleeds, oozes, or crusts and remains open for three or more weeks. A persistent, non-healing sore is a very common sign of an early basal cell carcinoma. Reddish Patch or irritated area, frequently occurring on the chest, shoulders, arms, or legs. Sometimes the patch crusts. It may also itch or hurt. At other times, it persists with no noticeable discomfort. A Shiny Bump or nodule, that is pearly or translucent and is often pink, red, or white. The bump can also be tan, black, or brown, especially in dark-haired people, and can be confused with a mole. A Pink Growth with a slightly elevated rolled border and a crusted indentation in the center. As the growth slowly enlarges, tiny blood vessels may develop on the surface. A Scar-like Area which is white, yellow or waxy, and often has poorly defined borders. The skin itself appears shiny and taut. Although a less frequent sign, it can indicate the presence of an aggressive tumor. Basal Cell Carcinoma Basal Cell Carcinoma BCC: Treatment Surgical: Curretage Surgical excision Mohs procedure Cryosurgery Antineoplastic Agents: 5-FU Imiquimod (Aldara) Interferon α-2b Squamous Cell Carcinoma Second most common skin cancer Occur on all areas of the body including the mucous membranes, but are most common in areas exposed to the sun Rarely metastasize, but metastatic disease can be fatal Sun is major cause, but also in areas of injured skin, ie scars, burns, radiation injuries, etc Relationship between SCC and actinic keratosis, actinic chelitis, leukoplakia, and Bowen’s disease Warning Signs for SCC 1. A wart-like growth that crusts and occasionally bleeds 2. A persistent, scaly red patch with irregular borders that sometimes crusts or bleeds 3. An open sore that bleeds and crusts and persists for weeks 4. An elevated growth with a central depression that occasionally bleeds. A growth of this type may rapidly increase in size Squamous Cell Carcinoma Squamous Cell Carcinoma SCC Treatment Medical therapy: early disease, antineoplastic agents Radiotherapy Chemotherapy Surgical resecttion Neck dissection Malignant Melanoma Melanoma is a malignancy of pigment-producing cells (melanocytes) located predominantly in the skin, but also found in the eyes, ears, GI tract, leptomeninges, and oral and genital mucous membranes Accounts for only 4% of all skin cancers; however, it causes the greatest number of skin cancer–related deaths worldwide The incidence of melanoma has more than tripled in the white population during the last 20 years, and melanoma currently is the seventh most common cancer in the United States Responsible for more than 77% of skin cancer deaths ; one death from melanoma every hour in the U.S. Melanoma: ABCDEs Asymmetry Border (Irregular) Color Diameter (Greater then 6mm) Evolving Stage TNM Class Histology 5 year survival 0 Tis N0 M0 Intraepithelial/in situ melanoma 100 IA T1a N0 M0 <1 mm without ulceration and level II/III >95 IB T1b N0 M0 T2a N0 M0 <1 mm with ulceration or level IV/V 1.01-2 mm without ulceration 89-91 IIA T2b N0 M0 T3a N0 M0 1.01-2 mm with ulceration 2.01-4 mm without ulceration 77-79 IIB T3b N0 M0 T4a N0 M0 2.01-4 mm with ulceration >4 mm without ulceration 63-67 IIC T4b N0 M0 >4 mm with ulceration 45 IIIA T1-4a N1a M0 T1-4a N2a M0 Single regional nodal micrometastasis, nonulcerated primary 2-3 microscopic positive regional nodes, nonulcerated primary 63-69 IIIB T1-4bN1a M0 T1-4bN2a M0 T1-4a N1b M0 T1-4a N2b M0 T1-4a/b N2c M0 Single regional nodal micrometastasis, ulcerated primary 2-3 microscopic regional nodes, nonulcerated primary Single regional nodal macrometastasis, nonulcerated primary 2-3 macroscopic regional nodes, no ulceration of primary In-transit met(s)* and/or satellite lesion(s) without metastatic lymph nodes 46-53 IIIC T1-4b N2a M0 T1-4b N2b M0 Any T N3 M0 Single macroscopic regional node, ulcerated primary 2-3 macroscopic metastatic regional nodes, ulcerated primary 4 or more metastatic nodes, matted nodes/gross extracapsular extension, or in-transit met(s)/satellite lesion(s) and metastatic nodes 24-29 IV Any T any N M1a Any T any N M1b Any T any N M1c Distant skin, subcutaneous, or nodal mets with normal LDH levels Lung mets with normal LDH All other visceral mets with normal LDH or any distant mets with elevated LDH 7-19 30-50 Malignant Melanoma Malignant Melanoma Malignant Melanoma: Treatment Medical Care: Numerous adjuvant therapies have been investigated for the treatment of localized cutaneous melanoma following complete surgical removal. No survival benefit has been demonstrated for adjuvant chemotherapy, nonspecific (passive) immunotherapy, radiation therapy, retinoid therapy, vitamin therapy, or biologic therapy Surgical Care: Mainstay of therapy Elective lymph node dissection Sentinel node biopsy/ dissection: Sentinel node status (positive or negative) is the most important prognostic factor for recurrence and is the most powerful predictor of survival in melanoma patients Question 1: A 70 year old male patient presents to your office for a routine check-up. When examining him, you note the following lesion on his back, which measure 9mm in diameter (see next slide). He states that this lesion has been there “for years,” but thinks that it may have gotten larger in the past 1-2 years. He states that the lesion never bothered him, in fact, he gave it very little thought over the years. After completing your physical exam, what is the most appropriate next step in the management of this patient? Question 1 continued A. Observe the lesion for now, see the patient back in six months for a follow up appointment B. Refer the patient to a surgeon for excision with wide margins C. Do a scrape biopsy in the office D. Do nothing; this is a benign lesion and treatment should be withheld until the lesion is symptomatic Question 2 An 85 year old male presents to your office for evaluation of a rash on his forehead (see next slide). The rash began approximately eight days ago. The emergence of the rash was preceded by two to three days of burning pain, followed by a vesicular eruption. He states that the pain is now 10/10, and he note blurred vision and decreased hearing in the effected side. Your next best step in the management of this patient is: Question 2 continued A. Start the patient on Acyclovir 800mg to be taken five times daily. Follow up in approximately one week to check his progress B. Prompt referral to ophthalmologist for evaluation of possible corneal involvement C. Give the patient a prescription for an oral analgesic, as the rash has been present for too long to treat with antivirals D. Instruct the patient to use a hot compress on his eye, ibuprofen or acetaminophen for pain, and reassure him that this ailment will pass within the next week or so. Question 3 A sixteen year old female presents to your clinic because of “acne.” She states she has tried numerous over the counter products with little effect. She states that she is sexually active, but her boyfriend and her use condoms “almost every time (they) have sex.” On physical exam, you note cystic acne on the fact and trunk, with both open and closed comedones. Which of the following is NOT an appropriate treatment in this patient? Question 3 continued A. B. C. D. Tertacycline Oral contraceptive pill Benzoyl peroxide Isoretinoin Works Cited http://bmj.bmjjournals.com/index.dtl http://www.blackwellscience.com/products/journals/BJD.HTM http://dermatology.cdlib.org/ http://www.eblue.org/