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Derm for the
Nurse Practitioner
Tim Berger, MD
Professor of Clinical Dermatology
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Case
• Painless penile ulcer for 2 weeks
• Moderate, non-tender inguinal
adenopathy
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• Diagnosis?
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Syphilis
Epidemiology
• San Francisco has a very high syphilis
rate
• 60% of syphilis cases are occurring in
HIV infected gay men
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Primary Syphilis
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Clean-based, moist ulceration
Painless, non-tender
Rubbery texture on palpation
Whole lesion moves as an unit
Single or multiple
Non-tender adenopathy 1 week later
Heals spontaneously in 1-4 months with NO
scarring
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Secondary Syphilis
• 80% of patients with secondary syphilis
have skin lesions
• Early secondary syphilis is more
exanthematous, transient, and macular
• Later secondary syphilis eruptions are
firmer, fixed, papular, pustular, or
nodular
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Secondary Syphilis (2)
• Alopecia (5%): Moth eaten, diffuse
• Adenopathy: Generalized, non-tender
• Mucous patches (33%): Denuded
(tongue), or white/stuck on plaques (other
oral areas)
• Glomerulonephritis, gastritis/gastric
ulcer, rectal ulcers, hepatitis, hearing loss
(acute, unilateral), uveitis, neuritis,
pulmonary infiltrates, etc.
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Secondary Syphilis (3)
• Think of syphilis whenever you see a skin
rash--It is the great imitator
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Fixed Drug Eruption
• Reappears at same site with each
rechallenge
• Individual lesion-iris or target, which
blisters, then erodes leaving a shalllow,
unilocular, wide ulcer
• Oral Mucosa, genitalia (2% of GUD)
• Causes: NSAIDs, laxatives, SMZ/TMP
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Case
• 34 year old gay man with a 2 week
history of lethargy, sore throat, fever,
pain when swallowing, and rash
• VS: Temp 38.6
• Ill appearing
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Case
• Physical Exam: Pharyngeal erythema
without exudate; 3 small ulcerations on
the tongue, pharynx; generalized
lymphadenopathy (cervical, axillary,
groin > 1cm)
• Oval plaques with petichiae on the upper
chest
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Case
• Lab: CBC-atypical lymphocytosis
• What is the differential diagnosis?
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Case
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Anticonvulsant hypersensitivity
Streptococcal Pharyngitis
Primary EBV
Primary CMV
Secondary syphilis
Primary HIV infection
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Case
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Lab: RPR- nonreactive, prozone checked
EBV serology: Negative
HIV Serology: ELISA: Negative
What is your diagnosis?
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Case
• CD4= 180
• HV Viral load=500,000
• Diagnosis: Primary HIV infection
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Primary HIV Infection
• Multi-system disease at the time of initial
virus replication in the recently infected
host (in the first few weeks of infection)
• Resembles mononucleosis: rash, oral and
genital ulcerations, adenopathy
• Skin eruption may precede other findings
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Primary HIV Infection
• Diagnosis: HIV Viral Load, Helper T cell
count; ELISA negative initially
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Case
• 34 year old healthy male
• 2 weeks of recurring blisters on the legs
• Mildly itchy
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Bullous Impetigo
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Bacterial Infections
• Pyoderma
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Impetigo
Folliculitis
Abscess
Ecthyma
• Cellulitis/Necrotizing Fasciitis
• Toxic Shock Syndromes
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Impetigo
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Folliculitis
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Ecthyma
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Abscess
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Cellulitis
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Cellulitis with Purpura and Bullae
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Erysipelas
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Necrotizing Fasciitis
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Quiz
• The Correct treatment for an abscess is?
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Answer
• Incision and Drainage for any areas of
loculation
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Quiz
• What is the most common cause of
cellulitis of the lower extremities in a
healthy person in the absence of a leg
ulcer?
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Answer
• Athlete’s foot: Look between the toes!!
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Quiz
• Drug of Choice for treating superficial
skin infections with CA-MRSA?
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Answer
• Doxycycline
• Options: SMZ/TMP, Quinolone,
Clindamycin (be alert for erythromycin
resistance on sensitivity)
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Quiz
• What is the most common cause of
recurrent S. aureus infections?
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Answer
• Activities that lead to nasal carriage of S.
aureus—IVDU, allegy shots, insulin
injections, atopic dermatitis, health care
worker
• Nasal carriage is the source of recurrent
infections
• Treatment of nasal carriage required to
stop recurrent episodes.
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Treatment of Recurrent
Furunculosis
• 1. Culture lesion/sensitivities
• 2. If S. aureus, treat with Rifampin 600 mg/day
X 5days, PLUS appropriate oral antibiotic
• 3. Treat regular partners and household
members for nasal carriage with rifampin.
• Alternatives :Clindamycin orally, Bactroban
intranasally
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Quiz
• What signs on physical examination of a
cellulitic lesion suggest necrotizing
fasciitis?
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Answer
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Very toxic appearance
Sepsis/hypotension/rhabdomyolysis/DIC
Necrosis of areas of the lesion
Bullae
Crepitus
Anestheia of the lesion
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Leg Ulcers
Etiologies
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Venous Insufficiency (60%-70%)
Arterial Insufficiency (25%-33%)
All others (5%)
Patients may have a combination of
causes, most commonly VI and AI in up
to 25% of cases
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Venous Insufficiency Ulcers
• 0.2% of the population, and 2% of those
over the age of 80
• F>M
• 50% have a family history of leg ulcers
• 50% have a history of previous DVT
• Pedal edema
• Sedentary lifestyle; prolonged sitting
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VI Ulceration (2)
Clinical Features
• L>R leg (venous pressure higher in the
left leg)
• Ulceration appears above the medial
malleolus
• Base of ulcer has fibrinous exudate
• VI ulcers are less painful than AI ulcers
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VI Ulceration (3)
Complications
• Secondary infection, cellulitis,
osteomyelitis
• Allergic contact dermatitis to applied
antibiotics, topical anesthetics
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VI Ulceration (4)
Diagnosis
• Clinical features often adequate
• Do ABI (ratio of BP in leg:arm). If less than 0.7,
minor AI (caution with compression), and if
<0.4-0.5, needs vascular referral
• Note: “small vessel disease,” especially in
diabetics, may give you a falsely normal ABI
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VI Ulceration (5)
Treatment
• Control Edema; Elevation of leg above heart 2
hours twice daily; Walk, don’t sit.
Compression. Diuretics overused and not
proven to be of benefit
• Create an appropriate wound environment for
healing--Paradigm shift: Ulcers that don’t heal
do not have the appropriate biochemical
environment to promote healing.
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VI Ulceration (6)
Treatment
• Compression dressing: (Unna boot covered by
Coban) this requires a good nursing staff with
training and experience
• This both provides graded compression AND
creates the correct wound environment
• Change dressing weekly
• Refer to dermatology if slow healing does not
occur
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Case
• 39 year old HIV+ man with 4 weeks of
foot eruption
• Scaly plaques on both soles, and the
palms
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• Diagnosis?
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Psoriasis
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Psoriasis
Triggers
• Bacterial Infections esp Strep (children
and young adults)
• Medications: Steroid (withdrawal),
Lithium, beta blockers, Terbinafine,
gemfibrozil, NOT NSAID’s
• HIV disease (up to 6% of AIDS patients
develop psoriasis)
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Case (cont.)
Routine UA shows WBC’s; you have been
treating the patient for plantar fasciitis
for several months (the patient is not
particularly active and not a runner).
DIAGNOSIS?
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Reiter’s Syndrome
Reactive Arthritis
• Triad of arthritis, conjunctivitis and
urethritis
• Partial forms
• Skin lesions common and clinically and
histologically identical to psoriasis
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Reiter’s Syndrome
Skin Lesions
• Keratoderma Blenorrhagicum (10%)
• Circinate Balanitis (25%)
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Reactive Arthritis
Reiter’s Syndrome
• Asymmetrical polyarticualr arthritis
• Predominant in the weight bearing joints of the
lower limbs (knees, ankles, feet and wrists)
• Also occurs in the sacroiliac joints
• Calcaneal spurs, plantar fasciitis, Achilles
tendonitis
• Repeated attacks which may progress to
chronic, erosive, disabling arthritis
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Case
• 80 year old chinese man presents with 3
years of lesion on the side of his nose.
• Multiple papules have occurred around
the eyes for many years
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• Diagnosis?
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Basal Cell Carcinoma
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Nonmelanoma Skin Cancer
(NMSC)
• Actinic Keratosis
• Basal Cell Carcinoma
• Squamous Cell Carcinoma
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Actinic Keratosis
• Diagnosis - Clinical inspection
– Red, scaly patch < 6mm.
– Tender to touch.
– Sandpaper consistency.
• Location - Scalp, face, dorsal hands,
lower legs (women)
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Basal Cell Carcinoma
• Most common of all cancers
– > 1,000,000 diagnosed annually in USA
– Lifetime risk for Caucasians: up to 50%
• Intermittent intense sun exposure
(sunburns)
• Locally aggressive, very rarely
metastasize
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Squamous Cell Carcinoma
• Chronic Sun Exposure
• 10 fold risk (at least) in fair organ
transplant recipients (OTR’s)
• 2% of all deaths in OTR’s in Australia
are due to actinic SCC’s that metastasize
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Squamous Cell Carcinoma (2)
• Presents as red plaque, ulceration, or
wart like lesion
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Pruritus
No Rash
• DRY SKIN
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Renal Failure
Iron Deficiency
Hepatitis C and other liver diseases
Thyroid Disease
Low or High Calcium
Cancer, especially lymphoma (Hodgkin’s)
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Case
• 11 year old boy with chronic pruritic
eruption of antecubital and popliteal
fossae.
• Has asthma
• Mother with asthma, and sibling with
seasonal allergies
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• Diagnosis?
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Atopic Dermatitis
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Atopic Dermatitis
• Extremely common (10-20% of children
in developed countries)
• Much less common in under-developed
nations
• Prevalence increase 10X in the last 30
years
• Hereditary Component (25% risk in one
parent, 80% risk if both parents atopic)
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Atopic Dermatitis (2)
• Part of a constellation of allergic
disorders which tend to occur together:
– Allergic rhinitis/conjunctivitis (Hay Fever)
– Asthma
– Atopic Dermatitis
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Food and Atopic Dermatitis
• Important allergen in INFANTS, but
NOT in most older children or adults
• Common allergens are egg, peanut, milk,
wheat, fish, soy and chicken (over age 3
also nuts)
• Screen with prick tests, but only a
negative prick test is useful in predicting
the lack of food allergy, not vice-versa
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Atopic Dermatitis (3)
• Diagnositic Criteria by Hanifin
• Major Criteria (need 3 of these)
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Pruritus
Typical morphology and distribution
Chronic or relapsing course
Personal of family history of other atopic
diseases (asthma, allergic rhinitis, AD)
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Atopic Dermatitis (4)
• Clinical picture changes over time
– Infants-extensor surfaces and cheeks
– Childhood-antecubital and popliteal fossae
– Adult- “sensitive skin,” nipple eczema, hand
eczema
• At all stages atopic dermatitis ITCHES
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Atopic Dermatitis
Treatment
• Confirm the diagnosis, use criteria
• 3 components
– Treat any secondary infection
– Topical therapy
• Steroids/Immunosuppressives
• Moisturizers
– Oral Antipruritics
• Reinforce good skin care regimen
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Atopic Dermatitis (Rx)
Good Skin Care Regimen
• Soap to armpits, groin, scalp only (no
soap on the rash)
• Short cool showers or tub soak for 15-20
minutes
• Apply medications and moisturizer
within 3 minutes of bathing or swimming
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Atopic Dermatitis (Rx)
Topical Therapy
• For Face: HC Ointment BID or Elidel or
Protopic. Fails, Aclovate, Desonide
• For Body: TAC Ointment BID, fails
Lidex
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Atopic Dermatitis (Rx)
Oral Antipruritics
• Atopic Dermatitis is the ITCH that
RASHES
• Suppress itching with nightly oral
sedating antihistamine
• If it is not sedating it doesn’t help AD
(Claritin, Allegra, Zyrtec not useful)
• Diphenhydramine, Hydroxyzine 25-50mg
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Atopic Dermatitis (Rx)
Severe Cases
• Refer to dermatologist
• Do not give systemic steroids!!!!
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Xerotic Eczema
• Xerotic Eczema is caused by the skin
being dry, that is the loss of the epidermal
water barrier
• More common in the elderly
• Worsened by hot showers, deodorant
soaps
• Worse in the winter (dry, heated air)
• Worse after ski trips (altitude, cold)
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Xerotic Eczema (3)
• Diagnostic clue: Itching is relieved by
prolonged submersion in bath (20-30
minutes), then itching starts again 5-30
minutes after getting out of the water
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Xerotic Eczema
Treatment
• You cannot hydrate your skin by
ingesting more water
• Moisturize (Vaseline)
• Soap to the axillae, groin, scalp only
• Mid potency topical steroid (TAC)
ointment to the areas of redness and itch
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Case
• 57 year old alcoholic admitted for
pneumonia
• On physical examination you note
multiple purpuric lesions on the lower
extremities.
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• Diagnosis?
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Scurvy
• Perifollicular purpura
• Large ecchymoses on the lower legs
• Intramuscular and periosteal
hemorrhage
• Keratotic plugging of hair follicles
• Hemorrhagic Gingivitis (only if the
patient has poor dental hygiene)
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Scurvy
• Scurvy is Vitamin C deficiency
• Still seen due to fad diets, social
disadvantage, or psychiatric disease
• Take a dietary history in every patient!
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Herbs and Coagulation
• Herbs can potentiate the antiplatelet
effects of ASA and NSAID’s. These herbs
include garlic, ginkgo, ginger, ginseng,
tumeric, dong quai, meadowsweet, willow
and feverfew
• 34% of patients having surgery are
taking at least one herbal medication that
can affect coagulation!!!!!
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QUIZ
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Pityriasis Rosea
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Erythema Migrans
(Lyme Disease)
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Necrotizing Fasciitis
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