Download Dermatology_in_Family_Practice

Dermatology for the Family Physician
Student Teaching Session
May, 2009
Dr. Laura Lyons
St. Joseph’s Family Medical Centre
Objectives
1) To review the approach to dermatological
complaints in primary care
2) To discuss common dermatological
infestations
3) To review frequently encountered viral
skin infections
4) To discuss: when to refer, to whom to
refer - the multidisciplinary team
In Primary Care
•
•
10 - 15% of clinical work
11,191 patients seen - 2,386 with dermatological
concerns
- Warts
23%
– Benign tumours
16%
– Eczema
14%
– Infectious
6%
– 3% premalignancies, malignancies, acne, psoriasis
Julian CG, Dermatology in General Practice, British Journal of Dermatology, 1999;141,51-520
Oh Doctor,
just one more thing”
“
Approaches in Primary Care
1) Definitive diagnosis
-
Reassurance
Treat as required
Refer for treatment (UV-psoriasis)
2) Differential diagnosis
-
monitor
treat for relief/cure = diagnosis
procedural diagnosis
refer for diagnosis
3) Surveillance/refer for surveillance
What’s the Story?
Putting the Patient’s Concern in Context
Demographics
• What is it? What else is there?
• Onset, duration, events
• Distribution, geography
• Any historical triggers or clues
• Has it responded to Rx
•
Bill Longsworth
25 year old male
• History of mild asthma and atopic eczema
• Recent trip to Punta Cana, spent time in
farm region
• Seven days ago, on the flight home he
began to itch
• Other family members similarly affected
•
Bill’s Rash
Infestations
Harbouring of insect or worm parasites in or
on the body
• Worm infestations are rare except in
tropical countries
• Insect life on the skin is usually transient in
temperate climates
•
Skin Reactions to Infestations
Insect
Animal ticks
Ants, bedbugs, flies
Bees, wasps
Caterpillars
Food and Harvest Mites
Lice
Mosquitoes
Sarcoptes scabei
Effect
Bites, disease vector
Bites
Stings
Dermatitis
Bites
Infestation, disease vector
Bites, myiasis, disease vector
Burrows (scabies), dermatitis
Insect Bites
Presentation:
Uritarica
Wheals - papules to
Large bulla
Cutaneous Reactions:
pharmacological
irritant
allergic
Complications:
secondary bacterial infection of excoriations
Myiasis: parasitic dipterous fly larvae
Lice Infestation (pediculosis)
Two species
Pediculus humanus var capitis and var
corporis
Phthirus pubis
Lice
Clinical Presentation
Itching of head lice starts at the sides and back of
scalp. May develop secondary impetigo
• Body lice result in excoriations on the trunk and in
chronic infestation, lichenification and
pigmentation. These lice are found in the seams of
clothes
• Pubic lice result in severe itching and secondary
eczema and infection
• They may involve eyelashes
•
Scabies
Ectoparasitic infection caused by
Scarcoptes scabiei var hominis
• Cannot be visualized without a microscope
upon examination of a scrapping from
unexcoriated lesion
• Mites burrow in be startum corneum
• Pruritis results from a hypersensitivity to
the organism
•
Scabies (continued)
Skin lesions are widely scattered macules, papules
or pustules, with common findings in the finger
webs, axillae, breasts, and genitals
• Nodular lesions are a result of epithelial
hyperplasia and inflammation
• Crusted lesions (Norwegian scabies) are thick
crusted or hyperkeratotic infestation by numerous
mites, and is often not pruritic
• Most commonly seen in immunocompromised
patients, neurologically impaired patients and in
nursing homes
•
Scabies
Treatment
Topical Lotions - repeat after 7 days
Permethrin
Phenothrin
Oral treatment
Ivermectin single dose - 150-200mcg/kg
Sanitizing bedding and clothing
Treat all contacts
VIRAL INFECTIONS
WARTS
Verrucae are common and benign cutaneous
tumours due to infection of epidermal cells with
human papillomavirus (HPV)
• Over 80 subtypes of DNA HPV have been
identified
• Types 1, 2, and 4 are associated with plantar
warts
• Types 3 and 10 are common hand warts
• Types 6, 11, 16 and 18 are associated with genital
warts
•
The virus infects by direct inoculation and is caught
by touch, sexual contact or at the pool (or gym)
Immonusuppressed patients are particularly
susceptible to viral warts
Common Warts - Verrucae vulgares
The epidermis is thickenened and hyperkeratotic
• Keratinocytes in the granular layer are vacuolated
due to being infected with the wart virus
• Usually multiple, common on hands and feet but
also affect the face and genitalia
• Rare in infants, incidence rises in school years.
10% of children between the ages of 2 and 12
have warts. Incidence peak between 12 - 16
•
Plantar Warts - Verrucae planae
On the soles of the feet, most common in
children and adolescents - painful
• Pressure causes them to grow into the
dermis
• Covered in callus, which when pared
reveals dark thrombosed capillaries
• Mosaic warts are plaques on the soles that
comprise multiple individual warts
•
Genital and Peri-anal Warts Condylomata acuminata
Discrete sessile, smooth surfaced
papillomas that can be flesh coloured,
brown or whitish
• They are most commonly found on the
external genitalia, perineum and peri-anal
areas
• Peak incidence between 25 - 45 years of
age
•
Risks for Cervical Cancer
GARDASIL is a vaccine indicated in girls
and women 9 to 26 years of age for the
prevention of cervical cancer, precancerous
or dysplastic lesions, and genital warts
caused by human papillomavirus (HPV)
Types 6, 11, 16, and 18.
• Test for HPV
•
What is this?
Molluscum Contagiosum
Mainly affects children and young adults
Spread by contact including sexual
transmission or on towels
Clinical Presentation
Discrete pearly-pink umbilicated papules a
that are caused by a DNA pox virus
Dome shaped and a few millimeters in
diameter
If squeezed releases a cheesy material
Usually multiple or grouped, sometimes with
localized eczema
Untreated they may persist for several months
Treatment Options
Topical
Salicylic and lactic acids
Glutaraldehyde
Formaldehyde
Podophyllotoxin 0.15% cream
Imiquimod cream
Other Treatments
Cryotherapy
Curretage and Cautery
Laser Surgery
Interferon
Intralesional Bleomycin
It is a cold wet day in early March.
Peter Graham, a 57 year old
homeless man arrives in your
community clinic requesting a
prescription for pain medication….
What you observe
Peter is limping on the way to the exam
room
• He looks flushed and fatigued
• He sits down while scratching his neck and
waist
• You notice he has multiple warts on his
knuckles
• What are your concerns?
•
Pediculosis corporis
Condylomata
Immersion Foot
To Whom to Refer:
The multidisciplinary team
-
Family physician
Dermatologist
Rheumatologist
Plastic surgeon
Pathologist
Internist / infectious disease
Psychologist / Social Worker
Nurse / Wound Care Specialist
Community Care Access Centre
Vascular surgeon
General surgeon
Shoppers Home Health Care
THE END