Download Skin Diseases

Common Skin problems
Family Medicine Specialist CME
October 15-17, 2012
Pakse
Objectives
• Identify common skin diseases based on the
pattern of the rash
• Describe strategies to prevent and treat common
skin diseases
Pre-Test 1
• What disease causes this scaly rash on extensor
surfaces (such as elbows and knees)?
a.
b.
c.
d.
Psoriasis
Eczema
Fungal infection
Skin cancer
Pre-test 2
• What is the diagnosis?
a. Chickenpox (varicella)
b. Yeast infection
c. Superficial bacterial
infection (impetigo)
d. Scabies
Pre-test 3
• This very itchy skin condition,
which affects flexor surfaces
(such as in front of the elbows
and behind the knees) can
occur in adults but more often
occurs young children
a.
b.
c.
d.
Psoriasis
Eczema
Fungal infection
Bacterial infection
Case 1
• A 4 year old female presents with a 2 day history
of this facial rash:
• What is the
diagnosis?
• What are the most
common bacteria
that causes this condition?
• How would you
treat this?
Impetigo
• Contagious superficial bacterial infection
• Most common in children
• 2 types
▫ Primary: Infection occurs on normal skin
▫ Secondary: Infection occurs on areas of skin where
there has been mild trauma or a break (such as
from scratching, abrasion, insect bite, eczema)
• Most caused by Staphylococcus aureus
Impetigo: Diagnosis
• Clinical diagnosis: no tests needed!
• Characteristics of the rash:
▫ Start as papules (non fluid filled)
▫ Progress to fluid filled vesicles with surrounding
erythema
▫ These turn into pus filled lesions called pustules
▫ Pustules break and the fluid forms a yellow or golden
crust
▫ The changes occur over 1 week
▫ Occurs mostly on face and legs/arms
Impetigo: Prevention
• Prevention
▫ Keep any cuts and scratches clean and covered
▫ This condition is very contagious through direct
contact, especially when there is fluid drainage
from the rash!
▫ Do not share towels or washcloths with someone
with impetigo
▫ Wash hands with soap and water each time you
touch the infected area
Impetigo: Treatment
• Topical treatment:
▫ Mupirocin three times a day is the best choice
▫ Other topical treatments: fusidic acid, hydrogen
peroxide 1% cream 2-3 times a day
• Oral antibiotics
▫ If a large area is involved, and rash is severe
▫ cephalexin 500mg q6h, or
▫ cloxacillin 500mg q6h, or
▫ clindamycin 300mg q6h
for 7 days (these are adult doses)
Case 2
A 65 year old man presents with this very painful rash to
his back.
• What is this
disease? What
characteristics of the
rash lead you to
this diagnosis?
• How do you treat it?
• What are some
complications
that can occur?
Herpes Zoster (shingles)
• Reactivation of latent varicella zoster virus
(same virus that causes chickenpox)
• Clinical diagnosis:
 Rash
 Starts off as papules, then progress to a cluster or
group of vesicles. Over 3-4 days they become more
pustular. The rash crusts by 10 days. Heal in 2-4weeks
 Follow 1-2 dermatomes and do not cross midline
 Usually on the trunk
 Pain
 “burning” pain that can start days- weeks before the
rash appears
Dermatomes
Herpes zoster: More examples
Herpes zoster: Complications
• Postherpetic neuralgia (pain even after rash is gone)
• Bacterial skin infection
• If trigeminal nerve involved: eye & corneal involvement
can lead to vision loss
▫ This is called herpes zoster opthalmicus
• Motor weakness
• Varicella zoster encephalitis
• If a patient has HIV, they are more likely
to get herpes zoster and its complications
Herpes zoster: Treatment
• Treatment with antiviral drugs can lead to faster
healing of the skin lesions if started within 72h
from symptom onset
▫ Oral Acyclovir 800mg five times/day x 7 days
• In herpes zoster opthalmicus, use
▫ IV Acyclovir 10mg/kg q8h x 7 days
▫ Topical steroid drops
Case 3
• A 10 year old girl presents with itchiness between her
fingers, worse at night
• What does she
have?
• How do you
diagnose it?
• What are the
characteristics of the
rash?
• How do you
treat it?
Case 3: Scabies
• From infestation of the mite Sarcoptes scabiei
• Typical lesion:
▫
▫
▫
▫
Small erythematous papule
Usually excoriated
Hemorrhagic crust
Burrows, when seen, make the diagnosis
 Thin gray/ red/ brown line 2-15mm long
• Typical distribution:
• Web of fingers, wrist flexor surface, elbow, axilla,
knees, buttocks, waist, male genitalia
Scabies distribution
Scabies: More examples
Examples of burrows
Scabies: Diagnosis
• Clinical diagnosis: (1 or more of)
▫ Itching, worse at night out of proportion to changes
that can be seen on the skin
▫ Itchy rash with characteristic lesions and distribution
▫ Other people in the house with same symptoms
• Investigations
▫ Skin scraping (can see mite under microscope)
▫ Adhesive tape test
 Use clear tape to apply directly over skin lesion. Pull it off
quickly. Using a microscope, look for eggs and mites
Scabies: Treatment
• Whole body application of 5% permethrin cream
or
• Whole body application of 1% lindane cream
or
• Single dose oral ivermectin 200mg/kg
• For the itching, can use antihistamine or topical
corticosteroid
Scabies: Prevention
• Transmitted by close skin to skin contact
• Contaminated clothing and linens should be put
in a plastic bag for at least 3 days before being
washed
• Treat everyone who lives in the same household
for scabies
Case 4
• A 6 year old boy is complaining of itchiness to
his wrists, neck, front part of his elbow, and
behind his knees.
His parents thought
the problem was dry
skin, but the rash
and itchiness have
been present for
several years.
Case 4
• Describe the rash. What is the diagnosis?
• What treatments (both lifestyle and medication)
can you recommend?
Eczema (atopic dermatitis)
• Often first present as children <2 years of age
• Clinical diagnosis
▫ Itchy skin. Evidence of rubbing/scratching
▫ Lichenified (thickened) skin from chronic scratching
▫ Distribution in the flexor skin creases
 In front of elbow, behind knees, neck, around eyes,
fronts of ankles
 Usually not in axilla, groin, or buttocks  think
psoriasis in this distribution
▫ Dry skin
Case 4: More examples
Eczema: Treatment
• Lifestyle changes
▫ Keep skin hydrated
 Use thick creams on the skin, and apply right after
bathing (while skin still damp)
• Medications
▫ Topical corticosteroids (apply at least once daily)
 Mild: Low potency (1% -2.5% hydrocortisone cream)
 Severe: Medium potency (triamcinolone 0.1% cream)
 Do not use higher potency steroid creams for more than
10 days
Case 5
• A 25 year old man says he has
noticed a scaly, non-itchy rash
to his scalp, along with some
changes to his nails.
• Describe this rash.
• What is the diagnosis?
• What other non-skin body
parts can this disease affect?
• What is the treatment?
Psoriasis
• Onset peaks at ages 20-30 and again at 50-60
• Clinical diagnosis
▫ Erythematous raised plaques with a thick silvery scale
▫ Better in summer months because of exposure to
ultraviolet light
▫ No or only mild itchiness
▫ Distribution
 Scalp, elbows, knees (extensor surfaces), back,
buttocks, and at old sites of trauma
Psoriasis: Distribution
Psoriasis: More examples
Associated non-dermatologic findings
• Inflammation of the eyes:
▫ Red, painful eyes, flaking or crusting of eyelashes,
swelling of eyelids, visual changes
• Arthritis
▫ Can involve distal joints (see picture), large joints such
as hips and knees, or the back
• Nails
▫ Pits, or brown
discoloration
Psoriasis: Treatment
• Mild-moderate
▫ Keep skin soft and moist with vaseline or creams
▫ Topical corticosteroids
 Mild potency (hydrocortisone 1%) on the face
 Medium potency (betamethasone 0.05%) on thick
plaques to elbows or knees
▫ Tar creams and shampoos
• Severe
▫ Phototherapy with UV light
▫ Oral drugs such as methotrexate
Post-Test 1
• This girl has a rash and she is very itchy! Which
skin disease(s) can cause itchiness? (Can have
more than one right answer)
a.
b.
c.
d.
Eczema
Herpes zoster
Scabies
Impetigo
Post-Test 2
• What common skin disease does not cross
midline and stays within 1-2 dermatomes?
a.
b.
c.
d.
Eczema
Psoriasis
Impetigo
Herpes Zoster
Post-Test 3
• What is the most common bacteria that causes
impetigo?
a.
b.
c.
d.
Beta-hemolytic streptococci
Staphylococcus aureus
Enterococci
Pseudomonas aeruginosa