4/26/2016 1 Dermatology for the Primary Care Provider Practical Advances in Internal Medicine April 14, 2016 Amy Swerdlin Frankel, MD Providence Medical Group Overview Common skin conditions and their mimics Atypical presentations of common dermatologic conditions Treatment pearls
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4/26/2016
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Dermatology for the Primary Care Provider
Practical Advances in Internal MedicineApril 14, 2016
Amy Swerdlin Frankel, MDProvidence Medical Group
Overview Common skin conditions and their mimics Atypical presentations of common
dermatologic conditions Treatment pearls
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Case #1 65 y/o M with 1 year h/o of a lesion
growing on his left clavicle Reports occasional bleeding and tenderness
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BCC
Case #2 40 y/o F with 8 month h/o a new growth
on her temple
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Pigmented BCC
Ddx?
Melanoma
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Case #3 85 y/o M with growing ulcer on his lip x 2
Amelanotic melanoma Up to 8% are this variant Often with hypopigmentation – sign of
regression Do not obey ABCDE rules Treat the same as pigmented melanomas,
but often more advanced due to delayed diagnosis
Case #8 76 y/o M avid golfer with the development
of several scaly lesions on his scalp
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Actinic keratoses
Pigmented actinic keratosis
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Most Common Skin cancers Basal cell carcinoma
~2.8 million cases/year in US Rarely fatal, but disfiguring
Squamous cell carcinoma ~700,000 cases/year in US
~2500 deaths in 2011
Melanoma ~123,590 cases/year in US
~8,790 deaths in 2011 Oregon ranks 5th in nation for new melanoma cases
www.skincancer.org/skincancerfacts
Basal cell
Keratinocyte
Melanocyte
Treatment options Non-melanoma skin cancer
Mohs Excision Curettage and Desiccation Topical chemotherapeutics
Aldara – for superficial BCC, AKs Efudex – AKs, SCCis (off label)
PDT; Cryotherapy – AK’s Radiation therapy
Melanoma 5mm margins for MIS WLE; sentinel node bx if ≥1mm depth OR >0.75mm
with adverse features (high mitotic rate/ulceration)
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Nicotinamide (Vitamin B3) Reduces the incidence of BCC & SCC in
people with a h/o NMSC Decreased rate of developing new NMSC by 23% Decreased rate of developing new AK’s by 13%
500mg PO BID Unlike niacin or nicotinic acid, the amide did NOT
cause HA, flushing or low BP Reports of increased blood sugar & sweating
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Case #9 66 y/o F with new rash x 3 months. Failed
a course of oral lamisil
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Granuloma annulare
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Granuloma annulare Benign inflammatory dermatosis Localized or generalized Associated with diabetes mellitus
Primarily Type I DM 21% of pts with generalized GA compared to
9.7% with localized GA Rarely pre-dates the onset of DM Pearl – check a fasting blood glucose if no
previous h/o DM
Case #10 30 y/o F with worsening acne in pregnancy
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Treatment of acne in pregnancy Topical erythromycin or clindamycin Topical Azelaic acid (Finacea) Oral erythromycin BASE (Base is safe for
Babies)
*Even benzoyl peroxide and salicyclic acid are category C in pregnancy
Case #11 20 y/o F with h/o dry skin who presents
with a diffuse itchy eruption Reports having asthma as a child and currently
has hayfever
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Atopic dermatitis
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Treatment for atopic dermatitis OINTMENTS are better than creams Triamcinolone 0.1% ointment (a favorite) Protopic ointment if on genital skin or face Moisturizing is VERY important
Cetaphil, Cerave or Vanicream (emphasize the jar cream); Vaseline ointment
Gentle moisturizing cleanser Recurrent infections
Always culture pustules! Bleach baths can be helpful Often require oral antibiotics
Allergic contact dermatitis to nickel
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Asteatotic dermatitis/Eczema craquele
Case #12 24 y/o F with h/o atopic dermatitis and a
progressive, painful & pruritic eruption on her face x 2 weeks
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Eczema herpeticum
Eczema herpeticum Complication of atopic dermatitis Viral culture important
Also consider bacterial culture since lesions frequently superinfected with staphylococcus
Treatment Oral acyclovir or Valtrex Ophthalmology consult if near the eye or on
the tip of the nose
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Case #13 26 y/o F with pruritic/burning eruption
around mouth, which recently spread around eyes
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Periorificial dermatitis
Periorificial dermatitis Cross between rosacea, acne & dermatitis Usually there is a history of steroid use Sometimes caused by prolonged topical
tacrolimus use Treatment
Taper topical steroids Can bridge with short course of topical tacrolimus
Oral tetracyclines (MCN or doxy for 6-8 wks) Topical erythromycin, clindamycin, azelaic acid
or metrocream
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Case #14 49 y/o F with 4 year history of acne-like
lesions and flushing
Rosacea
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Management of Rosacea Daily sunscreen important! Avoid triggers (hot fluid, spicy food, EtOH) Screen for ocular rosacea Treatment
If in question, get vitals, CBC, CMP Check for bullae
Morbilliform drug eruptionMost common type of drug eruption
1 to 5% of patients on antibiotics will develop
Don’t have to stop the causative drug In contrast, urticarial drug reaction could
progress to angioedema & anaphylaxis
Common causes Antibiotics (aminopenicillins, sulfa) Anticonvulsants
Treatment Takes days to weeks for rash to resolve Antihistamines and topical steroids
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Case #18 25 y/o F presenting with an asymptomatic
scaly pink eruption She is 12 weeks pregnant
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Pityriasis rosea Affects young adults (10-35 yrs) Peaks in spring and fall Lasts 6-8 wks Rare variant (inverse) is localized to the
axillae and groin Asymptomatic or mildly pruritic Treatment
Reassurance If pruritic: Topical steroids, Antihistamines If extensive: acyclovir
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Special consideration Reactivation of HHV-6 or HHV-7 Associated with miscarriage if develops in
the first 15 weeks of pregnancy
Case #19 61 y/o F with 8 month h/o itchy rash in
her groin
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Inverse psoriasis
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Plaque psoriasis
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Psoriasis Always ask about arthritis
Can be debilitating if left untreated Affects up to 30% of psoriatic patients
Increased risk for cardiovascular disease If guttate morphology
Consider throat culture to r/o strep infection
Nummular dermatitis
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Tinea corporis
Subacute cutaneous lupus
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Lichen planus
Wickham striae
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Mycosis Fungoides (CTCL)
Thank you! Our Office:
PMG-Dermatologic Specialties5330 NE Glisan St., Suite 200Portland, OR 97213
Phone: 503-215-9080
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Case #12 26 y/o M with spreading fine scaly rash x
3 months Rash is more prominent after tanning
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KOH
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Tinea Versicolor Caused by lipophilic yeast – Malassezia
Malassezia is naturally found on human skin Enzyme tyrosinase causes hypopigmentation Not contagious Recurrence is common Pigmentation change generally improves 2