Urgent Care Dermatology Dermatology Differential Diagnosis in Images James S. Studdiford, MD Kathryn P. Trayes, MD June 23, 2021
Urgent Care DermatologyDermatology Differential Diagnosis in Images
James S. Studdiford, MDKathryn P. Trayes, MDJune 23, 2021
2019 Eastern Shore Symposium Presentation
• Annals of Internal Medicine, February 4, 2020• Prolongation of the PR interval >200 ms occurs in 90% of
patients with disseminated Lyme disease.
Case 1• 57 yo M from Vermont: fever, fatigue, SOB, CP• EKG: first degree AV block with PR interval 220 ms• Lyme test ordered, came back + 2 days later, not treated• 8 days later, pt presented to ED, worsening symptoms, ID
consulted, F/U appt scheduled, no Tx• 12 days later: pt found unresponsive
Cautionary Tale: Fatal Lyme Carditis in New England: Two Case Reports
Ann Intern Med, Feb 4, 2020; 172(3): 222-24
• Case 2• 49 yo F presented to ED with HA, nausea, vomiting• Normal CT head and EKG• IV fluids, antiemetics, analgesics, D/C home• 2 weeks later, saw PCP with c/p 2 episodes of syncope with
bowel and bladder incontinence, persistent fatigue, nausea and SOB
• EKG: AV dissociation• Cardiology ordered cardiac event monitor and lab tests
including Lyme• 2 days later, + Lyme result, Doxy started, but before she
took the first dose, she went into V tach and died
Cautionary Tale:
Ann Intern Med, Feb 4, 2020; 172(3): 222-24
Cautionary Tale:
Ann Intern Med, Feb 4, 2020; 172(3): 222-24
• Carditis can be an early manifestation of Lyme disease
• Lyme carditis should be considered when younger patients present with severe conduction abnormalities
• EKG is essential
• AV block in Lyme carditis can progress rapidly and be fatal
• Treat with antibiotics empirically
Take Home Points
Ann Intern Med, Feb 4, 2020; 172(3): 222-24
Correctly diagnosing dermatologic disease can save lives!
Dermatology is more than just identifying and treating
rashes!
Objectives
● Outline and practice the approach to dermatologic diagnoses
● The role of the history and physical examination
● Common entities
● Diagnostic challenges
Our GOAL: - Master the diagnosis and treatment of skin conditions- Appreciate that this expertise falls within the purview of Family Med/EM/IM/peds/etc..
Treatment
Natural history
Visual diagnosis
Workup
Morphology
Location
Border
Pattern
Differential
Diagnosis
Welcome to DERM think – defining moments
Primary lesion
History
Nodular lesions: pyogenic granuloma, MRSA
6/20/2021
Erythema nodosum
Annular and Targetoid Lesions
American Family Physician, Sept 2018; 98(5): 283-91
69 yo F with “itchy/burning rash” which developed one week after initiating Bactrim
American Family Physician, Sept 2018; 98(5): 283-91
Fixed Drug Eruption
American Family Physician, Sept 2018; 98(5): 283-91
Erythema Multiforme
18 yo male with a rash that developed shortly after receiving Menactra
vaccination Pharmacotherapy, Nov 2006; 26(11): 1658-61,
Treatment:self-limited, ; steroids,
Anti-virals for associated recurrent
HSV-1
Workup:Visual Dx
(plus pertinent History)
“Multiple raised, annular, targetoid lesions”
Lesions appeared suddenly after
vaccination
Differential: urticaria, LD, pityriasis R,
contact dermatitis Diagnosis: Erythema
multiforme
Etiology:Infections (~90% ),
Medications (~10%)
vaccinations
18-y-o male developed a red rash following a menactra vaccination
Pharmacotherapy, Nov 6, 2006; 26(11): 1658-61
Erythema multiforme
IgA vasculitis, Henoch-Schonlein Purpura
21 yo with a sore throat. One week later developed small red spots on ankles which grew to larger lesions over the
next two days. + ankle swelling.American Family Physician, Sept 2018; 98(5): 283-91
IgA vasculitis Work up
16 yo with a history of eczema presents with fever, malaise and a one-week history of a
“bumpy”, painful skin rash. Emerg Med, Feb 2011; 40(2): 167-9
Herpes Zoster
Nails
Quote attributed to Abraham Herzberg, DPM
American Family Physician, April 15, 2012; 85(8): 779-87
Beau’s lines, vertical nail bands
American Family Physician, April 15, 2012; 85(8): 779-87
Splinter hemorrhages, koilonychia
Psoriasis
Studdiford JS,et al. Images from the Wards: Diagnosis and Treatment. Saunders Elsevier, 2010.
Queen Anne’s sign, trichotillomania,alopecia areata
Daycare specials
5 yo with fever and decreased appetite. Three days later she developed erythematous macules on cheeks and then a lacey
reticular rash on her upper extremities and trunk
6/20/2021
29
Erythema infectiosum
3 yo low-grade fever, malaise and decreased appetite. One day later, she developed a rash that started on her hands
30
Coxsackie
31
17 mos with three days of fever to 102-103°F, decreased appetite. On day three, he developed a rash on trunk and
proximal extremities
Roseola
In Summary….
• Urgent Care Dermatology
• Higher acuity
• Think like dermatologists
• Lyme carditis
• nodular, annular, violaceous
• A difficult diagnosis: Eczema herpeticum
• Update on nails and hair
• Childhood infectious diseases
Entities Discussed Today:
• Disseminate Lyme Disease• Pyogenic granuloma• MRSA cellulitis with
furuncle• Erythema nodosum• IgA vasculitis• Eczema herpeticum• Staphylococcus aureas• Varicella Zoster• Beau’s lines• Splinter hemorrhages
• Koilyonychia• Plaque psoriasis• Onycholysis• Alopecia universalis• Trichotillomania• Alopecia areata• Erythema infectiosum• Coxsackie• Roseola
References:• Fitzpatrick JE, High WA, Kyle WL. Urgent Care Dermatology Symptom-Based Diagnosis.
Philadelphia, Elseiver, 2018.
• Marx GE, Leikauskas J, Lindstrom K, etc. al. Ann Intern Med. Feb 4, 2020; 172(3): 222-24.
• Studdiford JS, Altshuler M, Salzman B, Tully A. Images from the Wards: Diagnosis and Treatment. Philadelphia, Saunders Elsevier, 2010.
• Studdiford JS, Altshuler M et al, "Erythema multiforme after meningitis vaccine: patient safety concerns with repeat immunization.” Pharmacotherapy. Nov 6, 2006; 26(11):1658-61.
• Studdiford JS, Valko G, Stonehouse AS. “Eczema herpeticum: Making the Diagnosis in the Emergency Department.” Emerg Med. Feb 2011; 40(2): 167-9.
• Trayes KP, Savage K, Studdiford JS. “Annular Lesions: Diagnosis and Treatment.” American Family Physician. Sept 1 2018; 98(5): 283-91.
• Tully AS, Trayes KP, Studdiford JS. “Evaluation of Nail Abnormalities.” American Family Physician. April 15, 2012; 85(8): 779-87.
Thank you for your time and attention!
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