Acne

Adolescent F presents with gradual appearance of comedones, papules/pustules, and nodules on face. Denies use of androgens/steroids, isoniazid, lithium, phenytoin (Dilantin). Non-inflammatory nodules, inflamed comedones, and nodules noted on face, back.

• Treatment

  • Stage 1

    • Noninflamed (blackheads and whiteheads)

    • Apply topical tretinoin 0.025% gel to acne lesions daily at bedtime

  • Stage 2

    • Inflamed comedones with few papules/pustules (pimples)

    • Apply benzoyl peroxide 10% gel sparingly twice daily; reduce frequency to once daily if excessive skin dryness occurs

  • Stage 3

    • Nodular lesions

    • Apply thin film of topical erythromycin 2.0% gel BID

  • Stage 4 refractory nodular/scarring acne: Start oral isotretinoin 1.0 mg/kg/day x 20 weeks and require pt

    • Enroll in iPLEDGE program

    • Obtain CBC, CMP, and fasting lipid panel

    • Obtain negative pregnancy test before starting medication and before each refill

    • Use two forms of birth control before engaging in sexually activity

  • Female: Consider combined oral contraceptives at any stage for improved acne control

• Refractory acne: Refer to dermatology

• Counseling

  • Pt counseled that acne is caused by bacterial infection with P. acnes

  • Pt informed that a minimum of 6-8 weeks is required to assess effectiveness of any one therapy

  • Pt advised that laser and light therapies are ineffective

  • Pt counseled that failure to comply with treatment may lead to continue acne and/or scarring

Notes

• Rule out drug induced acne which may be caused by androgens/steroids, isoniazid, lithium, phenytoin (Dilantin)

• Tretinoin = vitamin A derivative

• Benzoyl peroxide (topical antiseptic)

  • Reduces risk for bacterial resistance when used with antibiotics

  • Pt may stop daily use once symptoms are controlled

• Isotretinoin

  • Provider and pharmacy must be registered with iPLEDGE

  • Results

    • Long term remission in 40% of patients

    • 40% of patients controlled with topical therapy after course

    • 20% require re-treatment with isotretinoin 

Seborrheic Dermatitis

Pediatric (Cradle Cap)

6 month old female with no history of immunodeficiency disorders presents with chronic greasy scaling of the scalp. Lesions to not appear to irritate infant. Yellow-brown scaling on well-demarcated erythematous plaques covering scalp on exam.

• Recommend physical removal of plaques and regular hair washing

• Parents advised that condition generally resolves by 1 year of age

Adults (Dandruff)

55 year old male with history of parkinsonism and HIV presents with chronic greasy scaling of the skin. Reports mild, intermittent pruritus in affected regions. Patient has noted dermatitis improvement since starting L-dopa therapy and antiretrovirals. Greasy yellow scales present on scalp, central face, chest, ear canal, and groin.

• Head: Start ketoconazole 2% shampoo

  • Apply twice weekly and leave in place for 5 to 10 minutes before rinsing

  • Continue for 4 weeks and then transition to once weekly use to prevent relapse

• Face/Body

  • Apply ketoconazole 2% cream BID to affected areas x 4 weeks and then stop for 4 weeks before restarting

  • Corticosteroid: Apply BID x 2 weeks and then discontinue for 2 weeks before restarting

    • Face: Hydrocortisone cream 2.5% (Group 7)

    • Body: Triamcinolone acetonide cream 0.1%

• Seborrhea refractory to initial treatment and no history of elevated AST, ALT: Start itraconazole 200 mg qd x 7 days

Notes

• Pathophysiology (suspected): Abnormal immune response to Malassezia yeast

• Epidemiology

  • Most common in children < 1 year and adults > 40 years old

  • Risk factors in adults: Parkinsonism, untreated HIV

• Most commonly occurs in regions with high concentrations of sebaceous glands, e.g. head/face

• Differential in adults includes

  • Common: Psoriasis, rosacea, tinea capitis, tinea corporis, tinea versicolor

  • Less common: Lupus erythematosus, pemphigus foliaceus, secondary syphilis

Atopic Dermatitis (Eczema)

Pt with h/o atopy presents with pruritic, erythematous, and scaly skin lesions.

• Start topical steroids; agent choice pending location and severity of irritation

  • Group 7: Hydrocortisone cream 2.5%

  • Group 6: Triamcinolone acetonide cream 0.025%

  • Group 5: Triamcinolone acetonide ointment 0.025%

  • Group 4: Triamcinolone acetonide cream 0.1%

  • Group 3: Triamcinolone acetonide cream 0.5%

  • Group 2: Clobetasol propionate cream 0.025%

  • Group 1: Clobetasol propionate cream 0.05% (group 1)

• Refractory eczema in pt age 2 + years: Start pimecrolimus 1% cream

• Counseling

  • Educated about skin atrophy risk with topical corticosteroid use

  • Regular, liberal use of emollients recommended

Note: Group 1 is the most potent and group 7 is the least potent

Psoriasis

35 y/o M with a h/o HTN, DM, and tobacco/alcohol abuse disorder presents with pruritic skin scaling. Reports recent skin trauma in the most heavily affected areas. Family history includes psoriasis. BMI > 35 kg/m^2. Physical exam reveals sharply defined, erythematous plaques overlying course scales present on the scalp, ear, extensor surface of elbows, knees, and gluteal cleft. Plaque size ranges from 1 to 10 cm with positive Auspitz sign.

• Initial treatment

  • Start topical steroids

    • Apply two weeks and then discontinue for two weeks

    • Patient may continue two week cycle of use and discontinuation if symptoms recur

  • Scalp psoriasis

    • Apply 3% coal tar shampoo (e.g. MG 217) to wet scalp and leave in place for 5 minutes before rinsing

    • Continue daily use until symptoms resolve

• Refractory disease

  • Continued symptoms despite steroid use: Add topical calcitriol twice daily to affected areas (maximum weekly dose 200 g)

  • Consider skin biopsy versus dermatology referral

Notes

• Epidemiology

  • Obesity, tobacco, and alcohol use are risk factors for psoriasis

  • HTN and DM are often comorbid with psoriasis

  • Psoriasis is an autoimmune condition and may be more prevalent in patients with other forms of autoimmune disease

• Presentation

  • The vignette describes the most common form of psoriasis, chronic plaque psoriasis

  • Koebner phenomenon: Development of skin lesions such as psoriasis following skin trauma

  • Auspitz sign: Pinpoint bleeding when overlying scale is removed

• Treatment

  • Topical calcitriol: Vitamin D analog that can be used continuously unlike topical steroids

  • Tazarotene: Vitamin A analog also commonly used in psoriasis treatment

  • Severe disease may be treated with calcineurin inhibitors (e.g. tacrolimus) or biologic agents

• More information available through the National Psoriasis Foundation

Hidradenitis Suppurativa

Pt with h/o smoking, metabolic syndrome, poor hygiene presents with solitary inflamed nodules in intertriginous region. Previous complications have included abscesses and formation of sinus tracts. Inflamed skin nodules tender to palpation surrounded by open comedones and scarring.

• Treatment per Hurley classification

  • Hurley I (mild disease): Start topical clindamycin; intralesional steroids/oral antibiotics for flares

  • Hurley II (nodules, sinus tracts, scaring present): Start doxycycline

  • Hurley III (extensive sinus tracts)

    • Start acitretin (oral retinoids) and consider adalimumab (Humira) therapy

    • Refer to dermatology

    • Schedule for definitive treatment with wide surgical excision

• Acutely inflamed nodule/sinus tract: Perform punch debridement for small nodules, unroofing for larger tracts

• Chronic/extensive disease: Refer pt for wide excision of lesions

• Patient counseled to stop smoking and lose weight to decrease disease severity and improve treatment response

Notes

• Conditions sometimes associated with hidradenitis: Arthritis, Crohn disease, DM, metabolic syndrome, PCOS, pyoderma gangrenosum, Trisomy 21

• Surgical treatment options include punch debridement, unroofing, skin sparing excision with electrosurgical peeling, and wide excision

Cellulitis

This vignette includes possible findings for a complicated presentation.

40 y/o African American male with h/o peripheral arterial disease, ESRD requiring dialysis, DM with peripheral neuropathy, immunocompromised state, alcohol abuse presents with acute onset painful lower extremity redness and swelling. Reports recent hot tub use, athletic activity, and trauma at infection site. ROS positive for anorexia, vomiting. Fever, tachycardia, obesity, lymphedema, lymphedema, intravascular port on exam. Skin infection site reveals skin break surrounded by erythema, warmth, edema, induration, and tenderness to palpation. No bullous lesions, crepitus noted.

• Systemic s/sx symptoms of infectious spread (anorexia, vomiting, abnormal vitals) in an immunocompromised patient despite initial oral antibiotics: Admit for inpatient management

• Labs

  • Obtain CBC, CMP, CRP

  • S/sx of systemic involvement: Obtain blood cultures

  • Immunocompromised state and/or sepsis/lymphangitis on exam: Obtain wound cultures

• Adult patient: Wound ultrasound not indicated

• Antibiotic coverage

  • Uncomplicated, i.e. erythema/warmth/edema at site but no concerning risk factors or indications for hospitalization

    • Non-purulent: Cephalexin (Keflex) 500 mg 4x daily

    • Purulent infection concerning for MRSA: Doxycycline 100 mg BID

  • Hospitalized

    • Non-purulent: Ceftriaxone 1g IV qd

    • Purulent infection concerning for MRSA: Vancomycin 15 mg/kg q8h, maximum dose 2g; obtain trough before 4th dose with goal 10-15 if not septic

Cafe au Lait Spot

Pediatric pt presents with multiple hyperpigmented macules and patches. Some lesions have been present since birth while others developed in childhood. Family h/o 1st degree relative with neurofibromatosis type 1. Exam reveals axillary/groin freckling, two cutaneous neurofibromas, and multiple hyperpigmented macules/patches with discrete borders measuring 0.2 to 30 cm in diameter.

• Refer to ophthalmology to evaluate for iris hamartomas (Lisch nodules) and optic gliomas

• Refer for genetic consultation

• Pt advised that surgical or laser ablation of cafe au lait spots is only indicated for cosmetic purposes

Notes

• Cafe au lait spots can be benign or associated with neurofibromatosis

• If a patient does not meet NIH neurofibromatosis criteria, the macule is benign

• NIH criteria for neurofibromatosis requires the presence of two or more of the following:

  1. Six or more café au lait macules/patches larger than 5 mm in greatest diameter in prepubertal persons and larger than 15 mm in greatest diameter in postpubertal persons

  2. Freckling in the axillary or inguinal region

  3. Two or more neurofibromas of any type or one plexiform neurofibroma

  4. Optic glioma

  5. Two or more Lisch nodules (iris hamartomas)

  6. A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudoarthrosis

  7. A first-degree relative (i.e., parent, sibling, child) with neurofibromatosis type 1 by the above criteria

Melanoma (Cutaneous)

50 y/o white M with h/o extensive UV exposure and moles/dysplastic nevi presents with a hyperpigmented, macular skin lesion on trunk. Lesion has recently increased in shape, size, and appearance. Positive family h/o cutaneous melanoma. Flat/palpable hyperpigmented macule with asymmetric/irregular borders, color variation, and diameter > 6mm on exam.

• Dermoscopy reveals asymmetric color distribution and starburst pattern.

• Scoop shave biopsy positive for melanoma

• Refer to surgery for melanoma resection with margins per Breslow depth

• Lesion depth greater than 1.0 mm; refer for sentinel lymph node biopsy to determine stage/prognosis

Notes

• Epidemiology

  • 3 to 5% of all skin cancers

  • Responsible for 75% of skin cancer deaths

  • At-risk populations

    • Most cases occur in white males > 65 years

    • Most common cancer in women age 25-29 years

• Subtypes include superficial spreading, nodular, lentigo, amelanotic, acral-lentiginous, subungual

  • Superficial spreading

    • Most common subtype (70% of melanomas)

    • Occur between ages 30-50 years

    • Typically located on trunk in men and legs in women

  • Nodular

    • Second most common subtype (10-15%)

    • Generally occur in men on the trunk, head, or neck

• Diagnosis

  • ABCDE: Asymmetry, border irregularities, color variation, diameter, and evolution

  • Dermatoscope

    • Device used to magnify lesion under polarized light

    • Increases diagnostic accuracy by 10-27%

  • Biopsy: Scoop shave or punch biopsy can be performed

  • Breslow depth: Histopathologic depth of lesion used to determine prognosis and surgical margins

• Surgical margins

  • Per Breslow depth

    • In situ = 5 mm margins

    • 2.0 mm depth or less = 1 cm margins

    • > 2.0 mm depth = 2 cm margins

  • Narrow (1-2 cm) vs. wide surgical margins (3-5 cm) do not impact survival

Basal cell carcinoma

Pt > 50 y/o with h/o smoking, significant UV-B exposure presents with suspicious appearing papule. Reports frequent tanning bed use in adolescence. Exam reveals pearly white, dome-shaped papule with prominent telangiectatic surface vessels on nose.

• Shave biopsy performed and sent for histopathology; positive for BCC

• Treatment

  • Nodular or superficial subtype < 3 mm in depth; treat with cryotherapy

  • Tumor diameter < 2 cm and not located on H region of face; refer for standard surgical excision

  • Refer for Mohs micrographic surgery for tumors

    • Located on H region of face

    • > 2 cm in diameter

    • With invasive histologic subtype and/or high risk of recurrence

• Pt counseled about risk of recurrence and importance of monitoring for future lesions

• Schedule f/u yearly s/p tumor removal

Notes

• Epidemiology

  • BCCs comprise 80% of non-melanotic skin cancers and rarely metastasize

  • Tanning bed use is associated with 1.5-fold increase in BCC risk

• Histologic subtypes

  • Nodular (21%)

  • Superficial (17% and may resemble eczema or psoriasis)

  • Invasive subtypes

    • Micronodular (15%)

    • Infiltrative (7%)

    • Morpheaform (1%)

• Presentation

  • 85% occur on patients face with 25-30% occurring on the nose

  • Pigmented BCC may be confused with melanoma

• Diagnosis: Shave or 2-4 mm punch biopsy may be performed

• Risk of recurrence

  • Determined by lesion location, size, border definition, and status as primary or recurrent

  • Overall: 35% at 3 years and 50% at 5 years