dermatology for boards (and real life) dermatology.pdf · • vismodegib--hedgehog pathway...

Dermatology

Jenna Lester, MDAssistant Professor

Director, Skin of Color Program Department of Dermatology

UC San Francisco

Adapted from presentation by Rita Khodosh, MD, PhD

I have no financial relationships to disclose.

Question

A 32-year-old farmer comes to your office because of an upper respiratory infection. While he is there he points out a lesion on his forearm that he first noted approximately 1 year ago. It is a 1-cm asymmetric nodule with an irregular border and variations in color from black to blue. The patient says that it itches and has been enlarging for the past 2 months. He says he is so busy that he is not sure when he can return to have it taken care of.

Suspicious Pigmented Lesion

QuestionIn such cases the best approach would be to

A) perform a punch biopsy and have the patient return if the biopsy indicates pathology

B) perform a shave biopsy, with a recheck in 2 months for signs of recurrence

C) use electrocautery to destroy the lesion and the surrounding tissue

D) perform an excisional biopsy as soon as possible E) freeze the site with liquid nitrogen

Melanoma

• Destruction (cryotherapy, electrodessication, currettage) is NEVER appropriate

• Best way to biopsy a suspicious pigmented lesion is an EXCISIONAL BIOPSY (elliptical, punch, or saucerization)

• To properly stage and plan treatment of a Melanoma one needs to know it’s greatest DEPTH

Melanoma Margins

Melanoma Sentinel Lymph Node Biopsy

Sentinel Lymph Node Biopsy is offered for melanomas :

• >1mm Breslow Depth• <1mm with ulceration, increased mitotic rate

and certain adverse features

Melanoma Biopsy Real Life

Melanoma Biopsy Real Life

• Sometimes, a partial biopsy is okay.– Large lesion– For patients who might forget treatment

• Expedite appointment with provider performing biopsy (Dermatology, ENT, Plastics, General surgery, etc)

Melanoma Variants

Question

A 72-year-old white farmer presents to your office with an enlarging lesion on the dorsum of his hand. It appears to be arising from an area of actinic keratosis.

Erythematous scaly papule on dorsal hand

Question

Due to its location you suspect which one of the following? A) Basal cell carcinoma B) KeratoacanthomaC) Malignant melanoma D) Psoriatic plaque E) Squamous cell carcinoma

Cutaneous Squamous Cell Carcinoma

• Most associated with chronic sun exposure (cumulative effect)

• Scalp, face, dorsal hands, neck• Other risk factors for development of SCC:- burn- chronic ulcer or chronic inflammation- radiation- HPV (anogenital)- immunosuppression

Cutaneous Squamous Cell Carcinoma

Higher risk for recurrence and metastasis include:

• Size >2cm• Depth (>4cm)• Perineural invasion (Painful lesion)• Immunosuppression• Location on the ear, lip, anogenital

Keratoacanthoma

• A type of SCC?• Rapid growth• Nodule with keratinous core• Can involute on its

own but usually treated

• Excision is best

Question

You note a skin lesion on the nose of a 70-year-old male painter during a visit for a routine upper respiratory infection. He tells you that the lesion "sometimes bleeds a little." It is a raised, smooth, pale, pearly, shiny papule with prominent telangiectasia evident across its surface.

Shiny papule with prominent telangiectasia

Question

This lesion is most likely

A) a spider angiomaB) a basal cell carcinoma C) an atypical melanoma D) actinic keratosisE) sebaceous hyperplasia

Basal Cell Carcinoma

• Most common type of skin cancer• Sun-exposed areas (face, neck)• Fair skin, sunburn history• Rarely metastasize, some can be locally

invasive and aggressive• Diagnosed with shave or punch biopsy (punch

if you are worried about more infiltrative BCC)

BCC Treatment

• Face (especially mid face)—Mohs Micrographic surgery

• Excision• Electrodessication and Curettage (not on face or

neck, not for infiltrative BCC)• Imiquimod or 5FU (Superficial BCC)• Radiation if cannot tolerate surgery (usually

elderly patients)• Vismodegib--hedgehog pathway inhibitor

(metastatic or inoperable BCC)

Question

Which one of the following statements is consistent with current U.S. Preventive Services Task Force recommendations for skin cancer screening for the adult general population with no history of premalignant or malignant lesions?

Skin Cancer Screening

A) Whole-body examination should be conducted by a primary care provider every 3 years B) Whole-body patient self-examination should be performed every 6 months C) Benefits from screening have been established only for high-risk patients D) The evidence is currently insufficient to determine whether early detection reduces mortality and morbidity from skin cancer E) The harms of detection and early treatment outweigh the benefits

Skin Cancer Screening• The USPSTF concludes that the current evidence is

insufficient to assess the balance of benefits and harms of visual skin examination by a clinician to screen for skin cancer in adultsI screen

• patients with history of skin cancer• patients with fair skin over 50 (especially men) who

have evidence of significant sun damage or patients with other risk factors for NMSC

• patient with increased melanoma risk (have used tanning beds, outdoor occupation, significant FH of cancer)

Melanoma Risk Factors

• Dysplastic nevi• Many nevi• Personal history of melanoma (or other cancers)• Family history of melanoma• Fair skin, red hair, blue eyes • Blistering sunburns (especially prior to 21) • Tanning bed use• Outdoor summer jobs • Freckles

UV radiation causes melanoma

What about indoor tanning?

Question

A 55 year old white female presents with redness at the scar from a mastectomy performed for stage I cancer of her left breast 4 months ago. The patient has completed radiation treatments to the breast. She is afebrile and there is no axillary adenopathy. There is no wound drainage, crepitance, or bullous lesions.

Question

Which one of the following organisms would be the most likely cause of cellulitis in this patient?

A) Non group A Streptococcus B) Pneumococcus (Strep pneumoniae)C) Clostridium perfringensD) Escherichia coli E) Pasteurella multocida

Causes of Cellulitis

• Beta-hemolytic Streptococci (most often Group A)• Staph Aureus• Non-purulent cellulitis—cover for Strep and

MSSA (Cephalexin)• Purulent cellulitis—cover for MRSA (Bactrim DS,

Doxycycline, Clindamycin) and culture• Abscess—INCISION AND DRAINAGE

Unless complicated (cellulitis, immunocompromised, fever, etc)

Other Staph and Strep infections

Impetigo• S. aureus > Beta-hemolytic

Strep• Localized cases can be treated with mupriocin• More generalized with oral antibiotics

(Cephalexin or Dicloxacillin) for 7 days• Culture (if MRSA, tx with doxycycline, clinda or

trimethoprim-sulfamethoxazole)

Other Staph InfectionsAcute Paronychia

• No abscess—warm soaks and topical mupirocin

• Abscess—drainage, soaks and mupirocin• Culture• Oral anti-staph antibiotics for

7 days for more severe cases

Chronic Paronychia

- Eczematous process- Minimize irritation and damage- Treat with topical steroids first- Candidal infection is

secondary

Not to be confused with

Herpetic Whitlow

• Grouped vesicles on an erythematous base• HSV 1 or 2 infection of finger from oral

inoculation (most often in children, healthcare workers)

• Painful, can have fever and regional lymphadenopathy

• DFA or viral culture to confirm • Do not need to treat, self-limited

Herpes ZosterReactivation of latent VZV

Treatment of Herpes Zoster

• Antiviral therapy with acyclovir, valacyclovir, famciclovir

• Best when given within first 72 hours• Treat after 72 hrs if still getting new lesions,

immunosuppressed, pregnant• Treat pain!• Warn about contact with pregnant women,

unvaccinated babies, immunocompromised• Treat with antivirals AND call ophthalmology if

Herpes Zoster Ophthalmicus

Question

Imiquimod (Aldara) is approved by the FDA for treatment of which one of the following conditions? A) External anogenital wartsB) Plantar wartsC) Flat wartsD) Periungual wartsE) Molluscum contagiosum

External anogenital warts

Imiquimod

• A toll-like receptor-7 agonist• Enhances both the innate and acquired immune

response• FDA approved for treatment of external

anogenital warts • Sometimes used for other types of warts (flat

warts > verruca vulgaris), but it does not work as well

• Sometimes used for Molluscum, but cantharidinand cryotherapy work better

Question

• An otherwise healthy 37-year-old male presents to your office with a 2-week history of redness and slight irritation in his groin. On examination a tender erythematous plaque with mild scaling is seen in his right crural fold. The area fluoresces coral-red under a Wood’s light.

Question

Which one of the following would be the most appropriate treatment at this time? A) AmoxicillinB) ErythromycinC) KetoconazoleD) Nystatin (Mycostatin)E) Triamcinolone (Kenalog)

Erythrasma

Erythrasma

• Erythrasma is caused by C. minutissimum, a component of the normal skin flora

• Overgrowth in stratum corneum occurs under conditions of occlusion and moisture

• Topical erythromycin and clindamycin are first line

• Oral clarithromycin or erythromycin for extensive disease

• Topical imidazole antifungals (econazole) also work

Other Groin Rashes

Candida• Moist• beefy red• Satellite pustules• Keep area dry• Nystatin• Imidazole antifungals

Other Groin RashesTinea Cruris

• Scaly plaque• Serpiginous

scaly border- TopicalImidazoles orAllylamines(Terbinafine)- Oral Terbinafine for extensive tinea corporis

Question

A 69-year-old female sees you for an annual examination. She asks you to look at her toes, and you note a fungal infection in five toenails.She says the condition is painful and limits herability to complete her morning walks.She asks for treatment that will allow her to resume her daily walks as soon as possible. Her only other medical problem is allergic rhinitis which is well controlled.

Onychomycosis

Question

Which one of the following would be the most appropriate treatment for this patient? A) Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeksB) Oral terbinafine (Lamisil) daily for 12 weeksC) Topical terbinafine (Lamisil AT) daily for 12 weeksD) Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeksE) Toe nail removal

Onychomycosis• Dermatophyte infection most common—tinea

unguium• Candida and non-dermatophyte mold

(Fusarium, Aspergillus, others)• Diagnosis: PAS—most sensitive, Culture--only

about 50% sensitivity• Treatment not necessary if asymptomatic• Treat if recurrent cellulitis (diabetics), pain,

immunosuppression, patient preference

Onychomycosis Treatment

• Not that effective• Treat for presumed dermatophyte infection

while waiting for culture results• Oral Terbinafine 250mg daily for 12 weeks• Cure rate about 70%, but only 35% at 5 years• Itraconazole, same cure rate, more side effects• Topicals: Efinaconazole, Tavaborole, Ciclopirox

(cure rates 25%, 18%, 7% respectively)

Erythema Migrans7-14 days after tick bite

Lyme Disease- Caused by Borrelia spirochete transmitted by

bite of Ixodes deer tick- In early Lyme disease serologic testing is likely

to be negative- Diagnosis should be made based on the

clinical picture (EM lesion or lesions, non-specific viral symptoms, and history of living in or travel to an endemic area)Treatment:

- Doxycycline 100mg BID for 10-21 days or- Amoxicillin 500mg po BID for 14-21 days

Secondary Syphilis

Screen with non-treponemal test (RPR, VDRL), confirm with Treponemal test (FTA-ABS)Treat with Penicillin G

Scabies

Scabies

• Erythematous papules, pustules, burrows• Likes hands, skin folds, groin, less on head• Very itchy• SCRAPE IT• Treat all family members• Permethrin cream x 2• Ivermectin PO if crusted

Question

Which one of the following would be considered first-line therapy for mild to moderately severe psoriasis confined to the elbows and knees? A) Phototherapy using ultraviolet B light B) MethotrexateC) Etretinate (Tegison) D) Betamethasone dipropionate (Diprolene)

Psoriasis

Well-defined, erythematous plaques with silvery scale

Psoriasis Treatment

• LOCALIZED DISEASE—TOPICAL TREATMENT• Topical steroids (Clobetasol)• Topical retinoids (Tazorac)• Topical Vitamin D derivatives (Calcipotriene)• Tar• Combinations of topical treatments are more

effective• Intralesional Steroids• NB UVB (more generalized disease)

Psoriasis

Psoriasis Treatment

• Generalized disease, arthritis—systemic treatment

• Methotrexate• Acitretin, Cyclosporine (less often)• Apremilast—Otezla (oral PDE4 inhibitor)• Biologics:

- TNF alpha inhibitors (Adalimumab-Humira)- IL 12/23 inhibitor (Ustekinumab-Stelara)- IL 17 inhibitors (Secukinumab-Cosentyx)

PsoriasisReal Life

• Psoriasis patients have systemic inflammation• Co-morbidities: obesity, diabetes, cardiovascular

disease• More severe psoriasis--higher risk of co-

morbidities• Counsel patients about diet, exercise, treat co-

morbidities• TNF alpha inhibitors may be more effective at

reducing cardiovascular risk than Methotrexate

QuestionWhile vacationing, a 27-year-old white male was exposed to poison ivy. Between 48 and 72 hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms and neck. He was given oral methylprednisolone (Medrol Dosepak), starting with 24 mg/day and tapered by 4 mg/day over 6 days. His condition began to improve, but on day6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and vesiculation, involving extensive areas of his arms, neck, and face.

Allergic Contact DermatitisPoison Oak

Question

The most appropriate management at this time would be to A) prescribe a superpotent topical corticosteroid B) repeat the oral methylprednisolone treatment C) begin diphenhydramine (Benadryl), 4 times a day D) begin high-dose oral prednisone and taper over 2 weeks E) discontinue all medications and recommend cool compresses

Allergic Contact Dermatitis to Urushiolin Poison Oak (Ivy or Sumac)

• Type IV hypersensitivity reaction• Localized eruptions can be treated with potent

or superpotent topical steroids (clobetasol)• Oral prednisone is given for more extensive

eruptions• Needs to be started at a high dose (60mg) and

tapered slowly over 2-3 weeks• If tapered too quickly, patient will flare• Antibiotics if secondarily infected (Staph)

Eczema/Atopic dermatitis

Eczema/Atopic dermatitis

• Itchy erythematous scaly papules and plaques• Patients with atopy (allergic rhinitis, asthma,

FH)• Problem with epidermal barrier and immune

dysregulation• Treatment MUST address both!

Eczema Treatment

• Emollients, gentle skin care, avoidance of irritants and topical allergens

• Topical steroids 1st line• Topical calcineurin inhibitors• Do not use antibiotics unless impetiginized• Treat pruritus (sedating antihistamines)• Phototherapy• Immunosuppressive agents for severe cases• No evidence that dietary restriction is useful

Question

Patients presenting with erythema multiformeoften have a prodromal history of A) egg allergyB) recent immunizationC) herpes simplex infection D) thennal traumaE) streptococcal infection

Erythema Multiforme

Erythema Multiforme

• Target lesions (three zones: dark dusky center, pale ring of edema, erythematous halo)

• Can be atypical, with just 2 or 1 zone• Hypersensitivity reaction to• Infections (most commonly HSV, Mycoplasma

pneumoniae, many others)• Drugs are a less common cause (NSAIDs,

Antibiotics, Anticonvulsants, others)• If recurrent, treat with suppressive HSV therapy

Erythema Multiforme due to Mycoplasma pneumoniae infection

Check mycoplasma serologies (IgM, IgG)Treat infection with azythromycin or doxycycline

Stevens Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)

Stevens Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)

• Severe mucocutaneous reaction usually caused by a medication

• Starts with fever, flu-like symptoms, skin and mucosal pain

• Mortality up to 30%, higher in adults• Allopurinol• Aromatic anticonvulsants (phenobarbital)• Antibacterial sulfonamides (Bactrim)• Lamotrigine• STOP the MEDICATION and call a derm and a burn

center

QuestionA 20-year-old female college tennis player presents with painful anterior lower leg lesions. You note several 2- to 3- cm deep, tender, warm lesions over both shins. The patient denies specific trauma or increased exercise.The most significant etiology to be considered in this case is A) papular urticariaB) early rheumatoid arthritisC) shin splintsD) superficial thrombophlebitisE) oral contraceptive use

Erythema Nodosum

Erythema Nodosum

• Panniculitis• Delayed-type hypersensitivity reaction to:

– Infection (Streptococcal most common)– Drugs (OCPs, antibiotics)– IBD– Pregnancy

Erythema Nodosum Treatment

• Self-resolving, but takes several weeks• Treat underlying condition• Supportive treatment• Leg elevation• Rest• NSAIDs• If severe, can consider short course of low-

dose prednisone (20mg 7-10 days)

Acne

Acne• Assess severity• Mild to moderate—topical therapy (retinoids,

Benzoyl Peroxide, clindamycin)• Moderate—course of antibiotics (Doxy, Keflex,

Bactrim), limit to 3 months. Hormonal treatments for women (OCP, spironolactone)

• Severe (nodulocustic/scarring)—Isotretinoin(teratogen, otherwise quite safe)

UrticariaPruritic lesions last < 24hours

Urticaria

• Acute urticaria < 6 weeks• Chronic urticaria > 6 week• Triggers

- Foods—acute- Medications and Infections- Over 50% of chronic urticaria is idiopathic

• Treat with anti-histamines (non-sedating up to 4 times the daily dose)

• Do not use prednisone, especially for chronic

QuestionA 30-year-old white male presents with a polymorphous skin rash consisting of grouped vesicles, urticarial wheals, and papular lesions distributed symmetrically over the elbows, knees, and buttocks. A skin biopsy shows IgA deposition and a diagnosis of dermatitis herpetiformis is made.The mainstay of therapy is A) dapsoneB) prednisoneC) cephalosporinsD) methotrexateE) tetracycline

Dermatitis Herpetiformis

Dermatitis Herpetiformis

• Associated with gluten sensitivity—celiac disease

• ELISA for IgA tissue transglutaminaseantibodies and IgA epidermal transglutaminase antibodiesTreatment

• Strict gluten-free diet works slowly• Dapsone works quickly, can later be

discontinued

Question

A 25-year-old female has an annular rash on the dorsal surface of both hands. The rash does not respond to initial treatment with an antifungal medication, and a biopsy reveals granuloma annulare.Which one of the following would be the most appropriate advice for this patient?

A) Allow the rash to resolve without further treatment B) Cover the rash because it is contagiousC) Treat the rash with systemic corticosteroidsD) Treat the rash with a stronger antifungal medication

Granuloma Annulare

Granuloma Annulare

• Non-scaly erythematous annular papules and plaques on dorsal hands, elbows, feet, knees

• A benign, reactive condition, can self resolve• Treatments included superpotent topical

steroids, intralesional steroids, phototherapy• Systemic treatment, such as plaquenil or

dapsone, is offered for disseminated, symptomatic GA that does not respond to phototherapy

Question

A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterized by flat- topped violaceouspapules 3–4 mm in size. The lesions are located primarily on the volar wrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appeared she went to the emergency department and was treated for “possible scabies,” but the treatment has made little or no difference.

Question

Which one of the following treatments is indicated at this time? A) Clobetasol (Cormax, Temovate) 0.05% ointment B) Permethrin 5% cream C) Tacrolimus (Protopic) 0.1% ointment D) Triamcinolone 0.1% cream

Lichen Planus

• 5 P’s: pruritic, purple, planar (flat-topped), polygonal papules

• Wickham striae• wrists/ankles classic• Oral/genital involvement• Can be erosive• Etiology unknown• ?Associated with Hep C?

Lichen Planus

• Benign condition, erosive disease (oral/genital) requires more aggressive treatment

• Potent or superpotent topicals steroids (fluocinonide, clobetasol) are first line tx

• Topical calcineurin inhibitors can be used (tacrolimus)

• Other tx: phototherapy, oral prednisone course, oral retinoids (acitretin), MTX, plaquenil

AlopeciaScarring vs Non-Scarring

Non-scarringAlopecia Areata Scarring

Discoid lupus

Alopecia

Non-scarring- Androgenetic

(pattern)- Alopecia areata- Syphilis- Trichotillomania

Scarring- Discoid lupus- Lichen planopilaris- Folliculitis decalvans- Sarcoidosis- Traction-late

Question

A 5-year-old African-American child has been experiencing scalp pruritus for several months, along with hair loss in a “moth-eaten” pattern. Small block dots can be seen within the larger alopecic patches. A potassium hydroxide (KOH) prep shows occasional branching hyphae and multiple spores.

Tinea Capitis

Tinea Capitis

• Moth-eaten pattern alopecia in a child• Erythema• Scale• Black Dots (hairs broken off at skin surface)• Boggy induration (Kerion)

Question

Which one of the following is the preferred treatment?

A) Topical ketoconazole (Nizoral) B) Topical minoxidil (Rogaine) C) Oral griseofulvin (Fulvicin) D) Oral hydroxyzine (Atarax) E) Psoralen-ultraviolet A (PUVA) therapy

Tinea CapitisDiagnosis

• KOH preparation (scrape area of scale) hyphae and spores

• Culture (scrape area of scale and pluck hairs with roots)

• Culture will differentiate between MicrosporumSpecies and Trichophyton species (M. Canis and T. Tonsurans)

Tinea CapitisTreatment

• Long Course (4-6 weeks or more)• Griseofulvin 20-25 mg/kg divided bid x 6-12

weeks (give with ice cream of other fatty food)• Works best against Microsporum Species• Lamisil (Terbinafine) 5mg/kg/d x 4 wks• Works best against Trichophyton Species• Itraconazole has a worse side effect profile, do

not use first line for skin/nail infections

Kerion

Kerion

• Inflammatory reaction to tinea infection• Can lead to scarring• Not a bacterial infection—does not require

antiobiotics• We often add low-dose prednisone to treat

inflammation and to minimize scarring

Question• A 62-year-old female presents with painful lesions at

both corners of her mouth characterized by redness, scaling, and deep cracks. The cracks sometimes bleed when she opens her mouth. She has treated them with bacitracin/neomycin/polymyxin B ointment (Neosporin) but says it has not helped.

• Which one of the following would be most appropriate at this point?

• A) A biopsy of the lesions • B) An anticandidal medication • C) Bacitracin• D) Vitamin B12

Angular Cheilitis

Angular Cheilitis

• More common in elderly people• Ill-fitting dentures• Dry mouth• Poor oral hygiene• Complicated by candidal or staph infection• Barrier creams (zinc or vaseline)• Treat infection• Minimize exacerbating factors• Can check for B12 or iron deficiency