DEB BYNUM, MDMAY 2010

Beauty is only skin deep….

Questions:

1. What is the diagnosis?

2. What are the four types demonstrated in the pictures?

3. What are the treatment options?

Answers:

1. Rosacea2. Types

Erythematotelangiectatic Papulopustular Phymatous: rhinophyma ocular

3. Management: Topical metronidazole Oral antibiotics (tetracycline) Laser/surgery

Question:

A 76 year old woman comes to the office because she has multiple rough skin lesions on her forehead, temples, cheeks and forearms. Nasolabial folds are spared. The lesions bleed easily when she picks them off, and then recur. The lesions are scaly, <1 cm in diameter, and feel like sandpaper to the touch.

Which of the following is the most appropriate treatment? A. Moisturizing cream B. metronidazole gel C. Imiquimod 5% cream D. Ketoconazole 2% cream E. Sunscreen and observation

Questions:

1. What is the diagnosis?

2. A 76 year old woman comes to the office because she has multiple rough skin lesions on her forehead, temples, cheeks and forearms. Nasolabial folds are spared. The lesions bleed easily when she picks them off, and then recur. The lesions are scaly, <1 cm in diameter, and feel like sandpaper to the touch.

What is the appropriate therapy?

Actinic Keratosis

Lesions are single or multipleDry, rough, adherent and scalySun exposed skinSparing of nasolabial folds and nonexposed

areasSandpaper likeCream and sunscreen helpful

Actinic Keratosis: Precancer

Precancer!Treat!

Ablative (cryosurgery) Photodynamic therapy Topical therapies if multiple lesions

Flourouracil Imiquimod 5% cream Diclofenac 5% gel

Question:

A 70 year old chinese American man comes to the office because he has a widespread maculopapular eruption with formation of flaccid bullae and erosions. For 2 days before the rash, he had fever, odynophagia, and eye pain. Over the next few days, the rash evolved to extensive sloughing and peeling of the skin. History includes HTN, DM, and peripheral neuropathy. Two weeks ago, he began carbamazepine. Other medications include glipizide, felodipine, simvastatin, and aspirin.

Question…

On exam, the sloughing and peeling involve 40% of the body surface. His oral mucosa has erosions and exudates. He also has bilateral conjunctivitis.

Which of the following is the most likely diagnosis? A. Bullous pemphigoid B. Staphylococcal scalded skin syndrome C. Disseminated herpes zoster D. Toxic epidermal necrolysis

Answer:

D: TEN Stevens Johnson Syndrome and TEN are variants of

same process (SJS <10% body surface, TEN >30%, overlap if between)

30% mortality Reactions to medications HLA-B 1502 Allele: Asian and South Asian ancestry

FDA alert: screen this population before starting carbamazepine

Question:

What is the most common autoimmune subepidermal blistering disease, most often found in older adults?

Hints: Pruritic Tense blisters Blisters resolve without scarring Often self limited

Diagnosis?

Answer:

Bullous Pemphigoid Antibodies directed against basement membrane zone of

the epidermis, causing separation between epidermis and dermis

Differentiate from Pemphigus Vulgaris PV in younger patients PV more severe Nikolsky sign: Exfoliation of the skin with slight rubbing

Present with PV and with TEN Absent with bullous pemphigoid PV more often involves mucus membranes PV blisters flaccid, BP blisters tense Autoimmune, medications, paraneoplastic

What is the diagnosis?

What is the diagnosis? Some Hints:

inflammation of the eyelids causing red, irritated, itchy eyelids

formation of dandruff-like scales on eyelashes

It is a common eye disorder causes:

bacterial (staph) dandruff of the scalp or seborrhea acne rosacea

Blepharitis:

Treatment: Warm compresses Baby shampoo, dandruff shampoo Avoiding makeup Oral antibiotics (tetracycline)

New case…

What is the diagnosis?

Answer:

Melanoma

Acral lentiginous subtype:

Uncommon, but more often seen in patients over age 65

Can be seen in all skin types

What is the diagnosis?

Hints:

Very commonWaxy plaques or papulesStuck on appearanceFound everywhere except mucus membranes,

palms and solesMay be darkly pigmented

Answer:

Seborrheic Keratosis

Question:

Eruptive seborrheic keratoses, often across back in christmas tree pattern, associated with underlying malignancies (GI, prostate, etc) is known as…..

Answer:

Sign of Leser-Trelat

Itchy, Itchy, Itchy….

Typical distribution…

Severe form can be “crusted”, aka “norwegian”

Answer:

Scabies… More common in elderly and immunosupressed May not have rash, may present with severe pruritis Look in between toes and fingers burrows