dermatology in family medicine 1
DESCRIPTION
Dermatology in Family Medicine 1. Clerkship Briefing Dr. Clayton Dyck. Dermatology in Family Medicine 1 (Or, How To Suck Less in Derm). Clerkship Briefing Dr. Clayton Dyck. Objectives. Use appropriate terminology to describe common skin presentations seen in family medicine - PowerPoint PPT PresentationTRANSCRIPT
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Dermatology in Family Medicine 1
Clerkship Briefing
Dr. Clayton Dyck
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Dermatology in Family Medicine 1(Or, How To Suck Less in Derm)
Clerkship Briefing
Dr. Clayton Dyck
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Objectives
1. Use appropriate terminology to describe common skin presentations seen in family medicine
2. Apply a systematic approach to their diagnosis
3. Know the modalities used in their treatment
4. Understand basic principles of topical therapy
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A call from Victoria Beach…
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Dermatologic Diagnosis
Approach is same as for any other medical condition: History Examination Formulate differential diagnosis Apply investigations to confirm/rule out
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Dermatologic Diagnosis
Use whatever algorithm you like: TTIINNMAP VITTAMIN DD CITTIN VD
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Tools Used in Dermatologic Assessment Our ears Our eyes Our hands Our noses (thankfully infrequently!) Lab tests
Biopsies Scrapings/clippings Blood and urine samples
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Questions to ask Onset Pattern Skin symptoms Systemic symptoms Related factors
Environmental Occupational Other medical conditions Drugs Others affected? To name a few…
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An overview of terms…
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macule
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papule
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plaque
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nodule
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pustule
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vesicle
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bulla
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ulcer
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wheal
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purpura
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excoriation
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papulosquamous
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Some Common Conditions
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Herpes Zoster VZV reactivation Pain may precede rash Usually dermatomal Crusts usually fall off in 2-3 weeks Worse in immunocomprimised, elderly
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Herpes Zoster - Treatment Wet dressings Antivirals
May reduce post herpetic neuralgia Within 48-72 hours of vesicle appearance Eg famcyclovir 500 mg tid x 7 days
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Ophthalmic Zoster - Treatment Hutchinson’s sign Refer to ophthalmologist urgently 50% complications if antivirals not given
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Tinea infections Dermatophytes, candida Topical antifungals Keep dry! If resistant/severe consider
Scraping DM, immunocomprimised PO antifungals
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Onychomycosis Trichophyton sp., Candida Do KOH prep, culture first Topical treatment only in simple cases Usually needs oral treatment
Eg Lamisil 250 mg od x 12 weeks Watch for toxicity
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Dyshydrotic Eczema Common if hands frequently moist/wet Consider other irritants, allergens, fungi Watch for superinfection Treatment:
Moisturize x 3 Topical steroids (usually moderate to high
potency) Topical immune modulators
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Psoriasis Peaks in 20s and 50s Multifactorial Exacerbated by trauma, infections,
drugs, winter 5-8% have psoriatic arthritis
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Psoriasis - Treatment Topical tar (ick!) High - ultrahigh potency steroids Vitamin D analogues Phototherapy Immunosuppressive agents
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Topical Therapy Choice of vehicle important:
Powder Paste Solutions (water or alcohol based) Gels Lotions Creams Ointments
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Topical Therapy Usually only a thin layer needed 1 gram = 10 cm x 10 cm area OD to BID usually sufficient
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Topical Steroids Consider thickness of skin, thickness of
lesion, moistness of area Choose one drug of each potency Consider occlusion with lower potency
steroids Avoid extended periods of treatment
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Topical Steroids - Examples (by potency)Low Hydrocortisone 1 %
Medium Betamethasone 0.1%
High Mometasone
Ultrahigh Augmented betamethasone
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Topical Steroids - Adverse Fx Irritation Hypopigmentation Skin breakdown Rebound phenomenon Atrophy Striae Systemic adsorbsion And many more!
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Nevus
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Superficial spreading melanoma
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Basal cell carcinoma
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Cherry hemangioma
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Actinic keratosis
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When to biopsy Change in:
Colour Size (<6 mm) Shape Especially if weeks to months, rather than months
to years Bleeding Any doubt
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Impetigo S. aureus, S. pyogenes, or both Common in schools, daycares Treatment
Bactroban tid x 10 days Cloxacillin 250 qid x 5-10 days Keflex 250 qid x 5-10 days Resistance common, may need swab
Consider Bactroban in nares bid x 5 days
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Fifth’s Disease Parvovirus B19 Peaks in school age children Mild flu-like symptoms Arthritis in 10% Teratogenic, especially before 20
weeks
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Erysipelas Group A Streptococci Sudden onset, can be painful Fever, sick Penicillin V po/iv for 2 weeks Macrolide if penicillin allergic
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Hand Foot and Mouth Disease Coxsackie A16 virus Mild flu Sx, fever Usually children < 5 years Self limited, resolve within 10 days
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Scabies Itchy - worse at night Usually more than one family member A great mimic - consider if:
Impetigo Eczema Idonomata
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Scabies - Treatment Treat family concurrently Wash all clothes/bedding/towels Permethrin cream
Everywhere but hair, mouth, eyes Rinse after 12 hours
Infants - precipitated sulfur Consider 2nd treatment Itchiness persists days to weeks later
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Some short snappers
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Pityriasis rosea
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paronychia
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Molluscum contagiosum
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rosacea
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Stasis dermatitis
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wart
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Subungual hematoma
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Take home “berries” Know your terminology When in doubt - back to first principles Always keep a differential diagnosis Use the right topical for the job Don’t be afraid to overbiopsy
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Objectives
1. Describe common skin presentations seen in family medicine
2. Apply a systematic approach to their diagnosis
3. Know the modalities used in their treatment
4. Understand basic principles of topical therapy
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ReferencesSkin Diseases: Diagnosis and Treatment, T P
Habif et al, Elsevier 2005Color Atlas and Synopsis of Clinical
Dermatology, T B Fitzpatrick, McGraw-Hill, 1997
Images.MD (NJM Library Database)http://missinglink.ucsf.edu/lm/DermotologyGlossary
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Questions? Or itching to leave?