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DERMATOLOGY FOR ADULT PRIMARY CARE  (KP)       * Derm Cortisone Drugs  |  Topical_steroids2009.pdf    

http://www.modernmedicine.com/dermcounselor  

What To Look For: The ABCD's of Moles and Melanoma   

REF:   Dr. Arndt's  Dermatology in Primary Care 2002  Kenneth Arndt, MD  
Acne Actinic Keratoses Alopecia (Hair Loss) Atopic Dermatitis
Bacterial Infections / Cellulitis Aphthous Ulcer Contact Dermatitis Dry Skin (Xerosis)
Dyshidrosis Fungus/Tinea Infections Herpes Simplex Herpes Zoster -Shingles  | Shingles (Herpes Zoster) 
Hidradenitis Intertrignous Rashes
Itching all over - no rash Lichen Simplex Chronicus Lice (Pediculosis)   Melasma
Molluscum Contagiosum Nummular Eczema Onychomycosis Peri-oral Dermatitis
Pityriasis Rosea Psoriasis Rosacea Scabies
Seborrheic Dermatitis Seborrheic Keratosis   Skin Cancers Stasis Dermatitis
Tinea Pedis / Versicolor Urticaria \  pruritus   Vitiligo Warts
APPENDIX A (Benign Skin Conditions) Skin Tags   Benign lump & bump Skin Cancers
purpura   fever-rash  Poison Ivy, Oak Dermatitis Skin Ulcer/ Wound  
vitiligo scar gel Rx    urticaria/angioedema

 Scaling & Proliferative Skin Disorders:

Acne & Related Skin Syndromes

Infestation:  Lice (Pediculosis)   &   Scabies

Precancerous Growths & Skin Cancer:  

Primary Lesions

Secondary Lesions

Special Lesions and Descriptive Terms

When referring:

Please specify duration, location, morphology, any treatments already tried, and the patient's current medications. Please instruct the patient to bring all oral and topical prescriptions and OTC medications they are currently using.

Dermatologic Conditions Commonly Seen in Adult Primary Care

ACNE              

See also

Clogged pores and a reaction to the bacterium Propionibacterium (P. acnes) cause acne. It is characterized by comedones, blackheads, whiteheads, papules, pustules , nodules, cysts, & scars on the face and/or trunk. Almost all teenagers and many younger adult women have acne. In young adult women, the lesions often occur about the mouth and along the jaw-line and chin.

Classification of Acne - Its Severity & Types  (ACP PIER)
Drug Treatment for Acne - http://pier.acponline.org/physicians/diseases/d613/tables/d613-tdtx.html

Therapy of Acne

For mild acne, select an appropriate topical regimen.
Specific recommendation:

Before selecting topical therapy, consider the patient's skin type:

For dry and sensitive skin types, avoid:

When mild acne is mainly noninflammatory (comedonal),

For patients with known retinoid intolerance,

When mild acne is mainly inflammatory (papulopustular), add a topical antibacterial agent to a comedolytic agent:

Agents effective for Comedones: Retinoids, azetaic acid, salicyclic acid

Agents effective for inflammatory lesions: benzoyl peroxide, tretinoin, azetaic acid, topical erythromycin & clindamycin, Na sulfacetamine

Recommendations Regarding Oral Antibiotic Use in Acne:

Treatment

  1. Wash face twice a day with mild cleanser.

  2. Use only non-comedogenic products on the face. Use moisturizer with sunblock.

  3. Antimicrobials kill the bacteria. Common antimicrobials include benzoyl peroxide and topical antibiotics.

  4. Retinoids help to open the pores. Retinoids include Tretinoin (Avita® 0.025% or Retin A® Cream) and Adapalene (Differin® Gel).

Mild acne: (Primarily blackheads):

Moderate Acne: (Papules, pustules, or unresponsive to the above treatment)

Severe Acne: (Numerous cysts, scarring, or unresponsive to the above treatment)
If scarring is occurring, therapy must be aggressive.

Acne Keloidalis    
Rx: (Dr. S.Y.)

ACNE ROSACEA (SEE ROSACEA)

ACTINIC KERATOSES                

Actinic keratoses are sun-induced precancerous lesions. They present as persistent, scaly, red lesions and are often better felt than seen. Patients often say the spots hurt or sting.

Look and feel for actinic keratoses in the chronically sun exposed areas, e.g. nose, forehead, temples, sides of cheeks, ears, back of the hands, arms, etc.

Treatment

Refer patients presenting with greater than 15 lesions, with lesions on mucous membranes, and/or lesions failing to respond to recommended liquid nitrogen therapy.

Apply liquid nitrogen once to an actinic keratosis. Lesion should be sprayed until it turns white with a 1 mm margin. The treated lesion should stay white (frozen) for only 10-15 seconds. Longer freezing may result in ulceration. Discuss risk of blister and white discoloration that result from cryotherapy. Advise patients that they may need to be examined and treated annually for actinic keratoses.

Recommend DAILY MORNING SUNSCREEN (at least SPF 15 or SPF 30 or higher).

ALOPECIA AREATA (See Hair Loss.)

ATOPIC DERMATITIS           

Frequently flexural. Asthma and allergic rhinitis are often associated. Thickening of the skin (lichenification) indicates chronic scratching. Crusting may indicate Herpes or Staph infection.

Treatment

Advise patient to shower or bathe once daily for 5 minutes in cool to warm (not hot) water. Use mild, non-perfumed, non-dyed cleansers (e.g. Dove® unscented, Cetaphil®, Aquanil®, Purpose®, Aveeno®, Basis®). Apply a moisturizer (Cetaphil®, Eucerin®, Aquaphor®, SBR-Lipocream® or Vaseline®). No lotions please as they are more drying!

Apply topical steroids immediately after the bath/shower while still "sticky". May use Triamcinolone acetonide (Kenalog®) 0.025% or 0.1% ointment for teenagers and young adults. Avoid higher potency topical steroids on the face and body folds. Use Class VI or Class VII steroids in these areas. (See Table 1.)

Consider oral antihistamines Diphenhydramine or Hydroxyzine (Benadryl® or Atarax®) if scratching is a large component of the disease. They make the patient drowsy and less likely to scratch.

Have the patient use the topical steroid as needed, for flares and for stubborn areas. Cephalexin (Keflex®) or Dicloxacillin (Dynapen®) 500 mg QID for 10 days may be helpful if secondarily infected or treatment-resistant. Control but not cure is expected. Make sure it is eczema and not tinea as topical steroids may cause fungus to flourish.

Instruct patients that humidifiers are helpful in dry environments. Avoiding dust, wool, and animal dander may be helpful. Rarely does food play a role in atopic dermatitis. If food allergies are suspected, refer patient to allergy.

See dry skin treatment guidelines which may be helpful in treating atopic dermatitis.

BACTERIAL INFECTIONS (Impetigo, Folliculitis, Cellulitis)              

See Cellulitis, etc. - Johns Hopkins Advanced Studies in Medicine Feb 2006

Common bacterial infections affecting the skin include impetigo, folliculitis, and cellulitis.

Impetigo    
Impetigo is a common, contagious, superficial skin infection that is produced by streptococci, staphylococcus, or a combination of both bacteria. It can be vesicular/bullous or non-vesicular/non-bullous. It is characterized by honey-colored crust.

Treatment

Folliculitis        Images of Folliculitis    Images of Furuncle
Staphylococcal folliculitis is the most common form of infectious folliculitis. Folliculitis usually appears as multiple pustules with surrounding erythema.

Treatment

Cellulitis  
An infection of the dermis and subcutaneous tissue usually caused by Group A Streptococci and Staph aureus in adults. Typically occurs near surgical wounds or a cutaneous ulcer but may develop in apparently normal skin. Recurrent episodes occur with local anatomic abnormalities. Erythema, warmth, edema and pain are all distinctive clinical features.

Treatment

         

BENIGN SKIN CONDITIONS (Cosmetic- See Appendix A.)

CELLULITIS (See Bacterial Infections.)

CONTACT DERMATITIS                 

Lesions are microvesicular or eczematous.
Look for linear or bizarre shaped lesions.

Treatment

Advise patient to wash all objects that have come in contact with the allergen. Avoid topical benadryl and "caine" related products. Twice daily warm soaks may be applied to crusted, oozing areas.

For widespread involvement:
Use Prednisone. Recommended treatment includes a systemic prednisone burst of 0.75 mg/kg/day for 5-7 days followed by a tapering course of prednisone over the next 10-14 days. Avoid Medrol® dose pack alone as it uses inadequate dosing. It may, however, be used in conjunction with IM Kenalog®. Use a topical steroid cream or ointment as well, e.g. Betamethasone Valerate (Valisone®) 0.1% BID until clear.

For limited involvement:
Use Betamethasone Diproprionate (Diprolene®) 0.05% ointment or Clobetasol (Temovate®) ointment BID for 2-3 weeks.

For allergic contact dermatitis of the face:
Use either prednisone as outlined above or Betamethasone Valerate (Valisone®) 0.1% cream BID for 7 days, then Desonide (Desowen®) 0.05% cream or another less potent steroid until rash is clear.

Benadryl® or Atarax® may be helpful for nighttime itching.

DRY SKIN (XEROSIS)            

Dry skin itches! Treat the dry skin and the itch will go away. If there is redness, xerotic eczema may have set in.

Treatment

For dry skin:
Use Eucerin® or Cetaphil ® cream, Aquaphor®, Vaseline® or SBR-Lipocream® applied to affected skin immediately after the bath/shower. Ointments are better than creams. Lotions are less effective.

For more scaly skin:
Consider the use of OTC medicated products (e.g. Amlactin Lotion®, Eucerin Plus™, Lubriderm®, Carmol® 10%).

For xerotic eczema:
Treat dry skin as above and add a topical steroid e.g. Triamcinolone acetonide (Kenalog®) 0.1% ointment.

DYSHIDROSIS (See Hand and Foot Eczema.)           

FOLLICULITIS (See Bacterial Infections.)

FUNGUS (See Tinea Infections.)

HAIR LOSS (Alopecia)                  See also Alopecia (Hair Loss)  

REF:  Cleveland Clinic J of Med  August 2003  Alopecia  

If you suspect an underlying disease, order the following labs: TSH, CBC, and Ferritin (should be above 40). If there are signs of virilization (irregular menses, hirsuitism, change in body habitus, deepening voice and/or severe acne), consider ordering: Total Testosterone and DHEAS.

If all normal or negative, diagnosis is androgenetic alopecia

Androgenetic Alopecia

Hair loss in men and women is usually androgenetic alopecia. Treatment is not a covered benefit. Be very sensitive as both men and women are often very psychologically bothered by hair loss.

Look for the pattern of hair loss. Hair loss on the top of the scalp is usually androgenetic. Another useful clue can be to identify whether hair is falling out from the roots or breaking off. A family history of hair loss is NOT that reliable. Hair breakage is often caused by treatments to the hair. Can suggest that patient try Rogaine 2-3% (OTC) or 5% (Rx) topically BID. Women can only use 2% Rogaine.

Telogen Effluvium

New onset of diffuse hair loss called telogen effluvium can be caused by acute stress to the body. This occurs about 100 days after a stress such as pregnancy, severe illness or surgery, drugs (e.g., Beta-blockers, warfarin, Depo-Provera®) and abnormal diets (crash diets, excess Vitamin A). Make sure scalp is normal and that hair is falling out from root, not breaking.

Alopecia Areata

Appears as smooth, round areas of hair loss. Is commonly caused by stress and may be associated with thyroid disease.

Treatment

For alopecia areata: Consider initiating twice daily topical steroid therapy, e.g. Betamethasone Diproprionate (Diprolene® augmented gel) 0.05% and refer to Dermatology.

HAND AND FOOT ECZEMA (DYSHIDROSIS)             

Very common. Typical clinical features include red, scaly fissuring, small vesicles. Other things to consider in the differential diagnosis include irritant contact dermatitis and scabies, especially if there is web-space involvement with blisters and burrows. If the nails are dystrophic, consider tinea (two-foot, one-hand disease).

Treatment

Identify and advise the patient to avoid triggers. Otherwise, advise the use of gloves any time hands are in water, e.g. washing dishes and cleaning. Apply a heavy cream (e.g. Eucerin® cream or Neutrogena® hand cream) to hands multiple times per day, especially after hands have been wet and Betamethasone Diproprionate (Diprosone®) 0.05% ointment BID for redness. For painful fissures, antibiotic ointment (e.g. Bacitracin® or Poysporin®) ointment covered by bandage. Avoid Neosporin®) as neomycin is a common sensitizer! If these treatments fail, add Cephalexin (Keflex®) 250 mg QID for 10 days. If no improvement despite these measures, refer to Dermatology.

HERPES SIMPLEX                 

Herpes simplex is a virus that can infect any part of the skin, lips, or genitalia. The most common location for a flare of herpes is the border of the lip ("Cold Sore", "Fever Blister"). Colds, fever, and sun exposure are frequent triggers. Initially the patient may feel tingling, burning, or pain in the affected area. Within a day or so, the skin becomes swollen and red. Individual vesicles may be seen. Crusting follows after several days.

Herpes simplex may also occur on the finger (Herpetic Whitlow). This is a common presentation in people who often have their hands in patient's mouths, e.g. dentists or their assistants.

Herpes genitalis classically appears as grouped vesicles on an erythematous base; however, this is not frequently seen. Instead, localized pain, erosions, or erythema may be all that is seen.

Herpes simplex often develops on the buttocks of women. Why this occurs is unknown.

Treatment

HERPES ZOSTER (SHINGLES) in a normal host                 

See also Shingles (Herpes Zoster)    |  Postherpetic-Neuralgia  

Herpes Zoster presents as groupings of vesicles on an erythematous base. There may be multiple groupings in one dermatome. Pain may be significant and frequently precedes the onset of the rash.

Treatment

Hidradenitis                  

Hidradenitis Suppurativa is a chronic disease of the regions of apocrine gland activity. It begins as firm, tender, red nodules and develops into large sinuses under the surface of the skin. These sinuses drain pus and whereas some of the first lesions heal quickly, new nodules continue to form. Mostly seen on the groin, axillae, buttocks and the breasts, it is most common in young women.  Many cases, especially of the thighs and vulva, are mild and misdiagnosed as recurrent furunculosis. The disease is worse in the obese.   Click on Image to zoom.

A hallmark of hidradenitis is the double comedone, a blackhead with two or sometimes several surface openings that communicate under the skin.  This distinctive lesion may be present for years before other symptoms appear. Unlike acne, once the disease begins it becomes progressive and self-perpetuating. Extensive, deep, dermal inflammation results in large, painful abscesses. The healing process permanently alters the dermis. Cordlike bands of scar tissue criss-cross the axillae and groin. Reepithelialization leads to meandering, epithelial-lined sinus tracts in which foreign material and bacteria become trapped. A sinus tract may be small and misinterpreted as a cystic lesion. The course varies among individuals from an occasional cyst in the axillae to diffuse abscess formation in the inguinal region.

Like acne, the plugged structure dilates, ruptures, becomes infected, and progresses to abscess formation, draining, and fistulous tracts. In the chronic state, secondary bacterial infection probably is a major cause of exacerbations.

Management:

Tretinoin cream (0.05%) may prevent duct occlusion, but it is irritating and must be used only as tolerated. Large cysts should be incised and drained, whereas smaller cysts respond to intralesional injections of triamcinolone acetonide (Kenalog, 2.5 to 10 mg/ml). Weight loss helps to reduce activity.

  1. Antibiotics are the mainstay of treatment, especially for the early stages of the disease. As with acne vulgaris, long-term oral antibiotics such as tetracycline (1 gm daily), erythromycin (1 gm daily), or minocycline (200 mg daily) may prevent disease activation. High dosages, such as 500 mg of erythromycin four times daily for an average-sized adult, are effective for active disease.

  2. Isotretinoin (1 mg/kg/day for 20 weeks) may be effective in selected cases. The response is variable and unpredictable and complete suppression or prolonged remission is uncommon.

  3. Surgical excision is at times the only solution. Residual lesions, particularly indolent sinus tracts, are a source of recurrent inflammation. Local excision is often followed by recurrence. Wide excision of affected skin, and healing by granulation or applying split skin grafts or transposed or pedicle flaps, affords better control. Local recurrence after wide excision varies greatly with the disease site.

REF: Habif: Clinical Dermatology, 3rd ed., 1996  

IMPETIGO (See Bacterial Infections)

INTERTRIGINOUS RASHES                

The three key possibilities are tinea cruris (fungus), intertrigo (hot, sweaty, irritated skin) and erythrasma (a bacterial infection/colonization).

Avoid strong topical steroids (Class I and II) and combination steroids (e.g. Lotrisone®, Mycolog®) in the groin.

Treatment

ITCHING ALL OVER, LITTLE OR NO RASH               

Consider

LICHEN SIMPLEX CHRONICUS               

Lichenification means increased skin markings. Look for a thickened plaque in a typical area such as the dorsal foot, scrotum/vulva, or extremity. The condition is usually asymmetric.

Do not be afraid to tell the patient, "don't scratch! It does not matter how strong a steroid I give you, if you continue scratching, you will continue to have the rash."

Treatment

Lice (Pediculosis)              

Pediculus humanus var capitis, corporis, pubis (crabs)
Pubic lice, or crabs, is seen the most common.

Signs:  excoriation, infection, adenopahty.
Diagnosis:  nits (What you need to do is look closely at the hair, particularly at the roots of the hair, at the base of the scalp and over the ears.) 

Treatment

For the scalp & body & pubic lice :
Permethrin 1% cream rinse  for 5-10 min (OTC- Nix ®) should be used. Advise patient to apply to the scalp for 5-10 minutes then rinse. The treatment should be applied to dry hair for optimum efficacy. Successful treatment usually requires removing the nits as well as many will not be affected. They may be combed out with a fine-toothed comb after pretreatment with a loosening agent (OTC "Step 2"®).
Lindane 1% shampoo for 5-10 min
* Retreat symptomatic patients in 1 week.

It is important to remove lice and their nits from the hair DAILY with a metal comb. Combs, brushes, hats, etc. must also be treated. The permethrin should be reused in 7-10 days. It is important to examine and if needed treat all members in a family. Inform school and other close contacts.

For the groin:
Permethrin rinse 1% (OTC -Nix®)   Applying rinse from the trunk to knees is sufficient.

LUMPS AND BUMPS (BENIGN)             

Treatment

MELASMA                 

It is more common in women than in men.

Most commonly appears as symmetric brown patches on the face of a woman, frequently noted during pregnancy or while on hormone therapy (e.g. BCPs, HRT). However, it may occur with out a specific cause.

Treatment

MOLLUSCUM CONTAGIOSUM               

Molluscum is caused by a virus. Although it commonly affects children, adults may be affected as well. It may be sexually transmitted in adults.

Molluscum appears as multiple skin-colored to pink papules. There may be only a few or there may be more than 50. They may be grouped or scattered. Often the surrounding skin is irritated and red.

Treatment

Liquid nitrogen (cryotherapy) or curettage may be performed on individual lesions. For numerous lesions, e.g., in beard or groin areas: Apply Retin A® 0.05% Cream once daily for several months until resolved.

NUMMULAR ECZEMA              

Nummular eczema presents as very itchy, round or oval, eczematous areas. Occurs in the setting of dry skin.

Treatment

Limit daily shower to 5-minutes. Use cold or warm water and mild, non-perfumed, non-dyed cleansers, e.g., Dove® unscented soap. Avoid long, hot showers.

Therapy requires a relatively high-potency (Class II topical steroid Betamethasone Dipropionate (Diprolene®) 0.05% or Fluocinolone (Lidex®) 0.05% ointment. Apply Betamethasone Diproprionate (Diprolene®) ointment to red, inflamed areas immediately after the shower and cover the rest of the skin with Cetaphil® or Eucerin® cream, Aquaphor®, SBR-Lipocream® or petrolatum. No lotions please. If the condition worsens with topical steroids, rethink the diagnosis. Could it be tinea? See atopic dermatitis for additional treatment recommendations.

ONYCHOMYCOSIS                

REF:  fungal_nail2009.pdf  

A culture should be performed before initiating oral therapy.

Check a CBC and SGPT (ALT) at baseline and after one month.

Recommended treatment for fingernails:
Onycymycosis of the fingernails is a covered benefit. Terbinafine (Lamasil®) 250 mg QD for 6 weeks

Recommended treatment for toenails:
Onychomycosis of the toenails is only covered for diabetics and patients presenting with functional symptoms. Remember that 1 out of 3 older patients with thickened, abnormal nails does not have fungus.

The patient must wait a year for full results and use an OTC topical antifungal (Clotrimazole or Terbinafine) agent long term to prevent recurrence.

Advise patients to keep the nails trimmed.

PEDICULOSIS (See Lice)

       

Peri-oral Dermatitis     REF:   Dr. Arndt's  Dermatology in Primary Care 2002 Kenneth Arndt, MD

It looks like rosacea, but it's not, and this is an important diagnosis, because it's common, seen almost only in women. Red bumps around the mouth, so it's perioral, and you have the area immediately around the vermilion border spared, so this is perioral dermatitis, something that didn't exist when I was a resident but certainly exists and is common now, seen only in women in their 20's and 30's, cause unclear.   It's seen in young women, may last a long time; it certainly can be seen as a side effect of the use of topical steroids on the face, but in most cases the cause is not clear.

Red papules and pustules: sometimes it's red behind it, may be scaly. It can be seen; some people call it periorificial, because you can see a little bit around the nose and sometimes a little around the eyes, and it usually has some symptoms, a little burning and stinging, not too much itching.

Therapy of Perioral Dermatitis:

Well, you stop anything that may be turning it on - steroids - and you use usually topical metronidazole, which in 60 - 80% of cases, within six weeks you get it under pretty good control. It makes the inflammatory part go away or get much better; it makes the flushing and blushing a little bit better. If that isn't sufficient, use a systemic antibiotic, and if it's quite inflammatory, you can use a very low potency - i.e., hydrocortisone cream, hydrocortisone, desonide, which is another low-potency steroid. You can use topical antibiotics, but usually metronidazole is the best of the bunch.

PITYRIASIS ROSEA                 

Many patients experience an initial larger lesion (herald patch) 1-2 weeks before the eruption. Characteristic lesions include round or oval plaques with scale at the periphery. The rash has a predilection for the sun-protected sites of the trunk, axilla, groin and neck and may or may not be itchy.

[Pityriasis Rosea     REF:   Dr. Arndt's  Dermatology in Primary Care 2002 -

Treatment

Rule out secondary syphilis with RPR.

For localized itching: Triamcinolone acetonide (Kenalog®) 0.1% cream/ointment BID as needed until symptoms abate. For widespread itching: Hydrocortisone 2 1/2% Lotion BID as needed until itching subsides. Tell patient rash may persist for 1-3 months.

PSORIASIS                

Characteristic lesions include red, scaly plaques on the elbows and knees. Scalp involvement is common as well. A Strep or other infection may precipitate a flare.

[Scaling plaques on extensors, scalp

Asymptomatic or pruritic/painful

Nail pitting, onycholysis, dystrophy

Alternative forms: guttate, pustular, erythrodermic, arthritis

Early onset = greater severitiy

Genetically determined, hyperproliferative

Lithium, beta blockers, steroid withdrawal exacerbate

Therapy:
Topical corticosteroids (as Temovate/Ultravate/Diprolene ointment initially), potent, alone or with occlusion
Intralesional corticosteroids (triamcinolone 3-5 mg/ml)
Systemic steroids:  AVOID if possible
Calcipotriene (Dovonex) ointment, cream, solution, vitamin D3.  Use bid, < 100g/week may be an irritant
Tazorac (tazarotone) gel  0.05 - 0.1% - new topical retinoid, use with topical steroids
For Extensive Psoriasis Rx:
UVB phototherapy; Psoralen phototherapy; Methotrexate; Systemic retinoids (etretinate as Soriatane); Cyclosporin 3 - 5 mg/kg

Treatment

Excellent control, but not cure is the realistic goal of therapy.

For the scalp:
Shampoo at least 2-3 times/week with T/gel®, T/sal®, selenium sulfide (Selsun®) 2.5% shampoo (RX needed), Baker's P&S® shampoo etc.

For non- responsive areas:
Add Fluocinonide (Lidex®) 0.05% or Clobetasol (Temovate®) solution to scalp QD-BID as needed. May reduce to Fluocinolone acetonide (Synalar®) 0.01% for maintenance. May shampoo in-between with non-medicated shampoos as desired. Note that African American patients should not shampoo more than every 5-7 days.

For elbows, knees and body:
Betamethasone Diproprionate 0.05% (Diprosone®) ointment BID.

Many patients improve with sunlight. Psoriasis requires high potency topical steroids unless it is on the face or on areas in body folds. When the psoriasis improves, consider less frequent application of current treatment or a lower potency topical steroid for maintenance.

Advise patients that excess alcohol consumption, tobacco and certain medications (e.g. beta-blockers or lithium) may precipitate or flare psoriasis.

Refer patients with greater than 10% body involvement to Dermatology.

ROSACEA                See also Rosacea

Characteristic lesions include symmetrically distributed papules and pustules on the nose and cheeks. Telangiectasias and flushing are commonly associated findings but they do not respond to medical therapy. (Patients may have laser therapy for facial telangiectasias; however this is not a covered benefit and will and will only be treated for a fee.)

It is kind of a sebaceous, thick skin, a little bit swarthy, but this is with a lot of acneiform lesions so there are a lot of papules and pustules, no blackheads. So if you're not sure it's acne or if it's rosacea: rosacea you get no blackheads, no comedones; you just get pustules, sometimes cysts. It's in the middle third of the face, so it's on the cheeks, it's on the chin but it's not laterally. The nose is a little big here, so you can get sebaceous hyperplasia of the nose, going on to rhinophyma in men.

Differential Dx of Rosacea:
SLE, Acne vulgaris, Perioral dermatitis, Seborrheic dermatitis, Cutaneous sarcoid, Cutaneous TB, Leprosy

Treatment of Rosacea:

Treatment:

 

 SCABIES                      See also Scabies  

So this is infestation with a mite, and mites by definition pretty much are just small enough you can't see them with the naked eye, and this typically is a disease in which the itching is worse at night. Now all itching is worse at night. Anything that itches: when you go to bed, you stop moving around, you stop having other things on your mind, your body heats up a bit - it's going to itch worse. Scabies, however, itches really bad at night. You see it often in certain areas: hands, genitalia, in body folds, sometimes in the popliteal fossa. It may resemble a bunch of things: exzema, impetigo, dermatitis, psoriasis, and so forth; typically, burrows on interdigital area, nodules on genitalia.
When you get infected, it doesn't itch, and the itching is actually from sensitization to the mite, so it's one to three months from the time you get exposed and infested to the point you begin to itch, and the spread is like with lice: it can be person-to-person, but often it is just someone in the same bed as or sharing clothing or towels with. The mites don't travel much, and once they drop off of someone, they don't live a long time, a few days.

Look for burrows (thread-like scaly) in the wrists, web spaces and sides of feet. Inflammatory papules on the penis are classic for scabies.

Symptoms:
The lesions may be red or appear as white, gray, or black thread-like lines.  The lesions can be intensely pruritic, especialy at night.  Occasionally 2-5 mm nodules appear or vesicles develop, esp. in children.  The lesions can get secondarily infected with Streptococcus pyogenes or Staphylococcus aureus.

Diagnosis:
Definitive diagnosis of scabies is made by recovering the mite from a burrow by skin scraping & looking at the skin scraping under a microscope. Sensitivity of this method is low in typical scabies but very high in crusted scabies.

Treatment

REPORTING
Reporting of single cases of atypical or crusted scabies & outbreaks of scabies are mandated & should be reported immediately by telephone to the Communicable Disease Reporting System Hotline at (888) 397-3993

SEBORRHEIC DERMATITIS               seborrheic_dermatitis2009.pdf  

Characteristic lesions include redness and scaling along the nasolabial fold, eyebrows, and scalp. Severe cases may affect much of the face.

[Dandruff is not seborrheic dermatitis, but it kind of merges with it, so seborrheic dermatitis - there are more red, delimited plaques rather than diffuse, but they are both proliferative disorders: eyebrows, scaling in the eyebrows, scaling in the nasolabial folds, which is very common, or behind the ears.

Treatment

For the face:
Hydrocortisone 1% cream may be applied daily for persistent redness and scale. An alternative for facial seborrheic dermatitis is Ketaconazole (Nizoral®) 1% cream QD-BID.

For itching of the scalp:
Use a liquid steroid, e.g. Fluocinolone acetonide (Synalar®) 0.01% solution. May be used QD after shampooing with a medicated shampoo.

SKIN CANCERS           

The goal is to recognize patients who have suspected skin cancers. Patients with suspected skin cancers should then be referred to Dermatology for further evaluation and treatment.

Basal cell carcinomas (BCCs)  
are usually pearly, translucent papules (nodular type) or flat, ham-colored red areas (superficial type). However, they may be pigmented.

Squamous cell carcinomas (SCCs)  
classically are hyperkeratotic, growing papules or nodules.

Keratoacanthomas  
classically are rapidly growing nodules with a central keratotic core.

Melanoma   Images  

Asymmetry    BORDER -Irregular Border      Color      Diameter >6 mm
usually appears as asymmetric, irregularly bordered pigmented lesions with varied colors. Characteristic lesions are frequently > 6mm as well as smaller lesions that are undergoing change.

All of these occur in the chronically sun exposed areas. Superficial BCCs are common on the back and legs.

Refer suspected BCCs, SCCs, keratoacanthomas and melanomas to Dermatology.

STASIS DERMATITIS                           

Stasis dermatitis presents as an eczematous eruption that occurs on the lower legs in some patients with venous insufficiency. It mot commonly affects the lower 2/3 of the legs and frequently involves the area surrounding the inner ankle.

Skin in the affected area appears red and scaly. Edema is always present and may be severe. Varicosities may be seen about the lower leg. An ankle flare may be present. Over time, the skin may take on a brownish discoloration due to residual hemosiderin. In severe cases, ulceration may occur.

Treatment

Skin Fungal Infections / TINEA PEDIS  -              &    Images of Tinea Infections    

Clinical presentations may vary. Initially appears as red, scaly, macerated areas in the web spaces. Then, the scale spreads to the sole. In the fully developed stage, the entire sole is involved in a "moccasin" distribution.

Tinea pedis - Start terbinafine cream BID (after soaking/washing when time permits then apply hydrocortisone 1% ointment generously for up to 1 month until clear & smooth. 

Look for onychomycosis as well.

Treatment

If not responsive to treatment, consider foot eczema.

TINEA VERSICOLOR    

Lesions classically occur on the oily areas of the trunk of a young adult. The areas may be hypo- or hyperpigmented or pink. Scratching the area shows a fine scale.

Treatment

URTICARIA                 

Acute Urticaria

If the urticaria has been present for less than 6 weeks it is considered acute urticaria. Typically acute urticaria lasts a few days to a few weeks. There are no routine laboratory studies for the evaluation of acute urticaria. Ask about possible precipitating factors including food and drink, medications, e.g. aspirin, change of environment, recent travel, exposure to pollen or chemicals.

Most cases present with typical urticarial plaques (hives) larger than 2 cm. Stroke the patient's arm to rule out dermatographism.

Most urticaria is self-limited.

Treatment

[The drug of choice for control of urticaria is an H1 antihistaminic. In difficult cases, a combination of H1 and H2 antihistamines (as Tagemet-Cimetidine 300 mg q6h) may be more effective. Also, doxepin (Sinequan 10-25 mg tid) has both H1 and H2 antihistaminic properties and can be used when a single H1 agent fails to control disease activity. Severe or refractory urticaria may benefit from a prednisone 40-60 mg taper in combination with an antihistamine agent.-  EMedicine Nov.2001]

Chronic Urticaria

Patients who have a history of hives lasting for 6 or more weeks are classified as having chronic urticaria. The etiology is often unclear.

Treatment

VITILIGO                REF: Vitiligo 2009        

Vitiligo is a condition in which the skin loses its color in well-defined patches. They usually start small and expand. The extremities and the face are commonly involved. Patients 10-30 years of age are most commonly affected. Patients over 40 years of age who develop what appears to be new onset vitiligo should have a complete skin examination to rule out melanoma

Vitiligo occurs in about 1-2% of the population. A family history is present about 20-30% of the time and is more commonly seen in patients with younger onset of disease. It seems to represent an autoimmune condition in which the patient's own immune system is attacking the pigment-producing cells. Various autoimmune conditions (e.g. thyroid disease, pernicious anemia) are sometimes associated with vitiligo; however frequency is not high enough to warrant routine screening for vitiligo.

Treatment

There is no uniformly effective treatment for vitiligo. This is unfortunate as it can be psychologically devastating, especially in those patients with darker skin. Health care providers should be sensitive to the patient's emotional state.

Camouflage may be helpful for lesions on the face, hands, and other exposed areas. Various department stores with extensive cosmetics, e.g., Dermablend®, may be a good resource. Protection from the sun is important to prevent photodamage. Various skin dyes (e.g. self- tanners, vitadye) are available, but the color match is often less than optimum and overlap at the edges can make for uneven pigmentation.

Remember that treatment is not uniformly successful nor is it required. Refer patients to Dermatology for evaluation and treatment as appropriate. Treatment may include the use of topical steroids for a period of 2-4 months. Caution must be taken to assure that atrophy does not occur. Another option is systemic PUVA therapy for a 6 month period of time.

WARTS                 

If on the sole, be sure to confirm the diagnosis by paring. A wart has black dots; a corn has a clear center.

Treatment

For plantar warts: Home topical treatment can be very effective. Mediplast 40% daily or cryotherapy. Cryotherapy treatments can be performed as frequently as every 2-3 weeks. Use two applications of liquid nitrogen at each treatment session. Freeze wart until it turns white with a 1 mm margin. Repeat one time after thawing. Encourage home care between cryotherapy treatments. OTC salicylic acid QD (same ingredient as in medicated corn pads, e.g. Mediplast which has 40% salicylic acid) and paring every 2-3 days is a helpful adjunct to cryotherapy.

For other warts: One application of liquid nitrogen as described above at each clinic visit. Home support is helpful and should include topical salicylic acid preparations, e.g. Compound W.

Condyloma Acuminatum        
Treatment: (CDC 1998)

Patient Applied

Provider Administered

XEROTIC ECZEMA (See Dry Skin.)

Potency of Drugs                      REF:  Topical_steroids2009.pdf    

I  - Psoriasis (except body folds), allergic contact dermatitis, most rashes of the palms and soles, nummular eczema, pompholyx, lichen Simplex Chronicus

II -

III - Asteatotic or other severe eczemas

IV - Adult eczema, resistant childhood eczema

V - Resistant facial rashes, childhood eczema

VI - Resistant facial rashes, childhood eczema

VII - Seborrheic dermatitis of face, infantile eczema of face, most dermatitis of the face

APPENDIX A                

Benign Skin Conditions   (Considered Cosmetic)

Please note:

Visits or procedures for the following conditions are not covered benefits and are performed on a fee for service basis where available, unless otherwise stated.

ANDROGENETIC ALOPECIA

Androgenetic alopecia is not a covered benefit. Look for the pattern of hair loss. Hair loss on the top of the scalp is usually androgenetic.

BRUISES ON THE ARMS (Bateman's, Senile or Solar Purpura)

Many adults bruise very easily on the arms after the slightest trauma or even after no trauma at all. This occurs because sun damage has made the elastic tissue of the superficial blood vessels brittle and no longer pliable. This allows leakage of red blood cells out of the vessel with minimal provocation. The bruise tends to fade over a month or two. Steroid use can thin the skin and make this worse. Sun exposure also adds to the thinning.

CAPILLARY HEMANGIOMAS       Images of Hemangiomas  

Most adults over 30 have one or more red vascular papules on the trunk. They are little dome-shaped or slightly raised papules. In one study of adults 30-39 years of age, 90% of the men and 65% of the women had at least one cherry hemangioma. There seems to be no good reason to have these, but luckily, they are not dangerous. There is no home remedy for capillary hemangiomas. If the patient desires, they can be removed by a cosmetic dermatologist.

           DERMATOFIBROMA    

Many women will complain of this bump on the leg. It may be pink, red, tan, or brown. The key distinguishing feature is that you can grab it between two fingers and feel it within the dermis. Often, when you do this, the surface will be "sucked in". The upper back, especially over the scapula is another typical area. Men may also be affected. The surface of the dermatofibroma is often pigmented, and at times, velvety. There is no home remedy for dermatofibromas. If the patient desires, they can be removed by a cosmetic dermatologist.

DERMATOSIS PAPULOSA NIGRA    

DPN is a common papular condition of the face and neck in darker-skinned patients. They appear as multiple, brown, papules, small plaques and pedunculated lesions occur on the

face neck and upper trunk in a darker-skinned patient. No treatment is needed. If the patient desires, cosmetic removal may be pursued.

EPIDERMAL INCLUSION CYST  

The epidermal inclusion cyst--formerly known as the sebaceous cyst--is a sphere of skin within the skin. The cyst wall constantly flakes into the center of the cyst causing it to enlarge over time. A central pore is usually visible. Often the lesion periodically drains, releasing a foul smelling white material. At other times, the lesion may become acutely inflamed. This is usually a result of rupture of the cyst wall and release of the cyst contents into the surrounding dermis. A foreign body response results. Asymptomatic epidermal inclusion cysts do not need to be treated. If however, one large enough to be bothersome or if it periodically gets inflamed, it may be removed surgically. This is a covered benefit.

If the lesion becomes acutely inflamed, apply warm compresses twice a day. Such an inflammatory episode may actually cause to cyst to go away. If not, the lesion may be surgically excised after the inflammation has subsided. Surgery acutely will be very difficult with much intraoperative bleeding and pain.

FRECKLES

Freckles are caused by the sun. Light-skinned, red-haired patients are most susceptible. They appear as light tan or brown spots scattered on the face or nose of a child or young adult. The patient and/or parents should be educated on sun avoidance, sunscreens, and skin cancer.

LENTIGINES

Lentigines are flat, brown spots appearing on aged exposed skin, frequently on the back of the hands. They are due to the accumulation of lipofuscin in the tissue as one ages. They are commonly referred to as "liver spots"; however, there is no physiological relationship to the liver.

MILIA       

These tiny, white bumps on the face are most common in women. They represent tiny, benign cysts. There is no home remedy for milia, although over time, they may work themselves out. If the patient desires, they can be removed by a cosmetic dermatologist.

       

SEBACEOUS HYPERPLASIA  

This 3 mm. "yellow donut" is a common inhabitant of the face of an older adult. The characteristic 2-4 mm donut shape is classic and the yellowish color confirms the suspicion. This lesion requires no therapy. If the patient desires, they can be removed by a cosmetic dermatologist.

SEBORRHEIC KERATOSES    Seborrheic Keratosis images  

This "barnacle" on the ship of life can take on so many different appearances. It may be brown, black, white or tan, dry and warty or smooth and greasy. They are most common on the trunk, but may occur anywhere. As to why people get them, there is no good answer. They are very common, and are not dangerous or contagious. They often run in families. There is no home remedy for seborrheic keratoses. If the patient desires, they can be removed by a cosmetic dermatologist.

SKIN TAGS             

These tabs are common in the armpit, on the neck, in the groin and under the woman's breasts. They catch on necklaces, rub on collars and bras etc. Skin tags serve no good purpose. They seem to arise in areas of friction and they are slightly more common in taller patients and those of increased weight. For the majority their presence is another mystery of life. There is no home remedy for skin tags. If they are symptomatic, those lesions can be removed as a covered benefit. If not symptomatic and the patient desires, they can be removed by a cosmetic dermatologist.

       

SYRINGOMA               

The syringoma is a benign growth that most commonly occurs below the eyes. They are a little more common in women of Asian descent and they may run in families. They appear as multiple flesh-colored papules on the lower eyelids and upper cheek. No treatment is necessary. Cosmetic surgery may be pursued.

TELANGIECTASIAS

Telangiectasias commonly occur on the face and legs of middle-aged and older adults. Telangiectasias appear as small, thread-like blood vessels visible just below the skin's surface. On the face, the nose and cheeks are the most commonly affected areas, and the patient is usually fair-skinned. Facial telangiectasias may occur in association with rosacea, but they may not. Indeed, a patient with facial telangiectasias without pimples or pustules does not have rosacea. It must be emphasized that tetracycline and other medications for rosacea do not remove facial telangiectasias. Telangiectasias do not require treatment. If the patient prefers, cosmetic laser surgery may be done.

Telangiectasias of the legs (or spider veins) are common as well. No treatment is needed. Wearing support hose can decrease the development of future telangiectasias. If the patient desires, they may be seen and treated by a cosmetic dermatologist or plastic surgeon for sclerotherapy or other cosmetic (non-covered) treatment.

WRINKLES

Treating wrinkles is not a covered benefit. If the patient desires, wrinkles can be treated by a cosmetic dermatologist.

XANTHELASMA

Xanthelasma are soft, yellow deposits about the eyes. They appear as soft, yellow plaques on the upper inner eyelids although they can occur below the eyes as well. They may occur

as an isolated finding or associated with elevated lipids and/or cholesterol. All patients with xanthelasma should have a lipid profile. No treatment is needed although cosmetic surgery may be pursued.

Poison Ivy or Oak Contact Dermatitis
- secondary to Urushiol irritation

       

Skin Ulcer Care     |   Wound Rx 2008.pdf  

By: Rolf Paulson, MD, Pat Guthmiller, RN, BSN CWOCN, Dan Rustvang, RN, MSN, FNP-C
Source: Patient Care November 1, 2005  

ROLF PAULSON, MD, Medical Director, Chronic Wound Care Clinic, Altru Clinic and Hospital; Clinical Professor of Internal Medicine, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND.

The diagnosis and treatment of chronic wounds has received inadequate attention in medical schools and primary care residencies. Attention to wound management, especially the care of chronic cutaneous ulcers, is generally scattered throughout medical and surgical specialties, rehabilitation medicine, podiatry, dermatology, and primary care.

We have a 4-step protocol currently in use at our institution for the management of chronic cutaneous ulcers.

  1. The first and most important step is to determine and address the cause of the wound.
    Edema secondary to venous valvular incompetence, for example, can cause stasis ulcers; diabetes is a frequent cause of neuropathic ulcers; and arterial insufficiency often causes ulcers that lead to gangrene.

  2. The next step is to evaluate any comorbidities that may interfere with wound healing, such as arterial insufficiency that is preventing resolution of a heel ulcer caused by immobility, infection that is complicating healing of a statis ulcer, or neuropathy, arterial insufficiency, and infection all complicating healing of a ulcer.

  3. Third, we evaluate how well the patient understands the nature of the ulcer and the healing process, their motivation to improve, and the need for resources, such as caregivers, money or insurance for dressings or equipment, and transportation. A positive outlook and healing environment will optimize the outcome.

  4. The fourth and last step is to evaluate the wound and determine the appropriate treatment, type of dressing needed, and the need for debridement.

History and physical examination

At our institution, patients with chronic ulcers undergo a thorough history taking, physical examination, and, when appropriate, special studies. A complete history puts the wound in context; a history of arterial or venous disease or vasculitis is particularly important in the patient with a nonhealing leg ulcer. How was the initial wound treated? What treatments for previous ulcers have been successful? Has the patient undergone skin grafts or vascular bypass? What caused immobility that led to the decubitus ulcers? Does the patient appear well nourished?

During the wound examination, note the appearance of the wound itself and the surrounding skin and the presence and absence of pulses, edema, and other clues to the underlying cause. Measure the wound and note any necrosis, slough, or granulation tissue. Probe any fissures or deep aspects to the wound. Document the size and composition of the wound, including granulation tissue, eschar, or slough with both a flow chart and a digital camera. Images are excellent documentation for both the clinical staff and the patient; many patients with sacral or heel ulcers have never seen their wound.

A clinical suspicion of inadequate arterial supply that is suggested by the ankle-brachial ratio warrants formal arterial Doppler flow studies. Laboratory studies including serum albumin level, WBC count, and ESR may give evidence of inflammation and the patient's nutritional status. A suspicion of osteomyelitis warrants consideration of a bone scan or MRI. A biopsy may be in order if the history and examination are inconclusive regarding the type of ulcer.

Treatment

Ulcer treatment occurs in 2 phases;

first, the ulcer is prepared for healing, and then healing is promoted (see "Treating specific ulcers").

Because healing will not occur until granulation tissue has formed, the first step is to debride necrotic tissue or slough. Sharp debridement using a scalpel or scissors to remove necrotic tissue can be performed in the operating room or in the office. Mechanical debridement involves the use of a whirlpool, abrasive treatment, or wet-to-dry dressings to mechanically remove debris. Enzymatic debridement requires the use of a topical agent such as collagenase to remove and dissolve the slough. Autolytic debridement, or moist wound healing, involves the use of hydrocolloids, transparent films, and hydrogels to enable the body's own enzymes to eliminate devitalized tissue and encourage growth of granulation tissue. Advantages of autolytic debridement include less pain, less frequent dressing changes, and faster healing. Moist wound healing consists of occluding the wound, keeping the surface moist, keeping the edges dry, and removing exudate.

TABLE 1. Dressings for ulcer care

Dressings for Ulcer Care

Among the many available dressings, those used most commonly for ulcer treatment fall into either moisture-retentive or drying agents. Made of nonwoven fibers derived from seaweed, alginate dressings form an absorbent gel on contact with wound exudate. They are typically used for wounds with moderate to heavy drainage. Hydrocolloid dressings are composed of gelatin and gel-forming agents such as sodium carboxymethylcellulose. They also form an absorbent gel on contact with exudate and are used for wounds with light to moderate drainage. Hydrogel dressings contain a gel composed primarily of water and are used for wounds with minimal or no exudate (see Table 1). Wounds with extreme exudate may benefit from the use of vacuum-assisted closure.

SUGGESTED READING

Treating specific ulcers

IMAGES: ROLF PAULSON, MD

Stasis ulcers

The appearance of stasis ulcers, the most common type of chronic ulcer, is typically one of a shallow, irregularly shaped wound that is often hyperpigmented and usually occurs on the medial or lateral malleolus. Effective management of the constant edema is the key to treatment. At our institution, treatment using a 4-layer compression bandage system is often successful; patients tolerate the 4-layer compression bandages much better than they do the Unna boot dressings.

A wound dressing can be used under the 4-layer bandage. The initial 4-layer dressing is usually changed after 3 or 4 days and then weekly thereafter. Compression should only be initiated with adequate circulation. Stockings typically exert 30 to 40 mm of compression, although a greater degree of compression is often used in obese patients. We have found that antiembolism stockings provide inadequate compression in a wound care setting.

Healing a stasis ulcer is often easier than keeping it healed. Patients must understand the consequences of discontinuing compression.

Arterial ulcers These often painful ulcers caused by arterial insufficiency can occur anywhere, but appear most often in the feet. Gangrene of the toes or foot is a worrisome presentation of arterial insufficiency. Treatment is aimed at restoring blood flow, and options include revascularization by surgery or angioplasty. Amputation is a last resort.

Diabetic foot ulcers

These painless neurotrophic or neuropathic ulcers typically occur on the plantar surface of the foot below the first metatarsal head, at the heel, or at the top of the toes. Treatment involves eliminating the pressure that caused the ulcer and addressing any arterial deficiencies or infection; the latter can be complex and require complicated antibiotic regimens. Osteomyelitis is assessed by exam, x-ray studies, bone scan, or MRI and treated appropriately with antibiotics, surgery, or both.

Decubitus ulcers

The crucial element of treating these ulcers is relieving the pressure, or offloading. As for heel or other pressure ulcers, observe the patient in both the sitting and supine positions in the chair or mattress used regularly to determine the best way to alleviate pressure. The appropriate dressing depends on staging (see Table 1). In stage 1 decubitus ulcers, the skin is unbroken but red or otherwise discolored that does not fade within 30 minutes of the pressure being relieved. Stage 2 ulcers are characterized by a torn or broken top layer of skin that creates a shallow, open wound. Stage 3 ulcers are deeper than stage 2, and the wound extends through the fatty tissue. Stage 4 ulcers extend into the muscle and necrotic tissue, and drainage is often noted.

CLINICAL PEARLS

     

Scar gel Rx

OTC Mederma gel

Scarless gel (from Plastic Surgery Clinic)

Medscape Dermatology    

http://www.skincancer.org/  

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