Dermatology for Internists

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Dermatology for Internists

• Susan Riggs Runge, MD
• January 2008

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Pictures

• Pictures of common and less common skin lesions
• Cover each topic very briefly
• Realize most of you have vast experience in
  seeing many of these lesions in your years of
  practice
• This is a very superficial review of topics I
  hope you may find interesting
• All slides and photos are available at
• http//medicine.med.unc.edu/education/dermatology
  _for_internists.ppt

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Lupus Erythematosus

• One of the papulosquamous diseases
• Papules and scaly areas
• Other papulosquamous diseases include psoriasis,
  tinea, seborrheic dermatitis, pityriasis rosea,
  syphilis, lichen planus and other more rare skin
  disorders
• Many of these have differentiating
  characteristics but lots of overlap clinically
  makes skin biopsy particularly helpful in many
  cases

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Acute Cutaneous Lupus
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Acute Cutaneous Lupus

• Dilated capillary loops along nail fold
• This can also be seen in dermatomyositis and
  other connective tissue diseases

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Acute Cutaneous Lupus

• Malar erythema, can involve neck, forehead and
  periorbital area in photodistribution
• Erythema and sometimes edema of V of neck,
  forearms
• Look for ulcers on the hard palate
• ANA positive
• 60-80 will have positive dsDNA
• Other tests CBC, ESR, UA, skin biopsy
• Treatments Prednisone, hydroxychloroquine
• Referral to rheumatologist

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Subacute Cutaneous Lupus
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SCLE (subacute cutaneous lupus)

• Annular scaly erythematous patches in sun-exposed
  areas
• Worse upon sun exposure
• Non-scarring
• Many patients have arthralgias expecially of
  hands and wrists
• Consider drugs as cause HCTZ, calcium channel
  blockers, ACE inhibitors, terbinafine and
  TNF-antagonists

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Hands in Subacute Cutaneous Lupus

• Erythematous scaly patches between the knuckles
  (unlike Gottrons papules of dermatomyositis
  which are on the knuckles)

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Subacute Cutaneous Lupus Labs

• Most are ANA positive
• Most are Anti-Ro (SS-A) positive
• 1/3 will meet criteria for systemic lupus
• Other lab tests CBC, ESR, UA, Rheumatoid factor,
  complement levels, skin biopsy
• Treatment Stop suspected drugs, sunscreen,
  hydroxychloroquine
• Refer to rheumatologist if joint involvement,
  nephrologist if renal involvement, etc

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Subacute Cutaneous Lupus-more subtle
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Discoid Lupus
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Discoid lupus

• Hyperpigmentation and hypopigmentation
• Atrophy of skin
• These lesions cause SCARRING
• Skin lesions occur in photodistributed areas
  (wider distribution may correlate with greater
  likelihood of SLE)
• Discoid lesions and follicular prominence in
  conchae of ears

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Ear Lesions in Discoid Lupus
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Discoid Lupus Labs

• ANA positive in 5-20
• Do CBC, ESR, Rheumatoid factor, UA, complement
  levels, skin biopsy

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Discoid Lupus

• These patients rarely progress to SLE (5)
• Rarely have systemic disease
• Treatment sunscreen, topical steroids,
  intralesional steroids, hydroxychloroquine
• Referrals as indicated

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Other Papulosquamous Diseases Psoriasis
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Psoriasis
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Psoriasis

• Well-demarcated erythematous plaques
• Thick white or silvery scale
• Knees and elbows classically, can be scalp only
  or diffuse
• Also favors gluteal cleft, navel

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Psoriasis

• Not very itchy
• Scale is thicker and whiter than with fungal
  infection
• Less scaly in moist areas (in body folds) or if
  partially treated

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Psoriasis of scalp
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Psoriasis
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NOT psoriasis-cutaneous T cell lymphoma
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Not psoriasis - CTCL does not have thick scale

• Cutaneous T-cell lymphoma
• Could mimic psoriasis
• Atypical locations
• Biopsy should differentiate
• Refer skin problems that are atypical or do not
  resolve as expected

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Allergic Contact Dermatitis
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Allergic Contact Dermatitis

• Localized to area of contact
• Scaly erythematous plaques
• Can be blistering
• On eyelids, can be due to nail polish

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Allergic Contact Dermatitis
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Allergic Contact Dermatitis-fragrance
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Allergic Contact Dermatitis-diethylthiourea in
scuba diving gear
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Allergic Contact-cinnamon

• Cinnamon often used as flavoring agent in gum or
  toothpaste

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Allergic Contact Dermatitis

• Identify and avoid allergen if possible
• Increase moisturization of skin
• Topical steroid as needed
• Rarely oral steroid if severe

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Allergic Contact-Poison Oak

• Linear blisters are classic for allergic contact
  dermatitis due to poison ivy

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Allergic Contact Dermatitis-more subtle
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Seborrheic Dermatitis

• Erythematous patches on skin
• Thick, yellow greasy scale
• Seborrheic distribution eyebrows, sides of nose,
  nasolabial folds, ear canals, chest
• More severe in patients with HIV or Parkinsons
  disease

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Seborrheic Dermatitis

• Nasolabial fold
• Chin area

• Ear canal

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Dermatophyte
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Tinea

• Superficial fungal infection of skin

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Tinea corporis

• Tinea named by location tinea capitis, tinea
  corporis, tinea manum, tinea pedis, tinea barbae
  (beard), tinea cruris (body fold especially groin
  and pubic area), tinea unguium of nails
  (onychomycosis)

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Tinea faceii

• Erythematous annular plaques
• Not as well-demarcated as psoriasis
• Scaly, itchy
• Involved areas tend to fade centrally
• Treat with topical antifungal if limited area or
  oral agent if extensive

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(No Transcript)
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Tinea Corporis
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Tinea Capitis

• Causes itching and scaling of scalp
• More common in children
• Hair may break just beyond follicle
• Often more than one family member affected
• Can be severe and cause hair loss which can be
  scarring (loss of follicles)

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Tinea Capitis
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Tinea pedis
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Tinea-more subtle
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Atopic Dermatitis
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Atopic Dermatitis (Eczema)
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Nummular Eczema
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Severe Atopic Dermatitis
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Atopic Dermatitis

• Our Recommendations
• Bathe in tepid water with mild soap
• Moisturize skin frequently with vaseline or other
  thick cream
• Topical steroids as needed for control
• Rarely treated with oral immunosuppressive

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Benign Growths of the Skin

• There are many skin tags, cysts, lipomas,
  dermatofibromas, warts, keloidsand many others
• One of the most common in adults in seborrheic
  keratosis

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Seborrheic Keratosis
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Seborrheic Keratoses
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Seborrheic Keratosis

• Verrucous (warty looking) tan to black stuck-on
  appearing growth
• Common on back, chest, abdomen, but may be
  anywhere
• May be multiple or single
• Not necessary to remove treat with cryotherapy
  or electrodessication if symptomatic or as
  cosmetic procedure
• Treatment can cause a hypopigmented spot or
  scarring

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Moles and Melanoma
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Normal Moles (nevi)
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Normal Nevi

• Symmetrical
• Regular Borders
• One color or shades of brown
• Smaller size , less than 6 mm, although can be
  larger
• Do not grow or change
• Develop new nevi up to age 30s

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Dysplastic nevus
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Dysplastic Nevus
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Dysplastic Nevus

• Irregular borders
• May have more than one color
• If it meets two or more of the criteria for
  melanoma, we may remove it

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Dysplastic Nevus Syndrome

• Multiple dysplastic nevi
• Familial (also known as Familial Atypical Mole
  and Melanoma Syndrome FAMM)
• Melanoma common in one or more first or second
  degree relatives
• Histologic criteria
• Many cases linked to mutations in the CDKN2A
  gene, which codes for p16 (a regulator of cell
  division)
• Difficult to evaluate visually because have 50 or
  more moles
• Annual examinations by dermatologist plus
  frequent self-monitoring for change in moles
• Mole mapping (digital imaging at UNC) if prior
  melanoma or if available

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Melanoma
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Melanoma
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Melanoma

• Most common type is superficial spreading
• Tends to grow wide before it grows deep
• Look for the ugly duckling mole-one that is
  different than the patients other moles

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Melanoma
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• Lentigo maligna melanoma
• Occurs most often on head and neck
• Usually evolves slowly in older patients with
  significant sun damage

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Melanoma
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Melanoma

• ABCDEs
• Asymmetry
• Irregular BORDERS
• Colors (more than one)
• Diameter (more than 6 mm)
• Evolving-very important

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Melanoma-more subtle
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Melanoma
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Melanoma
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Nodular Melanoma

• Grows rapidly (6-8 weeks)
• Deeper
• Prognosis related to depth so worse prognosis
  than superficial melanoma

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Amelanotic Melanoma

• Lacks pigment so may not be recognized as melanoma

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Actinic keratoses
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Actinic keratoses

• Precancerous
• Scaly erythematous macules in sun-damaged skin
• Persistent scaly areas-patient scratches them off
  and they recur
• Treated with liquid nitrogen or topical
  5-fluorouracil or imiquimod

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Basal Cell Carcinoma
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Basal Cell Carcinoma

• Pearly papule with rolled borders
• Has central dell (indentation)-will erode with
  time and form ulcer
• Telangectasia
• Slow growing
• Extremely rare to metastasize but can erode bony
  structures
• Can be pigmented

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Basal Cell Carcinoma
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Pigmented Basal Cell Carcinoma
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Basal Cell Carcinoma-more subtle (morpheaform
looks like a scar)
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Squamous Cell Carcinoma
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Squamous Cell Carcinoma

• Enlarging scaly, crusty plaques
• Not the thick white scale of psoriasis
• Not symmetrical on the body (unlike psoriasis)
• Squamous cell or basal cell carcinomas may
  present as a non-healing spot (allow 4 weeks to
  heal if it doesnt , then biopsy)

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Outlier Topic
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Pyoderma Gangrenosum
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Pyoderma Gangrenosum

• Not all ulcers are infectious
• Diagnosis of exclusion rule out infection and
  tumor
• Starts as a small red papule, then spreads into
  ulcer
• Occurs in healthy-looking people (abdomen and
  legs), can occur anywhere including in the mouth
• Tendency to occur in patients with inflammatory
  bowel disease but idiopathic in 50
• Spreads to surrounding tissues if debrided or
  excised
• Responds to topical or oral steroids

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Referrals to Dermatology

• Any new growth that you are suspicious about
• Refer blistering processes early
• A rash (an eruption) in a body fold might be
  fungus or yeast, so an antifungal cream might be
  worth a trial
• Consider a trial of over the counter cortisone or
  topical triamcinolone for body lesions that you
  believe may be a transient dermatitis or eczema
  (we prefer ointments over creams)
• Refer when a skin lesion is growing or does not
  resolve with usual treatment
• Refer suspected melanoma promptly