Rashes/Dermatology

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Rashes/Dermatology

• Jackie Weaver-Agostoni, DO, MPH
• UPMC Shadyside
• Director, Osteopathic Family Medicine Residency
• 3/5/16

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Pre-Test 1
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Pre-Test 2
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Pre-Test 3
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Pre-Test 4
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Pre-Test 5
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Pre-Test 6
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Pre-Test 7
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History

• Length of symptoms
• Initial appearance and location
• Changes/Spread
• Treatments tried and response
• Associated symptoms
• Sick contacts
• History of similar symptoms and treatment
• New exposures

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History

• PMHx
• Medications
• Family history
• Social history- occupation, hobbies

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Lesion Morphology
Macule nonpalpable Ex vitiligo, cafe au lait,
petechiae
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Lesion Morphology

• Papule palpable, lt/ 5 mm

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Lesion Morphology

• Plaques - Large gt/ 5 mm superficial flat lesions

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Lesion Morphology

• Pustules small purulent-filled papules
• Vesicles small lt 5 mm papules containing serous
  material
• Bullae large gt/6 mm
• vesicles

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Lesion Morphology

• Nodules palpable, discrete lesions gt/ 6 mm
• Tumors large nodules

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Lesion Morphology

• Cysts enclosed lined cavities filled with
  liquid/semisolid material
• Telangiectasia dilated superficial blood vessel
• Wheals - hives

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Diagnostic Techniques

• KOH Prep
• Fungal
• Tzanck smear
• HSV
• VZV

• Woods Lamp
• Tinea
• Erythrasma
• Vitiligo
• Melasma
• Porphyria

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Melanoma

• Risk factors
• Moles Atypical, total gt 50
• Red hair and freckling
• Severe sunburn, especially in childhood
• First degree relative
• Prognosis
• Breslows classification (tumor thickness) and
  lymph node spread
• No staging workup needed if lesion lt 1 mm
  thickness as low risk

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Irritant Contact Dermatitis

• Xerosis, fissures, erythema, eczematous eruption
• Change frequently
• Increase air exposure
• Protective ointment
• Petroleum Jelly
• A and D ointment
• Desitin

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Diaper Candidiasis

• Satellite lesions
• Antifungal creams, frequent diaper changes
• Usually lasts about 10 days

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Rhus Dermatitis

• Lasts 1-2 weeks
• Linear Lesions
• Blister fluid can NOT spread the inflammation
• Remove source, wet dressings (Burows solution),
  Class I topical glucocorticoid if non-bullous
• Blisters may require oral Prednisone (1-2 week
  taper). Do NOT remove the tops.

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Miliaria Crystallina

• Miliaria- Heat rash
• Eccrine sweat duct occlusion
• Vesicles filled with clear fluid
• Asymptomatic
• Cool water compress and proper ventilation

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Pityriasis Rosea

• Benign and self-limiting
• Herald patch- trunk or proximal extremities
• Christmastree distribution
• Reach their maximum number in 1-2 wks.
• Clears in 1-3 months
• More papular/vesicular in kids

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Molluscum Contagiosum

• Virus
• Umbilicated, flesh-colored, dome-shaped papules
• Autoinnoculation, scratching, touching
• Most self-limited in 6-9 months
• Curettage, cryosurgery, tretinoin (not very
  effective), salicylic acid, cantharidin
• Physical expression of lesion rather than tx with
  phenol worked just as well with less scarring

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Primary Herpes Simplex

• HSV-1
• Kids- typically start around or in mouth
• Respiratory droplets, direct contact with active
  lesion, virus-containing fluid (saliva)
• Primary infection with more lesions than
  recurrence
• Uniform in size vs. herpes zoster
• Lasts 2-6 wks
• Acyclovir (Zovirax)

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Erythema Multiforme

• Acute, immune-mediated
• Target-like lesions
• Can have mucosal disease (erosions, bullae)
• Virus typical cause (HSV, mycoplasma pneumonia in
  kids)
• Medications, autoimmune dz, malignancy
• Usually self-limited over couple weeks
• Young adults
• Symmetrical, extensor surfaces, centripetal
  spread

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Stevens-Johnson Syndrome

• Commonly triggered by medications
• Allopurinol, antibiotics, antipsychotics and
  anti-epileptics, analgesics and NSAIDs
• Fever and mucocutaneous reaction followed by
  necrosis and sloughing of epidermis
• Starts as erythematous or purpuric macules and
  placques
• lt 10 body surface (vs. Toxic Epidermal
  Necrolysis)

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Varicella

• Chicken Pox
• Contagious 2 days before rash, and until all
  lesions crust
• Trunk ? face and extremities
• All phases present
• Dew drop on a rose petal
• March-May
• Complications secondary infection, encephalitis,
  Reyes syndrome, pneumonia
• Symptomatic tx, antivirals (Acyclovir approved)-
  within 24 hrs
• Immunization- 80 effective

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Measles

• Rubeola
• Droplets
• Cough, coryza, conjunctivitis
• Kopliks spots- blue-white spots with red halo
  on buccal mucosa
• Downward spread
• Morbilliform (confluent elevated maculopapules)

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Hand-Foot-and-Mouth Disease

• Coxsakievirus A16
• Oral-oral and fecal-oral routes
• Warmer months
• Linear vesicles on palms and soles
• Self-limited 7-10 days
• Symptomatic treatment
• 1st trimester may cause spontaneous abortion

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Scarlet Fever

• Strep pyogenes
• Downward spread
• Circumoral pallor, pinpoint papules, sandpaper
• Pastias sign- linear petechiae in skin folds
• Desquamation of palms and soles
• Beaus lines- transverse grooves on all nails
  several wks after rash gone
• PO abx- PCN, e-mycin

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Rubella

• German measles, 3-day measles
• Respiratory spread
• 1st trimester ? congenital rubella synd.
• Cataracts, deafness, heart defects, bone damage,
  neurologic issues including mental retardation
• Immunization- do not get pregnant for at least 1
  month following
• Downward spread
• Pinkish or rosy-red macules or maculopapules
• No treatment required- rash fades in 1-2 days

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Erythema Infectiosum

• Parvovirus B19
• Fifth disease
• Slapped cheek
• Lacy eruption on trunk and extremities
• 2-day prodrome
• Respiratory spread
• Symptomatic treatment
• Rash lasts approx 10 days
• Risk to pregnant women- fetal death

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Roseola Infantum

• Exanthem subitum, sixth disease
• HHV-6
• 6 mo.- 4y/o
• High fever (103-106 degrees) ? rash
• Pale-pink, almond shaped, macules
• Symptomatic tx.

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Kawasaki Syndrome

• Mucocutaneous lymph node syndrome
• Multisystem vasculitis
• Fever plus at least 4 bilateral conjunctivitis,
  red lips/pharynx/strawberry tongue, erythema
  palms or soles, edema of hands or feet,
  desquamation, rash (erythematous exanthem),
  cervical lymphadenopathy
• Cardiovascular sequelae
• Tx ASA, Gamma globulin

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• Rocky Mountain Spotted Fever
• Palms and Soles
• Tick-borne disease
• Rickettsia rickettsii
• Southeastern and south central states
• Spring and early summer
• Rash typically between 3rd and 5th day
• Early treatment

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Meningococcemia

• Petechial Rash- discrete 1-2 mm lesions can
  coalesce into larger purpuric/ecchymotic lesions
• Trunk and lower body
• Mucus membranes- hemorrhage

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Scabies

• Direct contact
• Nocturnal itching
• Burrows, vesicles or pustules on palms/soles-
  highly characteristic in infants
• More widespread in kids- face and scalp
  involvement (vs adults)
• Permethrin, Lindane (?safety re neurotoxicity,
  Ivermectin, sulfur (?safe), Crotamiton (60 cure
  vs 89 with permethrin)
• Launder contaminated items

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Lupus

• Butterfly Rash- spares nasolabial fold
• After sun exposure
• Can precede systemic symptoms
• Discoid lesions more inflammatory- scar
• If DLE alone, rarely anti-Ro ab and normal or low
  titer ANA
• Tx Topical glucocorticoids, antimalatial drugs

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Psoriasis

• Etiology- genetic, other (smoking, obesity, etc)
• Arthritis, nail involvement
• Tx Topical, Phototherapy, Systemic

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Henoch-Schonlein Purpura

• 2-10 y/o
• Palpable purpura of legs and buttocks, abdominal
  pain, GI bleed, arthralgia, hematuria
• Widespread vasculitis
• Prognosis based on renal involvement
• Usually benign and self-limited
• IgA deposition on biopsy
• Corticosteroids/dapsone

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Tinea
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Erythema migrans
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Secondary Syphilis
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References

• Habif, Thomas P. Clinical Dermatology A Color
  Guide to Diagnosis and Therapy. Mosby.
• Dermatology (Chapter 8) in Zitelli, Basil J. and
  Holly W. Davis. Atlas of Pediatric Physical
  Diagnosis, 4th edition, Philadelphia Mosby Inc.,
  2002. Pp 257-314.
• ONLINE Sites
• Ely JW, Stone MS. The Generalized Rash Part I
  and Part II. Differential Diagnosis. AFP, March
  2010.
• http//www.aafp.org/
• http//www.pediatrics.wisc.edu/education/derm/tuto
  rials.html
• http//dermatlas.med.jhmi.edu/derm/
• http//www.dermnet.com/
• http//www.meistermed.com/MoreMeister/dermmeister/
  index.htm
• Free dermatology photo atlas for your PDA
• http//www.uptodate.com