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Dermatology

Links

• local: Erythema Nodosum, Zoonoses
• AFP 1998: Photo Guide to Skin Neoplasms
• New Zealand DermNet

General Notes

Interpreting KOH preps

• tinea versicolor: spaghetti and meatballs (yeast)
• ringworm: hypae with "boxcars" (arthrospore) a fungus.
• yeast: hyphae with end "sprouts" (blastospore)

Atopic vs. seborrheic dermatitis in infants

supposedly cannot have atopic derm. prior to 2m of age. THREE Ls (for atopic): late (>3mo), lateral (perioral sparing), and lichenification. Atopic always pruritic!

Cryotherapy tips

• Use tongue blade with holes drilled in it as a cryo-shield

Caterpillar dermatitis

• funny tracks, southern us: use tape to remove hairs.

Erythema Multiforme

• may be often caused by Herpes, consider Rx acyclovir

Granuloma Annulare

• idiopathic transient ring like papules, expanding diameter. Dorsal surface of hands, fingers, feet, extensor surfaces of arms and legs.

Hyperhidrosis of the soles of feet

“Tanning the feet” (discolors the soles)

• boil six tea bags in water in a tea kettle and steep overnight as water cools.
• put one inch of tea solution in container
• soak feet in tea solution for 15-20 minutes twice daily for 3 days.

Icthyosis

• icthyosis vulgaris: childhood presentation, autosomal dominant.
• icthyosis (late onset): often lymphoma, esp. Hodgkins

Lichen Planus

• idiopathic recurrent violaceous papules (papulosquamous), sometimes with whitish scale on flexor surface forearm and wrist, also neck, legs, back. Usually symmetric. 2/3 get oral lesions. Often itches. Don't confuse name with other "lichen".
• seen with many drugs including diuretics and in chronic graft-versus-host disease
• associated with Hep C and abnormal liver function

Lichen Simplex Chronicus

• due to habitual scratching or rubbing
• isolated hyperpigmented edematous lesion, becomes scaly and thickened in center. See Xerosis

Lumbar striae

• physiologic in obese adolescent, in non-obese also consider Marfan, Ehrles-Danlos

Strep Guttate Psoriasis

• d/dx from Pityriasis Rosea, viral rashes
• acute onset small, widely scattered, uniform lessions

Warts

Warts are weird. In children just about anything seems to make them go away, including using occluding tape and sometimes simply suggestion. Sometimes though (even in children) nothing seems to work for years -- then they disappear.

ungal

• children: use ‘magic wart tape’ or a variant
• adult/resistant
  • chemical ablation (Canthrone was once used for this, but for odd regulatory reasons it's no longer available in the US)
  • 1:500 candida antigen and lidocaine multiple injection sites: I've no idea whether this really works, it's only been reported in a few limited studies.

Facial (flat)

• Retin A or Efudex

Xerosis

• dry skin in elderly, scaly -- poorly defined red, scaly plaques with fine fissures, esp. abdomen. See Lichen Simplex Chronicus.

African-American

Normal variations

• pigmentary demarcation lines on anterior arms and posterior legs
• midline ventral/vertical hyopigmentation lines
• longtitudinal melanonychia (beware acro-lentiginous melanoma, when in doubt biopsy)
• palmar crease pigmentation
• palmar crease puncate keratoses and pits: hyperkeratotic papules in palms
• oral hyperpigmentation
• hyperpigmented plantar macules

Adult

• keloids
• acne keloidalis nuchae: deep follicular inflammation in nape of nect in young men. Larger lesions -> surgery.
• pseudofolliculitis barbae: grow a beard

Infant & Child

• Mongolian spots - disappear often by age 5
• transient neonatal pustular melanosis: vesicopustules rupture < 48 hours, leave hypopig macule
• infantile acropustulosis: age 2-10 months, crops of 1-3 mm pruritic pustules on palms and soles lasting 1-2 weeks and recurring over months (? no Rx)
• lichen nitidus: chronic flesh or pale colored papules on forearm, chest, abdomen, penis. Resolves over months to years. Steroids may help.

Malignancy: Cutaneous Manifestations

• late-onset icthyosis: lymphoma, esp. Hodgkin's
• acanthosis nigricans: gastric CA, usually no CA
• acquired hypertrichosis (lanugo): nearly always CA -- lung, colon, uterus, bladder

Melanoma Genetics

1. dysplastic nevi + 2 or more 1st degree relatives w/ melanoma = almost certain to develop.

2. significant risk of nonfamilial melanoma with

• > 120 small nevi (< 5mm diameter)
• > 5 large nevi (5-10mm)
• one atypical nevus
• nevi on buttocks
• light skin, blue or green eyes, red hair

Pitted keratolysis

• dead fish smell feet, uv fluorescence
• rx bid ery gel or cream, replace shoes
• d/dx: fungus, dishydrotic eczema, contact dermatitis

Rosacea

• rev 011201
• flushing: avoid triggers, which can be idiosyncratic. Consider alcoholic beverages, skin irritants, calcium channel blockers.
• papules, pustules: tetracycline, very low dose accutane
• rosacea dermatitis: demodex mites? ketoconazole
• sensitive skin: must wash, but use moisturizer
• fibrosis/rhinophyma: surgery

Swimmer’s Itch, Cutaneous Schistosomiasis

• onset within days of swimming in infected waters
• June, July, Aug, esp. after onset warm spell
• papules, sometimes macules or confluent
• rx: antihistamine, steroids

Skin Sores and Ulcers

prevention

• turn q2h
• sitting: 2h limit
• dry the area: urinary diversion & stool control
• nutrition and hydration
  • multivitamin
  • consider zinc supplements
• diabetes control
• spread the weight
  • foam pads for elbows and heels
  • egg-crate mattress
  • water pillows for buttocks and heels
  • air mattress (expensive, hard to use)
  • water mattress (expensive)
  • Clinitron/Mediscus.

pressure sores: staging and therapy

I. pink skin, does not normalize when pressure removed.

• accelerated preventive measures
• apply Duoderm if more severe or poorer healing prognosis

II. cracked, blistered, broken skin. Shallow to full thickness skin injury.

• cleanse with normal saline
• Duoderm/Tegaderm dressing

III. distinct ulcer margin, dermis penetrated to fatty tissues and fascia.

• debride as necessary
• same as II.

IV. penetration to bone and muscle

• culture
  • PO/IV antibiotic as indicated
  • Bactroban ointment?
• debride
• cleanse
  • saline: use 20cc syringe with 20 gauge needle
• topical dressings (advanced)

venous leg ulcers

Any leg ulcer with an arterial peripheral pulse can be treated as a venous ulcer. Compression is key to therapy.

• elastic bandages, then stockings once healed. Stockings must provide 30-40mm of pressure at the ankle
• walking
• DuoDerm paste and dressing
• Unna Boot
  • change q2-3 weeks
  • may use with Omniderm dressing (permeable)
• Duke Boot
  • provides hemodynamic support and restores normal calf muscle pump therapy.
  • encourage ambulation
  • change weekly
    • zinc oxide paste gauze
    • Coban wrap at full stretch (watch arterial circulation!!)
• sugardine: to heal wounds, place in open wound twice daily. Refrigerate?
• • eight parts granulated sugar
  • 1 part providone-iodine ointment
  • 1 part providone-iodine solution

debriding

Mechanical

Venous leg ulcers: EMLA cream in a thick layer (max 10g) together with occlusive plastic wrap applied for 30-45 minutes prior to procedure. After debriding, cover with sterile petrolatum dressing; or below as indicated.

Nu-Gel Collagen Wound Gel (J&J)

Provides a moist wound environment and encourages autolytic debridement. Mild debridement.

Wet-to-dry dressings

Effective but non-selective, remove granulation tissue as well as necrotic tissue. The occlusive dressings also produce debridement through leukocytic migration. Can use Dakins solution (dilute QID, good for staph, strep, liquefy necrotic tissue) or normal saline.

Elase ointment: 10gm and 30gm tube

Works on necrotic soft tissue and purulent discharge. If there’s a hard eschar it must be removed or have slits made to allow penetration. Apply qD or more, change dressing BID-TID. Irrigate with saline each changing. Recheck weekly.

Mezinc

Semi-occlusive zinc releasing dressing. Supplied as 10x10 cm and 6x7 cm sizes.
Good for stripping of an eschar, apply directly to facilitate debridement

• cleanse wound with normal saline
• dry surrounding skin
• cut Mezinc to extend 0.5 cm beyond the wound margin.
• apply directly and anchor with steri-strips
  
• cover with absorbent pad and tape
• observe daily. May leave in place up to 5 days.
• exudate may be removed from the surrounding skin with dry gauze until full dressing change.

debriding and heavily exudating wounds

Mesalt

Gauze dressing, impregnated with hypertonic saline solution. Supplied as 5x5 cm and 10x10 cm patches. Apply dry. Useful for severe exudation wound with debris. Use until wound bed is clean.

procedure

• cleanse wound using normal saline (only)
• dry and apply Vaseline or barrier ointment to surrounding skin
• fluff Mesalt dressing and apply dry to wound.
• cover with absorbent pad and cover wound and surrounding area.
• change daily, or BID for severe drainage.

Actisorb

Activated charcoal cloth dressing that removes debris and controls odor and necrosis in chronic wounds. Less debriding than Mesalt. Supplied as 10x10 cm and 20x10 cm patches. Example: management of a necrotic breast mass.

procedure

• cleanse with normal saline
• apply barrier ointment to surrounding skin
• apply Actisorb dressing to the wound bed
• apply absorbent pad on top and secure with cover-all.
• repeat q24-48 hours, depending on drainage volume.

exudative wounds (not debriding)

Sorbsan (calcium alginate, Dow-Hickam)

• wet wounds: dermal ulcers, pressure ulcers. Forms hyrdrocolloid gel. Sterile non-woven dressing.
• size: 2x2, 3x3, 4x4 and packing strips
• cost: $3-6 each dressing

Tielle Hydropolymer dressing  (J&J)

• pressure, venous, diabetic ulcers
• moist environment, very absorbent
• can leave in place 5-7 days
• size: 3x3, 4x4"
• cost: $5-8 each

Fibracol Collagen-Alginate (J&J)

• soft, absorbent dressing. Less absorbent than Sorbasan?
• size: 2x2, 4x4, 4x8"
• cost: $3-$14 each dressing

partial-thickness wounds/ulcers

For "road rash", start with Nu-Gel or Duoderm CGF, can switch to Bioclusive or Tegaderm as heals (cheaper).

procedure

• cleanse with normal saline
• dry
• if using paste fill wound cavity
• apply over wound, extend 1.5 inches beyond margins
• “picture frame” using paper tape
• date dressing
• change qweekly or prn if leaking

Tegaderm (3M), Bioclusive (J&J)

• superficial wounds  incl "road rash"
• transparent, permeable to air and moisture
• 2x3 and 4x5"
• $.5 - $1 each

Duoderm Extra-Thin CGF and CGF Spots

• superficial, minimally exudative wounds incl "road rash"
• translucent
• 1x1 "spots", 4x4, 6x6, 8x8
• $4 - $7 each

Nu-Gel occlusive-hydrogel (J&J)

• partial-thickness wounds that have decreasing exudate, may be day 2-3
• severe or early "road rash"
• moist healing environment
• translucent -- allows monitoring
• 3x3 and 6x8"
• $4 to $8 each

Duoderm CGF

• partial-thickness wounds that have decreasing exudate
• creates a moist surface across wound, prevents dehydration and scab formation
• facilitates autolytic debridement
• opaque
• 4x4, 6x6, 8x8
• $6 - $ 25 each

Topical Steroids

widespread use

Mix steroids with a 1 lb jar of EUCERIN (or acid mantle cream for less greasy feel).

• ATOPIC ECZEMA: 5 gm hydrocortisone powder makes 1% hydrocortisone.
• PSORIASIS: kenalog 5 ml amp (10mg/ml).

types

Creams are usually best, lotions for hairy areas or large surfaces, gels for mucosal surfaces. Ointments are more potent. Start strong, if get response change to weaker prep. Occlusion increases effect 10x. If something worsens on steroids r/o fungus. PULSE DOSING: get remission with 2 weeks of diprolene then use Sat-Sun only and emollient rest of week.

preparations

avail. 15, 60 g size

HIGH POTENCY (scrape for fungus prior to use)

• aristocort cream (HP) .5%
• diprolene ointment .05%
• topicort .25% cream, gel, ointment, less $$

MID POTENCY

• kenalog ointment, cream or lotion .1% (see bulk prep above)
• aristocort ointment .1%

LOW POTENCY

• hydrocortisone 1% (OTC .5%) (see bulk prep)
• tridesilon cream .03%

Therapeutics (see steroids below)

acne

systemic antibiotics (inflammatory acne)

• erythromycin (Emycin) 333 mg PO TID
• doxycycline100 mg PO BID

topical therapy

• retin-A cream .05% in 20g and 45 g sizes
• Also .1% cream and .01% and .025% gel if want more drying. Use q2 nights for 2 w then qhs. NEED SUN PROTECTION (PreSun factor 15 or better, non-comedogenic variety). Esp. for non-inflammatory stage, after pus clear.
• benzac (benzyl peroxide) 5% and 10% in 60 g tube.
• erycette pledget: 60 per box (bid)
• T-Stat 2% solution (erythro.): 60 ml with applicator, esp. for comedomal acne.
• benzamycin: 5% benzyl peroxide and erythromycin; good for inflamm. acne. BID if alone, in am when use retin-A hs.

actinic keratosis

• Fluoroplex 1% solution (5-fluorouracil) BID x 2w on face and v-neck
• Efudex 5% cream for arms and back for 6-8w.
• Topicor emollient .25% for 1-2w.

antifungals and onychomycosis

topical

• lotrimin (clotrimazole) 1% cream (15,30, 45g)
• nizoral (ketoconazole) 2% cream (15,30g)

systemic, esp. onychomycosis

Costly, side-effects, variable effect, can recurr.

• itraconazole (Sporanox) 200 mg qD for 12 weeks or 200 mg BID for 1 wk/m for 3-4 months (cheaper)
• terbinafine (Lamisil): 250 mg daily x 12 weeks (toenail) or 250 mg qD x 6 weeks (fingernail)

atopic dermatitis

(Hurwitz, Clinical Pediatric Dermatology)

dove soap, emollient (eucerin or acid mantle cream) post bathing, erythromycin if any evidence of pyoderma (TID x 2w then BID x 2-3w more), cotton clothes, dietary revision. If icthyosis (present 20%) add 3-6% lactic acid to HC mixture. Lacticare (6% NH4 lactate) good for eliminating scales.

dietary revision

(food in under 2yo, inhalant in over 4 yo)

• avoid foods producing flushing, sweating, rash
• suspect: milk, wheat, eggs, tomatoes, citruses, chocolate, wheat and wheat products, spiced foods, fish, nuts and peanut butter

cleaning

• tepid bath
• cetaphil

drugs and lotions

• 1% hydrocortisone (see low cost recipe below)
• hydroxyzine (atarax) 1-2 mg/kg/hs (HUGE dose)
• cetaphil lotion for cleansing qD-BID prn
  • apply liberally, rub gently until light foaming occcurs
  • wipe with diaper or soft cotton cloth

wet compresses

Burrow’s Solution (AlAcetate)

• Domeboro tablet, 1 in a pint of tepid water
• apply wet dressing for <= 5 days using a handkerchief. Allow to dry and reoisten. Body temperature. Follow with topical steroids.

head lice

All therapy requires consistent louse combing to remove any nits. Treat, comb, cut hair short if possible, then recomb.

• 1% permethrin shampoo (RID)
• 5% permethrin cream (Elimite, approved for scabies)
  • leave on clean,dry hair overnight under a show cap for treatment failures.
• ivermectin (Mectizan) single dose 200 mcg/kg. (review literature)
  • if fail all other therapy, give one dose and repeat in 10 days.

intertrigo

Zeesorb Powder

moisturizers

eucerin cream (oily), nutraderm, acid mantle cream (emollient, less greasy feel).

plantar wart

scrape and duofilm BID (lactic/ASA); (same as ASA but 2x strength)

poison ivy/contact dermatitis

prednisone 1-2 mg/kg over 2 week taper. For recalcitrant might need 3 weeks, ex 60 mg qD for 1 week, 40 mg qD for 1 week, 20 mg qD for 1 week. For blistering eczema Burrow's soln soaks 1:40, Domboro (Al subacetate) 1 pill to pint water and soak. Medrol dose pack starts with two low a dose and finishes too soon.

pruritis

Sarma lotion (OTC, methol and camphor)

psoriasis

calcipotriene: few side effects, works as well as steroids.

scabies

DX by placing immersion oil on skin, scrape with scalpel, trsfr to slide, view 10x. Itching 4-6 w post initial infestation. No old clothes, bedding x 72h.

• Permethrin 5% cream first line therapy.
• Eurax in pregancy (less effective).
• ivermectin (Stromectol) 150-200 mcg/kg of body weight -- not approved. Consider with dermatology review for resistant scabies.

sebaceous cyst

Iodine Crystal to dry up a sebaceous cyst

seborrheic dermatitis

shampoo qD, topicort GEL (liquefies) .05% qD.

soaps

DOVE, PURPOSE, NEUTROGENA. If cannot use soap at all try cetaphil lotion as subst.

xanthelasma

• Haygood LJ, Bennett JD, Brodell RT. Treatment of xanthelasma palpebrarum with bichloracetic acid. Dermatol Surg. 1998 Sep;24(9):1027-31.