10/2/19 Disclosures Dermatology in Primary Care: I have no - - PDF document

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10/2/19 Disclosures Dermatology in Primary Care: I have no - - PDF document

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10/2/19 Disclosures Dermatology in Primary Care: I have no conflicts of interest to disclose. Recognition and treatment of common disorders of the skin I may discuss off-label use of treatments for cutaneous disease. Kanade Shinkai, MD PhD

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10/2/19 1

Dermatology in Primary Care: Recognition and treatment of common disorders

  • f the skin

Kanade Shinkai, MD PhD Professor of Clinical Dermatology University of California, San Francisco

Disclosures

I have no conflicts of interest to disclose. I may discuss off-label use of treatments for cutaneous disease.

A preview

  • Fictional patient
  • Series of dermatology visits
  • Numerous concerns
  • Changing mole
  • Red leg
  • Drug eruption

“Spots,” skin cancers, melanoma

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Our patient presents with a changing mole

Melanoma

Melanoma

A = asymmetry B = irregular border C = color D = diameter >6mm E = evolution complete biopsy

Melanoma: initial evaluation

  • Prognosis is DEPENDENT on the depth of

lesion (Breslows depth) – < 1mm thickness is low risk – > 1mm consider sentinel lymph node biopsy

D/dx of a pigmented lesion?

Seborrheic keratoses

  • benign scaly papule
  • stuck-on tan, ovoid

papule/ plaque

  • +/- symptoms

Lentigo

  • flat, even color
  • irregular borders
  • sun-exposed areas:

face, dorsal hands Pigmented BCC

  • pearly papule
  • prominent

telangiectasias

  • flecks of pigment
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Common non-melanoma skin cancers

  • pearly papule or plaque
  • central ulceration
  • telangiectasia
  • slow growing

Basal cell carcinoma Squamous cell carcinoma

  • scaly pink plaque, nodule
  • sun-damaged areas
  • potential for metastasis,

invasion

What is the recommended frequency of skin cancer screening in asymptomatic adults?

  • USPTF: 2016 update
  • insufficient evidence to assess benefits,

harms of visual skin exam by a clinician

JAMA 2016; 316(4):429-435 Ann Int Med 2009; 150(3):188-193

  • Primary care sensitivity 42-100% melanoma
  • Primary care specificity 70-98% melanoma

Prevention? Let’s talk about photoprotection Ultraviolet radiation

UVA: 320-400nm Photoaging, melanoma Not blocked by glass, clouds, ozone UVB: 290-320nm Sunburn, skin cancer, melanoma Blocked by clouds, ozone

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Sunscreen and the UV spectrum

Sunscreen ban 2018: Hawaii bans oxybenzone, octinoxate Sunscreen versus sunblock

https://www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/prevent/is-sunsceen-safe https://www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/prevent/how-to-select-a-sunscreen Matta et al (2019) JAMA, 321:2082-2091

Counseling: SPF 30 Broad-spectrum Nano-technology Vitamin D Chemicals -> systemic absorption

Photoprotection Next clinic visit: The red leg

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D/dx of the red leg?

  • erysipelas
  • cellulitis
  • DVT
  • vasculitis
  • pyomyositis
  • necrotizing fasciitis
  • asteatotic dermatitis
  • venous stasis dermatitis
  • contact dermatitis

Red Leg: Speed rounds

No fever, no leukocytosis, bilateral itchy red legs Stasis dermatitis

Key features:

  • bilateral erythema, edema (L>>R)
  • varicose veins
  • brawny (golden) hyperpigmentation
  • no WBC, LAD, lymphangitis

Rx: compression topical steroids

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Fever, leukocytosis, red leg

  • Unilateral
  • GAS, Staph aureus
  • Rapid spread
  • Toxic-appearing patient
  • WBC up, LAD, streaking

Cellulitis Fever, leukocytosis, red leg

  • Superficial cellulitis (leg, face)
  • Strep (GAS > GBS)
  • F>M
  • Involves lymphatics
  • Clue: raised, shiny plaques

Erysipelas

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Fever, leukocytosis, minimally red leg not responding to antibiotics Pyomyositis

  • bacterial infection of muscle
  • S aureus (77%), strep (12%)
  • risk factors:
  • trauma
  • travel (tropics)
  • immunocompromised
  • Dx: MRI
  • Rx: surgical drainage

psoas, gluteus, quadriceps*

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Necrotizing fasciitis

  • Strep/ staph infection of fascia
  • post-surgical
  • 20% mortality
  • pain out of proportion to exam
  • rapid spread (minutes to hours)
  • Dx: MRI
  • Rx: surgical debridement

IV antibiotics

No fever, no leukocytosis, but a red leg history of topical neomycin for rash Contact dermatitis

  • clue: red, angry, weeping, itch>pain
  • patient looks well
  • history is key
  • neomycin is top contact allergen
  • also:

poison oak (rhus) topical diphenhydramine

Red leg: Pearls

Not all red legs are cellulitis Bilateral cellulitis is rare. Reconsider diagnosis

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Drug eruptions Morbilliform drug eruption

  • common
  • erythematous macules, papules

(can be confluent)

  • pruritus
  • no systemic symptoms
  • begins in 1st or 2nd week
  • treatment:
  • D/C med if severe
  • symptomatic treatment:

hydroxyzine, topical steroids

When do the symptoms subside? Up to 1 week

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Drug eruptions: when to worry

Potentially life threatening Require systemic immunosuppression

Morbilliform drug eruption Simple DRESS AGEP Stevens-Johnson (SJS) Toxic epidermal necrolysis (TEN) Complex Minimal systemic symptoms Systemic involvement

Signs of a serious drug eruption:

  • Mucosal involvement (ie, oral ulcerations)
  • Erythroderma
  • Skin pain
  • Target lesions
  • Bullous lesions
  • Denudation (skin falling off in sheets)
  • Pustules
  • Facial swelling, anasarca
  • Fever
  • Internal organ involvement: liver, kidney > lung, cardiac

Target lesions: Stevens Johnson Syndrome (SJS) Mucosal involvement: SJS/ TEN

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Bullous lesions, denudation, pain: TEN Facial swelling: drug-induced hypersensitivity syndrome or DRESS Also: eosinophilia, transaminitis, renal failure Drug eruption pearls

Look for cutaneous signs of a potentially-fatal drug eruption Consider ordering labs if you are not sure

Lab order What you are looking for Drug eruption CBC with differential Eosinophilia Any drug hypersensitivity (may be slightly increased in simple drug eruption) ALT, AST Transaminitis Drug-induced hypersensitivity syndrome BUN, Cr Acute renal failure Drug-induced hypersensitivity syndrome, AGEP

Q&A