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

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 Professor of Clinical Dermatology University of California, San Francisco A preview • Fictional patient “Spots,” skin cancers, melanoma • Series of dermatology visits • Numerous concerns • Changing mole • Red leg • Drug eruption 1

10/2/19 Melanoma Our patient presents with a changing mole A = asymmetry B = irregular border C = color D = diameter >6mm E = evolution complete biopsy Melanoma Melanoma: initial evaluation D/dx of a pigmented lesion? Seborrheic keratoses Lentigo Pigmented BCC • Prognosis is DEPENDENT on the depth of lesion (Breslow � s depth) – < 1mm thickness is low risk – > 1mm consider sentinel lymph node biopsy • benign scaly papule • flat, even color • pearly papule • stuck-on tan, ovoid • irregular borders • prominent papule/ plaque telangiectasias • sun-exposed areas: • +/- symptoms • flecks of pigment face, dorsal hands 2

10/2/19 What is the recommended frequency of skin Common non-melanoma skin cancers cancer screening in asymptomatic adults? • USPTF: 2016 update Basal cell carcinoma Squamous cell carcinoma - insufficient evidence to assess benefits, harms of visual skin exam by a clinician • pearly papule or plaque • scaly pink plaque, nodule - Primary care sensitivity 42-100% melanoma - central ulceration • sun-damaged areas - Primary care specificity 70-98% melanoma - telangiectasia • potential for metastasis, JAMA 2016; 316(4):429-435 • slow growing invasion Ann Int Med 2009; 150(3):188-193 Ultraviolet radiation Prevention? Let’s talk about photoprotection UVA: 320-400nm UVB: 290-320nm Photoaging, melanoma Sunburn, skin cancer, melanoma Not blocked by glass, clouds, ozone Blocked by clouds, ozone 3

10/2/19 Sunscreen and the UV spectrum Counseling: Chemicals -> systemic absorption SPF 30 Broad-spectrum Nano-technology Vitamin D Sunscreen versus sunblock Sunscreen ban 2018: https://www.aad.org/public/spot-skin-cancer/learn-about-skin-cancer/prevent/is-sunsceen-safe Hawaii bans oxybenzone, octinoxate 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 Photoprotection Next clinic visit: The red leg 4

10/2/19 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 5

10/2/19 Fever, leukocytosis, red leg Cellulitis • Unilateral • GAS, Staph aureus • Rapid spread • Toxic-appearing patient • WBC up, LAD, streaking Fever, leukocytosis, red leg Erysipelas • Superficial cellulitis (leg, face) • Strep (GAS > GBS) • F>M • Involves lymphatics • Clue: raised, shiny plaques 6

10/2/19 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* 7

10/2/19 No fever, no leukocytosis, but a red leg Necrotizing fasciitis history of topical neomycin for � rash � • 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 Contact dermatitis Red leg: Pearls Not all red legs are cellulitis • clue: red, angry, weeping, itch>pain • patient looks well Bilateral cellulitis is rare. Reconsider diagnosis • history is key • neomycin is top contact allergen • also: poison oak (rhus) topical diphenhydramine 8

10/2/19 Drug eruptions When do the symptoms subside? Morbilliform drug eruption Up to 1 week • common • erythematous macules, papules (can be confluent) • pruritus • no systemic symptoms • begins in 1 st or 2nd week • treatment: -D/C med if severe -symptomatic treatment: hydroxyzine, topical steroids 9

10/2/19 Drug eruptions: Signs of a serious drug eruption: when to worry • Mucosal involvement (ie, oral ulcerations) Minimal systemic symptoms Systemic involvement • Erythroderma • Skin pain Morbilliform drug eruption DRESS • Target lesions AGEP • Bullous lesions Stevens-Johnson (SJS) • Denudation (skin falling off in sheets) Toxic epidermal necrolysis • Pustules (TEN) • Facial swelling, anasarca Simple Complex • Fever • Internal organ involvement: liver, kidney > lung, cardiac Potentially life threatening Require systemic immunosuppression Target lesions: Stevens Johnson Syndrome (SJS) Mucosal involvement: SJS/ TEN 10

10/2/19 Facial swelling: drug-induced hypersensitivity Bullous lesions, denudation, pain: TEN 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 Q&A 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 11