Dermatology For Boards (And Real Life) Rita Khodosh, MD, PhD - PowerPoint PPT Presentation

Other Groin Rashes Tinea Cruris • Scaly plaque • Serpiginous scaly border - Topical Imidazoles or Allylamines (Terbinafine) - Oral Terbinafine for extensive tinea corporis

Question A 69-year-old female sees you for an annual examination. She asks you to look at her toes, and you note a fungal infection in five toenails . She says the condition is painful and limits her ability to complete her morning walks . She asks for treatment that will allow her to resume her daily walks as soon as possible. Her only other medical problem is allergic rhinitis which is well controlled.

Onychomycosis

Question Which one of the following would be the most appropriate treatment for this patient? A) Oral griseofulvin ultramicrosize (Gris-PEG) daily for 12 weeks B) Oral terbinafine (Lamisil) daily for 12 weeks C) Topical terbinafine (Lamisil AT) daily for 12 weeks D) Topical ciclopirox (Penlac Nail Lacquer) daily for 12 weeks E) Toe nail removal

Onychomycosis • Dermatophyte infection most common—tinea unguium • Candida and non-dermatophyte mold ( Fusariam , Aspergillus , others) • Diagnosis: PAS—most sensitive, Culture--only about 50% sensitivity • Treatment not necessary if asymptomatic • Treat if recurrent cellulitis (diabetics), pain, immunosuppression, patient preference

Onychomycosis Treatment • Not that effective • Treat for presumed dermatophyte infection while waiting for culture results • Oral Terbinafine 250mg daily for 12 weeks • Cure rate about 70%, but only 35% at 5 years • Itraconazole, same cure rate, more side effects • Topicals: Efinaconazole, Tavaborole, Ciclopirox (cure rates 25%, 18%, 7% respectively)

Erythema Migrans 7-14 days after tick bite

Lyme Disease - Caused by Borrelia spirochete transmitted by bite of Ixodes deer tick - In early Lyme disease serologic testing is likely to be negative - Diagnosis should be made based on the clinical picture (EM lesion or lesions, non- specific viral symptoms, and history of living in or travel to an endemic area Treatment: - Doxycycline 100mg BID for 10-21 days or - Amoxicillin 500mg po BID for 14-21 days

Secondary Syphilis Treponemal test (FTA-ABS) to screen and non-treponemal test (RPR) to confirm Treat with Penicillin G

Scabies

Scabies • Erythematous papules, pustules, burrows • Likes hands, skin folds, groin, less on head • Very itchy • SCRAPE IT • Treat all family members • Permethrin cream x 2 • Ivermectin PO if crusted

Question Which one of the following would be considered first-line therapy for mild to moderately severe psoriasis confined to the elbows and knees? A) Phototherapy using ultraviolet B light B) Methotrexate C) Etretinate (Tegison) D) Betamethasone dipropionate (Diprolene)

Psoriasis Well-defined, erythematous plaques with silvery scale

Psoriasis Treatment • LOCALIZED DISEASE—TOPICAL TREATMENT • Topical steroids (Clobetasol) • Topical retinoids (Tazorac) • Topical Vitamin D derivatives (Calcipotriene) • Tar • Combinations of topical treatments are more effective • Intralesional Steroids • NB UVB (more generalized disease)

Psoriasis

Psoriasis Treatment • Generalized disease, arthritis—systemic treatment • Methotrexate • Acitretin, Cyclosporin (less often) • Apremilast—Otezla (oral PDE4 inhibitor) • Biologics: - TNF alpha inhibitors (Adalimumab-Humira) - IL 12/23 inhibitor (Ustekinumab-Stelara) - IL 17 inhibitors (Secukinumab-Cosentyx)

Psoriasis Real Life • Psoriasis patients have systemic inflammation • Co-morbidities: obesity, diabetes, cardiovascular disease • More severe psoriasis--higher risk of co- morbidities • Counsel patients about diet, exercise, treat co- morbidities • TNF alpha inhibitors may be more effective at reducing cardiovascular risk than Methotrexate

Question While vacationing, a 27-year-old white male was exposed to poison ivy . Between 48 and 72 hours after exposure he developed a pruritic, erythematous, papulovesicular eruption on his arms and neck. He was given oral methylprednisolone (Medrol Dosepak) , starting with 24 mg/day and tapered by 4 mg/day over 6 days . His condition began to improve, but on day 6 he noted a dramatic exacerbation of the eruption with intense pruritus, erythema, and vesiculation, involving extensive areas of his arms, neck, and face.

Allergic Contact Dermatitis Poison Oak

Question The most appropriate management at this time would be to A) prescribe a superpotent topical corticosteroid B) repeat the oral methylprednisolone treatment C) begin diphenhydramine (Benadryl), 4 times a day D) begin high-dose oral prednisone and taper over 2 weeks E) discontinue all medications and recommend cool compresses

Allergic Contact Dermatitis to Urushiol in Poison Oak (Ivy or Sumac) • Type IV hypersensitivity reaction • Localized eruptions can be treated with potent or superpotent topical steroids (clobetasol) • Oral prednisone is given for more extensive eruptions • Needs to be started at a high dose (60mg) and tapered slowly over 2-3 weeks • If tapered too quickly, patient will flare • Antibiotics if secondarily infected (Staph)

Eczema/Atopic dermatitis

Eczema/Atopic dermatitis • Itchy erythematous scaly papules and plaques • Patients with atopy (allergic rhinitis, asthma, FH) • Problem with epidermal barrier and immune dysregulation • Treatment MUST address both!

Eczema Treatment • Emollients, gentle skin care, avoidance of irritants and topical allergens • Topical steroids 1 st line • Topical calcineurin inhibitors • Do not use antibiotics unless impetiginized • Treat pruritus (sedating antihistamines) • Phototherapy • Immunosuppressive agents for severe cases • No evidence that dietary restriction is useful

Question Patients presenting with erythema multiforme often have a prodromal history of A) egg allergy B) recent immunization C) herpes simplex infection D) thennal trauma E) streptococcal infection

Erythema Multiforme

Erythema Multiforme • Target lesions (three zones: dark dusky center, pale ring of edema, erythematous halo) • Can be atypical, with just 2 or 1 zone • Hypersensitivity reaction to • Infections (most commonly HSV , Mycoplasma pneumoniae , many others) • Drugs are a less common cause (NSAIDs, Antibiotics, Anticonvulsants, others) • If recurrent, treat with suppressive HSV therapy

Erythema Multiforme due to Mycoplasma pneumoniae infection Check mycoplasma serologies (IgM, IgG) Treat infection with azythromycin or doxycycline

Stevens Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN)

Stevens Johnson Syndrome (SJS) & Toxic Epidermal Necrolysis (TEN) • Severe mucocutaneous reaction usually caused by a medication • Starts with fever, flu-like symptoms, mucosal pain • Mortality up to 30%, higher in adults • Allopurinol • Aromatic anticonvulsants (phenobarbetal) • Antibacterial sulfonamides (Bactrim) • Lamotrigine • STOP the MEDICATION and call a derm and a burn center

Question A 20-year-old female college tennis player presents with painful anterior lower leg lesions. You note several 2- to 3- cm deep, tender, warm lesions over both shins. The patient denies specific trauma or increased exercise. The most significant etiology to be considered in this case is A) papular urticaria B) early rheumatoid arthritis C) shin splints D) superficial thrombophlebitis E) oral contraceptive use

Erythema Nodosum

Erythema Nodosum • Panniculitis • Delayed-type hypersensitivity reaction to: • Infection (Streptococcal most common) • Drugs (OCPs, antibiotics) • IBD • Pregnancy

Erythema Nodosum Treatment • Self-resolving, but takes several weeks • Treat underlying condition • Supportive treatment • Leg elevation • Rest • NSAIDs • If severe, can consider short course of low- dose prednisone (20mg 7-10 days)

Acne

Acne • Assess severity • Mild to moderate—topical therapy (retinoids, Benzoyl Peroxide, clindamycin) • Moderate—course of antibiotics (Doxy, Keflex, Bactrim), limit to 6 months. Hormonal treatments for women (OCP, spironolactone) • Severe (nodulocustic/scarring)—Isotretinoin (teratogen, otherwise quite safe)

Urticaria Pruritic lesions last < 24hours

Urticaria • Acute urticaria < 6 weeks • Chronic urticaria > 6 week • Triggers - Foods—acute - Medications and Infections - Over 50% of chronic urticaria is idiopathic • Treat with anti-histamines (non-sedating up to 4 times the daily dose) • Do not use prednisone, especially for chronic

Question A 30-year-old white male presents with a polymorphous skin rash consisting of grouped vesicles,urticarial wheals, and papular lesions distributed symmetrically over the elbows, knees, and buttocks. A skin biopsy shows IgA deposition and a diagnosis of dermatitis herpetiformis is made. The mainstay of therapy is A) dapsone B) prednisone C) cephalosporins D) methotrexate E) tetracycline

Dermatitis Herpetiformis

Dermatitis Herpetiformis • Associated with gluten sensitivity—celiac disease • ELISA for IgA tissue transglutaminase antibodies and IgA epidermal transglutaminase antibodies Treatment • Strict gluten-free diet works slowly • Dapsone works quickly, can later be discontinued

Question A 25-year-old female has an annular rash on the dorsal surface of both hands. The rash does not respond to initial treatment with an antifungal medication, and a biopsy reveals granuloma annulare . Which one of the following would be the most appropriate advice for this patient? A) Allow the rash to resolve without further treatment B) Cover the rash because it is contagious C) Treat the rash with systemic corticosteroids D) Treat the rash with a stronger antifungal medication

Granuloma Annulare

Granuloma Annulare • Non-scaly erythematous annular papules and plaques on dorsal hands, elbows, feet, knees • A benign, reactive condition, can self resolve • Treatments included superpotent topical steroids, intralesional steroids, phototherapy • Systemic treatment, such as plaquenil or dapsone, is offered for disseminated, symptomatic GA that does not respond to phototherapy

Question A 50-year-old female presents with a 3-week history of a moderately pruritic rash, characterized by flat- topped violaceous papules 3–4 mm in size. The lesions are located primarily on the volar wrists and forearms, lower legs, and dorsa of both feet. Ten days after the rash first appeared she went to the emergency department and was treated for “possible scabies,” but the treatment has made little or no difference.

Question Which one of the following treatments is indicated at this time? A) Clobetasol (Cormax, Temovate) 0.05% ointment B) Permethrin 5% cream C) Tacrolimus (Protopic) 0.1% ointment D) Triamcinolone 0.1% cream

Lichen Planus • 5 P ’ s: pruritic, purple, planar (flat-topped), polygonal papules • Wickham striae • wrists/ankles classic • Oral/genital involvement • Can be erosive • Etiology unknown • ?Associated with Hep C?

Lichen Planus • Benign condition, erosive disease (oral/genital) requires more aggressive treatment • Potent or superpotent topicals steroids (fluocinonide, clobetasol) are first line tx • Topical calcineurin inhibitors can be used (tacrolimus) • Other tx: phototherapy, oral prednisone course, oral retinoids (acitretin), MTX, plaquenil

Alopecia Scarring vs Non-Scarring Non-scarring Scarring Alopecia Areata Discoid lupus

Alopecia Non-scarring Scarring - Androgenetic - Discoid lupus (pattern) - Lichen planopilaris - Alopecia areata - Folliculitis decalvans - Syphilis - Sarcoidosis - Trichotillomania - Traction-late

Question A 5-year-old African-American child has been experiencing scalp pruritus for several months, along with hair loss in a “moth- eaten” pattern. Small block dots can be seen within the larger alopecic patches. A potassium hydroxide (KOH) reparation shows occasional branching hyphae and multiple spores.

Tinea Capitis

Tinea Capitis • Moth-eaten pattern alopecia in a child • Erythema • Scale • Black Dots (hairs broken off at skin surface) • Boggy induration (Kerion)

Question Which one of the following is the preferred treatment? A) Topical ketoconazole (Nizoral) B) Topical minoxidil (Rogaine) C) Oral griseofulvin (Fulvicin) D) Oral hydroxyzine (Atarax) E) Psoralen-ultraviolet A (PUVA) therapy