Dermatology in Family Medicine
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Transcript Dermatology in Family Medicine
Dermatology in Family Medicine 1
Clerkship Briefing
Dr. Clayton Dyck
Dermatology in Family Medicine 1
(Or, How To Suck Less in Derm)
Clerkship Briefing
Dr. Clayton Dyck
Objectives
1.
2.
3.
4.
Use appropriate terminology to describe
common skin presentations seen in family
medicine
Apply a systematic approach to their
diagnosis
Know the modalities used in their treatment
Understand basic principles of topical
therapy
A call from Victoria Beach…
Dermatologic Diagnosis
Approach is same as for any other
medical condition:
History
Examination
Formulate differential diagnosis
Apply investigations to confirm/rule out
Dermatologic Diagnosis
Use whatever algorithm you like:
TTIINNMAP
VITTAMIN DD
CITTIN VD
Tools Used in Dermatologic
Assessment
Our ears
Our eyes
Our hands
Our noses (thankfully infrequently!)
Lab tests
Biopsies
Scrapings/clippings
Blood and urine samples
Questions to ask
Onset
Pattern
Skin symptoms
Systemic symptoms
Related factors
Environmental
Occupational
Other medical conditions
Drugs
Others affected?
To name a few…
An overview of terms…
macule
papule
plaque
nodule
pustule
vesicle
bulla
ulcer
wheal
purpura
excoriation
papulosquamous
Some Common Conditions
Herpes Zoster
VZV reactivation
Pain may precede rash
Usually dermatomal
Crusts usually fall off in 2-3 weeks
Worse in immunocomprimised, elderly
Herpes Zoster - Treatment
Wet dressings
Antivirals
May reduce post herpetic neuralgia
Within 48-72 hours of vesicle appearance
Eg famcyclovir 500 mg tid x 7 days
Ophthalmic Zoster Treatment
Hutchinson’s sign
Refer to ophthalmologist urgently
50% complications if antivirals not given
Tinea infections
Dermatophytes, candida
Topical antifungals
Keep dry!
If resistant/severe consider
Scraping
DM, immunocomprimised
PO antifungals
Onychomycosis
Trichophyton sp., Candida
Do KOH prep, culture first
Topical treatment only in simple cases
Usually needs oral treatment
Eg Lamisil 250 mg od x 12 weeks
Watch for toxicity
Dyshydrotic Eczema
Common if hands frequently moist/wet
Consider other irritants, allergens, fungi
Watch for superinfection
Treatment:
Moisturize x 3
Topical steroids (usually moderate to high
potency)
Topical immune modulators
Psoriasis
Peaks in 20s and 50s
Multifactorial
Exacerbated by trauma, infections,
drugs, winter
5-8% have psoriatic arthritis
Psoriasis - Treatment
Topical tar (ick!)
High - ultrahigh potency steroids
Vitamin D analogues
Phototherapy
Immunosuppressive agents
Topical Therapy
Choice of vehicle important:
Powder
Paste
Solutions (water or alcohol based)
Gels
Lotions
Creams
Ointments
Topical Therapy
Usually only a thin layer needed
1 gram = 10 cm x 10 cm area
OD to BID usually sufficient
Topical Steroids
Consider thickness of skin, thickness of
lesion, moistness of area
Choose one drug of each potency
Consider occlusion with lower potency
steroids
Avoid extended periods of treatment
Topical Steroids - Examples
(by potency)
Low
Hydrocortisone 1 %
Medium
Betamethasone 0.1%
High
Mometasone
Ultrahigh
Augmented
betamethasone
Topical Steroids - Adverse Fx
Irritation
Hypopigmentation
Skin breakdown
Rebound phenomenon
Atrophy
Striae
Systemic adsorbsion
And many more!
Nevus
Superficial spreading melanoma
Basal cell carcinoma
Cherry hemangioma
Actinic keratosis
When to biopsy
Change in:
Colour
Size (<6 mm)
Shape
Especially if weeks to months, rather than months
to years
Bleeding
Any doubt
Impetigo
S. aureus, S. pyogenes, or both
Common in schools, daycares
Treatment
Bactroban tid x 10 days
Cloxacillin 250 qid x 5-10 days
Keflex 250 qid x 5-10 days
Resistance common, may need swab
Consider Bactroban in nares bid x 5 days
Fifth’s Disease
Parvovirus B19
Peaks in school age children
Mild flu-like symptoms
Arthritis in 10%
Teratogenic, especially before 20 weeks
Erysipelas
Group A Streptococci
Sudden onset, can be painful
Fever, sick
Penicillin V po/iv for 2 weeks
Macrolide if penicillin allergic
Hand Foot and Mouth Disease
Coxsackie A16 virus
Mild flu Sx, fever
Usually children < 5 years
Self limited, resolve within 10 days
Scabies
Itchy - worse at night
Usually more than one family member
A great mimic - consider if:
Impetigo
Eczema
Idonomata
Scabies - Treatment
Treat family concurrently
Wash all clothes/bedding/towels
Permethrin cream
Everywhere but hair, mouth, eyes
Rinse after 12 hours
Infants - precipitated sulfur
Consider 2nd treatment
Itchiness persists days to weeks later
Some short snappers
Pityriasis rosea
paronychia
Molluscum contagiosum
rosacea
Stasis dermatitis
wart
Subungual hematoma
Take home “berries”
Know your terminology
When in doubt - back to first principles
Always keep a differential diagnosis
Use the right topical for the job
Don’t be afraid to overbiopsy
Objectives
1.
2.
3.
4.
Describe common skin presentations
seen in family medicine
Apply a systematic approach to their
diagnosis
Know the modalities used in their
treatment
Understand basic principles of topical
therapy
References
Skin Diseases: Diagnosis and Treatment, T P
Habif et al, Elsevier 2005
Color Atlas and Synopsis of Clinical
Dermatology, T B Fitzpatrick, McGraw-Hill,
1997
Images.MD (NJM Library Database)
http://missinglink.ucsf.edu/lm/DermotologyGloss
ary
Questions?
Or itching to leave?