Transcript Some

KIN 405: Medical Aspects of
Sports
Dermatology: Recognizing
Illnesses and Disorders of the
Skin
Skin Lesions
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Often overlooked or trivialized
Can signify serious disease in well
patients
Local conditions
Systemic conditions
Difficult for many health professionals to
recognize
Athletic Trainers’ Goals
 Recognize various
forms of skin lesions
 Reassure patients that
every little blemish is
NOT skin cancer
 Refer for definitive
diagnosis and treatment
 Restrict competition for
athletes with
communicable illness
Presentation Outline
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Anatomy of the skin
Types of lesions
Rashes
Infections
– Bacterial
– Fungal
– Viral
Presentation Outline (cont)
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Skin cancer
Assessment techniques
Treatment techniques
Anatomy of the Skin
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Stratum corneum
Epidermis
Dermis
Pilosebaceous unit
Subcutaneous fat
Stratum Corneum
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Top layer of skin
Flakes off
imperceptibly
Barrier to noxious
substances
Totally replaced
every 27 days
Epidermis
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Protects against UV
damage
Provides cutaneous
immunity
Dermis
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Connective tissue
Provides elasticity &
strength
Contains blood
vessels, nerves, &
sweat glands
Skin splits when
dermis is cut
Pilosebaceous Unit
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Hair shaft
Hair follicle
Erector muscle
Sebaceous gland
Common site of
bacterial infections
Subcutaneous Fat
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Insulates
Protects
Kinds of Skin Lesions
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Macules
Papules
Plaques
Pustules
Vesicles
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Nodules
Desquamination
Bullae
Ulcers
Wheals
Macules
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Flat
Nonpalpable
Discolored
Less than 1cm
Causes of Macules
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Hypopigmentation
Hyperpigmentation
Permanent vascular abnormalities of
the skin
Transient capillary dilatation (erythema)
Hypopigmentation Macules
Vitiligo Depigmentation
Hyperpigmentation Macules
Café-au-lait spots
Permanent Vascular
Abnormalities of the Skin
CAPILLARY HEMANGIOMA OF INFANCY
PORT-WINE STAIN
Transient Capillary Dilatation
(Erythema)
Erythema Infectiosum (systemic viral)
Papules
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Latin for “Pimple”
Raised lesion
Less than .5 cm
Solid
Example of Papules
Rosacea
Plaques
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Large, raised lesion
Well-defined
Confluence of
multiple papules
Chronic rubbing
leads to
“lichenification”
(thickened skin)
Example of Plaques
PSORIASIS VULGARIS OF THE ELBOW
Pustules
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Circumscribed
Superficial
Contains purulent
exudate that may be
–
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–
–
white
yellow
greenish yellow
hemorrhagic.
Example of Pustules
Acne Vulgaris
Vesicles
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Latin for “little
bladder”
Fluid filled cavity
Less than .5 cm
Walls can be
translucent
Contains serum,
lymph, blood, or
extracellular fluid
Example of Vesicles
Nongenital herpes simplex virus (HSV) infection
Bullae
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Latin for “bubble”
Fluid filled cavity
Greater than .5 cm
Walls can be
translucent
Contains serum,
lymph, blood, or
extracellular fluid
Diabetic bullae
Nodules
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Latin for “small knot”
Palpable, solid
Round or ellipsoid
Epidermal, dermal,
or subcutaneous
Generally deeper
and larger than
papules
Example of Nodules
Adult T-Cell Leukemia/Lymphoma
Desquamination
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Proliferation of
epidermis resulting
in abnormally
formed stratum
corneum
“Scaly”
Large
(membranous) or
small (dust)
Example of Desquamination
Solar Keratosis
Ulcers
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Pathologically
altered tissue
(different from a
wound)
Epidermal - heals
w/out scar
Dermal - heals w/
scar
Example of Ulcers
Stage IV Pressure Ulcer on Sacrum
Wheals
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Hives
Rounded or flat
topped
Pale red
Transient
Can change rapidly
in size, shape, and
location due to
shifting edema in
the dermis
Example of Wheals
Cutaneous Vasculitis
Rashes
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Acne
Dermatitis
Intertrigo
Urticaria
Psoriasis
Seborrheic dermatitis
Pityriasis rosea
Acne
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Affects 75% of the population
Can involve inflammation of the
pilosebaceous unit
Food choices NOT causative
Endocrine and emotional links
Not contagious
Four stages
Grade I Acne
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Comedones
(blackheads)
Some whiteheads
Topical antibiotics
(clindamycin,
erythromycin
Benzoyl peroxide
gels (2%,5%,10%)
Tretinoin (Retin-A)
creams
Grade II Acne
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Erythematous
papules
Oral tetracycline
antibiotics added to
previous tx regimen
For females, oral
estrogens combined
with progesterone or
antiandrogens
Grade III Acne
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Pustules
Isotretinoin
(Accutane)
Contraception (2
forms) is absolutely
necessary
Do not combine
tetracycline and
isotretinoin
Risk of psychiatric
side effects
Grade IV Acne
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Cysts
Nodules
Scars
Dermatitis
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Inflammation of the skin
Sometimes called eczema
Many causes and forms (allergic vs
non-allergic)
Not contagious
Contact dermatitis caused by contact
with noxious substances (formaldehyde,
plant oils, rubber, etc)
Dermatitis-Signs and Symptoms
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Pruritis (itching)
Erythematous
papules
Vesicles (or bullae)
Crusting
Edema
Poison Ivy, 5 days post exposure
Dermatitis-Treatment
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Identify and remove
the etiologic agent
Bullae may be
drained, but tops
should not be
removed
Cool compresses
Topical
corticosteroids
Contact dermatitis from parabencontaining foot cream
Dermatitis-Treatment (cont)
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In severe cases,
systemic
corticosteroids may
be indicated
Prednisone: twoweek course, 70 mg
initially, tapering by
5 mg daily
Chronic contact dermatitis on the
hands of a concrete worker
Intertrigo
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Caused by friction in skin folds
Axilla, inframammary area, groin
Gradual and progressive skin abrasion
irritated by sweat and heat
Intertrigo-Treatment
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Mild topical
hydrocortisone
Zinc oxide ointment
Reduce friction
Corn starch/baby
powder
Expose to air
Urticaria
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Transient hives characterized by wheals
Pruritis
Caused by sunlight, medication or food
allergy, cold, and exercise
Urticaria
Wheals with white-to-light-pink color centrally
and peripheral erythema in a close-up view.
Cholinergic Urticaria
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Exercise-induced
wheals & pruritis
Hot shower may
also reproduce
symptoms
Urticarial papules on neck
w/in 30 minutes of vigorous
exercise
Cold-Induced Urticaria
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Caused by cold sensitivity
Ten minute application of ice pack
cause a wheal w/in five minutes of the
removal of the ice
Urticaria-Treatment
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Oral antihistamines
(Benadryl)
Avoidance of
causative agent
Prednisone
May compete as
long as pruritis is not
disabling &
breathing not
compromised
Urticaria as it appeared 5
minutes after stroking the skin
with a wooden stick. The patient
had experienced generalized
pruritus for several months with
no spontaneously occurring
urticaria.
Psoriasis
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Genetically inherited disease
Erythematous papules and plaques
Primarily on extensor surfaces
– elbows
– knees
– scalp
– intergluteal area
Psoriasis-Trigger Factors
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Trauma (Koebner
effect)
Drugs
Stress
Infections
Psoriasis of the elbow
Psoriasis-Treatment
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Limited course of
topical
corticosteroids (long
term application
causes skin
breakdown)
Triamicinolone
acetonide
(Aristocort, Kenalog)
Psoriasis-Treatment (cont)
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Anthralin (AnthraDerm cream -- not
for use on face or
skin creases)
Vitamin D analogues
(e.g., calcipotriol)
UV light therapy
No participation
restrictions
Seborrheic Dermatitis
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Common chronic dermatosis
Characterized by redness and scaling
occurring in regions where the
sebaceous glands are most active, such
as the face and scalp, and in the body
folds.
Mild scalp SD causes flaking (dandruff)
Seborrheic Dermatitis-Treatment
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Creams or
shampoos
containing
– selenium (Selsun
Blue)
– ketocanazole
(Nizoral)
Similar lesions were also
present in the retroauricular
areas and presternal chest.
Pityriasis Rosea
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Distinctive morphology
Characteristic course
“Herald” plaque lesion develops, usually
on the trunk, and
1 or 2 weeks later a generalized
secondary eruption develops in a typical
distribution pattern
Spontaneous remission in 6 weeks
without any therapy
Pityriasis Rosea (cont)
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Herald Patch (80 %
of patients) oval,
slightly raised
plaque
2 to 5 cm, bright red,
fine scale at
periphery
Pityriasis Rosea (cont)
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Long axes of the
lesions follow the
lines of cleavage in
a “Christmas tree”
distribution
Lesions usually
confined to trunk
and proximal arms
and legs
Rarely on face
Pityriasis Rosea-Treatment
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Pruritus may be controlled by UVB
phototherapy or natural sunlight
exposure if begun in the first week of
eruption.
Five consecutive exposures, starting
with 80 % of the minimum erythema
dose and increasing 20 % each
exposure.
Usually goes away by itself.
Infectious Disorders
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Bacterial Infections
Fungal Infections
Viral Infections
Bacterial Infections
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Impetigo & ecthyma
Abscess, furuncle, & carbuncle
Scarlet fever
Impetigo & Ecthyma
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Caused by
Staphylococcus
aureus and
Streptococcus
pyogenes
Impetigo-epidermis
Ecthyma-dermis
Scattered, discrete, thinSuperficial breaks in walled vesicles and bullae that
the skin
easily rupture and form
erosions.
Impetigo
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Transient superficial
small vesicles or
pustules, rupture
resulting in erosions,
which in turn
become surmounted
by a crust
Crusted (golden-yellow,
stuck-on) erosions
becoming confluent on the
nose, cheek, lips, and chin.
Ecthyma
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Ulceration with a
thick adherent crust
A large, circumscribed ulcer
with a necrotic base and
surrounding erythema in the
pretibial region.
Impetigo & Ecthyma-Treatment
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Mupirocin (Bactroban) applied three
times daily to involved skin and to nares
for 7 to 10 days.
Oral antibiotics (10 day course is
typical)
Highly infectious -- disqualify from
contact athletics until infection is cleared
by physician
Abscess, Furuncle, & Carbuncle
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Abscess - a circumscribed collection of pus
appearing as an acute or chronic localized
infection with tissue destruction.
Furuncle - an acute,deep-seated, red, hot,
tender nodule or abscess that evolves from a
staphylococcal folliculitis.
Carbuncle - a deeper infection composed of
interconnecting abscesses usually arising in
several contiguous hair follicles.
Abscess
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Usually caused by
Staphylococcus
aureus.
Very tender
Warm
Will develop a
pustulent head
A very tender abscess with
surrounding erythema
on the heel.
Furuncle (boil)
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Firm tender nodule
1 to 2 cm
Central necrotic
plug.
staphylococcal
folliculitis in beard
area or neck.
Nodule becomes
fluctuant with
abscess formation
Furuncle (boil)
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Necrotic plug often
topped by a central
pustule.
Following drainage
a nodule.
A zone of cellulitis
may surround the
furuncle.
Carbuncle
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Evolution similar to that
of furuncle.
Comprised of multiple,
adjacent, coalescing
furuncles
Characterized by
multiple dermal and
subcutaneous
abscesses,pustules,
necrotic plugs, and
sieve-like openings
draining pus
Treatment
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Incision and
drainage
Systemic antibiotics
(10 day course)
Local heat
Disqualification from
contact sport until
resolved
Highly contagious
Scarlet Fever
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Acute infection of the tonsils, skin, or
other sites by Streptococcus
Associated with a characteristic
toxigenic rash
Scarlet Fever
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Erythema on the
upper trunk
Face flushed with a
perioral pallor.
Linear petechiae
(Pastia’s sign) occur
in body folds.
Rash fades w/in 5
followed sheetlike
exfoliation on the
palms and soles.
Pastia’s Sign
Scarlet Fever-Treatment
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Aspirin or
acetaminophen for
fever and/or pain
The goal of therapy is to
eradicate Streptococcus
throat carriage to
prevent rheumatic fever.
Drug of choice is
penicillin because of its
efficacy in prevention of
rheumatic fever.
Desquamation of the volar
fingertips 10 days after onset
of streptococcal pharyngitis
in an adult female.
Fungal Infections
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Varieties of Tinea infections
Onychomycosis
Candidiasis
Pityriasis versicolor
Tinea Pedis (Athlete’s Foot)
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Dermatophytic
infection of the feet
Erythema,desquam
ation, and/or bulla
formation
Hot, humid weather,
occlusive footwear, Scaling, maceration,
excessive sweating erythema, and erosion in the
4-5 webspace. 4th toenail also
infected.
Tinea Pedis (Athlete's Foot)
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Walking barefoot on
contaminated floors
Arthrospores can
survive in human
skin scales 12
months.
Pruritus
Pain with secondary
bacterial infection
Moccasin type tinea pedis.
Erythema, fine white
scaling of the plantar and
lateral foot, and keratoderma(thickening of the
keratin layer)
Tinea Pedis-Treatment
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Keep feet clean, dry,
exposed to air
Dry shoes
thoroughly
Terbinafine (Lamisil)
cream
Tinea Manuum
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Fungal infection of the
hands
Diffuse hyperkeratosis
of the palms (especially
the creases)
Patchy scaling on the
dorsa and sides of
fingers
50% of patients have
unilateral involvement
Erythema and scaling of the
right hand, associated with
bilateral tinea pedis; the “one
hand, two feet” distribution is
typical of epidermal
dermatophytosis of the hands
and feet.
Tinea Manuum-Treatment
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Must eradicate all
other sources of
tinea infection
Topicals don’t work
(stratum corneum
too thick)
Terbinafine (Lamisil)
Itraconazole
(Sporanox)
Griseofulvin
(Grisactin)
Tinea Cruris (Jock Itch)
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Subacute or chronic
dermatophytosis of
the groin, pubic
regions,and thighs.
Warm, humid
environment, tight
clothing worn by
Erythematous, scaling plaques
men, obesity.
on the medial thighs,inguinal
Pruritis
folds, and pubic area. The
margins are raised and
sharply marginated.
Tinea Cruris
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Most individuals with
tinea cruris have tinea
pedis.
Dermatophyte is
transferred from feet to
crural region by hands.
Affects groins and
thighs. May extend to
buttocks. Scrotum and
penis are rarely
involved.
TOPICAL ANTIFUNGALS
CATEGORIES
Imidazoles
Mycelex
AGENTS
Clotrimazole
TRADE NAMES
Lotrimin,
Miconazole
Micatin
Ketoconazole
Nizoral
Econazole
Spectazole
Oxiconizole
Oxistat
Sulconizole
Exelderm
Allylamines
Naftifine
Naftin
Terbinafine
Lamisil
Naphthiomates
Tolnaftate
Tinactin
Substituted pyridone Ciclopiroxalamine Loprox
Tinea Cruris-Treatment
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Eradicate other
sources of tinea
infection
Differentiate from
intertrigo
Avoid tight clothing
Keep dry, cool
Tinea Corporis (Ringworm)
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Dermatophyte
infections of the
trunk, legs, and
arms, excluding the
feet, hands, and
groin.
More common in
animal workers in
tropical climates.
Sharply marginated,
hyperpigmented plaques of
chronic duration. Associated
tinea cruris and tinea pedis
are usually present.
Tinea Corporis
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Often asymptomatic
Mild pruritus
Scaling, sharply
marginated plaques
Peripheral
enlargement and
central clearing
Annular
Tinea corporis contracted
configuration with
from a pet guinea pig.
concentric rings
Tinea Corporis-Treatment
CATEGORIES
Imidazoles
AGENTS
TRADE NAMES
Clotrimazole
Lotrimin, Mycelex
Miconazole
Micatin
Ketoconazole
Nizoral
Econazole
Spectazole
Oxiconizole
Oxistat
Sulconizole
Exelderm
Allylamines
Naftifine
Naftin
Terbinafine
Lamisil
Naphthiomates
Tolnaftate
Tinactin
Substituted pyridone Ciclopiroxalamine Loprox
Tinea Facialis (Face Ringworm)
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Dermatophytosis of
the glabrous facial
skin
Well-circumscribed
erythematous patch
More commonly
misdiagnosed than
any other
dermatophytosis.
Sharply marginated,
erythematous plaque with
some central clearing and
peripheral scaling on the
lower eyelid and cheek
Tinea Facialis
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Pruritus and
photosensitivity
Pink to red
In black patients,
hyperpigmentation
Scaling often is
minimal but can be
pronounced
Sharply marginated,
erythematous, scaling, and
crusted plaques on the face of
a child. Note asymmetry.
Tinea Facialis-Treatment
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Topical antifungal
preparations
Eradicate
dermatophyte
infection at other
sites such as feet
and hands.
Tinea Facialis is more
common in children.
Tinea Capitis
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Fungal infection of
the scalp
Follicular
inflammation with
painful, boggy
nodules that drain
pus
Scarring alopecia
Scaling patches
Large, round, hyperkeratotic
plaque of alopecia due to
breaking off of hair shafts
close to the surface, giving
the appearance of a mowed
wheat field on the scalp of a
child.
Tinea Capitis
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Blacks>whites
Children>adults
Three types
– “Black dot”
– Kerion
– Favus
Tinea Capitis-”Black Dot” Type
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Broken-off hairs
near surface give
appearance of
“dots” in dark-haired
patients
Tends to be diffuse
and poorly
circumscribed
Resembles
seborrheic
dermatitis.
A subtle, asymptomatic patch
of alopecia due to breaking
off of hairs on the frontal
scalp in a 4-year-old black
child.
Tinea Capitis-Kerion Type
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Boggy, purulent,
inflamed nodules and
plaques
Usually extremely
painful
Drains pus from
multiple openings
Hairs do not break off
but fall out and can be
pulled without pain
Heals with scarring
alopecia.
Large, very painful,
inflammatory tumor with hair
loss, studded with multiple
pustules on the scalp of a
young child.
Tinea Capitus-Favus Type
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Thick yellow
adherent crusts
(scutula)
Fetid odor
Untreated results in
cutaneous atrophy,
scar formation, and
scarring alopecia.
Tinea Capitis-Treatment
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Topical antifungal agents are ineffective
in management of tinea capitis
Systemic antifungals should be used
until symptoms have resolved and
fungal cultures negative
Terbinafine and itraconazole superior to
ketoconazole and all three to
griseofulvin. Side effects in increasing
order: terbinafine < itraconazole <
ketoconazole < griseofulvin
Tinea Barbae- Ringworm of the
Beard
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Fungal infection of
the beard and
moustache areas
Adult males only
More common in
farmers
Pruritus,tenderness,
pain
Scattered, discrete follicular
pustules and papules in the
moustache area, easily
mistaken for S. aureus
folliculitis.
Tinea Barbae-Treatment
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Similar to tinea
capitis
Topical antifungals
ineffective
Systemic antifungals
should be used until
symptoms have
Confluent, painful papules,
resolved and fungal nodules, and pustules on the
cultures negative
upper lip. Tinea facialis
present on the cheeks, eyelids,
eyebrows,and forehead.
Onychomycosis
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Toenail becomes
opaque, thickened,
cracked, friable, raised
by underlying
hyperkeratotic debris in
the nail bed
Toenails more common
than fingernails
When fingernails are
involved, pattern is
usually two feet and
one hand
Distal subungual
hyperkeratosis and
onycholysis involving most of
the nail bed of the great
toenails; these findings are
usually associated with tinea
pedis.
Onychomycosis-Treatment
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Does not resolve
spontaneously;involvement of multiple
toenails is the rule.
Relapse occurs in the
majority of persons
treated with
griseofulvin.
Relapse rate with
itraconazole or
terbinafine is less than
with griseofulvin
The proximal nail plate is a chalky white
color due to invasion from the
undersurface of the nail matrix. The
patient had advanced HIV disease.
Cutaneous Candidiasis
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Superficial infection
occurring on moist
cutaneous sites
Many patients have
predisposing factors
that alter local
immunity such as
increased moisture
at the site of
infection, diabetes,
or alteration in
systemic immunity
Erosions on the medial thighs,
inguinal folds, and scrotum
with “satellite” pustules and
papules of an obese male.
Cutaneous Candidiasis
Cutaneous Candidiasis
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

Penis/scrotum
Vulva
Fingernails
Interdigital
Treatment is
primarily topical
Erythematous eroded area
with surrounding
maceration in a webspace of
the hand occurring in a
health care worker is a type
of intertrigo.
Pityriasis Versicolor





Also known as tinea
versicolor
Yeast infection
Usually on the trunk
Depigmentation of
the skin
Should not
disqualify am
athletes from
participation
Hypopigmented, sharply marginated,
scaling macules on the shoulder area
of an individual with brown skin.
Gentle abrasion of the surface
accentuates the scaling.
Pityriasis Versicolor-Treatment


Selenium sulfide
(2.5%) lotion or
shampoo: Apply
daily for 10 to 15
minutes, followed by
shower, for 1 week.
Azole creams
(ketoconazole,
econazole,
micronazole,
clotrimazole): Apply
b.i.d. for 2 weeks.
Follicular, hypopigmented
macules on the upper chest of
an individual with black skin.
Viral Infections



Molluscum Contagiosum
Herpes
Warts
Molluscum Contagiosum




Epidermal viral
infection
Skin-colored
papules
Children and
sexually active
adults
Transmission by
skin-to-skin contact
Discrete, solid,
skin-colored
papules, 1 to 2mm
in diameter with
central
umbilication on the
chest of an
adolescent female.
The lesion with an
erythematous halo
is undergoing
spontaneous
regression.
Molluscum Contagiosum




In healthy
individuals resolves
spontaneously.
In HIV-infected
individuals often
progresses despite
treatment.
Painful aggressive
therapy is best
avoided.
Avoid skin-to-skin
contact
Herpes Simplex Virus

Three types
– Nongenital
– Genital
– Herpes Gladiatorum
Multiple painful erosions on the lower
labial mucosa with erythema and
edema of the gingiva; plaque has
formed on the teeth because of pain
within the lesions that restricts
brushing. Fever and tender
submandibular lymphadenopathy
were also present.
Nongenital
Herpes Simplex
– Grouped vesicles
arising on an
erythematous base
on keratinized skin or
mucous membrane
– Lips most common
– Incubation 3-12 days
– Chronic and
recurrent
A. Grouped and confluent vesicles
with an erythematous rim on the
lips. B. Edema with crusting of the
lips which followed sun exposure;
vesiculation is present but difficult
to detect because of confluence of
lesions. In some cases, crusting is
the only finding.
Nongenital
Herpes Simplex




Restrict from
athletics until lesions
crusted and dry
Acyclovir (Zovirax)
800 mg b.i.d. for 5
days
Valacyclovir
(Valtrex) 500 to
1000 mg b.i.d.
Famciclovir (Famvir)
Herpetic Whitlow-Painful, grouped,
confluent vesicles on the volar finger
on an erythematous edematous base.
Genital
Herpes Simplex
– Grouped vesicles at
the site of inoculation
and inguinal
Group of vesicles with early central
lymphadenopathy
crusting on a red base arising on the
– Flu-like symptoms
shaft of the penis.
(myalgia, headache)
Multiple,
extremely
– Chronic and
painful,
recurrent
punched-out,
– Oral antiviral meds
confluent,
shallow ulcers
– May participate
on the vulva
unless they feel too
and perineum.
crummy
Herpes Gladiatorum






Spread of herpes to
abraded of injured
skin
Associated with
widespread dermatitis
Looks like impetigo
Oral antivirals
Common in wrestlers
No participation until
cleared
Herpes Zoster (Shingles)






Chicken pox virus
Distribution along
dermatomes
Painful
Headache, malaise,
fever
Spontaneous
resolution 2-3 weeks
Analgesics,
antivirals (acyclovir)
Dermatomal, grouped and
confluent vesicles and pustules arising
in the third sacral dermatome; note
extension of lesions 1–2 cm across the
midline.
Warts


Caused by human
papillomavirus
(HPV)
Three types
– Common warts
(verruca vulgaris70%)
– Plantar warts
(verruca plantaris30%)
– Flat warts (verruca
plana-4%)
The thrombosed capillaries
(brown dots) differentiate the
lesion from a corn or callus.
Common Warts (Verruca
Vulgaris)


Palmar lesions
disrupt the normal
line of fingerprints.
Return of fingerprints a sign of
resolution of the
wart.
Hands, fingers,
knees.
Hyperkeratotic papules
becoming confluent around
the periungual tissue of four
fingers; the brown dots
represent thrombosed
capillaries.
Plantar Warts (Verruca Plantaris)



Plantar surface of
feet
Often solitary but
may be three to six
or more
Pressure points,
heads of metatarsal,
heels, toes
The warts are surrounded by nonwarty
callus. Tinea pedis is also present in
the webspaces and instep with sites of
excoriation.
Flat Warts (Verruca Plana)


Always numerous
discrete lesions,
closely set
Face, beard area,
dorsa of hands,
shins
Flat-topped, pink papules with
sharp margination and minimal
hyperkeratosis on the dorsum
on the hands and fingers.
Wart Treatments






Usually resolve
sponatneously
Painful plantar warts
warrant more
aggressive treatment
40% salicylic acid
plaster for 1 week
Cryosurgery
Electrosurgery
CO2 laser surgery
Infestations


Scabies
Pediculosis
Scabies




Mites burrow
beneath stratum
corneum
Undiagnosed pruritis
Palms, wrists,
ankles, nipples,
ubilicus, genitals
Acquired sexually or
through crowded
living conditions
Papules and burrows in typical
location on the finger webs.
Burrows are tan or skin-colored
ridges with linear configuration
with a minute vesicle or papule
at the end of the burrow and are
often difficult to locate.
Scabies





No contact sports until
cleared (1 wk)
Examine sexual
partners
Wash bedding
Lindane (Kwell,
Scabene lotion or
shampoo). Do not use
after bathing, with
pregnancy or lactation
Permethrin (Nix
lotion)
A mite at the end of a burrow
with 8 eggs and smaller fecal
particles obtained from a papule
on the webspace of the hand.
Pediculosis (Lice)







Pediculosis capitis
Pediculosis pubis
Pediculosis corporis
Highly infectious
Pruritis
Regional
lymphadenopathy
Eggs (nits) adhere
to hair
A crab louse (see arrow) on
the skin in the pubic region.
Pediculosis (Lice)





No contact sports
until all nits removed
Examine sexual
partners
Wash bedding
Lindane (Kwell)
Pyrethins (RID,
R&C, A-200 gel,
liquid, shampoo)
Crab lice (see arrow) and
nits on the upper eyelashes of
a child; this was the only site
of infestation.
Skin Cancer

Three major types
– Basal cell carcinoma
– Squamous cell
carcinoma
– Melanoma
Oral Leukoplakia - The lesion,
in a heavy pipe smoker,
progressed to a verrucous
carcinoma.
Basal Cell Carcinoma




Most common type
of skin cancer.
Locally invasive,
aggressive, and
destructive
Limited capacity to
metastasize
Exposure to UV light Large, shiny, red nodule with a
cobblestoned surface and an
ulcerated nodule.
Basal Cell Carcinoma



Excision with
primary closure, skin
flaps, or grafts.
Cryosurgery and
electrosurgery
Danger sites nasolabial area,
around the eyes, ear
canal, posterior
auricular sulcus,
scalp - microsurgery
required
Squamous Cell Carcinoma




Less common than
basal cell carcinoma
Exposure to UV light
and x-rays, arsenic
Slowly evolving
Cheeks, nose, lips,
tips of ears,
preauricular areas,
scalp, dorsa of the
hands, forearms,
trunk, and shins
(females)
A large notch on the superior
aspect of the helix, a nodule of
SCC with hyperkeratosis
and ulceration.
Squamous Cell Carcinoma
Any isolated keratotic or eroded
papule or plaque in a suspect
patient that persists for over a
month is considered a carcinoma
until proved other-wise.
Squamous Cell Carcinoma



Surgery
Microscopically
controlled surgery in
difficult sites
Radiotherapy should
be performed only if
surgery is not
feasible
Melanoma





Most deadly kind of
skin cancer
Increasing rapidly
Sun exposure?
Thinning ozone
layer?
Assymetric,pigment
ed, irregular, large
lesions
Suspicious nevi: Two large,
variegated, brown oval
macules.
Melanoma



Radial growth phase
Vertical growth
phase
Critical to identify &
treat early during
radial growth phase
The lighter macular portion of
this lesion is a suspicious nevus
on the upper back; the
blue-black plaque is a superficial
spreading melanoma (1.2 mm
thickness). The patient was a 34year-old internist who died 36
months following detection and
excision of this lesion.
Melanoma


Surgery is treatment
Suspicious nevi
(moles):
– changing (increase
in size, change in
pigmentation pattern,
changes in shape
and/or border)
– location that cannot
be closely followed
by the patient by
self-examination (on
the scalp, genitalia,
upper back)
Melanoma-The left image
(1990) shows variegation of
pigmentation and irregular
borders. Five years later, the
lesion (right) shows darkening
of melanin pigmentation, more
irregularity in shape, and
elevation in the most darkly
pigmented region.
Six Warning Signs for Melanoma
A ASYMMETRY in shape—one-half unlike the other half
B BORDER is irregular—edges irregularly scalloped
C COLOR is mottled—haphazard display of colors; shades of
brown, black, gray, red, and white
D DIAMETER is usually large—greater than the tip of a pencil
eraser (6.0 mm)
E ELEVATION is almost always present—surface distortion is
assessed by side-lighting.
ENLARGEMENT—a history of an increase in the size of lesion
is perhaps one of the most important signs of melanoma
Dermatology Assessment
General Approach to Patients
With Skin Signs and Symptoms
Epidemiology and Etiology




Age
Race
Sex
Occupation
History



Duration of onset
Relationship of skin lesions to season,
travel history, heat, cold, previous
treatment, drug ingestion, occupation,
hobbies, effects of menses, pregnancy
Skin symptoms: pruritus, pain,
paresthesia
History (cont)

Constitutional symptoms
– “Acute illness’’ syndrome: headaches,
chills, feverishness, weakness
– “Chronic illness’’ syndrome: fatigue,
weakness, anorexia, weight loss,
malaise

Systems review
Physical Examination



Appearance of patient: uncomfortable,
“toxic,’’ well
Vital signs: pulse, respiration,
temperature
Skin—four major skin signs: (1) type, (2)
shape, (3) arrangement, (4) distribution
of lesions
Types of Skin Lesions





Macules
Papules
Plaques
Pustules
Vesicles





Nodules
Desquamination
Bullae
Ulcers
Wheals
Color and Palpation






White
Brown
Purple
Violet
Red
“Flesh”





Consistency
Temperature
Mobility
Tenderness
Depth of lesion (i.e.,
dermal or
subcutaneous)
Shape






Round
Oval
Annular (ring-shaped)
Serpiginous (snakelike)
Umbilicated
Margination
– well-defined (can be traced with the tip of a
pencil)
– ill-defined
Arrangement


Grouped
Disseminated
Distribution

Extent
– isolated (single
lesions),
– localized
– regional
– generalized
– universal

Pattern
–
–
–
–
–
–
symmetrical
exposed areas
sites of pressure
intertriginous area
follicular localization
random