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Beauty is only skin deep….
DEB BYNUM, MD
MAY 2010
Questions:
 1. What is the diagnosis?
 2. What are the four types demonstrated in the
pictures?
 3. What are the treatment options?
Answers:
 1. Rosacea
 2. Types
Erythematotelangiectatic
 Papulopustular
 Phymatous: rhinophyma
 ocular
 3. Management:
 Topical metronidazole
 Oral antibiotics (tetracycline)
 Laser/surgery

Question:
 A 76 year old woman comes to the office because she has
multiple rough skin lesions on her forehead, temples,
cheeks and forearms. Nasolabial folds are spared. The
lesions bleed easily when she picks them off, and then
recur. The lesions are scaly, <1 cm in diameter, and feel
like sandpaper to the touch.
 Which of the following is the most appropriate
treatment?
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A. Moisturizing cream
B. metronidazole gel
C. Imiquimod 5% cream
D. Ketoconazole 2% cream
E. Sunscreen and observation
Questions:
 1. What is the diagnosis?
 2. A 76 year old woman comes to the office because
she has multiple rough skin lesions on her forehead,
temples, cheeks and forearms. Nasolabial folds are
spared. The lesions bleed easily when she picks
them off, and then recur. The lesions are scaly, <1
cm in diameter, and feel like sandpaper to the touch.

What is the appropriate therapy?
Actinic Keratosis
 Lesions are single or multiple
 Dry, rough, adherent and scaly
 Sun exposed skin
 Sparing of nasolabial folds and nonexposed areas
 Sandpaper like
 Cream and sunscreen helpful
Actinic Keratosis: Precancer
 Precancer!
 Treat!
 Ablative (cryosurgery)
 Photodynamic therapy
 Topical therapies if multiple lesions
Flourouracil
 Imiquimod 5% cream
 Diclofenac 5% gel

Question:
 A 70 year old chinese American man comes to the
office because he has a widespread maculopapular
eruption with formation of flaccid bullae and
erosions. For 2 days before the rash, he had fever,
odynophagia, and eye pain. Over the next few days,
the rash evolved to extensive sloughing and peeling
of the skin. History includes HTN, DM, and
peripheral neuropathy. Two weeks ago, he began
carbamazepine. Other medications include glipizide,
felodipine, simvastatin, and aspirin.
Question…
 On exam, the sloughing and peeling involve 40% of
the body surface. His oral mucosa has erosions and
exudates. He also has bilateral conjunctivitis.
 Which of the following is the most likely diagnosis?
 A. Bullous pemphigoid
 B. Staphylococcal scalded skin syndrome
 C. Disseminated herpes zoster
 D. Toxic epidermal necrolysis
Answer:
 D: TEN
 Stevens Johnson Syndrome and TEN are variants of same
process (SJS <10% body surface, TEN >30%, overlap if
between)
 30% mortality
 Reactions to medications
 HLA-B 1502 Allele: Asian and South Asian ancestry

FDA alert: screen this population before starting carbamazepine
Question:
 What is the most common autoimmune
subepidermal blistering disease, most often found in
older adults?
 Hints:
 Pruritic
 Tense blisters
 Blisters resolve without scarring
 Often self limited
Diagnosis?
Answer:
 Bullous Pemphigoid
 Antibodies directed against basement membrane zone of the
epidermis, causing separation between epidermis and dermis
 Differentiate from Pemphigus Vulgaris
 PV in younger patients
 PV more severe
 Nikolsky sign: Exfoliation of the skin with slight rubbing
Present with PV and with TEN
 Absent with bullous pemphigoid
 PV more often involves mucus membranes
 PV blisters flaccid, BP blisters tense
 Autoimmune, medications, paraneoplastic

What is the diagnosis?
What is the diagnosis? Some Hints:
 inflammation of the eyelids causing red, irritated,
itchy eyelids
 formation of dandruff-like scales on eyelashes
 It is a common eye disorder
 causes:
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
bacterial (staph)
dandruff of the scalp or seborrhea
acne
rosacea
Blepharitis:
 Treatment:
 Warm compresses
 Baby shampoo, dandruff shampoo
 Avoiding makeup
 Oral antibiotics (tetracycline)
New case…
What is the diagnosis?
Answer:
 Melanoma

Acral lentiginous subtype:

Uncommon, but more often seen in patients over age 65

Can be seen in all skin types
What is the diagnosis?
Hints:
 Very common
 Waxy plaques or papules
 Stuck on appearance
 Found everywhere except mucus membranes, palms
and soles
 May be darkly pigmented
Answer:
 Seborrheic Keratosis
Question:
 Eruptive seborrheic keratoses, often across back in
christmas tree pattern, associated with underlying
malignancies (GI, prostate, etc) is known as…..
Answer:
 Sign of Leser-Trelat
Itchy, Itchy, Itchy….
Typical distribution…
Severe form can be “crusted”, aka
“norwegian”
Answer:
 Scabies…
 More common in elderly and immunosupressed
 May not have rash, may present with severe pruritis
 Look in between toes and fingers
 burrows