Transcript Common Dermatologic Issues - 4.69 MB

Common Dermatologic Issues in the
Geriatric Population
Steve Marchenko, Janelle Pavlis and
Kristen M. Kelly, M.D.
University of California, Irvine
• Objectives:
List dermatologic diseases commonly seen in the
elderly
 Identify terms used to describe dermatologic lesions
and/or rashes
Identify treatment options for common dermatologic
conditions seen in the elderly
Approach to Making
Dermatologic Diagnoses
• Obtain Focused History
 Time/duration/change over time, initial site and spread/symptoms
 General health, occupation, family history, medications, previous
treatments, allergies
• Characterize morphology of basic lesion
 Primary-original lesion
 Secondary-changes to lesion over time
 Characterize shape, color, texture, & arrangement of the lesions
• Determine distribution of lesions
 Lesion distribution often provides important diagnostic clues
Approach to Making
Dermatologic Diagnoses
• Diagnostic Testing to consider
 Shave, punch biopsy
 KOH for fungal infections
 Gram stain for bacterial infections
Image courtesy of www.visualdx.com © Logical Images, Inc
 Tzanck preparations for herpetic infection (shown)
 Oil mount of skin scrapings for scabies infection
Victor Newcomer, MD (UCLA). (Jan 2006). Herpetic Whitlow [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=50694&imageIndex=11
Defining Skin Lesions
A primary lesion is the initial lesion that characterizes a
dermatologic disorder
Being able to recognize primary skin lesions is critical in
making the correct diagnosis
Over time, primary lesions may continue to develop or
be modified, producing secondary lesions
Keep in mind, when examining a patient:
• The primary lesion may have evolved
• Any combination of primary and secondary lesions may be
present
Primary Skin Lesions
Lesion
Description
Example
Macule Circumscribed, flat, <0.5 cm (centimeter) freckle (ephelis)
Patch
Papule
Macule >0.5cm
Elevated, solid lesion <0.5cm
Plaque
Elevated, plateau-like lesion without
substantial depth
vitiligo
molluscum
contagiosum
psoriasis
Note multiple hyperpigmented
macular lesions and a single patch
found in this patient with
neurofibromatosis type 1. A papule is
seen above the patch.
*the definition of these lesions vary by the dermatology reference, but usually is 0.5-1.0cm.
Image courtesy of www.visualdx.com © Logical Images, Inc
(NYU, Department of Dermatology). (Dec 2004). Neurofibromatosis [photograph]. Retrieved Oct 3, 2011,
from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52014&
ImageIndex=0
Primary Skin Lesions
Lesion
Nodule
Wheal
Vesicle
Description
Example
Elevated, solid lesion >0.5cm with some depth rheumatoid
nodule
Firm, edematous plaque
hives
Circumscribed, elevated lesion with free fluid, Varicella
<0.5cm
Bulla
Vesicle >0.5cm
Bullous
pemphigoid
Pustule
Circumscribed, elevated lesion with purulent
material
acne
Primary Skin Lesions
Image courtesy of www.visualdx.com © Logical Images, Inc
Note multiple pustulo-vesicles and plaques
in a patient with subcorneal pustular dermatosis
(University of Rochester, Department of Dermatology). Sneddon-Wilkinson Subcorneal Pustulosis. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=8&diagnosisId=52332&imageIndex=5
Secondary Skin Lesions
Scale: White, dry flakes (e.g. dermatophyte infection)
Crust: A “scab” formed from dried serum, blood or
exudate on skin (e.g. impetigo)
Erosion: Focal loss of epidermis not extending below
dermal/epidermal junction; heals without scarring (e.g.
following blister rupture)
Secondary Skin Lesions
Image courtesy of www.visualdx.com © Logical Images, Inc
In this patient with pemphigus,
superficial blisters have ruptured
and formed crusted erosions and scales
(NYU, Department of Dermatology). Pemphigus Foliaceus. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52136&imageIndex=0
Secondary Skin Lesions
Ulcer: Focal loss of epidermis & dermis extending into
hypodermis; heals with scarring (e.g. decubitus ulcer)
Fissure: Linear loss of epidermis (+/-) dermis (e.g.
“chapping” of fingers)
Lichenification: Area of thickened epidermis with
accentuated skin lines due to chronic rubbing (e.g. long
standing atopic dermatitis)
Benign Skin Growths
Benign skin growths are common, especially in older
individuals
It is important to differentiate these lesions from skin
cancer
A clinician should try to categorize any skin lesion as:
• Most likely benign, most likely malignant, or unclear
• The last 2 categories should be biopsied
Examples of common benign lesions include:
• Seborrheic keratoses and cherry angiomas
Benign Skin Growths
Seborrheic Keratoses (SKs)
SKs are the most common benign tumor in the elderly
•Clinical:
 Brown or black raised, waxy spots or wart-like growths that
appear “stuck-on”
 Represent benign thickening of epidermis
•Epidemiology:
 Incidence increases with age and tendency to develop SKs can
be inherited
Image courtesy of www.visualdx.com © Logical Images, Inc
Tindall JP, Smith JG Jr. Skin lesions of the aged and their association with internal changes. JAMA. Dec 21 1963;186:1039-42
Victor Newcomer, MD (UCLA). (Aug 2006). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51808&imageIndex=1
Benign Skin Growths
•Management of SKs:
Always differentiate from cancer – can be confused with
pigmented basal cell carcinoma, melanoma
•SKs appear as multiple lesions
 Managed with cryotherapy, curettage or shave biopsy if they
become irritated or for cosmetic reasons
Image courtesy of www.visualdx.com © Logical Images, Inc
(University of Rochester, Department of Dermatology). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2001, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51808&imageIndex=8
Benign Skin Growths
Cherry Angiomas
 Benign dome-shaped capillary
proliferations.
 Usually appear in individuals over
35 on arms and trunk and tend to
bleed when injured.
 Successfully treated with laser or
electrocautery
Image courtesy of www.visualdx.com © Logical Images, Inc
(NYU, Department of Dermatology). Cherry Hemangioma. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=51676&imageIndex=4
Pre-cancerous Skin Growths
Actinic Keratoses
•Clinical:
 Ill-marginated, reddish, papules with rough, adherent scale
 More easily felt than seen
 Can involute or persist
 Occur on sun-exposed areas as a result of cumulative UV damage
 Precursors to squamous cell carcinomas (up to 10% may advance
to SCC)
Image courtesy of www.visualdx.com © Logical Images, Inc
Criscione, VD, Weinstock, MA, Naylor, MF, Luque, C, Eide, MJ and Bingham, SF. Actinic keratoses natural history and risk of malignant transformation in the
Veterans Affairs Tropical Tretinoin Chemoprevention Trial. Cancer 2009; 115: 2523-2530
(University of Rochester, Department of Dermatology). Actinic Keratosis. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51805&imageIndex=5
Actinic Keratoses
•Differential Diagnosis:
 Squamous cell carcinoma, SK, superficial basal cell carcinoma
•Management:
 Depends on number of lesions and area of involvement
 For few localized lesions, cryotherapy with liquid nitrogen
 For multiple, widespread lesions treatment options include:
 Photodynamic therapy
 Chemical Peels
 Topical antineoplastic agents
Examples include
• 5-Fluorouracil (5-FU) Cream
• Imiquimod Cream
Skin Cancer
 Skin cancer is the most common of all human cancers
• It is diagnosed in more than 1 million people in the United
States each year
 Skin cancers are of three major types:
• Basal cell carcinoma (BCC), squamous cell carcinoma (SCC)
and melanoma
 The majority of skin cancers are BCCs or SCCs
• Although metastatic rate is low, may be locally destructive and
disfiguring if not treated early
• Solar UV radiation is responsible for the majority of BCCs
and SCCs
Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010; 146(3):283-287.
Skin Cancer
Squamous Cell Carcinoma (SCC)
• Epidemiology
 Second most common skin cancer
 Most frequently affects Caucasians with extensive sun exposure
• Risk factors
 Chronic environmental damage
• UV/ionizing radiation
• Tobacco
• Arsenic exposure
 History of actinic keratoses
 HPV infection 6,11,16,18
 Chronic immunosupression
Image courtesy of www.visualdx.com © Logical Images, Inc
Charles E. Crutchfield III, MD. (Nov 2007). Squamous Cell Carcinoma. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52735&imageIndex=0
Skin Cancer
Squamous Cell Carcinoma
•Clinical
 A scaly patch or warty growth that may crust, bleed, and ulcerate
 Frequently develops on sun-exposed areas or at sites of chronic
injury, e.g., chronically draining sinuses or burns
 Some types have greater metastatic potential than basal cell
carcinoma
•Management
 Excision with margins
 Mohs micrographic surgery in
cosmetically sensitive areas
Image courtesy of www.visualdx.com © Logical Images, Inc
(University of Rochester, Department of Dermatology). (Augu 2009). [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52735&imageIndex=42
Skin Cancer
Basal Cell Carcinoma (BCC)
•Epidemiology
 Most common human malignancy
 800,000 new cases every year in US
•Risk factors
 Skin type 1
 Blistering sunburns in childhood
 Family history of skin cancer
 Immunosuppression
Image courtesy of www.visualdx.com © Logical Images, Inc
Nodular BCC
(NYU, Department of Dermatology). Basal Cell Carcinoma, Nodular. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=51167&imageIndex=0
Basal Cell Carcinoma
Clinical
Several subtypes are described
•Nodulocystic:
single shiny, red nodule w/ telangiectasia
•Superficial:
least aggressive
 erythematous plaques
can mimic psoriasis
•Sclerotic/Morpheiform:
 most aggressive
5% of all BCC’s.
Ill-defined borders
•Pigmented
Shiny, blue-black papule, speckled
Superficial
pigment, rolled borders.
Image courtesy of www.visualdx.com © Logical Images, Inc
Charles E. Crutchfield III, MD. (Jan 2007). Basal Cell Carcinoma, Superficial. [photograph]. Retrieved Oct 3, 2011,
from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52756&imageIndex=16
BCC
Skin Cancer
Basal Cell Carcinoma
•Management
Depends on location, size, histopathology, and patient factors
Very low risk/superficial: consider curettage + topical 5-FU or
imiquimod
Most low risk lesions: curettage and electrodessication
For higher risk or recurrent BCC: excision with margins or Mohs
micrographic surgery
Elderly patients or those in whom surgery contraindicated: consider
radiation.
Basics of Dermatologic Surgery
• Cryosurgery
• Electrodessication and curettage
• Excision
• Mohs Micrographic Surgery
Basics of Dermatologic Surgery
Cryosurgery
 Liquid nitrogen -195.8º C
 To produce adequate treatment, tissue temperature -50º C is
needed
 Fast freeze, slow thaw ; generally 2 cycles
 PROS: cost effective, no surgery, minimal equipment
 CONS: no specimen for evaluation, skin discoloration may
occur and may be permanent (especially in tanned skin or
patients with darker skin types)
Basics of Dermatologic Surgery
Electrodessication and Curettage
 Only indicated for low-risk lesions
 PROS: minimal blood loss, ease, convenience for the patient
 CONS: no specimen for pathology, clinician experience influences
cure rate
Images courtesy of Margaret Mann, M.D.
Basics of Dermatologic Surgery
Excision
 PROS
• Shorter procedure time
• Closure performed at the same time
• Less expensive
 Margins depend on lesion
Leffell DJ, Brown MD, eds. Basic excisional surgery. In: Manual of Skin Surgery: A Practical Guide to Dermatologic Procedures. 1997. New York, NY: Wiley-Liss; 149-80.
Basics of Dermatologic Surgery
Mohs Micrographic Surgery
• Indications:
 Recurrent or incompletely excised BCC or SCC
 Primary BCC or SCC with indistinct borders
 Lesions located in high-risk or cosmetically and
functionally important areas (e.g. face)
 Tumors with aggressive clinical behavior (i.e., rapidly
growing, >2 cm in diameter) or aggressive histologic
subtype
 Tumors arising in sites of previous radiation therapy
 Tumors arising in immunosuppressed patients
Basics of Dermatologic Surgery
• Advantages:
Mohs Micrographic Surgery
 Low risk of recurrence
 Exceptionally high cure rates
 Designed to remove tumor with smallest possible margins
• Disadvantages:
 Surgical risks
 Requires special equipment and technician
 More technically difficult
 Not optimal for all tumors
Basics of Dermatologic Surgery
Mohs Micrographic Surgery
• Step 1: Clinical examination and determination of
visible margins
• Step 2: Visible tumor is surgically removed
• Step 3: A layer of skin is removed and divided into
sections, which are color coded with dyes; reference
marks made on skin for orientation; map of surgical
site drawn
• Step 4: Undersurface and edges of each section are
microscopically examined for evidence of remaining
cancer
Image courtesy of American College of Mohs Surgery
The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohsprocedure.php
Basics of Dermatologic Surgery
Mohs Micrographic Surgery
•Step 5: If residual cancer is seen under the
microscope, surgeon marks location on map and
returns to patient to remove another layer of skin
where cancer cells remain
•The removal process stops when there is no longer
any evidence of cancer remaining in the surgical site
Image courtesy of American College of Mohs Surgery
The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohsprocedure.php
Drug Eruptions
•Epidemiology
Drug eruptions are a frequent cause of skin lesions in the elderly
population
Drug eruptions occur in approximately 2-5% of inpatients and in
greater than 1% of outpatients
 Older patients have an increased prevalence of drug eruptions due
to high incidence of polypharmacy and decreased kidney function
Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331:1272
Drug Eruptions
• Etiology
Often classified as immune and non-immune
•Immune: type I, II, III IV hypersensitivity reactions
•Non-immune: cumulative toxicity, overdose, photosensitivity,
drug interactions, and metabolic alterations
 A drug reaction should be considered in any patient on medication
with acute onset of an eruption (usually symmetric)
Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331:1272
Drug Eruptions
• Common morphologies:
morbilliform (95%) and urticarial (5%)
Less common morphologies include: pustular,
bullous and papulosquamous
Drug reactions can also cause pruritis without
an obvious eruption
Image courtesy of www.visualdx.com © Logical Images, Inc
Morbiliform eruption
• Drugs most commonly implicated:
antimicrobial agents, nonsteroidal antiinflammatory drugs (NSAIDs), cytokines,
chemotherapeutic agents, anticonvulsants, and
psychotropic agents
Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York,
NY: McGraw-Hill; 2008:355-362
Drug Eruptions
Drugs commonly implicated in each type of reaction
Urticaria
Morbilliform rash
Lichenoid rash
Cutaneous Vasculitis
Antibacterial, nonsteroidal
antiinflammatory drugs,
antidepressants, opioids, imidazoles
Antibacterial (penicillin,
sulfonamides), anticonvulsants,
gold, allopurinol, diuretics
Antimalarials, gold, β-blockers,
diuretics, sulfonylureas, hypoglycemic
agents
Diuretics (furosemide,
thiazides),antibacterials, allopurinol,
amiodarone
Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131
Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York,
NY: McGraw-Hill; 2008:355-362
Drug Eruptions
Drugs commonly implicated in each type of reaction
Photosensitivity
Drug-induced autoimmune rash
Stevens Johnson
Toxic Epidermal Necrolysis
Amiodarone, phenothiazines,
sulfonamides, tetracyclines,
nonsteroidal antiinflammatory drugs
Penicillamine, hydralazine, gold
Anti-gout agents (allopurinol),
NSAIDS, antibiotics, anticonvulsants
Anti-gout agents (allopurinol),
NSAIDS, antibiotics, anticonvulsants
Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131
Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York,
NY: McGraw-Hill; 2008:355-362
Drug Eruptions
• Benign drug reaction
 Most patients with a drug eruption complain only of itching
 Most drug eruptions are mild, self-limited, and usually resolve after
the offending agent has been discontinued
 Look for: absence of systemic manifestations and normal lab values
• Warning signs of a more serious reaction







Skin pain, skin necrosis
Fever
Conjunctivitis or mucous membrane involvement
Blisters
Angioedema
Palpable purpura
Elevated BUN/creatinine or liver function tests
Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York,
NY: McGraw-Hill; 2008:355-362
Drug Eruptions
Erythema Multiforme (EM)
Target lesions
 EM is a spectrum of diseases ( EM minor, EM major)
 EM Minor (less often due to a drug eruption)
• May be due to infection (e.g. herpes simplex
virus)
• Characterized by target lesions distributed
predominantly on the distal extremities (including
palms/soles)
• Mucous membrane involvement may occur but is
not severe
• Patients recover, but relapses are common
Image: Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text, Sanders, CV, Nesbitt, LT Jr (Eds), Williams & Wilkins, Baltimore 1995.
Auquier- Dunant A, Mockenhaupt M, Naldi L, et al. Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome,
and toxic epidermal necrolysis; results of an international prospective study. Arch Dermatol 2002; 138: 1019.
Erythema Multiforme Major
Severe drug reaction requiring immediate medical attention
Subcategories include: Stevens-Johnson syndrome (SJS) and toxic
epidermal necrolysis (TEN)
Characterized by epidermal necrosis and sloughing of the mucous
membranes and skin
In SJS, lesions affect less than 10 % of the body surface; In TEN,
greater than 30% affected
Victor D. Newcomer, MD (UCLA). Toxic Epidermal Necrolysis. [photograph].
Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52413&imageIndex=29 Image courtesy of www.visualdx.com © Logical Images, Inc
Drug Eruptions
Erythema Multiforme Major
• Etiology:
 Not completely understood
 80% of cases associated with adverse drug
reaction
Image courtesy of www.visualdx.com © Logical Images, Inc
Victor D. Newcomer, MD (UCLA). Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52413&imageIndex=29
Erythema Multiforme Major
• Presentation
 Prodrome of fever, malaise and pain (often like a sunburn)
 Primary lesions include dusky red macules of irregular size
that start on the trunk and spread
 Always screen for mucosal symptoms including: painful
eyes, painful swallowing, dysuria and diarrhea
 Ocular, oral, and genital mucosa are affected in >90% of
cases
• Mortality
 Varies with type
 SJS 1-5% mortality; TEN carries a 25-30% mortality
Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev.
2008 Sep;7(8)598-605.
Drug Eruptions
• Work-up
Consider alternative etiologies, e.g. viral exanthems and
bacterial infections
Take a good medication history
• Review the complete medication list, including overthe-counter supplements
• Note the interval between the introduction of a drug
and onset of the eruption
• Patients can develop drug eruptions to medications
they have been on for prolonged periods
• Document any history of previous adverse reactions
to drugs or foods
Drug Eruptions
• Work-up
Biopsy can be helpful in confirming the diagnosis (e.g.,
by showing eosinophils in morbilliform eruptions)
CBC with diff, Liver function tests, immunoserology
tests may be ordered for suspected drug induced
autoimmune rash, cultures if infection is suspected
Drug Eruptions
• Treatment of Common Drug Eruption
 Stop all non-essential meds (for >1 month)
 Monitor for signs of systemic involvement or SJS/TEN
 Therapy for most drug eruptions is mainly supportive
• Morbilliform eruptions can be treated with oral
antihistamines and topical steroids
• Prednisone may be used cautiously in the treatment of
hypersensitivity syndrome with heart and lung
involvement or severe serum sickness–like reaction
 Slowly re-introduce other medications after suspected agent is
identified
French LE, Trent JT, Kerdel FA. Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome: our current understanding. Int
Immunopharmacol. Apr 2006;6(4):543-9.
Erythema Multiforme Major
• Treatment of Erythema Multiforme Major
 Transfer to a burn unit with aggressive supportive care is the
most critical step in management
 Consultation with Dermatology and Ophthalmology
 Rapid identification and
withdrawal of offending drug
improves survival
 IVIG may be indicated;
efficacy is controversial
Image courtesy of www.visualdx.com © Logical Images, Inc
Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev. 2008 Sep;7(8)598-605.
Robert Chalmers, MD. Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52413&imageIndex=12
Other Dermatologic Conditions
in the Geriatric Population
Several dermatologic conditions have a higher
incidence in the geriatric population
Examples include:
•
•
•
•
Herpes Zoster
Bullous Pemphigoid
Venous Stasis
Sun - induced skin changes
Herpes Zoster
• Etiology
 Reactivation of Varicella Zoster
Virus
• Clinical
Image courtesy of www.visualdx.com © Logical Images, Inc
 Prodrome of radicular pain &
pruritus followed by skin eruption
consisting of grouped vesicles on
erythematous base in dermatomal
distribution
 Postherpetic neuralgia may follow
causing debilitating pain in the
affected dermatome
(University of Rochester, Department of Dermatology). Zoster. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52552&imageIndex=4
Herpes Zoster
• Diagnosis
 Typically clinical. Can also
perform Tzanck smear, viral
culture, or direct
immunofluorescence
Image courtesy of www.visualdx.com © Logical Images, Inc
Victor Newcomer, MD (UCLA). (Jan 2006). Herpetic Whitlow [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=50694&imageIndex=11
Herpes Zoster
• Prevention
 Zostavax – live herpes zoster
vaccine
 Reduces Shingles by 51.3%
Image courtesy of www.visualdx.com © Logical Images, Inc
 Reduces cases of postherpetic
neuralgia by 66.5%
Oxman MN, Levin MJ et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2;352(22):2271-84.
Nancy Esterly, MD. Zoster. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52552&imageIndex=8
Herpes Zoster
• Treatment
Image courtesy of www.visualdx.com © Logical Images, Inc
 Best if initiated within 72 hours of
start of symptoms
 Antivirals: Acyclovir,
Valcyclovir or Famciclovir
 Supportive: pain control,
sedatives, moist dressings to
affected skin
 Use of gabapentin may reduce the
incidence of post-herpetic
neuralgia
Lapolla W, DiGiorgio C, Haitz K et al. Incidence of portherpetic neuralgia after combination treatment with gabapentin and valacyclovir in patient with acute
herpes zoster. Arch Derm; 147:901-907.
Victor D. Newcomer, MD (UCLA). (Nov 2005) Zoster. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52552&imageIndex=2
Bullous Pemphigoid
• Etiology
 Autoimmune disorder caused by
autoantibodies to
hemidesmosomes – attachment
complexes anchoring basal
keratinocytes to the basement
membrane
 Antibody deposition at the
basement membrane leads to
inflammatory response and
formation of subepidermal blisters
Image courtesy of www.visualdx.com © Logical Images, Inc
(NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52132&imageIndex=3
Bullous Pemphigoid
• Clinical
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 Begins as pruritic papular
eruption evolving into large, tense
oval bullae with serous or
hemorrhagic fluid
 Commonly affected areas include
axillae, medial thigh, groin,
abdomen and lower leg
 Mucous membranes are seldomly
involved.
(NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52132&imageIndex=0
Bullous Pemphigoid
• Diagnosis
 Based on clinical presentation,
presence of subepidermal blisters
on histology and demonstration
of anti-hemidesmosome
antibodies by direct and indirect
immunofluorescence
Image courtesy of www.visualdx.com © Logical Images, Inc
(University of Rochester, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52132&imageIndex=14
Bullous Pemphigoid
• Treatment
 Immunosupressive therapy with:
o Prednisone
o Azathioprine
o Methotrexate
 Tetracycline and nicotinamide
 In refractory cases can use IVIG
Image courtesy of www.visualdx.com © Logical Images, Inc
(NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52132&imageIndex=4
Venous Stasis Disease
• Etiology
 Risk factors include:
• Age
• Family History
• Prolonged Standing
• Increased BMI
• Sedentary lifestyle
 Venous hypertension develops
due to one or combination of:
• Poor muscle pump
function
• Incompetent venous valves
Charles E. Crutchfield III, MD. (March 2007). Venous Ulcer. [photograph]. Retrieved Oct 3,
2011, from http://www.visualdx.com/visualdx/visualdx6/
• Venous obstruction
getZoomImage.do?moduleId=11&diagnosisId=52465& imageIndex=0
Image courtesy of www.visualdx.com © Logical Images, Inc
• Clinical
Image courtesy of Margaret Mann, M.D.
 Severity of symptoms depends
on degree of venous reflux.
 In order of severity:
• Telangiectasias and
Reticular Veins
• Varicose Veins – dilated,
tortuous veins > 3mm in size
• Chronic Venous
Insufficiency
o Edema
o Skin discoloration
o Ulcers
o Lipodermatosclerosis –
fibrosing panniculitis
with hyperpigmentation
Venous Stasis Disease
• Diagnosis
 Venography – gold
standard, but invasive,
expensive, associated with
complications
 Duplex ultrasound – most
frequently used to assess
for deep venous
thrombosis, venous reflux
 Ankle-brachial index –
used to exclude arterial
disease
Image courtesy of Margaret Mann, M.D.
Venous Stasis Disease
• Treatment
 Conservative management:
• Leg elevation, compression therapy
• Skin cleansing, emollients, and topical steroids
 Ablation therapy:
• Liquid and foam sclerotherapy for treatment of telangiectasias,
reticular veins and small varicose veins
• Endovenous laser or radiofrequency ablation as well as
mechanical ablation are used to destroy large veins
Sun-Induced Skin Changes
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• “Sun spots” or “liver spots” are
also called lentigines, often on
backs of hands and shoulders
• Caused by the sun and generally
harmless, but can be confused with
more serious skin growths
• Can be treated with liquid nitrogen
cryotherapy or melanin-targeting
lasers (e.g., the Q-switched ruby
laser)
Charles E. Crutchfield III, MD. (March 2007). Lentigo, Solar. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51834&imageIndex=8
Sun-Induced Skin Changes
• Telangiectasias, or dilated blood
vessels , can arise as a result of
photodamage, rosacea, radiation
exposure, long term topical steroid
therapy or hereditary causes
Image courtesy of www.visualdx.com © Logical Images, Inc
• Mostly benign and can be
effectively treated with pulsed dye
lasers, other vascular targeting
lasers or in some cases,
electrocautery
(NYU, Department of Dermatology). Telangiectasia. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52379&imageIndex=1
Questions
1. Which 2 primary lesions are elevated:
a) Macule and Plaque
b) Macule and Papule
c) Papule and Patch
d) Papule and Plaque
2. True or False, drug eruptions occur more frequently in elderly patients?
a) True
b) False
Answers: 1. d, 2. a
3. The patient is a 75 yo male with no history of skin cancer who
presents because his wife became concerned about large “mole-like”
growths on his back, which have increased in number over the years.
The patient says some of them are itchy. On physical exam the
lesions are dark brown symmetric papules and plaques of uniform
color with stuck-on waxy appearance. What is the diagnosis?
a) Actinic Keratosis
b) Solar lentigo
c) Seborrheic Keratosis
d) Benign Nevus
4. In this patient, what is the most appropriate
next step in management?
a) Urgent referral to a dermatologist for biopsy
b) Photodynamic therapy
c) Full body CT scan to look for metastases
d) Cryotherapy with application of liquid nitrogen to symptomatic
lesions
Answers 3. c, 4. d.
Image courtesy of www.visualdx.com © Logical Images, Inc
Victor Newcomer, MD (UCLA). (Aug 2006). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2011, from
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5. The patient is a 60 year-old male with a history of significant sun
exposure who presents for a routine skin check. He has a history of
multiple rounds of cryotherapy for “pre-cancerous” lesions. On
physical exam there are multiple skin-colored papules with rough
adherent scale located on his hands and face. What is the diagnosis?
a) Actinic Keratosis
b) Seborrheic Keratosis
c) Basal cell carcinoma
d) Melanoma
6. For the patient in question 5, besides cryotherapy what is an
additional treatment option
a) 5- Fluorouracil cream
b) Chemical peels
c) Imiquimod Cream
d) Photodynamic therapy
e) All of the above
Answers: 5. a, 6. e
Image courtesy of www.visualdx.com © Logical Images, Inc
(University of Rochester, Department of Dermatology). Actinic Keratosis. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51805&imageIndex=5
7. A 55 year old female with a history of a blistering sunburn as a child and
family history of skin cancer presents with a lesion on her chest, which
she first noticed 1 month ago. She denies any pain but reports the lesion
bled with minor trauma last week. On physical exam the lesion is a
shiny, red lesion with rolled borders and prominent telangiectasias. The
most likely diagnosis is:
a. Melanoma in-situ
b. Squamous cell carcinoma
c. Nodular BCC
d. Superficial BCC
e. Herpes Zoster
f. Pigmented BCC
Answer: c
Image courtesy of www.visualdx.com © Logical Images, Inc
(NYU, Department of Dermatology). Basal Cell Carcinoma, Nodular. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=51167&imageIndex=0
8. This patient is a 60 year old female who presents with a large, tense
bullae, as shown below. Prior to the appearance of the bullae, she noted a
pruritic papular eruption in the same distribution. A biopsy was
performed, which revealed a subepidermal blister and
immunofluorescence demonstrated presence of anti-hemidesmosome
antibodies in the serum. What is the diagnosis?
a) Herpes Zoster
b) Bullous Pemphigoid
c) Drug eruption
d) Dermatomyositis
Answer: b
Image courtesy of www.visualdx.com © Logical Images, Inc
NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52132&imageIndex=4