Transcript Dark Rashes - American Academy of Dermatology

Blotches:
Dark rashes
Medical Student Core Curriculum
in Dermatology
Last updated April 18, 2011
1
Module Instructions
 The following module contains a number
of blue, underlined terms which are
hyperlinked to the dermatology glossary,
an illustrated interactive guide to clinical
dermatology and dermatopathology.
 We encourage the learner to read all the
hyperlinked information.
2
Goals and Objectives
 The purpose of this module is to help medical students
develop a clinical approach to the evaluation and initial
management of patients presenting with
hyperpigmented rashes.
 After completing this module, the medical student will
be able to:
• Identify and describe the morphology of common
hyperpigmented rashes
• Provide an initial treatment plan for selected dark rashes
• Determine when to refer a patient with a dark rash to a
dermatologist
3
Case One
Scott Goff
4
Case One: History
 HPI: Scott Goff is a 28-year-old male who presents
with “blotches” on his upper back and chest for
several years. They do not cause any symptoms other
than anxiety because he has these dark spots.
 PMH: no major illnesses or hospitalizations
 Allergies: none
 Medications: protein supplements
 Family history: none
 Social history: accountant; weightlifter
 ROS: negative
5
Case One: Skin Exam
6
Case One: Skin Exam
7
Case One, Question 1
 Mr. Goff’s chest shows hyperpigmented, scaly
macules on his upper chest and back. Which
is the best test to confirm the diagnosis?
a.
b.
c.
d.
Bacterial culture
Direct fluorescent antibody (DFA) test
Potassium hydroxide (KOH) exam
Wood’s light
8
Case One, Question 1
Answer: c
 Mr. Goff’s chest shows hyperpigmented, scaly
macules on his upper chest and back. Which
is the best test to confirm the diagnosis?
a.
b.
c.
d.
Bacterial culture
Direct fluorescent antibody (DFA) test
Potassium hydroxide (KOH) exam
Wood’s light
9
Case One, KOH exam
Spores (yeast forms)
Short
Hyphae
The KOH exam shows short hyphae and small round spores. This is
diagnostic of tinea (pityriasis) versicolor.
10
Diagnosis: Tinea versicolor
 Based on his skin findings and KOH
exam, Mr. Goff has tinea versicolor
 It’s called “versicolor” because it can
be light, dark, or pink to tan
 Let’s look at some examples of the
various colors of tinea versicolor
11
Tinea versicolor: lighter
12
Tinea versicolor: darker
13
Tinea versicolor: pink or tan
14
Case One, Question 2
 What is the best treatment for Mr. Goff?
a.
b.
c.
d.
e.
Ketoconazole shampoo
Narrow band UVB phototherapy
Oral griseofulvin
Tacrolimus cream
Triamcinolone cream
15
Case One, Question 2
Answer: a
 What is the best treatment for Mr. Goff?
a. Ketoconazole shampoo
b. Narrow band UVB phototherapy (may
worsen appearance by increasing contrast)
c. Oral griseofulvin (does not work for
Malassezia species)
d. Tacrolimus cream (does not fight yeast)
e. Triamcinolone cream (does not fight yeast)
16
Case One, Question 3
 Which of the following statements is true
about the treatment of tinea versicolor?
a. Normal pigmentation should return within a
week of treatment
b. Oral azoles should be used in most cases
c. When using shampoos as body wash, leave
on for ten minutes before rinsing
17
Case One, Question 3
Answer: c
 Which of the following statements is true about
the treatment of tinea versicolor?
a. Normal pigmentation should return within a week of
treatment (usually takes weeks to months to return to
normal)
b. Oral azoles should be used in most cases (mild
cases can be treated with topicals)
c. When using shampoos as body wash, leave on
for ten minutes before rinsing
18
Case Two
Melinda Kinsley
19
Case Two: History
 HPI: Melinda Kinsley is a 48-year-old Guatemalan
woman who presents with ten years of dark spots on her
face. She tried a bleaching cream she got from Mexico
but her friend told her it could make the spots worse.
 PMH: three normal pregnancies; s/p tubal ligation
 Allergies: none
 Medications: supplements black cohosh, evening
primrose
 Family history: noncontributory
 Social history: lives with husband and children
 ROS: negative
20
Case Two: Skin Exam
21
Case Two, Question 1
 Which of the following is most likely associated
with this symmetric hyperpigmentation?
a.
b.
c.
d.
e.
Ginseng
Limes
Minocycline
Malassezia furfur
Pregnancy
22
Case Two, Question 1
Answer: e
 Which of the following is most likely associated
with this symmetric hyperpigmentation?
a.
b.
c.
d.
e.
Ginseng
Limes
Minocycline
Malassezia furfur
Pregnancy
23
Melasma
24
Melasma (aka Chloasma)
 Melasma is characterized by patchy light
to dark brown hyperpigmentation of the
face
 Usually affects women, runs in families
 Associated with hormonal changes
• Called the “mask of pregnancy”
• May occur with pregnancy, birth control pills,
and hormone replacement therapy
25
Melasma (aka Chloasma)
 Worse with exposure to UV radiation
 Treatments
• Strict sun avoidance, daily sunscreen with
broad spectrum coverage and SPF > 30
• Hydroquinone 4% cream BID
• If this fails, may refer to dermatology for
cosmetic treatments like triple topical therapy,
lasers, or chemical peels, but these will usually
be at the patient’s expense
26
Case Three
Henry Fontana
27
Case Three: History
 HPI: Henry Fontana is a 78-year-old man who presents with of
darkening of his arms and neck over the past few years. He
recently underwent knee replacement surgery, and the
orthopedist noticed a greenish pigmentation of his bones.
 PMH: hypertension, GERD, osteoarthritis, BPH, basal cell and
squamous cell carcinomas, rosacea
 Allergies: none
 Medications: atenolol, felodipine, celecoxib, oxybutinin,
rabeprazole, minocycline
 Family history: noncontributory
 Social history: widower; lives alone
 ROS: negative
28
Case Three: Skin Exam
29
Case Three, Question 1
 Which of the following medications is most
likely associated with this pigmentation?
a.
b.
c.
d.
e.
Atenolol
Celecoxib
Minocycline
Oxybutinin
Rabeprazole
30
Case Three, Question 1
Answer: c
 Which of the following medications is most
likely associated with this pigmentation?
a.
b.
c.
d.
e.
Atenolol
Celecoxib
Minocycline
Oxybutinin
Rabeprazole
31
Minocycline pigmentation
32
Minocycline pigmentation
 Deposition appears after months to years in a small
percentage of patients
 First noticeable on the alveolar ridge, palate, sclera
 May involve bones, thyroid, but this is harmless
 Skin deposition can be brown or blue-grey
 Blue-grey pigmentation may occur in scars
 Skin pigmentation may not fade after discontinuation
 Patients on long-term minocycline should be screened;
if seen on gums or sclerae, discontinue
33
Other causes of medication-related
hyperpigmentation
 Amiodarone
 Antimalarials
• Hydroxychloroquine
• Chloraquine
 Calcium channel blockers
• Verapamil
• Diltiazem
 Zidovudine
 Imipramine
• Some antipsychotics
 Some chemotherapy agents
34
Case Four
Elaine Gosnel
35
Case Four: History
 HPI: Elaine Gosnel is a 66-year-old woman with a
two-year history of an itchy rash on her legs that
has resulted in dark spots.
 PMH: hypertension, diabetes, hyperlipidemia
 Allergies: none
 Medications: metoprolol, simvastatin, metformin
 Family history: noncontributory
 Social history: widowed; lives in a retirement
community
 ROS: edematous legs
36
Case Four: Skin Exam
37
Case Four, Question 1
 The patient’s legs show scaly brown plaques on
her lower legs bilaterally. Pedal pulses are normal.
What is the most likely diagnosis for Mrs. Gosnel’s
rash?
a.
b.
c.
d.
e.
Atopic dermatitis
Erysipelas
Irritant contact dermatitis
Stasis dermatitis
Tinea corporis
38
Case Four, Question 1
Answer: d
 The patient’s legs show scaly brown plaques on her
lower legs bilaterally. Pedal pulses are normal. What
is the most likely diagnosis for Mrs. Gosnel’s rash?
a. Atopic dermatitis (wrong location, no history)
b. Erysipelas (usually unilateral, acute not chronic)
c. Irritant contact dermatitis (not good location, no
history)
d. Stasis dermatitis
e. Tinea corporis (more superficial)
39
Stasis dermatitis
40
Case Four, Question 2
 You correctly diagnose Mrs. Gosnel with stasis
dermatitis. What do you recommend?
a. Bacitracin ointment twice daily
b. Daily oral trimethoprim-sulfamethoxazole
c. Debridement of superficial erosions
d. Elevation and compression stockings
e. Immediate referral to vascular surgery
41
Case Four, Question 2
Answer: d
 You correctly diagnose Mrs. Gosnel with stasis
dermatitis. What do you recommend?
a. Bacitracin ointment twice daily (likely to cause allergic
contact dermatitis)
b. Daily oral trimethoprim-sulfamethoxazole (no active
infection)
c. Debridement of superficial erosions (may worsen)
d. Elevation and compression stockings
e. Immediate referral to vascular surgery (not indicated
for most stasis dermatitis)
42
Stasis dermatitis
 Venous stasis dermatitis is an eczematous
eruption that occurs in venous insufficiency and
leg edema
• Acute eczematous dermatitis (itchy red scaly plaques)
leads to chronic eczematous dermatitis; may be weepy
• Extravasation leads to brown pigmentation and
petechiae
• Venous ulcers may result, especially on medial
malleolus
Refer to the module on Stasis Dermatitis and
Leg Ulcers for more information
43
Stasis dermatitis: Treatment
 Reduce edema with elevation and
compression stockings
 Wet compresses may aid in healing erosions or
ulcers
 Mid-potency topical steroids control
inflammation
 Avoid topical antibiotics because up to half
develop allergic contact dermatitis,
especially to neomycin and bacitracin
44
Quick Case: Dark spot on the leg
 This 32-year-old
man who had a
small laceration two
years ago and
presents with a dark
spot
 He’s worried it might
be something bad
45
Quick Case: Diagnosis?
 What is the most likely
diagnosis?
a. Drug-induced
pigmentation
b. Melanoma
c. Postinflammatory
hyperpigmentation
d. Post-traumatic fungal
infection
46
Quick Case: Diagnosis?
Answer: c
 What is the most likely
diagnosis?
a. Drug-induced
pigmentation
b. Melanoma
c. Postinflammatory
hyperpigmentation
d. Post-traumatic fungal
infection
47
Postinflammatory hyperpigmentation
 Postinflammatory hyperpigmentation describes
a common phenomenon of darkening of the
skin at or around sites of injury or inflammation
• Individuals with olive or slightly darker
complexion are at particular risk
• The pigmentation takes months to years to fade
but usually improves gradually over time
48
Postinflammatory hyperpigmentation
 Reassure patients this is normal
• This is not a scar; it’s just increased
pigment
• Use sunscreen after injuries or surgical
procedures
• For significant or problematic
hyperpigmentation, refer to a
dermatologist
49
Postinflammatory hypopigmentation
 Some patients heal with
light spots instead
 Stigma may be caused by
fear of infectious diseases
 Social impact can be more
severe than original rash
 Pigmentation may return
slowly
 It is important to treat
rashes aggressively to
avoid this if possible
50
Common dark rashes





Tinea versicolor
Melasma
Drug pigmentation
Stasis dermatitis
Postinflammatory hyperpigmentation
51
Take Home Points: Dark Rashes
 Tinea versicolor may be hyperpigmented
 Symmetric brown patches on the zygomatic, buccal,
and mandibular cheeks of adult women are usually
melasma
 Some medications (especially minocycline) cause
hyperpigmentation; warn patients and monitor for it
 Venous stasis can cause hyperpigmentation
 Postinflammatory hyperpigmentation and
hypopigmentation are very common in darker skin
types, so treat skin conditions aggressively
52
Acknowledgements
 This module was developed by the American
Academy of Dermatology Medical Student Core
Curriculum Workgroup from 2008-2012.
 Primary author: Patrick McCleskey, MD, FAAD.
 Peer reviewers: Timothy G. Berger, MD, FAAD;
Peter A. Lio, MD, FAAD; Jennifer Swearingen, MD;
Sarah D. Cipriano, MD, MPH.
 Revisions: Patrick McCleskey, MD, FAAD.
 Last revised April 2011.
53
References
 Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The WebBased Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007.
Available from: www.mededportal.org/publication/462.
 Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy,
4th ed. New York, NY: Mosby; 2004.
 Layton AM, Cunliffe WJ. Minocycline induced skin pigmentation in the
treatment of acne—a review and personal observations. J Dermatol
Treatment 1989;1:9-12.
 Lio PA. Little white spots: an approach to hypopigmented macules.
Arch Dis Child Pract Ed 2008;93:98-102.
 Marks Jr JG, Miller JJ. Chapter 13. White Spots (chapter). Lookingbill
and Marks’ Principles of Dermatology, 4th ed. Elsevier; 2006:187-197.
 Wolverton SE. Systemic drugs for infectious diseases (Chapter 5) and
Topical Antifungal Agents (Chapter 29). Comprehensive Dermatologic
Drug Therapy, 2nd ed. Elsevier; 2007: 80-99, 547-559.
54