Transcript The most likely diagnosis is

Assessing and
Managing Commonly
Encountered
Rashes and Lesions
HISTORY
• How long has the lesion been present?
• How did it look when it first appeared, and how is it now
different?
• Where did it first appear?
• What associated symptoms, such as itching or pain, are
associated with the lesion?
• Are any other family members affected or have a similar
history?
• Has the patient ever had this rash or lesion before?
• What does the patient think caused the rash or lesion?
• Is anything new or different (eg, medications, personal
care products, occupational or recreational exposures)?
PHYSICAL EXAMINATION
• Type of lesion
• Morphology of individual lesions
• Configuration of multiple lesions (eg,
scattered, grouped, linear..)
• Distribution of lesions
• Color
• Consistency and feel
Can you describe this rash?
MORPHOLOGY
• Macules are nonpalpable lesions ≤1 cm that vary in
pigmentation from the surrounding skin.
• Patches are nonpalpable lesions >1 cm. There are no
elevations or depressions.
• Papules are palpable, discrete lesions measuring ≤5 mm
in diameter .
• Plaques are large (>5 mm) superficial slightly raised
lesions, often formed by a confluence of papules.
• Nodules are palpable, discrete lesions measuring ≥5 mm
in diameter
• Tumors are large nodules.
MORPHOLOGY
• Telangiectasia is a dilated superficial blood vessel
• Purpura are red-purple lesions that do not blanch under
pressure Purpuric lesions can be macular or raised
(palpable purpura)
• Pustules are small, circumscribed skin papules containing
purulent material
• Vesicles are small (<5 mm diameter), circumscribed skin
papules containing serous material
• Bullae are large (≥6 mm) vesicles.
• Wheals are irregularly elevated edematous skin areas
that are often erythematous
Red scaly spots
70-year-old retired college professor
Notes multiple rough red scaly spots on forehead
over past few years
Unresponsive to triamcinolone cream
These lesions most likely represent:
1. Actinic keratoses
2. Basal cell carcinomas
3. Seborrheic keratoses
4. Seborrheic dermatitis
5. Psoriasis
Actinic Keratoses
• These scaly sometimes red small patches
and rough papules are considered precursors
to squamous cell carcinoma
• Basal cell carcinomas are usually pearly
papules
• Seborrheic dermatitis may involve the
hairline but not usually the mid forehead, and
will often respond to hydrocortisone
• Lesions of psoriasis are usually more distinct
and the face is often spared in adults
• Treatments for actinic keratoses including
topical agents (5-fluoruracil, imiquimod,
diclofenac), cryotherapy, etc
Rashes you need to know
17-year-old male presented with skin rash and low-grade fever with intense
pruritus:
This patient presented with - lesions that appear as papules, about 2 to 6 millimeters in
diameter
Patient presented with complaints of a solitary, lesion that enlarged over several
days.
Over the next several weeks, a generalized exanthem developed with mild to
moderate pruritus.
What is the cause of this pruritic dermatologic manifestation?
Describe the patient at risk for developing this condition?
Cauliflower-like lesion
55-year-old police officer
Patient’s wife notices lesion on upper back
enlarging progressively over last few years
The most likely diagnosis of this lesion
is:
1. Actinic keratosis
2. Basal cell carcinoma
3. Keratoacanthoma
4. Seborrheic keratosis
5. Squamous cell carcinoma
• The lesion is a seborrheic keratosis,
which often have a walnut- or
cauliflower-like surface
• They are common in middle aged and
elderly patients
• Actinic keratoses and squamous cell
carcinomas are crusted plaques or
papules, usually in sun-damaged skin
• Basal cell carcinoma is a pearly papule
Enlarging red crusted patch/plaque on the face
73-year-old retired secretary,
self-confessed “sun worshiper” with lesion on arm
Worse over last 6 months
Occasional bleeding
Different than many other “barnacles” he’s had
treated in the past
Changing mole
63-year-old house painter with changing mole
Was present for “several years”, but seems to be changing
more over last 6 months
What is the appropriate next step?
1. Have patient return in 6 months to
recheck mole
2. Refer to oncologist
3. Perform shave biopsy
4. Perform punch biopsy
5. Refer to dermatologic surgeon
Worsening acne
22-year-old law student
Acne reappeared after 5-year hiatus
Which is the least likely cause of her
flaring acne?
1. Isoniazid for positive PPD
2. Lithium citrate for bipolar disorder
3. Stress of law school exams
4. Zolpidem for sleep disturbance
5. Polycystic ovarian syndrome
Acne
• Isoniazid, lithium chloride, stress from
exams all associated with new onset
acne eruptions or exacerbation of
acne
• Zolpidem not reported to affect acne
• Acne may be a presenting sign of
polycystic ovarian syndrome
Petechiae surrounding the hair follicles on
the legs in association with bleeding gums
is a sign of
1. Vitamin B6 deficiency
2. Vitamin C deficiency
3. Drug reaction
4. Vitamin A deficiency
Scurvy
• The patient has the findings of vitamin C deficiency:
bleeding gums and petechia surrounding the hair
follicles especially on the legs
• The hairs may be twisted (“corkscrew hairs”)
• Zinc deficiency is associated with a periorificial and
acral psoriasiform and desquamating eruption
• Gluten sensitive enteropathy is associated with the
blistering eruption, dermatitis herpetiformis
• Vitamin B12 deficiency is associated with pernicious
anemia
Solitary lesion on lip
58-year-old attorney notes lesion on lip
for 2 days preceded by tingling.
Recently returned from ski trip
What is the most likely diagnosis?
1. Staphylococcal impetigo
2. Tinea faciei
3. Primary herpetic gingivostomatitis
4. Pemphigus vulgaris
5. Herpes labialis
Herpes labialis
• Herpes labialis is very common and can
be recurrent
• Primary herpetic gingivostomatitis
usually seen in younger patient, often
associated with multiple lesions,
extensive oral involvement
• Often provoked by UV exposure,
infection, or other physiologic or other
stressor
• Tinea would not present as lip vesicles
38-year-old male physician, 8-year
history of multiple sclerosis, currently
not on treatment. Lesions present for
several months, growing
What is the most likely diagnosis?
1. Molluscum
2. Secondary syphilis
3. Filiform warts
4. Actinic keratoses
5. Seborrheic keratoses
Filiform warts
• Warts on face, especially nostrils, eye lids or
corners of mouth, often show finger-like
(filiform) projections
• Molluscum are dome shaped
• Syphilis lesions typically moister, non-filiform,
bilateral
• Wrong location for actinic/seborrheic
keratoses
• Treatment includes cryotherapy, curettage,
etc.
Multiple facial papules
46-year-old physician, history of bilateral facial
papules for many years. No improvement with
topical salicylic acid or tretinoin
What is your diagnosis?
1. Molluscum
2. Dermatosis papulosa nigra
3. Flat warts
4. Adenoma sebaceum
5. Nevoid basal cell carcinoma syndrome
Dermatosis papulosa nigra
• Share histopathology with seborrheic
keratoses
• Often inherited as a dominant trait
• Malar location
• More raised than flat warts, not
centrofacial like adenoma sebaceum
Worsening facial rash
28-year-old day care worker, facial rash worsening
over last 12 weeks
Past medical history: migraines as teenager
Applied hydrocortisone cream for 4 days with no
improvement
What is the most appropriate next step?
1. Terbinafine cream
2. Mupirocin ointment
3. Punch biopsy
4. Nystatin cream
5. Scraping for fungal culture
Tinea faciei
• The patient has tinea faciei, a superficial infection
caused by dermatophytes like Trichophyton
tonsurans
• Terbinafine is effective against most
dermatophytes; nystatin is effective only against
yeasts like Candida
• While topical therapy may work, widespread or
longstanding cases may require oral antifungal
therapy
• Best to establish diagnosis before instituting oral
antifungal therapy
Itchy rash
40-year-old waiter, Itchy rash behind knees
appeared over last few weeks. Similar lesions in
antecubital fossae. Has had problem off and on
all of his life. Worse when he was a child, now
more restricted in distribution
Which is the most likely diagnosis?
1. Atopic dermatitis
2. Psoriasis
3. Seborrheic dermatitis
4. Allergic contact dermatitis
5. Tinea corporis
Atopic dermatitis
• Typical distribution in antecubital and
popliteal fossae, neck
• Itching is chief symptom
• May resolve over time or persist into
adulthood
Which organism is most likely to
be cultured from these lesions?
1. Streptococcus pyogenes
2. Streptococcus pneumoniae
3. Staphylococcus epidermidis
4. Staphylococcus aureus
Culture results
• The correct answer is “Staphylococcus
aureus.” S aureus can be cultured from
active lesions of atopic dermatitis in
> 75% of patients
Which is the most appropriate topical
treatment for this eruption?
1. Corticosteroid
2. Mupirocin
3. Retapamulin
4. Pimecrolimus
5. Tretinoin
Answer
• The correct answer is topical corticosteroid
• Even if staphylococcus is present, studies show that
treatment with a topical corticosteroid will reduce
bacterial counts
• Use of a topical antimicrobial such as mupirocin or
retapamulin will not treat underlying atopic
dermatitis
• Pimecrolimus, a calcineurin inhibitor, is indicated as
second line therapy for atopic dermatitis in patients
in whom a conventional therapy is ineffective or
would be inappropriate
Targetoid rash after URI
24-year-old college student
Upper respiratory infection 10 days ago
Treated with amoxicillin/clavulanic acid
Rash appeared 6 days into therapy
What is your diagnosis?
1. Fixed-drug eruption
2. Erythema multiforme
3. Henoch-Schoenlein purpura
4. Urticaria
5. Tinea corporis
40-year-old female.
Upper respiratory infection 10 days ago
Treated with amoxicillin/clavulanic acid
Sores in mouth for 3 days, painful
What is your diagnosis?
1. Erythema multiforme
2. Pemphigus vulgaris
3. Urticaria
4. Urticaria pigmentosa
5. Dermatomyositis
Erythema multiforme
• Correct answer is erythema multiforme
• Erosive mucositis combined with fixed,
painful,target-like lesions with necrotic
centers
• Pemphigus vulgaris is not associated with
target-like lesions
• Urticaria is migratory and lacks mucositis
• Lesions of urticaria pigmentosa are brown
oval macules and plaques and do not appear
suddenly
Single target
30-year-old attorney
Returns from camping trip in upstate New York
Target-like lesion on arm
Fever, malaise
Camping trip redux
22-year-old male returns from a winter camping trip
in Upstate New York
3-day history of itchy and painful lesions
Previously healthy
What is the most likely diagnosis?
1. Rhus (poison ivy) dermatitis
2. Lyme borreliosis
3. Contact dermatitis to backpack
4. Herpes zoster
5. Bed bug bites
What is the most likely diagnosis?
1.Eczema
2.Herpes zoster
3.Tinea corporis
4.Psoriasis
Which could be the cause of her
worsening psoriasis?
1. Bronchitis treated with azithromycin
2. Hepatitis A infection
3. Fluconazole for vaginal candida
4. Initiation of beta-blocker for
hypertension
5. Initiation of atorvastatin for
hypercholesterolemia
What is the most appropriate next step?
1. Initiate treatment with topical
corticosteroid
2. Prescribe a short course of prednisone
3. Prescribe a week of oral amoxicillin
4. Recommend daily use of tanning booth
5. Refer to dermatologist
Next step
• The next step is to refer to dermatologist
• Severe extensive psoriasis is unlikely to show
acceptable response to even potent
corticosteroids
• Prednisone can be associated with severe
rebound flares of psoriasis or conversion to
pustular form; moreover it is not an
appropriate solution for a chronic condition
• Dermatologist may choose to treat patient with
ultraviolet B light, systemic TNF-alpha-blocker
or oral agent (eg, methotrexate)
Extensive hair loss
23-year-old medical student
Rapid loss of hair within 2 weeks of starting first
clinical rotation
Which is the most likely diagnosis?
1. Hypothyroidism
2. Telogen effluvium
3. Alopecia areata
4. Discoid lupus
5. Trichotillomania
Eruption on face and hands
38-year-old pastry chef
Notes history of facial rash that waxes and wanes,
sometimes present on hands
Recently diagnosed with “fibromyalgia”
What test do you think is most likely to be
abnormal?
1. Patch testing for allergic contact
dermatitis
2. Anti-thyroid microsomal antibodies
3. Creatine phosphokinase
4. Glucose-6-phosphate dehydrogenase
5. Total iron binding capacity
Dermatomyositis
• This woman has the heliotrope rash of
dermatomyositis
• Rash is often photo-exacerbated
• Elevation of muscle enzymes (creatine
phosphokinase, aldolase) are typical
due to the myositis
• In adults, dermatomyositis may occur in
association with a variety of malignant
neoplasms
Facial hair/pigmentation
42-year-old HIV-positive nurse
On highly active anti-retroviral therapy
Over past year, notes facial hyperpigmentation and
increased facial hair
Also complains of new onset hand rash
Porphyria cutanea tarda
• Can be associated with ethanol,
estrogen, hepatitis and HIV
• Phototoxic and photoallergic eruptions
do not generally manifest with
temporal/cheek hypertrichosis and
hyperpigmentation
• Elevated urine porphyrins
• Treatment with phlebotomy
“Dirty neck”
38-year-old office worker complains of “dirty neck”
that won’t wash off
Past medical history: unremarkable
Which test is most likely to be abnormal?
1. Thyroid stimulating hormone
2. Chest X-ray
3. Stool guaiac
4. HbA1C
5. Serum prolactin
Acanthosis nigricans
• Acanthosis nigricans is a brown velvety
thickening of the skin on the neck and
body folds, especially the axillae
• It is most commonly associated with
abnormal glucose tolerance and obesity
New onset face and hand lesions
55-year-old saxophonist
New onset eruption
Denies fever or other systemic symptoms
Lesions asymptomatic
Hypertension well-controlled on enalapril
What blood test will you order?
1. ANA
2. EBV serology
3. Hepatitis screen
4. Scl-70
5. VDRL
Secondary syphilis
• Diagnosis of secondary syphilis made by
VDRL
• EBV can be associated with a
morbilliform eruption upon exposure to
ampicillin or related drugs
• Hepatitis rarely associated with
lichenplanus like eruptions
• Scl-70 and ANA used to diagnose
scleroderma and lupus; findings
generally do not resemble these
Soft bumps
30-year-old man sent for pre-employment physical
More than 30 soft bumps on arms, trunk, and face
Multiple flat, brown spots on trunk
Bowed shins
Hypertension
Seen by audiologist; bilateral hearing normal
The most likely diagnosis is:
1. Tuberous sclerosis
2. Cowden syndrome
3. Nevus sebaceus of Jadassohn
4. Neurofibromatosis Type 1
5. Neurofibromatosis Type 2
Next Generation
Which of the following is least likely to be
positive in a 10-year-old child with NF-1?
1. Skin examination for café-au-lait
macules
2. Skin examination for neurofibromas
3. Ocular examination for Lisch nodules
4. Skin examination for axillary freckling
Facial pigmentation
76-year-old retired auto worker
Worsening blue-gray facial pigmentation
over last year
Which medications can be associated
with this problem?
1. Albuterol
2. Amiodarone
3. Cromolyn sodium
4. Bortezomib
5. Montelukast