common dermatologic issues in the geriatric population steve marchenko, janelle marshall and kristen...
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Common Dermatologic Issues in the Geriatric Population
Steve Marchenko, Janelle Marshall 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 HistoryTime/duration/change over time, initial site and spread/symptomsGeneral 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 lesionsLesion distribution often provides important diagnostic clues
Approach to Making Dermatologic Diagnoses
• Diagnostic Testing to consider
Shave, punch biopsyKOH for fungal infectionsGram stain for bacterial infectionsTzanck preparations for herpetic infection (shown)Oil mount of skin scrapings for scabies infection
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
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 LesionsLesion Description Example
Macule Circumscribed, flat, <0.5 cm (centimeter) freckle (ephelis)
Patch Macule >0.5cm vitiligo
Papule Elevated, solid lesion <0.5cm molluscum contagiosum
Plaque Elevated, plateau-like lesion without substantial depth
psoriasis
*the definition of these lesions vary by the dermatology reference, but usually is 0.5-1.0cm.
Note multiple hyperpigmented macular lesions and a single patch found in this patient with neurofibromitosis type 1. A papule is seen above the patch.
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 Description Example
Nodule Elevated, solid lesion >0.5cm with some depth rheumatoid nodule
Wheal Firm, edematous plaque hivesVesicle Circumscribed, elevated lesion with free fluid,
<0.5cmVaricella
Bulla Vesicle >0.5cm Bullous pemphigoid
Pustule Circumscribed, elevated lesion with purulent material
acne
Primary Skin Lesions
Note multiple pustulo-vesicles and plaquesin a patient with subcorneal pustular dermatosis
Image courtesy of www.visualdx.com © Logical Images, Inc
(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
In this patient with pemphigus, superficial blisters have ruptured
and formed crusted erosions and scales
Image courtesy of www.visualdx.com © Logical Images, Inc
(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
Tindall JP, Smith JG Jr. Skin lesions of the aged and their association with internal changes. JAMA. Dec 21 1963;186:1039-42
Image courtesy of www.visualdx.com © Logical Images, Inc
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
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
Benign dome-shaped capillary
proliferations that blanch with pressure.
Usually appear in individuals over 35 on arms and trunk and tend to bleed when injured.
Successfully treated with laser or electrocautery
Cherry Angiomas
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
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
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
Actinic Keratoses
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
• 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
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
•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
Nodular BCC
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
ClinicalSeveral subtypes are described•Nodulocystic:
single shiny, red nodule w/ telangiectasia •Superficial:
least aggressive erythematous plaquescan mimic psoriasis
•Sclerotic/Morpheiform: most aggressive5% of all BCC’s.Ill-defined borders
•PigmentedShiny, blue-black papule, speckled pigment, rolled borders.
Superficial BCC
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
Skin Cancer
•Management
Depends on location, size, histopathology, and patient factorsVery low risk/superficial: consider curettage + topical 5-FU or imiquimodMost low risk lesions: curettage and electrodessication For higher risk or recurrent BCC: excision with margins or Mohs micrographic surgeryElderly 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
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 (ie, 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
Mohs Micrographic Surgery• Advantages:
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
The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohs-procedure.php
Image courtesy of American College of Mohs Surgery
Basics of Dermatologic Surgery
Mohs Micrographic Surgery•Step 5: If residual cancer is seen under 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
The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohs-procedure.php
Image courtesy of American College of Mohs Surgery
Drug Eruptions
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
• Drugs most commonly implicated:antimicrobial agents, nonsteroidal anti-
inflammatory drugs (NSAIDs), cytokines, chemotherapeutic agents, anticonvulsants, and psychotropic agents
Morbiliform eruption
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
Image courtesy of www.visualdx.com © Logical Images, Inc
Drug Eruptions
Urticaria Antibacterial, nonsteroidal antiinflammatory drugs,antidepressants, opioids, imidazoles
Morbilliform rash Antibacterial (penicillin, sulfonamides), anticonvulsants,gold, allopurinol, diuretics
Lichenoid rash Antimalarials, gold, β-blockers, diuretics, sulfonylureas, hypoglycemic agents
Cutaneous Vasculitis Diuretics (furosemide, thiazides),antibacterials, allopurinol, amiodarone
Drugs commonly implicated in each type of reaction
Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131Shear 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
Photosensitivity Amiodarone, phenothiazines, sulfonamides, tetracyclines,nonsteroidal antiinflammatory drugs
Drug-induced autoimmune rash Penicillamine, hydralazine, gold
Stevens Johnson Anti-gout agents (allopurinol), NSAIDS, antibiotics, anticonvulsants
Toxic Epidermal Necrolysis Anti-gout agents (allopurinol), NSAIDS, antibiotics, anticonvulsants
Drugs commonly implicated in each type of reaction
Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131Shear 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
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 (EM)Drug Eruptions
Target lesions
Erythema Multiforme Major
Severe drug reaction requiring immediate medical attentionSubcategories include: Stevens-Johnson syndrome (SJS) and toxic
epidermal necrolysis (TEN)Characterized by epidermal necrosis and sloughing of the mucous
membranes and skinIn SJS, lesions affect less than 10 % of the body surface; In TEN,
greater than 30% affected
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
• Etiology: Not completely understood 80% of cases associated with adverse drug
reaction
Drug Eruptions
Erythema Multiforme Major
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-upConsider alternative etiologies, e.g. viral exanthems and
bacterial infections Take a good medication history
• Review the complete medication list, including over-the-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-upBiopsy 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
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.
• 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
Erythema Multiforme Major
• Treatment of Erythema Multiforme MajorTransfer to a burn unit with aggressive supportive care is the
most critical step in managementConsultation with Dermatology and OphthalmologyRapid identification and
withdrawal of offending drug
improves survival IVIG may be indicated;
efficacy is controversial
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.
Image courtesy of www.visualdx.com © Logical Images, Inc
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
• EtiologyReactivation of Varicella Zoster
Virus
• ClinicalProdrome 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
Image courtesy of www.visualdx.com © Logical Images, Inc
(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
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
Image courtesy of www.visualdx.com © Logical Images, Inc
Herpes Zoster
• Prevention
Zostavax – live herpes zoster vaccine
Reduces Shingles by 51.3%
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.
Image courtesy of www.visualdx.com © Logical Images, Inc
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
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.
Image courtesy of www.visualdx.com © Logical Images, Inc
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
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. 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=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 Azathioprineo 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
• Venous obstruction
Image courtesy of www.visualdx.com © Logical Images, Inc
Charles E. Crutchfield III, MD. (March 2007). Venous Ulcer. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52465& imageIndex=0
• Clinical 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 Insufficiencyo Edemao Skin discolorationo Ulcerso Lipodermatosclerosis –
fibrosing panniculitis with hyperpigmentationImage courtesy of Margaret Mann, M.D.
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
• “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)
Image courtesy of www.visualdx.com © Logical Images, Inc
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
• Mostly benign and can be effectively treated with pulsed dye lasers, other vascular targeting lasers or in some cases, electrocautery
Image courtesy of www.visualdx.com © Logical Images, Inc
(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
Questions1. 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 Keratosisb) Solar lentigoc) Seborrheic Keratosisd) Benign Nevus
4. In this patient, what is the most appropriate next step in management?a) Urgent referral to a dermatologist for biopsyb) 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.
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 Keratosisb) Seborrheic Keratosis c) Basal cell carcinomad) Melanoma
6. For the patient in question 5, besides cryotherapy what is an additional treatment option a) 5- Fluorouracil creamb) Chemical peelsc) Imiquimod Creamd) Photodynamic therapye) All of the above
Answers: 5. a, 6. e
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
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 Zosterb) Bullous Pemphigoidc) Drug eruptiond) Dermatomyositis
Answer: b