KIN 405: Medical Aspects of Sports

Dermatology: Recognizing Illnesses and Disorders of the

Skin

Skin Lesions

Often overlooked or trivialized Can signify serious disease in well

patients Local conditions Systemic conditions Difficult for many health professionals to

recognize

Athletic Trainers’ Goals RRecognize various forms of

skin lesions

RReassure patients that every little blemish is NOT skin cancer

RRefer for definitive diagnosis and treatment

RRestrict competition for athletes with communicable illness

Presentation Outline

Anatomy of the skin Types of lesions Rashes Infections

– Bacterial– Fungal– Viral

Presentation Outline (cont)

Skin cancer Assessment techniques Treatment techniques

Anatomy of the Skin

Stratum corneum Epidermis Dermis Pilosebaceous unit Subcutaneous fat

Stratum Corneum

Top layer of skin Flakes off

imperceptibly Barrier to noxious

substances Totally replaced

every 27 days

Epidermis

Protects against UV damage

Provides cutaneous immunity

Dermis

Connective tissue Provides elasticity &

strength Contains blood

vessels, nerves, & sweat glands

Skin splits when dermis is cut

Pilosebaceous Unit

Hair shaft Hair follicle Erector muscle Sebaceous gland Common site of

bacterial infections

Subcutaneous Fat

Insulates Protects

Kinds of Skin Lesions

Macules Papules Plaques Pustules Vesicles

Nodules Desquamination Bullae Ulcers Wheals

Macules

Flat Nonpalpable Discolored Less than 1cm

Causes of Macules

Hypopigmentation Hyperpigmentation Permanent vascular abnormalities of

the skin Transient capillary dilatation (erythema)

Hypopigmentation Macules

Vitiligo Depigmentation

Hyperpigmentation Macules

Café-au-lait spots

Permanent Vascular Abnormalities of the Skin

CAPILLARY HEMANGIOMA OF INFANCY PORT-WINE STAIN

Transient Capillary Dilatation (Erythema)

Erythema Infectiosum (systemic viral)

Papules

Latin for “Pimple” Raised lesion Less than .5 cm Solid

Example of Papules

Rosacea

Plaques

Large, raised lesion Well-defined Confluence of

multiple papules Chronic rubbing

leads to “lichenification” (thickened skin)

Example of Plaques

PSORIASIS VULGARIS OF THE ELBOW

Pustules

Circumscribed Superficial Contains purulent

exudate that may be– white– yellow– greenish yellow– hemorrhagic.

Example of Pustules

Acne Vulgaris

Vesicles

Latin for “little bladder”

Fluid filled cavity Less than .5 cm Walls can be

translucent Contains serum,

lymph, blood, or extracellular fluid

Example of Vesicles

Nongenital herpes simplex virus (HSV) infection

Bullae

Latin for “bubble” Fluid filled cavity Greater than .5 cm Walls can be

translucent Contains serum,

lymph, blood, or extracellular fluid

Diabetic bullae

Nodules

Latin for “small knot” Palpable, solid Round or ellipsoid Epidermal, dermal,

or subcutaneous Generally deeper

and larger than papules

Example of Nodules

Adult T-Cell Leukemia/Lymphoma

Desquamination

Proliferation of epidermis resulting in abnormally formed stratum corneum

“Scaly” Large

(membranous) or small (dust)

Example of Desquamination

Solar Keratosis

Ulcers

Pathologically altered tissue (different from a wound)

Epidermal - heals w/out scar

Dermal - heals w/ scar

Example of Ulcers

Stage IV Pressure Ulcer on Sacrum

Wheals Hives Rounded or flat

topped Pale red Transient Can change rapidly in

size, shape, and location due to shifting edema in the dermis

Example of Wheals

Cutaneous Vasculitis

Rashes

Acne Dermatitis Intertrigo Urticaria Psoriasis Seborrheic dermatitis Pityriasis rosea

Acne

Affects 75% of the population Can involve inflammation of the

pilosebaceous unit Food choices NOT causative Endocrine and emotional links Not contagious Four stages

Grade I Acne Comedones

(blackheads) Some whiteheads Topical antibiotics

(clindamycin, erythromycin

Benzoyl peroxide gels (2%,5%,10%)

Tretinoin (Retin-A) creams

Grade II Acne

Erythematous papules

Oral tetracycline antibiotics added to previous tx regimen

For females, oral estrogens combined with progesterone or antiandrogens

Grade III Acne Pustules Isotretinoin (Accutane) Contraception (2

forms) is absolutely necessary

Do not combine tetracycline and isotretinoin

Risk of psychiatric side effects

Grade IV Acne

Cysts Nodules Scars

Dermatitis

Inflammation of the skin Sometimes called eczema Many causes and forms (allergic vs non-

allergic) Not contagious Contact dermatitis caused by contact with

noxious substances (formaldehyde, plant oils, rubber, etc)

Dermatitis-Signs and Symptoms

Pruritis (itching) Erythematous

papules Vesicles (or bullae) Crusting Edema

Poison Ivy, 5 days post exposure

Dermatitis-Treatment

Identify and remove the etiologic agent

Bullae may be drained, but tops should not be removed

Cool compresses Topical

corticosteroids Contact dermatitis from paraben-containing foot cream

Dermatitis-Treatment (cont)

In severe cases, systemic corticosteroids may be indicated

Prednisone: two-week course, 70 mg initially, tapering by 5 mg daily

Chronic contact dermatitis on the hands of a concrete worker

Intertrigo

Caused by friction in skin folds Axilla, inframammary area, groin Gradual and progressive skin abrasion

irritated by sweat and heat

Intertrigo-Treatment

Mild topical hydrocortisone

Zinc oxide ointment Reduce friction Corn starch/baby

powder Expose to air

Urticaria

Transient hives characterized by wheals Pruritis Caused by sunlight, medication or food

allergy, cold, and exercise

Urticaria

Wheals with white-to-light-pink color centrally and peripheral erythema in a close-up view.

Cholinergic Urticaria

Exercise-induced wheals & pruritis

Hot shower may also reproduce symptoms

Urticarial papules on neck w/in 30 minutes of vigorous exercise

Cold-Induced Urticaria

Caused by cold sensitivity Ten minute application of ice pack

cause a wheal w/in five minutes of the removal of the ice

Urticaria-Treatment Oral antihistamines

(Benadryl) Avoidance of

causative agent Prednisone May compete as

long as pruritis is not disabling & breathing not compromised

Urticaria as it appeared 5 minutes after stroking the skin with a wooden stick. The patient had experienced generalizedpruritus for several months with no spontaneously occurring urticaria.

Psoriasis

Genetically inherited disease Erythematous papules and plaques Primarily on extensor surfaces

– elbows– knees– scalp– intergluteal area

Psoriasis-Trigger Factors

Trauma (Koebner effect)

Drugs Stress Infections

Psoriasis of the elbow

Psoriasis-Treatment

Limited course of topical corticosteroids (long term application causes skin breakdown)

Triamicinolone acetonide (Aristocort, Kenalog)

Psoriasis-Treatment (cont)

Anthralin (Anthra-Derm cream -- not for use on face or skin creases)

Vitamin D analogues (e.g., calcipotriol)

UV light therapy No participation

restrictions

Seborrheic Dermatitis

Common chronic dermatosis Characterized by redness and scaling

occurring in regions where the sebaceous glands are most active, such as the face and scalp, and in the body folds.

Mild scalp SD causes flaking (dandruff)

Seborrheic Dermatitis-Treatment

Creams or shampoos containing– selenium (Selsun

Blue)– ketocanazole

(Nizoral)

Similar lesions were also present in the retroauricular areas and presternal chest.

Pityriasis Rosea Distinctive morphology Characteristic course “Herald” plaque lesion develops, usually on the

trunk, and 1 or 2 weeks later a generalized secondary

eruption develops in a typical distribution pattern

Spontaneous remission in 6 weeks without any therapy

Pityriasis Rosea (cont)

Herald Patch (80 % of patients) oval, slightly raised plaque

2 to 5 cm, bright red, fine scale at periphery

Pityriasis Rosea (cont) Long axes of the

lesions follow the lines of cleavage in a “Christmas tree” distribution

Lesions usually confined to trunk and proximal arms and legs

Rarely on face

Pityriasis Rosea-Treatment Pruritus may be controlled by UVB

phototherapy or natural sunlight exposure if begun in the first week of eruption.

Five consecutive exposures, starting with 80 % of the minimum erythema dose and increasing 20 % each exposure.

Usually goes away by itself.

Infectious Disorders

Bacterial Infections Fungal Infections Viral Infections

Bacterial Infections

Impetigo & ecthyma Abscess, furuncle, & carbuncle Scarlet fever

Impetigo & Ecthyma

Caused by Staphylococcus aureus and Streptococcus pyogenes

Impetigo-epidermis Ecthyma-dermis Superficial breaks in

the skin

Scattered, discrete, thin-walled vesicles and bullae that easily rupture and form erosions.

Impetigo

Transient superficial small vesicles or pustules, rupture resulting in erosions, which in turn become surmounted by a crust

Crusted (golden-yellow, stuck-on) erosionsbecoming confluent on the nose, cheek, lips, and chin.

Ecthyma

Ulceration with a thick adherent crust

A large, circumscribed ulcer with a necrotic base andsurrounding erythema in the pretibial region.

Impetigo & Ecthyma-Treatment

Mupirocin (Bactroban) applied three times daily to involved skin and to nares for 7 to 10 days.

Oral antibiotics (10 day course is typical)

Highly infectious -- disqualify from contact athletics until infection is cleared by physician

Abscess, Furuncle, & Carbuncle

Abscess - a circumscribed collection of pus appearing as an acute or chronic localized infection with tissue destruction.

Furuncle - an acute,deep-seated, red, hot, tender nodule or abscess that evolves from a staphylococcal folliculitis.

Carbuncle - a deeper infection composed of interconnecting abscesses usually arising in several contiguous hair follicles.

Abscess

Usually caused by Staphylococcus aureus.

Very tender Warm Will develop a

pustulent headA very tender abscess with surrounding erythemaon the heel.

Furuncle (boil)

Firm tender nodule 1 to 2 cm

Central necrotic plug. staphylococcal

folliculitis in beard area or neck.

Nodule becomes fluctuant with abscess formation

Furuncle (boil)

Necrotic plug often topped by a central pustule.

Following drainage a nodule.

A zone of cellulitis may surround the furuncle.

Carbuncle Evolution similar to that of

furuncle. Comprised of multiple,

adjacent, coalescing furuncles

Characterized by multiple dermal and subcutaneous abscesses,pustules, necrotic plugs, and sieve-like openings draining pus

Treatment

Incision and drainage

Systemic antibiotics (10 day course)

Local heat Disqualification from

contact sport until resolved

Highly contagious

Scarlet Fever

Acute infection of the tonsils, skin, or other sites by Streptococcus

Associated with a characteristic toxigenic rash

Scarlet Fever Erythema on the upper

trunk Face flushed with a

perioral pallor. Linear petechiae

(Pastia’s sign) occur in body folds.

Rash fades w/in 5 followed sheetlike exfoliation on the palms and soles.

Pastia’s Sign

Scarlet Fever-Treatment Aspirin or

acetaminophen for fever and/or pain

The goal of therapy is to eradicate Streptococcus throat carriage to prevent rheumatic fever.

Drug of choice is penicillin because of its efficacy in prevention of rheumatic fever.

Desquamation of the volar fingertips 10 days after onset of streptococcal pharyngitis in an adult female.

Fungal Infections

Varieties of Tinea infections Onychomycosis Candidiasis Pityriasis versicolor

Tinea Pedis (Athlete’s Foot)

Dermatophytic infection of the feet

Erythema,desquamation, and/or bulla formation

Hot, humid weather, occlusive footwear, excessive sweating

Scaling, maceration, erythema, and erosion in the 4-5 webspace. 4th toenail also infected.

Tinea Pedis (Athlete's Foot)

Walking barefoot on contaminated floors

Arthrospores can survive in human skin scales 12 months.

Pruritus Pain with secondary

bacterial infection

Moccasin type tinea pedis. Erythema, fine white scaling of the plantar and lateral foot, and kerato-derma(thickening of the keratin layer)

Tinea Pedis-Treatment

Keep feet clean, dry, exposed to air

Dry shoes thoroughly

Terbinafine (Lamisil) cream

Tinea Manuum Fungal infection of the

hands Diffuse hyperkeratosis

of the palms (especially the creases)

Patchy scaling on the dorsa and sides of fingers

50% of patients have unilateral involvement

Erythema and scaling of theright hand, associated with bilateral tinea pedis; the “one hand, two feet” distribution is typical of epidermal dermatophytosis of the hands and feet.

Tinea Manuum-Treatment Must eradicate all other

sources of tinea infection

Topicals don’t work (stratum corneum too thick)

Terbinafine (Lamisil) Itraconazole

(Sporanox) Griseofulvin (Grisactin)

Tinea Cruris (Jock Itch)

Subacute or chronic dermatophytosis of the groin, pubic regions,and thighs.

Warm, humid environment, tight clothing worn by men, obesity.

Pruritis

Erythematous, scaling plaques on the medial thighs,inguinal folds, and pubic area. The margins are raised and sharply marginated.

Tinea Cruris Most individuals with

tinea cruris have tinea pedis.

Dermatophyte is transferred from feet to crural region by hands.

Affects groins and thighs. May extend to buttocks. Scrotum and penis are rarely involved.

TOPICAL ANTIFUNGALS

CATEGORIES AGENTS TRADE NAMESImidazoles Clotrimazole Lotrimin, Mycelex

Miconazole MicatinKetoconazole NizoralEconazole SpectazoleOxiconizole OxistatSulconizole Exelderm

Allylamines Naftifine NaftinTerbinafine Lamisil

Naphthiomates Tolnaftate TinactinSubstituted pyridone Ciclopiroxalamine Loprox

Tinea Cruris-Treatment

Eradicate other sources of tinea infection

Differentiate from intertrigo

Avoid tight clothing Keep dry, cool

Tinea Corporis (Ringworm)

Dermatophyte infections of the trunk, legs, and arms, excluding the feet, hands, and groin.

More common in animal workers in tropical climates.

Sharply marginated, hyperpigmented plaques of chronic duration. Associated tinea cruris and tinea pedis are usually present.

Tinea Corporis Often asymptomatic Mild pruritus Scaling, sharply

marginated plaques Peripheral

enlargement and central clearing

Annular configuration with concentric rings Tinea corporis contracted

from a pet guinea pig.

Tinea Corporis-Treatment

CATEGORIES AGENTS TRADE NAMESImidazoles Clotrimazole Lotrimin, Mycelex

Miconazole MicatinKetoconazole NizoralEconazole SpectazoleOxiconizole OxistatSulconizole Exelderm

Allylamines Naftifine NaftinTerbinafine Lamisil

Naphthiomates Tolnaftate TinactinSubstituted pyridone Ciclopiroxalamine Loprox

Tinea Facialis (Face Ringworm)

Dermatophytosis of the glabrous facial skin

Well-circumscribed erythematous patch

More commonly misdiagnosed than any other dermatophytosis.

Sharply marginated, erythematous plaque with some central clearing and peripheral scaling on the lower eyelid and cheek

Tinea Facialis

Pruritus and photosensitivity

Pink to red In black patients,

hyperpigmentation Scaling often is

minimal but can be pronounced

Sharply marginated, erythematous, scaling, and crusted plaques on the face of a child. Note asymmetry.

Tinea Facialis-Treatment

Topical antifungal preparations

Eradicate dermatophyte infection at other sites such as feet and hands. Tinea Facialis is more

common in children.

Tinea Capitis

Fungal infection of the scalp

Follicular inflammation with painful, boggy nodules that drain pus

Scarring alopecia Scaling patches

Large, round, hyperkeratoticplaque of alopecia due to breaking off of hair shafts close to the surface, giving the appearance of a mowed wheat field on the scalp of a child.

Tinea Capitis

Blacks>whites Children>adults Three types

– “Black dot”– Kerion– Favus

Tinea Capitis-”Black Dot” Type Broken-off hairs near

surface give appearance of “dots” in dark-haired patients

Tends to be diffuse and poorly circumscribed

Resembles seborrheic dermatitis.

A subtle, asymptomatic patch of alopecia due to breaking off of hairs on the frontal scalp in a 4-year-old black child.

Tinea Capitis-Kerion Type Boggy, purulent, inflamed

nodules and plaques Usually extremely painful Drains pus from multiple

openings Hairs do not break off but

fall out and can be pulled without pain

Heals with scarring alopecia. Large, very painful,

inflammatory tumor with hair loss, studded with multiple pustules on the scalp of a young child.

Tinea Capitus-Favus Type

Thick yellow adherent crusts (scutula)

Fetid odor Untreated results in

cutaneous atrophy, scar formation, and scarring alopecia.

Tinea Capitis-Treatment Topical antifungal agents are ineffective in

management of tinea capitis Systemic antifungals should be used until

symptoms have resolved and fungal cultures negative

Terbinafine and itraconazole superior to ketoconazole and all three to griseofulvin. Side effects in increasing order: terbinafine < itraconazole < ketoconazole < griseofulvin

Tinea Barbae- Ringworm of the Beard

Fungal infection of the beard and moustache areas

Adult males only More common in

farmers Pruritus,tenderness,

pain

Scattered, discrete follicular pustules and papules in themoustache area, easily mistaken for S. aureus folliculitis.

Tinea Barbae-Treatment

Similar to tinea capitis

Topical antifungals ineffective

Systemic antifungals should be used until symptoms have resolved and fungal cultures negative

Confluent, painful papules, nodules, and pustules on the upper lip. Tinea facialis present on the cheeks, eyelids, eyebrows,and forehead.

Onychomycosis Toenail becomes

opaque, thickened, cracked, friable, raised by underlying hyperkeratotic debris in the nail bed

Toenails more common than fingernails

When fingernails are involved, pattern is usually two feet and one hand

Distal subungual hyperkeratosis and onycholysis involving most of the nail bed of the great toenails; these findings are usually associated with tinea pedis.

Onychomycosis-Treatment Does not resolve

spontaneously;invol-vement of multiple toenails is the rule.

Relapse occurs in the majority of persons treated with griseofulvin.

Relapse rate with itraconazole or terbinafine is less than with griseofulvin The proximal nail plate is a chalky white

color due to invasion from the undersurface of the nail matrix. The patient had advanced HIV disease.

Cutaneous Candidiasis Superficial infection

occurring on moist cutaneous sites

Many patients have predisposing factors that alter local immunity such as increased moisture at the site of infection, diabetes, or alteration in systemic immunity

Erosions on the medial thighs,inguinal folds, and scrotum with “satellite” pustules and papules of an obese male.

Cutaneous Candidiasis

Cutaneous Candidiasis

Penis/scrotum Vulva Fingernails Interdigital Treatment is

primarily topical Erythematous eroded area with surrounding maceration in a webspace of the hand occurring in a health care worker is a type of intertrigo.

Pityriasis Versicolor Also known as tinea

versicolor Yeast infection Usually on the trunk Depigmentation of

the skin Should not disqualify

am athletes from participation

Hypopigmented, sharply marginated, scaling macules on the shoulder area of an individual with brown skin. Gentle abrasion of the surface accentuates the scaling.

Pityriasis Versicolor-Treatment Selenium sulfide (2.5%)

lotion or shampoo: Apply daily for 10 to 15 minutes, followed by shower, for 1 week.

Azole creams (ketoconazole, econazole, micronazole, clotrimazole): Apply b.i.d. for 2 weeks.

Follicular, hypopigmented macules on the upper chest of an individual with black skin.

Viral Infections

Molluscum Contagiosum Herpes Warts

Molluscum Contagiosum

Epidermal viral infection

Skin-colored papules

Children and sexually active adults

Transmission by skin-to-skin contact

Discrete, solid, skin-colored papules, 1 to 2mm in diameter with central umbilication on the chest of an adolescent female. The lesion with an erythematous halo is undergoing spontaneous regression.

Molluscum Contagiosum In healthy individuals

resolves spontaneously. In HIV-infected

individuals often progresses despite treatment.

Painful aggressive therapy is best avoided.

Avoid skin-to-skin contact

Herpes Simplex Virus

Three types– Nongenital – Genital – Herpes Gladiatorum

Multiple painful erosions on the lower labial mucosa with erythema and edema of the gingiva; plaque has formed on the teeth because of pain within the lesions that restricts brushing. Fever and tender submandibular lymphadenopathy were also present.

NongenitalHerpes Simplex

– Grouped vesicles arising on an erythematous base on keratinized skin or mucous membrane

– Lips most common– Incubation 3-12 days– Chronic and

recurrent

A. Grouped and confluent vesicles with an erythematous rim on the lips. B. Edema with crusting of the lips which followed sun exposure; vesiculation is present but difficult to detect because of confluence of lesions. In some cases, crusting is the only finding.

Nongenital Herpes Simplex Restrict from

athletics until lesions crusted and dry

Acyclovir (Zovirax) 800 mg b.i.d. for 5 days

Valacyclovir (Valtrex) 500 to 1000 mg b.i.d.

Famciclovir (Famvir) Herpetic Whitlow-Painful, grouped, confluent vesicles on the volar finger on an erythematous edematous base.

Genital Herpes Simplex

– Grouped vesicles at the site of inoculation and inguinal lymphadenopathy

– Flu-like symptoms (myalgia, headache)

– Chronic and recurrent– Oral antiviral meds– May participate

unless they feel too crummy

Group of vesicles with early central crusting on a red base arising on the shaft of the penis.

Multiple, extremely painful,punched-out, confluent, shallow ulcers on the vulva and perineum.

Herpes Gladiatorum Spread of herpes to

abraded of injured skin Associated with

widespread dermatitis Looks like impetigo Oral antivirals Common in wrestlers No participation until

cleared

Herpes Zoster (Shingles) Chicken pox virus Distribution along

dermatomes Painful Headache, malaise,

fever Spontaneous resolution

2-3 weeks Analgesics, antivirals

(acyclovir)

Dermatomal, grouped andconfluent vesicles and pustules arising in the third sacral dermatome; note extension of lesions 1–2 cm across themidline.

Warts Caused by human

papillomavirus (HPV) Three types

– Common warts (verruca vulgaris-70%)

– Plantar warts (verruca plantaris-30%)

– Flat warts (verruca plana-4%)

The thrombosed capillaries (brown dots) differentiate the lesion from a corn or callus.

Common Warts (Verruca Vulgaris) Palmar lesions

disrupt the normal line of fingerprints. Return of finger-prints a sign of resolution of the wart.

Hands, fingers, knees.

Hyperkeratotic papules becoming confluent around the periungual tissue of four fingers; the brown dots represent thrombosed capillaries.

Plantar Warts (Verruca Plantaris)

Plantar surface of feet

Often solitary but may be three to six or more

Pressure points, heads of metatarsal, heels, toes

The warts are surrounded by nonwarty callus. Tinea pedis is also present in the webspaces and instep with sites of excoriation.

Flat Warts (Verruca Plana)

Always numerous discrete lesions, closely set

Face, beard area, dorsa of hands, shins

Flat-topped, pink papules with sharp margination and minimal hyperkeratosis on the dorsum on the hands and fingers.

Wart Treatments Usually resolve

sponatneously Painful plantar warts

warrant more aggressive treatment

40% salicylic acid plaster for 1 week

Cryosurgery Electrosurgery CO2 laser surgery

Infestations

Scabies Pediculosis

Scabies

Mites burrow beneath stratum corneum

Undiagnosed pruritis Palms, wrists,

ankles, nipples, ubilicus, genitals

Acquired sexually or through crowded living conditions

Papules and burrows in typical location on the finger webs.Burrows are tan or skin-colored ridges with linear configuration with a minute vesicle or papule at the end of the burrow and are often difficult to locate.

Scabies No contact sports until

cleared (1 wk) Examine sexual partners Wash bedding Lindane (Kwell,

Scabene lotion or shampoo). Do not use after bathing, with pregnancy or lactation

Permethrin (Nix lotion)A mite at the end of a burrow with 8 eggs and smaller fecal particles obtained from a papule on the webspace of the hand.

Pediculosis (Lice)

Pediculosis capitis Pediculosis pubis Pediculosis corporis Highly infectious Pruritis Regional

lymphadenopathy Eggs (nits) adhere to

hair

A crab louse (see arrow) on the skin in the pubic region.

Pediculosis (Lice)

No contact sports until all nits removed

Examine sexual partners

Wash bedding Lindane (Kwell) Pyrethins (RID, R&C,

A-200 gel, liquid, shampoo)

Crab lice (see arrow) and nits on the upper eyelashes of a child; this was the only site of infestation.

Skin Cancer

Three major types– Basal cell carcinoma– Squamous cell

carcinoma– Melanoma

Oral Leukoplakia - The lesion, in a heavy pipe smoker, progressed to a verrucous carcinoma.

Basal Cell Carcinoma

Most common type of skin cancer.

Locally invasive, aggressive, and destructive

Limited capacity to metastasize

Exposure to UV light Large, shiny, red nodule with a cobblestoned surface and an ulcerated nodule.

Basal Cell Carcinoma Excision with primary

closure, skin flaps, or grafts.

Cryosurgery and electrosurgery

Danger sites - nasolabial area, around the eyes, ear canal, posterior auricular sulcus, scalp - microsurgery required

Squamous Cell Carcinoma Less common than basal

cell carcinoma Exposure to UV light and

x-rays, arsenic Slowly evolving Cheeks, nose, lips, tips

of ears, preauricular areas, scalp, dorsa of the hands, forearms, trunk, and shins (females) A large notch on the superior

aspect of the helix, a nodule of SCC with hyperkeratosisand ulceration.

Squamous Cell Carcinoma

Any isolated keratotic or eroded papule or plaque in a suspectpatient that persists for over a month is considered a carcinoma until proved other-wise.

Squamous Cell Carcinoma

Surgery Microscopically

controlled surgery in difficult sites

Radiotherapy should be performed only if surgery is not feasible

Melanoma

Most deadly kind of skin cancer

Increasing rapidly Sun exposure? Thinning ozone

layer? Assymetric,pigmente

d, irregular, large lesions

Suspicious nevi: Two large, variegated, brown oval macules.

Melanoma

Radial growth phase Vertical growth

phase Critical to identify &

treat early during radial growth phase

The lighter macular portion of this lesion is a suspicious nevus on the upper back; theblue-black plaque is a superficial spreading melanoma (1.2 mm thickness). The patient was a 34-year-old internist who died 36 months following detection and excision of this lesion.

Melanoma Surgery is treatment Suspicious nevi (moles):

– changing (increase in size, change in pigmentation pattern, changes in shape and/or border)

– location that cannot be closely followed by the patient by self-examination (on the scalp, genitalia, upper back)

Melanoma-The left image (1990) shows variegation of pigmentation and irregular borders. Five years later, the lesion (right) shows darkening of melanin pigmentation, more irregularity in shape, and elevation in the most darkly pigmented region.

Six Warning Signs for Melanoma

A A ASYMMETRY in shape—one-half unlike the other half

B B BORDER is irregular—edges irregularly scalloped

CC COLOR is mottled—haphazard display of colors; shades of brown, black, gray, red, and white

DD DIAMETER is usually large—greater than the tip of a pencil eraser (6.0 mm)

EE ELEVATION is almost always present—surface distortion is assessed by side-lighting.

ENLARGEMENT—a history of an increase in the size of lesion is perhaps one of the most important signs of melanoma

Dermatology Assessment

General Approach to Patients With Skin Signs and Symptoms

Epidemiology and Etiology

Age Race Sex Occupation

History

Duration of onset Relationship of skin lesions to season,

travel history, heat, cold, previous treatment, drug ingestion, occupation, hobbies, effects of menses, pregnancy

Skin symptoms: pruritus, pain, paresthesia

History (cont)

Constitutional symptoms– “Acute illness’’ syndrome: headaches,

chills, feverishness, weakness– “Chronic illness’’ syndrome: fatigue,

weakness, anorexia, weight loss,malaise

Systems review

Physical Examination

Appearance of patient: uncomfortable, “toxic,’’ well

Vital signs: pulse, respiration, temperature

Skin—four major skin signs: (1) type, (2) shape, (3) arrangement, (4) distribution of lesions

Types of Skin Lesions

Macules Papules Plaques Pustules Vesicles

Nodules Desquamination Bullae Ulcers Wheals

Color and Palpation

White Brown Purple Violet Red “Flesh”

Consistency Temperature Mobility Tenderness Depth of lesion (i.e.,

dermal or subcutaneous)

Shape Round Oval Annular (ring-shaped) Serpiginous (snakelike) Umbilicated Margination

– well-defined (can be traced with the tip of a pencil)– ill-defined

Arrangement

Grouped Disseminated

Distribution

Extent– isolated (single

lesions),– localized– regional– generalized– universal

Pattern– symmetrical– exposed areas– sites of pressure– intertriginous area– follicular localization– random