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Introduction to DermatologyA review of the basic science of the skin, morphology, general examination, and

therapeutics.

Essentials of Clinical Reasoning -2, Fall 2013

Jim Carlson, PhD, PA-C

1


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Content and images for this slide set werero!ided in art "# the American Academ#of Dermatolog#$

Acknowledgements


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1$ %o thro&gh the slides with the goal of "eing a"leto al# the content to dermatologic case st&dies$

2$ Re!iew the ECR-1 'lides (eseciall#) art 2 of the

series on Dermatolog# gi!en last #ear$

3$ *nce #o& comlete re!iewing the slides ta+e the&i in D2.$

/$ o& ma# &se all the information in this t andan# other reso&rces #o& nd to assist #o& with theD2. &i$

How to approach this module andreview.


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Lesson Objectives

Recognize pertinent history for a patient who presents with a dermatologic

problem. Utilize the descriptors and definitions of morphology for primary and

secondary skin lesions.

Apply a systematic approach to describing skin eruptions to include history,primary and secondary lesion descriptions, other descriptors (color,

pigmentation, vascular), arrangement, and distribution of lesions. Recognize different classifications for rashes and skin lesions.

Recognize the indications for cryotherapy, !" preparation, shave biopsy, andpunch biopsy.

Applybasicmanagement principles for#

Use of topical steroids Acne

$ungal skin infections


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The skin regulates water loss and protects againstinsults from the external environment.

Dysfunction leads to injury, dehydration, infection and

inflammation.

This child has atopicdermatitis, a chronic skin

condition associated with

barrier dysfunction.

5

Functions of the Skin

!arrier function
http://missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.htmlhttp://tp//missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.htmlhttp://tp//missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.htmlhttp://tp//missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/atopic_dermatitis.html


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s an immunologic !arrier, the skin !oth sensesand responds to pathogens.

Dysfunction of the immunologic !arrier leads toinfection, skin cancer, inflammatory skin

conditions and allergy.

This "#$%positive man hasmolluscum contagiosum, a skin

infection caused !y a virus.

&

Functions of the skin

Immunologic function


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The skin helps maintain a constant !ody

temperature with the insulating properties of fat

and hair and through accelerating heat loss withsweat production and a dense superficial

microvasculature.

'


"emperature regulation


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The dark pigment melanin in the epidermis protects cells againstultraviolet radiation.

Dysfunction of melanin production causes the patient to !e more

suscepti!le to skin cancer.

(


#rotection from radiation

This patient with al!inism

has a skin cancer on the

!ack.


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)ensory receptors allow the skin to constantly monitorthe environment.

Dysfunction leads to pruritus *itch+, dysesthesia

*a!normal sensation+, and insensitivity to injury *e.g.dia!etes, leprosy+.


$erve sensation

This photo is of a chronic

ulcer on the foot of a patientwith peripheral neuropathy

related to dia!etes.


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-oss of a!ility to repair injury *e.g. post%radiation

treatment+ leads to delayed wound healing.

1


In%ury repair

This patient has a chronic ulcer

following trauma on the scalp in

a site previously irradiated as

part of treatment fors/uamous cell carcinoma.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/squamous_cell_carcinoma.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/squamous_cell_carcinoma.html


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)kin is composed of three layers0 pidermis

Dermis )u!cutis

11

&ayers of the skin


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&ayers of the skin

pidermis

Dermis

The epidermisis the topmost layer, and consistsprimarily of keratinocytes.

The dermislies !elow the epidermis, and

consists primarily of fi!ro!lasts, collagen, and

elastic fi!ers.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/epidermis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/dermis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/dermis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/epidermis.html


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&ayers of the skin

)u!cutis

pidermis

Dermis

4elow the

dermis lies fat,

also calledsu!cutis,

panniculus, or

hypodermis.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/subcutaneous_tissue.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/subcutaneous_tissue.html


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1

"he four ma%or layers of the epidermis

)tratum corneum

)tratum granulosum

*granular cell layer+

)tratum spinosum

*spiny layer+

)tratum !asale*!asal cell layer+


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&llo&s emhigoid an a&toimm&ne "listering disease,t#icall# a4ects older atients$ A&toanti"odies form toantigens directl# "eneath the basal layer of theepidermis$ Clinicall#, resents as tense "lister with redness(er#thema)

15

Diseases related to dysfunction of the

epidermal layers ' loss of adhesion
http://missinglink.ucsf.edu/lm/DermatologyGlossary/bullous_pemphigoid.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/bullous_pemphigoid.html


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#n psoriasis, the rate of

epidermal turnover is

increased *thickening+.

The accelerated rate of

movement through the

epidermis doesn6t allow

ade/uate time for differentiation,which is recogni7ed as scale.

1&

Diseases related to dysfunction of the

epidermal layers
http://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/psoriasis.html


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Three main types of cells make up the epidermis0

8eratinocytes

9elanocytes

-angerhans cells

1'

(pidermis "ypes of )ells


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8eratinocytes make up the majority of

cells. 8eratinocytes are held together !y

macromolecular structures that look likestripes *or spines+ !etween cells, called

desmosomes *primarily visi!le in the

spinous layer+.

:rovide structure and protection.

1(

*eratinocytes


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9elanocytes are staggeredalong the !asal layer at around

one in every 1 keratinocytes.

They are the pigment%

producing cells, and transfer

their pigment, called melanin,

to the keratinocytes in the!asal cell layer.

1

+elanocytes


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9elanocytic nevi, or moles, are !enigncollections of melanocytes.

9elanoma, shown !elow, is a malignancy of

melanocytes.

2

$evi and +elanoma
http://missinglink.ucsf.edu/lm/DermatologyGlossary/nevus.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/melanoma.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/melanoma.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/nevus.html


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:rovide for the recognition, uptake, processing, and

presentation of antigens to sensiti7ed T%lymphocytes, and

are important in the induction of delayed%type

hypersensitivity ; immune response.

21

&angerhans )ells

21

common skin disease in which

-angerhans cells play a

prominent role is allergic

contact dermatitis, such as

poison oak
http://missinglink.ucsf.edu/lm/DermatologyGlossary/contact_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/contact_dermatitis.html


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22

&ayers of the skin

pidermis

Dermis

The dermislies !elow the epidermis, andconsists primarily of fi!ro!lasts, collagen, and

elastic fi!ers.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/dermis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/dermis.html


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9ast cells are speciali7ed cells that areresponsi!le for immediate%type

hypersensitivity reactions in the skin

2

)ells of the dermis

The mast cell is the major

effector cell in urticaria,

which is a vascular reaction

of the skin characteri7ed !ywheals*hives+ surrounded !y

a red halo or flare.
http://missinglink.ucsf.edu/lm/DermatologyGlossary/urticaria.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/wheal.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/wheal.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/urticaria.html


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The su!cutis is the fat layer which separates thedermis from deeper underlying structures such as

fascia and muscles.

The su!cutis insulates the !ody, serves as an

energy supply, cushions and protects the skin,

and allows for its mo!ility over underlying

structures

25

"he Subcutis


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dnexal structures include thepilose!aceous unit and eccrine

gland :ilose!aceous unit consists of0

1. hair follicle2. )e!aceous *oil+ glands

3. pocrine= sweat glands

. n arrector pili muscle *when these

contract you get goose!umps+

Aocrine glands are fo&nd in the a5illar# andanogenital areas, which is wh# we do not see themon this "ios# of the scal$ 6hese glands oendirectl# in to the hair follicle$

2&

"he pilosebaceous hair-oil gland unit


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cne vulgarisis a disorder of thepilose!aceous unit.

#t is caused !y factors0

:resence of hormones *androgens+ )e!aceous gland activity *increased in the

presence of androgens+

:lugging of the hair follicle>a!normal

keratini7ation%*comedones+

P. acnes *!acteria+ which !reaks down

oils to free fatty acids and leads to

inflammation+

2'

Disorder of pilosebaceous unit
http://missinglink.ucsf.edu/lm/DermatologyGlossary/acne_vulgaris.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/acne_vulgaris.html


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/eneral (xamination and +orphology

0ow to describe what you see

2(


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%ermatologic %ifferential %iagnosis# &he 'hallenge

Appro *** named diseases in %ermatology.

!rganize and narrow in terms of importance#

+ost common +ost dangerous

+ost curable

+ost contagious

&his brings the list down to around * dermatologicdiagnoses you should know something about.


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A general approach dermatologic diagnosis

-oth history and physical are important.

However, visual inspection of the lesion often takes someprecedence when diagnosing dermatologic problems.

&he physical is often performed early in the encounter to identify a general %%/attern of recognition0.

&he history is then used to further narrow the %%.


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A methodological and systematic approach to diagnosis

"istory

Distribution(1here is the location on the body2)

3ocalized

1idespread and systemic

4amine and %45'R6-4 the lesion(s).

Arrangement and shape of lesions (Morphology

/rimary 3esions 5econdary 3esions

'olor

Arrangement


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A methodological and systematic approach to diagnosis

1hen possible, classify the lesion into a diagnostic group based on

distribution and morphology.

74czematous disorders (erythematous patches)

7+aculopapular disorders and pigmented lesions

78esicular and -ullous %iseases

7/soriasis and papulars9uamous disorders.

7"air and nail disorders

78ascular disorders

!rder testing if appropriate, but many %ermatologic diagnoses are clinical0,based on symptoms and signs.

&reatment# 5ometimes treatment is diagnostic.


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/attern of recognition# %istribution


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6he word morphologyis &sed "# dermatologists to acc&ratel#characterie and doc&ment s+in lesions$

Primar# .esions

'econdar# .esions

7asc&lar Patterns Color

6he morhologic characteristics of s+in lesions are +e# elementsin esta"lishing the diagnosis and comm&nicating s+in ndings$

6here are two stes in esta"lishing the morholog# of an# gi!ens+in condition

1$ Caref&l !is&al insection

2$ Alication of correct descritors

35

Pattern of Recognition:Morphology


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Visual inspection at its core ism&ch li+e anal#ing a ainting orloo+ing at an# o"8ect for the frsttime$

3&

Visual nspection


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+orphology# /rimary 3esions

+acule /atch

/apule

/la9ue

1heal ;odule 8esicle -ulla /ustule 'yst

9orphology allowshealthcare providers

to communicate skin

findings succinctly.

Dermatologists

attempt to identify the

primary lesion ofany skin eruption.


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3(

Primary lesion: Macule

macule is flat? if you can feel it, then

it6s not a macule.

@ 1. cm

Asually caused !y color changes in

the epidermis or upper dermis


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3

!"amples of Macules


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Presence of a mac&le indicates that therocess is conned to the eidermis$

9ac&les do not contain :&id and are notraised$

9ac&les can ha!e secondary changes

s&ch as scaleor cr&st

;f a fat lesion is o!er 1 cm it is called aatch

Macules
http://missinglink.ucsf.edu/lm/DermatologyGlossary/scaling.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/crusting.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/patch.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/patch.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/crusting.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/scaling.html


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Patches are :at "&tlarger thanmac&les$

;f it


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2

!"amples of Patches


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3

Macules and Patches

9AC=.E (>1cm)

PA6C? (@1cm)


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(.$ a&la, imleB)

Pa&les are raisedlesions less than #

cm

A roliferation of cells

in eidermis ors&ercial dermis

Primary lesion: Papule


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5

!"amples of Papules


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Pla&es are raisedlesions larger than 1cm

o& can feel them Cast a shadow with side

lighting

A roliferation of cellsin eidermis ors&ercial dermis

&

Primary lesions: Pla$ue


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'

!"amples of Pla$ues


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(

Papule and Pla$ue

PAP=.E (>1cm)

P.A=E (@1cm)


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A larger dee a&le

A roliferation of cells

down to the mid-dermis$

%odule


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5

%odule

A raised area in thes+in where theo!erl#ing eidermis

loo+s and feelsnormal, "&t there is aroliferation of cellsin deeer tiss&es is

called a nod&le$
http://missinglink.ucsf.edu/lm/DermatologyGlossary/nodule.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/nodule.html


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Vesiclesare :&id-lled a&les(small "listers > 1

cm)

A large (@ 1cm)"lister is called abulla

51

Primary lesion: Vesicle

vesicle !ulla
http://missinglink.ucsf.edu/lm/DermatologyGlossary/bulla.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/bulla.html


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52

!"amples of Vesicles


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P&s is made & ofle&+oc#te$

53

Pustule


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!heal

> "levated,palpable> 6rregular shaped area of

cutaneousedema

> 5olid, transient, changing

> 8ariable diameter> /ale pink with lighter

center

> 4amples# Urticaria,insect bites,%ermatographism


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#yst

> "levated, palpable,but deep.

> 'ircumscribed,

encapsulated

> $illed with li9uid orsemi7solid material

> 4ample# 4pidermoidcyst


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'lassifying /rimary 3esions


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5econdary 3esions

5cale 'rust

4coriation

4rosion

Ulcer

Atrophy

3ichenification

5car ? eloid $issure

5triae

'hanges in an area ofprimary pathology due tosecondary events#

(scratching, infection,trauma, inappropriatetreatments, naturalprogression of the

disease etc.)


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$cale7small, thin dryefoliation shed from theupper layers of skin

#rust7scab@ dry serous orseropurulent eudation

5econdary 3esions


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"%coriation7abrasion of theepidermis

"rosion7eternal or internaldestruction of a surface layer

5econdary 3esions


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&lcer7an open sore or lesion

of the skin or mucousmembrane accompanied bysloughing of inflamed necrotictissue

'trophy7a wasting ordecrease in size of a tissue

5econdary 3esions


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Lichenification7cutaneous

thickening and hardening fromcontinued irritation

$car( )eloid7mark left by

healing of a wound due toreplacement of the inuredtissue by connective tissue

5econdary 3esions


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*issure7an ulcer or crack7likesore

$triae7a line or band differingin color and teture

5econdary 3esions


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+ascular *indings

4cchymoses/etechiae

/urpura

"emangioma&elangiectasia


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"cchymoses bruising

> Red7purplenonblanchablediscoloration of variablesize

> 'ause# 8ascular walldestruction, trauma,


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-etechiae

> Red7purplenonblanchablediscoloration less than./ cm in diameter

> 'ause# 6ntravasculardefects, infection,meningococcemia


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-urpura

> Red7purplenonblanchablediscoloration greaterthan ./ cm indiameter

> 'ause# 6ntravasculardeficit, infection,

vasculitis

i


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Hemangioma

> Red, irregular macules orpatches

> 'ause# 'ollection:

dilation of dermalcapillaries

l i i


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0elangiectasia

> $ine, irregular lines

> 'ause# %ilation of thecapillaries,

inflammation, Rosacea

$ id i


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$pider 'ngioma

> Red, central body withradiating spider like legs

> -lanches with pressureto the central body

> 'ause# 3iver disease,vitamin - deficiency,6diopathic

! h d i i


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!ther descriptive terms

$lat toped vs./edunculated (stalk)

8errucous (wart7like)

Umbilicated

5ize

Ab l 5ki ' l


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Abnormal 5kin 'olors

#yanosisB. Acrocyanosis( in palms and soles of feet)

. Peripheral cyanosis( in arms and legs)

C. Central cyanosis(in mouth and tongue)

"rythema 1edness

2aundice($cleral icterus yellowskin(yellow sclera

Locali3ed -igmentary changes


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D di


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Daundice

4 th


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4rythema

/i t h


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Hypopigmentation Hyperpigmentation

/igmentary changes

'l if i / i 3 i


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'lassifying /rimary 3esions

6


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6n summary

7$or each lesion, try and identify#7"istory of lesion(s)

7&he %65&RU-U&6!; (is the lesion present in a

classic pattern2).7 /R6+ARE lesion

7Any associated 54'!;%ARE lesions

7&he ARRA;


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;et

'lassify the lesion into a diagnostic category.4amples inlcude#

74czematous disorders (erythematous patches)7+aculopapular disorders and pigmented lesions

78esicular and -ullous %iseases

7/soriasis and papulars9uamous disorders.

7"air and nail disorders

78ascular disorders

l i d


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&ermatologic Procedures

6here are a n&m"er of Dermatologicroced&res that are &sef&l for "othdiagnosis and treatment$ 6hese incl&de,"&t are not limited to

Cr#othera# *? rearation

'ha!e ios# P&nch ios#

l i d


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%o tohttwww$aad$orged&cationmedical-st&dent-core-c&rric&l&mdermatolog#-s+ills-!ideos

Re!iew Cr#othera#

Re!iew *? Prearations

oth can "e fo&nd &nder the Cr#othera#, *?, and local anesthesia section

%o tohttwww$aad$orged&cationmedical-st&dent-core-c&rric&l&mdermatolog#-s+ills-!ideos

Re!iew ?ow to erform a '?A7E ios# Re!iew ?ow to erform a P=C? ios#

oth can "e fo&nd &nder the ios# and Patholog# section

&ermatologic Procedures
http://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videoshttp://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videoshttp://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videoshttp://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videoshttp://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videoshttp://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videoshttp://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videoshttp://www.aad.org/education/medical-student-core-curriculum/dermatology-skills-videos


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'eneral (reatment


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'eneral (reatmentPrinciples Do no harmG (sometimes no treatment is necessar#)$

ios# or c&lt&re s&sicio&s lesions (s&sected cancer, etc$)

'imle common treatments

;n:ammator# (&s&all# toical or oral steroids H caution,antihistamines, etc.)$

;nfectio&s (anti!iral, anti"acterial, antif&ngal, etc)$

Cancero&s (remo!e Cr#othera#, '&rgical, harmacologic)$

Cosmetic (remo!e or reass&re)

Dressings occl&sions H accelerates toical treatment$

Patient Ed&cation and managing e5ectations is !er# imortant$


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Dermatologic

"herapies

(3

#rinciples of Dermatologic "herapy


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#rinciples of Dermatologic "herapy

The efficacy of any topical medication isrelated to0

The active ingredient *inherent strength+

natomic location The vehicle*the mode in which it is

transported+

The concentrationof the medication

(

1ehicles


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)olutions

(5

)prays

'els

*oams+reams

,ils

,intments

1ehicles

1 hi l


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1ehicles 2intments*e.g. $aseline+0 lu!ricating, occlusive? greasy

A) for smooth, non%hairy skin? dry, thick, or hyperkeratoticlesions

$C#D on hairy and intertriginous *when skin is in contact with skin, e.g. armpits,

groin, pannus+ areas

)reams*vanish when ru!!ed in+0 less greasy, drying effects? not

occlusive, can sting, more likely to cause irritation

*preservatives>fragrances+ A) for acute exudative inflammation, intertriginous areas

&otion*poura!le li/uid+0 less greasy, less occlusive? may containalcohol *drying effect on oo7ing lesion+? penetrate easily, little residue A) for hairy areas

(&

1 hi l t
http://missinglink.ucsf.edu/lm/DermatologyGlossary/hyperkeratosis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/hyperkeratosis.html


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1ehicles cont.

2ils0 less stinging than lotions or solutions A) for the scalp, especially for people with coarse or very curly hair

/el*jelly%like+0 may contain alcohol, greaseless, least occlusive? dry

/uickly

A) for acne, exudative inflammation *e.g. acute contact dermatitis+? onscalp>hairy areas without matting

Foams*cosmetically elegant+0 spread readily, easier to apply? more

expensive

A) for hairy areas? inflammation

Sprays0 erosols *rarely used+, pump sprays('
http://missinglink.ucsf.edu/lm/DermatologyGlossary/contact_dermatitis.htmlhttp://missinglink.ucsf.edu/lm/DermatologyGlossary/contact_dermatitis.html


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3hat goes into a topical

prescription4

((

" i l i ti


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"opical prescriptions

Ihat goes into a rescrition Desonide cream 0$0KL al# to a4ected area

(face) ;D PR for scaling M1K %rams RF3

(

" i l i ti


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Ihat goes into a rescrition Desonidecream 0$0KL al# to a4ected area


%eneric name

" i l i ti


91/123


Ihat goes into a rescrition Desonide cream0$0KL al# to a4ected area


%eneric name

7ehicle

1

" i l i ti


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Bhat goes into a prescription Desonide cream .5Eapply to affected area *face+

4#D :FG for scaling H15 Irams F


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Bhat goes into a prescription Desonide cream .5E apply to affected area *face+



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"opical )orticosteroids


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Topical steroids produce an anti%inflammatoryresponse in the skin.

They are effective for conditions that are

characteri7ed !y hyperproliferation, inflammation,

and immunologic involvement.

They can also provide symptomatic relief for !urningand pruritic lesions

'



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Jorticosteroids are organi7ed into classes !asedon their strength *potency+ Therefore, steroids within any class are e/uivalent in

strength

)trength is inherent to the molecule, not theconcentration

8now one steroid from each class that would !e

availa!le to the majority of your patients *the

generic in that class+

(


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"opical Steroid Strength


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"opical Steroid Strength Remem"er to loo+ at the

classnot the ercentage

ote that clo"etasol

0$0KL is stronger than

h#drocortisone 1L$

Ihen se!eral are listed,the# are listed in order of

strength

ote that triamcinolone

ointment is stronger than

triamcinolone cream orlotion "eca&se of the

nat&re of the !ehicle

899

#otency )lass (xample Agent

)uperhigh

# Jlo!etasol .5E

"igh ##


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)orticosteroid Selection

Super high potency *)lassI+ are used for severedermatoses over nonfacial and nonintertriginous areas Scalp, palms, soles, andthick pla:ues onextensor surfaces

+edium to high potency steroids *Jlasses II;1+ are

appropriate for mild to moderate nonfacial andnonintertriginous areas Ckay to use on flexural surfaces for limited periods

&owpotency steroids *Jlasses 1I, 1II+ can !e used for

large areas and on thinner skin Face, eyelid, genitaland intertriginousareas

11

&ocal Side (ffects of"opical Steroids


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"opical Steroids

.ocal side e4ects of toical steroidsincl&de

'+in atroh#

6elangiectasias

'triae

6he higher the otenc# the more li+el#side e4ects are to occ&r$

6o red&ce ris+, the least otent steroidsho&ld "e &sed for the shortest time, whilestill maintaining e4ecti!eness

12

Acne

'teroid Rosacea

?#oigmentatio

n


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&ocal )orticosteroid Skin Side (ffects


104/123

1

"ypopigmentation

Systemic Side (ffects of"opical Steroids


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"opical Steroids

)ystemic side e-ects are rare d&e to lowa"sortion

6he# can incl&de %la&coma (when steroid alied to the e#elid)

?#othalamic it&itar# a5is s&ression

C&shing


106/123

D&ration of treatment is limited "# side e4ects$ ;n general

'&er high otenc# treat for >3 wee+s

?igh and 9edi&m otenc# >N-O wee+s

.ow otenc# side e4ects are rare$ 6reat facial,intertrigino&s, and genital dermatoses for 1-2 wee+inter!als to a!oid s+in atroh#, telangiectasia, andsteroid-ind&ced acne

'to treatment when s+in condition resol!es

1&

&irections to patients and prescribing information


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&irections to patients and prescribing information.

Al# in thin la#er onl# %enerall#, onl# ;D is necessar#, more than that does

not increase ecac#, onl# the ris+ of side e4ects$

Estimation for amo&nt needed

%enerall# (1Kg, 30g, N0g, 120g) 1Kg Q eno&gh for the face 5 1 mo

30g Q eno&gh for larger area (e5tremit#) 5 1 mo N0 -120g ma# "e necessar# for larger "od# areas$

How To treat ACNE


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sk the patient what type of cne they get.

com!ination of medications will !e helpfulto treat each type of cne

Deep Jystic

cne

)urface Fed

4umps

and :apules

Jomedones

*4lack "eads and Bhite

"eads+

Gon

hormonal

"ormonal

*Bomen

Cnly+

Cral 4xor

ccutane

moxicillin 5mg 4#D

9inocycline 1mg

4#D

)eptra D) 4#D

#f !x kg>day

up to

2 mg>kg>day

)piranolactone1mg / day

and>or

-ow strogen

Cral

Jontraceptive0

Crtho%Tri%Jyclen

#f !x and

"ormonalpproaches fail

Jonsider

ccutane

Topical

nti!iotics

Jlindamycin

)olution-otion or Iel

4#D

4en7oyl

:eroxide,

4en7aclin,

/hs or /ohs

xfoliating>

8eratolytic

gents

Fetin ,

Ta7orac,Differin,

/hs to /ohs


109/123

"opical Antibiotics


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"opical Antibiotics

Ased to reduce the num!er of :. acnes andreduce inflammation in inflammatory acne.

rythromycin 2E *solution, gel+

Jlindamycin 1E *lotion, solution, gel, foam+

9etronida7ole .'5E, 1E *cream, gel+ is used in

the treatment of rosacea

11

"opical 6etinoids


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tretinoin, all trans retinoic acid

:atients should !e warned of common adverse

effects0 Dryness, pruritus, erythema, scaling

:hotosensitivity

vaila!le as a cream or gel

Do not apply at the same time as !en7oyl peroxide

!ecause !en7oyl peroxide oxidi7es tretinoin111

2ral Antibiotics


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Use for moderate to severe acne

Tetracycline, doxycycline, minocycline

re contraindicated in pregnancy and children age

@( years

9ay cause I# upset *epigastric !urning, nausea,vomiting and diarrhea can occur+

Jan cause photosensitivity *patients may !urn

easier, which can !e easily managed with !etter

sun protection+. Fecommend sun !lock with A$coverage for all acne patients on tetracyclines

112

2ral Isotretinoin


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2ral Isotretinoin Cral isotretinoin, a retinoic acid derivative, is indicated in

severe, nodulocystic acne failing other therapies

)hould !e prescri!ed !y physicians with experience using

this medication

Typically given in a single 5%& month course #sotretinoin is teratogenic and therefore a!solutely

contraindicated in pregnancy


114/123

Isotretinoin Side (ffects

Jommon side effects of isotretinoin include0 Kerosis *dry skin+

Jheilitis *chapped lips+

levated liver en7ymes

"ypertriglyceridemia

#ndividuals with severe acne may suffer mood

changes and depression and should !e monitored

)evere headache can !e a manifestation of theuncommon side effect pseudotumor cere!ri

11

Topical ntifungals


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The following are some examples of topical antifungals0

#mida7oles *fungistatic+0 8etocona7ole *Fx L CTJ+,

cona7ole, Cxicona7ole, )ulcona7ole, Jlotrima7ole *Fx L

CTJ+, 9icona7ole *CTJ+; Aseful to treat candida and dermatophytes

llylamines and !en7ylamines *fungicidal+0 Gaftifine,

Ter!inafine *CTJ+, 4utenafine

; 4etter for dermatophytes, !ut not candida :olyenes *fungistatic in low concentrations+0 Gystatin

; 4etter for candida, !ut not dermatophytes115

Antihistamines


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Antihistamines

The following are examples of "1antihistamines0 1stIeneration

Diphenhydramine *CTJ+

"ydroxy7ine *Fx, generic+

Jhlorpheniramine *CTJ+


117/123

Acknowledgements This module was developed !y the merican

cademy of Dermatology 9edical )tudent Jore

Jurriculum Borkgroup from 2(%212.

:rimary authors0 lina 9arkova, )arah D. Jipriano,

9D, 9:"? Timothy I. 4erger, 9D,


118/123

6eferences erger 6, ?ong J, 'aeed ', Colaco ', 6sang 9, aser R$ 6he Ie"-

ased ;ll&strated Clinical Dermatolog# %lossar#$ 9edEdP*R6A.200S$ A!aila"le from www$mededortal$org&"lication/N2$

Dra+e .A, Dinehart '9, Farmer ER, et al$ %&idelines of care for the

&se of toical gl&cocorticosteroids$ American Academ# of

Dermatolog#$ J Am Acad Dermatol 1TTN 3KN1K$

Ference J, .ast A$ Choosing 6oical Corticosteroids$ Am Fam

Ph#sician 200TST (2)13K-1/0$

Ioldstein 4, Ioldstein . Ieneral principles of dermatologic therapy and

topical corticosteroid use.;n =6oDate, asow, D' (Ed), =6oDate,

Ialtham, 9A, 2011$

?ettiaratch# ', Paini R$ AC of "&rns$ ;nitial management of a

ma8or "&rn ;; H assessment and res&scitation$ 9J$ 200/32T101-

103$11(

6eferences


119/123

6eferences ?igh Ihitne# A, Fitatric+ James E, UChater 21T$ 6oical

Antif&ngal AgentsU (Chater)$ Iol4 , %oldsmith .A, at ';,%ilchrest , Paller A', .e4ell DJ Fitatric+Vs Dermatolog# in%eneral 9edicine, Se

httwww$accessmedicine$comcontent$as5a;DQ2TNTONN$

.im" '&san ., Iood Ro"ert A, UChater 230$ AntihistaminesU(Chater)$ Iol4 , %oldsmith .A, at ';, %ilchrest , Paller A',.e4ell DJ Fitatric+Vs Dermatolog# in %eneral 9edicine, Se

httwww$accessmedicine$comcontent$as5a;DQ300311N$

elson A, 9iller A, Fleischer A, al+rishnan R, Feldman '$ ?ow

m&ch of a toical agent sho&ld "e rescri"ed for children ofdi4erent sies J Derm 6reat 200N 1S22/-22O$

Ieller R, ?&nter J, Dahl 9$ Clinical Dermatolog#$ 200O KK$

Iol4 , Johnson R$ Fitatric+


120/123

6his mod&le was de!eloed "# the American Academ#

of Dermatolog#


121/123

This module was developed !y the merican cademy

of Dermatology6s 9edical )tudent Jore Jurriculum

Borkgroup from 2(%212.

:rimary author0 li7a!eth 4u7ney, 9D.

Jontri!utors0 )arah D. Jipriano, 9D, 9:"? Fon4irn!aum, 9D.

:eer reviewers0 )usan 4urgin, 9D,


122/123

erger 6, ?ong J, 'aeed ', Colaco ', 6sang 9, aser R$ 6he Ie"-

ased ;ll&strated Clinical Dermatolog# %lossar#$ 9edEdP*R6A.200S$ A!aila"le from www$mededortal$org&"lication/N2$

9orholog# ill&strations are from the Dermatolog# .e5iconPro8ect, which is now maintained "# the American Academ# ofDermatolog# as Derm.e5$

Dole! JC, Friedlaender J, ra!erman, ;9$ =se of ne art toenhance !is&al diagnostic s+ills$JAMA 2001 2ON(T), 100-2$ ?a"if 6P$ Clinical Dermatolog# a color g&ide to diagnosis and

thera#, /thed$ ew or+, 9os"# 200/$ 9ar+s Jr J%, 9iller JJ$ .oo+ing"ill and 9ar+s< Princiles of

Dermatolog#, /thed$ Else!ier 200N$ Re!iew rimar# lesions and other morhologic terms at

httwww$logicalimages$comed&cational6oolslearnDerm$htm$

122

6eferences


123/123

erger 6, ?ong J, 'aeed ', Colaco ', 6sang 9, aser R$ 6he

Ie"-ased ;ll&strated Clinical Dermatolog# %lossar#$9edEdP*R6A. 200S$ A!aila"le fromwww$mededortal$org&"lication/N2$

4olognia M-, Mori77o M-, Fapini F:. Dermatology, 23, lsevier

-imited.

Jhu David ", NJhapter '. Development and )tructure of )kinN*Jhapter+. Bolff 8, Ioldsmith -, 8at7 )#, Iilchrest 4, :aller ), -effell

DM0 >www.accessmedicine.com>content.aspxa#DP2''&22.

6eferences

stand up posture

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