ANNUAL PICTURE ISSUE The Intersection of Dermatology and Infectious Disease: A Visual Guide

Recognizing the cutaneous signs and symptoms of infectious diseases is key in early diagnosis and harm reduction. BY ART PAPIER, MD

There is a constant demand in public health to US government to >> address diagnostic decision-making broadly and prepare for the pos- All images used with permission from VisualDx. not focus solely on the diagnosis of the moment. Nearly 20 sibility of bioterrorism years ago, health systems and government agencies realized broadly. Public health clinicians’ need for accurate and timely information to assist officials sought to rap- infectious disease diagnosis and surveillance following the idly educate medical threat of bioterrorism triggered by the September 11, 2001 professionals, in par- terrorist attacks as well as anthrax spread via the US mail. ticular emergency phy- Today, clinicians need to recognize COVID-19 as well as sicians and generalists, all the other diseases that are in the differential diagnoses of to quickly recognize A depressed, black eschar on the fever, cough, abdominal pain, headache, loss of sense of taste signs and symptoms of chest. or smell, rash of toes, and more. Skin is the window into a bioterrorism diagnoses person’s overall health. Still, generalists receive an average of that they were almost universally unfamiliar with. 21 hours of training in dermatology,1 making it difficult for Cutaneous anthrax lesions begin as nonpainful, pruritic them to accurately diagnose skin conditions and their cor- papules before forming clusters of vesicles to ulcers within responding illnesses. one to two days following exposure. The ulcers then devel- As dermatologists, we should be empowering all front-line health care clinicians with tools and knowledge that will Although the skin is a window into a person’s overall health, help them make better decisions in the exam room, wheth- generalists receive an average of 21 hours of training in dermatol- er in person or via telemedicine. Recognizing the cutaneous ogy. This makes it difficult for them to accurately diagnose skin signs and symptoms of infectious diseases is key in early conditions and their corresponding illnesses. Dermatologists diagnosis and harm reduction. should empower all front-line health care clinicians with tools The following six infectious diseases have had a significant and knowledge that will help them make better decisions in the impact on public health over the past few decades and have exam room, whether in person or via telemedicine. Recognizing placed a spotlight on the importance of dermatology skills the cutaneous signs and symptoms of infectious diseases aids in infectious disease diagnosis. Disease information is derived early diagnosis and treatment. from diagnosis summaries in VisualDx.

ANTHRAX Anthrax sent through the mail after the September 11, 2001 terrorist attacks triggered an immediate effort by the thebottomline

28 PRACTICAL DERMATOLOGY NOVEMBER 2020 ANNUAL PICTURE ISSUE

op into depressed, black eschars over the next two to five papules on the trunk days. The arms, face, and neck are most commonly affected. and extremities. It is Some lesions may have extensive edema. associated with pain- Without treatment, cutaneous anthrax can progress to ful small joint poly- a systemic form with a mortality rate of approximately 20 articular arthralgias. percent. Occasionally, the rash may also appear on the MEASLES face, palms, and soles. Measles is transmitted It may be difficult to via respiratory droplets identify in patients with Erythematous macules on the palms and is highly infectious. dark skin. and some papules on the wrist. The incubation period Oral manifestations after the measles virus are a less frequent occurrence and are seen more commonly enters the upper respira- in children. Perineal, genital, and intertriginous ulceration tory tract and nasal pas- has also been reported. sages is about 10 days, Variant presentations include the presence of petechiae, with the rash typically purpura, targetoid lesions, vasculitic lesions, or vesicles and appearing about 14 days bullae. The vesiculobullous form is more commonly seen in Widespread erythematous patches after a person is exposed. children. on the face and chest of a child. Infected individuals are Chikungunya was once considered a tropical disease, considered contagious found mainly in Africa, India, and Southeast Asia. However, from four days before to four days after the rash appears. outbreaks have occurred in southern Europe, the Caribbean The exanthem consists of erythematous macules and pap- Islands, and Central and South America. In 2014, locally ules beginning at the forehead and behind the ears, eventu- transmitted cases were reported in Florida. ally spreading down the neck, upper extremities, trunk, and lower extremities. Confluent lesions can occur on the face. The rash typically peaks for three to four days, then begins Lyme disease is the to fade at day five in the same manner in which it appeared. result of infection with Desquamation typically occurs after approximately one the bacteria Borrelia week. Thrombocytopenia, with resultant purpuric lesions, burgdorferi that is may complicate measles. transmitted by infected Oral lesions called Koplik spots may develop two to three ticks. The tick can be days after symptoms begin and prior to the generalized found attached to the cutaneous eruption. Look for minute, white papules, which skin in many cases. may have a central bluish-white portion, usually opposite Erythema migrans, the second molars on the buccal mucosa. They can also A large erythematous, annular plaque the classic unraised, appear red. Bluish-gray or white papules can also be seen on with a “bull’s-eye” appearance. red “bull’s-eye” lesion the tonsils. on the skin, will appear Although measles was declared eliminated in the United days to weeks after the bite. However, about 25 percent of States in 2000, outbreaks resulting from imported cases affected people never get this lesion. Some may complain continue to occur. There was a high number of reported of flu-like symptoms, including fever; head, neck, and joint measles cases in the United States from January through pain; and generalized muscle pain. The lesion will resolve July 2019, with 1,100 cases from 30 states reported to the without treatment in about a month. Centers for Disease Control and Prevention (CDC), largely In most cases, Lyme disease can be eliminated with anti- from under-immunized communities. biotics, especially if treatment is started when symptoms are first noted. Untreated Lyme disease may affect the joints, CHIKUNGUNYA heart, and nervous system. Chikungunya is transmitted by the bite of infected mos- quitoes. The rash typically begins as flushing of the face and trunk and progresses to macules and then erythematous Syphilis is considered “the great mimicker” and has

NOVEMBER 2020 PRACTICAL DERMATOLOGY 29 ANNUAL PICTURE ISSUE

stumped even the most The most com- seasoned clinicians. mon manifestations of According to the CDC, CA-MRSA infections primary and second- are skin and subcutane- ary syphilis rates have ous infections. MRSA increased in the United skin infections present States almost every year similarly to any bacterial 2 since 2001. , although Culture-confirmed MRSA showing It is important to rec- skin caused by a furuncle with overlying scale and Untreated syphilis that progressed ognize infection in the MRSA can often appear central purulence on the knee. to secondary syphilis, seen here as primary stage, as lesions larger and more severe discrete orange-red papules, some in this stage will heal than other infections. Look for follicular pustules, furuncles with thick overlying scale, on the without therapy and all (), abscesses, and bullous and non-bullous . palms. patients who contract syphilis will go on to EMPOWERING PHYSICIANS AT THE POINT OF CARE develop secondary syphilis if the initial infection is not treated. As a dermatologist and health informaticist, one of my When treated early enough, syphilis can be completely cured. missions is to put knowledge and visualization at the point of Look for one or more painless ulcers () ranging care to drive better treatment, testing, and diagnostic deci- from a few millimeters to several centimeters at the site of sions. While the COVID-19 pandemic is placing additional inoculation. The classically described round, punched-out pressure on health care professionals, the use of tools that ulcer is pink and shiny and has a nonpurulent, clean base provide education in the skin exam, improve diagnostic with scant serous exudate and an indurated raised border. accuracy, and speed medical care is essential. Clinical decision Genital sites affected in women are the cervix, vagina, vulva, support can be used as a second opinion right at the point and clitoris. In men, the is easily seen on the penis. of care, giving clinicians the information they need to make There may be a mixed infection of syphilis with any other informed decisions and improve patient engagement. sexually transmitted disease (STD) that may change the As we wind down from the acute phase of this current appearance of the ulcer. Atypical chancres have been noted pandemic, we should consider the structure and functional- to present as painful erosions or ulcers with soft or hard ity of a modern public health digital infrastructure. Since no borders with a dirty or clean base. Anal erosions, ulcers, and one knows which public health threats will emerge in the fissures may also be seen. future as our next crisis, the only sensible strategy is to pre- Secondary syphilis typically occurs one to three months pare for all infectious diseases and diseases of public health after the first stage of syphilis. It has a wide range of cutane- significance. We must make sure we are empowering all cli- ous manifestations. These include a generalized nonpruritic nicians with the tools and knowledge to recognize early skin papulosquamous eruption including the palms and soles, manifestations of infectious diseases. n with pink, violaceous, or copper-colored papules, each with a collarette of scale. Patchy alopecia of the scalp is All images used with permission from VisualDx. also observed in secondary syphilis. Ocular symptoms may include lacrimation, photophobia, and red, painful eyes. Dr. Art Papier is the co-founder of VisualDx (VisualDX.com) and Chief Executive Officer. A thought leader in health infor- MRSA mation technology, Dr. Papier maintains the overall vision for Skin and soft tissue infections including , - the VisualDx product with a keen focus on software integra- es, impetigo, , and furunculosis can all be caused by tion and impacting costs in healthcare through clinical accu- infection with , including methicillin- racy. VisualDx clinical decision support is the most widely used resistant S aureus (MRSA). Over the past two decades, the diagnostic system in healthcare. He is an Associate Professor incidence of community-associated MRSA (CA-MRSA) has of Dermatology and Medical Informatics at the University of been increasing. In many parts of the United States, more Rochester School of Medicine and Dentistry. than 50 percent of community-associated S aureus isolates 1. Fleischer AB Jr, Herbert CR, Feldman SR, O’Brien F. Diagnosis of skin disease by nondermatologists. Am J Manag Care. are MRSA. Hence, infections where S aureus is suspected 2000 Oct;6(10):1149-56. should be considered MRSA unless susceptibility studies 2. Sexually Transmitted Disease Surveillance 2017. Centers for Disease Control and Prevention. Accessed at: https://www. demonstrate otherwise. cdc.gov/std/stats17/2017-STD-Surveillance-Report_CDC-clearance-9.10.18.pdf.

30 PRACTICAL DERMATOLOGY NOVEMBER 2020