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Home , Lentigo, Poikiloderma

Goals and Objectives: Dermatomyositis

• At the end of this lecture, the learner will be able to: • Skin Signs: • Work Up: 1. Identify benign growths of the face • Heliotrope rash • Myopathy (may be amyopathic) • Cuticular dilated capillary loops • Malignancy (ovarian, breast, lung) 2. Identify manifestations of collagen vascular disease on the face • Others: • Interstitial lung disease • Anti‐Jo1, Anti‐MDA5 3. Appreciate the difficulty in identifying maligna • Gottron’s • Mechanics hands • Tx: 4. Create a differential diagnosis of perioral, peri‐ocular, labial, and • atrophicans vasculare • Prednisone malar lesions and rashes • Shawl sign • Hydroxychloroquine • V‐sign • Methotrexate 5. Implement basic treatment paradigms of common conditions, • Calcinosis cutis including , , and eczema • Scalp scaling • Mycophenolate mofetil • IVIg

Heliotrope Rash Dermatomyositis ‐ heliotrope eyelids

Heliotrope, the flower

She is not wearing eyeshadow. Dermatomyositis Seborrheic Dermatitis Gottron’s papules & cuticular dilated capillary loops • Same etiology as …BUT ALSO…. • Caused by Malassezia fungus • Signs: scaling and erythema of: • Brow • Paranasal gutters • Posterior auricular (behind ears) • Conchae of ears • Scalp (a.k.a. dandruff) • Chest • Worse in HIV • Treatment: ketoconazole 2%, pimecrolimus, hydrocortisone 1%

melanoma Seborrheic Dermatitis Seborrheic Dermatitis in HIV Perioral Dermatitis from Topical Steroids • Looks like a mix of acne and eczema • Acquired • DDx: allergic contact • no zinc in baby formula dermatitis (e.g., to • alcoholics toothpaste) • Genetic • Treat: • acrodermatitis enteropathica • tacrolimus • autosomal recessive • pimecrolimus • zinc malabsorption • d/c topical steroid

Photo from: http://healthh.com/wp‐ content/uploads/2014/05/perioral‐ dermatitis‐pictures‐3.jpg

Scleroderma

• Pinched nose • Immune‐mediated • Tightened orifice displaying teeth depletion of • Few wrinkles • Tx: tacrolimus & excimer laser • Telangiectases

• Therapy: • Mycophenolate mofetil • Methotrexate • Prednisone pernio (sarcoidosis of face) Discoid Lupus

• Aka chronic cutaneous • Cutaneous sarcoidosis • Hyperpigmented border, hypopigmented/pink center • Nose, scalp with scarring alopecia • Face, ears, scalp (with scarring alopecia) • More indurated than DLE • • Therapy: Therapy: hydroxychloroquine; thalidomide • infliximab • intralesional triamcinolone 5‐10mg/cc

Discoid Lupus Acute systemic lupus

• “Butterfly” malar (cheek) rash • Photosensitivity • Spares nasolabial fold Lupus vulgaris Tinea faciei: note annular, scaly border (cutaneous tuberculosis) • + PPD • Search for TB elsewhere Treatment: • Slowly progressive terbinafine 250mg po qd x 14 days

Psoriasis Seborrheic dermatitis

• Can look like seb derm Therapy: • but more well‐demarcated • Ketoconazole 2% cream bid than seb derm • • Treat face with: Topical calcineurin inhibitors • Tacrolimus • Tacrolimus • Pimecrolimus • Pimecrolimus • Topical steroid • mid‐potent steroid • for flare, not for maintenance Eczema Psoriasis Dry, scaly, red plaques Well‐demarcated Red Often impetiginized Plaque(s) • swab culture Silver scale • mupirocin New therapy: Therapies: Anti‐IL 23 agent: guselkumab • 90% of folks get 75% clear • Tacrolimus 0.1% ointment • 40% of folks get 100% clear • Pimecrolimus 1% cream Very safe! • Crisaborole 2% ointment Primary care can do it! • Topical steroids

Pityriasis alba Allergic • Associated with eczema • Treatment: Diagnosis: • Tacrolimus • Patch testing • Pimecrolimus • Hydrocortisone • Crisaborole Therapy: NEW! • Allergen avoidance Dupilumab • Topical steroids • IL 4/13 receptor antagonist • Tacrolimus • moderate to severe • Pimecrolimus eczema • safer than prednisone • may cause conjunctivitis Intradermal – scalp, flesh colored Intradermal nevus – face Syringoma

• Benign rest of non‐functional eccrine (sweat gland) cells • Cluster of 1 to 3 mm dermal papules • Eyelids or upper cheeks Compound nevus • Onset: puberty or adult Junctional nevus - • Tx: electrofulguration but recur with risk of post‐inflammatory brown macule

Intradermal nevus: Junctional nevus: nests in dermis only nests in dermo- epidermal junction only Sebaceous

• Small, mamillated yellow papules with and umbilication • depressed center, like “inny” belly button • Confused with basal cell carcinoma • Harmless Compound nevus: • nests both in dermis Seen in folks with rosacea and in D-E junction Seborrheic Keratosis

• Warty, stuck‐on papule • Greasy • Tan to black • Elderly – “barnacles of life”  • VERY COMMON LESION • BENIGN…but if something looks funky to you, always involve the dermatologist

Milium Dermatosis Papulosa Nigra (pl. milia) • Many little SKs • Small • Treat via I&D Incision Extraction with comedone extractor Traction behind blade = GOOD (or long finger nails :O)

Epidermoid Cyst: Schematic Epidermoid Cyst

• Misnomer = sebaceous cyst • Hair follicle gets occluded  Skin still sloughing below occlusion  Keratin collects and causes inflammation and scarring around it  Capsule/cyst wall formation • Periodically, keratin discharges (smells!!!) accounting for “growing and shrinking” course Epidermoid Cyst

Central punctum

Central punctum

Nevus areneus (aka spider telangiectasia) Nevus araneus

• Associations: cirrhosis • Therapy: • Electrodesiccation of central feeder vessel • Pulse dye laser abaltion

Spider photo from: http://zerotermitepest.com.au/spider‐control‐sunshine‐coast/ Hidrocystoma

• Translucent, fluid‐filled cyst on eyelid • Lined by sweat gland epithelium • Treatment: • Incision and drainage • Excision • Electrofulguration

Xanthelasma Hordeolum (stye)

• Yellow plaques on • acute focal infection eyelids • staphylococcal • Sometimes associated • sebaceous gland with • glands of Zeis hypertriglyceridemia, • external hordeola – lash but often, not found • meibomian glands • Tx: 100% TCA; • internal hordeola – tarsal plate electrodesiccation; ablative laser https://en.wikipedia.org/wiki/Stye BONUS FINDING: SYRINGOMA!!!! Chalazion Acrochordon • Chronic inflammation of Zeis or meibomian glands • Aka Therapy: • Pedunculated • warm compress • Snip excision • ILTAC 2.5‐5mg/cc • Cauterize base

By Michal Klajban (Hikingisgood.com) ‐ Own work, CC BY‐SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11037123

Lentigo Maligna vs. Solar Lentigo Melanoma vs. Solar Lentigo?

• Lentigo maligna = melanoma in situ, usu. face • Solar lentigo = hyperpigmented macule from excess sun exposure

To distinguish: • Time/progression • Color variegation • Size • Similar lesions • Old melanoma excision scar Lentigo Maligna Melanoma vs. Solar Lentigo? vs. Solar Lentigo?

Lentigo Maligna Melanoma vs. Solar Lentigo? Solar lentigo or melanoma?

Photo from: https://edrugsearch.com/age‐spot‐removal/ Solar lentigo – dirt comes off with alcohol!!! Basal Cell Cancer

• Rolled border • Telangiectasia • +/‐ Ulceration

• Does not usually metastasize BUT locally destructive

Basal Cell Carcinoma Squamous Cell Cancer (SCC)

• Morphology: • Hyperkeratotic • Red base

• Sun damaged skin; Organ transplant patients

• Metastatic risk • Mucosa (e.g., Lip) • Ear • Genitalia • > 2cm • Recurrent SCC in situ SCC (Bowen’s disease)

SCC

Note background of photodamaged skin and actinic SCC keratoses SCC

• Rough, thin, scaly papule • sometimes felt, not seen • Precursor to SCC • Sun exposed areas: • bald scalp • face • forearms • dorsal hands

Actinic Keratoses Actinic Keratosis

forehead Solitary Hyperkeratotic Papule Cryotherapy – 10 sec freeze

Cutaneous Horn Verruca Vulgaris Seborrheic Squamous cell carcinoma () keratosis Can be: red base, • Wart filiform pigmented, hyperkeratotic • SCC stuck on, • AK waxy

After 5‐FU Osler‐Weber‐Rendu Disease

• Aka Hereditary hemorrhagic telangiectasia • AV malformations  GI bleed • Epistaxis • Lip telangiectases • Gene: • endoglin (ENG) • activin receptorlike kinase type I (ALK‐1) • Cf: Venous Lake Venous Lake Peutz‐Jagher Syndrome • Brown macules of lips • Benign hamartomas polyps in GI tract  intussusception • Venous ectasia of lip • Cancer predisposition • • breast Benign • pancreas • Tx: • others • pulse dye laser • Gene: STK11/LKB1 • electrodesiccation • Cf: solitary labial lentigo – very common • Cf: – cardiac myxoma, lentigines Figure from: https://openi.nlm.nih.gov/detailedresult.php?img= PMC3505710_medoral‐17‐e919‐g003&req=4

Carney Complex Solitary Labial Lentigo – very common! (LAMB/NAME syndrome) • Labial lentigines • Cardiac myxomas • Cancers • Endocrine abnormalities • Gene: PRKAR1A

Figure from: https://www.researchgate.net/publication/234124406_The_complex_of_myxomas _spotty_skin_pigmentation_and_endocrine_overactivity_Carney_complex_Imagin g_findings_with_clinical_and_pathological_correlation/figures Herpes Associated Angioedema • Allergic vs. hereditary • Targetoid • Angioedema + = allergic • Ulcerative enanthem • Therapy: • + HSV 1 or 2 serology • Epinephrine • Therapy: • Prednisone • Famciclovir • Antihistamines • Valacyclovir • Apremilast • Stop offending drug • Prednisone • E.g., ACE inhibitor • Thalidomide • Cyclosporine

Herpes pearls… Angular Cheilitis

• Topical don’t work • Maceration from drooling • First outbreak (1o HSV1) • Candida worse than recurrent • Vitamin deficiency • 1st outbreak can be intraoral • • Subsequent usually just Therapy: lip/nose • Mid‐potent steroid • • Dosing options for recurrent Clotrimazole • MVI • Valacyclovir: 2g bid x 1d • I use VZV dosing: 1g tid x 7d Figure from: http://www.webmd.com/oral‐health/angular‐ cheilitis#1 Retinoid Cheilitis Actinic cheilitis

• Lip inflammation from isotretinoin • Actinic keratosis of the lower lip • Tx: • Due to chronic sun exposure • decrease dose • Precursor to SCC • Low potency topical steroid • Tx: • Imiquimod • 5‐fluorouracil

• CO2 laser • Photodynamic therapy

Melasma Therapy

Retinoid: sloughs pigmented stratum corneum (qd) Steroid: (bid) Hydroquinone 4%: inhibits tyrosinase (bid)

Combo cream is qd due to retinoid, but retinoid is weak, so bid is ok