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Home , Actinic keratosis, Freckle, Keratosis pilaris, Lentigo

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A Pictorial Review of Primary Care PCOM BOARD REVIEW 3-10-18

Rob Danoff, DO, MS, FACOFP, FAAFP + In the Beginning Proof that babies are delivered by storks + What’s the Diagnosis? + Stork bite = simplex = Salmon patch n Red dilatation of blood vessels often on eyelid, , or nape of neck (stork bite)

n They are usually small flat patches of pink or red with poorly defined borders

n Very common and occur in over 40% of all newborns

n The facial patches are sometimes referred to as an “angel's kiss” and tend to fade over the first year of life + Nevus simplex = Stork bite= Salmon patch n Often deepen in color with crying, straining with defecation, breath holding or with changes in ambient temperature

n Not painful or itchy

n Benign course, reassurance, lighten with age

n Those on the eyelids and below towards the nose usually disappear by 2 to 3 years of age

n Rarely detected after age 6 years – those on neck (stork bite)often fade and/or are covered up by through adult life + What’s the Diagnosis? +

n Mainly affects children and adolescents – prevalence about 5%

n A type of eczema – unknown cause - often seen in those with dry skin and – exposure may trigger

n Most common locations are face: cheeks and chin

n May also be seen on neck, shoulders and upper arm

n more noticeable in summer, especially on darker skin tones

n Dry skin and scale more noticeable in dry winter weather

n Lesions go through stages – scaly pink plaque to hypo- pigmented plaque with fine scale to post-inflammatory macule with no scale and then eventual resolution in a few months or a few years + Key Points – Pityriasis Alba n Does NOT enhance with a Woods lamp – no fluorescence n Fungal cultures are negative n No treatment needed but if do for symptoms: n may help dry skin n Mild steroid cream may decrease erythematous areas n Calcineurin inhibitor cream (pimecrolimus) or ointment (tacrolimus) may speed recovery of skin color + What is the diagnosis? + Atopic Dermatitis - Eczema

n Most common form of eczema

n Often affects those who have:

n Asthma or seasonal allergies

n Family history of eczema, asthma or seasonal allergies

n Usually begins during infancy or childhood, but may occur anytime

n Defects in the skin barrier + A Moisture Barrier Problem + Atopic Dermatitis / Eczema n Treatment: n Avoid triggers—cold, wet, irritants, emotional stress n Aggressive hydration with cream based or petrolatum based moisturizer to restore skin barrier n Less irritating soap n Infants--Low potency corticosteroid ointments for maintenance n Older children and adults—medium potency corticosteroid ointments, sparing the face n Stronger corticosteroids ointments should be used for flares or refractory plaques short term only to avoid thinning of skin n Calcineurin inhibitors (tacrolimus or picrolimus) –useful on face or eyelids n Short course oral Prednisone only for severe flares n Antihistamine therapy n New treatment option – crisaborole (Eucrisa) – a topical (PDE-4) phosphodiesterase 4 inhibitor for those age two and older + What is the diagnosis? + Key Clues n Dandruff is often present n Typical symmetrical distribution on the head and on the body n More severe presentations - erythematous plaques, often with powdery/greasy scale in the n Besides itchy scalp, a burning sensation may occur in affected facial regions n A chronic, relapsing condition n Tends to worsen during cold and dry winter and improve during the summer + Seborrheic Dermatitis n Chronic, superficial, inflammatory predilection for the scalp, eyebrows, eyelids, nasolabial creases, lips, ears, sternum, axillae, submammary folds, umbilicus, groin, and gluteal crease

n Indirect evidence for a role of lipid dependent fungi of the genus Malassezia

n Presentation: yellow, greasy, scaling on an erythematous base Dandruff is a mild form / Cradle cap is an infant form

n Parkinsons disease can often have severe refractory seborrheic derm

n Treatment: Face--Antifungal agents, corticosteroid cream, gel, sprays, and foam

n Scalp– Selenium sulfide, ketoconazole, tar, zinc, pyrithione, fluocinolone, resorcin shampoos + What is the diagnosis? + Seborrheic

n Facts: Oval, raised, brown to black sharply demarcated or plaques; they appear stuck on or warty

n Involving mostly chest or back but can be anywhere

n Pathogenesis: Unknown

n Treatment: Removed by liquid nitrogen, curettage, light fulguration, shave removal, and CO2 laser vaporization + What is the diagnosis? +

n Facts: Affects young children, sexually active adults, and immunosuppressed

n Pathogenesis: Pox virus via skin-to-skin contact especially if wet

n Appearance: smooth surfaced, firm, dome-shaped pearly papules, many times umbilicated

n Treatment: Young immunocompetent children - usually spontaneous resolution n Other options include topical cantharidin, light , or manual extraction of core + What is the diagnosis? +

n Facts: Persistent of the convex surfaces of the face n Commonly assoc. with , , erythematous papules and pustules

n Cheeks and nose of light skinned women age 30-50 most commonly affected

n Severe phymatous changes in men

n Exacerbated by stressful stimuli, spicy food, exercise, cold or hot, and alcohol

n Pathophysiology: Abnormal vasomotor response to stimuli

n Treatment: , avoidance of triggers, laser, metronidazole cream, sodium sulfacetamide, sulfa cleansers and creams, azaleic acid, Low dose Tetracycline or Minocycline po daily + What’s the diagnosis?

n Generalized pruritis or the sensation of burning

n Irritation at one site of the body can result in mast cells in other parts of the body releasing histamine although they have not been directly stimulated

n Can be induced by tight or abrasive clothing, watches, glasses, heat, cold, or anything that causes stress or pressure to the skin

n In many cases it is merely a minor annoyance, but in some rare cases symptoms are severe enough to impact a patient's life

n Can last minutes, hours or days + + + TYPES

n Red dermatographism : most common type - develops as small raised scratches on the skin which occurs on trunk.

n Follicular dermatographism : prominent follicular papules on the skin with a well defined background.

n Cholinergic dermatographism : somewhat large embedded with punctuate wheals resembling urtica. Brought on by a physical stimulus. Although this stimulus might be considered to be heat, the actual precipitating cause is sweating

n Delayed dermatographism : papules develop after several hours of initial response forming deep wheal like structure. + Treatment Approaches

n Antihistamines

n A combination of 2 or more antihistamines may be required

n Moisturize to reduce scratching in case of dry skin

n Xolair (Omalizumab) – 150 mg SC – may relieve persistent symptoms of persistent urticaria within days

n Narrowband (UV)-B phototherapy and oral psoralen plus UV-A have both been used as treatments for symptomatic dermographism – relapse often occurs in two to three months

n Decrease and/or avoid symptom triggers + What’s the Diagnosis? Key Clues n Benign – usually inherited

n Begins by age two or during teenage years

n Can extend into adult years, often gradually fades

n More common in women

n Occurs when too much builds up in hair follicles – forms hard bumps = rough skin surface

n Appear in different colors - the same color as the skin, white, red, pinkish purple and brownish black (on )

n Most commonly found on upper arms and , less common and cheeks

n Often worse during winter and when skin is dry + What’s the Diagnosis? + - KP + Treatment of Keratosis Pilaris

n Gently exfoliate

n Diminish the bumpy appearance – remove dead skin cells with a with one or more of the following ingredients: Alpha hydroxyl acid, , lactic acid, , and/or a (, , etc.)

n Relieve the and dryness – cream or ointment with either urea or lactic acid right after using a keratolytic

n Integrative therapy – omega 3 fatty acids, topical coconut oil after a warm (not hot) bath or shower + What’s the Diagnosis?

n Common, can occur on most areas of the body n Usually found in those greater than 30 years of age n The dilated interconnecting capillaries appear “cherry red” to dark purple n May increase in size and numbers with age n Cause unknown but benign n Smooth or upraised, can appear on all body sites n Mucous membranes usually spared n May bleed if scratched + Cherry Angioma “Campbell de Morgan spots”

n Usually no treatment needed

n Occasionally are removed to exclude a malignant skin lesion such as nodular

n If removed for cosmetic reasons, cryotherapy, electrosurgery or vascular laser are options + What’s the diagnosis? + n Benign, self-limited eruption n Generally affects adolescents and young adults as a response to a viral infection n Most commonly seen between ages 10 – 35 and during

Treatment n Directed to symptom relief with antihistamines for itching n Moderate-potency steroids may be used for itching if necessary n Spontaneous resolution usually occurs within 1-2 months. + What’s the Diagnosis? n Skin cells that multiply up to 10 times faster than normal n As new cells reach skin’s surface and die, huge volume of cell causes raised and reddish plaques, often with white scales n Pruritus very common n Most likely to affect elbows, knees, and lower back, but can affect other areas + Key Clue Can also affect the nails + What’s the Diagnosis? + Plaque

n Most common type of psoriasis

n Chronic and relapsing in nature

n Symmetrically distributed over the body

n Small to large, well demarcated, red, scaly and thickened areas, lesions on the legs sometimes carry a blue tint

n Large plaques with silvery scale may join to involve large areas of skin, especially trunk and limbs

n Large plaque form usually begins before age 40, difficult to treat. Often family history.

n Small plaque form often begins after age 40 + Treatment of Plaque Psoriasis

n Sunshine (heliotherapy), warm water baths (soften plaques), , (urea, salicylic acid)

n Topical agents include: Corticosteroids, coal tar, anthralin, Calcipotriene, Tazarotene

n Phototherapy:

n Ultraviolet B (UVB) irradiation - usually combined with one or more topical treatments

n Psoralen plus ultraviolet A irradiation (PUVA) - This treatment uses the photosensitizing drug 8- methoxypsoralen in combination with UVA irradiation to treat patients with more extensive disease + Systemic Treatment

n Often utilized if other treatment options and phototherapy have proved unsuccessful

n Considered for patients with very active psoriatic arthritis, as well as for patients whose disease is physically, psychologically, socially, or economically disabling

n Psoriatic arthritis - Occurs in approximately 10-20% of all cases of plaque psoriasis, symptoms may include:

n Red, warm, tender, and inflamed joints, joint deformity

n Options include: methotrexate, cyclosporin, others

n Biologics response modifiers such as infliximab, etanercept, others + What is the Diagnosis ? +

n Facts: Manifestation of Lyme disease; caused by Borrelia burgdorferi

n Occurs in approximately 50% of patients most commonly on legs, groin, and axilla

n 3-32 days after tick bite there is a gradual expansion of redness around an initial creating a target-like lesion

n Rarely pruritic or painful

n Primary and secondary lesions fade in approx. 28 days

n Treatment: Doxycycline 100mg BID for 10-30 days + Sun and Skin

n Fitzpatrick skin phototype + Working On More Than A Tan AND Higher risk for squamous cell + What’s the Diagnosis?

n A UV light induced lesion

n Malignant potential

n Begin as small “rough spots”

n Over time the lesions enlarge, usually becoming red and scaly + – AK Treatment Options

n PROCEDURES n MEDICATIONS

n Cryotherapy n 5- (5-FU) cream n n sodium n Curettage – possibly gel followed by Electrosurgery n cream

n Photodynamic n gel therapy (PDT)

n Laser resurfacing +AK on bottom lip =

Potential Signs Actinic Cheilitis n Whitish scale on bottom lip

n Rough scaly lip

n Splitting lips or your

n Lips always feel dry + What is the Diagnosis ? + Basal Cell

n Facts: Common in fair-skinned people with UVR (blistering as a child) and

n Usually appears as a small waxy, translucent, pearly or rolled border around a central depression that may be ulcerated, crusting or bleeding; course throughout

n Commonly on the head or neck (esp nose)

n These tumors grow slowly and more laterally; rarely metastatic

n Treatment: suspected lesions n Imiquimod if superficial lesions, or excision with clean margins; n MOHS if cosmetic area or extensive, invasive lesion + What is the diagnosis? +

n Common in fair-skinned people from UVR.

n Usually at site of initial actinic keratosis; appears from an indurated base and becomes elevated with telangiectasias becoming progressively nodular and ulcerated—hidden by a thin

n Usually on the face, ear, lips, mouth or dorsal and arms

n Increased likelihood with immunosuppression

n Can develop into large masses and spread deeper into the tissues and occasionally to other parts of the body

n Treatment: Biopsy suspected lesion; Electrodessication and curettage x 3 and/or 5-FU, or imiquimod if small & superficial + What is the diagnosis? + Melanoma

n Facts: of the pigment producing cells in the , or upper surface of the skin.

n Frequently metastatic if not found early

n Most common locations are the exposed parts of the skin, particularly the face and neck

n Hereditary forms have a predilection for areas of sun protection– palms, soles, fingernails and vaginal mucosa + Melanoma Variants of melanoma - maligna - flat and thin variant, frequently presenting as a Superficial Spreading large Desmoplastic -superficial spreading - flat, or only slightly raised, and a bit more uniform in color - – elevated and often rounded growth of the Nodular cancer -acral lentigenous - occurs on the palms and soles of the and feet, or in the cuticles or bed -desmoplastic - does not often Acral Lentiginous produce pigment and is the most difficult to diagnose without a biopsy +

Asymmetry - Melanoma lesions are typically irregular in shape. Benign moles are round. Border - Melanoma lesions typically have uneven borders, while benign moles have smooth, even borders. Color - Melanoma lesions often contain many shades of brown or black; benign moles are usually one shade. Diameter - Melanoma lesions are often more than 5 millimeters in diameter (the size of a pencil eraser); benign moles are smaller. Evolutionary Change - Documented change of appearance in the lesion over time. + The American Joint Committee on Cancer (AJCC) TNM System – extent of disease

progressionn Three Key Components

n T - tumor (how far it has grown within the skin - thickness and other factors – ulceration and mitotic rate

n N - spread to nearby lymph nodes

n M - whether the melanoma has metastasized to distant organs, which organs it has reached, and on blood levels of LDH.

n Two types of staging for melanoma:

n Clinical staging - what is found on physical exam, biopsy/removal of the main melanoma, and any imaging tests that are done.

n Pathologic staging - determined after node biopsy results – may be higher than clinical stage + AJCC Melanoma Staging 8th Edition + + Melanoma

n Melanoma Diagnostics Indicators

n Breslow Thickness - the Breslow's Depth of Invasion (thickness of the tumor) is the most important determinant of prognosis for

n Increased tumor thickness is correlated with metastasis and poorer prognosis

n Breslow Thickness and Approximate 5 - Year Survival :

n <1mm: 5-year survival is 95-100%

n 1-2mm: 5-year survival is 80-96%

n 2.1-4mm: 5-year survival is 60-75%

n >4mm: 5-year survival is 37-50% + Melanoma

§ MOHS may be an option for which has frequent asymmetrical growth patterns

§ Sentinal Node Biopsy in pts whose melanoma is thicker than 1 mm, or if ulceration present

§ Adjuvant therapy if node positive or increased tumor thickness + Melanoma +

Best of success on your boards!