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Home , Cellulitis, Dyshidrosis, Herpes gladiatorum, Hidradenitis, Impetigo, Miliaria

Clinical Objectives Part 1 • At the end of the lecture the participant Infectious Dermatology should be able to: – Describe the basic characteristics of common . – Describe the etiology, Patricia R Jennings DrPH, PA-C and of common Professor infectious skin diseases. UAB – Describe the laboratory / special studies evaluation, treatment and prognosis of common infectious skin diseases.

Anatomy and Physiology

• Skin functions:

• 1. holds body fluids within its boundaries • 2. protects underlying tissues • 3. synthesizes vitamin D • 4. helps modulate body temperature

Anatomy and Physiology Physical Examination

• Color: depends primarily on four pigments: • Skin: Inspect and Palpate melanin, carotene, oxyhemoglobin and • Color: basic (tan, brown, black, red, pink, deoxyhemoglobin. white, yellow, purple, green) • Moisture: moist, dry, diaphoretic • Temperature: cool, warm, hot • Texture: smooth, rough, edematous • Mobility: turgor • Lesions When describing lesions note their characteristics Flexor Surface •size(in centimeters) • color: basic colors • anatomic location • distribution: face only, sparing face, sun exposed areas, etc. • margination: sharp, well defined borders versus poorly defined borders • arrangement: linear, scattered, dermatome • surface characteristics / types of lesions

Extensor Surface

Macule

• Macule: Small, flat • Papule: small, spot. <0.5cm in palpable lesion less diameter. They may than 0.5cm in be any color. diameter. • may be of • Example: , any color and their petechiae. surface may be smooth or rough. NODULE PATCH

• Nodule: enlargement • Patch: extension of a of a papule in three macule in two dimensions: length, dimensions: length width and height. and width, i.e. an area of color change that is 0.5cm or larger in diameter.

PLAQUE PUSTULE

• Plaque: enlargement • Pustule: vesicle that of a papule in two is filled with dimensions: length neutrophils. For this and width. reason it is white, or yellow-white in color.

VESICLE BULLA

• Vesicle: small • Bulla: vesicle which is less than 0.5cm in 0.5cm or larger in diameter. diameter. It is Conceptually it can be otherwise entirely considered as a fluid- similar to a vesicle. filled papule in which the fluid is loculated. SCALE

• Crust: The dried • Scale: A thin flake of residue of serum, exfoliated . or blood. • Example: , dry skin, . • Example:

Target Lesions ZOSTER

• Herpes Zoster, • Target Lesions: The : vesicular outer zones are lesions in a usually rings of dermatomal pattern. or , • Example of typical while the central pattern in an portion is an opaque immunocompetent white, yellow or patient (dusky) gray color. • Example:

Infectious • Etiology: caused by the poxvirus. • Molluscum Contagiosum • Presents as a single or • multiple rounded, dome- • Verrucae shaped, waxy papules 2-5mm, that are umbilicated. • • Lesions are autoinocuable and • Scalded Skin Syndrome spread by wet skin to skin • Impetigo contact. • Furuncle • May be in genital region; • • When in the genital region is considered a sexually • Pediculosis transmitted disease Molluscum Contagiosum Molluscum Contagiosum

• Diagnosis: established by the distinctive central umbilication of the dome-shaped . • Treatment is by curettage or applications of liquid nitrogen. • Molluscum is more responsive to therapy than verrucae () to applications of liquid nitrogen

Herpes Simplex Virus (HSV) HSV • Treatment: systemic agents • Grouped vesicles on an erythematous base (acyclovir, , valacyclovir); topical agents are • Principal symptoms are burning and stinging. Neuralgia may not as efficatious (acyclovir precede or accompany attacks. ointment, penciclovir cream) • Regional lymph nodes may be • Complications: , swollen and tender , herpetic • Tzanck smear is positive for , , multinucleated giant cells; viral esopagitis, neonatal , cultures may be positive, keratitis and encephalitis. serologies (IgM, IgG), ELISA, and direct fluorescent antibody tests.

Herpes Zoster Verrucae “Warts”

• Herpes Zoster, “Shingles”: • Verrucous papules vesicular lesions in a anywhere on the skin or dermatomal pattern, mucous membranes. involvement is unilateral. • Caused by human • Treatment: Acyclovir 800mg five times a day for 7 days; papillomaviruses (HPV) valacyclovir 1gm TID x 7 days, • Prolonged incubation or famciclovir 500mg TID x 7. period (2-18 months) • If involves facial nerve, • Spontaneous “cures” are hospitalize and administer IV frequent. “Recurrences” acyclovir, ophthalmologist are frequent. consult, “emergency”. Verrucae “Warts” Cellulitis

• Treatment: • The word cellulitis literally – liquid nitrogen means of the cells. It generally indicates – Keratolytic agents and occlusion an acute spreading – Podophyllum resin infection of the and – Imiquimod subcutaneous tissues – Operative removal resulting in pain, – Laser therapy erythema, edema, and warmth. – Bleomycin

• Associated red streaking visible in skin Cellulitis proximal to the area of cellulitis is characteristic of ascending . In • Begins as a small patch lymphangitis, the infection is carried through the lymphatic system. • Lesion expands over hours (onset to presentation is usually 6 – 36 hrs) – Regional may be present. – The margin of cellulitis will not be palpable. • Patient becomes more ill with time (, – Fever may be present. chills, and may progress to – Cellulitis characterized by violaceous color and septicemia) bullae suggests infection with • Hallmarks of cellulitis include the following: pneumoniae (pneumococcus). • Warmth, erythema, edema, and * Cellulitis of the lower extremities is more likely to tenderness of affected area are present. develop into thrombophlebitis in geriatric patients.

• Leukocytosis with left shift is usually present. Treatment • Aspiration of the advancing edge is usually not • -- Empiric coverage for group A performed streptococci and S aureus should be provided. • Acceptable inpatient regimens (MSSA) include a (eg, • Areas of or bullae formation Cefuroxime (Kefurox, Zinacef) -- second-generation (loculated site) . Ceftriaxone (Rocephin) -- Third- – Culture and Gram stain of fluid may be helpful. generation cephalosporin) or a penicillinase-resistant – Yield is positive approximately 90% of the time. synthetic (). • If unusual organism is suspected or patient is • In certain geographical areas of the country with high immunocompromised rates of methicillin-resistant S aureus (MRSA), alternative antimicrobial agents such as or – Full thickness skin performed and send for trimethoprim-sulfamethoxazole (TMP-SMZ) should be culture and histologic evaluation with gram stain. considered. Scalded Skin Syndrome Scalded Skin Syndrome • In the US: SSSS is most • Staphylococcal scalded common in children and skin syndrome (SSSS) neonates. It is rare in adults is a syndrome of acute • Mortality rate from SSSS in exfoliation of the skin children is very low (1-5%), following an unless associated or erythematous cellulitis. an underlying serious • SSSS is caused by an medical condition exists. exotoxin from a Mortality rate in adults is . higher (as high as 20-30%). Significant morbidity can result from hematologic or local spread of infection.

Treatment Scalded Skin Syndrome • The major focus of ED care should be to identify staphylococcal scalded skin syndrome (SSSS) and to • Fever, although patients may be afebrile stabilize the patient's condition. • Tenderness to palpation • Patients need fluid rehydration, – Fluid rehydration is initiated with lactated Ringer solution at • Warmth to palpation 20 cc/kg initial bolus. Repeat as clinically indicated. • Diffuse erythematous • Topical wound care similar to thermal , • Exfoliation of skin – Saline (wet to dry), followed by topical ointment. • Facial edema • Parenteral antibiotics to cover S aureus • Perioral crusting – MSSA (Nafcillin, Penicillin G procaine, and clavulanate (Clavulin, Augmentin) (Ancef, Kefzol, • Sandpaper like rash and Zolicef). – Accentuated in flexor creases – MRSA (Vancomycin)(Daptomycin) • should be avoided.

Impetigo Impetigo • Impetigo contagiosa is a – Most frequently on the face superficial, intraepidermal, (around the mouth and the unilocular, vesiculopustular nose) or at a site of trauma infection. Impetigo contagiosa is – Red macule or papule as the most common early lesion in children. – Lesions with ruptured bullae • Impetigo is an infection caused and crusted edges by group A beta-hemolytic – Lesions with -colored streptococci (GABHS) or crusts aureus. – Thin-roofed vesicle or bullae • In the US: Approximately 9-10% (usually nontender) of all children presenting to clinics with skin complaints have impetigo • Topical antibiotics –( ointment) (Bactroban) These agents pose fewer Impetigo potential problems than systemic antibiotics, but their use is reserved only for cases • Recurrent impetigo is associated with involving lesions that are small or few in nasal carriage of S aureus number. – Treatment: rifampin 600mg orally QD or • In most cases, Systemic antibiotics are intranasal mupirocin for 5 days indicated – Cephalexin (Keflex), if MRSA • Crusts and weepy areas may be treated suspected then , clindamycin or with compresses ( washcloths and towels TM-SMZ (Bactrim). must be segregated and washed • (older generation) Quinolones have poor separately) activity against streptococci.

Furuncle Furuncle • Furuncles are very common. They are caused by staphylococcus , which are normally found on the skin surface. Damage to the allows these bacteria to enter deeper into the tissues of the follicle and the . Furuncles may occur in the hair follicles anywhere on the body, but they are most common on the face, neck, armpit, buttocks, and thighs.

Furuncle Treatment • Small firm tender red nodule in skin (early) • Furuncles may heal on their own after an initial period • Later becomes fluctuant nodule (being movable and of itching and mild pain. More often, they progress to compressible ); Tender, mildly to moderately pustules that increase in discomfort as pus collects. painful; May be single or multiple; Swollen; Pink They finally burst, drain, and then heal spontaneously. or red; May grow rapidly • Furuncles usually must drain before they will heal. • May develop white or yellow centers (pustules) This most often occurs in less than 2 weeks. May weep, ooze, crust • Warm moist compresses encourage furuncles to • May join together or spread to other skin areas drain, which speeds healing. Gently soak the area with • Increasing pain as pus and dead tissue fills the a warm, moist cloth several times each day. Deep or area large lesions may need to be drained surgically. • Decreasing pain as the area drains • Meticulous is vital to prevent the spread of infection. • Skin redness or inflammation around the lesion Folliculitis Folliculitis

• Folliculitis is an inflammation of the hair • A patient with mild follicles caused by infection (MSSA but folliculitis complains of increasing number of MRSA noted), gradually evolving red bumps in the hair- physical or chemical irritation. The most bearing areas that may common form of superficial folliculitis is be painless or cause idiopathic. mild discomfort or • Folliculitis is the result of obstruction or pruritus. disruption of individual hair follicles and the associated pilosebaceous units.

Treatment of folliculitis Treatment of folliculitis – Systemic antibiotics with coverage of MRSA • Treatment with topical and oral antibiotics is – Hot tub pseudomonas folliculitis (usually resolves empiric. without treatment) but may be treated with – Control blood glucose in ciprofloxin – Wash with antibacterial soaps (eg, Dial soap, – Gram-negative folliculitis in patients may be Betadine skin cleanser, Hibiclens wash) to treated with isotretinoin prevent or control mild cases of folliculitis. – Folliculitis with M furfur (yeast) is treated with – Utilize wash clothes to gently debride skin topical 2.5% selenium sulfide or oral ketoconazole – Water in hot tubs and spas should be treated – Eosinophilic folliculitis may be treated with a properly with chlorine combination of topical and oral .

“Whirlpool” Folliculitis Pediculosis • Infestation with lice is referred to as pediculosis. • “Whirlpool or hot tub Lice are ectoparasites that live on the body. The 3 folliculitis”: organism types of lice that parasitize humans are Pediculus most likely humanus capitis (head louse), Pediculus humanus pseudomonas. corporis (body louse), and Pthirus pubis (pubic louse). • The disease is spread from person to person by close physical contact or through fomites (eg, combs, clothes, hats, linens). Overcrowding encourages the spread of lice. The body louse is the vector of typhus, , and relapsing fever. Human Body Louse • P capitis • In the US: Pediculosis – Head lice are found most often on the back of the head affects 6-12 million people and neck and behind the ears. annually. P capitis is – Eyelashes may be involved. common among school • P corporis children. Head lice are very – Adult lice and nits are found in clothing seams. rare among American – Uninfected bites present as erythematous papules, 2-4 blacks. mm in diameter, with an erythematous base. • P pubis – Pubic hair is the most common site. – Pubic lice may spread to hair around the anus, abdomen, axillae, and chest.

Treatment Pharmacologic Treatment • Permethrin 5% (Elimite) or 1% (Nix) lotion -- DOC, • Nits are best removed with a very fine comb. especially for infants >2 mo and small children. Even • Soaking the hair in a solution of equal parts after successful treatment, postscabietic nodules and water and white vinegar and then wrapping pruritus may persist for mo. the wet scalp in a towel for at least 15 • Lindane 1% shampoo (Kwell) -- Stimulates nervous minutes may facilitate removal. system of parasite, causing seizures and death. Second-line treatment if other agents fail or are not • Treat all family members. tolerated. Not very safe in children due to • Discard infested clothing or wash in very hot transcutaneous absorption leading to neurotoxicity water. • Pyrethrin/Piperonyl butoxide shampoo (RID Mousse, • Eyelash infestation can be treated effectively RID Shampoo, A-200) -- Treatment of P humanus with petrolatum ointment (eg, Vaseline). infestations. Stimulates nervous system, causing seizures and death of parasite

Stay-Tuned for Part II Newest Non-Infectious Dermatology • On April 9, 2009, the FDA approved Benzyl Alcohol 5% lotion for the treatment of head lice infestation in patients 6 months and older. The lotion has no neurotoxic side effects and is the first prescription medication to kill head lice through asphyxiation. • Two, 10 minute treatments, applied 1 week apart (second application is to kill the eggs that hatch-out after the initial therapy). Contact Information Clinical Dermatology • Patricia R Jennings DrPH, PA-C Part II • Professor Non-Infectious Dermatology • University of Alabama at Birmingham • 1530 3rd Ave South, SHPB 466 • Birmingham, Alabama 35294-1212 Patricia R Jennings DrPH, PA-C • [email protected] Professor • 205-934-4432 UAB

Objectives Non-Infectious Dermatitis

• At the end of the lecture the participant • Rosea • Seborrheic Dermatitis should be able to: • • Lichen Simplex – Describe the etiology, signs and symptoms • Chronicus and differential diagnosis of common non- Suppurativa • infectious skin diseases. • • – Describe the laboratory / special studies • evaluation, treatment and prognosis of • Squamous Cell common non-infectious skin diseases. • Carcinoma • • Basal Cell Carcinoma • Urticaria

Pityriasis Rosea • Differential diagnosis: • Herald patch precedes ; , eruption by 1-2 weeks seborrheic dermatitis, viral and • Oval, fawn-colored, drug eruptions. scaly eruption following • Treatment: symptomatic cleavage lines of trunk and may include (so-called “Christmas antihistamines, topical Tree Pattern”) steroids, and oral • Common, mild, acute inflammatory disease. • Prognosis: self-limiting; disappears in 6 weeks Rosacea

• Rosacea, or acne rosacea, is a skin disorder leading to redness and on the nose, forehead, cheekbones, and chin. • Rosacea is most common in white women between the ages of 30 and 60. • When it occurs in men, it tends to be more severe and may eventually cause the nose to become red and enlarged ().

Treatment • Treatment includes avoidance of anything that makes one flush and known precipitants of flare- • Hidradenitis suppurativa is an annoying chronic ups. Overheating - whether due to direct sun, condition characterized by swollen, painful, excess clothing, or hot foods - is uniformly a problem. Avoid hot showers, saunas, excessively inflamed lesions in the axillae, groin, and other warm environments, and extremes of weather parts of the body that contain apocrine glands. (strong winds, cold, humidity). • The condition occurs when apocrine gland • The most effective treatments are oral tetracycline outlets become blocked by perspiration or are (or similar antibiotics) and low-dose oral Accutane. unable to drain normally because of incomplete Mild cases can be controlled by gels or creams gland development. such a Metrogel, Cleocin-T, Azelex, or sulfa.

Hidradenitis Suppurativa Hidradenitis Suppurativa • The patient may present in considerable pain, with multiple red, hard, raised nodules in areas where apocrine glands are concentrated. • The patient may present with a chronic condition in which the multiple nodules have coalesced and are surrounded by a fibrous reaction. This results in scarred and unsightly appearance of the area. • Hidradenitis suppurativa may resemble recurrent bacterial folliculitis and furunculosis. Hidradenitis Suppurativa • Excessive perspiration, often observed in athletes and the obese, may contribute to clogging of the apocrine glands. • Disease activity may be related to stress. • Hidradenitis may be observed as a primary condition without any obvious cause, but it is more commonly observed in association with the following conditions: – Crohn disease; Irritable bowel syndrome; Down syndrome; Certain forms of arthritis; Graves disease or Hashimoto thyroiditis; Sjögren syndrome; Herpes simplex

Lab Studies Hidradenitis Suppurativa • Culture any exudate obtained (if aspiration or • The nodules of drainage of larger nodules is necessary) hidradenitis suppurativa • Thyroid function studies may be useful if should be drained if they clinically indicated because an association are very large, fluctuant, with Graves disease or Hashimoto thyroiditis and painful. may occasionally occur. • Antibiotics are indicated if cellulitis or fever is • If a patient appears toxic or is febrile, present, and admission laboratory tests should include the following: should be considered if – CBC, Blood cultures, Culture of exudate, Routine the patient appears toxic. chemistries

Treatment Treatment

• Tetracycline and erythromycin may be • Topical products, such as benzoyl helpful on a long-term basis, and peroxide, may be helpful. Retin-A has often will help in acute been found to be helpful in some patients. cellulitis. • Accutane can reduce the severity of • Consideration must be given to using a attacks in some patients but is not a sulfonamide or clindamycin antibiotic reliable cure for hidradenitis because of the growing presence of methicillin-resistant (MRSA) in both short-term and long-term treatment. Dyshidrosis (dyshidrotic eczema) Dyshidrosis

• Tapioca vesicles of 1-2 • Treatment: mm on the palms, soles – Topical and systemic corticosteroids and sides of fingers, – Avoid anything that irritates the skin associated with pruritis. – PUVA therapy and injection of botulinum toxin • Vesicles may coalesce to into the palms as for hyperhidrosis form multiloculated • Prognosis: . – The disease is an inconvenience. • Scaling and fissuring may follow drying of the – Vesiculo-bullous can be blisters. incapacitating. • Differential diagnosis includes fungal infections.

Hyperhidrosis • The production of perspiration beyond what is necessary to cool the body. • The process of sweating is controlled by the Sympathetic Nervous System. This involuntary nervous system maintains the five million or so sweat glands throughout the body. In fact, about two-thirds of our body's sweat glands are located in the hands alone. The answer to the problem of hyperhidrosis lies within these nerves. Research has found that "supercharged" nerves cause excessive sweating.

Treatment Treatment

• Topical (Prescription antiperspirants) • Iontophoresis. This FDA-approved procedure uses electricity to temporarily turn off the . It is – aluminum hexahydrate in alcohol most effective for sweating of the hands and feet. The – tannic acid solution hands or feet are placed into water, and then a gentle – formalin solution current of electricity is passed through it. The electricity is gradually increased until the patient feels – glutaraldehyde solution a light tingling sensation. The therapy lasts about 10- 20 minutes and requires several sessions. • Oral include: • Botulinum toxin (Botox) Researchers have discovered that Botox injections – Tranquilizers, Anticholinergics, NSAIDs, Calcium also effectively treat hyperhidrosis by blocking the channel blockers, Catapres nerves that trigger the sweat glands. – (the results only last from four months to a year) Surgical Treatment Miliaria (heat rash) • Miliaria crystallina is a common condition that • Endoscopic thoracic sympathectomy occurs in neonates, with a peak in those aged 1 (ETS). In severe cases, a minimally- invasive surgical procedure called week, and in individuals who are febrile or sympathectomy may be recommended those who recently moved to a hot, humid when other treatments fail. The procedure climate. turns off the signal that tells the body to sweat excessively. It is usually done on • Miliaria rubra also is common in infants and patients whose palms sweat much more adults who move to a tropical environment; this heavily than normal. It may also be used to form occurs in as many as 30% of persons treat extreme sweating of the face. ETS exposed to such conditions. does not work as well for those with excessive armpit sweating.

Miliaria crystallina

Prevention and Treatment Treatment • Topical treatments that have been advocated involve • The prevention and treatment of miliaria – lotions containing calamine, boric acid, or primarily consists of controlling heat and menthol; humidity so that sweating is not stimulated. – cool wet-to-dry compresses; Measures may involve treating a febrile illness; – frequent showering with soap (although some removing occlusive clothing; limiting activity; discourage excessive use of soap); providing air conditioning; or, as a last resort, – topical corticosteroids; and topical antibiotics. having the patient move to a cooler climate. Atopic Dermatitis (eczema) Atopic Dermatitis (eczema) • Pruritic, exudative or lichenified eruption on face, neck, upper • Differential diagnosis: trunk, wrists and hands and in , impetigo, the antecubital and popliteal and seborrheic dermatitis. folds. • Treatment: Prevention • Personal or family history of – Increase moisture allergic manifestations – Decrease drying • Tendency to recur – Avoid heat (hot bathes, • Itching may be severe and sweating) prolonged. – Liberal use of Emollients • Eosinophilia and increased – Avoid washcloths and brushes serum IgE levels are non- – Soft fabrics specific.

Atopic Dermatitis (eczema) Urticaria

• Treatment: systemic – Corticosteroids are indicated for severe acute exacerbations • Complications – Eczema herpeticum (generalized HSV) – VACCINATION is contraindicated !!! • Urticaria, commonly known as , is a frequent • Prognosis complaint of patients in the ED. It consists of – Poor prognostic factors for persistence into circumscribed areas of raised erythema and edema adulthood include onset early in childhood, early of the superficial dermis. Urticaria can be acute or generalized disease and asthma chronic.

Urticaria • Urticaria occurs following release of histamine, bradykinin, kallikrein, or acetylcholine, resulting in intradermal edema from capillary and venous vasodilation and occasional leukocyte infiltration. • Urticaria has 3 major mechanisms. Most commonly, it is a manifestation of acute immunoglobulin E (IgE)– mediated with histamine released from mast calls as its primary mediator. It also may be a result of complement-mediated reactions or specific drug reactions. • Urticaria also may be idiopathic. Etiologies of Urticaria Etiologies of Urticaria

• The cause of acute generalized urticaria often – Foods (particularly shellfish, fish, eggs, is undetermined, but it may be related to the cheese, chocolate, nuts, berries, tomatoes) following: – Infections (eg, pharyngitis, GI infections, – Drugs (eg, , sulfonamides, genitourinary infections, respiratory infections, salicylates, NSAIDS, codeine); Environmental fungal infections [eg, ], , factors (eg, pollens, chemicals, plants, amebiasis, hepatitis, mononucleosis, danders, dust, mold) , mycoplasmal infections, infestations [eg, ], HIV, parasitic infections [eg, ascariasis, strongyloidiasis, schistosomiasis, – Exposure to latex; exposure to cold or heat; trichinosis]) Emotional stress; Exercise

Laboratory tests to consider Management • Antihistamines, primarily those working on H1 – Stool examination for fecal WBCs, ova, and receptors, are the first line of therapy for parasites urticaria. – Antinuclear antibody (ANA) titer – Diphenhydramine and hydroxyzine are the most – Hepatitis B and C screen commonly used antihistamines. Hydroxyzine is – Thyroid function tests considered superior to diphenhydramine. These medications are potentially sedating. Therefore, – Tests for CBC, prostate-specific antigens one may want to consider one of the newer (PSA), and serum calcium, or other tests nonsedating H1 blockers as first-line therapy in directed at the diagnosis of neoplasm certain patient populations.

Management Management • H2 antihistamines, such as cimetidine, famotidine, – H1 antihistamines are effective in relieving the and ranitidine, may have a role when used in pruritus and rash of acute urticaria in most cases. combination with H1 antihistamines in selected – Newer H1 nonsedating antihistamines are now instances of urticaria. H1 and H2 antihistamines are available and include astemizole, loratadine, thought to have a synergistic effect. desloratadine, doxepin, cyproheptadine, and • Glucocorticoids stabilize mast cell membranes and cetirizine. inhibit further histamine release. They also reduce – These may have a more dominant role in the the inflammatory effect of histamine and other management of chronic urticaria. mediators. – The use of glucocorticoids in acute urticaria remains somewhat controversial. It generally is recommended in more severe and refractory cases. Management Seborrheic Dermatitis

• Epinephrine may be used in conjunction • Seborrheic dermatitis is a with antihistamines when deemed patterned on the sebum-rich areas of the scalp, face, appropriate. Epinephrine's alpha- and trunk. In addition to sebum, this dermatitis is linked to, immunologic abnormalities, and activation adrenergic effects result in of complement. It is commonly aggravated by vasoconstriction of the superficial changes in humidity, changes in seasons, trauma cutaneous vessels and directly oppose the (eg, scratching), or emotional stress. vasodilatory effect of histamine. Epinephrine has no effect on pruritus.

Seborrheic Dermatitis Seborrheic Dermatitis • Scalp appearance varies from mild, patchy scaling to widespread, thick, adherent crusts. Plaques are rare. From the scalp, seborrheic dermatitis can spread onto the forehead, the posterior part of the neck, and the postauricular skin, as in psoriasis. • Skin lesions manifest as branny or greasy scaling over red, inflamed skin. Hypopigmentation is seen in blacks. Infectious eczematoid dermatitis, with oozing and crusting, suggests secondary infection. • A skin biopsy may be needed in persons with exfoliative , and a fungal culture can be used to rule out

Treatment Seborrheic • Topical corticosteroids may hasten recurrences, however, they may foster dependence because of a • A seborrheic blepharitis may occur rebound effect, and are discouraged except for independently. short-term use. • Skin involvement responds to ketoconazole, naftifine, or ciclopirox creams and gels. • Alternatives include calcineurin inhibitors (Elidel (pimecrolimus), Protopic ()), sulfur or sulfonamide combinations, or propylene glycol. • Class IV or lower creams, lotions, or solutions can be used for acute flares. • Systemic ketoconazole or fluconazole may help if seborrheic dermatitis is severe or unresponsive. • Dandruff responds to more frequent shampooing or a longer period of lathering. Use of hair spray or hair pomades should be stopped. • Shampoos containing salicylic acid, tar, selenium, • Self-perpetuating scratch- cycle. sulfur, or zinc are effective and may be used in an alternating schedule. • Lichenified lesions with exaggerated skin lines overlying a thickened, well-circumscribed scaly • Overnight occlusion of tar, bath oil, or Baker's P&S plaque. solution may help to soften thick scalp plaques. • Predilection for nape of neck, wrists, external • Selenium sulfide (2.5%), ketoconazole, and surfaces of forearms, lower legs, scrotum and ciclopirox shampoos may help by reducing yeast vulva. scalp reservoirs. • Dry, leathery, hypertrophic, plaques. • Shampoos may be used on truncal lesions or in beards but may cause inflammation in the facial areas.

Lichen Simplex Chronicus

• Treatment for extra-genital areas: steroids, use of tars, occlusive flexible hydrocolloid dressings ( 7 days at a time). • The disease tends to remit during treatment but may recur or develop at another site. • Stop scratching!

Treatment Seborrheic Keratosis

• The use of tretinoin (trans-retinoic-acid) can be • Benign plaques, beige to effective as monotherapy. brown or even black, • Depigmenting agent: Hydroquinone USP 4% with a velvety or warty (Claripel cream with sunscreens) surface. • Antibiotic agent: (Azelex) • Common, especially in • All wavelengths of sunlight, including the visible the elderly, and may be spectrum, are capable of inducing . mistaken for or other neoplasms. • Regardless of the treatments used, all will fail if sunlight is not strictly avoided. • Treatment: liquid nitrogen or curetted; usually require no tx. Actinic Keratosis Treatment • Liquid nitrogen is a rapid and effective • Common, persistent, keratotic method of eradication lesions with malignant potential. • Alternative treatment with 5-fluorouracil • It is estimated that one in five (5-FU) cream rubbed into the lesions patients with multiple actinic morning and night until they crust and keratoses develops squamous erode (usually 2-3 weeks). cell carcinoma in one or more lesions. • Any lesion that persists should be evaluated for biopsy. • Lesions become progressively more common after age 40 • Biopsy is helpful for distinguishing advanced actinic keratoses from invasive squamous cell carcinoma.

Actinic Keratosis Squamous Cell Carcinoma

• Squamous Cell Carcinoma: usually occurs subsequent to prolonged sun exposure on exposed parts in fair- skinned persons with prominent sun exposure history. • May arise from an actinic keratosis

Squamous Cell Carcinoma Basal Cell Carcinoma

• Treatment of primary squamous cell carcinoma • Basal Cell Carcinoma is a of the skin involves wide local excision with primary cutaneous histologic confirmation of margins malignancy. It is locally • Mohs’ micrographic excision may be useful for destructive, slow growing specific sites where tissue sparing is of and relentless. importance • It occurs more commonly • Palpation of regional lymph nodes is mandatory in persons >40 and it is for all invasive squamous cell carcinomas less common among Asian-Americans and rare • Careful follow-up at regular intervals is in African-Americans. recommended. Basal Cell Carcinoma

• Without treatment, basal cell carcinomas persist, enlarge and invade and destroy the surrounding structures. • Basal cell carcinomas are rarely, if ever, life threatening; metastases virtually never occurs. • The treatment is determined by the size and site. Electrosurgery involves electrodessication and curettage; excision is the preferred method; Mohs’ is used for difficult tumors.

Contact Information

• Patricia R Jennings DrPH, PA-C • Professor • University of Alabama at Birmingham • 1530 3rd Ave South, SHPB 466 • Birmingham, Alabama 35294-1212 • [email protected] • 205-934-4432