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Subungual Melanoma: •Location: Thumb > Great Toe > Index Finger Hot Topics In Podiatric Dermatology Evan Rieder, MD Dermatologist, Psychiatrist Assistant Professor of Dermatology The Ronald O. Perelman Department of Dermatology Disclosures Advisory Board Member: UCB Pharmaceuticals Consultant: UCB Pharmaceuticals Unilever The Ronald O. Perelman Department of Dermatology 2 Podiatrists & Dermatologists The Ronald O. Perelman Department of Dermatology General Outline Bumps Stripes Collimated Lights The Ronald O. Perelman Department of Dermatology 4 The Power of Observation The Ronald O. Perelman Department of Dermatology Robert Ryman, Untitled 1960-1961 The Ronald O. Perelman Department of Dermatology The Ronald O. Perelman Department of Dermatology The Ronald O. Perelman Department of Dermatology Bumps The Ronald O. Perelman Department of Dermatology Outline Common Podiatric Rashes Keys To Differential Diagnosis Uncommon Presentations The Ronald O. Perelman Department of Dermatology Bumps The Ronald O. Perelman Department of Dermatology Classic Psoriasis Well-demarcated Erythematous plaque Silvery scale Classic locations: Scalp, elbows, knees, buttocks 3% of the population Nail, joint involvement common Dx: clinical +/- biopsy Tx: topical steroids, nbUVB, immunomodulators The Ronald O. Perelman Department of Dermatology Psoriasis of the Foot & Lower Leg May appear like classic plaque psoriasis However may have different presentation Patchy or generalized thickening and scaling of nearly entire surface of palms / soles without redness •Keratoderma Greater associations with nail and joint psoriasis Chronic, difficult to treat The Ronald O. Perelman Department of Dermatology Palmoplantar Pustulosis Different presentation Palms and soles, especially lateral Localized or entire surface Sterile pustules admixed with yellow-brown macules +/- scaly erythematous plaques No longer considered psoriasis 10-25% of patients with palmoplantar pustulosis also have plaque psoriasis The Ronald O. Perelman Department of Dermatology SAPHO Syndrome May be associated with sterile inflammatory bone lesions Synovitis Acne Pustulosis Hyperostosis Osteitis AKA chronic recurrent multifocal osteomyelitis, pustulotic arthro- osteitis Misdiagnosis, mistreatment common Dermatology referral The Ronald O. Perelman Department of Dermatology Psoriasis / Palmoplantar Pustulosis Important differential diagnosis Tinea pedis •Pustular or bullous variant Eczematous dermatitis •Dyshidrotic •Contact (allergic or irritant) Scabies Uncommon diagnoses: •Bazex syndrome •Bullous disorders The Ronald O. Perelman Department of Dermatology Common Differential Diagnoses The Ronald O. Perelman Department of Dermatology Tinea pedis Pruritic Macular Scaly (thin) Erythematous Leading edge of scale KOH+ The Ronald O. Perelman Department of Dermatology Eczematous dermatidites Dyshidrotic: Tense, deep-seated vesicles of palms +/- soles Intensely pruritic The Ronald O. Perelman Department of Dermatology Eczematous dermatidites Contact: Well-demarcated Erythematous Diffuse scale +/-Serous drainage +/-Vesicobullae Distribution of contactant: e.g. cream, sandal •May need patch testing •History is relevant Kline 2008 The Ronald O. Perelman Department of Dermatology Scabies Interdigital burrows: fingers > toes Severe pruritus Not restricted to palms and soles History is relevant When widespread / on feet, think crusted The Ronald O. Perelman Department of Dermatology Crusted scabies Thick, crusted plaques Typically acral, may be generalized Dystrophic nails May not see burrows Severe pruritus Socioeconomic considerations The Ronald O. Perelman Department of Dermatology Uncommon Diagnoses The Ronald O. Perelman Department of Dermatology Bazex Syndrome Acrokeratosis Paraneoplastica Psoriatic-appearing nails Psoriasiform erythematous, squamous lesions of feet, ears, nose •Visible without disrobing •Not common areas for psoriasis Assoc with UGI or respiratory malignancies Medical referral is mandatory Sator PG et al, 2006 The Ronald O. Perelman Department of Dermatology Blistering Disorders Bullous Pemphigoid •Erythematous wheals tense bullae (lower abdomen, thighs, forearms) •May result in milia with healing •May have underlying systemic illness or medication trigger The Ronald O. Perelman Department of Dermatology Blistering Disorders Epidermolysis Bullosa Acquisita •Erosions of feet / hands, tense vesicobullae that may be hemorrhagic •May also result in milia with healing •May be associated with IBD The Ronald O. Perelman Department of Dermatology Take Home Points Sometimes scaly red plaques are just psoriasis Lower leg psoriasis may have an atypical presentation Sometimes the differential diagnosis is broad Observation of key clinical features can be very helpful in events when diagnosis is uncertain Dermatologic +/- medical referral to rule out atypical syndromes or underlying systemic disease The Ronald O. Perelman Department of Dermatology Stripes (Longitudinal) Melanonychia The Ronald O. Perelman Department of Dermatology Outline Non-Melanocytic Melanocytic Tips for Diagnosis Common & Rare Conditions Image via regionalderm.com Melanonychia Non- Melanocytic Melanocytic Fungal Melanocyte Melanocytic Subungual activation Nail staining Melanonychia hemorrhage hyperplasia Benign Malignant Single Multiple Nail matrix Subungual nevus melanoma Trauma- Periungual Nail apparatus induced tumor-induced Laugier- lentigo Drug/systemic Ethnic type nail Peutz Jeghers Hunziker dz-induced pigmentation syndrome syndrome 30 Non- Melanocytic Fungal Subungual Nail staining Melanonychia hemorrhage 31 Clinical Scenario A patient presents for a routine exam and you see yellow discoloration of multiple fingernails. How can this help you meet your Clinical Quality Measures (CQM) for meaningful use? Recording smoking status for patients 13 years or older is a core objective Smoking cessation medical assistance is an additional set CQM Hardin ME, Greyling LA, Davis LS. Nicotine staining of the hair and nails.32 J Am Acad Dermatol. 2015 Sep;73(3):e105-6. doi: 10.1016/j.jaad.2015.05.020. Nail Staining Location: Bilateral thumbnails, 2nd & 3rd fingernails of dominant hand Causes: •Brown: hobbies, occupational exposure to Hardin ME, Greyling LA, Davis LS. Nicotine staining of the hair and nails. foods, clothing dyes J Am Acad Dermatol. 2015 Sep;73(3):e105-6. doi: 10.1016/j.jaad.2015.05.020 •Yellow: smoking, nail polish (red) Dermoscopy of Pigment: •Irregularly shaped •Well-demarcated border, may be parallel to PNF Tx: Easily removed w/ 15 blade 33 Jin H, Kim JM, Kim GW, et al. Diagnostic criteria for and clinical review of melanonychia in Korean patients. J Am Acad Dermatol. 2016 Jan 30. Nail Staining Huang Guofu www.dailymail.co.uk/news/article-1384841/The-incredible-paintings-amputee-Chinese-artist-creates-pictures-toes-mouth.html Clinical Scenario A 39yo man presents with 1 month of discoloration of multiple toenails. He is concerned about melanoma. He has no personal or family h/o of skin cancer. What questions are important to ask this patient? -Medication history -Trauma Most appropriate next steps? -PAS, fungal culture, +/- PCR -Dermoscopy Wang YJ, Sun PL. Fungal melanonychia caused by Trichophyton rubrum and the 35 value of dermoscopy. Cutis. 2014 Sep;94(3):E5-6. A Word On Dermoscopy Non-invasive diagnostic test for evaluation of lesions of skin, hair, & nails Low-powered microscope with contact or polarized light to reduce surface light-scatter interference Image via: www.medicalexpo.com/prod/dermlite/product-79388-506390.html A Word On Dermoscopy Helpful tool, low cost, portable Eliminates biopsies Pilot study of pigmented lesions shows that old dogs can learn new tricks Pigmented lesions are much more difficult to assess than nails Terushkin et al 2010 Lasers for Onychomycosis Fungal Melanonychia Location: toenails > fingernails •Men > Women Causes: Most common 1) Non-Dermatophyte, dematiaceous fungus: Scytalidium dimidiatum 2) Dermatophyte, nondematiaceous fungus: Trichophyton rubrum 38 Fungal Melanonychia Clinical clue: often spares matrix Dermoscopy of pigment: •Pigment streak w/ distal widening •Yellowish streaks w/ jagged borders composed of spikes Dx: KOH, fungal Cx (cycloheximide-free media) Tx: Azole (Fluconazole, Itraconazole); Allylamine (Terbinafine) Wang YJ, Sun PL. Fungal melanonychia caused by Trichophyton rubrum 39 and the value of dermoscopy. Cutis. 2014 Sep;94(3):E5-6. Fungal Melanonychia: Dermoscopy • Pigmented streak • Distal widening • Yellowish streaks • Jagged borders • Spikes Ohn et al, JAAD 2017 Wang YJ, Sun PL. Fungal melanonychia caused by Trichophyton rubrum 40 and the value of dermoscopy. Cutis. 2014 Sep;94(3):E5-6. Clinical Scenario A 35yo construction worker presents to your clinic after slamming his hand in a door. You notice that the nail bed edges are disrupted. Would you perform a nail bed trephination for evacuation of the subungual hematomas? Are there any additional exams that you would order? 41 Bharathi RR, Bajantri B. Nail bed injuries and deformities of nail. Indian J Plast Surg. 2011 May;44(2):197-202. doi: 10.4103/0970-0358.85340. Subungual Hemorrhage Location: single or multiple nails; toes > fingers (great toe) Causes: trauma (overt episode, exercise) Dermoscopy of pigment: purple- black: homogenous, globular & peripheral fading patterns 42 Photos courtesy: Dr. Jennifer Stein Subungual Hemorrhage Dx: Serial dermoscopy (color fading & distal movement of features), does not involve matrix Radiology: X-Ray of affected digit to r/o: • Fracture of distal phalanx • Extensor tendon avulsion of distal phalanx Tx: Drainage indicated
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