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Differentiating Dermatological Diagnosis and Treatment

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Differentiating Dermatological Diagnosis and Treatment M C e o d n i t ca in l u CONTINUING MEDICAL EDUCATION Ed in u g c at io n Objectives Differentiating 1) To provide a systematic approach to examining and Dermatological treating inflamma - tory skin conditions Diagnosis and 2) To discuss the most common skin conditions seen in Treatment the podiatric practi - tioner’s office The authors present a systematic approach to 3) To discuss the examining and treating inflammatory skin first line treatment for inflammatory conditions. skin disorders Welcome to Podiatry Management ’s CME Instructional program. Our journal has been approved as a sponsor of Contin - uing Medical Education by the Council on Podiatric Medical Education. You may enroll: 1) on a per issue basis (at $20.00 per topic) or 2) per year, for the special introductory rate of $139 (you save $61). You may submit the answer sheet, along with the other information requested, via mail, fax, or phone. In the near future, you may be able to submit via the Internet. If you correctly answer seventy (70%) of the questions correctly, you will receive a certificate attesting to your earned credits. You will also receive a record of any incorrectly answered questions. If you score less than 70%, you can retake the test at no additional cost. A list of states currently honoring CPME approved credits is listed on pg. 182 . Other than those entities currently accepting CPME-approved credit, Podiatry Management cannot guarantee that these CME credits will be acceptable by any state licensing agency, hospital, man - aged care organization or other entity. PM will, however, use its best efforts to ensure the widest acceptance of this program possible. This instructional CME program is designed to supplement, NOT replace, existing CME seminars. The goal of this program is to advance the knowledge of practicing podiatrists. We will endeavor to publish high quality manuscripts by noted authors and researchers. If you have any questions or comments about this program, you can write or call us at: Podiatry Management, P.O. Box 490, East Islip, NY 11730, (631) 563-1604 or e-mail us at [email protected]. Following this article, an answer sheet and full set of instructions are provided (p. 182 ).— Editor By Tracey C. Vlahovic, DPM, FAPWCA tice the color, shape, and size in ad - be used to describe the rash appro - and Michelle Oliver, BA dition to laterality of the lesions on priately, both in the chart and in correspondence to other physi - patient first presenting with cians. When looking at the shape a red, scaly, itchy foot or leg of the lesions, it is helpful to deter - Acan prove to be a challenge Plaque psoriasis mine if they were self-induced by to diagnose and manage. When the patient (excoriation by a finger - faced with a patient with an in - presents as nail) or naturally caused (a plantar flammatory skin condition in the heel fissure). One should document office, the podiatric physician an erythematous if the lesions are plantar foot, dor - should have a systematic approach plaque with a sal foot, or proximal on the lower to arrive at a baseline differential leg. Nail involvement should be diagnosis: observe, ask, and apply silvery scale. noted. Finally, the fingernails and an algorithm. dorsum and palmar aspects of the hands should be examined as many Observe skin dermatoses mirror the pedal Upon entering the treatment the lower extremity. Primary and involvement there. room, the practitioner should no - secondary lesions (Table 1) should Continued on page 176 www.podiatrym.com APRIL/MAY 2010 • PODIATRY MANAGEMENT 175 n g o in ti u a n c the dermis from a pathology per - ostasis, trans-epidermal water loss, ti u Differentiating... n d o E spective. and prevents entry of foreign parti - C al ic Ask Other questions to consider ask - cles and pathogens into the body. d e Questions that will help form ing patients are the color of socks Trans-epidermal water loss is the M differential diagnoses should be they wear (azo dyes in blue socks newest target in the dermatological asked while completing the physi - can be a potential allergen), occu - pharmaceutical armamentarium in pation, and any associated daily order to reduce skin flares and com - hazards. Also, one fort the patient should ask about with an inflam - TABLE 1 both over-the- matory skin der - counter and Trans-epidermal water matosis. Primary Skin Lesions: homeopathic or Macule natural treatment loss is the newest Apply an Patch options they have Algorithm Plaque tried. In order to target in the To begin for - Nodule plan for a possi - dermatological mulating a differ - Vesicle ble in-office biop - ential diagnosis, Bullae sy during that pharmaceutical there is a basic al - Wheal visit, it is impor - gorithm to follow Telangiectasia tant to ask what armamentarium in for treating the Secondary Skin Lesions: the natural pro - order to reduce skin most common Ulcer gression of the le - skin disorders en - Atrophy sions has been flares and comfort the countered in the Scale and where the office: is it a Crust newest crops of patient with an plaque, scale, or Erosion lesions are. inflammatory skin zebra? (Table 2) A Excoriation Now that well-defined and Scar basic observation dermatosis. geometric shaped Lichenification and questioning plaque is often have occurred, psoriasis, but it’s important to eczema and cal exam of the skin. Often, the pa - delve more deeply into the chief lichen planus also must be consid - tient will answer a question that complaint and examine the skin ered. Circular, serpiginous scales are will help direct the diagnosis. Be - fully. Common skin signs of in - most often tinea but xerosis should yond asking the history of present flammation are calor (heat), rubor be ruled out. Remember that tinea illness, past medical history and (redness), tumor (swelling) and pru - pedis is KOH positive and may in - family history, the podiatric physi - ritis (itching), which ultimately volve both the interspaces and the cian should consider asking if there point to skin barrier dysfunction. plantar foot. Any papules, vesicles is a personal or family history of al - The skin barrier, which is stratum or other skin markings are consid - lergic rhinitis, sensitive skin, asth - corneum with the lipid-enriched ered “zebras” for this algorithm’s ma or skin cancer. The patient extracellular matrix surrounding purpose. should be asked if he has ever seen the corneocytes, is the body’s pro - Following the above algorithm, a dermatologist before and if he has tective wall and regulates home - the most common inflammatory any skin lesions or “rashes” any - skin conditions the where else on the body that may or podiatric practition - may not be similar to what is seen er will encounter are on the feet. TABLE 2 as follows: Unfortunately, most patients do not correlate what is happening on Algorithm Plaque the rest of the body to what is man - Plaque psoria - ifesting on the plantar aspect of the Plaque —® Consider psoriasis, lichen planus, sis presents as an feet. It is the physician’s responsi - eczema erythematous plaque bility to ask the questions in order with a silvery scale. to make that connection. It is help - Scale —® Consider xerosis, tinea pedis, These lesions are ge - ful to ask if the skin has ever been ichythosis, non-inflamed to mildly inflamed ographic, bilateral, biopsied (for example, “did you psoriasis and eczema and symmetrical, have a piece of skin removed and and typically occur Zebra —® Blisters? Bullous diabeticorum, then have stitches?”). A skin scrap - pemphigus, drug reaction on the extensor sur - ing for KOH that was completed by Target lesions? Erythema multiforme faces. The plaques another physician does not count minor, drug reaction can also be pruritic as a proper biopsy to base the diag - and affect joints as nosis on, as a biopsy of inflamma - well as the nails dur - tory skin disorders should include Continued on page 177 176 PODIATRY MANAGEMENT • APRIL/MAY 2010 www.podiatrym.com M C e o d n i t Wickham’s stri - ca in Differentiating... l u Ed in ae, which is the fine u g c ing the progression of the disease. white lacy overlay on at io Psoriasis can develop either in the plaques, may also be n childhood or as an adult. Besides seen. This skin condition can plaque psoriasis, pustular psoriasis be so pruritic that activities of appears as sterile pustules on the daily living may be compromised. plantar foot. It may also affect the toenails, ap - Plantar pearing anywhere from a proximal plaque and subungual onychomycosis-like pre - pustular pso - Figure 4: Nail involvement in lichen sentation to a thinning of the nail riasis are fre - planus with a ‘wing’ of skin or pteryigium quently mis - pointing distally (Figure 4). 1 Nail diagnosed as arthritic component of psoriasis involvement should be treated im - either vesicu - which may manifest in dactylitis of lar or moc - the digits (sausage toes), enthesitis Figure 1: Nail disease casin tinea of the Achilles tendon, and distal in psoriasis pedis. Due to interphalangeal joint involvement. the fissuring that often accompanies psoriatic Case Example #1 plaques, it has also been misdiag - A young male patient presented nosed as xerosis. If the patient’s to the clinic with a pruritic and current treatment consists of either scaly plantar rash (Figures 2-3) that an oral or topical antifungal, and was mis-diagnosed as tinea pedis at isn’t improving the skin condition the emergency department. He had within the appropriate time frame, presented there for painful fissures Figure 5: Pedal lichen planus a biopsy of the skin, in order to de - on his feet that prevented him termine if a topical steroid should from walking properly.
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