Lecture Overview Dermatology Review

2020 EMRAM In-Service ◼ Terminology Review ◼ Describe the key features and a typical Julie Parks Bortel MD, FACEP dermatologic presentation for each condition ◼ Case review of common and important rashes

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Approach to rashes Terminology ◼ Determine how the rash started and evolved ◼ Note the distribution, pattern, and configuration ◼ Excoriation – linear ◼ Fissure - linear cracks  mucous membrane involvement erosion in skin surface  palm/sole involvement ◼ Is it pruritic or painful ◼ Any prodromal symptoms

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Terminology Terminology

◼ Macular –Flat and ◼ Patch – Flat and ◼ Papule – Raised ◼ Plaque – Raised <1cm >1cm <1cm >1cm

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1 Terminology Terminology

◼ Vesicle - Blister <1cm ◼ Bullae - Blister >1cm ◼ Nodule – Dermal or ◼ Tumor – Dermal or subcutaneous lesion subcutaneous lesion <2 cm >2cm

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Terminology Terminology

◼ Pustule – vesicle with Scale - visible layers of ◼ Erosion – Loss of part ◼ Ulcer – Dermis or purulent fluid stratum corneum or all of the epidermis deeper getting shed from the skin

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Terminology Terminology

◼ Telangiectasia - small, blanching surface capillaries

◼ Purpura – non- ◼ Petechiae -- non- blanching purple blanching purple spots discoloration > 2mm < 2mm in diameter

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2 Terminology Dermatitis

◼ Wheal -- transient, edematous papule or plaque with peripheral erythema

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Rash #1 Dermatitis aka Eczema

◼ A 9 month old boy ◼ Inflammation of the epidermis with a history of ◼ Group of skin conditions that includes: asthma is brought in by his mother for an Atopic dermatitis itchy red rash Allergic contact dermatitis Irritant contact dermatitis Stasis dermatitis ◼ Exact cause is often unknown

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Atopic Dermatitis Atopic Dermatitis

◼ A type of dermatitis with a hereditary component ◼ Atopic triad – asthma, eczema, allergies ◼ Common in developing countries ◼ Variety of symptoms – erythema, edema, vesiculation, flaking, weeping, & itching ◼ Treatment aimed at decreasing inflammation

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3 Atopic Dermatitis Atopic Dermatitis

◼ Diagnosis is made by having three or ◼ Major Features more major features and three or more Pruritis minor features Typical morphology and distribution

◼ Flexural lichenification in adults

◼ Facial and extensor involvement in kids Dermatitis – chronic or relapsing Personal or Family History of atopy

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Minor Features Atopic Dermatitis

◼ Cataracts ◼ Elevated IgE ◼ NOT caused by a true allergic reaction ◼ Chelitis ◼ White dermographism ◼ Results from defective cell mediated ◼ Recurrent conjunctivitis ◼ Wool intolerance immunity reactions brought on by ◼ Facial pallor/erythema ◼ Xerosis environmental stress ◼ Food intolerance ◼ Infections – Staph, ◼ Hand dermatitis herpes ◼ May have a primary T-cell defect

◼ Ichthyosis

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Atopic Dermatitis Atopic Dermatitis

◼ Highest incidence in children

◼ Two Subgroups ◼ Clinical Features 1. Patients with asthma and enhanced IgE Starts with itching producing potential 2. Patients without asthma or enhanced IgE The scratching creates the patterns of the disease ◼ More than 50% of kids with atopic dermatitis develop asthma by the age of 13 Initially there is acute inflammation followed by slow resolution and replacement with dry, scaly skin (Ichthyosis/xerosis)

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4 Atopic Dermatitis 3 Phases of Atopic Dermatitis

◼ Acute ◼ Infantile Phase (2mo-2yrs)  Bright red swollen plaques Affects cheeks, perioral area, scalp, ears,  Often linear vesicles trunk (spares diaper area), tops of feet, and ◼ Chronic  Intense itching elbows  Inflamed area is ◼ Subacute thickened Lesions often exudative  Various patterns of  Parallel skin markings erythema and scale  Commonly involved  Mild to moderate areas are easy to itching reach  Indistinct borders

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Atopic Dermatitis Phases Atopic Dermatitis Phases

◼ Childhood Phase (2-12 yrs) ◼ Adult Phase (12-adult) Flexural involvement Flexural involvement is common Scratching and chronicity leads to Hand dermatitis may be only manifestation lichenification Upper lid dermatitis is also common Associated findings include dry skin, ichthyosis vulgaris, and keratosis pilaris

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Atopic Dermatitis Complications Atopic Dermatitis Treatment

◼ Skin lesions frequently colonized with staph and secondary infections are common ◼ Topical Steroids ◼ Increased susceptibility to viral infections ◼ Oral Antibiotics for secondary infection ◼ Inflammation can lead to pigmentation ◼ Burrow’s Solution changes ◼ Lubricant to restore skin barrier ◼ In children with moderate-severe disease ◼ Eliminate aggravating factors may also have emotional/behavioral ◼ Control Pruritis problems ◼ Short course of oral steroids if needed

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5 Rash #2 Allergic Contact Dermatitis ◼ 35 y.o. male was outside yesterday mowing his lawn and trimming bushes ◼ Delayed hypersensitivity reaction now presents to the ER for an intensely ◼ It affects a limited number of people after itchy rash. they have been exposed to an antigenic substance ◼ Reactions develop acutely in 6-72 hours

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Allergic Contact Dermatitis Poison Ivy/Oak/Sumac

◼ Examples ◼ Requires prior sensitization Poison Ivy/oak/sumac ◼ Caused by the antigen Urushiol Glue ◼ Rash occurs between 6-72 hours after Insecticides exposure Acrylics ◼ Lasts 2 days – 3 weeks Latex ◼ Rupturing the vesicles does not spread the Nickel rash Neomycin ◼ Highly characteristic linear lesions

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Poison Ivy Poison Oak

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6 Poison Sumac Treatment

◼ Mild Calamine lotion Benadryl Topical Steroid ◼ Moderate – Severe Aveeno bath Oral Benadryl Systemic steroids

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Rash #3 Irritant Contact Dermatitis ◼ 40 y.o. construction worker who has been on a job repaving I-75 presents with an ◼ Caused by exposure to environmental itchy rash. He reports that it improved substances over vacation but now seems worse ◼ Level of irritation is related to duration of exposure and concentration of substance ◼ Gradual onset ◼ Borders correspond to the pattern of the offending agent and often assist in the diagnosis

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Contact Dermatitis Irritant Contact Dermatits

◼ Shampoos/soaps ◼ Fuels/lubricants/cement ◼ Pineapple juice ◼ Alcohols, alkalies, grease

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7 Rash #4 Diaper Dermatitis ◼ A mom presents to the ER with her 4 month old for a rash. She reports that she ◼ Candida – beefy red plaques with well noticed it while changing the diaper and defined edges the child was screaming while being wiped ◼ Irritant/Contact so she came in for evaluation.

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Dyshidrotic Dermatitis Rash #5 ◼ A 77y.o. male with a history of HTN, DM, ◼ Itchy 1-2mm blisters on the palms of the CAD, & CHF comes in for a rash that has hands or soles of the feet been progressively more noticeable for the ◼ Take ~3wks to heal last 6 years but it was on his mind and he ◼ Often recur couldn’t sleep so he came in for evaluation at 3am. ◼ Cause is unknown

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Stasis Dermatitis Rash #6

◼ 30 y.o. female presents for a bump on the ◼ Skin changes in the back of her neck which started to leak a legs that occur from cheesy material prompting her insufficient venous return leading blood presentation to the E.R. to pool ◼ Pooling blood increases pressure in the capillaries and fluid leaks into the tissue

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8 Epidermal Inclusion Cyst Epidermal Inclusion Cyst

◼ Solitary lesion that usually occurs on the face/neck/scalp/upper trunk ◼ May occasionally become inflamed, tender, and have foul-smelling drainage ◼ Mobile dermal to subcutaneous nodule

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Epidermal Inclusion Cyst Rash #7

◼ Treatment – non-emergent unless ◼ 25 y.o. female presents with a red scaly inflamed prominent itchy rash on the scalp ◼ If inflamed I&D may be helpful ◼ May inject steroids ◼ Keflex if indicated ◼ PCP can excise after inflammation improves

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Psoriasis Psoriasis Subtypes

◼ Abnormal immune reaction to skin cells ◼ Plaque – red patches with white scales ◼ Causes acceleration of the growth cycle of cells ◼ Guttate - small droplike papules ◼ Salmon colored plaques and papules that are ◼ Pustular – presents with small non- well-circumscribed infectious pus filled blisters. Often on ◼ Most commonly on extensor surfaces such palms and soles as the knees and elbows ◼ Treatment: topical, phototherapy, & immune ◼ Inverse – Red patches in skin folds modulators ◼ Erythroderma – near to total body psoriasis

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9 Psoriasis Psoriasis

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Rash #8

◼ Mom presents to the ER with her 4 month old infant complaining of a greasy yellow rash on her baby’s head

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Seborrheic Dermatitis Seborrheic Dermatitis

◼ Common chronic inflammatory dermatitis ◼ Characteristic distribution Infants – vertex of scalp, diaper area, skin folds Adults – scalp, eyebrows, nasolabial folds, paranasal skin, around the ears, presternal skin and upper back

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10 Seborrheic Dermatitis Treatment Cradle Cap

◼ Shampoos to decrease dandruff

◼ Low dose steroid creams – when ◼ neonatal seborrheic dermatitis – greasy, yellow rash necessary ◼ Uncertain of cause  ? Related to eczema  Fungal  Overactive sebaceous glands ◼ Treatment  Many home remedies – Vegetable oil, Baking soda, herbal washes  Shampoo, Tar, Steroids, Ketoconazole

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Maculopapular Rash #9 Rashes ◼ A 22 y.o. male presents to the EC complaining of an intensley painful red rash. Yesterday he was out on a boat all day partying at jobbienooner.

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Sunburn Rash #10

◼ Acute inflammatory reaction in ◼ Treatment response to UV A & B rays  Cool soaks or OTC cooling ◼ Erythema peaks at 12-24 hours agents ◼ A 7 y.o. male presents to the ER for an ◼ In severe cases, can lead to 2nd  Anti-prostaglandins – ASA or degree burns NSAIDS itchy rash after playing outside on a hot ◼ Are there any photosensitizing  Steroids medications?  Rehydrate and treat at burn humid day center

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11 Heat Rash Rash #11

◼ A 10-year-old boy had a seizure & was started on oral phenytoin. 3 weeks later he developed conjunctivitis & painful oral sores and was brought to the ER for evaluation

◼ Pruritic erythematous vesicles and papules ◼ Accompanied by burning, “prickly” sensation ◼ Common in kids due to underdeveloped sweat glands

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Erythema multiforme Erythema multiforme

◼ Acute inflammatory mucocutaneous skin disease ◼ Clinical ◼ Pathogenesis – unknown  Malaise, arthralgias, myalgias, fever, diffuse  likely hypersensitivity reaction to infection such as HSV or mycoplasma, connective tissue disorders, malignancy, drugs pruritis, generalized burning sensation may (antibiotics and anticonvulsants), pregnancy precede rash  50% are idiopathic  Skin lesions ◼ Wide clinical spectrum ◼ Erythematous papules  EM minor ◼ 24-48 hrs: maculopapules, target lesions with  EM major dusky violaceious center, urticarial plaques,  Stevens-Johnson Syndrome vesicles, bullae, and mucosal erosions  TEN (Toxic epidermal necrolysis) ◼ Palms and soles are characteristic ◼ Ocular involvement particularly in SJS, TEN

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Spectrum of Erythema Multiforme Erythema Multiforme Treatment

Course Cutaneuos Mucosal Duration Prognosis involvement involvement ◼ EM minor and major – may be treated as EM minor Self-limited Target lesions, blisters Absent or limited 1-3 Good, may < 10% BSA, (-) to 1 site weeks be episodic outpatient with analgesics, oral Nikolsky EM major Self-limiited Target lesions, blisters Involvement 1-6 May be care/rinses, acyclovir if caused by HSV < 10% BSA, (-) almost exclusively weeks episodic Nikolsky oral Widespread outbreaks may respond to SJS Progressive Widespread bullae, 2 or more mucous 2-6 10% severe predominantly torso, membrane weeks mortality steroids systemic epidermal detachment involved illness < 10%, (+) Nikolsky extensively TEN Prodrome Widespread lesions, 1 or more mucous 2-6 30% then predominantly torso, membrane weeks mortality mucosal, epidermal detachment involved followed by > 30%, (+) Nikolsky extensively systemic illness

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12 Stevens-Johnson Syndrome Stevens-Johnson Syndrome

◼ Symmetric severe vesicobullous eruption ◼ History of Illness ◼ Affects at least 2 mucous membranes 1-3 week prodrome of fever, malaise, mayalgias ◼ 5-10% mortality rate Usually in children and young adults Commonly caused by HSV, mycoplasma or drugs

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Stevens Johnson Syndrome Stevens Johnson Syndrome

◼ Physical Findings ◼ Physical Findings Rash lesions vary from erythematous Mostly on extremities, but may spread to face papules, vesicles, to target lesions and trunk Bullae erode resulting in gray-yellow fibrinous Fever – 3% exudates with thick hemorrhagic crusts Pneumonitis – 23% Ocular changes – conjunctivitis, bullae, Bronchitis – 6% corneal ulcers, and uveitis

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Stevens Johnson Treatment Toxic Epidermal Necrolysis

◼ Supportive care ◼ Exfoliative disease that affects 30-100% of ◼ Ophthalmology consult BSA ◼ Self limited disease ◼ High mortality ◼ 10% mortality for extensive disease ◼ 80% are secondary to drugs Dilantin, barbs, tegretol, sulfa, PCN, & NSAIDS Other causes include vaccines, TB, & viruses

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13 Toxic Epidermal Necrolysis Toxic Epidermal Necrolysis

◼ Skin eruptions are often confluent with ◼ Symptoms target lesions or bullae Fever, malaise, arthralgias, ◼ Widespread full thickness necrolysis of Leukopenia, thrombocytopenia, and anemia the epidermis 30% have upper airway involvement ◼ Involve mucous membranes Hypovolemia Wound infections & sepsis ◼ Positive Nikolsy sign

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Stevens-Johnson Syndrome TEN

10-year-old boy had a seizure & started on oral phenytoin. 3 weeks later he developed conjunctivitis & oral mucositis. The picture is 48 hours later.

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SJS & TEN Treatment Parkland Formula

◼ SJS and TEN – ◼ Wt 100kg Stop the offending drug/treat underlying ◼ BSA 25% illness May require supportive, ICU care ◼ Fluids = BSA x wt(kg) x 4ml/kg Treat as burn patient Remember to check eyes and consult ophthalmology ◼ Answer 10 liter fluid deficit

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14 Rash #12 Pityriasis Rosea

◼ 23 y.o. female presents with a painless rash. She is otherwise healthy but mentioned that ◼ Oval shaped salmon colored papules or plaques she had a cold a on the trunk & proximal extremities with a red halo couple weeks ago. ◼ Herald patch and Christmas tree pattern ◼ Children and young adults ◼ Resolves in weeks to months

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Rash #13 Erythema Nodosum

26 y.o. female with a ◼ Inflammatory/immunologic reaction ◼ Women 15-30 y.o. history of sarcoid ◼ Deep painful nodules on the lower presents with a extremities ◼ Bilateral but not symmetric history of a week of ◼ Tender to palpation myalgias and a ◼ Preceded by fever, malaise, & fever. Today noticed arthralgias ◼ Causes: Infection, Drugs, Cancers, a painful rash on her Sarcoid/IBD, Pregnancy ◼ Self limited if the cause can be bilateral shins eliminated

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Rash #14 Henoch-Schonlein Purpura 7 y.o. male presents for severe abdominal pain. ◼ Systemic vasculitis that causes palpable purpura Parents say that he had ◼ Usually follows an upper respiratory infection jaundice at birth but no ◼ 90% of cases occur in children <10 y.o. other health problems. He is fully immunized and takes ◼ Triad – purpura, joint pain, and abdominal pain no medications. A week ◼ Purpura is usually located on the legs and ago he had a runny nose buttocks but they otherwise deny any ◼ 40% of cases involve the kidneys constitutional symptoms.  Hematuria, proteinuria, and some will have nephrotic On exam you completely syndrome undress the boy and see this rash

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Viral Rashes

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Rash #15 Herpes Simplex ◼ A 35 y.o. female presents with a painful rash on her lip. She is otherwise healthy ◼ HSV I – associated with oral lesions but reports being under a lot of stress with ◼ HSV II – associated with genital lesions her work and family ◼ Treatment – Oral antiviral agents are most effective within 48 hours of outbreak

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Herpes Simplex Rash #16

◼ A 38 y.o. male presents with severe RLQ pain

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16 Herpes Zoster Shingles/Herpes Zoster Shingles

- Reactivation of latent varicella zoster - Starts as pain and paresthesias in a dermatomal - 10-20% Incidence distribution 3-5 days prior to rash - Triggers – age, immunosuppression, fatigue, stress - Herpetiform clusters of vesicles on an erythematous - Patient’s with Hodgkin’s disease are uniquely susceptible edematous base - May have constitutional symptoms of fever, HA, & - Hutchinson’s sign – lesions on the tip of the nose can malaise prior to the rash signal eye involvement - Ramsay Hunt Syndrome – Lesions in the ear canal associated with facial palsy - Treatment – analgesics and antivirals

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Shingles Ophthalmic Zoster

◼ 10-20% of all zoster cases ◼ 72% develop ocular complications ◼ Hutchinson’s sign

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Zoster Diagnosis and Treatment Postherpetic Neuralgia

◼ Tzank smear shows multinucleated giant ◼ Incidence and duration of pain increases cells with age ◼ Oral antivirals – most effective in the first ◼ Patients over 60 may benefit from Elavil or 48hours Neurontin ◼ Sympathetic blocks with bupivicaine may help the pain of acute zoster

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17 Rash #17 On exam you see ◼ 4 y.o. female is brought Social Hx: lives at home into the ER for a fever with 5y.o. brother and pet and rash. Mom reports dog that the child has had a cough, runny nose, and ◼ Immunizations: None increasing fever over the ◼ Vitals: T 39, RR 20, HR last 3 days. This morning 120 the child woke up with a rash and mom became concerned. ◼ PMHx: NSVD, no health problems ◼ Rx: none

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Measles/Rubeola Rash #18

◼ Erythematous maculopapular to confluent rash ◼ A 5 y.o. boy presents to the ER for a rash ◼ Starts on the forehead/behind ears and spreads downward to the face, trunk, and extremities (includes on his face and body. Mom reports that he the palms and soles) had a mild fever and didn’t feel well over ◼ Paramyxovirus the weekend and then today (2 days later) ◼ Infectious from 3 days prior to rash to 5 days after he woke up with a rash on his face and ◼ Symptoms:  Gradually increasing fever now mom says it has spread further.  4 C’s - “barking” cough, coryza, conjunctivitis, Koplick spots ◼ white papules on an erythematous base on buccal mucosa

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PMHx: Recurrent OM Vaccines: Mom gave most of them but got nervous about autism so she skipped “a few” Rubella/German Measles Exam: T 37.4 RR18 HR 105

◼ Pink/Red maculopapular rash ◼ Starts on the face and rapidly spreads down ◼ Fades by the 3rd day ◼ Rubivirus ◼ Complications – arthritis, encephalitis, thrombocytopenia, congenital rubella in first trimester exposure ◼ Symptoms  Prodrome of fever and malaise  Forchheimer’s sign – pinpoint petechiae on the soft palate  Lymphadenopathy

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18 Exam Rash #19 Vitals: T 39.6 RR 18 HR 131 ◼ 3 y.o. female brought to the EC for a high fever for 4 days that persists in spite of Tylenol and Motrin ◼ The child is otherwise healthy, immunized, and behaving normally

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Roseola Rash #20

◼ High fever for 3-4 days in a well-appearing ◼ 6 y.o. male presents with a mild fever and child followed by rash malaise and a rash on his cheeks. ◼ Blanching rose colored macular to maculopapular rash that starts on the trunk and spreads outward ◼ Human herpes virus 6 & 7 ◼ Usually in kids 6 months to 3 years

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Erythema Infectiosum/ Fifth’s Disease Fifth’s Disease

◼ Bright red malar rash - “slapped cheek” - followed in 2 days by an erythematous maculopapular rash on the trunk and limbs ◼ Central fading leads to a lacy pattern ◼ Parvovirus B19 ◼ No longer contagious once rash appears ◼ Can cause hydrops fetalis in pregnancy or aplastic crisis in hemolytic anemias

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19 Rash #21 Exam

◼ 4 y.o. male presents with fever, headache,

malaise over the last 3 days. Mom noticed ◼ T 38.2 RR 20 HR120 a rash on the face that is now spreading ◼ The child now has a poor appetite and is intensely itchy

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Varicella Rash #22

◼ Vesicular rash that starts on the face and ◼ A 15 y.o. wrestler spreads to the trunk (includes mucus presents for a membranes) and extremities (palms/soles rash on his feet spared) ◼ Vesicles rapidly evolve into pustules which umbilicate and crust “dew drop on a rose petal”

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Warts Wart Treatment

◼ Usually disappear after several months but can last years and/or recur

◼ Viral infection caused by HPV ◼ May resolve spontaneously ◼ Cauliflower-like appearance ◼ Salicylic acid ◼ Transmission occurs by direct contact and ◼ Liquid nitrogen cryotherapy autoinocculation ◼ Electrocautery

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20 Rash #23 Molluscum Contagiosum

◼ 10 y.o. female brought ◼ A viral infection of the skin and occasionally to the ER by her mom mucous membranes who is frustrated that ◼ Most commonly on the trunk/arms/legs she has had a rash for ◼ DNA poxvirus 4 months ◼ Spread from person to person via direct ◼ Occasionally itchy but contact no other symptoms ◼ Most common in children one – 11 y.o. ◼ She is fully vaccinated ◼ Contagious until the lesions are gone and otherwise healthy

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Molluscum Contagiosum Molluscum Contagiousum

◼ Flesh-colored, dome-shaped, and pearly appearance ◼ 1-5mm diameter with a dimpled center ◼ Painless but may be pruritic ◼ Most lesions clear in 6-12 months and average outbreak is 8-18 months ◼ Resolves without scarring ◼ Extremely contagious

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Molluscum Contagiosum Treatment

◼ Usually self-limiting ◼ Mild Cases – OTC Salicylic acid or retinoin cream Other Rashes

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21 Rash #24 Erysipelas

◼ Painful, shiny, erythematous plaques with raised ◼ 72 y.o. female presents for a painful rash on her and sharply demarcated borders cheek. She reports 2 ◼ Form of cellulitis and favors extremities days of a fever, poor appetite, and malaise ◼ Group A strep ◼ T 38.7 RR 18 HR 117 ◼ Usually occurs in young kids and the elderly 98% RA ◼ Associated with high fever, chills, & anorexia PMHx: DM, HTN ◼ Treatment: PCN, E-mycin, or Clindamycin

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Rash #25 Disseminated gonococcal infection

◼ 25 y.o. female presents for a painful rash ◼ Clinical on her finger and joint pain  Fever ◼ PMHx: Asthma, genital warts  Classic triad ◼ Social Hx: +tob, social Etoh, works at a ◼ 1. migratory arthralgias ◼ 2. tenosynovitis (usually fingers) gentleman’s club as a dancer ◼ 3. dermatitis  multiple papular, vesicular, or pustular skin lesions (usually initially small papules or macules that evolve to pustules), often on extremities *6 million new gonorrhea infections yearly in US. 3% cases may become disseminated. Up to 75% of those diagnosed with disseminated disease are females in late pregnancy, immediate post-partum, or within 1 week of onset of menses.

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Disseminated gonococcal infection Rash #26

◼ Diagnosis ◼ 28y.o. male presents to  Gram stain or culture of an urgent care after he blood or lesions reveals noticed a rash on his leg Neisseria gonorrhoeae ◼ PMHx: None ◼ Treatment ◼ Social Hx: Social Etoh, no  Begin parenteral treatment with ceftriaxone – tobacco, worked as a quinolones should be camp counselor over the avoided in certain regions summer and returned to due to resistance college 2 weeks ago

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22 Lyme Disease Rash #27

◼ Tick born disease ◼ 8 y.o. male presents to the ER for fever, ◼ Early localized disease has a circular outwardly malaise, headache, and nausea. Mom expanding rash – erythema chronicum migrans reports that he hasn’t felt well since they – at the site of the tick bite returned from a hiking trip in Virginia a ◼ Occurs 3-30 days after bite week ago ◼ Associated with flu-like symptoms ◼ Treatment – Doxycycline or Amoxicillin for 10-28 days

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Rocky Mountain Spotted Fever Rocky Mountain Spotted Fever

◼ Epidemiology ◼ Initial symptoms 5-7 ◼ Later symptoms days after inoculation  Rickettsia rickettsii  Petechial rash spread transmitted to humans by  Fever – only universal sx towards trunk wood ticks and dog ticks  Nausea, vomiting  Abdominal pain  All US states except AK, HI  Frontal headache  Joint pain  90% patients infected April  Myalgias ◼ Extreme gastrocnemius to Sept  Anorexia tenderness may be a clue  Half of cases from S.  Light macules on distal  Diarrhea Atlantic states extremities/palmar  CNS, renal, and respiratory  >60% history of tick bite surfaces failure  Peak age 5 to 9 years old

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Rocky Mountain Spotted Fever Rash #28

◼ Diagnosis is clinical ◼ A 22 y.o. male presents complaining of an  1. Fever 2. HA 3. Rash intensely itchy rash on his hands that ◼ Lab findings  Low sodium and platelets seems worse at night.  Elevated liver enzymes ◼ Treatment  Supportive  Doxycycline or chloramphenicol – begin prior to lab confirmation of diagnosis! ◼ High mortality rate due to late/missed diagnosis

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23 Scabies Scabies

◼ Caused by the mite sarcoptes scabiei ◼ Burrows under the skin, usually in the creases ◼ Pruritis intensifies at night ◼ Treatment – Permethrin, Ivermectin ◼ Reinfection is common

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Rash #29 Impetigo

◼ A 2 y.o. girl is brought in by her mother for ◼ Bacterial skin infection a rash on her mouth ◼ Children < 6 y.o. ◼ Highly contagious ◼ Impetigo Contagiosa  Most common, usually occurs on the face & extremities  S. aureus, Group A Strep  Small pustules/vesicles with erythematous margins that rupture and cause thick honey colored crusts  Treatment – Antiobiotics - Oral or topical (Mupirocin 2%) depending on severity and Good hygiene

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Impetigo Impetigo

◼ Bullous Impetigo Usually seen in neonates Lesions are usually periumbilical, perineal, or on extremities in older kids Flaccid bullae (1-3 cm) that rupture and leave shiny, round erythematous erosions with peeling edges (“coin lesions”)

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24 Rash #30 Meningococcemia

◼ A 4 y.o. male is brought to the ER by his ◼ Epidemiology mother for a fever, lethargy, and vomiting.  Incidence higher in spring and fall On exam you see the following rash:  Highest incidence in children < 5 ◼ Pathophysiology  N. meningitidis enters the body via the nasopharynx ◼ Asymptomatic carrier: remains in nasopharynx ◼ Mild URI ◼ Severe disease  Bacteremia, sepsis, meningitis

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Meningococcemia Purpura fulminans

◼ Clinical – wide spectrum  Classic – fever and petechiae or purpura present 60% cases  Other symptoms ◼ n/v/d, seizure, lethargy, cough, rhinorrhea  Danger -- extremely rapid course to sepsis, DIC ◼ vascular disorder characterized by fever,  10% develop fulminant meningococcemia mulitorgan failure and hemorrhagic skin necrosis (Waterhouse-Friederichson syndrome)

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Rash #31 Skin Cancers ◼ A 70 y.o. man ◼ Skin ca presents for bleeding from a wound on his back

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25 Basal Cell Carcinoma Basal Cell Carcinoma

-Most common skin cancer ◼ Appearances -Usually caused by sun exposure but some Typical have a genetic component ◼ Shiny, pearly skin nodule -Low risk of metastasis Superficial ◼ A red patch similar to eczema -Usually occur after 40 y.o. Infiltrative

◼ Skin thickening or scar tissue appearance

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Basal Cell Carcinoma Basal Cell Carcinoma ◼ Rarely life threatening ◼ Metastasis is rare ◼ 96% five year survival rate after excision

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Basal Cell Variants Basal Cell Variants

◼ Nodular ◼ Pigmented most common Pearly, white dome-shaped lesion with telangiectasias. Often has a central ulceration

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26 Basal Cell Variants Basal Cell Variants

◼ Superficial ◼ Micronodular

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Basal Cell Variants Basal Cell Nevus Syndrome

◼ Morpheaform ◼ Autosomal dominant condition Most subtle ◼ Involves defects in the skin, nervous Least common system, eyes, bones, & endocrine system Pale white to yellow ◼ Atypical facial appearance ◼ 90% develop basal cell cancers

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Squamous Cell Carcinoma Basal Cell Nevus Syndrome

◼ Basal_cell_nevus_sye ◼ Usually occurs in 50-70 year olds ◼ 2nd most common skin cancer (20%) ◼ ~ 90% occur in sun exposed areas ◼ Risk of metastasis

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27 Squamous Cell Skin Cancer Squamous Cell Carcinoma Presentation Prognosis

◼ Slow Growing asymptomatic lesion ◼ Excellent long term prognosis after ◼ Ulcer or reddish skin plaque to hard surgical excision plaque/papule ◼ Topical chemotherapy and radiation may ◼ May start as actinic keratosis also be used ◼ May have intermittent bleeding ◼ ~4% at risk of metastasis Higher in immune compromised patients ◼ Risk of metastasis is higher in lip or scar lesions 10-20% risk in lip or ear lesions

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Malignant Melanoma

◼ 8th most common cancer in the US ◼ Caused by UV exposure and/or genetics ◼ 25% develop from moles ◼ Diagnosed with biopsy

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Malignant Melanoma Malignant Melanoma Presentation

◼ Risk Factors ◼ Change in Mole Appearance Atypical Nevi – 25-30% develop from moles Increase Size Fair skin Change in Shape UV exposure Change in Color Family History ◼ Early Symptoms are itching, pain, Immune deficiency bleeding, and ulceration Congenital - xeroderma pigmentosum ◼ 70% develop de novo

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28 Malignant Melanoma Malignant Melanoma Subtypes

◼ ABC’s ◼ Superficial Spreading  Asymmetry Most common  Border Irregularity – may have edges or corners Occur on the trunk or extremities  Color Variation Usually develop from a prior mole  Diameter - >6mm Has a prolonged radial growth phase prior to  Evolving over time/Elevated above skin surface vertical growth  Firm to Touch  Growing

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Superficial Spreading Nodular Melanoma Melanoma

◼ Most aggressive form of melanoma ◼ 10-15% of melanoma ◼ Grows rapidly in thickness ◼ Often grows de novo instead of from an existing mole ◼ Raised and darkly pigmented

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Nodular Melanoma Lentigo Maligna Melanoma

◼ Found on chronically sun damaged skin ◼ 5-10% of all melanomas ◼ Darkly pigmented flat brown/black lesion ◼ Occurs on face or arms, often in the elderly ◼ Lentigo maligna  non-invasive skin growth considered to be melanoma-in-situ vs a melanoma precursor  LMM is invasive

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29 Lentigo Maligna Acral Lentiginous Melanoma Lentigo Maligna Melanoma

◼ ~7% of all melanomas ◼ Average age is 60-70 y.o. ◼ Most common melanoma in Asians and African Americans ◼ Similar appearance to LMM ◼ Typically occurs on the hands & feet

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Acral Lentiginous Melanoma Amelanotic Melanoma

◼ Non-pigmented ◼ 2% of all cases ◼ Often diagnosed later in the course

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Amelanotic Melanoma Melanoma Prognosis

◼ Depends on depth

◼ Females and young adults do better ◼ Extremity lesions have a better prognosis than trunk, head, or neck lesions The scalp has the worst prognosis

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