Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

DISCLOSURES

•There are no financial relationships with Dermatology Conundrums: commercial interests to disclose Interesting Cases •Any unlabeled/unapproved uses of drugs or products referenced will be disclosed Peggy Vernon, RN, MA, CPNP, DCNP, FAANP

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RESTRICTIONS OBJECTIVES

•Permission granted to the 2021 National Nurse • Name common contacts in phytophotodermatitis Practitioner Symposium and its attendees •All rights reserved. No part of this presentation • List a treatment of choice for Majocchi Granuloma may be reproduced, stored, or transmitted in any form or by any means without written permission of the author • Identify two symptoms of jellyfish sting

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56 Year Old Female Differential •Rash on trunk; started on back, spreading to • Drug eruption chest and abdomen • Tinea corporis •Only occasional itch • Tinea Versicolor •No history of allergies, • Pityriasis Rosea atopic dermatitis, • Nummular dermatitis psoriasis • Guttate psoriasis •No recent illness • Secondary syphilis •OTC HC no help Photo Courtesy Visual DX •OTC anti-fungal no help

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1 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

Pityriasis Rosea Diagnosis and Treatment •Herald patch: oval, salmon colored patch with fine collarette of • Biopsy if unclear scale; develops over 1-2 • Spontaneous remission weeks in 6-12 weeks • Smaller oval plaques • follow lines of Blashko Treat symptomatically: in “christmas tree” • Antihistamines for configuration itching •Usually confined to • Topical glucocorticoids trunk, proximal arms • UVB and legs, rarely on face; never on palms and

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43 Year Old Male Onychomadesis

•Painless spontaneous •Separation of proximal nail plate on several separation of proximal fingernails nail plate •Toe nails not involved •Painless •Cosmetically bothersome © pvernon2015

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Onychomadesis 30 Year Old Female

A •Trauma (e.g. subungual •Areas of hair loss with hematoma) thick sticky yellow scale •Inflammation or infection (fever, HFM •Non-tender disease) •No adenopathy •Peripheral vascular •No one else in family disease with sx •Raynaud’s

Photo courtesy •Familial trait Visual DX

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2 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

Pityriasis Amiantacea Differential Photos courtesy Visual DX • Distinct scalp disorder • Female predilection: young •Atopic dermatitis adults, adolescents, and •Psoriasis children • Clinical diagnosis: Adherent •Pityriasis Amiantacea thick silver, gray, or yellow •Seborrheic dermatitis scales which surround and bind down hair tufts. Scale •Tinea capitis attached to hair shaft and scalp • Fungal cultures usually negative Photo Courtesy Visual DX • Staph most common

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Pityriasis Amiantacia Treatment 10 Year Old Female

•Keratolytic shampoos: 2% salicylic acid •Spontaneously shampoo developed lesion on •Urea 20% or 40% cream forearm •Topical steroids in oil •Rapidly increasing in base (flucinolone oil size 0.01%) •Frequently bleeds •Antibiotics if cultures • positive Non-tender

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Differential Diagnosis Pyogenic Granuloma

•Cherry Hemangioma •Rapidly growing •Aplastic Large Cell vascular lesion Lymphoma •Friable, prone to •Cutaneous bleeding Melanoma •Often as a result of •Pyogenic Granuloma trauma •BCC •Spitz Nevus

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3 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

Treatment Pyogenic Granuloma 23 Year Old Male

•Small lesions may •Malodorous feet spontaneously •Works as chef regress •Feet moist, peeling, •Excision with pitted on weight- Pathology bearing surfaces •Cautery, electrodessiccation •Vascular laser for recurrent lesions

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Pitted Keratolysis Treatment • Superficial bacterial infection of the soles of the foot, lateral toes, occasionally palms • Remove environment, • Asymptomatic erythematous promote dryness plaques and circular shallow pits • 20% aluminum chloride on weight-bearing areas; occasionally painful (Drysol) BID • Often misdiagnosed as tinea • Alcohol-based benzoyl • Hyperhidrosis, moist socks, peroxide humid environment, occlusive • Topical erythromycin or shoes and prolonged immersion clindamycin in water are predisposing factors • OTC: Carpe

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31 YEAR OLD MALE DIFFERENTIAL DIAGNOSIS •Two day history pruritic, tender papules and vesicles •Rocky Mountain Spotted Fever •Recent camping trip •Recent fever, headache, •Lyme Disease lethargy, “flu symptoms” •Varicella •Developed rash on trunk day two •Day three increased lesions spreading to entire body with increased lethargy and fever

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4 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

Rocky Mountain Spotted Fever RMSF

•Rash appears 2-5 days •2-4 days after after onset of symptoms infected tick bite •Macular, erythematous •Fever •Begins on extremities, •Headache spreads to trunk •Nausea, Vomiting •Petechiae appear on •Abdominal pain sixth day or later Photo Courtesy Visual DX •Muscle pain Photo Courtesy Visual DX

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Lyme Disease Varicella

•Fever •Prodrome nausea, •Headache anorexia, myalgias, •Fatigue headache •Rash at site of tick bite •Vesicles and pustules • circular outwardly •Begins on head and expanding rash trunk, spreads to (erythema migrans) extremities • innermost portion dark red, indurated •Lesions at various (bull’s eye) stages of healing

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58 Year Old Female VARICELLA TREATMENT •Annual Skin Exam •Valcyclovir(Valtrex) 1 gm TID x 7 days •Lesion on posterior L •Famcyclovir(Famvir) 500 mg q8h x 7 days shoulder, scapula, axilla, •Acyclovir(Zovirax) 800 mg qid x 5 days neck, extending to anterior L upper chest •Symptomatic care and L upper arm •IMMUNIZE •Present since early childhood •Increased slightly in size during teen years

•No problems with lesion © pvernon2009

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5 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

ILVEN ILVEN Differential Diagnosis •Inflammatory linear verrucous epidermal nevus (ILVEN) •Linear psoriasis •Erythematous, hyperkeratotic •Linear porokeratosis plaques following lines of • Blaschko Lichen striatus •ILVEN may represent mosaic •Warts inflammatory disorder similar to linear psoriasis and linear lichen planus © pvernon2009 •Usually appear in early childhood

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ILVEN Treatment 6 month old male

•Difficult to manage •Large congenital lesion with topical therapy •Increasing in size with •CO2 laser growth •Full-thickness •Lesion crosses mid-line excision

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Congenital Hairy Nevus

Lie in the distribution of a dermatome Vary in size to cover large areas Uneven pigment brownblack 95% have hairy component Numerous pigmented nevi co-exist in lesion Consult neurology if lesion is

large or crosses the midline © pvernon2008

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6 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

21 Year old Female

•Nevus on dorsal foot •Tattoo in and around •Present since lesion 5 years ago childhood •Lesion has always •Recently increasing been cosmetically in size bothersome; patient thought tattoo •Developing red ring would help around lesion

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Dysplastic nevi Dysplastic Nevi Treatment

• Clinically atypical with size, • Grading: symmetry, color, and/or borders –Mild: Observe, annual exam • Usually benign –Moderate: Conservative excision, annual exam • Appear in childhood through early adulthood –Severe: Excision 5 mm margins, annual exam • More common in Fitzpatrick I-III • Biopsy of changing nevi • Increased risk of melanoma in patients with multiple dysplastic • Annual Skin Exam nevi • Self Exams • Current evidence does not © pvernon2002 support dysplastic nevus as • Sunscreen premalignant lesion • Protective clothing

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10 year old female Differential Diagnosis

•Developed blisters and •Atopic Dermatitis itching on legs and •Burns hands while on •Contact Dermatitis vacation •Child Abuse •Lesions have not spread •Phytophoto • Slight itching Dermatitis

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7 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

Phytophoto Dermatitis Phytophoto Dermatitis Causes •Redness and blisters in bizarre shapes •Citrus and Lime found in drinks and food •Exposure to plants, • Figs especially those in celery, • Celery citrus, and grass family •Lemon and Lime oil •Plants produce psoralen •Queen Anne’s lace on the skin • Giant Russian hogweed • Exposure to sunlight • Bergapten produces photodermatitis with blister formation, • Component of bergamot oil followed by intense • Found in cosmetics, perfumes, lotions, stimulation of melanin sunscreens and household products ©PVernon2021 ©PVernon2021

Workup Treatment

• Clinical suspicion •Remove offending substance •Photopatch test if photoallergy suspected: •No treatment necessary if asymptomatic • Occlusive application of test chemical(s) •Topical corticosteroids if pruritic • Irradiation with UV light at several intervals • Phototoxicity: controls positive •Analgesics • Photoallergy: controls negative •Sunscreen •Treat resulting PIH

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Differential Diagnosis 8 year old female

•Herpes simplex •Developed red, pruritic rash •Impetigo •Began as small cut at oral •Atopic dermatitis commissure •Cellulitis •Spreading to chin and •Contact dermatitis cheeks Photos Courtesy Visual DX

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8 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

58 year old Female Neosporin Contact Dermatitis

•Neomycin: 2010 Allergen of •Annular plaques on the Year (American Contact upper back Dermatitis Society) •Red borders with scale •Remove offending agent •Central clearing •Recent vacation with sun exposure

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Differential Diagnostics

•Tinea corporis •ANA, CBC with Differential, ESR •Nummular Dermatitis (sedimentation rate) •Psoriasis •UA •Sarcoidosis • Biopsy •Lupus •Hematoxylin and eosin staining (H & E) • •Syphilis Direct immunofluorescnce (DIF) on lesional and peri-lesional skin •Drug eruption •Photodermatitis

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Lupus Management

• Refer to rheumatology and dermatology 63 Year Old Male for co-management • Sunscreen • Topical and intralesional steroids • Long standing history of folliculitis on hips, • Oral steroids buttocks, and lower • Azathioprine (Imuran, Azasan) back • Cyclophosamide (Cytoxan) • Coincidental history of • Cyclosporine (Neoral) tinea cruris: untreated • Hydroxychloroquine (Plaquenil) ©Pvernon 2013 • Treated with oral • Mycophenolate (Myfortic) antibiotics and topical • Methotrexate (Rheumatrex, Trexall, corticosteroids without Xatmep)) relief • Belimumab (Benlysta) ©PVernon2021 ©PVernon2021

9 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

DIFFERENTIAL

•Folliculitis •Acne Keloidalis •Scabies •Onychomycosis ©Pvernon 2013 •Kaposi Sarcoma •Nodular Vasculitis

•Majocchi Granuloma ©Pvernon 2013

MAJOCCHI GRANULOMA

DIAGNOSIS TREATMENT

•KOH usually negative • Systemic antifungals: •Tissue biopsy terbinafine x 6 weeks • • Remove exacerbating factors: Gram stains topical steroids •Periodic acid-Schiff (PAS) stains reveal fungal • Antibiotics for secondary hyphae in tissue, surrounded by bacterial infections granulomatous reaction

©Pvernon 2013

10 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

28 YEAR OLD MALE Past History 2-3 cm enlarging non- tender violaceous ulcer with rolled edges on right Previously healthy, and forearm. currently no acute distress. Tender adenopathy with No recent travel. Family erythema in antecubetal members well. fossa. Ulcer developed 4 weeks Visibly enlarged node above ago. the fossa. Chopping wood 3 weeks Tender shoddy prior to ulcer development. ©Pvernon 2017 subcutaneous nodes along PCP treated with Cephalexin lymphatic drainage proximal (Keflex) 1 week ago without arm to axillary node. ©Pvernon 2017 response.

Differential Diagnosis SPOROTRICHOSIS

Granulomatous fungal infection Cellulitis Occurs in all ages in patients exposed to Sporothrix ©Pvernon 2017 contaminated soil or vegetation Norcardia Usually follows a wound inflicted by a Brown recluse spider bite contaminated object (splinter, thorn, straw, grain, rock, glass, cat bite, or cat scratch)

Treatment 9 Year Old Male

Itraconazole ( Sporonox) •Swimming off the 100-200 mg/day coast of Spain Terbinafine (Lamisil) 250 •Presented at ER with mg/day hives and lesions on Fluconazole (Diflucan) medial right thigh 100-200 mg/day ©Pvernon 2013 • Amphotericin B Intense stinging and 0.25mg/kg- ro 1.0 mg/kg pain by slow IV infusion • No SOB 66 66 ©Pvernon 2017

11 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

Jellyfish Jellyfish Symptoms

•Free-swimming non- •Intense stinging, pain, rash aggressive gelatinous •Progressive symptoms: nausea, vomiting, marine animals surrounded by tentacles diarrhea, adenopathy, muscle spasms •Tentacles covered with •Severe reactions cause difficulty breathing, nematocysts filled with coma, death venom •Found near the water surface at dusk

Jellyfish Sting Treatment 10 Days Post-Injury •Diphenhydramine and acetaminophen or ibuprofen •Soak area in acetic acid (vinegar), sea water, or 70% isopropyl alcohol 15-30 minutes (fresh water will cause nematocysts to continue to release toxins) • Remove tentacles with tweezers ©Pvernon 2013 •Apply shaving cream or paste of baking powder, shave area with razor or credit card

6 Weeks Post-Injury 2 Weeks Post-injury

©Pvernon 2013

12 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

Photo Courtesy Visual DX

36 Year Old Female Seabather’s Eruption

•Developed rash on 4th •Pruritic dermatitis day of vacation in •Hypersensitivity Costa Rica reaction to •Developed papular, nematocysts of pruritic rash after larval-stage thimble swimming in ocean ©Pvernon 2013 jellyfish ©Pvernon 2013 •Now spreading on •Sometimes called trunk “sea lice”

Seabather’s Eruption Treatment

•Small red papules on • Scratching causes areas covered by water- intense itching and permeable clothing swelling during ocean swimming • Prompt removal of •Upon leaving the ocean, swim clothing while wet

organisms stuck against • Warm sea-water ©Pvernon 2013 skin die, discharge ©Pvernon 2013 shower nematocysts • Diphenhydramine, topical corticosteroids

13 Dermatology Conundrums Peggy Vernon, RN, MA, CPNP, DCNP, FAANP Pre 2

References • Bobonich, M, Nolen, M. Dermatology for Advanced Practice Clinicians. Wolters Kluwer, 2015. First Edition. • Foe, Donna Poma, Cutaneous Drug Eruption: A Case Study and Review; Journal of the Dermatology Nurses’ Association, Nov/Dec 2009, Vol 1 Issue 6, p 345-409 • Goodhearts, Herbert P. Goodheart’s Photoguide to Common Skin Disorders, Third Edition, Lippincott Williams & Wilkins 2009 • Habif, Thomas. Clinical Dermatology. Fourth Edition, Mosby, 2004 • Mina, Michael, et al: Science, 2/19/2019 • Schachner, Lawrence A. & Hansen, Rondal C. Pediatric Dermatology, Third Edition, Mosby, 2003 • Sulzberger and Zaidems: “Psychogenic factors in Dermatological Disorders”. Medical Clinics of North America, 1948, Vol. 32, P. 669. • Wollf, Klaus et al. Fitzpatrick’s Color Atlas & Synopsis of Clinical Dermatology, Sixth Edition, McGraw-Hill, 200 • Internet Resources • American Academy of Dermatology, www.aad.org • American Academy of Pediatrics, www.aap.org • American Lyme disease Foundation, www.aldf.com • Centers for Disease Control and Prevention, www.cddc.gov • DermNetNZ, www.dermnetnz.org • Mayo Clinic: diseases and conditions, www.mayoclinic.com/health/DiseasesIndex • Medscape:dermatology; http://emedicine.medscape.com • National Eczema Association, www.nationaleczema.org • UpToDate ©PVernon2021 • VisualDx