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Home , Pimecrolimus, Sebaceous hyperplasia

Goals and Objectives: Dermatomyositis

• At the end of this lecture, the learner will be able to: • Skin Signs: • Work Up: 1. Identify benign growths of the face • Heliotrope rash • Myopathy (may be amyopathic) • Cuticular dilated capillary loops • Malignancy (ovarian, breast, lung) 2. Identify manifestations of collagen vascular disease on the face • Others: • Interstitial lung disease • Anti‐Jo1, Anti‐MDA5 3. Appreciate the difficulty in identifying lentigo maligna melanoma • Gottron’s papules • Mechanics hands • Tx: 4. Create a differential diagnosis of perioral, peri‐ocular, labial, and • Poikiloderma atrophicans vasculare • Prednisone malar lesions and rashes • Shawl sign • Hydroxychloroquine • V‐sign • 5. Implement basic treatment paradigms of common conditions, • Calcinosis cutis including , , and eczema • Scalp scaling • Mycophenolate mofetil • IVIg

Heliotrope Rash Dermatomyositis ‐ heliotrope eyelids

Heliotrope, the flower

She is not wearing eyeshadow.

Dermatomyositis Seborrheic Gottron’s papules & cuticular dilated capillary loops • Same etiology as …BUT ALSO…. • Caused by Pityrosporum fungus • Signs: scaling and erythema of: • Brow • Paranasal gutters • Posterior auricular (behind ears) • Conchae of ears • Scalp (a.k.a. dandruff) • Chest • Worse in HIV • Treatment: 2%, pimecrolimus, 1% melanoma Seborrheic Dermatitis Seborrheic Dermatitis in HIV

Zinc Deficiency from Topical Steroids • Looks like a mix of acne and eczema • Acquired • DDx: allergic contact • no zinc in baby formula dermatitis (e.g., to • alcoholics toothpaste) • Genetic • Treat: • acrodermatitis enteropathica • • autosomal recessive • pimecrolimus • zinc malabsorption • d/c

Photo from: http://healthh.com/wp‐ content/uploads/2014/05/perioral‐ dermatitis‐pictures‐3.jpg

Scleroderma

• Pinched nose • Immune‐mediated • Tightened orifice displaying teeth depletion of melanocytes • Few wrinkles • Tx: tacrolimus & excimer laser • Telangiectases

• Therapy: • Mycophenolate mofetil • Methotrexate • Prednisone Lupus pernio (sarcoidosis of face) Discoid Lupus

• Aka chronic cutaneous • Cutaneous sarcoidosis • Hyperpigmented border, hypopigmented/pink center • Nose, scalp with scarring alopecia • Face, ears, scalp (with scarring alopecia) • More indurated than DLE • Therapy: hydroxychloroquine; • Therapy: • • intralesional triamcinolone 5‐10mg/cc

Discoid Lupus Acute systemic lupus

• “Butterfly” malar (cheek) rash • Photosensitivity • Spares nasolabial fold

Lupus vulgaris Tinea faciei: note annular, scaly border (cutaneous tuberculosis) • + PPD • Search for TB elsewhere Treatment: • Slowly progressive terbinafine 250mg po qd x 14 days Psoriasis Seborrheic dermatitis

• Can look like seb derm Therapy: • but more well‐demarcated • Ketoconazole 2% cream bid than seb derm • • Treat face with: Topical inhibitors • Tacrolimus • Tacrolimus • Pimecrolimus • Pimecrolimus • Topical steroid • mid‐potent steroid • for flare, not for maintenance

Eczema Psoriasis Dry, scaly, red plaques Well‐demarcated Red Often impetiginized Plaque(s) • swab culture Silver scale • mupirocin New therapy: Therapies: Anti‐IL 23 agent: guselkumab • 90% of folks get 75% clear • Tacrolimus 0.1% ointment • 40% of folks get 100% clear • Pimecrolimus 1% cream Very safe! • Crisaborole 2% ointment Primary care can do it! • Topical steroids

Pityriasis alba Allergic Contact Dermatitis • Associated with eczema • Treatment: Diagnosis: • Tacrolimus • Patch testing • Pimecrolimus • Hydrocortisone • Crisaborole Therapy: NEW! • Allergen avoidance Dupilumab • Topical steroids • IL 4/13 receptor antagonist • Tacrolimus • moderate to severe • Pimecrolimus eczema • safer than prednisone • may cause conjunctivitis Intradermal nevus – scalp, flesh colored papule Intradermal nevus – face

• Benign rest of non‐functional eccrine (sweat gland) cells • Cluster of 1 to 3 mm dermal papules • Eyelids or upper cheeks Compound nevus • Onset: puberty or adult Junctional nevus - • Tx: electrofulguration but recur with risk of post‐inflammatory brown macule hyperpigmentation

Intradermal nevus: Junctional nevus: nests in dermis only nests in dermo- epidermal junction only Sebaceous hyperplasia

• Small, mamillated yellow papules with telangiectasia and umbilication • depressed center, like “inny” belly button • Confused with basal cell carcinoma • Harmless Compound nevus: • nests both in dermis Seen in folks with rosacea and in D-E junction

Seborrheic Keratosis Seborrheic Keratosis

• Warty, stuck‐on papule • Greasy • Tan to black • Elderly – “barnacles of life”  • VERY COMMON LESION • BENIGN…but if something looks funky to you, always involve the dermatologist Dermatosis Papulosa Nigra (pl. milia) • Many little SKs • Small epidermoid • Treat via I&D

Incision Extraction with comedone extractor Traction behind blade = GOOD (or long finger nails :O)

Epidermoid Cyst: Schematic

• Misnomer = • gets occluded  Skin still sloughing below occlusion  Keratin collects and causes and scarring around it  Capsule/cyst wall formation • Periodically, keratin discharges (smells!!!) accounting for “growing and shrinking” course Epidermoid Cyst

Central punctum

Central punctum

Nevus areneus (aka spider telangiectasia) Nevus araneus

• Associations: cirrhosis • Therapy: • Electrodesiccation of central feeder vessel • Pulse dye laser abaltion

Spiderman photo from: http://www.marveldirectory.com/individuals/s/spiderman.htm Spider photo from: http://zerotermitepest.com.au/spider‐control‐sunshine‐coast/

Hidrocystoma Xanthelasma

• Translucent, fluid‐filled cyst on eyelid • Yellow plaques on • Lined by sweat gland epithelium eyelids • Treatment: • Sometimes associated • Incision and drainage with • Excision hypertriglyceridemia, but often, not found • Electrofulguration • Tx: 100% TCA; electrodesiccation; ablative laser

BONUS FINDING: SYRINGOMA!!!! Hordeolum (stye) Chalazion • Chronic inflammation of Zeis or meibomian glands • acute focal infection • staphylococcal Therapy: • • warm compress • glands of Zeis • ILTAC 2.5‐5mg/cc • external hordeola –lash • meibomian glands • internal hordeola –tarsal plate

https://en.wikipedia.org/wiki/Stye

By Michal Klajban (Hikingisgood.com) ‐ Own work, CC BY‐SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11037123

Acrochordon Lentigo Maligna vs. Solar Lentigo

• Aka skin tag • Lentigo maligna = melanoma in situ, usu. face • Pedunculated • Solar lentigo = hyperpigmented macule from excess sun exposure • Snip excision • Cauterize base To distinguish: • Time/progression • Color variegation • Size • Similar lesions • Old melanoma excision scar

Lentigo Maligna Melanoma vs. Solar Lentigo? Lentigo Maligna Melanoma vs. Solar Lentigo? Lentigo Maligna Melanoma Lentigo Maligna Melanoma vs. Solar Lentigo? vs. Solar Lentigo?

Photo from: https://edrugsearch.com/age‐spot‐removal/

Basal Cell Carcinoma Basal Cell Cancer

• Rolled border • Telangiectasia • +/‐ Ulceration

• Does not usually metastasize BUT locally destructive

SCC in situ Squamous Cell Cancer (SCC) (Bowen’s disease) • Morphology: • Hyperkeratotic • Red base

• Sun damaged skin; Organ transplant patients

• Metastatic risk • Mucosa (e.g., Lip) • Ear • Genitalia • > 2cm • Recurrent SCC SCC

Note background of photodamaged skin and actinic keratoses

SCC

SCC

Actinic Keratosis Actinic Keratosis

• Rough, thin, scaly papule • sometimes felt, not seen • Precursor to SCC • Sun exposed areas: • bald scalp • face • forearms • dorsal hands

forehead Actinic Keratoses Solitary Hyperkeratotic Papule

Verruca Vulgaris Seborrheic Squamous cell Cutaneous Horn carcinoma (wart) keratosis Can be: red base, • Wart filiform pigmented, hyperkeratotic • SCC stuck on, • AK waxy

Cryotherapy –10 sec freeze

After 5‐FU Osler‐Weber‐Rendu Disease

• Aka Hereditary hemorrhagic telangiectasia • AV malformations  GI bleed • Epistaxis • Lip telangiectases • Gene: • endoglin (ENG) • activin receptorlike kinase type I (ALK‐1) • Cf: Venous Lake Peutz‐Jagher Syndrome Solitary Labial Lentigo –very common! • Brown macules of lips • Benign hamartomas polyps in GI tract  intussusception • Cancer predisposition • breast • pancreas • others • Gene: STK11/LKB1

• Cf: solitary labial lentigo –very common • Cf: Carney complex – cardiac myxoma, lentigines Figure from: https://openi.nlm.nih.gov/detailedresult.php?img= PMC3505710_medoral‐17‐e919‐g003&req=4

Carney Complex Venous Lake (LAMB/NAME syndrome) • Labial lentigines • Cardiac myxomas • Venous ectasia of lip • Cancers • Benign • Endocrine abnormalities • Tx: • Gene: PRKAR1A • pulse dye laser • electrodesiccation

Figure from: https://www.researchgate.net/publication/234124406_The_complex_of_myxomas _spotty_skin_pigmentation_and_endocrine_overactivity_Carney_complex_Imagin g_findings_with_clinical_and_pathological_correlation/figures

Herpes Associated Angioedema Erythema Multiforme • Allergic vs. hereditary • Targetoid exanthem • Angioedema + hives = allergic • Ulcerative enanthem • Therapy: • + HSV 1 or 2 serology • Epinephrine • Therapy: • Prednisone • Famciclovir • • Valacyclovir • • Stop offending drug • Prednisone • E.g., ACE inhibitor • Thalidomide • Cyclosporine Herpes pearls… Angular Cheilitis

• Topical don’t work • Maceration from drooling • First outbreak (1o HSV1) • Candida worse than recurrent • Vitamin deficiency • 1st outbreak can be intraoral • • Subsequent usually just Therapy: lip/nose • Mid‐potent steroid • • Dosing options for recurrent • MVI • Valacyclovir: 2g bid x 1d • I use VZV dosing: 1g tid x 7d Figure from: http://www.webmd.com/oral‐health/angular‐ cheilitis#1

Retinoid Cheilitis Actinic cheilitis

• Lip inflammation from • Actinic keratosis of the lower lip • Tx: • Due to chronic sun exposure • decrease dose • Precursor to SCC • Low potency topical steroid • Tx: • Imiquimod • 5‐fluorouracil

• CO2 laser • Photodynamic therapy

Rosacea

• Pustules • Telangiectasia • Flushing • Sebaceous Sebaceous hyperplasia Hyperplasia • • Ocular rosacea (dry eyes) Rhinophyma Rosacea Therapy • Pustules: • Ivermectin cream 1% (kills Demodex folliculorum) • Metrogel is out • Azelaic acid –does ok • Doxycycline 40mg daily • Low dose isotretinoin (e.g., 10mg/d) • Erythema: • gel 0.33% daily –beware rebound erythema • Oxymetazoline cream 1% daily • Ocular: • Isotretinoin 1mg/kg/d x 5 months • Doxycycline 100mg po bid • Phymas/Sebaceous Hyperplasia: • Isotretinoin (1mg/kg/d) • CO2 laser ablation • Electrodesiccation

Lesions of Acne: Etiology Open Comedones (black heads)

• Papule: inflammation (vasodilation, edema), no pus • Pustule: pus, inflammation • Comedone: keratin plug in ostium of hair follicle Acne surgery • Open comedone (aka blackhead): wide ostium, oxidized sebum, appears Topical retinoid black • Closed comedone (aka whitehead): narrow ostium, appears white (sebum remains protected from open air) • Cyst: deep encapsulated pustule

Closed comedones (white heads) Comedone extraction

Acne surgery Topical retinoid Acne Papules and Pustules Topical: Acne (here, too) • Clinda/BPO • Topical retinoid • Dapsone Endocrine w/u: • • Prolactin • LH Oral: • FSH • Doxycycline • DHEAS • free and total testosterone For red scars: • Pulse dye laser Menstrual history for scars Doxy or Isotretinoin or ILTAC

Acne Cysts Scarring from Untreated Acne

Isotretinoin  1‐1.5mg/kg/d x 5 months

Acne Acne – Pathophysiology Treatment post inflammatory hyperpigmentation Follicular occlusion Acne surgery (I&D) • Keratin viewed as foreign  inflammation • for comedones Retinoids (topical and oral) Intralesional triamcinolone (ILTAC) 2.5mg/cc Tx: • for cysts • Propionibacterium acnes Doxycycline hyclate 100mg po bid 4% bid Clindamycin 1%/benzoyl peroxide 5% gel bid • Chemical • clinda monotx  resistance peels Sebaceous hyperactivity Retinoids (topical and oral) • by Oral contraceptives • food for P. acnes • ↑sex steroid binding protein  less available free testosterone 25‐100mg bid • antagonist, esp. for PCOS Melasma Therapy Melasma Retinoid: sloughs pigmented stratum corneum (qd) Steroid: hypopigmentation (bid) Hydroquinone 4%: inhibits tyrosinase (bid)

Combo cream is qd due to retinoid, but retinoid is weak, so bid is ok

How Hydroquinone works: Pseudofolliculitis barbae • Pathophysiology: • Shave  hairs grow curving inward  skin views hair as “foreign”  inflammation  pustules and scarring • Treatment: • prevent close shave  no sharply angled hair tips • hydrate beard  thick shaving gel  bump‐fighter razor • hydrocortisone after shaving • Inhibit tyrosinase in basal layer  no new pigment forms • Shave less often • Old pigment sloughs • Laser • Dermal pigment, if present, remains

Impetigo Impetigo • Bullous and non‐bullous forms • Causes: Staphylococcus aureus, streptococci (often colonize nose) • Superinfects any defect in skin (eczema, arthropod bite, etc.) • Appearance: honey‐colored crust • Treatment: mupirocin = best 3x/day!!!; may require oral antibiotics