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 • Methotrexate 5. Implement basic treatment paradigms of common conditions, • Calcinosis cutis including acne, rosacea, and eczema • Scalp scaling • Mycophenolate mofetil • IVIg Heliotrope Rash Dermatomyositis ‐ heliotrope eyelids Heliotrope, the flower She is not wearing eyeshadow. Dermatomyositis Seborrheic Dermatitis Gottron’s papules & cuticular dilated capillary loops • Same etiology as psoriasis…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: ketoconazole 2%, pimecrolimus, hydrocortisone 1% melanoma Seborrheic Dermatitis Seborrheic Dermatitis in HIV Zinc Deficiency Perioral Dermatitis 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 • tacrolimus • autosomal recessive • pimecrolimus • zinc malabsorption • d/c topical steroid Photo from: http://healthh.com/wp‐ content/uploads/2014/05/perioral‐ dermatitis‐pictures‐3.jpg Scleroderma Vitiligo • 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 lupus erythematosus • Cutaneous sarcoidosis • Hyperpigmented border, hypopigmented/pink center • Nose, scalp with scarring alopecia • Face, ears, scalp (with scarring alopecia) • More indurated than DLE • • Therapy: Therapy: hydroxychloroquine; thalidomide • infliximab • 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 calcineurin 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 Syringoma • 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 Milium Dermatosis Papulosa Nigra (pl. milia) • Many little SKs • Small epidermoid cyst • Treat via I&D Incision Extraction with comedone extractor Traction behind blade = GOOD (or long finger nails :O) Epidermoid Cyst: Schematic Epidermoid Cyst • Misnomer = sebaceous cyst • Hair follicle gets occluded Skin still sloughing below occlusion Keratin collects and causes inflammation 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 Spider photo from: http://zerotermitepest.com.au/spider‐control‐sunshine‐coast/ Hidrocystoma • Translucent, fluid‐filled cyst on eyelid • Lined by sweat gland epithelium • Treatment: • Incision and drainage • Excision • Electrofulguration Xanthelasma Hordeolum (stye) • Yellow plaques on • acute focal infection eyelids • staphylococcal • Sometimes associated • sebaceous gland with • glands of Zeis hypertriglyceridemia, • external hordeola –lash but often, not found • meibomian glands • Tx: 100% TCA; • internal hordeola –tarsal plate electrodesiccation; ablative laser https://en.wikipedia.org/wiki/Stye BONUS FINDING: SYRINGOMA!!!! Chalazion Acrochordon • Chronic inflammation of Zeis or meibomian glands • Aka skin tag Therapy: • Pedunculated • warm compress • Snip excision • ILTAC 2.5‐5mg/cc • Cauterize base By Michal Klajban (Hikingisgood.com) ‐ Own work, CC BY‐SA 3.0, https://commons.wikimedia.org/w/index.php?curid=11037123 Lentigo Maligna vs. Solar Lentigo Lentigo Maligna Melanoma vs. Solar Lentigo? • Lentigo maligna = melanoma in situ, usu. face • Solar lentigo = hyperpigmented macule from excess sun exposure To distinguish: • Time/progression • Color variegation • Size • Similar lesions • Old melanoma excision scar Lentigo Maligna Melanoma Lentigo Maligna Melanoma vs. Solar Lentigo? vs. Solar Lentigo? Lentigo Maligna Melanoma vs. Solar Lentigo? Solar lentigo or melanoma? Photo from: https://edrugsearch.com/age‐spot‐removal/ Solar lentigo –dirt comes off with alcohol!!! Basal Cell Cancer • Rolled border • Telangiectasia • +/‐ Ulceration • Does not usually metastasize BUT locally destructive Basal Cell Carcinoma Squamous Cell Cancer (SCC) • Morphology: • Hyperkeratotic • Red base • Sun damaged skin; Organ transplant patients • Metastatic risk • Mucosa (e.g., Lip) • Ear • Genitalia • > 2cm • Recurrent SCC in situ SCC (Bowen’s disease) SCC Note background of photodamaged skin and actinic SCC keratoses SCC Actinic Keratosis • Rough, thin, scaly papule • sometimes felt, not seen • Precursor to SCC • Sun exposed areas: • bald scalp • face • forearms • dorsal hands Actinic Keratoses Actinic Keratosis forehead Solitary Hyperkeratotic Papule Cutaneous Horn Verruca Vulgaris Seborrheic Squamous cell 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 Venous Lake • Aka Hereditary hemorrhagic telangiectasia • AV malformations GI bleed • Venous ectasia of lip • Epistaxis • Benign • Lip telangiectases • Tx: • Gene: • pulse dye laser • endoglin (ENG) • • activin receptorlike kinase type I (ALK‐1) electrodesiccation • 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 Angioedema (LAMB/NAME syndrome) • Labial lentigines • Allergic vs. hereditary • Cardiac myxomas • Angioedema + hives = allergic • Cancers • Therapy: • Endocrine abnormalities • Epinephrine • Prednisone • Gene: PRKAR1A • Antihistamines • Stop offending drug • E.g., ACE inhibitor 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 Erythema Multiforme Herpes pearls… • Targetoid exanthem • Topical don’t work • Ulcerative enanthem • First outbreak (1o HSV1) • + HSV 1 or 2 serology worse than recurrent • Therapy: • 1st outbreak can be intraoral • Famciclovir • Subsequent usually just • Valacyclovir lip/nose • Apremilast • Dosing options for recurrent • Prednisone • Valacyclovir: 2g bid x 1d • Thalidomide • I use VZV dosing: 1g tid