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 ©PVernon2021 ©PVernon2021 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 •[email protected] ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 soles ©PVernon2021 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 © pvernon2015 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 Photo Courtesy Visual DX ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 Photo Courtesy Visual DX ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 © pvernon2008 © pvernon2009 ©PVernon2021 ©PVernon2021 Congenital Hairy Nevus Lie in the distribution of a dermatome Vary in size to cover large areas Uneven pigment brownblack 95% have hairy component Numerous pigmented nevi co-exist in lesion Consult neurology if lesion is large or crosses the midline © pvernon2008 ©PVernon2021 ©PVernon2021 © pvernon2015 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 © pvernon2009 © pvernon2009 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 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 ©Pvernon 2009 ©Pvernon 2009 ©PVernon2021 ©PVernon2021 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 ©PVernon2021 ©PVernon2021 Differential Diagnosis 8 year old female •Herpes simplex •Developed red,