Pitfalls & Pearls in Diagnosis and Treatment

Carol Soutor, MD Adjunct Professor Dermatology Department University of Minnesota

1 Disclosure

• No pertinent conflicts of interest

2 Topics

• Books and web sites for dermatology content • The 7 broad categories of common skin disorders • Important diagnostic features of these 7 categories • 5 common pitfalls in diagnosis Web sites with dermatology content

Emedicine.com Free site that has extensive dermatology content, including pediatric, skin signs of systemic diseases, surgery and skin tumors. Written in a clear and standardized format

UptoDate.com Similar to Emedicine, but not a free site. However, it is available in most clinic and hospital systems

Dermnet.org.nz A New Zealand site created by dermatologist for primary care. Content is translated into over 50 languages by Google Translate

MedlinePlus.gov NIH site with useful information for patients

AAD.org. American Academy of Dermatology site with a “For the Public” section with information on skin cancer and other topics

4 Books for Primary Care

Clinical Dermatology, Mc Graw-Hill, Lange series, 2013, Carol Soutor and Maria Hordinsky eds, designed for primary care clinicians http://www.langeclinicaldermatology.com has lectures and videos from book . Fitzpatrick’s Color Atlas and Synopsis of Clinical Dermatology, Mc Graw-Hill, 2013. good for skin signs of systemic disease,

Clinical Dermatology, great pictures, Saunders, 2015, Thomas Habif.

5 Dermatologists and primary care clinicians make similar diagnostic errors

6 Pitfall #1 Making a specific diagnosis before making a broad diagnosis

It is important to place a skin problem in the proper broad diagnostic category before you try to make a more specific diagnosis, because the workup and management for the diseases within the various categories is quite different.

7 I can’t get a diagnosis‐ I am going to ask Dr Google The 50 most common skin diseases fall into 7 broad categories

• Dermatitis • Papulosquamous • Urticaria/erythema • Infectious • Follicular • Tumor • Miscellaneous

9 7 Broad categories

• Dermatitis • Papulosquamous • Urticaria/erythema ______these respond to steroids • Infectious • Follicular ______these respond to antimicrobials • Tumor ______Persistent lesions • Miscellaneous

10 Are you in the right category? Most Dx errors of rashes are in the inflammatory vs infectious (e.g dermatitis vs tinea)

Inflammatory Infectious Tumor Other

11 Each broad category of disease has at least one important characteristic in these 4 diagnostic tools

• EXAM: The morphology of the primary lesion is most important feature. Important to locate a typical, unexcoriated lesion • HISTORY: Itch and pain and response to treatment • PATHOLOGY: very helpful in tumors and many rashes • LAB: KOH, and cultures

12 What do we look for in the exam ? WE LOOK FOR PATTERNS Pattern Recognition

• What is the morphology of the primary lesion? Macule, patch, papule, plaque, vesicle, bulla, pustule, nodule or wheal • Are there any secondary changes in the primary lesion? Scales, crust, lichenification, erosions, ulcers, fissures, atrophy, scars • What is the color(s) of the lesions? Red, pink, purple, tan, brown, black, grey, white, yellow? • What is the configuration of the lesions? Discrete, confluent, linear, serpiginous, annular • What parts of the body are involved?

14 DERMATITIS Atopic, Contact, Nummular, Dyshidrotic, Xerotic, Stasis, Seborrheic, Lichen Simplex

• EXAM: Primary lesion is pink‐red and has some surface changes e.g. scales, crusts, excoriations. Each have a characteristic distribution and borders are indistinct • HISTORY: Lesions are usually pruritic and respond to topical steroids • PATH: usually not helpful “nonspecific dermatitis” • LAB: n/a except for elevated IgE in atopic dermatitis

15 16 PAPULOSQUAMOUS Psoriasis, Pityriasis Rosea, Lichen Planus

• EXAM: primary lesion is scaly papule or plaque and each disease has a characteristic distribution • HISTORY: lesions are usually not as pruritic as dermatitis except for lichen planus and they respond to topical steroids more slowly than dermatitis • PATH: may be helpful in psoriasis and lichen planus • LAB: not helpful

17 18 URTICARIA/ERYTHEMAS Hives, Drug Rashes, Erythemas

• EXAM: pink lesions which may have a blanched white border. Lesions begin discrete and then may be confluent. Little to no surface changes • HISTORY: usually sudden onset, pruritic and responds to antihistamines • PATH: helpful, but not diagnostic • LAB: WBC differential may be abnormal

19 Lesions of urticaria last < 24 hrs and have no surface changes

• > 80% of cutaneous drug reactions are the classic maculopapular “drug rash” • However drugs can cause almost every possible cutaneous reaction pattern • Or they make flare a preexisting dermatoses INFECTIONS Tineas, Herpes Simplex And Zoster, Impetigo, Boils, Cellulitis, HPV, Molluscum

• EXAM: heterogeneous morphology, but most have some surface changes • HISTORY: usually not pruritic except for folliculitis and the infestations. Herpes zoster is painful. Infections worsen with topical steroids but respond to appropriate antimicrobials • PATH: usually diagnostic • LAB: appropriate cultures are positive

22 INFECTIONS

Reproduced from Soutor & Hordinsky, Clinical Dermatology, (c) 2013, McGraw-Hill Education (Lange), New York, NY. 23 Follicular Disorders Acne, Rosacea, Folliculitis, Keratosis Pilaris, Perioral Dermatitis, Hidradenitis Suppurativa • EXAM: discrete papules or pustules in characteristic distributions • History: usually asymptomatic, except for folliculitis witch my be itchy and hidradenitis which may be tender. Usually respond to tetracycline family of antibiotics • Path: N/A • Lab: bacterial cultures usually isolate normal flora, but pathogenic organisms may be present in cases of folliculitis and hidradenitis

24 Follicular Disorders

25 TUMORS Nevi, Seborrheic Keratoses, Skin Tag, Epidermal Cyst, Milia, Sebaceous Hyperplasia, Lipoma, Angioma, Dermatofibroma, Actinic Keratosis, Basal Cell Carcinoma, Squamous Cell Carcinoma, Melanoma • EXAM: persistent discrete lesions. Malignant lesions are usually on sun exposed areas • HISTORY: slow onset, chronic • PATH: diagnostic • LAB: n/a

26 Tumors that look like a “rash”

Superficial basal cell ca In situ squamous cell carcinoma

28 Watch Out For The Mimics

• Lupus‐rosacea • Tinea capitis‐seborrheic dermatitis • Rosacea/acne papules‐basal cell ca • Nail psoriasis‐fungal nail • Tinea corporis‐nummular dermatitis‐lymes disease • Seborrheic keratosis‐atypical nevus‐melanoma • Scabies‐ dermatitis • Lymphomas‐dermatitis

29 Psoriasis vs Fungus

Psoriasis Fungal Nail

30 Pitfall #3 Atypical Presentations

31 Interdigital vs vesicular tinea pedis

33 Atypical Presentations as compared with other body areas • Mouth: lichen planus • Genitals: dermatitis • Axillae and inguinal fold: psoriasis

34 Lichen Planus

On wrist On buccal mucosa

36 Atypical/different Presentations

• Dermatoses may have significant hyper or hypopigmentation in darker skin • Macular diseases may be papular or more follicular in African Americans • Vitiligo may be very subtle in very fair skin • Melasma may be worse in Hispanic and Asian groups

37 DLE with marked hypo & hyperpigmentation

39 Primary lesion evolves over time

Bullous pemphigoid: bulla>crust>erosion>discolored macule Excoriations masking primary lesion

Reproduced from Soutor & Hordinsky, Clinical Dermatology, (c) 2013, McGraw-Hill Education (Lange), New York, NY. 41 Pitfall #5 Two diseases may be present at the same time What are some of the skin diseases that are in different categories that may occur together?

42 2 Skin Diseases May Be Present

• Dermatitis and secondary bacterial infection • Dyshidrotic dermatitis and tinea pedis • Herpes simplex and impetigo • Stasis dermatitis and cellulitis

43 DERMATITIS AND INFECTION

Atopic dermatitis + herpes + coag + staph Stasis dermatitis + cellulitis

• Choosing proper vehicle for steroids and other skin products • Choosing optimal class of steroids • Hypoallergenic products • Cost issues, generics, OTC products Useful web sites for medications

• Drugstore.com One of the few sites that lists the active and inactive ingredients in OTC products • Dailymed.nim.nih.gov NIH site that contains the package inserts for most medications • Goodrx.com prices of many prescription drugs at Walmart, Target, CVS, etc • Genericmedlist.com has links to the $4 drugs available at Walmart, Target, Walgreens, CVS #1 Use the right vehicle: cream, ointment, lotion, gel, solution

Gel Lotion Ointment Cream Ointments

• Clear greasy base as in petroleum jelly • Contain no preservatives • Less irritating, but messy • Apply at bedtime to minimize stains • Preferred base for atopic dermatitis, irritant dermatitis and psoriasis or any of the dry dermatoses especially during winter months Ointment base for atopic dermatitis and lichen simplex chronicus

Lichen simplex chronicus on scrotum Atopic dermatitis Creams

• White , non greasy base that absorbs into the skin • Little staining of clothes, can be used during the day • May be too drying • Best for blistered or oozing dermatoses and in hot humid climates Creams for office work and vesicular disorders like poison ivy Lotions

• Creams with added water • Cosmetically acceptable, especially in moisturizers and sunscreens • May be irritating in atopic dermatitis Gels

• Thin transparent base • Can be used in scalp and other hair bearing areas • Steroids in gels good for oral diseases and bug bites • Good vehicle for sunscreens Solutions

• Clear liquid base of water and/or alcohol • Ideal for scalp diseases • Too irritating and drying for use in other areas #2 Choose the optimal steroid class Bolded steroids are covered in most drug plans

Class Potency Generic Name Formulations

Cream, ointment, gel, solution, foam, 1 Super Clobetasol propionate shampoo. 0.05% potent Diflorasone diacetate Ointment 0.05%

Cream, ointment , 0.25% , Gel 0.5% 2 High Desoximetasone potency Fluocinonide Cream, ointment, gel, , solution 0.05%

Betamethasone valerate Cream, ointment, lotion 0.1% and foam 0.12% 3,4,5 Mid potency Cream, ointment, 0.025% and solution 0.01% Fluocinolone acetonide

Triamcinalone Cream, ointment 0.1%

Cream, ointment 0.05% 6 Low potency Desonide

Cream, ointment 1% and 2.5% 7 Least potent Hydrocortisone acetate Generic Name Potency Price at discount stores Tips for use Clobetasol propionate For intermittent use of < 2 weeks and About $15/oz < 50 grams per wk to dermatitis or psoriasis not responding to other Super steroids. Do not use on face or thin skin, potent (eg axillae, groin, diaper area) do not use in children

Diflorasone diacetate

High Desoximetasone potency Fluocinonide Use when mid potency steroids are not About $25/oz effective. Do not use on face or thin areas of skin, or in young children

Betamethasone valerate

Triamcinalone , Commonly used first line product for about $4/oz Inflammatory skin disorders in adults. Not for use on face and thin skin Mid potency Fluocinolone acetonide

Low potency Desonide $30/oz Use when 1 % hydrocortisone not effective

Use in all ages and areas except for Least potent Hydrocortisone acetate chronic use by eyes #3 Order sufficient quantity

• 30 grams (1 oz) are needed for one application to the entire adult body The following are quantities for a BID one month supply • Face and neck‐ 90 grams, 3 oz • Trunk‐ 180 grams, 6 oz • Arms ‐120 grams, 4 oz • Legs‐ 360 grams, 12 oz • Hands or feet‐ 90 grams, 3 oz The finger tip unit

• One finger tip unit as shown is 0.5 grams • This will cover an area of skin equivalent to size of 2 hands #4 Avoid prior authorization limbo

• Most of the time No prior generic substitutes auths for me will be effective • Generics are cheaper for most of you patients # 5 Use Hypoallergenic Products for dermatitis and inflamed or fissured skin

• Skin may be not intact with erosions & fissures • Many OTC products may sting or be painful when applied to inflamed skin Original hypoallergenic companies now have dozens of non‐ hypoallergenic products

These are some remaining hypoallergenic products • Aveeno Daily Moisturizing Lotion, generic OK • Eucerin Original Cream and Lotion • Cetaphil Moisturizing Cream and Lotion, Cetaphil Gentle Skin Cleanser, generic OK PSICO.COM focused on Hypoallergenic products, Rochester MN

This company focuses only on hypoallergenic products • Vanicream • Bar and liquid soaps • Bath oil • Shave cream • Lip balm • Sunscreens • Shampoo & conditioners • Hair gel and spray very cheap moisturizers

• Mineral oil • Cooking oils • Crisco vegetable shortening Dry skin without inflammation

• Aveeno lotion • Cetaphil lotion • 20% and 40% urea lotions • Cerimide lotions (CereVe) • Lactic acid lotions • Dove and Aveeno bar and liquid soaps • Cetaphil skin cleanser Avoid most topical “baby products” in children with dermatitis

• Often have perfumes, and other potential irritants or allergens • May cause stinging and burning in atopic children • Cost • Many good alternatives • Use the previous hypoallergenic suggested products # 6 Wet dressings for vesicular, crusted or oozing rash

• Domeboro (aluminum sulfate) Powder, generic OK • Wet cheese cloth or kerlix & apply for 15 min tid • Apply topical steroid during or after dressings • Wet dressing therapy in conjunction with topical corticosteroids is effective for rapid control of severe pediatric atopic dermatitis: experience with 218 patients over 30 years at Mayo Clinic. PMID: 21978575 # 7 Itchy skin with minimal inflammation: drug rash, xerosis, insect bites, etc

• Sarna “original” 0.5% menthol, 0.5% camphor • Sarna “sensative” 1% pramoxine • Sarna “ultra” 0.5% menthol,1% pramoxine, • Bites, poison ivy: 2% diphenhydramine (Benadryl) Gel • Prax lotion 1% pramoxine jelly for genital skin • Zonalon (5% doxepin) prescription only • Sedating and non sedating antihistamines 40% zinc oxide ointment

• Fungal or inflammatory Candida Lichen sclerosis rash in genital & rectal area may cause painful fissures • Adults in “day care” • 40% zinc oxide oint “seals” the fissures, but is as thick as caulk • Will stain underwear • Desitin Maximum Strength, Walmart Equate brand Bacterial infections folliculitis and infected dermatitis • Bleach baths: ¼ cup of bleach in a tub of water • Acetic acid (vinegar) soaks for pseudomonas Sunscreens and Sun blocks

Sunblocks • Contain zinc oxide and/or titanium dioxide • Good for people with connective tissue disorders and people sensitive to chemical sunscreens • Block all UV rays including visible light • Thick and may stain clothes • Vanicream SPF 50, Blue Lizard Australian Sunscreen, Sensitive, SPF 30 Sunscreens • Contain benzophenones, cinnamates, salicylates, etc • SPF 30 offers adequate protection for most people • Pick the right vehicle. Some people will only put up with spray. Sun protection

• When possible avoid direct sun exposure at mid day when UV index is high (varies with time of year, location, etc) • Use broad brimmed hats and sunglasses • Remember it takes 1 oz of sunscreen (a shot glass) to cover the entire adult body one time • Sunscreens should be applied 15 minutes before sun exposure and every 2 hrs • Use sunscreen that protects from UVA and UVB rays • Do not leave sunscreen bottle in hot car or direct sun. Check expiration dates • Use protective clothing rather than screen for children < 6 months Search “aad or aafp + sun protection” Self tanning lotions: Good alternatives to suntan – Contain DHA (dihydroxyacetone) which temporarily stains proteins in the strateum corneum – Streaking may occur – Gradual tan moisturizers, eg Jergens Natural Glow Summary

• Advantage of a limited formulary for skin disease • Most generics are OK for skin disease • Many cheap OTC products are efficacious Questions ?