Common Dermatologic Issues

CommonDermatologicIssuesinthe
GeriatricPopulation
SteveMarchenko,JanelleMarshalland
KristenM.Kelly,M.D.
UniversityofCalifornia,Irvine
Objectives:
Listdermatologicdiseasescommonlyseeninthe
elderly
Identifytermsusedtodescribedermatologiclesions
and/orrashes
Identifytreatmentoptionsforcommondermatologic
conditionsseenintheelderly
ApproachtoMaking
DermatologicDiagnoses
ObtainFocusedHistory
Time/duration/changeovertime,initialsiteandspread/symptoms
Generalhealth,occupation,familyhistory,medications,previous
treatments,allergies
Characterizemorphologyofbasiclesion
Primaryoriginallesion
Secondarychangestolesionovertime
Characterizeshape,color,texture,&arrangementofthelesions
Determinedistributionoflesions
Lesiondistributionoftenprovidesimportantdiagnosticclues
ApproachtoMaking
DermatologicDiagnoses
DiagnosticTestingtoconsider
Shave,punchbiopsy
KOHforfungalinfections
Gramstainforbacterialinfections
Imagecourtesyofwww.visualdx.comLogicalImages,Inc
Tzanckpreparationsforherpeticinfection(shown)
Oilmountofskinscrapingsforscabiesinfection
VictorNewcomer,MD(UCLA).(Jan2006).HerpeticWhitlow[photograph].RetrievedOct3,2011,from
http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=50694&imageIndex=11
DefiningSkinLesions
Aprimarylesionistheinitiallesionthatcharacterizesa
dermatologicdisorder
Beingabletorecognizeprimaryskinlesionsiscriticalin
makingthecorrectdiagnosis
Overtime,primarylesionsmaycontinuetodevelopor
bemodified,producingsecondarylesions
Keepinmind,whenexaminingapatient:
Theprimarylesionmayhaveevolved
Anycombinationofprimaryandsecondarylesionsmaybe
present
PrimarySkinLesions
Lesion
Description
Example
Macule Circumscribed,flat,<0.5cm(centimeter) freckle(ephelis)
Patch
Macule>0.5cm
vitiligo
Papule
Elevated,solidlesion<0.5cm
Plaque
Elevated,plateaulikelesionwithout
substantialdepth
molluscum
contagiosum
psoriasis
Notemultiplehyperpigmented
macularlesionsandasinglepatch
foundinthispatientwith
neurofibromitosistype1.Apapuleis
seenabovethepatch.
*thedefinitionoftheselesionsvarybythedermatologyreference,butusuallyis0.51.0cm.
(NYU,DepartmentofDermatology).(Dec2004).Neurofibromatosis[photograph].RetrievedOct3,2011,
fromhttp://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52014&
ImageIndex=0
PrimarySkinLesions
Lesion
Nodule
Wheal
Vesicle
Bulla
Pustule
Description
Example
Elevated,solidlesion>0.5cmwithsomedepth rheumatoid
nodule
Firm,edematousplaque
hives
Circumscribed,elevatedlesionwithfreefluid, Varicella
<0.5cm
Vesicle>0.5cm
Bullous
pemphigoid
Circumscribed,elevatedlesionwithpurulent
material
acne
PrimarySkinLesions
Notemultiplepustulovesiclesandplaques
inapatientwithsubcornealpustulardermatosis
(UniversityofRochester,DepartmentofDermatology).SneddonWilkinsonSubcornealPustulosis.[photograph].RetrievedOct3,2011,from
SecondarySkinLesions
Scale:White,dryflakes(e.g.dermatophyteinfection)
Crust:Ascabformedfromdriedserum,bloodor
exudateonskin(e.g.impetigo)
Erosion:Focallossofepidermisnotextendingbelow
dermal/epidermaljunction;healswithoutscarring(e.g.
followingblisterrupture)
Inthispatientwithpemphigus,
superficialblistershaveruptured
andformedcrustederosionsandscales
(NYU,DepartmentofDermatology).PemphigusFoliaceus.[photograph].RetrievedOct3,2011,from
Ulcer:Focallossofepidermis&dermisextendinginto
hypodermis;healswithscarring(e.g.decubitusulcer)
Fissure:Linearlossofepidermis(+/)dermis(e.g.
chappingoffingers)
Lichenification:Areaofthickenedepidermiswith
accentuatedskinlinesduetochronicrubbing(e.g.long
standingatopicdermatitis)
BenignSkinGrowths
Benignskingrowthsarecommon,especiallyinolder
individuals
Itisimportanttodifferentiatetheselesionsfromskin
cancer
Aclinicianshouldtrytocategorizeanyskinlesionas:
Mostlikelybenign,mostlikelymalignant,orunclear
Thelast2categoriesshouldbebiopsied
Examplesofcommonbenignlesionsinclude:
Seborrheickeratosesandcherryangiomas
BenignSkinGrowths
TindallJP,SmithJGJr.Skinlesionsoftheagedandtheirassociationwithinternalchanges.JAMA.Dec211963;186:103942
VictorNewcomer,MD(UCLA).(Aug2006).Keratosis,Seborrheic.[photograph].RetrievedOct3,2011,from
BenignSkinGrowths
(UniversityofRochester,DepartmentofDermatology).Keratosis,Seborrheic.[photograph].RetrievedOct3,2001,from
BenignSkinGrowths
CherryAngiomas
Benigndomeshapedcapillary
proliferationsthatblanchwith
pressure.
Usuallyappearinindividualsover
35onarmsandtrunkandtendto
bleedwheninjured.
Successfullytreatedwithlaseror
electrocautery
(NYU,DepartmentofDermatology).CherryHemangioma.[photograph].RetrievedOct3,2011,from
PrecancerousSkinGrowths
Criscione,VD,Weinstock,MA,Naylor,MF,Luque,C,Eide,MJandBingham,SF.Actinickeratosesnaturalhistoryandriskofmalignanttransformationinthe
VeteransAffairsTropicalTretinoinChemopreventionTrial.Cancer2009;115:25232530
(UniversityofRochester,DepartmentofDermatology).ActinicKeratosis.[photograph].RetrievedOct3,2011,from
ActinicKeratoses
SkinCancer
Skincanceristhemostcommonofallhumancancers
Itisdiagnosedinmorethan1millionpeopleintheUnited
Stateseachyear
Skincancersareofthreemajortypes:
Basalcellcarcinoma(BCC),squamouscellcarcinoma(SCC)
andmelanoma
ThemajorityofskincancersareBCCsorSCCs
Althoughmetastaticrateislow,maybelocallydestructive
anddisfiguringifnottreatedearly
SolarUVradiationisresponsibleforthemajorityofBCCs
andSCCs
Rogers,HW,Weinstock,MA,Harris,AR,etal.IncidenceestimateofnonmelanomaskincancerintheUnitedStates,2006.ArchDermatol2010;146(3):283287.
SkinCancer
Epidemiology
Secondmostcommonskincancer
MostfrequentlyaffectsCaucasianswithextensivesunexposure
Riskfactors
Chronicenvironmentaldamage
UV/ionizingradiation
Tobacco
Arsenicexposure
Historyofactinickeratoses
HPVinfection6,11,16,18
Chronicimmunosupression
CharlesE.CrutchfieldIII,MD.(Nov2007).SquamousCellCarcinoma.[photograph].RetrievedOct3,2011,from
SkinCancer
(UniversityofRochester,DepartmentofDermatology).(Augu2009).[photograph].RetrievedOct3,2011,from
SkinCancer
Epidemiology
Mostcommonhumanmalignancy
800,000newcaseseveryyearinUS
Riskfactors
Skintype1
Blisteringsunburnsinchildhood
Familyhistoryofskincancer
Immunosuppression
NodularBCC
(NYU,DepartmentofDermatology).BasalCellCarcinoma,Nodular.[photograph].RetrievedOct3,2011,from
Clinical
Severalsubtypesaredescribed
Nodulocystic:
singleshiny,rednodulew/telangiectasia
Superficial:
leastaggressive
erythematousplaques
canmimicpsoriasis
Sclerotic/Morpheiform:
mostaggressive
5%ofallBCCs.
Illdefinedborders
Pigmented
Shiny,blueblackpapule,speckled
SuperficialBCC
pigment,rolledborders.
CharlesE.CrutchfieldIII,MD.(Jan2007).BasalCellCarcinoma,Superficial.[photograph].RetrievedOct3,2011,
fromhttp://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52756&imageIndex=16
SkinCancer
Management
Dependsonlocation,size,histopathology,andpatientfactors
Verylowrisk/superficial:considercurettage+topical5FUor
imiquimod
Mostlowrisklesions:curettageandelectrodessication
ForhigherriskorrecurrentBCC:excisionwithmarginsorMohs
micrographicsurgery
Elderlypatientsorthoseinwhomsurgerycontraindicated:
considerradiation.
BasicsofDermatologicSurgery
Cryosurgery
Electrodessicationandcurettage
Excision
MohsMicrographicSurgery
Cryosurgery
Liquidnitrogen195.8C
Toproduceadequatetreatment,tissuetemperature50Cis
needed
Fastfreeze,slowthaw;generally2cycles
PROS:costeffective,nosurgery,minimalequipment
CONS:nospecimenforevaluation,skindiscolorationmay
occurandmaybepermanent(especiallyintannedskinor
patientswithdarkerskintypes)
ElectrodessicationandCurettage
Onlyindicatedforlowrisklesions
PROS:minimalbloodloss,ease,convenienceforthepatient
CONS:nospecimenforpathology,clinicianexperience
influencescurerate
ImagescourtesyofMargaretMann,M.D.
Excision
PROS
Shorterproceduretime
Closureperformedatthesametime
Lessexpensive
Marginsdependonlesion
Indications:
RecurrentorincompletelyexcisedBCCorSCC
PrimaryBCCorSCCwithindistinctborders
Lesionslocatedinhighriskorcosmeticallyand
functionallyimportantareas(e.g.face)
Tumorswithaggressiveclinicalbehavior(ie,rapidly
growing,>2cmindiameter)oraggressivehistologic
subtype
Tumorsarisinginsitesofpreviousradiationtherapy
Tumorsarisinginimmunosuppressedpatients
Advantages:
Lowriskofrecurrence
Exceptionallyhighcurerates
Designedtoremovetumorwithsmallestpossiblemargins
Disadvantages:
Surgicalrisks
Requiresspecialequipmentandtechnician
Moretechnicallydifficult
Notoptimalforalltumors
Step1:Clinicalexaminationanddeterminationof
visiblemargins
Step2:Visibletumorissurgicallyremoved
Step3:Alayerofskinisremovedanddividedinto
sections,whicharecolorcodedwithdyes;reference
marksmadeonskinfororientation;mapofsurgical
sitedrawn
Step4:Undersurfaceandedgesofeachsectionare
microscopicallyexaminedforevidenceofremaining
cancer
ImagecourtesyofAmericanCollegeofMohsSurgery
TheMohsSurgeryProcedure.StepbyStepProcess.[illustration].RetrievedOct3,2011,fromhttp://www.skincancermohssurgery.org/mohssurgery/mohs
procedure.php
Step5:Ifresidualcancerisseenundermicroscope,
surgeonmarkslocationonmapandreturnstopatient
toremoveanotherlayerofskinwherecancercells
remain
Theremovalprocessstopswhenthereisnolonger
anyevidenceofcancerremaininginthesurgicalsite
ImagecourtesyofAmericanCollegeofMohsSurgery
TheMohsSurgeryProcedure.StepbyStepProcess.[illustration].RetrievedOct3,2011,fromhttp://www.skincancermohssurgery.org/mohssurgery/mohs
procedure.php
DrugEruptions
Roujeau,JC,SternRS.Severeadversecutaneousreactionstodrugs.NEnglJMed1994;331:1272
DrugEruptions
Etiology
Oftenclassifiedasimmuneandnonimmune
Immune:typeI,II,IIIIVhypersensitivityreactions
Nonimmune:cumulativetoxicity,overdose,photosensitivity,
druginteractions,andmetabolicalterations
Adrugreactionshouldbeconsideredinanypatientonmedication
withacuteonsetofaneruption(usuallysymmetric)
Roujeau,JC,SternRS.Severeadversecutaneousreactionstodrugs.NEnglJMed1994;331:1272
DrugEruptions
Commonmorphologies:
morbilliform(95%)andurticarial(5%)
Lesscommonmorphologiesinclude:pustular,
bullousandpapulosquamous
Drugreactionscanalsocausepruritiswithout
anobviouseruption
Morbiliformeruption
Drugsmostcommonlyimplicated:
antimicrobialagents,nonsteroidalanti
inflammatorydrugs(NSAIDs),cytokines,
chemotherapeuticagents,anticonvulsants,and
psychotropicagents
ShearNH,KnowlesSR,ShapiroL.Cutaneousreactionstodrugs.In:FitzpatrickTB,WolffK,eds.FitzpatricksDermatologyinGeneralMedicine.7thed.NewYork,
NY:McGrawHill;2008:355362
DrugEruptions
Drugscommonlyimplicatedineachtypeofreaction
Urticaria
Morbilliformrash
Lichenoidrash
CutaneousVasculitis
Antibacterial,nonsteroidal
antiinflammatorydrugs,
antidepressants,opioids,imidazoles
Antibacterial(penicillin,
sulfonamides),anticonvulsants,
gold,allopurinol,diuretics
Antimalarials,gold,blockers,
diuretics,sulfonylureas,hypoglycemic
agents
Diuretics(furosemide,
thiazides),antibacterials,allopurinol,
amiodarone
YawalkarN.Druginducedexanthems.Toxicology2005;209:131
DrugEruptions
Drugscommonlyimplicatedineachtypeofreaction
Photosensitivity
Druginducedautoimmunerash
StevensJohnson
ToxicEpidermalNecrolysis
Amiodarone,phenothiazines,
sulfonamides,tetracyclines,
nonsteroidalantiinflammatorydrugs
Penicillamine,hydralazine,gold
Antigoutagents(allopurinol),
NSAIDS,antibiotics,anticonvulsants
Antigoutagents(allopurinol),
NSAIDS,antibiotics,anticonvulsants
YawalkarN.Druginducedexanthems.Toxicology2005;209:131
DrugEruptions
Benigndrugreaction
Mostpatientswithadrugeruptioncomplainonlyofitching
Mostdrugeruptionsaremild,selflimited,andusuallyresolveafter
theoffendingagenthasbeendiscontinued
Lookfor:absenceofsystemicmanifestationsandnormallabvalues
Warningsignsofamoreseriousreaction
Skinpain,skinnecrosis
Fever
Conjunctivitisormucousmembraneinvolvement
Blisters
Angioedema
Palpablepurpura
ElevatedBUN/creatinineorliverfunctiontests
DrugEruptions
ErythemaMultiforme(EM)
Targetlesions
EMisaspectrumofdiseases(EMminor,EM
major)
EMMinor(lessoftenduetoadrugeruption)
Maybeduetoinfection(e.g.herpessimplex
virus)
Characterizedbytargetlesionsdistributed
predominantlyonthedistalextremities(including
palms/soles)
Mucousmembraneinvolvementmayoccurbutis
notsevere
Patientsrecover,butrelapsesarecommon
Image:LeeTNesbitt,Jr.TheSkinandInfection:AColorAtlasandText,Sanders,CV,Nesbitt,LTJr(Eds),Williams&Wilkins,Baltimore1995.
AuquierDunantA,MockenhauptM,NaldiL,etal.Correlationsbetweenclinicalpatternsandcausesoferythemamultiformemajus,StevensJohnsonsyndrome,
andtoxicepidermalnecrolysis;resultsofaninternationalprospectivestudy.ArchDermatol2002;138:1019.
ErythemaMultiformeMajor
Severedrugreactionrequiringimmediatemedicalattention
Subcategoriesinclude:StevensJohnsonsyndrome(SJS)andtoxic
epidermalnecrolysis(TEN)
Characterizedbyepidermalnecrosisandsloughingofthemucous
membranesandskin
InSJS,lesionsaffectlessthan10%ofthebodysurface;InTEN,
greaterthan30%affected
VictorD.Newcomer,MD(UCLA).ToxicEpidermalNecrolysis.[photograph].
RetrievedOct3,2011,fromhttp://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?
moduleId=7&diagnosisId=52413&imageIndex=29
DrugEruptions
Etiology:
Notcompletelyunderstood
80%ofcasesassociatedwithadversedrug
reaction
VictorD.Newcomer,MD(UCLA).ToxicEpidermalNecrolysis.[photograph].RetrievedOct3,2011,from
Presentation
Prodromeoffever,malaiseandpain(oftenlikeasunburn)
Primarylesionsincludeduskyredmaculesofirregularsize
thatstartonthetrunkandspread
Alwaysscreenformucosalsymptomsincluding:painful
eyes,painfulswallowing,dysuriaanddiarrhea
Ocular,oral,andgenitalmucosaareaffectedin>90%of
cases
Mortality
Varieswithtype
SJS15%mortality;TENcarriesa2530%mortality
BorchersAT,LeeJL,NaguwaSM,CheemaGS,GershwinME.StevensJohnsonsyndromeandtoxicepidermalnecrolysis.AutoimmunRev.
2008Sep;7(8)598605.
DrugEruptions
Workup
Consideralternativeetiologies,e.g.viralexanthemsand
bacterialinfections
Takeagoodmedicationhistory
Reviewthecompletemedicationlist,includingoverthe
countersupplements
Notetheintervalbetweentheintroductionofadrugand
onsetoftheeruption
Patientscandevelopdrugeruptionstomedicationsthey
havebeenonforprolongedperiods
Documentanyhistoryofpreviousadversereactionsto
drugsorfoods
DrugEruptions
Workup
Biopsycanbehelpfulinconfirmingthediagnosis(e.g.,
byshowingeosinophilsinmorbilliformeruptions)
CBCwithdiff,Liverfunctiontests,immunoserology
testsmaybeorderedforsuspecteddruginduced
autoimmunerash,culturesifinfectionissuspected
DrugEruptions
TreatmentofCommonDrugEruption
Stopallnonessentialmeds(for>1month)
MonitorforsignsofsystemicinvolvementorSJS/TEN
Therapyformostdrugeruptionsismainlysupportive
Morbilliformeruptionscanbetreatedwithoral
antihistaminesandtopicalsteroids
Prednisonemaybeusedcautiouslyinthetreatmentof
hypersensitivitysyndromewithheartandlung
involvementorsevereserumsicknesslikereaction
Slowlyreintroduceothermedicationsaftersuspectedagentis
identified
FrenchLE,TrentJT,KerdelFA.UseofintravenousimmunoglobulinintoxicepidermalnecrolysisandStevensJohnsonsyndrome:ourcurrentunderstanding.Int
Immunopharmacol.Apr2006;6(4):5439.
TreatmentofErythemaMultiformeMajor
Transfertoaburnunitwithaggressivesupportivecareisthe
mostcriticalstepinmanagement
ConsultationwithDermatologyandOphthalmology
Rapididentificationand
withdrawalofoffendingdrug
improvessurvival
IVIGmaybeindicated;
efficacyiscontroversial
BorchersAT,LeeJL,NaguwaSM,CheemaGS,GershwinME.StevensJohnsonsyndromeandtoxicepidermalnecrolysis.AutoimmunRev.2008Sep;7(8)598605.
RobertChalmers,MD.ToxicEpidermalNecrolysis.[photograph].RetrievedOct3,2011,from
OtherDermatologicConditions
intheGeriatricPopulation
Severaldermatologicconditionshaveahigher
incidenceinthegeriatricpopulation
Examplesinclude:
HerpesZoster
BullousPemphigoid
VenousStasis
Suninducedskinchanges
HerpesZoster
Etiology
ReactivationofVaricellaZoster
Virus
Clinical
Prodromeofradicularpain&
pruritusfollowedbyskineruption
consistingofgroupedvesicleson
erythematousbaseindermatomal
distribution
Postherpeticneuralgiamayfollow
causingdebilitatingpaininthe
affecteddermatome
(UniversityofRochester,DepartmentofDermatology).Zoster.[photograph].RetrievedOct3,2011,from
HerpesZoster
Diagnosis
Typicallyclinical.Canalso
performTzancksmear,viral
culture,ordirect
immunofluorescence
VictorNewcomer,MD(UCLA).(Jan2006).HerpeticWhitlow[photograph].RetrievedOct3,2011,from
HerpesZoster
Prevention
Zostavaxliveherpeszoster
vaccine
ReducesShinglesby51.3%
Reducescasesofpostherpetic
neuralgiaby66.5%
OxmanMN,LevinMJetal.Avaccinetopreventherpeszosterandpostherpeticneuralgiainolderadults.NEnglJMed.2005Jun2;352(22):227184.
NancyEsterly,MD.Zoster.[photograph].RetrievedOct3,2011,from
HerpesZoster
Treatment
Bestifinitiatedwithin72hoursof
startofsymptoms
Antivirals:Acyclovir,
ValcyclovirorFamciclovir
Supportive:paincontrol,
sedatives,moistdressingsto
affectedskin
Useofgabapentinmayreducethe
incidenceofpostherpetic
neuralgia
LapollaW,DiGiorgioC,HaitzKetal.Incidenceofportherpeticneuralgiaaftercombinationtreatmentwithgabapentinandvalacyclovirinpatientwithacute
herpeszoster.ArchDerm;147:901907.
VictorD.Newcomer,MD(UCLA).(Nov2005)Zoster.[photograph].RetrievedOct3,2011,from
BullousPemphigoid
Etiology
Autoimmunedisordercausedby
autoantibodiesto
hemidesmosomesattachment
complexesanchoringbasal
keratinocytestothebasement
membrane
Antibodydepositionatthe
basementmembraneleadsto
inflammatoryresponseand
formationofsubepidermalblisters
(NYU,DepartmentofDermatology).BullousPemphigoid.[photograph].RetrievedOct3,2011,from
BullousPemphigoid
Clinical
Beginsaspruriticpapular
eruptionevolvingintolarge,tense
ovalbullaewithserousor
hemorrhagicfluid
Commonlyaffectedareasinclude
axillae,medialthigh,groin,
abdomenandlowerleg
Mucousmembranesareseldomly
involved.
(NYU,DepartmentofDermatology).BullousPemphigoid.[photograph].RetrievedOct3,2011,fromhttp://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?
BullousPemphigoid
Diagnosis
Basedonclinicalpresentation,
presenceofsubepidermalblisters
onhistologyanddemonstration
ofantihemidesmosome
antibodiesbydirectandindirect
immunofluorescence
(UniversityofRochester,DepartmentofDermatology).BullousPemphigoid.[photograph].RetrievedOct3,2011,from
BullousPemphigoid
Treatment
Immunosupressivetherapywith:
o Prednisone
o Azathioprine
o Methotrexate
Tetracyclineandnicotinamide
InrefractorycasescanuseIVIG
(NYU,DepartmentofDermatology).BullousPemphigoid.[photograph].RetrievedOct3,2011,from
VenousStasisDisease
Etiology
Riskfactorsinclude:
Age
FamilyHistory
ProlongedStanding
IncreasedBMI
Sedentarylifestyle
Venoushypertensiondevelops
duetooneorcombinationof:
Poormusclepump
function
Incompetentvenousvalves
CharlesE.CrutchfieldIII,MD.(March2007).VenousUlcer.[photograph].RetrievedOct3,
2011,fromhttp://www.visualdx.com/visualdx/visualdx6/
Venousobstruction
getZoomImage.do?moduleId=11&diagnosisId=52465&imageIndex=0
Clinical
ImagecourtesyofMargaretMann,M.D.
Severityofsymptomsdepends
ondegreeofvenousreflux.
Inorderofseverity:
Telangiectasiasand
ReticularVeins
VaricoseVeinsdilated,
tortuousveins>3mminsize
ChronicVenous
Insufficiency
o Edema
o Skindiscoloration
o Ulcers
o Lipodermatosclerosis
fibrosingpanniculitis
withhyperpigmentation
VenousStasisDisease
Diagnosis
Venographygold
standard,butinvasive,
expensive,associatedwith
complications
Duplexultrasoundmost
frequentlyusedtoassess
fordeepvenous
thrombosis,venousreflux
Anklebrachialindex
usedtoexcludearterial
disease
ImagecourtesyofMargaretMann,M.D.
VenousStasisDisease
Treatment
Conservativemanagement:
Legelevation,compressiontherapy
Skincleansing,emollients,andtopicalsteroids
Ablationtherapy:
Liquidandfoamsclerotherapyfortreatmentoftelangiectasias,
reticularveinsandsmallvaricoseveins
Endovenouslaserorradiofrequencyablationaswellas
mechanicalablationareusedtodestroylargeveins
SunInducedSkinChanges
Sunspotsorliverspotsare
alsocalledlentigines,oftenon
backsofhandsandshoulders
Causedbythesunandgenerally
harmless,butcanbeconfusedwith
moreseriousskingrowths
Canbetreatedwithliquidnitrogen
cryotherapyormelanintargeting
lasers(e.g.,theQswitchedruby
laser)
CharlesE.CrutchfieldIII,MD.(March2007).Lentigo,Solar.[photograph].RetrievedOct3,2011,from
SunInducedSkinChanges
Telangiectasias,ordilatedblood
vessels,canariseasaresultof
photodamage,rosacea,radiation
exposure,longtermtopicalsteroid
therapyorhereditarycauses
Mostlybenignandcanbe
effectivelytreatedwithpulseddye
lasers,othervasculartargeting
lasersorinsomecases,
electrocautery
(NYU,DepartmentofDermatology).Telangiectasia.[photograph].RetrievedOct3,2011,fromhttp://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?
Questions
1.Which2primarylesionsareelevated:
a)MaculeandPlaque
b)MaculeandPapule
c)PapuleandPatch
d)PapuleandPlaque
2.TrueorFalse,drugeruptionsoccurmorefrequentlyinelderly
patients?
a)True
b)False
Answers:1.d,2.a
3. Thepatientisa75yomalewithnohistoryofskincancerwho
presentsbecausehiswifebecameconcernedaboutlargemole
likegrowthsonhisback,whichhaveincreasedinnumberover
theyears.Thepatientsayssomeofthemareitchy.Onphysical
examthelesionsaredarkbrownsymmetricpapulesandplaques
ofuniformcolorwithstuckonwaxyappearance.Whatisthe
diagnosis?
a)ActinicKeratosis
b)Solarlentigo
c)SeborrheicKeratosis
d)BenignNevus
4.Inthispatient,whatisthemostappropriatenextstepin
management?
a)Urgentreferraltoadermatologistforbiopsy
b)Photodynamictherapy
c)FullbodyCTscantolookformetastases
d)Cryotherapywithapplicationofliquidnitrogento
symptomaticlesionsAnswers3.c,4.d.
5.Thepatientisa60yearoldmalewithahistoryofsignificantsun
exposurewhopresentsforaroutineskincheck.Hehasahistoryof
multipleroundsofcryotherapyforprecancerouslesions.On
physicalexamtherearemultipleskincoloredpapuleswithrough
adherentscalelocatedonhishandsandface.Whatisthediagnosis?
a)ActinicKeratosis
b)SeborrheicKeratosis
c)Basalcellcarcinoma
d)Melanoma
6.Forthepatientinquestion5,besidescryotherapywhatisanadditional
treatmentoption
a)5Fluorouracilcream
b)Chemicalpeels
c)ImiquimodCream
d)Photodynamictherapy
e)Alloftheabove
Answers:5.a,6.e
7.A55yearoldfemalewithahistoryofablisteringsunburnasachild
andfamilyhistoryofskincancerpresentswithalesiononherchest,
whichshefirstnoticed1monthago.Shedeniesanypainbutreports
thelesionbledwithminortraumalastweek.Onphysicalexamthe
lesionisashiny,redlesionwithrolledbordersandprominent
telangiectasias.Themostlikelydiagnosisis:
a.Melanomainsitu
b.Squamouscellcarcinoma
c.NodularBCC
d.SuperficialBCC
e.HerpesZoster
f.PigmentedBCC
Answer:c
8.Thispatientisa60yearoldfemalewhopresentswithalarge,tensebullae,asshown
below.Priortotheappearanceofthebullae,shenotedapruriticpapulareruptioninthe
samedistribution.Abiopsywasperformed,whichrevealedasubepidermalblisterand
immunofluorescencedemonstratedpresenceofantihemidesmosomeantibodiesinthe
serum.Whatisthediagnosis?
a)HerpesZoster
b)BullousPemphigoid
c)Drugeruption
d)Dermatomyositis
Answer:b

Common Dermatologic Issues

Uploaded by

Copyright:

Available Formats

Common Dermatologic Issues

Uploaded by

Document Information

Original Description:

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Common Dermatologic Issues

Uploaded by

Copyright:

Available Formats

CommonDermatologicIssuesinthe

You might also like