DERMATOLOGY UPDATE
From the Annual Spring Family Practice Review, sponsored by the Temple University School of Medicine,
Philadelphia
| COMMON SKIN PROBLEMS —Jennifer T. Clarke, MD, Assistant Professor of Dermatology, Pennsylvania State University,
College of Medicine, Milton S. Hershey Medical Center, Hershey, Pennsylvania
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Acne
| Physical examination of acne: look for comedones, papules, pustules, nodules, cysts, and scarring; acne affects face, upper
trunk, shoulders, and chest
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| Comedones: closed—flesh-colored follicular-based papules; whiteheads; initiating lesions of acne; seen in patients with
mild acne and in older children or early adolescents; open—dilated follicular papules with dark centers; blackheads
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| Inflammatory acne: red inflamed papules; pustules; patients who develop nodules, cysts, and have potential for scarring
need more aggressive therapy; patients with history of scarring need strong therapy and referral
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| Pathogenesis of acne: 1) increased cohesion or hyperkeratosis of epidermal cells that line follicular ostia; epidermal cells
lining hair follicle become more cohesive, plug follicular ostia, and prevent outflow of dead keratinocytes and sebum; 2)
increased sebum production and follicular hyperkeratinization result in comedones; 3) influx of inflammatory cells often
in response to overproliferation of Propionibacterium acnes; 4) development of red papules and pustules; can progress
to cyst formation and rupture; patients develop deeper nodules, large cysts, and scarring
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| Treatment: choose agents that target pathogenic factors; topical retinoid for retention hyperkeratosis that causes comedonal
acne; treat P acnes with oral or topical antibiotic and benzoyl peroxide; no antibiotic resistance shown with benzoyl peroxide;
oral antibiotics—eg, tetracycline, for inflammatory acne; wait 6 to 8 wk for anti-inflammatory effect (give minimum
3-mo course); oral contraceptives, hormonal therapy, and isotretinoin (Accutane) decrease sebum production; combination
of topical retinoid, benzoyl peroxide, and antibiotic works synergistically
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Atopic Dermatitis
| Major criteria for diagnosis: patient should meet ≥3; 1) pruritus; 2) typical morphology and distribution of rash; infants
often present with first signs on face and extensor surfaces (areas where infant able to rub or scratch); later distribution on
popliteal and antecubital fossa, neck, and wrists; 3) chronic or chronically relapsing course; 4) personal or family history
of atopic disease (including allergic rhinitis, asthma, eczema)
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| Treatment: flares—bathing for maintenance and prevention; mid-potency steroid (eg, triamcinolone ointment); adequate
moisturization and skin care recommended between flares; for earliest signs of erythema or pruritus, use topical immunomodulator
(eg, tacrolimus, pimecrolimus); bathing once daily or once every other day; recommend mild soap (eg, Dove)
and immediate moisturization; minimize bath time to 5 to 10 min in lukewarm water; no bubble baths; wash child’s hair
at end of bath to avoid having child sit in soapy water; bar soaps recommended; moisturizing with ointments (eg, Vaseline
petroleum jelly) and creams (eg, Eucerin, Cetaphil) important; avoid lotions; encourage patients to moisturize skin at
least twice daily all over body in between flares; overmedication occurs when patients use moisturizer and combination
product of medication and moisturizer; topical immunomodulators as efficacious as low-potency corticosteroids; for
flares, use stronger mid-potency steroids (eg, triamcinolone, mometasone); prescribe ointments rather than creams
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Dermatophyte Infections
| Case presentation: Puerto Rican woman 61 yr of age presents with 2-mo history of itchy burning papules and purplish
plaques around swollen eyelids; woman presents 1 day after arriving in United States from visiting Puerto Rico; no improvement
with low- and ultra-high potency steroids, mupirocin ointment, oral ampicillin sulbactam, oral ciprofloxacin, and oral
acyclovir; woman had annular patches on cheeks and forehead; diagnosis—KOH examination of scraping from patches on
eyelids showed branching hyphae; dermatophyte infection; scraping scales allows for definitive diagnosis; pets common
source of dermatophyte infections; scraping scales on scalp often unhelpful because fungus lives within hair shaft (obtain
culture); untreated tinea capitis can result in inflammatory plaques with alopecia, widespread patches of alopecia, or permanent
alopecia
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| Treatment of dermatophytosis: topical azoles or allylamines; if fungus affects hair or nails, use oral agent (eg, griseofulvin,
azole, allylamine); griseofulvin 25 mg/kg daily for 8 wk; corticosteroids—allow fungus to thrive and penetrate deeper into
hair follicles, resulting in deep plaques with patches of alopecia (Majocchi’s granuloma), and topical treatment ineffective
(patients need oral antifungal agents); combination products (eg, clotrimazole, betamethasone, lotrisone) do not treat fungus
adequately, and patients develop side effects from steroid (eg, atrophy and hypopigmentation from betamethasone)
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Warts
| Wart therapy: destructive or immunologic; requires repeated applications; 35% to 65% resolve spontaneously over 2 yr;
duct tape—61 patients randomized to cryotherapy for 10-sec freezes every 2 to 3 wk or duct tape every 6 days for 2 mo;
51 patients completed study; 22 of 26 in duct tape group cleared; 15 of 25 in cryotherapy group cleared
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| Flat warts: flat-topped papules on back of hand; patients often misdiagnosed with seborrheic keratoses or actinic keratoses;
can appear on face; spread by trauma (often seen in areas where patients shave); tretinoin liquid effective
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| Plantar warts: distinguish from corns—warts interrupt skin lines with black puncta (dilated blood vessels); corns occur
over bony prominences (warts do not)
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Psoriasis
| Evaluation of psoriasis: look at morphology and distribution; determine whether psoriasis involves localized amounts of
skin, small scaly plaques, facial skin, or scalp; identify large confluent plaques that involve most of body surface; determine
whether disease more localized with potential to cause functional impairment
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| Topical therapy: best for patients with limited skin involvement, milder psoriasis, or widespread disease (but for whom systemic
therapies too risky); refer patients when psoriasis spreads
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| UV light therapy: UV-A (add oral sensitizing agent [eg, psoralens]) and UV-B can produce excellent results in widespread
psoriasis; tanning beds increase risk for skin cancer (screen patients periodically)
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| Systemic agents: immunosuppressive agents (eg, methotrexate, cyclosporin); retinoids (eg, acitretin [Soriatane]); biologic
agents—best for patients with involvement of ≥10% of body surface or patients with less body surface involvement in whom
psoriasis causes functional impairment; refer to specialist; etanercept (Enbrel), alefacept (Amevive), and efalizumab (Raptiva)
approved by Food and Drug Administration (FDA) for psoriasis
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Skin Cancer
| Evaluation of melanoma: patients often have irregularly shaped, dark-colored macules and papules all over body, representing
atypical nevi and melanoma; watch for “ugly duckling” sign (look for things that stand out on skin); ABCDs—
asymmetry; border of growth; color; diameter
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| Treatment of benign growths: when uncertain, refer or perform biopsy; when concerned about melanoma, perform excisional
biopsy or deep-shave biopsy
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| Basal cell carcinoma: scarlike morphology characteristic of morphea-form basal cell carcinoma (tends to infiltrate widely
and deeply); can be locally aggressive when left alone for long time; surgical removal can be disfiguring; be aware of “red
dot” (spot on skin that does not resolve)
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| Skin cancer therapy: preventive therapy includes education about looking for “ugly duckling” and “red dot,” using sunscreen,
performing self-skin examinations; performing biopsy on suspicious lesions; referral to dermatologist for surgical
treatment after diagnosis; radiation plays small role
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| MALIGNANT MELANOMA —Robert J. Pariser, MD, Professor, Department of Dermatology, Eastern Virginia Medical
School, Norfolk, Virginia
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| Introduction: ≈59,000 new cases annually estimated in United States (excluding in situ lesions); most common malignancy
in 20- to 30-yr age range; slight male predominance; >100,000 new cases yearly worldwide
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| Risk predictors: positive history of melanoma highest predictor; increased nevi; positive family history; atypical nevi; fair
complexion, blue eyes, and red or blonde hair; history of blistering childhood sunburns; immunosuppression; xeroderma
pigmentosum
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| Prognosis: depth of invasion of melanoma related to likelihood of regional and distal metastases; penetration <0.75 mm implies
nearly no risk for distant disease and small risk for regional adenopathy; most patients have regional and distant metastases
with penetration >4.00 mm
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| Types of melanoma: superficial spreading—flat and broad; clearly violates ABCDs; ruler sign shows long diameter; hypopigmented
or amelanotic melanomas difficult to diagnose or recognize; nodular—round; may or may not be dark or
asymmetric; ABCD criteria may fail; lentigo maligna—broad, flat, spreading melanoma seen in sun-damaged skin;
usually on face in elderly people; can be large with typical irregular border and variable pigmentation; presents in shades
of brown rather than red, white, and blue as seen in more deeply situated melanomas; acral lentiginous—affects distal
parts; subungual and periungual melanomas often diagnosed late because often treated as other condition (eg, fungal infections,
psoriasis); small melanomas—ABCDs least useful; lesions 2 to 4 mm with some irregularity in color, shape,
and border; some lesions round; diagnosis not obvious
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| Emerging criteria: newly noted lesion in at-risk patient; “ugly duckling” syndrome; melanomas can affect eyes and central
nervous system (CNS)
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| Nevi: preexisting nevus—performing biopsy on thickest part of lesion may result in benign results and missed melanomas;
dysplastic nevus syndrome—people with above-average number of pigmented nevi at risk; follow patients who have moles;
congenital nevi—substantial risk for melanoma from large bathing-trunk nevi; less risk with smaller (eg, palm-sized) nevi;
halo nevus—preexisting nevus suddenly surrounded by hypopigmented halo; usually benign; lymphocyte attack on melanocytes
results in regressed nevus and vitiliginous circle
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| Pigmented nail streak (melanonychia striata): present and stable cases with involvement of multiple nails usually do not
imply risk; recent involvement of one nail usually benign nevus (perform nail matrix biopsy to rule out melanoma)
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| Melanoma: public awareness increasing; uncertainty in clinical and pathologic diagnosis increasing; width of specimen becoming
more important than depth
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| Diagnostic tools: ≈60% accurate; dermoscopy or epiluminiscent microscopy—magnification under oil; algorithm—
look at dermatoscopic structures (eg, pigment network); score according to ABCDs (eg, 0 points for symmetry, 1 point
for asymmetry in only 1 plane, 2 points for asymmetry in 2 planes); multiply by appropriate factor; score <4.76 implies
benign lesion, >5.45 implies melanoma, 4.76 to 5.45 implies suspicious lesion; not standard of care
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| Conclusion: better prognosis with earlier diagnosis; less concern about width and surgical margins; lymph nodes “up in the
air”; sentinel nodes becoming standard of care; suspicious mole—remove entire lesion if possible; request consultation
when uncertain
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| SKIN MANIFESTATIONS OF SYSTEMIC DISEASE AND DRUGS —O. Fred Miller III, MD, Director, Department of
Dermatology, Geisinger Medical Center, Danville, Pennsylvania
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| Approach to cutaneous diagnosis: adequate lighting (no incandescent bulbs); magnification; use fingers to examine skin
(eg, pinch or stretch skin to bring out morphology); location, distribution, color, and size of lesions; determine whether
lesions primary or secondary; pruritus—itchy; look for primary lesions; impetigo—honeycomb-colored (ie, brown yellow)
crust; seen more in pediatric population than adult population; look for systemic implications (eg, small ulcerations
caused by group A β-hemolytic Streptococcus and associated glomerulonephritis); blisters frequently not seen because
completely contained within epidermis and often become broken or rubbed off; may or not present with associated adenopathy;
usually caused by Staphylococcus
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| Dermatomyositis: distinctive purple color with unusual reticulated pattern of hypopigmentation within pigmented area;
more pruritus (especially on scalp) than lupus
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| Lupus: more erythematous color; sometimes subacutely ery-thematous; no lavender color; discoid lupus—coin-shaped
lesions present in more discrete patches; little plugs of keratin (carpet-tack plugging) visible with good lighting and magnification
in lupus plaque; severity of lesions varies; usually fade without scarring; butterfly rash of lupus—usually presents
with systemic signs and symptoms; frequently occurs with lupus flare; patients often lose hair; hairs break and
become unmanageable (hair returns after acute episode); scarring of scalp can be permanent; some patients develop rheumatoid
nodules
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| Seborrheic dermatitis: waxy scales in nasolabial folds, glabella, and anterior chest can be misdiagnosed as systemic disease;
responds well to ketoconazole cream
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| Medication reactions: itchiness variable; no rash specificity for particular drug (eg, cephalexin [Keflex] can result in maculopapular
eruption or Stevens-Johnson eruption); adverse cutaneous reaction usually fades when drug discontinued; eosinophilia
variable (not significant criterion); bilateral involvement; skin can react with identical rash to many stimuli and drugs;
phototoxic reaction (ie, sunburn) seen with hydrochlorothiazide; pigmentary changes seen with amiodarone; pigmentation
with minocycline (Minocin) common; fixed-drug eruption (involvement of same area every time drug taken) unusual; consider
group A β-hemolytic streptococcal infection in children with urticaria; erythema nodosum—can be caused by medications
but usually caused by β-hemolytic Streptococcus and ulcerative colitis or Crohn’s disease; also associated with
sarcoidosis, hilar adenopathy, and deep fungal disease; can be caused by oral contraceptives; toxic epidermal necrolysis—
patients shed skin in entirety; can be caused by sulfonamides
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Educational Objectives
| The goal of this program is to educate the listener about common skin disease and skin cancer. After hearing and assimilating
this program, the clinician will be better able to:
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 | 1. Select appropriate therapy for acne and atopic dermatitis.
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| 2. Choose effective therapy for dermatophyte infections and warts.
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| 3. Assess risk for malignant melanoma.
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| 4. Evaluate lesions for cutaneous diagnosis.
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| 5. Recognize adverse skin reactions to medications.
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Discussed on This Program
Acitretin [Soriatane]
Acyclovir (acycloguanosine) [Zovirax]
Alefacept [Amevive]
Ampicillin [Principen]
Benzoyl peroxide (several trade names)
Betamethasone [Celestone]
Cephalexin [Biocef, Keflex]
Cetaphil (soap-free therapeutic cleanser) Ciprofloxacin [Ciloxan, Cipro, Cipro I.V., Cipro XR]
Clotrimazole (several trade names)
Cyclosporine (cyclosporin A) [Neoral, Sandimmune, SangCya]
Efalizumab [Raptiva]
Etanercept [Enbrel]
Eucerin (petrolatum, mineral oil, mineral wax, woolwax alcohol) Griseofulvin microsize [Fulvicin U/F, Grifulvin V,
Grisactin 250, Grisactin 500]
Griseofulvin ultramicrosize [Fulvicin P/G, Grisactin Ultra, Gris-PEG]
Isotretinoin (13-cis-retinoic acid) [Accutane]Ketoconazole [Nizoral, Nizoral A-D, Nizoral Cream Shampoo]
Lotrisone (combination of betamethasone [as dipropionate] and clotrimazole )
Methotrexate (amethopterin; MTX) [Methotrexate LPF, Rheumatrex Dose Pack, Trexall]
Minocycline HCl (minomycin) [Arestin, Dynacin, Minocin, Minocin IV, Vectrin]
Mometasone furoate [Elocon, Asmanex Twisthaler]
Mupirocin (pseudomonic acid A) [Bactroban, Bactroban Cream, Bactroban Nasal] Pimecrolimus [Elidel]
Tacrolimus (FK506) [Prograf, Protopic]
Tetracycline HCl (several trade names)
Tretinoin (trans-retinoic acid; vitamin A acid) [Altinac, Atragen (investigational), Avita, Renova, Retin-A, Retin-A Micro,
Vesanoid]
Triamcinolone (oral) [Aristocort, Atolone, Kenacort]
Triamcinolone acetonide (several trade names)
White petrolatum [Vaseline]
Suggested Reading
Aloia TA et al: Management of early-stage cutaneous melanoma. Curr Probl Surg 42:460, 2005; Chapman MS et al:
Tacrolimus ointment 0.03% shows efficacy and safety in pediatric and adult patients with mild to moderate atopic dermatitis.
J Am Acad Dermatol 53:S177, 2005; Charles CA et al: Variation in the diagnosis, treatment, and management of melanoma
in situ: a survey of US dermatologists. Arch Dermatol 141:723, 2005; Dyson SW et al: Impact of thorough block
sampling in the histologic evaluation of melanomas. Arch Dermatol 141:734, 2005; Joseph WS: The oral antifungal patient.
Clin Podiatr Med Surg 21:591, 2004; Khachemoune A et al: Assessing malignant melanoma: a case study. Dermatol
Nurs 17:188, 2005; McKenna JK et al: Dermatologic drug reactions. Immunol Allergy Clin North Am 24:399, 2004;
Micali G et al: Management of cutaneous warts: an evidence-based approach. Am J Clin Dermatol 5:311, 2004; Schattner
A et al: The future of the treatment of systemic lupus erythematosus. Clin Exp Rheumatol 23:254, 2005; Simonart T
et al: Treatment of acne with topical antibiotics: lessons from clinical studies. Br J Dermatol 153:395, 2005; Van de
Kerkhof PC et al: Recommendations for the topical treatment of psoriasis. J Eur Acad Dermatol Venereol 19:495, 2005;
Wong SL: The role of sentinel lymph node biopsy in the management of thin melanoma. Am J Surg 190:196, 2005;
Zouboulis CC et al: What is the pathogenesis of acne? Exp Dermatol 14:143, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Drs. Clarke, Pariser, and Miller spoke in Lancaster, Pennsylvania at the annual Spring Family Practice Review, presented
March 13-18, 2005, by Temple University School of Medicine and Lancaster General Hospital. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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