DERMATOLOGY
From the University of California, San Diego, School of Medicine’s Topics and Advances in Internal Medicine,
February 22-28, 2007
| DERMATOLOGY PEARLS: DIAGNOSIS AND MANAGEMENT —Michelle Pelle, MD, Adjunct Assistant Clinical
Professor of Medicine/Dermatology, University of California, San Diego, School of Medicine
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| Dermatitis and use of prednisone: classification of dermatitis—atopic, allergic, contact, hypersensitivity, or viral
exanthem; may appear alike at presentation; diagnostic and treatment considerations—symmetry key to diagnosis;
avoid just putting patient on prednisone if condition chronic; avoid use of methylprednisolone (Medrol) dose
pack for dermatologic conditions (too short acting; potential for rebound); dermatitis requires longer steroid taper;
dermatitis also requires barrier repair mechanism while patient tapering steroids; recommend oral antibiotics during
prednisone taper to manage Staphylococcus and other skin organisms, or if unsure whether dermatitis atopic;
corticosteroids contraindicated in patient with psoriasis, because of severe rebound reaction (can cause erythrodermic
psoriasis; associated with congestive heart failure); also consider nummular eczema (can resemble psoriasis);
once barrier breakdown occurs, rebound effect occurs after withdrawal from systemic anti-inflammatory agents;
recommend use of ointments on skin as barrier-repair mechanism; consider pharmaceutical-grade moisturizer to repair
skin barrier; refer to dermatologist if unsure; avoid application of cream for dermatitis (tends to burn); tapering
prednisone—start with 1 mg/kg of corticosteroid, maximum 60 mg in most patients; maintain maximum dose for
3 to 5 days; taper by 10 mg every 3 days; have patient take calcium and vitamin D during treatment; add bisphosphonate
if duration of treatment >1 mo; recommend topical steroid ointment once patient taking <20 mg; consider
oral antibiotics to avoid infection
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| Acne in adults: treatment options—include topical retinoid (tretinoin [eg, Retin-A], tazarotene [eg, Tazorac], and
adapalene [Differin]), topical antibiotics, exfoliants, and oral antibiotics; “beard presentation” in women—acne
usually distributed over lower face in adult women; may see more comedonal presentation on forehead, with cystic
presentation on lower face; presentation indicates androgens involved; end organ hypersensitivity to testosterone
leads to acne cysts; most patients not hyperandrogenic (usually find normal serum levels of dihydroepiandrosterone
sulfate [DHEAS] and testosterone); treatment usually involves antiandrogenic agent, eg, spironolactone 25 to 50
mg/day; consider addition of spironolactone if patient already taking oral contraceptive (synergistic response;
lower dose); obtain DHEAS and testosterone levels in all patients; check potassium levels at beginning of treatment
and if dosage increased; dosage usually <100 mg/day; consider external application of green tea extract (contains
slight antiandrogenic properties); consider use of exfoliant, eg, salicylic acid or glycolic acid; also consider
oral antibiotics; isotretinoin—recommended in nodular cystic acne; not for women with cystic acne that follows
beard distribution; drug-induced acne—can occur in patient taking antiseizure medication, antipsychotic drug, or
from topical steroid overuse in patient with tendency toward acne rosacea; pseudofolliculitis—problem in men; not
just shaving issue; hair follicle coming out of skin at acute angle can create foreign body response (ingrown hair
phenonenon); tell patients to avoid pulling skin taught while shaving, shave with grain, use razor that does not produce
closest shave; use topical retinoids for ingrown hairs or skin redness; consider occasional use of topical steroid
to prevent redness; consider laser hair removal in severe cases
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| Melanoma: classic atypical mole syndrome (CAMS)—patient has many moles on body that all look different from
each other, eg, mole with “fried egg look”; indicates atypical cystology; associated with higher rates of melanoma
(10-yr cumulative risk 10.7%, compared to 0.62% in control population); however, mortality highest in older man
with new amelanotic melanoma
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| Actinic keratosis (AK): occurs in lighter skin types; treatment—cryotherapy, 5-fluorouracil, and imiquimod (Aldara),
δ-aminolevulinic (ALA) photodynamic therapy; off-label use of tricholoracetic acid (TCA) peel not recommended
because of inadequate treatment response; topical retinoids prevent AK and keep patients in remission, but
not effective treatment; δ-ALA photodynamic therapy—paint skin with ALA and let incubate for 1 hr; shine blue
light on skin; can treat entire face with only 2 to 3 days of down time; other treatments—cryotherapy leaves white
marks and scars; consider topical therapy or photodynamic therapy for AKs that lie close together; 5-fluorouracil
(eg, Efudex)—recommend 5% cream applied only at night; do not treat entire face, but treat small areas in series;
apply cream for 3 wk, then patient can undergo another round in another area if needed; keep skin barrier intact
(have patient apply white petrolatum [Vasoline] on treated areas every morning); in patient with hypertrophic AK,
numb area, scrape off AK, and send to histology (avoid topical therapy)
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| Rosacea vs lupus erythematosus: difficult to distinguish in some cases; rosacea—associated with classic butterfly
pattern of erythema (sparing of upper cutaneous lip and nasolabial folds); central-face erythema (glabella,
cheeks, nose, chin; papule or pustule presentation; telangiectasia over nose, without lip involvement); rosacea in
men generally more sebaceous, with hypertrophic or hyperplastic sebaceous changes; rosacea can affect eyes (blepharitis
common presentation; sties good diagnostic clue); frequently associated with seborrheic dermatitis; lupus
erythematosus—lip involvement, significant phototoxic element, crusting, and phototoxic erythematous scale in
other locations; look for erythema between and on joints; refer to dermatologist if unsure of diagnosis
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| Seborrhea: found more often in older individuals; can occur along with rosacea; frequently associated with psoriasis
in young men; common in patients with HIV and AIDS (can be presenting sign); beard distribution characteristic
pattern; associated with neurologic disorders, eg, Parkinson’s disease; treatment—consider once-weekly
treatment with low- or mid-potency topical steroids, eg, desonide ointment; recommend zinc and sulfur products
(zinc soap, ZNP Bar [pyrithione zinc] or sulfur bar available generically); ketoconazole cream can decrease
yeast load; consider calcineurin inhibitors (eg, tacrolimus [eg, Protopic ointment] and pimecrolimus [Elidel
cream]); pimecrolimus easier to use; consider oral tetracycline in HIV-positive patients
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| Use of ointments: ointments preferred for dry scale (suggests barrier-repair issue); alcohol-based products cause
burning; gel form recommended for hot area (eg, axilla); ointment for dry areas; lotion or gel on wet areas; creams
effective if barrier intact
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| Shaving vs depilatory in pseudofolliculitis: epilation effective if patient tolerates epilation without pain or dyschromia
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| Hormone therapy for adult female acne: look at free T4 and DHEAS levels; free T4 level provides information
about functioning of ovaries (elevation suggests polycystic ovary syndrome [PCOS]), and DHEA sulfate provides
information about adrenal glands
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| MELANOMA: UNUSUAL PRESENTATIONS —Terence C. O’Grady, MD, Clinical Professor of Medicine (Dermatology)
and Pathology, University of California, San Diego, School of Medicine
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| Extracutaneous melanomas: epidemiology—≈15% of melanomas; distributed all over body, and only one-
third metastasize; exclude possibility of metastasis rather than primary lesion before labeling it extracutaneous;
≈80% of extracutaneous melanomas involve ocular region, genitourinary (GU) tissues next most common; also
examine scalp, nail beds, interdigital folds of toes, and perianal area
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| Oral mucosa: pigmented spots fairly common; labial melanosis—refers to pigmented freckle-like spots on lips,
particularly on lower lip; seen in some congenital disorders, eg, Peutz-Jeghers syndrome; benign condition that
can mimic malignant melanoma (eg, can appear dark, large, and irregularly outlined); pigment produced by melanocytes;
can refer patient to oral surgeon or otolaryngologist for biopsy; pathology shows some hyperpigmentation
along base; immunohistochemistry shows slight increase in number of melanocytes; oral melanomas—
can occur on oral mucosa, although rare; usually occur in older patients and usually in men; found more often on
hard palate, back of oral cavity, and maxillary gingiva; one-third associated with melanotic lesion; associated
with early neural invasion, and can spread directly to central nervous system
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| Rectal mucosa: melanomas—rare, represent <2% of extracutaneous melanomas; rectal melanosis can occur, primarily
in late adulthood; patients typically present because of bleeding, pain, or mass in area; associated with dismal
prognosis because of delay in diagnosis
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| Genital mucosa: appearance clinically suspicious; dark large (sometimes centimeters in diameter) pigmented lesions;
usually seen on non-hair–bearing skin; biopsy indicated (should involve more than one area of lesion);
vulvar melanoma—rare; most discovered late, usually occur after menopause, and usually located on glaborous
skin of labia minora; many amelanotic and present with discharge or bleeding; 5-yr survival <50%; characterized
by large polygonal cells and sometimes abundant pigment; penile melanoma—less common than vulvar
melanomas; <0.5% of all penile neoplasms; can present as macule or mass lesion; 60% occur on glans; prognosis
dismal
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| Ocular lesions: pigmented lesions of eye and adnexa can resemble cutaneous counterparts, but some lesions
unique to that area; conjunctiva—mucosal membrane; pigment found in this area cause for concern; refer for biopsy
any raised pigmented lesions in fornix or at intersection of palpebral and bulbar conjunctiva (frequently
malignant); primary acquired melanosis (PAM)—pigment found on conjunctiva; 2 forms, with atypia and without
atypia; PAM with atypia associated with risk for development of melanoma; conjunctival melanomas not
uncommon; 75% of melanomas that occur in conjunctiva occur in context of previous PAM; greater tendency
for malignant melanoma if PAM involves limbus, between cornea and sclera; can see extension of pigmented lesions
on eyelid into conjunctiva
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| Acral skin: eg, palms and soles; unique characteristics; dermatoglyphs, eg, fingerprints and footprints, cause pigmented
lesions to look different in this area; ridges contain sweat ducts and produce moisture that runs down
grooves; benign lesions tend to form in grooves; more atypical lesions show pigment at top of ridge and are
broader; acral melanosis—also referred to as volar melanotic macules; cytologic atypia; not common; other
conditions can cause pigment in these areas, including fungal infections; acral melanoma—occurs in patients of
all skin types; plantar surface most common location; histology shows lentiginous growth pattern (acral lentiginous
melanoma); usually discovered late; delay in diagnosis important to prognosis
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| Subungal melanoma: can mimic other types of inflammatory or traumatic conditions, making it difficult to diagnose;
presents as melanonychia striata (brown lines); many benign conditions can leave pigmented lines in nail
bed; examine pigmented lines for evenness, whether sharply circumscribed, and whether pigment extends to surrounding
skin; subungal melanomas tend to be more diffuse, poorly delineated, and can involve periungal skin;
amelanotic lesions can resemble warts and pyogenic granuloma and can lead to delay in diagnosis
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| Other extracutaneous sites rare: eg, nasal cavity, larynx, prostate, urethra, cervix, gallbladder; usually incidental
finding during surgical procedure or autopsy
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Questions and Answers
| Subungal melanoma and fingernail trauma: probably no relationship, although patients may present with
complaint
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| Pigmented nevi in acral area and malignancy: nevi found on surface of acral areas not different from nevi
seen in other areas of body; may look more suspicious because of type of surface and because patients have poor
recollection of when nevi first appeared
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| Punch vs excisional biopsy: with punch biopsy, cannot determine margins on specimen; in general, speaker prefers
excisional biopsy; punch actually invented to examine inflammatory lesions and not meant to examine pigmented
lesions; excisional biopsy heals better and provides more adequate margins of specimen
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| Dysplastic nevus syndrome and extracutaneous melanomas: dysplastic nevus syndrome now referred to as
familial atypical mole melanoma syndrome; relatively rare condition; patients with genetic syndrome have much
higher risk of developing melanoma; however, cannot apply term to every patient who has had dysplastic nevus;
dysplastic nevi one of most common forms of moles; no studies show that those with syndrome have more atypical
or extracutaneous melanomas
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| Sending skin tags to pathology: do not send true skin tags to pathology; send to pathology if skin tag large or associated
with bleeding
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| Dermatoglyphs: glyph refers to “valley” or furrow between ridges; ridge contains eccrine glands; benign pigmented
moles or nevi that occur on palms and soles usually located in valley; atypical lesions, including melanomas,
usually located on ridge
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| Sun exposure and extracutaneous melanomas: sun exposure not only factor involved in development of
melanoma; sun’s role much different in formation of extracutaneous melanomas than in other types of skin neoplasms
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Suggested Reading
Beylot C et al: Oral contraceptives and cyproterone acetate in female acne treatment. Dermatology 196:148, 1998;
Comert A et al: Efficacy of oral fluconazole in the treatment of seborrheic dermatitis: a placebo-controlled study.
Am J Clin Dermatol 8:235, 2007; Crawford GH et al: Rosacea: I. Etiology, pathogenesis, and subtype classification.
J Am Acad Dermatol 251:327, 2004; Fien SM et al: Photodynamic therapy for non-melanoma skin cancer. J
Natl Compr Canc Netw 5:531, 2007; Izikson L et al: The flushing patient: differential diagnosis, workup, and treatment.
J Am Acad Dermatol 55:193, 2006; Korfitis C et al: Pimecrolimus versus topical corticosteroids in dermatology.
Expert Opin Pharmacother 8:1565, 2007; Krengel S et al: Melanoma risk in congenital melanocytic naevi:
a systematic review. Br J Dermatol 155:1, 2006; Lemay A et al: Oral contraceptives as anti-androgenic treatment
of acne. J Obstet Gynaecol Can 24:559, 2002; Moloney FJ et al: Randomized, double-blind, prospective study to
compare topical 5-aminolaevulinic acid methylester with topical 5-aminolaevulinic acid photodynamic therapy for
extensive scalp actinic keratosis. Br J Dermato 157:87, 2007; Pelle MT et al: Rosacea: II. Therapy. J Am Acad
Dermatol 51:499, 2004; Pelle MT: Issues and advances in the management and pathogenesis of cutaneous lupus
erythematosus. Adv Dermatol 22:55, 2006; Pelle MT: Rosacea therapy update. Adv Dermatol 19:139, 2003; Piris
A et al: Pigmented lesions in unusual anatomic sites. Semin Diagn Pathol 20:249, 2003; Warshaw EM et al: Results
of a randomized, double-blind, vehicle-controlled efficacy trial of pimecrolimus cream 1% for the treatment of
moderate to severe facial seborrheic dermatitis. J Am Acad Dermatol 57:257, 2007.
Educational Objectives
| The goal of this program is to improve the diagnosis and management of dermatologic conditions and extracutaneous
melanoma. After hearing and assimilating this program, the clinician will be better able to:
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 | 1. Treat dermatitis.
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| 2. Treat acne in adults.
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| 3. Distinguish between rosacea and lupus erythematosus.
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| 4. Discuss the characteristic differences between extracutaneous melanotic lesions and melanomas.
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| 5. Determine when to refer a patient with a suspicious pigmented lesion to a dermatologist.
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Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, the Audio-Digest Foundation requires all faculty members
to disclose relevant financial relationships within the past 12 months that might create any personal conflict of
interest. Any identified conflicts were resolved to ensure that this educational activity promotes quality in healthcare
education and not a proprietary business or commercial interest. For this issue, Drs. Pelle and O’Grady indicated
nothing to disclose.
Acknowledgment
Drs. Pelle and O’Grady were recorded February 22-28, 2007, in San Diego, CA, at Topics and Advances in Internal
Medicine, sponsored by the University of California, San Diego, School of Medicine. The Audio-Digest Foundation
thanks the speakers and the sponsors for their cooperation in the production of this program.
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