Wounds, Lesions, and Eruptions A Dermatologist’s Perspective Amber Robbins, MD FAAD June 4, 2015

Case 1 Overweight 59 yo male Bilateral, somewhat tender and red lower legs He’s had bilateral cellulitis before, and is pretty sure he has it again

Fallacies of Bilateral Cellulitis How cellulitis happens in the first place – External not internal Clinicians worry about missing something ‘really bad’ – A patient with unilateral cellulitis feels very ill Antibiotics won’t hurt anything – C-Diff, Resistance

Stasis Dermatitis

Not just bilateral cellulitis Study of cellulitis randomized to be treated by PCPs vs dermatology – Of the patients randomized to dermatology Only 10% really had cellulitis Actual diagnoses: Eczematous dermatitis, Stasis dermatitis, Erythema Migrans, Arthropod reaction, Gout, others… Had to terminate study early, due to being unethical to continue randomizing patients Arakaki et al; JAMA Dermatology October 2014

Cellulitis Acute presentation Warm Erythematous Painful NOT pruritic

Case 2 47 year old female Cellulitis on legs not getting better with multiple antibiotic courses She feels fine, except she hasn’t been sleeping well due to the itching Also, now it’s spreading to the other leg, and even a few places on her arms and abdomen She’s really worried she might have staph in her system

Allergic Contact Dermatitis Allergy caused by contact with allergen on the skin Has a delayed onset and a prolonged course Prototype is Poison Ivy Can cause vesicles to larger blisters Usually very pruritic

Allergic Contact Dermatitis Common allergens – Nickel – Latex – Neomycin – Benadryl Cream – Preservatives (Methylchlorisothiazolinone) Formaldehyde releasers – Fragrance – Many, many others

Allergic Contact Dermatitis Testing = Patch Testing Not the same allergens as Prick Testing Patches are left on about hours, then removed and allergens can be observed Use testing can also be helpful

Case 3 New recruit at basic training Developed pain and redness in both lower legs Tired from training, but not ill, no fever Has limited range of motion

Bilateral LE Inflammatory Lymphedema Painful, pitting edema and erythema Both medial and lateral ankles, and dorsal feet In one 4 month period (Nov-Jan) at Lackland AFB, 55 of 14,243 trainees (0.4%) developed bilateral lower extremity inflammatory lymphedema Fajardo et al JAMA Dermatol 2015;151(4);

Case 4 Patient with ‘blisters’ on the back of hands and some fingers Feels ‘OK’, no major complaints

Further Investigation Many neutrophils on biopsy, edema but no true blister cavity, some vasculitis Patient has a blood disorder needing further workup

Neutrophilic Dermatosis of the Dorsal Hands Highly pathergic Pathergy = developing at sites of minimal trauma Associations have been reported with myelodysplasias/leukemias (about ½), inflammatory bowel disease, drugs/other

NDDH Patients may have fever – further confusion with infection Treatment is corticosteroids – high potency topical, injections, or oral; also dapsone Heal without scarring, usually not recurrent

Skin Lesions Overview of common skin lesions Benign vs malignant vs I’m not sure Sin of omission

Sin of Omission Better term? You see something the patient/client can’t see You see something you’re pretty sure the patient is aware of, you’re not sure it’s OK, and you don’t mention it The act of you observing, and not mentioning, when you are in a medical relationship is an act of validation

Skin cancer types Basal Cell Carcinoma (BCC) Squamous Cell Carcinoma (SCC) Melanoma Other

Basal Cell Carcinoma (BCC) Easy Bleeding Non Healing New facial lesions

Squamous Cell Carcinoma Most common skin cancer in the immunosuppressed – Organ transplant patients – Chronic Leukemia patients Also more common in certain sites – Dorsal hands – Legs – Chronic Burn Wounds

Squamous Cell Carcinoma Often tender Can be quick-growing Pink Sometimes scaly, or even creating ‘horn’

Melanoma Cancer of melanocytes Curable when identified early Depth of invasion is key ABCDE rule

Melanoma - Asymmetry

Melanoma - Border

Melanoma - Colors

Melanoma - Diameter

Melanoma E: Evolution (or Change)

Seborrheic keratoses Non cancerous Break the ABCD rules Common areas: back, temples Run in families

Seborrheic keratoses