1. DEB BYNUM, MD MAY 2010 Beauty is only skin deep….

6. Questions: 1. What is the diagnosis? 2. What are the four types demonstrated in the pictures? 3. What are the treatment options?

7. Answers: 1. Rosacea 2. Types  Erythematotelangiectatic  Papulopustular  Phymatous: rhinophyma  ocular 3. Management:  Topical metronidazole  Oral antibiotics (tetracycline)  Laser/surgery

8. Question: A 76 year old woman comes to the office because she has multiple rough skin lesions on her forehead, temples, cheeks and forearms. Nasolabial folds are spared. The lesions bleed easily when she picks them off, and then recur. The lesions are scaly, <1 cm in diameter, and feel like sandpaper to the touch. Which of the following is the most appropriate treatment?  A. Moisturizing cream  B. metronidazole gel  C. Imiquimod 5% cream  D. Ketoconazole 2% cream  E. Sunscreen and observation

10. Questions: 1. What is the diagnosis? 2. A 76 year old woman comes to the office because she has multiple rough skin lesions on her forehead, temples, cheeks and forearms. Nasolabial folds are spared. The lesions bleed easily when she picks them off, and then recur. The lesions are scaly, <1 cm in diameter, and feel like sandpaper to the touch.  What is the appropriate therapy?

11. Actinic Keratosis Lesions are single or multiple Dry, rough, adherent and scaly Sun exposed skin Sparing of nasolabial folds and nonexposed areas Sandpaper like Cream and sunscreen helpful

12. Actinic Keratosis: Precancer Precancer! Treat!  Ablative (cryosurgery)  Photodynamic therapy  Topical therapies if multiple lesions  Flourouracil  Imiquimod 5% cream  Diclofenac 5% gel

13. Question: A 70 year old chinese American man comes to the office because he has a widespread maculopapular eruption with formation of flaccid bullae and erosions. For 2 days before the rash, he had fever, odynophagia, and eye pain. Over the next few days, the rash evolved to extensive sloughing and peeling of the skin. History includes HTN, DM, and peripheral neuropathy. Two weeks ago, he began carbamazepine. Other medications include glipizide, felodipine, simvastatin, and aspirin.

14. Question… On exam, the sloughing and peeling involve 40% of the body surface. His oral mucosa has erosions and exudates. He also has bilateral conjunctivitis. Which of the following is the most likely diagnosis?  A. Bullous pemphigoid  B. Staphylococcal scalded skin syndrome  C. Disseminated herpes zoster  D. Toxic epidermal necrolysis

15. Answer: D: TEN  Stevens Johnson Syndrome and TEN are variants of same process (SJS 30%, overlap if between)  30% mortality  Reactions to medications  HLA-B 1502 Allele: Asian and South Asian ancestry  FDA alert: screen this population before starting carbamazepine

16. Question: What is the most common autoimmune subepidermal blistering disease, most often found in older adults? Hints:  Pruritic  Tense blisters  Blisters resolve without scarring  Often self limited

17. Diagnosis?

18. Answer: Bullous Pemphigoid  Antibodies directed against basement membrane zone of the epidermis, causing separation between epidermis and dermis Differentiate from Pemphigus Vulgaris  PV in younger patients  PV more severe  Nikolsky sign: Exfoliation of the skin with slight rubbing  Present with PV and with TEN  Absent with bullous pemphigoid  PV more often involves mucus membranes  PV blisters flaccid, BP blisters tense  Autoimmune, medications, paraneoplastic

19. What is the diagnosis?

20. What is the diagnosis? Some Hints: inflammation of the eyelids causing red, irritated, itchy eyelids formation of dandruff-like scales on eyelashes It is a common eye disorder causes:  bacterial (staph)  dandruff of the scalp or seborrhea  acne  rosacea

21. Blepharitis: Treatment:  Warm compresses  Baby shampoo, dandruff shampoo  Avoiding makeup  Oral antibiotics (tetracycline)

22. New case…

26. What is the diagnosis?

27. Answer: Melanoma  Acral lentiginous subtype:  Uncommon, but more often seen in patients over age 65  Can be seen in all skin types

28. What is the diagnosis?

29. Hints: Very common Waxy plaques or papules Stuck on appearance Found everywhere except mucus membranes, palms and soles May be darkly pigmented

30. Answer: Seborrheic Keratosis

32. Question: Eruptive seborrheic keratoses, often across back in christmas tree pattern, associated with underlying malignancies (GI, prostate, etc) is known as…..

33. Answer: Sign of Leser-Trelat

34. Itchy, Itchy, Itchy….

35. Typical distribution…

36. Severe form can be “crusted”, aka “norwegian”

37. Answer: Scabies…  More common in elderly and immunosupressed  May not have rash, may present with severe pruritis  Look in between toes and fingers  burrows