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

2. 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

3. 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

4. Stasis Dermatitis

5. 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

6. Cellulitis Acute presentation Warm Erythematous Painful NOT pruritic

7. 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

8. 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

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

10. Allergic Contact Dermatitis Testing = Patch Testing Not the same allergens as Prick Testing Patches are left on about 48-72 hours, then removed and allergens can be observed Use testing can also be helpful

11. 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

12. 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);395-400

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

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

15. 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

16. 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

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

18. 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

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

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

21. 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

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

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

24. Melanoma - Asymmetry

25. Melanoma - Border

26. Melanoma - Colors

27. Melanoma - Diameter

28. Melanoma E: Evolution (or Change)

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

30. Seborrheic keratoses