1. Dermatology for Internists Susan Riggs Runge, MD January 2008

2. Pictures Pictures of common and less common skin lesions Cover each topic very briefly Realize most of you have vast experience in seeing many of these lesions in your years of practice This is a very superficial review of topics I hope you may find interesting All slides and photos are available at: http://medicine.med.unc.edu/education/der matology_for_internists.ppt

3. Lupus Erythematosus One of the papulosquamous diseases Papules and scaly areas Other papulosquamous diseases include: psoriasis, tinea, seborrheic dermatitis, pityriasis rosea, syphilis, lichen planus and other more rare skin disorders Many of these have differentiating characteristics but lots of overlap clinically makes skin biopsy particularly helpful in many cases

4. Acute Cutaneous Lupus

5. Dilated capillary loops along nail fold This can also be seen in dermatomyositis and other connective tissue diseases

6. Acute Cutaneous Lupus Malar erythema, can involve neck, forehead and periorbital area in photodistribution Erythema and sometimes edema of V of neck, forearms Look for ulcers on the hard palate ANA positive 60-80% will have positive dsDNA Other tests: CBC, ESR, UA, skin biopsy Treatments: Prednisone, hydroxychloroquine Referral to rheumatologist

7. Subacute Cutaneous Lupus

8. SCLE (subacute cutaneous lupus) Annular scaly erythematous patches in sun-exposed areas Worse upon sun exposure Non-scarring Many patients have arthralgias expecially of hands and wrists Consider drugs as cause: HCTZ, calcium channel blockers, ACE inhibitors, terbinafine and TNF- antagonists

9. Hands in Subacute Cutaneous Lupus Erythematous scaly patches between the knuckles (unlike Gottron’s papules of dermatomyositis which are on the knuckles)

10. Subacute Cutaneous Lupus Labs Most are ANA positive Most are Anti-Ro (SS-A) positive 1/3 will meet criteria for systemic lupus Other lab tests: CBC, ESR, UA, Rheumatoid factor, complement levels, skin biopsy Treatment: Stop suspected drugs, sunscreen, hydroxychloroquine Refer to rheumatologist if joint involvement, nephrologist if renal involvement, etc

11. Subacute Cutaneous Lupus-more subtle

12. Discoid Lupus

13. Discoid lupus Hyperpigmentation and hypopigmentation Atrophy of skin These lesions cause SCARRING Skin lesions occur in photodistributed areas (wider distribution may correlate with greater likelihood of SLE) Discoid lesions and follicular prominence in conchae of ears

14. Ear Lesions in Discoid Lupus

15. Discoid Lupus Labs ANA positive in 5- 20% Do CBC, ESR, Rheumatoid factor, UA, complement levels, skin biopsy

16. Discoid Lupus These patients rarely progress to SLE (5%) Rarely have systemic disease Treatment: sunscreen, topical steroids, intralesional steroids, hydroxychloroquine Referrals as indicated

17. Other Papulosquamous Diseases: Psoriasis

18. Psoriasis

19. Well-demarcated erythematous plaques Thick white or silvery scale Knees and elbows classically, can be scalp only or diffuse Also favors gluteal cleft, navel

20. Psoriasis Not very itchy Scale is thicker and whiter than with fungal infection Less scaly in moist areas (in body folds) or if partially treated

21. Psoriasis of scalp

22. Psoriasis

23. NOT psoriasis-cutaneous T cell lymphoma

24. Not psoriasis - CTCL: does not have thick scale Cutaneous T-cell lymphoma Could mimic psoriasis Atypical locations Biopsy should differentiate Refer skin problems that are atypical or do not resolve as expected

25. Allergic Contact Dermatitis

26. Localized to area of contact Scaly erythematous plaques Can be blistering On eyelids, can be due to nail polish

27. Allergic Contact Dermatitis

28. Allergic Contact Dermatitis- fragrance

29. Allergic Contact Dermatitis- diethylthiourea in scuba diving gear

30. Allergic Contact-cinnamon Cinnamon often used as flavoring agent in gum or toothpaste

31. Allergic Contact Dermatitis Identify and avoid allergen if possible Increase moisturization of skin Topical steroid as needed Rarely oral steroid if severe

32. Allergic Contact-Poison Oak Linear blisters are classic for allergic contact dermatitis due to poison ivy

33. Allergic Contact Dermatitis-more subtle

34. Seborrheic Dermatitis Erythematous patches on skin Thick, yellow greasy scale Seborrheic distribution: eyebrows, sides of nose, nasolabial folds, ear canals, chest More severe in patients with HIV or Parkinson’s disease

35. Seborrheic Dermatitis Nasolabial fold Chin area Ear canal

36. Dermatophyte

37. Tinea Superficial fungal infection of skin

38. Tinea corporis Tinea named by location: tinea capitis, tinea corporis, tinea manum, tinea pedis, tinea barbae (beard), tinea cruris (body fold especially groin and pubic area), tinea unguium of nails (onychomycosis)

39. Tinea faceii Erythematous annular plaques Not as well- demarcated as psoriasis Scaly, itchy Involved areas tend to fade centrally Treat with topical antifungal if limited area or oral agent if extensive

41. Tinea Corporis

42. Tinea Capitis Causes itching and scaling of scalp More common in children Hair may break just beyond follicle Often more than one family member affected Can be severe and cause hair loss which can be scarring (loss of follicles)

43. Tinea Capitis

44. Tinea pedis

45. Tinea-more subtle

46. Atopic Dermatitis

47. Atopic Dermatitis (Eczema)

48. Nummular Eczema

49. Severe Atopic Dermatitis

50. Atopic Dermatitis Our Recommendations: Bathe in tepid water with mild soap Moisturize skin frequently with vaseline or other thick cream Topical steroids as needed for control Rarely treated with oral immunosuppressive

51. Benign Growths of the Skin There are many: skin tags, cysts, lipomas, dermatofibromas, warts, keloidsand many others One of the most common in adults in seborrheic keratosis

52. Seborrheic Keratosis

53. Seborrheic Keratoses

54. Seborrheic Keratosis Verrucous (warty looking) tan to black stuck-on appearing growth Common on back, chest, abdomen, but may be anywhere May be multiple or single Not necessary to remove; treat with cryotherapy or electrodessication if symptomatic or as cosmetic procedure Treatment can cause a hypopigmented spot or scarring

55. Moles and Melanoma

56. Normal Moles (nevi)

57. Normal Nevi Symmetrical Regular Borders One color or shades of brown Smaller size, less than 6 mm, although can be larger Do not grow or change Develop new nevi up to age 30’s

58. Dysplastic nevus

59. Dysplastic Nevus

60. Irregular borders May have more than one color If it meets two or more of the criteria for melanoma, we may remove it

61. Dysplastic Nevus Syndrome Multiple dysplastic nevi Familial (also known as Familial Atypical Mole and Melanoma Syndrome FAMM) Melanoma common in one or more first or second degree relatives Histologic criteria Many cases linked to mutations in the CDKN2A gene, which codes for p16 (a regulator of cell division)CDKN2Ap16 Difficult to evaluate visually because have 50 or more moles Annual examinations by dermatologist plus frequent self- monitoring for change in moles “Mole mapping” (digital imaging at UNC) if prior melanoma or if available

62. Melanoma

64. Most common type is superficial spreading Tends to grow wide before it grows deep Look for the “ugly duckling” mole-one that is different than the patient’s other moles

65. Melanoma

66. Lentigo maligna melanoma Occurs most often on head and neck Usually evolves slowly in older patients with significant sun damage

67. Melanoma

68. ABCDEs Asymmetry Irregular BORDERS Colors (more than one) Diameter (more than 6 mm) Evolving-very important

69. Melanoma-more subtle

70. Melanoma

72. Nodular Melanoma Grows rapidly (6-8 weeks) Deeper Prognosis related to depth so worse prognosis than superficial melanoma

73. Amelanotic Melanoma Lacks pigment so may not be recognized as melanoma

74. Actinic keratoses

75. Precancerous Scaly erythematous macules in sun-damaged skin Persistent scaly areas- patient scratches them off and they recur Treated with liquid nitrogen or topical 5- fluorouracil or imiquimod

76. Basal Cell Carcinoma

77. Pearly papule with rolled borders Has central dell (indentation)-will erode with time and form ulcer Telangectasia Slow growing Extremely rare to metastasize but can erode bony structures Can be pigmented

78. Basal Cell Carcinoma

79. Pigmented Basal Cell Carcinoma

80. Basal Cell Carcinoma-more subtle (morpheaform: looks like a scar)

81. Squamous Cell Carcinoma

82. Enlarging scaly, crusty plaques Not the thick white scale of psoriasis Not symmetrical on the body (unlike psoriasis) Squamous cell or basal cell carcinomas may present as a non-healing spot (allow 4 weeks to heal: if it doesn’t, then biopsy)

83. Outlier Topic

84. Pyoderma Gangrenosum

85. Not all ulcers are infectious Diagnosis of exclusion: rule out infection and tumor Starts as a small red papule, then spreads into ulcer Occurs in healthy-looking people (abdomen and legs), can occur anywhere including in the mouth Tendency to occur in patients with inflammatory bowel disease but idiopathic in 50% Spreads to surrounding tissues if debrided or excised Responds to topical or oral steroids

86. Referrals to Dermatology Any new growth that you are suspicious about Refer blistering processes early A rash (an eruption) in a body fold might be fungus or yeast, so an antifungal cream might be worth a trial Consider a trial of over the counter cortisone or topical triamcinolone for body lesions that you believe may be a transient dermatitis or eczema (we prefer ointments over creams) Refer when a skin lesion is growing or does not resolve with usual treatment Refer suspected melanoma promptly