Common Dermatologic Issues

Common Dermatologic Issues in the Geriatric Population

Steve Marchenko, Janelle Marshall and Kristen M. Kelly, M.D.

University of California, Irvine

• Objectives:List dermatologic diseases commonly seen in the

elderly

Identify terms used to describe dermatologic lesions and/or rashes

Identify treatment options for common dermatologic conditions seen in the elderly

Approach to Making Dermatologic Diagnoses

• Obtain Focused HistoryTime/duration/change over time, initial site and spread/symptomsGeneral health, occupation, family history, medications, previous

treatments, allergies

• Characterize morphology of basic lesion Primary-original lesion Secondary-changes to lesion over time Characterize shape, color, texture, & arrangement of the lesions

• Determine distribution of lesionsLesion distribution often provides important diagnostic clues

Approach to Making Dermatologic Diagnoses

• Diagnostic Testing to consider

Shave, punch biopsyKOH for fungal infectionsGram stain for bacterial infectionsTzanck preparations for herpetic infection (shown)Oil mount of skin scrapings for scabies infection

Image courtesy of www.visualdx.com © Logical Images, Inc

Victor Newcomer, MD (UCLA). (Jan 2006). Herpetic Whitlow [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=50694&imageIndex=11

Defining Skin Lesions

A primary lesion is the initial lesion that characterizes a dermatologic disorder

Being able to recognize primary skin lesions is critical in making the correct diagnosis

Over time, primary lesions may continue to develop or be modified, producing secondary lesions

Keep in mind, when examining a patient: • The primary lesion may have evolved

• Any combination of primary and secondary lesions may be present

Primary Skin LesionsLesion Description Example

Macule Circumscribed, flat, <0.5 cm (centimeter) freckle (ephelis)

Patch Macule >0.5cm vitiligo

Papule Elevated, solid lesion <0.5cm molluscum contagiosum

Plaque Elevated, plateau-like lesion without substantial depth

psoriasis

*the definition of these lesions vary by the dermatology reference, but usually is 0.5-1.0cm.

Note multiple hyperpigmented macular lesions and a single patch found in this patient with neurofibromitosis type 1. A papule is seen above the patch.

Image courtesy of www.visualdx.com © Logical Images, Inc (NYU, Department of Dermatology). (Dec 2004). Neurofibromatosis [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52014&ImageIndex=0

https://vpn.nacs.uci.edu/+CSCO+c0756767633A2F2F6A6A6A2E697666686E79716B2E70627A++/visualdx/visualdx6/-CSCO-30--getZoomImage.do?moduleId=7&diagnosisId=52014&imageIndex=0

https://vpn.nacs.uci.edu/+CSCO+c0756767633A2F2F6A6A6A2E697666686E79716B2E70627A++/visualdx/visualdx6/-CSCO-30--launch.jsp

http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52014&imageIndex=0

http://www.visualdx.com/visualdx/visualdx6/launch.jsp

Primary Skin Lesions

Lesion Description Example

Nodule Elevated, solid lesion >0.5cm with some depth rheumatoid nodule

Wheal Firm, edematous plaque hivesVesicle Circumscribed, elevated lesion with free fluid,

<0.5cmVaricella

Bulla Vesicle >0.5cm Bullous pemphigoid

Pustule Circumscribed, elevated lesion with purulent material

acne

Primary Skin Lesions

Note multiple pustulo-vesicles and plaquesin a patient with subcorneal pustular dermatosis


(University of Rochester, Department of Dermatology). Sneddon-Wilkinson Subcorneal Pustulosis. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=8&diagnosisId=52332&imageIndex=5

Secondary Skin Lesions

Scale: White, dry flakes (e.g. dermatophyte infection)Crust: A “scab” formed from dried serum, blood or

exudate on skin (e.g. impetigo)Erosion: Focal loss of epidermis not extending below

dermal/epidermal junction; heals without scarring (e.g. following blister rupture)


In this patient with pemphigus, superficial blisters have ruptured

and formed crusted erosions and scales


(NYU, Department of Dermatology). Pemphigus Foliaceus. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52136&imageIndex=0




Ulcer: Focal loss of epidermis & dermis extending into hypodermis; heals with scarring (e.g. decubitus ulcer)

Fissure: Linear loss of epidermis (+/-) dermis (e.g. “chapping” of fingers)

Lichenification: Area of thickened epidermis with accentuated skin lines due to chronic rubbing (e.g. long standing atopic dermatitis)

Benign Skin Growths

Benign skin growths are common, especially in older individuals

It is important to differentiate these lesions from skin cancer

A clinician should try to categorize any skin lesion as:• Most likely benign, most likely malignant, or unclear

• The last 2 categories should be biopsied

Examples of common benign lesions include: • Seborrheic keratoses and cherry angiomas

Benign Skin Growths

Tindall JP, Smith JG Jr. Skin lesions of the aged and their association with internal changes. JAMA. Dec 21 1963;186:1039-42


Victor Newcomer, MD (UCLA). (Aug 2006). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51808&imageIndex=1

Benign Skin Growths


(University of Rochester, Department of Dermatology). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2001, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51808&imageIndex=8

Benign Skin Growths

Benign dome-shaped capillary

proliferations that blanch with pressure.

Usually appear in individuals over 35 on arms and trunk and tend to bleed when injured.

Successfully treated with laser or electrocautery

Cherry Angiomas


(NYU, Department of Dermatology). Cherry Hemangioma. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=51676&imageIndex=4

Pre-cancerous Skin Growths

Criscione, VD, Weinstock, MA, Naylor, MF, Luque, C, Eide, MJ and Bingham, SF. Actinic keratoses natural history and risk of malignant transformation in the Veterans Affairs Tropical Tretinoin Chemoprevention Trial. Cancer 2009; 115: 2523-2530


(University of Rochester, Department of Dermatology). Actinic Keratosis. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51805&imageIndex=5

Actinic Keratoses

Skin Cancer

Skin cancer is the most common of all human cancers• It is diagnosed in more than 1 million people in the United

States each year Skin cancers are of three major types:• Basal cell carcinoma (BCC), squamous cell carcinoma (SCC)

and melanoma The majority of skin cancers are BCCs or SCCs • Although metastatic rate is low, may be locally destructive

and disfiguring if not treated early• Solar UV radiation is responsible for the majority of BCCs

and SCCs

Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010; 146(3):283-287.

Skin Cancer

• Epidemiology Second most common skin cancer Most frequently affects Caucasians with extensive sun exposure

• Risk factors Chronic environmental damage• UV/ionizing radiation• Tobacco• Arsenic exposure

History of actinic keratoses HPV infection 6,11,16,18 Chronic immunosupression


Charles E. Crutchfield III, MD. (Nov 2007). Squamous Cell Carcinoma. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52735&imageIndex=0

Skin Cancer


(University of Rochester, Department of Dermatology). (Augu 2009). [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52735&imageIndex=42

Skin Cancer

•Epidemiology Most common human malignancy 800,000 new cases every year in US

•Risk factors Skin type 1 Blistering sunburns in childhood Family history of skin cancer Immunosuppression

Nodular BCC


(NYU, Department of Dermatology). Basal Cell Carcinoma, Nodular. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=51167&imageIndex=0

ClinicalSeveral subtypes are described•Nodulocystic:

single shiny, red nodule w/ telangiectasia •Superficial:

least aggressive erythematous plaquescan mimic psoriasis

•Sclerotic/Morpheiform: most aggressive5% of all BCC’s.Ill-defined borders

•PigmentedShiny, blue-black papule, speckled pigment, rolled borders.

Superficial BCC


Charles E. Crutchfield III, MD. (Jan 2007). Basal Cell Carcinoma, Superficial. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52756&imageIndex=16





Skin Cancer

•Management

Depends on location, size, histopathology, and patient factorsVery low risk/superficial: consider curettage + topical 5-FU or imiquimodMost low risk lesions: curettage and electrodessication For higher risk or recurrent BCC: excision with margins or Mohs micrographic surgeryElderly patients or those in whom surgery contraindicated: consider radiation.

Basics of Dermatologic Surgery

• Cryosurgery

• Electrodessication and curettage

• Excision

• Mohs Micrographic Surgery


Cryosurgery Liquid nitrogen -195.8º C

To produce adequate treatment, tissue temperature -50º C is needed

Fast freeze, slow thaw ; generally 2 cycles

PROS: cost effective, no surgery, minimal equipment

CONS: no specimen for evaluation, skin discoloration may occur and may be permanent (especially in tanned skin or patients with darker skin types)


Electrodessication and Curettage Only indicated for low-risk lesions

PROS: minimal blood loss, ease, convenience for the patient

CONS: no specimen for pathology, clinician experience influences cure rate

Images courtesy of Margaret Mann, M.D.


Excision PROS• Shorter procedure time• Closure performed at the same time• Less expensive

Margins depend on lesion


Mohs Micrographic Surgery• Indications:

Recurrent or incompletely excised BCC or SCC Primary BCC or SCC with indistinct borders Lesions located in high-risk or cosmetically and

functionally important areas (e.g. face) Tumors with aggressive clinical behavior (ie, rapidly

growing, >2 cm in diameter) or aggressive histologic subtype

Tumors arising in sites of previous radiation therapy Tumors arising in immunosuppressed patients


Mohs Micrographic Surgery• Advantages:

Low risk of recurrence Exceptionally high cure rates Designed to remove tumor with smallest possible

margins

• Disadvantages: Surgical risks Requires special equipment and technician More technically difficult Not optimal for all tumors


Mohs Micrographic Surgery• Step 1: Clinical examination and determination of visible margins• Step 2: Visible tumor is surgically removed• Step 3: A layer of skin is removed and divided into sections, which are color coded with dyes; reference marks made on skin for orientation; map of surgical site drawn• Step 4: Undersurface and edges of each section are microscopically examined for evidence of remaining cancer

The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohs-procedure.php

Image courtesy of American College of Mohs Surgery


Mohs Micrographic Surgery•Step 5: If residual cancer is seen under microscope, surgeon marks location on map and returns to patient to remove another layer of skin where cancer cells remain•The removal process stops when there is no longer any evidence of cancer remaining in the surgical site

The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http://www.skincancermohssurgery.org/mohs-surgery/mohs-procedure.php

Image courtesy of American College of Mohs Surgery

Drug Eruptions

Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331:1272

Drug Eruptions

• Etiology

Often classified as immune and non-immune•Immune: type I, II, III IV hypersensitivity reactions•Non-immune: cumulative toxicity, overdose, photosensitivity, drug interactions, and metabolic alterations

A drug reaction should be considered in any patient on medication with acute onset of an eruption (usually symmetric)

Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331:1272

Drug Eruptions

• Common morphologies: morbilliform (95%) and urticarial (5%)Less common morphologies include: pustular,

bullous and papulosquamous Drug reactions can also cause pruritis without

an obvious eruption

• Drugs most commonly implicated:antimicrobial agents, nonsteroidal anti-

inflammatory drugs (NSAIDs), cytokines, chemotherapeutic agents, anticonvulsants, and psychotropic agents

Morbiliform eruption

Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:355-362


Drug Eruptions

Urticaria Antibacterial, nonsteroidal antiinflammatory drugs,antidepressants, opioids, imidazoles

Morbilliform rash Antibacterial (penicillin, sulfonamides), anticonvulsants,gold, allopurinol, diuretics

Lichenoid rash Antimalarials, gold, β-blockers, diuretics, sulfonylureas, hypoglycemic agents

Cutaneous Vasculitis Diuretics (furosemide, thiazides),antibacterials, allopurinol, amiodarone

Drugs commonly implicated in each type of reaction

Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York,

NY: McGraw-Hill; 2008:355-362

Drug Eruptions

Photosensitivity Amiodarone, phenothiazines, sulfonamides, tetracyclines,nonsteroidal antiinflammatory drugs

Drug-induced autoimmune rash Penicillamine, hydralazine, gold

Stevens Johnson Anti-gout agents (allopurinol), NSAIDS, antibiotics, anticonvulsants

Toxic Epidermal Necrolysis Anti-gout agents (allopurinol), NSAIDS, antibiotics, anticonvulsants

Drugs commonly implicated in each type of reaction

Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209:131Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York,

NY: McGraw-Hill; 2008:355-362

Drug Eruptions

• Benign drug reaction Most patients with a drug eruption complain only of itching Most drug eruptions are mild, self-limited, and usually resolve after

the offending agent has been discontinued Look for: absence of systemic manifestations and normal lab values

• Warning signs of a more serious reaction Skin pain, skin necrosis Fever Conjunctivitis or mucous membrane involvement Blisters Angioedema Palpable purpura Elevated BUN/creatinine or liver function tests

Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7th ed. New York, NY: McGraw-Hill; 2008:355-362

EM is a spectrum of diseases ( EM minor, EM major)

EM Minor (less often due to a drug eruption)

• May be due to infection (e.g. herpes simplex virus)

• Characterized by target lesions distributed predominantly on the distal extremities (including palms/soles)

• Mucous membrane involvement may occur but is not severe

• Patients recover, but relapses are common

Image: Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text, Sanders, CV, Nesbitt, LT Jr (Eds), Williams & Wilkins, Baltimore 1995.Auquier- Dunant A, Mockenhaupt M, Naldi L, et al. Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome, and toxic epidermal necrolysis; results of an international prospective study. Arch Dermatol 2002; 138: 1019.

Erythema Multiforme (EM)Drug Eruptions

Target lesions

Erythema Multiforme Major

Severe drug reaction requiring immediate medical attentionSubcategories include: Stevens-Johnson syndrome (SJS) and toxic

epidermal necrolysis (TEN)Characterized by epidermal necrosis and sloughing of the mucous

membranes and skinIn SJS, lesions affect less than 10 % of the body surface; In TEN,

greater than 30% affected


Victor D. Newcomer, MD (UCLA). Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52413&imageIndex=29

• Etiology: Not completely understood 80% of cases associated with adverse drug

reaction

Drug Eruptions



Victor D. Newcomer, MD (UCLA). Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52413&imageIndex=29


• Presentation Prodrome of fever, malaise and pain (often like a sunburn) Primary lesions include dusky red macules of irregular size

that start on the trunk and spread Always screen for mucosal symptoms including: painful

eyes, painful swallowing, dysuria and diarrhea Ocular, oral, and genital mucosa are affected in >90% of

cases

• Mortality Varies with type SJS 1-5% mortality; TEN carries a 25-30% mortality

Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev. 2008 Sep;7(8)598-605.

Drug Eruptions

• Work-upConsider alternative etiologies, e.g. viral exanthems and

bacterial infections Take a good medication history

• Review the complete medication list, including over-the-counter supplements

• Note the interval between the introduction of a drug and onset of the eruption

• Patients can develop drug eruptions to medications they have been on for prolonged periods

• Document any history of previous adverse reactions to drugs or foods

Drug Eruptions

• Work-upBiopsy can be helpful in confirming the diagnosis (e.g.,

by showing eosinophils in morbilliform eruptions) CBC with diff, Liver function tests, immunoserology

tests may be ordered for suspected drug induced autoimmune rash, cultures if infection is suspected

Drug Eruptions

French LE, Trent JT, Kerdel FA. Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome: our current understanding. Int Immunopharmacol. Apr 2006;6(4):543-9.

• Treatment of Common Drug Eruption Stop all non-essential meds (for >1 month) Monitor for signs of systemic involvement or SJS/TEN Therapy for most drug eruptions is mainly supportive

• Morbilliform eruptions can be treated with oral antihistamines and topical steroids

• Prednisone may be used cautiously in the treatment of hypersensitivity syndrome with heart and lung involvement or severe serum sickness–like reaction

Slowly re-introduce other medications after suspected agent is identified


• Treatment of Erythema Multiforme MajorTransfer to a burn unit with aggressive supportive care is the

most critical step in managementConsultation with Dermatology and OphthalmologyRapid identification and

withdrawal of offending drug

improves survival IVIG may be indicated;

efficacy is controversial

Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev. 2008 Sep;7(8)598-605.


Robert Chalmers, MD. Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52413&imageIndex=12

Other Dermatologic Conditions in the Geriatric Population

Several dermatologic conditions have a higher incidence in the geriatric population

Examples include:• Herpes Zoster

• Bullous Pemphigoid

• Venous Stasis

• Sun - induced skin changes

Herpes Zoster

• EtiologyReactivation of Varicella Zoster

Virus

• ClinicalProdrome of radicular pain &

pruritus followed by skin eruption consisting of grouped vesicles on erythematous base in dermatomal distribution

Postherpetic neuralgia may follow causing debilitating pain in the affected dermatome


(University of Rochester, Department of Dermatology). Zoster. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52552&imageIndex=4

Herpes Zoster

• Diagnosis

Typically clinical. Can also perform Tzanck smear, viral culture, or direct immunofluorescence

Victor Newcomer, MD (UCLA). (Jan 2006). Herpetic Whitlow [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=50694&imageIndex=11


Herpes Zoster

• Prevention

Zostavax – live herpes zoster vaccine

Reduces Shingles by 51.3%

Reduces cases of postherpetic neuralgia by 66.5%

Oxman MN, Levin MJ et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2;352(22):2271-84.


Nancy Esterly, MD. Zoster. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52552&imageIndex=8

Herpes Zoster

• Treatment

Best if initiated within 72 hours of start of symptoms

Antivirals: Acyclovir, Valcyclovir or Famciclovir

Supportive: pain control, sedatives, moist dressings to affected skin

Use of gabapentin may reduce the incidence of post-herpetic neuralgia

Lapolla W, DiGiorgio C, Haitz K et al. Incidence of portherpetic neuralgia after combination treatment with gabapentin and valacyclovir in patient with acute herpes zoster. Arch Derm; 147:901-907.


Victor D. Newcomer, MD (UCLA). (Nov 2005) Zoster. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52552&imageIndex=2

Bullous Pemphigoid

• Etiology

Autoimmune disorder caused by autoantibodies to hemidesmosomes – attachment complexes anchoring basal keratinocytes to the basement membrane

Antibody deposition at the basement membrane leads to inflammatory response and formation of subepidermal blisters


(NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52132&imageIndex=3

Bullous Pemphigoid

• Clinical

Begins as pruritic papular eruption evolving into large, tense oval bullae with serous or hemorrhagic fluid

Commonly affected areas include axillae, medial thigh, groin, abdomen and lower leg

Mucous membranes are seldomly involved. Image courtesy of www.visualdx.com © Logical Images, Inc


Bullous Pemphigoid

• Diagnosis

Based on clinical presentation, presence of subepidermal blisters on histology and demonstration of anti-hemidesmosome antibodies by direct and indirect immunofluorescence


(University of Rochester, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=52132&imageIndex=14

Bullous Pemphigoid

• Treatment Immunosupressive therapy with:

o Prednisone o Azathioprineo Methotrexate

Tetracycline and nicotinamide In refractory cases can use IVIG



Venous Stasis Disease• Etiology

Risk factors include:

• Age

• Family History

• Prolonged Standing

• Increased BMI

• Sedentary lifestyle Venous hypertension develops

due to one or combination of:

• Poor muscle pump function

• Incompetent venous valves

• Venous obstruction


Charles E. Crutchfield III, MD. (March 2007). Venous Ulcer. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52465& imageIndex=0

• Clinical Severity of symptoms depends

on degree of venous reflux. In order of severity:

• Telangiectasias and Reticular Veins

• Varicose Veins – dilated, tortuous veins > 3mm in size

• Chronic Venous Insufficiencyo Edemao Skin discolorationo Ulcerso Lipodermatosclerosis –

fibrosing panniculitis with hyperpigmentationImage courtesy of Margaret Mann, M.D.

Venous Stasis Disease

• Diagnosis Venography – gold

standard, but invasive, expensive, associated with complications

Duplex ultrasound – most frequently used to assess for deep venous thrombosis, venous reflux

Ankle-brachial index – used to exclude arterial disease

Image courtesy of Margaret Mann, M.D.

Venous Stasis Disease

• Treatment Conservative management:

• Leg elevation, compression therapy

• Skin cleansing, emollients, and topical steroids

Ablation therapy:

• Liquid and foam sclerotherapy for treatment of telangiectasias, reticular veins and small varicose veins

• Endovenous laser or radiofrequency ablation as well as mechanical ablation are used to destroy large veins

Sun-Induced Skin Changes

• “Sun spots” or “liver spots” are also called lentigines, often on backs of hands and shoulders

• Caused by the sun and generally harmless, but can be confused with more serious skin growths

• Can be treated with liquid nitrogen cryotherapy or melanin-targeting lasers (e.g., the Q-switched ruby laser)


Charles E. Crutchfield III, MD. (March 2007). Lentigo, Solar. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=7&diagnosisId=51834&imageIndex=8

Sun-Induced Skin Changes

• Telangiectasias, or dilated blood vessels , can arise as a result of photodamage, rosacea, radiation exposure, long term topical steroid therapy or hereditary causes

• Mostly benign and can be effectively treated with pulsed dye lasers, other vascular targeting lasers or in some cases, electrocautery


(NYU, Department of Dermatology). Telangiectasia. [photograph]. Retrieved Oct 3, 2011, from http://www.visualdx.com/visualdx/visualdx6/getZoomImage.do?moduleId=11&diagnosisId=52379&imageIndex=1

Questions1. Which 2 primary lesions are elevated:

a) Macule and Plaque

b) Macule and Papule

c) Papule and Patch

d) Papule and Plaque

2. True or False, drug eruptions occur more frequently in elderly patients?

a) True

b) False

Answers: 1. d, 2. a

3. The patient is a 75 yo male with no history of skin cancer who presents because his wife became concerned about large “mole-like” growths on his back, which have increased in number over the years. The patient says some of them are itchy. On physical exam the lesions are dark brown symmetric papules and plaques of uniform color with stuck-on waxy appearance. What is the diagnosis?a) Actinic Keratosisb) Solar lentigoc) Seborrheic Keratosisd) Benign Nevus

4. In this patient, what is the most appropriate next step in management?a) Urgent referral to a dermatologist for biopsyb) Photodynamic therapy c) Full body CT scan to look for metastases d) Cryotherapy with application of liquid nitrogen to symptomatic lesions Answers 3. c, 4. d.

5. The patient is a 60 year-old male with a history of significant sun exposure who presents for a routine skin check. He has a history of multiple rounds of cryotherapy for “pre-cancerous” lesions. On physical exam there are multiple skin-colored papules with rough adherent scale located on his hands and face. What is the diagnosis?a) Actinic Keratosisb) Seborrheic Keratosis c) Basal cell carcinomad) Melanoma

6. For the patient in question 5, besides cryotherapy what is an additional treatment option a) 5- Fluorouracil creamb) Chemical peelsc) Imiquimod Creamd) Photodynamic therapye) All of the above

Answers: 5. a, 6. e

7. A 55 year old female with a history of a blistering sunburn as a child and family history of skin cancer presents with a lesion on her chest, which she first noticed 1 month ago. She denies any pain but reports the lesion bled with minor trauma last week. On physical exam the lesion is a shiny, red lesion with rolled borders and prominent telangiectasias. The most likely diagnosis is:

a. Melanoma in-situ

b. Squamous cell carcinoma

c. Nodular BCC

d. Superficial BCC

e. Herpes Zoster

f. Pigmented BCC

Answer: c

8. This patient is a 60 year old female who presents with a large, tense bullae, as shown below. Prior to the appearance of the bullae, she noted a pruritic papular eruption in the same distribution. A biopsy was performed, which revealed a subepidermal blister and immunofluorescence demonstrated presence of anti-hemidesmosome antibodies in the serum. What is the diagnosis?a) Herpes Zosterb) Bullous Pemphigoidc) Drug eruptiond) Dermatomyositis

Answer: b

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