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Emergent and Urgent Dermatology, Eruptions, and Wound Care · “Emergent and Urgent Dermatology,...
Transcript of Emergent and Urgent Dermatology, Eruptions, and Wound Care · “Emergent and Urgent Dermatology,...
“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 1
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Emergent and Urgent
Dermatology, Eruptions,
and Wound Care
G. Scott Drew, DO, FAAD, FAOCD
Dermatology Associates of Mid Ohio
POMA District 8
February 3, 2019
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Disclosures Dr. Drew is a consultant for AbbVie, Inc., Sun
Pharmaceutical Industries, Ltd, Pfizer, Inc.,
Centocor Biopharmaceutical, Ortho
Pharmaceutical Corp., Galderma Laboratories, LP,
Medimetriks Pharmaceuticals, Inc., and Novartis
Pharmaceuticals Corp.
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Acute Cutaneous Lupus
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 2
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Acute Cutaneous Lupus
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Acute Cutaneous Lupus
ANA positive, Anti Ro, La Positive
Photo distributive
Need Systemic Work up
Initial tx, systemic corticosteroids, SPF
Antimalarials following negative G6PD
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Subacute Cutaneous Lupus
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 3
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Subacute Sutaneous Lupus
Erythematosis
ANA negative, Ro and La positive
Fewer systemic symptoms
Less systemic co morbidities
Corticosteroids and steroid sparing agents, spf
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Discoid Lupus
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Discoid lupus
ANA, Ro and La negative
Usually not systemic
Scarring and Scaling alopecia
Photo distributed
Treatment include systemic, topical and
intralesional corticosteroids, steroid sparing agents
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 4
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Acral Lentiginous Melanoma
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Acral Lentiginous Melanoma Highest morbidity and Mortality of the Melanomas
Due to delay in Diagnosis
Bob Marley’s demise
Breslow depth
Work up and wide excision based on Breslow depth
FSE monthly by patient, quarterly by physician
Excision, not biopsy
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Congential Nevus
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 5
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Congential (Hairy) Nevus
Very low malignant risk
High parental concern
Watch for changes
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Bullous Pemphigoid
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Bullous Pemphigoid Differentiate from Pemphigus, a far more serious Dx
H & E and DIF biopsy
Systemic corticosteroids
Steroid Sparing agents
Often burns out
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 6
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Stasis dermatitis
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Stasis dermatitis
Chronic
Circulatory Compromise
Compression Essential
Work up for Co morbidities
Prevention of Ulcerations
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Necrotic Ulcers
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 7
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Leg Ulcers-
-Leg ulcers are symptoms, not diagnoses
-treatment based on etiology
-biopsy if treatment not effective
-work up for co morbidities (malignancy, trauma,
diabetes, PVD, abuse, et al
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The magic changing ink
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Dermatomyositis
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 8
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Dermatomyositis Classic but subtle clinical presentation, including
Heliotrope rash, shawl sign, gottron’s papule
Work up essential: CK, Aldolase, LDH, etc
50% with associated malignancy
Biopsy confirmation
Treatment systemic corticosteroids, steroid sparing
agents, spf, others
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Pyogenic Granuloma
Etiology often trauma and microtrauma. Surgical treatment
asap
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Foreign Body Granuloma
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 9
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Foreign Body Granuloma
History of injury important
Can be recent, usually remote
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Erythema Multiforme Minor
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Erythema Multiforme Minor Usually due to Drug reactions or HSV
Treatment directed at etiology
Palms, soles, mucous membranes.
Often recurrent, esp if HSV induced
Avoidance of offending drug (sulfonyl ureas,
bactrim) and/or supressive anti virals
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 10
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EM Major/SJS
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Molluscum contagiosum
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Molluscum contagiosum
In toddlers, almost always associated with atopic
dermatitis.
If fewer than 10, treat the AD first
If greater than 10, treat the MC
If associated with wrestling, sports, STD, treat the
MC
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 11
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Atopic dermatitis
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Atopic Dermatitis
A lifestyle, not a tube of hydrocortisone
Increased risk of Bacterial, viral, fungal and
parasitic skin infections
Associated allergy, otitis, asthma
Treatment: steroid sparing agents, emollients, mild
cleaners, food, mild detergents, anti pruritics,
bleach baths. Limited corticosteroids
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 12
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Pityriasis alba
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 13
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Cellulitis
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Cellulits
Usually staph or strep
Community acquired vs Hospital acquired MRSA
Topical, oral, systemic antibiotics
History of prior manipulation, puncture,
penetration with home sterilized safety pins, awls,
needles, razors
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 14
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Pityriasis Rosea
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Pityriasis Rosea Herald Patch
Self limited
Pruritis variable
Rx supportive, accurate diagnosis
DDX includes parapsoriasis, guttate psoriasis,
tinea, et al
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Hidradenitis supprativa
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 15
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Hidradenitis supprativa
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Hidradenitis Supprativa Symptoms progressive and can be debilitating
Surgical tx as a LAST resort
TNF alfa inhibitors are first line treatment
Alternative tx include isotretinoin, rifampin,
minocyline, spirinolactone, surgery
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Basal Cell Carcinoma
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 16
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Basal Cell Carcinoma
Most common Human Malignancy >
1,000,000/year
Rare metastasis
Surgical excision is ToC
Radiation, MOHS, ED&C, Imiquimod, vismodegib
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SCC
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Squamous Cell Carcinoma Slightly higher risk of metastasis, particularly of
hands, face, scalp and neck
Surgical treatment ASAP
Clean margins
SPF
Frequent FSE
In immunocompent host, usually sun exposed
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 17
#POMAD8#ChoosePOMA
Squamous Cell Carcinoma
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Squamous Cell Carcinoma
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 18
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Systemic Malignancy
Metastatic to Skin
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Systemic Malignancy
Metastatic to skin
Occasionally primary malignancy is previously
unknown
Almost all systemic malignancies known to
metastasize to skin
History is irregularly irregular
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 19
#POMAD8#ChoosePOMA
Squamous Cell Carcinoma in the
immunocompromised patient
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SCC in Immunocompromised
patients
Often in solid organ transplant patients, those on
chemotherapy, or systemic immunosuppressants
Metastatic rate higher
Clinical presentation often more aggressive
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Granuloma Annulare
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 20
#POMAD8#ChoosePOMA
Granuloma Annulare
Distinct presentations in pediatrics vs adult pts
Often confused with tinea (no scale with GA)
Can be associated with DM
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Tinea Capitis with Kerion
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Tinea Capitis with Kerion Epidermophyton, Microsporum and Trichophyton
spp are causative organisms
Usually associated with regional adenopathy
Tinea capitis requires oral treatment
Griseofulvin 20mg/kg x 6 weeks, terbinafine by
weight
Kerion is a late sequellae.
Power of a Nickel (Powerofanickel.org) and DOcare
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 21
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Epidermal Inclusion cyst
Topical therapy, vs ILK, vs Excision
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Plaque Psoriasis
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Plaque Psoriasis
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 22
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Treatment Options
for BSA > 10%
Narrowband UVB
Methotrexate
Acetretin
Apremilast (PDE 4 inhibitors)
Biologics
Combinaiton theraby
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Sebopsoriasis with Isomorphic
phenoenon
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Pediatric psoriasis
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“Emergent and Urgent Dermatology, Eruptions and Wound Care”G. Scott Drew, DO
POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 23
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One month of adalimumab
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Compulsive excoriation
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Compulsive
Excoriation/Neurodermatitis
Rarely a primary dermatitis
Often require multidisciplinary approach
Recognition of the patients participation in the
disease
Elimination of the picking/scratching/digging
Often requires psychoactive agents (doxepin,
fluvoxamine, benzodiazapines)
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