Objective: Bilateral lower extremities, extensive, confluent blue-gray macules. Nonblanchable. Non tender. Skin cool, dry. No erosions or crusts or exudates. Extends from upper tibia to distal interphalangeal joint. Denser confluence at anterior and medial pre-tibial areas. No lesions on soles of feet. Actual cause: 87 y.o. man reports progressive darkening of skin and chronic leg swelling. Denies pruritis, trauma. Hx of CHF, RA. Unknown use of meds. Dx: minocycline induced hyperpigmentation. http://www.clinicaladvisor.com/derm-dx-elderly-man-with-blue-gray-pigmentation/slideshow/413/?DCMP=EMC-CA_dermdx091711#examDetails

Extensive erythmatous macules, scattered vesicles. Areas of confluence. Might add: covering trunk, mildly tender to touch. This is varicella. Accompanied by low grade fever, malaise.

Cluster of irregularly shaped hypo-pigmented macules without induration, scale or surface change. Non-tender. 33 y.o. black woman. Unclear hx in terms of duration or changes. Pt noted areas of hypo-pigmentation on her back. Denied pruritis. An exam technique: press clear lab slide on skin over lesion. What color is it under the glass? Here – normal pigmentation returned. Dx – nevus anemicus – genetic illness, hypersensitivity to endogenous catecholamines, wherein local vasoconstriction occurs. Melanin is present. Benign, painless.

Unilateral, medial left lower leg, (estimated) 14cm x 8cm area of confluent erythematous papules, vesicles, and intact bullae. Mild warmth on palpation. Non-tender. Lesions extend to posterior lower leg in more proximal distribution of erythmatous papules approx. 6x6 cm. This is poison ivy.

Bilateral rash in folds beneath breasts. R 10cm x 9cm. L 7 cm x 7cm. Deeply erythmatous papular rash with central fissure at skin fold. Satellite lesions present bilaterally. Mild warmth. Non tender. This is a candidiasis infection. The satellite lesions are one diagnostic key, as is deeply red/purple color and relative lack of denuded skin.

The infection spreads laterally along the connective tissue layers of the skin, not superficially. Dangerous! Esp peri orbital cellulitis.

Dependent rubor – occurs with claudication and occlusive diseases of the lower half of the body. If the rubor subsides on elevation, then dependent rubor should be noted. Hemosiderin staining may look similar but does not subside on elevation. Arterial ulcers can develop. Punched hole look. Very slow to heal, Painful. Common in diabetics. Note gangrenous toes. Arterial insufficiency & claudication may appear as pain on walking which subsides with rest. But is NOT relieved with elevation, in fact elevation makes pain worse.

Hemosiderin staining. Chronic redish/brownish discoloration of lower extremity skin due to chronic poor venous return.

Skin NSG 464 Spring 2012 Part Two

Conditions you should know Which is candidiasis (above) and which is contact dermatitis (incontinence associated dermatitis – left) ?

Skin Cancer Basal cell carcinoma – papule, pearly translucent top, rounded pearly borders, central ulceration. Squamous Cell Carcinoma Erythmatous scaly patch with sharp margins, >1cm.

Melanoma vs. Seborrheic keratosis

Superficial spreading Most common Flat, irregular. Usually brown or black Most common in Caucasians Nodular Look for raised bluish-black or bluish-red Can be without color Most lethal Four types of melanoma

Lentigo maligna melanoma Usually found in elders Look on sun damaged skin Large, flat, tan and brown lesions Acral lentiginous melanoma Least common form On palms, soles, in nail beds More common in Af-Am Melanomas can appear on mouth, eyes, and (rarely) genitals and other mucus membranes Four types of melanoma

More Acral Lentiginous Melanomas

Think ABCDE A –asymmetry B – border irregularity, poorly defined margins C – color variation within lesion D – diameter > 6mm E – elevation or enlargement KNOW THESE! Any lesion that changes noticably is suspicious. Be safe & biopsy!!! Danger signs for skin CA

How would you assess this?

How would you assess this?

How would you assess this? Below: Diascopy. A glass slide is pressed on the skin and see normal pigmentation returned to the skin

How would you assess this?

How would you assess this? Satellite lesions

Cellulitis The infection spreads laterally through the connective tissue layers of the skin, not superficially. Dangerous! Especially peri-orbital cellulitis.

Arterial Insufficiency Dependent rubor – occurs with claudication and occlusive diseases of the lower half of the body. Subsides on elevation Hemosiderin staining may look similar but does not subside on elevation. Arterial ulcers can develop. Punched hole look. Very slow to heal, Painful. Common in diabetics. Note gangrenous toes. Arterial insufficiency & claudication may appear as pain on walking which subsides with rest. But is NOT relieved with elevation, in fact elevation makes pain worse.

Hemosiderin Staining

Lesions caused by trauma or abuse

Freckles – small, flat, brown Moles (nevus or nevi) Symmetric, small, smooth borders, uniform in color Junctional nevi – flat, usually only kids/adolescents Compound nevi – raised or flat, see in young adults Intradermal nevi – common in elders Other skin discolorations

Lentigines – “age spots” Actinic keratoses (scaly) Pre-malignant Other skin discolorations

Gangrene – tissue necrosis, blackened atrophic eschar Wet – local infection – e.g. necrotizing fasciitis Dry – arterial insufficiency Gangrene

Abnormal drying of the skin Xerosis and anhydrosis

Gas under the skin. More felt than seen. Associated with subcutaneous emphysema, trauma, or gas gangrene (bacteria produce gas bubbles by fermentation) Crepitus

Comedomes Open (blackheads) Closed (whiteheads) Papules, pustules, cysts Acne vulgaris Stages of acne. (A) Normal follicle; (B) open comedo (blackhead); (C) closed comedo (whitehead); (D) papule; (E) pustule.

Flushing, erythema, papules, pustules Rhinophyma (enlargement of nose) Telangiectases Watery, bloodshot eyes Cause unknown, no cure but medication can manage sx Acne Rosacea

Also called eczema Autoimmune, inflammatory Often pre-cursor to asthma Familial tendencies See itchy rashes on flexor surfaces of arms, legs Skin highly reactive, sensitive Onset in childhood. Often improves by 20’s Atopic dermatitis

Reaction to external substance Erythema, macules, papules, vesicles Confluent Borders sometimes sharp Often itchy Contact dermatitis

Inflammatory, autoimmune (thought to be), familial tendency Extensor surfaces See scale, plaques Several varieties Psoriasis

Inflammatory condition, thought to be a reaction to certain yeast infections White to yellowish scales form on oily skin Esp. on scalp, behind hears, Around nose, genitals Seborrheic dermatitis

Fungal infection “ringworm” Erythema, scale Often annular Central clearing Itchy KOH scraping will show budding hyphae Tinea corporis

Common fungal infection See pale macules, patches Can be hyperpigmented in light skinned pts Fine ash scale Usually not itchy Worse when hot/humid KOH shows “spaghetti & meatballs” Tinea versicolor

Viral infection Common Can appear in mouth, genital areas Look for cauliflower like appearance, discrete borders Usually painless Non-itchy Warts

Hypersensitivity reaction to meds, infections Minor – reaction to herpes simplex or mycoplasma Major (serious illness) Also known as Stevens-Johnson syndrome, a reaction to medications Systemic sx as well as rash. Fast onset. Erythema multiforme

Thought to be a viral illness Seen in young adults Herald patch Rash lasts weeks Pink/red, oval lesions Scaly, itchy Christmas tree pattern Pityriasis rosea

Highly variable Widespread Morbilliform (looks like measles – macular lesions, red, 2-10mm, may be confluent), or urticarial, papulosquamous, pustular, bullous Drug eruptions

Fat builds up under the skin around eye Benign Xanthelasma

Normal skin does not fluoresce Shine UV light on skin ~4” away– no prep required Woods light Coral red. Erythrasma – a bacterial infection of the keratin layer. Tinea on scalp - green Hypopigmented area of vitiligo

Woods Light

See list newly posted on D2L for listing of most common vocab words Know all lesion/abnormality descriptors Know the typical presentation of the listed conditions Look at multiple sources for study purposes Identify the references you find most useful Multiple lists of internet ‘slide shows’ on D2L for your use – do not memorize all diseases but be able to describe all types of lesions/rashes Study Guide

Fitzpatrick, T.B., Johnson, R.A., and Wolff, K. Color Atlas & Synopsis of Clinical Dermatology, 4th ed. A standard in most courses Goodheart, H.P. Goodheart’s Photoguide of Common Skin Disorders. Handy and more extensive treatment of common problems. Good references

Last slide in lecture