Common Skin problems Family Medicine Specialist CME - PowerPoint Presentation

1. Common Skin problemsFamily Medicine Specialist CMEOctober 15-17, 2012Pakse

2. ObjectivesIdentify common skin diseases based on the pattern of the rashDescribe strategies to prevent and treat common skin diseases

3. Pre-Test 1What disease causes this scaly rash on extensor surfaces (such as elbows and knees)?a. Psoriasisb. Eczemac. Fungal infectiond. Skin cancer

4. Pre-test 2What is the diagnosis?a. Chickenpox (varicella)b. Yeast infectionc. Superficial bacterial infection (impetigo)d. Scabies

5. Pre-test 3This very itchy skin condition, which affects flexor surfaces (such as in front of the elbows and behind the knees) can occur in adults but more often occurs young childrena. Psoriasisb. Eczemac. Fungal infectiond. Bacterial infection

6. Case 1A 4 year old female presents with a 2 day history of this facial rash:What is the diagnosis?What are the most common bacteria that causes this condition?How would you treat this?

7. ImpetigoContagious superficial bacterial infectionMost common in children2 typesPrimary: Infection occurs on normal skinSecondary: Infection occurs on areas of skin where there has been mild trauma or a break (such as from scratching, abrasion, insect bite, eczema)Most caused by Staphylococcus aureus

8. Impetigo: DiagnosisClinical diagnosis: no tests needed!Characteristics of the rash:Start as papules (non fluid filled)Progress to fluid filled vesicles with surrounding erythemaThese turn into pus filled lesions called pustulesPustules break and the fluid forms a yellow or golden crustThe changes occur over 1 weekOccurs mostly on face and legs/arms

9. Impetigo: PreventionPreventionKeep any cuts and scratches clean and coveredThis condition is very contagious through direct contact, especially when there is fluid drainage from the rash!Do not share towels or washcloths with someone with impetigoWash hands with soap and water each time you touch the infected area

10. Impetigo: TreatmentTopical treatment:Mupirocin three times a day is the best choiceOther topical treatments: fusidic acid, hydrogen peroxide 1% cream 2-3 times a dayOral antibioticsIf a large area is involved, and rash is severecephalexin 500mg q6h, orcloxacillin 500mg q6h, or clindamycin 300mg q6h for 7 days (these are adult doses)

11. Case 2A 65 year old man presents with this very painful rash to his back. What is this disease? What characteristics of the rash lead you to this diagnosis?How do you treat it?What are some complications that can occur?

12. Herpes Zoster (shingles)Reactivation of latent varicella zoster virus (same virus that causes chickenpox)Clinical diagnosis:Rash Starts off as papules, then progress to a cluster or group of vesicles. Over 3-4 days they become more pustular. The rash crusts by 10 days. Heal in 2-4weeksFollow 1-2 dermatomes and do not cross midlineUsually on the trunkPain“burning” pain that can start days- weeks before the rash appears

13. Dermatomes

14. Herpes zoster: More examples

15. Herpes zoster: ComplicationsPostherpetic neuralgia (pain even after rash is gone)Bacterial skin infection If trigeminal nerve involved: eye & corneal involvement can lead to vision lossThis is called herpes zoster opthalmicusMotor weaknessVaricella zoster encephalitisIf a patient has HIV, they are more likely to get herpes zoster and its complications

16. Herpes zoster: TreatmentTreatment with antiviral drugs can lead to faster healing of the skin lesions if started within 72h from symptom onsetOral Acyclovir 800mg five times/day x 7 daysIn herpes zoster opthalmicus, use IV Acyclovir 10mg/kg q8h x 7 daysTopical steroid drops

17. Case 3A 10 year old girl presents with itchiness between her fingers, worse at nightWhat does she have?How do you diagnose it? What are the characteristics of the rash?How do you treat it?

18. Case 3: ScabiesFrom infestation of the mite Sarcoptes scabieiTypical lesion:Small erythematous papuleUsually excoriatedHemorrhagic crustBurrows, when seen, make the diagnosisThin gray/ red/ brown line 2-15mm longTypical distribution:Web of fingers, wrist flexor surface, elbow, axilla, knees, buttocks, waist, male genitalia

19. Scabies distribution

20. Scabies: More examplesExamples of burrows

21. Scabies: DiagnosisClinical diagnosis: (1 or more of)Itching, worse at night out of proportion to changes that can be seen on the skinItchy rash with characteristic lesions and distributionOther people in the house with same symptomsInvestigationsSkin scraping (can see mite under microscope)Adhesive tape testUse clear tape to apply directly over skin lesion. Pull it off quickly. Using a microscope, look for eggs and mites

22. Scabies: TreatmentWhole body application of 5% permethrin cream orWhole body application of 1% lindane cream orSingle dose oral ivermectin 200mg/kgFor the itching, can use antihistamine or topical corticosteroid

23. Scabies: PreventionTransmitted by close skin to skin contactContaminated clothing and linens should be put in a plastic bag for at least 3 days before being washed Treat everyone who lives in the same household for scabies

24. Case 4A 6 year old boy is complaining of itchiness to his wrists, neck, front part of his elbow, and behind his knees. His parents thought the problem was dry skin, but the rash and itchiness have been present for several years.

25. Case 4Describe the rash. What is the diagnosis?What treatments (both lifestyle and medication) can you recommend?

26. Eczema (atopic dermatitis)Often first present as children <2 years of ageClinical diagnosisItchy skin. Evidence of rubbing/scratchingLichenified (thickened) skin from chronic scratchingDistribution in the flexor skin creasesIn front of elbow, behind knees, neck, around eyes, fronts of anklesUsually not in axilla, groin, or buttocks  think psoriasis in this distributionDry skin

27. Case 4: More examples

28. Eczema: TreatmentLifestyle changesKeep skin hydratedUse thick creams on the skin, and apply right after bathing (while skin still damp)MedicationsTopical corticosteroids (apply at least once daily)Mild: Low potency (1% -2.5% hydrocortisone cream)Severe: Medium potency (triamcinolone 0.1% cream)Do not use higher potency steroid creams for more than 10 days

29. Case 5A 25 year old man says he has noticed a scaly, non-itchy rashto his scalp, along with some changes to his nails.Describe this rash.What is the diagnosis?What other non-skin body parts can this disease affect?What is the treatment?

30. PsoriasisOnset peaks at ages 20-30 and again at 50-60Clinical diagnosisErythematous raised plaques with a thick silvery scaleBetter in summer months because of exposure to ultraviolet lightNo or only mild itchinessDistributionScalp, elbows, knees (extensor surfaces), back, buttocks, and at old sites of trauma

31. Psoriasis: Distribution

32. Psoriasis: More examples

33. Associated non-dermatologic findingsInflammation of the eyes:Red, painful eyes, flaking or crusting of eyelashes, swelling of eyelids, visual changesArthritisCan involve distal joints (see picture), large joints such as hips and knees, or the backNailsPits, or brown discoloration

34. Psoriasis: TreatmentMild-moderateKeep skin soft and moist with vaseline or creamsTopical corticosteroidsMild potency (hydrocortisone 1%) on the faceMedium potency (betamethasone 0.05%) on thick plaques to elbows or kneesTar creams and shampoosSeverePhototherapy with UV lightOral drugs such as methotrexate

35. Post-Test 1This girl has a rash and she is very itchy! Which skin disease(s) can cause itchiness? (Can have more than one right answer)a. Eczemab. Herpes zosterc. Scabiesd. Impetigo

36. Post-Test 2What common skin disease does not cross midline and stays within 1-2 dermatomes?a. Eczemab. Psoriasisc. Impetigod. Herpes Zoster

37. Post-Test 3What is the most common bacteria that causes impetigo?a. Beta-hemolytic streptococcib. Staphylococcus aureus c. Enterococci d. Pseudomonas aeruginosa