(Pictured above and below) A 54-year-old male presents with two bald patches on the scalp. He complains that the bald patches itch. Diagnosis: Alopecia Areata
(Pictured below) A one-year-old presents with a lesion on her scalp since birth. Diagnosis: Nevus Sebaceous
Nevus Sebaceous has three clinical stages:
1. At birth, as seen in this picture, patients have a solitary, hairless, pinkish-yellow lesion on the scalp.
2. At puberty, the lesion becomes verrucous and nodular.
3. Later in life, the lesions may develop into various types of tumors including basal cell carcinoma, squamous cell carcinoma or apocrine carcinomas.
The treatment of choice is to monitor yearly for changes and possible excision once the patient becomes an adult.
More dermatological procedures, such as biopsies and
excisions, are being done in primary care settings than ever before. With this
in mind I want to give everyone some food for thought as to how they can more
accurately read the pathology. As clinicians seeing patients, we have the
advantage of talking to a patient, seeing their rashes and lesions first hand,
and learning of any past treatments they have had.
The dermatopathologists do not have this advantage. We
send them a small sample of a lesion or rash and expect an answer as to what we
are seeing or confirmation that what we are excising has clear margins. To aid
them in assisting us to provide optimal care, several measures can be
First, give an accurate description of what is seen.
If there are multiple lesions, describe them, their distribution and how long
they have been present. If an isolated lesion, describe the size, color, shape
and consistency. Is it ulcerated, hypertrophic, lichenified, erythematous? All
this can help in proper diagnosis.
Second, inform the dermatopathologist if any
treatments have been used. If steroids, topically or orally, have been used, it
will change the appearance under microscopy. If the area has been treated with
liquid nitrogen, electrocautery, or previous excision, that information is
important and should be communicated. Do not send fragments of cauterized skin
asking for margins, it cannot be determined from these.
Third, take appropriate and adequate samples. Rashes
should be biopsied with full thickness or a punch. Knowing where the rash
originates, epidermal, subepidermal, dermal or subcutaneous fat is vital for
diagnoses. Lesions suspicious for basal cell and squamous cell should be taken
through to the papillary dermis to prevent superficial, non-diagnostic samples.
If biopsying a pigmented lesion suspicious of melanoma, take the entire lesion
to make sure the depth is properly diagnosed as this will dictate treatment.
By doing these things, we can help our colleagues
help us. This will in turn help us help our patients.
Sometimes I enjoy things that occur in the office to spice
up the traditional clinic day. Recently, I have had several high school
students "job shadow" me for their senior project. Essentially, they are required to shadow a
career they have interest in for eight hours.
I love teenagers and I love my job so it's a perfect
marriage! I require them to stop by a week before their scheduled date for a
tour and HIPAA briefing. I find
the preview visit to be quick, but extremely valuable.
This visit assists the student in feeling more comfortable
when they job shadow and offers a chance for the staff to meet the student as
well. This way there are no surprises come Monday morning. Nothing is worse
than starting the day off in the wrong direction, let alone a work week.
I have the medical assistant inform the patient I have a
student with me for the day. Additionally, I enter the room alone and confirm
the student's presence is ok with the patient.
I was quickly reminded last month that students do faint. A demonstration
on standing against the wall to assist in bracing their fall should they faint
is definitely mandatory.
I felt my patients enjoyed having the students and I always
get wonderful feedback from everyone. Medicine truly is, "See one, do one, teach
If you don't know the children's book character "Flat
Stanley" you must Google him.
I received Flat Stanley in the mail two weeks ago from a
first grader in Indiana. I was instructed to take Flat Stanley with me everyday
and take photos of our adventures.
So, in the theme of spicing up the workplace, I brought Flat
Stanley (pictured) into surgery.
Naturally, I chose a patient I knew would love to
participate and once the procedure was completed, we had a photo shoot.
Medicine is so complex and serious all the time,
I truly believe everyone benefits from a slight amount of diversion every now
and then. Whether human or paper, visitors offer a professional amount of
There are several presentations for patients who have or believe they have "bugs" in or on their skin. There are the haves, have nots and the "I know I have it and I brought proof but have nots." The haves are easy to diagnose. The most common of these are lice, scabies, ticks, bed bugs and the occasional erythema migracans.
The have nots are those who are told they have something such as the above listed diagnoses but don't. These patients are usually treated for scabies or lice but do not improve or worsen. In most cases, the patient's correct diagnosis is papular urticaria, lichenoid drug eruption, photoallergy, or any one of several hypersensitivity reactions. When treated with topical steroids and avoidance of the assaulting agent, the eruption resolves.
The last group of patients can be far more challenging. These patients believe they have bugs in them and on them. They believe they are seeing them crawling in their skin and they try to get them out through scratching and sometimes cutting the skin (figures 1 and 2).
They will bring in clothing that supposedly is covered in the bugs and baggies that they believe have definitive proof of the parasites (figures 3 and 4). This condition is known as delusions of parasitosis.
If you have not seen this in the clinics, it is likely that someday you will. Here are some helpful hints to dealing with the problem. The goal I have is to get the patient to see a psychiatrist as soon as possible to deal with the delusional aspect of the condition.
To do this, I refuse to acknowledge the delusion as a possibility of reality. I simply tell them that there are no bugs. The bags brought in are filled with scabs and clothing debris. I tell them there are no bugs and that the delusion is normally associated with a stress response that, if treated properly by a psychiatrist, can be cured.
Treatment includes antibiotics, due to infections caused by scratching and digging, topical steroids to reduce the inflammation caused by the itching, and petroleum-based emollients under occlusion to help the affected areas heal without further trauma.
This was a 71-year-old female who reported a rash for 7 months. Her primary physician thought she needed a dermatologist evaluation.
At the beginning of taking her history, she was pointing to lentigines scattered on her face, arms and legs that she "disliked." The patient reports the ability to remove each lentigo with toe nail clippers, except she couldn't remove the "seed" and that's what truly bothered her. She wanted the seeds gone.
Neurodermatitis is a very difficult disease to treat. These visits are extensive and require a tremendous amount of patience and hand holding. I explained she was digging out her hair follicles and not "seeds." I also felt she needed a follow up with her primary and perhaps an adjustment on her antipsychotic medications. I also arranged for her visits to the wound clinic. I will see this patient biweekly until we resolve her condition.
I had a student ask me
recently if I had a dermatoscope and if I could show her how to use it. The
answer was simple enough. No, I don't need one. This of course led to the
logical question...Why? This blog post was inspired by this exchange.
The simplest answer to
this question is that if I see something that looks abnormal, I biopsy it. If a
patient is reporting a progression, or symptomology, of a lesion that is potentially
abnormal, I biopsy it. For this reason, I have no need for a dermatoscope. I am
not saying that there is not adequate science to support the use of these
devices. Although, consistency and accuracy amongst novice users is poor.
The use of the dermatoscope
will never convince me that a lesion I believe to be potentially abnormal,
either by clinical evaluation or patient history, doesn't need to be biopsied.
The liability involved in not doing so is too great. To illustrate this point
further I gave my student the following scenario.
What happens if I
believe something is abnormal, take a biopsy, and it shows the lesion is benign?
The patient is left with a small scar. What if I evaluate a suspicious
pigmented lesion with a dermatoscope, believe it is benign based on this
evaluation, and I am wrong? Well, the worst case scenario is that this lesion
is a melanoma and the patient could die as a result of my mistake. Therefore,
if a lesion makes me want to reach for a dermatoscope, I'm leaving it in my
pocket and consenting the patient for a biopsy.
Therefore, when asked
why I don't have a dermatoscope? It would not benefit my clinical practice.
Take a good history. Do a complete examination in sufficient light. Wear
glasses if you need them or surgical loops to see small lesions. If there is a
question as to malignancy, biopsy it. If you have a dermatoscope, use it. But
if you do, unless you are a highly trained expert with thousands of supervised
hours evaluating lesions under dermoscopy...I would suggest you biopsy.
A new patient (below), a 60-year-old woman, presented for "spongiotic dermatitis" diagnosed after a biopsy in March 2011. At the time, she received cortisone cream and no follow-up appointment. She comes to my office because she is concerned that the spot never went away and now it is very sore and tender. A shave biopsy shows this to be nodulocystic basal cell carcinoma.
This case is a friendly reminder that follow-up appointments are absolutely necessary to providing quality patient care. You can always tell the patient that "If you feel the spot/lesion/rash has 100% resolved by your follow-up appointment you may cancel, but as soon as you notice something developing/growing please return to the clinic as soon as possible." This unfortunate patient just assumed she had a "funny rash" that never went away.
I always inform patients that "My dermascope informs me if your condition is still lingering or has completely resolved, so I prefer you return for your follow-up appointment even if you think it's gone."
I saw this patient (below) for a full-body exam 6 weeks ago. He presented last week with this new, incredibly rapid growing nodule behind his left ear. I was shocked by how fast it grew and was certain it was a basal cell carcinoma. I even scheduled him for MOHS that day! Two days later, the lesion was biopsied and proven to be a benign pilomatrixoma.
Pilomatrixomas are single tumors derived from hair matrix cells and may closely resemble an epidermoid cyst. They can also present in a malignant form. This patient will be monitored and re-checked in 90 days.
This 66-year-old man (below) presents with a growing "bump" that he believes began 2 years ago. Diagnosis: nodular basal cell carcinoma.
As the universities and secondary schools are
preparing for spring break, it is important that we are educated and educate
our young patients on the dangers of ultraviolet exposure. I am going to focus
this blog more specifically towards the use of tanning beds.
As a dermatology specialist and a parent, I find it
unconscionable that children under the age of 18 can still access and utilize
tanning beds. It is even more disturbing that parents consent for their minor
children to lay in these cancer boxes and put their lives at risk. I am very
passionate about this issue and hopefully when I lay out the disturbing facts
about tanning beds, you as providers will be as well. If you use tanning beds,
stop! If you allow your children to use them, shame on you and...stop!!!
Why did I choose this month for this topic? Now is a
big time for tanning companies. As our children, including college aged
students, prepare to go to the warmer climates for spring break, many of them
go to tanning beds to get that "base tan." They don't want go to the beaches all
pale and "chalky" looking. They also use the excuse that they don't want to get
a burn when they go lay out in the sun.
I am going to give you the short version of what I
tell my patients and their parents when they come in tanned, let alone when
they admit to tanning bed use. There is no such thing as a healthy tan. The
skin does not produce melanin as an indictor of how healthy it is. It produces
melanin to protect itself from the assault of ultraviolet radiation. In
essence, a tan is just a sign that someone has received excess radiation.
The notion that tanning beds are safer than natural
light because they don't use UVB light is ridiculous. The UVA that is utilized
by tanning beds is less likely to burn you because it penetrates through the
top layers of the skin. It is more likely to cause melanoma though, because it
stimulates the melanocytes to produce more melanin.
So, UVA radiation will not burn you, it will kill
you. In support of this fact, the International Agency for Research on Cancer,
a research arm of the World Health Organization, developed a comprehensive list
of carcinogens. On this list, tanning beds are in its most dangerous category,
"carcinogenic to humans." Furthermore they found that risk of developing
melanoma is 75% higher for individuals who use tanning beds before the age of
30 compared to those who never used a tanning bed.
The tanning industry should be put in the same
category as tobacco. No minors should be allowed to use them. It should be
taxed at the same rates as tobacco products to aid in education and prevention
of melanoma. Parents who allow their children to tan in these devices should be
charged with endangering the welfare of a minor in the same way someone who
buys alcohol or tobacco for a child is charged.
I will close with what I tell my college age daughter
before she goes out. Don't do anything stupid that's gonna get yourself killed.
Have fun at spring break. Wear your sun-block. Reapply every two hours. Try to
avoid the sun from 11am-2pm. STAY OUT OF TANNING BEDS!
Above, a 75-year-old patient with stage 4 metastatic melanoma. He came to us after a staged excision and graft. The black dots are new satellite nodal mets.
Above, metastatic satellite lesions on the scalp of the same patient. He had the original
scalp lesion treated numerous times with LN2. The lesion continued to be
treated with LN2 for an entire year before a biopsy was performed and
confirmed to be metastatic melanoma. His prognosis is less than six
Above, the same area two weeks later. This demonstrates how rapid this stage 4 metastatic melanoma is.
These photos are an excellent reminder that if a lesion remains present after two treatments of liquid nitrogen, a biopsy is the next appropriate course of action. In the case of this patient, it could have been life saving.
If you have been around medicine long enough and seen enough patients with rashes then you have probably heard the term "creeping crud." It is often used by older patients to describe a rash that appears to be spreading or moving to other areas of the body. In most cases, these rashes are not actually creeping or moving. They are one of the various subtypes of eczema, a newly diagnosed psoriasis, pityriasis rosea or tinea.
The creeping crud does have a foundation in dermatology and refers to a specific parasitic infestation. The correct medical diagnosis is cutaneous larva migrans or creeping eruption. It is caused by the hook worm larvae aimlessly wandering under the skin (figure 1 and 2 below).
It is common in warm climates and amongst people who garden or work in environments where animals, most commonly cats, dogs or raccoons can get, such as under trailers or elevated homes. The eggs are in the fecal matter of these animals and when they hatch they lie in wait for a warm blooded animal to infest and mature.
Figure 1 (above)
Figure 2 (above)
Luckily this condition is easily treated with Albendazole 200mg twice daily for 3 days. The larvae die and the trails left by the infestation will flatten and slowly fade away (figures 3 and 4). So the next time a patient comes to see you and says they have the creeping crud you can assure them that they do not, or if they do you, now know how to cure it.
Figure 3 (above)
Figure 4 (above)
(Above) Heart-shaped pigmented Basal Cell Carcinoma on the back of a 71-year-old male.
(Above) Heart-shaped Actintic Keratosis on the left forearm of an 88-year-old male.
(Above) Heart-shaped squamous cell carcinoma on the lower leg of a 73-year-old male with a history of previous skin cancers.
(Above and below) Bilateral Syndactyly on a 43-year-old female.
Malignant Melanoma on a 69-year-old female
Breslow Thickness: 0.9mm
Clark Level 3/Early 4
Mitotic Index: 2 dermal mitosis
Referred for Lymph node mapping and treatment
Cellulitis on the lower leg.
Cellulitis on the lower leg 2 days later, following Predinsone 60mg QD, Bactrim DS BID, Domeboro Soaks QID
19-year-old presented to the clinic with a letter from the Navy denying his enlistment and failing his medical exam secondary to "chest infection."
Dx: Acne Granulomatous
As this is my first attempt at blogging I will start by introducing myself. My name is Raymond Shulstad, DNP, ARNP-C, BC, DCNP. I have been practicing dermatology for the past 11 years in the Tampa Bay area. I completed my DNP in December of 2009 at the University of South Florida, after finishing my dermatology residency. As with all areas of medicine, it is important to guide treatments on the evidenced-based practices that are available. However, some of what we all do is empirical and knowing some tricks to the trade can be helpful at optimizing patient outcomes.
I am a strong advocate for educating our patients and keeping interventions and treatments as simple as possible. It is my belief and has been my experience that this leads to higher compliance and better outcomes. The treatment for a condition shouldn’t be more stressful than the condition itself. I operate under the K.I.S.S. (keep it simple silly) principle.
One condition that I find to be chronically mismanaged or over-managed is stasis dermatitis. This condition is caused by edema in the lower legs and can result in mild erythema and itching in the early stages to blister and ulcer formation if untreated. Most patients I see with this come to the office saying that they have been given “water pills” or T.E.D. hoses to get the excess fluid out of their legs.
Most will not wear the hose due to discomfort and the water pills are of little use if the edema has progressed to the point of causing stasis dermatitis. Patients are also given topical antibiotics and some are being treated by wound care are receiving dressing changes regularly to treat ulcerations.
The next time someone presents with this condition in clinic I encourage you to try a simple approach that educates and empowers the patient to treat the current eruption and prevent further problems. After explaining that the irritation in the legs is being caused by the edema, I explain to them that the only way to treat this properly is to get the fluid out. To do this we use gravity to our advantage. It is, after all, gravity that is causing it.
Patients know that blood is being pumped by the heart to all parts of the body. I explain to them, though, that nothing pumps the blood back. It is pushed back by the blood being pumped out from the heart.
In the lower legs, when valves are failing, it is easier for the fluid to third space, causing edema and eventually stasis dermatitis, than it is for it to fight gravity and return to where it belongs. Fluids will always follow the path of least resistance. In these cases the force of gravity keeps the fluid in the legs. Since there is no way to reverse the valve damage, it is vital to long term control to keep the edema down to a minimum.
Instruct your patient to elevate their legs for 15 minute every two hours. Additionally, have them go to bed with the legs elevated. Elevation must be above the level of the heart or this intervention will be ineffective. By allowing the forces of gravity to work on the edema, it is now easier for the fluid to be reabsorbed and returned to the heart for circulation or elimination through the kidneys than it is for it to stay in the legs. Again, liquids will always follow the path of least resistance.
Low- to mid-potency topical steroids can be used if pruritis is present but in most cases it is not needed. Petroleum-based emollients can be applied to help hydrate the skin and prevent scaling and irritation. This treatment should be continued for two weeks and then re-evaluated. You will be amazed at the results and so will they. Keep it simple: no hose, no dressing changes, just using gravity to our advantage.
patient had perfectly symmetrical basal cell carcinomas on both
forearms. The patient even remembers getting horribly sun burned on both
arms twenty years ago!
This 72 year old patient presented for a total body exam. The patient reported a pencil stabbing by a classmate at age 10. Had the patient not remembered a specific incident a bx to rule out melanoma would have been performed.
This patient is an 81 year old with a boil on the right arm for 3 months. The Bx proved Invasive Squamous Cell Carcinoma with Keratocanthomatous features. This case will be treated by MOHS.
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1. 61 y/o M new patient presents for rapidly growing bump on right cheek. Shave biopsy proven Invasive Squamous Cell Carcinoma and scheduled for MOHS.
2. 56 y/o F spilled hot water on her ankles on Thanksgiving. Patient is complaining of soreness and pain. Treated with Omnicef 300mg BID for 5 days, Biafine BID, Topicort Ointment BID.
This is the burn on foot four days later following treatment.
3. 81 y/o M retired MD with history of MM presented for a Total Body Skin Exam. This lesion on the right forearm was reported "unchanged for years"Shave biopsy proven Melonoma in Situ. Excision was performed in the office three days later.
4. 52 y/o F with Graves Disease was referred by primary for rash on the BL lower legs. Dx: Pretibial Myxedema. Treatment with Clobex Ointment occlusion QHS. Patient denied Intralesional injections of Kenalog.