day thousands of people go to their practitioner's offices, walk-in clinics and
emergency rooms complaining of a "rash". Some of them itch, some of them don't.
Some have been present for a few days, some for many years. Some come and go
sporadically without warning, some present acutely, some appear like clockwork
at specific times of the year or after exposure to specific irritants.
of these conditions are either related to exposure to an allergy or irritant or
are in the atopic dermatitis spectrum. Most practitioners can recognize and
distinguish the urticarias and things such as scabies relatively easily and
treat them appropriately. For the majority of patients, many exanthems will
resolve without treatment; for those that don't, a topical steroidal cream or
ointment will resolve or improve them.
Sometimes though, something that appears to be a rash is
only a cutaneous manifestation of something that has the potential to be
significantly more ominous. One such example of this is mycosis fungoides or
cutaneous T-cell lymphoma. This form of lymphoma can look exactly like an
atopic dermatitis and have the same symptomology (redness, pruritis, sporadic
and transient). The difference is that
this condition, if it advances, can be lethal.
So, how can you tell the difference if they all look the
same? In a word, BIOPSY! If an elderly person presents to your clinic with
complaints of a long standing rash, treated for multiple years with minimal
success with topical steroids and the erythema seems to be confined to
photo-protected areas of the body, or those covered with clothing, take a
It is unlikely that
atopic dermatitis will acutely begin in the fifth or sixth decades of life with
no previous history. It also usually presents on the antecubital and posterior
knees. Mycosis fungoides usually presents in the fifth or sixth decades of life
and ultraviolet light suppresses rash. Therefore, the exposed areas of skin are
spared and as mentioned earlier, the trunk or covered regions of the skin are
the most common sites of presentation.
If you take a biopsy and it is consistent with mycosis
fungoides, don't panic. Refer them to hematology/oncology for evaluation and
management. The majority of cases do not progress to the more dangerous stages
and can be controlled with topical steroids and ultraviolet treatments. I would
advise anyone who sees a person with rashes on the body that appear in the sun
covered regions to keep this disease in mind and familiarize themselves with
I just returned from a
Culinary Tour in Morocco and one afternoon we ventured to the spice market in
After several days of
cooking lessons, I had formulated my list of spices I would be purchasing and
bringing back home to create decadent meals for my family and friends. To my
surprise, I discovered their version of "dermatologic compounding," and I was immediately
I also was humored to
see the man behind the counter, wearing a white lab coat identical to medical
providers in the states. I asked him if he was a pharmacist or attended
any medical training. He replied, "No, my family is in the spices." Okay. So, a
long standing family business of spices and no medical science background, (my
I was drilling him with
questions, quickly jotting down ingredients and attempting to avoid looking
like a lunatic tourist or compounding spy!
The herpes compound
included saffron, almond oil and jasmine. The spice "expert" claimed he
formulated this for canker sores, cold sores and cracked lips. Saffron?
Hilarious. Can you imagine telling your patient to rub a little saffron cream
on their lips BID? Maybe? Someone should try it. Might I suggest one
thing: change the name! What would your date think if he/she used the
restroom and your Herpe jar was accidently left on the counter?
Next up was my personal
favorite because we all know I LOVE teenage acne: acne compound. This consisted
of tea tree, Palm Oil, Argan Oil and Rosemary Oil. Clearly, I'm not versed in
Arabic spice concoctions, especially for dermatologic application; however,
this seems like a very OILY mixture.
I can't imagine the Tea
Tree properties to be drying enough to overcompensate for all the oils. Maybe?
Again, who's trying this? Argan Oil is simply delicious! Processed from
grinding argan nuts, Moroccans serve this at every meal as a finishing oil. I
quite possibly consumed several cups of this oil during my two weeks of
Argan Oil was also found
in his Exzema compound. I love the spelling of this! Rosemary nut oil and Clove
oil are the other two components that "smooth the skin," he said. I don't know
about you but if I rubbed Rosemary on my atopic skin, I‘d have urticarial
wheals before I could count to one hundred. I do have several patients that
swear by Rosemary drops to help their xerosis. Maybe?
Lastly, the Psoriasis
cream compounded of Black Tar, Sulfur and yes, you're seeing the trend; ARGAN
OIL. We all love the Black tar & Sulfa combo for psoriasis, minus the
smelly mess. Does the Argan Oil take this compound to the next level? Maybe? Could Argan Oil be the
next magical dermatology trend?
Traveling through third
world countries is always fascinating, particularly when seeking out pieces of
culture that relate to your profession. Stumbling upon these dermatology
compounds was definitely unexpected and incredibly enjoyable.
It is fall again. If
the temperatures haven't started to drop yet where you live, they likely will
soon. It is time to break out the sweaters, jackets, coats, sweatshirts and
warmer sheets, blankets and comforters. It is also prime time for dust
Usually around this
time of year I see an influx of patients presenting to the office complaining
of new onset itching and redness primarily to the neck, intertriginous areas
and waist/trunk. As a young practitioner, this perplexed me and I would biopsy
these rashes and they would invariably come back as being consistent with an
arthropod assault. Not to age myself, but this pre-dated the time when everyone
became aware of the bed bugs and dust mites in hotels that caused such a stir a
few years ago.
What was happening with
my patients is that they would take the warmer clothes and blankets off the
shelf in the closet and wear them without washing them first. The dust that had
accumulated in the closets and on the clothes/sheets had dust mites in them.
Not all people are as sensitive to the bites but for those who are, this was a
recipe for disaster ... or at least a lot of short-term intense itching.
How do we solve this
dilemma? When the patient presents to the office with these symptoms, part of
the history I take will be to ask if they recently started wearing the warmer
clothes mentioned above or were using blankets they have been in storage or on
a rack the last six months.
I also find out if they
washed them prior to use. Most of the time, the answer is no, because the
clothes were clean when they stored them there for the winter. A mid-potency
topical steroid and non-sedating anti-histamine can be given to alleviate
symptoms and patients should be encouraged to wash all remaining clothes and
linens prior to use, as well as using any one of the commercially available
sprays that can kill dust mites and bed bugs.
This is a 68-year-old man who
arrived in our clinic complaining of a rash on his trunk beginning four weeks
prior. Treatment by his primary included anti-fungal creams and OTC
His first presentation
resembled Grover's and was later confirmed by punch biopsy. The puritis seemed to be under control with Clobetasol solution
mixed in Cerave cream. I also added Hydroxyzine 50mg QHS as needed for
We had his symptoms 90% improved
and the lesions were faded about 75% with no evidence of new lesions.
Exactly three weeks
from his first visit he returned complaining of a "new rash". Upon
examination were intact subepitheial bullous lesions on trunk and arms ranging
from 4mm to the largest measuring 8mm.
screamed bullous impetigo and was confirmed by two punch biospies.
Initially, we started
him on 40mg Prednisone QD but new bullae was forming, so we increased
his dosage to 80mg QD. We will complete two weeks on this dose and taper
him off. We also suggested he review blood pressure medications with his
I'd like to thank everyone who tuned into the
webinars on common skin cancers and their pathogenesis last night and on August
14. Having completed the second one in the series on squamous cell carcinoma
and melanoma, I found myself wanting to offer so much more but I ran out of
If you were unable to sit in and listen to parts one
or two of my presentation, you will be able to do so at http://nurse-practitioners-and-physician-assistants.advanceweb.com/Web-Extras/Online-Extras/Editorial-Webinars.aspx.
Part one of the presentation, "Basic Skin Anatomy"
is available to watch now. Part two, "Skin Cancer Overview" will be up soon.
I have been practicing dermatology for over 10 years
now and I still am learning new intricacies about the various malignancies and
new treatment modalities.
I hope to offer more of these sessions if people
would like me to that can touch on some of the more rare cutaneous malignancies
and specifics on treatments and response rates. I am planning to present again
early next year, so stay tuned for coming announcements.
These sessions are available on demand, so whenever
you have an hour to devote to learning more about skin anatomy and skin
cancers, click the link, watch the video and tell me what you think.
For those who tuned in, thank you and I hope you
note: If you have questions about upcoming webinars or questions for the
presenter, contact assistant editor Kelly Wolfgang at firstname.lastname@example.org.
clinic, I will allow my red fox labrador retriever to assist me in chart
completion and pathology management.
I absolutely love having
her nap under my desk and her presence brightens up our entire office.
I live in a very dog
friendly community and the majority of my patients own a dog, which makes an
easy conversation for even those personality challenged patients.
Booker is my first dog,
aside from those I grew up with. I honestly can't believe I lived this long
without a dog. Once you experience the bond with a dog there is an immediate
connection with every human who also owns a dog. I imagine the same for cat
I love talking to
patients about their dogs and watching their faces light up with joy. Nothing
compares to the amazing connection built from the incredible stories and tears
that are shared with my dog owner patients.
Booker has become quite
popular among my patients and one 72-year-old gentlemen last week asked if he
could move his six month body exam up to three months so he could get a
"Booker" update. The week prior, a bag of dog treats was dropped off to the
front desk with an attached note: "For Booker."
I can only imagine how
the love would blossom if she hung out in the office during the day.
I would love to hear
other "office dog" stories and your opinions on pets in the clinic.
Cryosurgery is a
process where liquid nitrogen is applied to a lesion to induce cell death. It
is a procedure done every day in dermatology offices and is now done routinely
in primary care offices as well. It is a relatively low-risk procedure, causes
minimal scarring and can be used for a multitude of conditions, including
actinic keratoses, warts, seborrheic keratoses, molluscum contagiosum,
superficial basal cell carcinoma, and squamous cell carcinoma in situ.
Problems arise however
when cryosurgery is improperly used. The effects can be devastating and
potentially life threatening. In order to avoid this potential hazard I have
come up with a short list of don'ts regarding its use.
- Do not use the cryosurgery gun within
the ocular rim or the internal ear canal. The potential risk to the eyes and
tympanic membrane if a patient moves are too great. Employ the old Q-tip
- Do not use cryosurgery more than once on
the same lesion, with the exception of warts. If you freeze something such as
an actinic keratosis, superficial basal cell carcinoma or squamous cell
carcinoma in situ and the lesion recurs, a biopsy should be done. This goes to
the old adage that cutaneous malignancies on presentation may just be the tip
of the iceberg and the lesion may be more involved than it appears. If the
lesion is truly superficial in nature the liquid nitrogen will resolve it.
- Do not use cryosurgery on invasive
squamous cell carcinoma, morpheaform basal cells, sclerotic basal cells or
infiltrative basal cells. Although unlikely, squamous cell carcinoma can
metastasize and kill patients. It is a necessity to know margins are free. The
more aggressive basal cells can involve nerves and muscles and lead to significant
tissue destruction. Treat them with caution. I recommend they all be sent for
- Do not over or under freeze lesion. The
most common thing I see with students I mentor is either a fear of or a lack of
respect for cryosurgery. Some will barely squirt an area for a fraction of a
second. If the lesion does not sufficiently freeze, the cells will not be
destroyed. Others pull the trigger on the cryo gun like the area shooting an
M-16 on rapid fire. Blasting lesions for too long can lead to significant
ulcerations and necrosis of the underlying fat cells. Lesions should be frozen
for 3-5 seconds. The frozen, or white area, should extend about 0.3cm from the
lesion edge. Utilizing a freeze thaw freeze cycle of 3-5 seconds each can
enhance cellular death and should be used on thicker lesions.
- Do not use cryosurgery on pigmented or
melanocytic lesions. This should never be done. If you do not know the
difference between a melanocytic lesion and a seborrheic keratosis then you
should not be using cryosurgery at all. If a lesion that appears to be a
seborrheic keratosis has irregular pigmentation, take a biopsy to remove it. I
tell my patients that I may be 99% sure the lesion is harmless but there is a
1% chance it can be life threatening. I am not willing to take that risk when
there is a better alternative. Melanocytic lesions, or nevi all have a potential
for developing into melanoma. That potential may be small but it exists. Freezing
a melanocytic lesion can prevent pigmentary changes from being seen and can
lead to deeper melanomas and death. It's
just simply bad practice and should never be done.
A 54-year-old male
presents for a total body mole check and reports hair loss for 6 months. The
patient says, "I don't care about the hair loss, I am here to have my moles
checked for cancer. I'm going to buzz my hair anyway."
After completing the
total body mole exam, I explained the condition on his scalp - alopecia areata.
After screening for
stress, trauma, loss of a loved one and family history, we discussed
inerlesional injections of Kenalog 10mg/cc, 0.1cc-0.2cc per patch. The patient
agreed to the treatment.
Blood work was also
performed and returned WNL. This patient was instructed to return to the clinic
in three weeks for repeat injections.
Having practiced in
dermatology for close to 12 years now, it is rare that I see something in the
clinic that I have not treated or diagnosed before. This past month I had such
an experience. A fourteen year old boy presented to the office with multiple
annular erythematous patches, with irregular borders, peripheral scaling and
The lesions rapidly
appeared over the last week and began as small bullae of less than 1cm. The
patient and mother reports the areas itched and are tender. Their primary care
provider had given him antihistamines and cortisone cream and sent him to me.
The diagnosis of
bullous impetigo was suspected due to the multiple vesicles on non erythematous
skin that, when unroofed, ulcerated and created the rings seen in the following
images. A culture was taken of one of the unmolested vesicles which showed
staph aureus. The patient was given doxycyline 100mg twice daily for two weeks
and on follow-up the lesions had resolved.
Though not a
particularly rare disorder, I had not seen bullous impetigo in the clinical
setting because I do not see children under the age of 12. For me, this was a
chance to hone my skills in history taking and refreshed my memory as to how to
treat this disease. That came in handy as the following week two other patients
presented to the office with the same condition. What are the chances that
after not seeing something for 12 years that three cases present in a
In the end,
understanding the progression of the lesions from their presenting symptoms to
what they became was key to properly diagnosing and treating these skin
infections and is the key to treating most all dermatoses.
As the summer comes to a close and students and parents begin to plan for the next school year, inevitably there is a mad dash to the dermatology office to treat acne. Freshmen want to be clear to start high school, seniors want to be pimple-free for senior pictures. The problem is that they like to wait until 2 weeks before the start of school to come in.
I have found the easiest way to get teenagers to comply with therapies, acne or otherwise, is to manage expectations. This includes explaining what the medications are for, how they work, and expected side effects.
Generally, there are two types of medications to treat acne. Many would argue this point with me and, technically, they would be right. There are topical retinoids, oral retinoids, keratolytics, oral antibiotics, topical antibiotics, and anti-inflammatories. These medications take the forms of creams, foams, gels, washes, leave-on and short contact preparations, pills, capsules, tablets, etc. The various amounts of medications and their mechanisms of action can be overwhelming. I would argue that the two types of medications are the ones that treat the causes of acne and ones that treat the symptoms of acne.
There has been a perception, justifiably so, that when a patient leaves the dermatology office he or she has a handful of prescriptions for acne: topical retinoids, benzoyl peroxide washes and gels, topical clindamycin or erythromycin, doxycyline/tetracycline/minocycline and a sulfa wash. I call this carpet bombing the face. It is an aggressive and often effective way to treat acne but, as prices of prescriptions rise and coverage for medications shrink, patients are unable to afford this type of treatment. Furthermore, for our young patients, the side effects of the medications and the time required to maintain the regimen make adherence a huge problem.
Acne is a disease of the pilosebaceous unit. The lesions commonly seen are open/closed comedones, papules, pustules, nodules and cysts. The most common mistake I see in young patients that are referred to me for acne treatment is that they were either not prescribed or are not using the retinoids. If they are not using one, then they are not treating their acne, only managing the symptoms. In the simplest terms, retinoids are the only medications that treat the causes of acne. They cause the skin to turn over faster, opening the pilosebaceous units and decreasing their depth. If the pores don't get blocked, then you can't have acne. Topical and oral antibiotics decrease the amount of P acnes on the skin, reducing the inflammatory lesions, but they do nothing to the pores. Keratolytics such as benzoyl peroxide and salicylic acid reduce the adhesion of the superficial kerotinocytes and can open some of the pores, but they are not nearly strong enough to keep the pores permanently open.
Many patients, especially teenagers, shy away from the retinoids because of the peeling and irritation they cause. This is where managing their expectations and educating them on their importance is most vital. Tell them that peeling is to be expected for the first several weeks as the medication works to decrease the depth of the pores and open them. Once this phase is clear, the acne begins to improve and healing begins. The peeling is not a side effect, it is the desired outcome. Gentle cleansers and moisturizers can and should be used to reduce irritation and oil production. It takes 2 months to see a difference with the medications and 4 months before the maximum effects can be seen. Skipping days results in starting the process over again, so consistency is the key.
In patients with mild to moderate acne, consisting of primarily comedones, papules and a few pustules, my first-line treatment includes a retinoid every night and a topical antibiotic every morning. For moderate to severe cases in which pustules and a few nodules predominate, oral antibiotics are added to more rapidly reduce the inflammatory lesions and prevent scarring. Patients are informed that on follow-up, I expect to see a reduced number of inflamed bumps and a bunch of red smooth spots where the acne use to be. These spots will fade over time if medication is used consistently. If inflamed lesions have resolved, the oral medications are tapered and discontinued and the acne is managed topically. Keeping it simple and managing expectations has allowed my patients to consistently improve and reduce the need for extra medications, costs and office visits.
This post is an update on the patient I reported on in my March 1 post. He is 75 years old and came to our office as follow-up after excision of scalp lesions. He was diagnosed with Stage 4 metastatic melanoma.
The photo shows his scalp involvement 3 months later. These satellite lesions are growing at an exponential rate. The patient is fatigues, having difficulty ambulating and complains of intestinal pain.
As the temperatures rise and people begin to venture
outdoors to enjoy all the activities that come with beautifully sunny days,
providers will see an influx of patients presenting with a variety of
dermatoses. Over the last 12 years in practice, this is my empirically derived
top 5 list of what to look for and how to treat it.
- Irritant/Allergic Contact Dermatitis:
As the diagnosis implies, these patients will present with a pruritic eruption
after coming in contact with something that they were either allergic to or
sensitive to. The distribution is usually seen in exposed skin areas on the
arms and legs. Most people will report that they were working in the yard, pulling
weeds, trimming bushes, cleaning with harsh chemicals, fertilizing, or spraying
weed/insect killers. If patients were going without a shirt or wearing a
tank-top or bathing suit top, the rash can also appear on the abdomen or chest;
the back is usually spared. The reason is that people will cut limbs, pull
weeds, cut the grass and then pick up the clippings and hold them against their
body to put in lawn bags/compost areas. The eruptions are erythematous with
evidence of excoriations. Treatment includes topical steroids class 1-3 (5-6
for face) twice daily until clear or no longer than 2 weeks and avoidance of
repeat exposure. This is a self-limited condition and would resolve if we did
nothing, so symptom management is the key.
- Discoid Lupus:
Presents as multiple annular/semi-annular erythematous pruritic plaques
erupting in sun exposed regions, usually within 24 - 48 hours. Patients may
believe they have contracted a fungal infection but the pruritis and rapid
development can eliminate this as a potential diagnosis. Gutatte psoriasis and
nummular eczema can be excluded because they tend to improve with sun exposure.
Biopsies should be taken to confirm the diagnosis and an ANA ordered to rule
out systemic lupus. Treatment once again relies heavily on topical steroids
classes 1-3 and avoiding sun exposure. Sun block and protective clothing should
be used daily.
- Tinea Versicolor:
Fungal infection presenting most commonly after sun exposure. Common
presentations include hypopigmented, annular macules on the exposed areas of the
trunk, upper arms and thighs. The sun has nothing to do with the infection
itself, the affected areas just don't pigment normally and patients will say
they have "sun spots" or look like a leopard. Mild pruritis can be seen, but is
rare. Treatment includes topical antifungal shampoos applied like a lotion to
the exposed areas, allowed to sit for 15 minutes then rinsed. Done correctly every
day for two weeks, most will be clear of the infection but should continue to
use the shampoo in this fashion once or twice a week. Repigmentation can take
several months to occur. In extreme cases, oral ketoconazole can be used.
- Cutaneous Herpes Simplex Type I:
The same virus that causes "cold sores" can result in a cutaneous eruption.
Seen commonly on the back 24 - 28 hours after sun exposure, the patient will
present complaining of an itchy, slightly burning sensation on the affected
area. On examination, there is usually a well demarcated erythematous patch
with multiple small vesicles or scabbed papules. This can be differentiated
from shingles by its limited surface area; spots tend to be small and don't
follow a dermatome. Also itching tends to be reported more than intense pain
and this area tends to break out repeatedly in the same location whereas shingles
is usually one and done. Treatment includes antiviral medication and sun
protective measures. Patients should also be made aware that this is contagious
so sharing of towels and clothes is ill advised.
- Photoallergic Drug Eruption:
Differentiated from a drug allergy by the distribution and sun exposure being
the precipitating factor. Eruptions occur most commonly on the forearms but can
occur in any area of prolonged sun exposure. Unlike drug allergies which cause
an overall erythematous eruption and is associated with an actual allergy to a
medication, this eruption is caused by a metabolite of a medication reacting
with UV radiation. It is important to differentiate because the patients do not
need to change their medication - they need to avoid sun exposure. Topical
steroids can be used to calm flares but UV avoidance is curative.
I hope this list can help narrow down the diagnoses
that you will be seeing soon as temperatures rise and UV exposure increases.
Editori's note: The information and photos in this post were provided by Amy Gouley.
A patient presented today for a patch on left temple that "stings."
Diagnosis: Proven by biopsy, Basal Cell Carcinoma
A 12-year-old male presents with a new lesion on his forehead that has been growing for 2 years.
Diagnosis: Verrucous Vulgaris
I have been fortunate enough to have spent the last
week at the 2nd annual National Association of Dermatology Nurse Practitioners (NADNP) conference in Clearwater Beach, Fla. It
has been personally rewarding to see all the hard work over the last year pay
off as the conference has been a huge success. Professionally, it has been
wonderful to see the mixture of dermatology specialists and primary care
providers who have come to expand on their current knowledge base or begin to
explore the specialty I love.
Many times during the conference, after my lectures,
attendees approached me and asked how they can learn more or what resources would
be good for them to get. I want to take this time to encourage every
practitioner to get a good, basic dermatology book to reference in their
office. Text books that I recommend for students I mentor include: Andrews'
Diseases of the Skin: Clinical Dermatology, Clinical Dermatology by Thomas
Habif, and Fitzpatrick's color atlas and synopsis of Clinical Dermatology.
Additionally, reach out in the community and talk to
local dermatologists or dermatology specialists to consult when needed and refer
to when applicable. Also, if you are sending biopsies off for pathology, make
sure a dermatopathologist is reading your samples. If they are not, find
The most important thing you can do is take the time
to read the articles in ADVANCE
for NPs & PAs that reference dermatology. May's
issue spotlighted dermatological conditions and included a
profile of my good friend, colleague and mentor Dr.
Debra Shelby who is the president of the NADNP. You can view a webinar Dr. Shelby presented
on dermatology here.
You should also attend a dermatology conference or
ask local dermatology specialists if they will allow you to shadow for a few
days. Seeing things in texts and trying to match pictures to patients is
suboptimal, but from what I heard, routine practice. Meetings will have some
basic lectures concerning dermatological conditions and therapies that will
enhance your practice.
In short, utilize the resources that are available
to you. They are there for the choosing and readily available. Most, if not all
of us received very little training in dermatology while in school. As professionals
it is our responsibility to attain the knowledge needed to care for our
patients. It is there for the taking, so take it.
(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.