Bumps, Bites, Bugaboos,

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Bumps, Bites, Bug-a-boos, Bad Stuff
M. Lynne McElroy, CFNP Dominion Dermatology
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The Descriptive Language of Dermatology
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The Descriptive Language of Dermatology

• Primary Lesions

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Primary lesion 10mm or less gt10mm
flat, circumscribed, varies in color
macule patch
palpable lesion, varies in color
papule plaque
circumscribed, often round, solid lesion
nodule tumor
superficial collection of fluid
vesicle bulla
deposits of blood or blood pigments
petechiae purpura
collection of pus
pustule (varies in size)
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Dermatofibroma

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The Descriptive Language of Dermatology

• Secondary Lesions

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Secondary lesions
scale
excess dead epidermal cells
crust
dried serum and cellular debris (scab)
thickened epidermis
lichenification
excoriation
erosion caused by scratching
fissure
linear loss of epidermis dermis,
sharply defined, vertical walls
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Evaluation
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A Good History

• Talk First Look Later

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History the usual
onset
duration
symptoms
alleviating / aggravating factors
location
associated / constitutional sx
comorbidities
medications
prior hx
family hx
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The Extras
travel
recreation / hobbies
season
self-treatment
what do they think?
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Take a good look!
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Physical exam
get undressed
look palpate!
type of lesion.........primary / secondary
distribution....location
configuration .........arrangement
pts behavior.......anxious, scratching, etc.
nails nodes scalp
mucous membranes
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Diagnostic Tools
KOH Prep
Wet Prep
Tzanck
Cultures
Other Labs
Biopsy
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BUMPS

• What is that??

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Case 1

• Dilon is a 3 y.o. child who comes in with his
  mother. He fell off his bed and hit his head a
  few weeks ago. Now he has a red bump that
  bleeds when his mother washes his face.
• What is it?

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Pyogenic Granuloma
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Pyogenic Granuloma

• Rapidly developing hemangioma
• Often at site of prior trauma
• Bleeds easily
• Treatment surgical removal

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Case 2

• Casey is an 8 y.o third grader who has pink bumps
  on her chin. They have been present for a few
  months and are spreading.
• What is it?

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Molluscum Contagiosum
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Molluscum Contagiosum

• Caused by pox virus
• Most frequently seen in ages 3-16
• Contagious..to others and self
• Treatment watchful waiting, curettement, plain
  cantharidin, liquid nitrogen, imiquimod

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Case 3

• Brittany is horrified by the huge zits on her
  face. She has tried Proactiv, Apricot Scrub, and
  witch hazel. Nothing works!
• What can she do?

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Pathogenesis of Acne
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Acne Vulgaris
Mild Grade I-II
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Keratosis Pilaris
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Acne Vulgaris
Mild Grade I-II
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Acne Vulgaris
Moderate Grade III
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Acne Vulgaris
Severe Grade IV
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Acne Vulgaris
Severe Grade IV
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Making decisions about acne treatment is never
easy.
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Acne Treatment
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Acne Vulgaris Pearls

• Realistic expectations and timing of therapy
• Review correct use of meds
• Ask about menses, especially if hirsute

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Case 4

• Jeff is a 17 y.o. football player. He is
  planning to go to the prom and is very concerned
  about some new bumps that have occurred on his
  chin.
• What is this??

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Flat Warts
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Plantar Warts
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Mosaic Wart
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Paronychial Warts
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Warts

• Over 150 different nononcogenic HPV types
• Affects 7 - 10 of population, average age
  12 -16 years
• Contagious
• Can be difficult to treat and often recur

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Warts treatment

• 60 of warts in children resolve spontaneously in
  2 years
• FDA approved
• Salicylic acid Liquid
  nitrogen
• Off-Label
• Cantharidin Podophyllin
  
• Imiquimod Retin-A
• Intralesional immunotherapy
• Topical 5 FU
• Laser, excision

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Bites
BITES
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Case 5

• 14 y.o John has red bumps all over for several
  weeks. His PCP treated him with Triamcinolone
  0.1 cream, which helps the itch temporarily.
  For the past 3 nights, he has awoken scratching
  until he bleeds.
• What is it?

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Scabies
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Scabies

• Dx based on clinical exam and hx
• May not see mite on wet prep.
• Occurs 2-6 weeks after exposure

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Scabies treatment

• Permethrin .. 2 applications . Repeat in 1 week
• Wash all bedding, clothing, towels, in HOT water
• Topical steroids for 2-3 weeks
• Antihistamines prn itch
• Family members.???

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Case 6

• 18 y.o Wesley comes in with a red patch on his
  left thigh/buttock. He recently went hunting
  with his grandfather in Maryland.
• What is this?

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Erythema Migrans
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Erythema Migrans

• Caused by spirochete Borrelia burgdorferi
• The cutaneous eruption of Lyme disease (stage 1)
• Midwest Eastern U.S. / Spring - Fall
• 3-28 days after tick bite
• Dx clinical..enlarging red ring at bite site,
  fades in 2-3 weeks

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Lyme Disease Treatment

• gt8y.o. Doxycycline, Amoxicillin, Ceftin,
  Emycin
• lt8y.o. Amox. , Ceftin, Emycin
• Prevention Deet 10 recommended (30 max if gt
  2 months)
• Permethrin treated clothing

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Case 7

• 9 y.o Hunter has had itchy bumps on his arms and
  abdomen for several weeks. Cortisone cream helps
  with the itch, but the bumps are spreading.
• What is it?

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Bed Bugs
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Bed Bugs Cimex lectlarius hemipterus

• Live in mattress, bedframes, cracks in floors
• See bugs or smell pungent odor
• See dark fecal spots or blood spots on sheets
• Painless bite, nocturnal feeders
• Dxclinical.pruritic papules on exposed skin in
  linear arrangement
• Treatment Eliminate bugs
• Symptomatic tx of bites

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Bored?????
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Bug-A-Boos
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Case 8

• 8 y.o. Caitlin has had dry skin itchy bumps
  since she was a baby. Her mother uses cocoa
  butter which helps sometimes. She also has
  frequent colds and ear infections.
• Whats going on with Caitlin?

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Eczema
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Eczema

• Prevalence15-20 of US children with 60 of
  cases arising by age 1
• Etiology genetic and environmental
• Flexual and symmetric
• Remissions and exacerbations
• Atopic history

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Eczema Treatment

• Goal maintain skin barrier relieve sx
• not to cure
• Avoid irritants / triggers
• Keep skin hydrated
• Acute
• topical steroids
• rarely need oral steroids
• r/o secondary infection and tx prn
  antihistamines

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A word on steroids..

• Seven classes (I - VII)
• High (I-II) Mid (III-V) Low (VI-VII)
• Learn 1 or 2 in each class
• Consider location
• Consider vehicle.oint, cream, foam, lotion
• Avoid combination products!
• Remember side effects!

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Chronic Maintenance

• Emollients
• Avoid irritants (allergy testing?)
• Steroid free meds Pimecrolimus
• Tacrolimus
• Mimyx
• Atopiclar
• If recurrent infection consider Staph carrier

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Topical Calcineurin Inhibitors

• The boxed warning concerns regarding the risk of
  lymphoma cutaneous malignancies were based on
  the FDA review of animal studies involving oral
  intake (30x gttopical) of Tacrolimus
  Pimecrolimus.

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Case 9

• 18 y.o Matt comes home from college. He has had
  pus bumps on his hands for a month. The NP at
  student health treated him with antibiotics,
  but the bumps are still there.
• What is this?

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Palmar Pustular Psoriasis
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Case 10

• 17 y.o Joshua has had red, scaly spots all over
  for about 1 week. He feels well and is sleeping
  and eating as usual. He had a high fever and
  sore throat several weeks ago.
• Whats going on with Josh?

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Guttate Psoriasis
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The Many Faces of
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Psoriasis
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Inverse Psoriasis
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Psoriasis

• Affects 2 of the general population (33
  develop before age 30)
• Bimodal peak adolescence and 60s
• Familial.often triggered by stressors
• Inflammation and rapid proliferation of
  keratinocytes
• Clinically thick white scales extensor
  surfaces,
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  scalp, gluteal cleft
• nail changes 80 dev.
  Arthritis
• associated seronegative
  arthritis (ask!)

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Psoriasis treatment

• Topicals
• Corticosteroids
• Keratolytics Tar, SA
• Others Calcipotriol Anthralin
• Emollients Retinoids
• Pimecrolimus Tacrolimus
  (off label)
• Phototherapy / natural sunlight
• Systemic Tx Rarely use systemic steroids,
• MTX, Cyclosporine,
  Acitretin,
• Biologics
• Consider secondary infection

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Case 11

• 16 y.o. Chuck has recently joined the football
  team. He comes in with his mother concerned
  about acne on his back and chest.
• How would you treat this?

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Pityrosporum Folliculitis
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Tinea Versicolor
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Yeast

• Pityrosporum Candida albicans
• Folliculitis
  Intertrigo
• Seborrheic Dermatitis Thrush
• Tinea Versicolor Diaper
  Dermatitis

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Yeast

• Overgrowth of normal flora
• Thrive in high humidity, high sebum oil, and
  oil grease on the skin
• Mild itch
• Tends to recur
• Dx clinical and KOH
• Consider predisposing factors DM, antibiotics,
  immunosuppression

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KOH
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Yeast treatment

• Shampoos Pyrithione zinc, Ketoconazole
• Selenium sulfide
• Topicals Anti-fungals
• Ketoconazole
• Vusion (for DD)
• ZNP soap
• Rarely need oral antifungals
• Keep skin dry, avoid occulsion, avoid oils/grease

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Case 12

• 17 y.o Haley has had dry skin on her feet for
  months. She complains that her feet itch and
  burn.
• What is this and how can this be treated?

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Tinea Pedis
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Dermatophytes..the Tineas

• 3 common pathogens Trichophyton
• Microsporum
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  Epidermophyton
• Thrive on non-viable keratinized structures
  skin, hair, nails
• Dx Clinical and KOH

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Tinea corporis
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Granuloma Annulare
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Tinea cruris
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Tinea capitis
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Tinea unguium (onychomycosis)
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Tineas treatment

• Determined by site of infection
• Topical antifungals for skin
• Oral antifungals scalp nails
• dosage 15-25mg/kg/day
• duration of tx

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SunscreenClothingMinimize exposureBe careful
with photosensitizing meds
Stay safe in the sun..
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Uh-oh
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When to Refer
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1.
Unclear diagnosis
Common - but not responding to treatment
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Difficult to treat cutaneous disease
vitiligo, sarcoid, scarring acne / acne needing
Accutane
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Lesion or rash needing biopsy to clarify
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Red flags of dermatology purpura /
petechiae lesions of palms/soles
mucosal involvement bullae / unclear
blistering atypical moles
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Purpura
Meningococcemia
Rocky Mountain Spotted Fever
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Lesions palms soles
Secondary Syphilis
Erythema Multiforme
RMSF
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Secondary Syphillis
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Mucosal Involvement
Kawasaki Disease
Stevens-Johnson Syndrome
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Bullae
SJS
Bullous Drug Reaction
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Dermatology Pearls for the Road
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If it scales, SCRAPE it!
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As a rule, avoid combination products
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When referring a rash of unclear etiology Stop
treatment (in at least one area) Allow to
flare to provide a clear visual exam of the
primary rash and an untreated spot for biopsy or
culture
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Take every opportunity to LOOK!
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Questions
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References
Fitzpatrick TB, Johnson RA, Wolff K, Suurmond D.
(2001) Color Atlas Synopsis of Clinical
Dermatology Common Serious Diseases, 4th
edition New York The McGraw-Hill
Companies Goodheart HP, (2009) Goodhearts
Photoguide to Common Skin Disorders Diagnosis
Management, 3rd edition Philadelphia
Lippincott Williams Wilkins Habif TP,
Campbell JL, Chapman MS, Dinulos JG, Zug KA,
(2005) Skin Disease Diagnosis and Treatment 2nd
edition, Philadelphia Elsevier Mosby Inc.
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