4/23/10
Justin Endo, M.D.
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No financial disclosures
Primary reference and images unless
otherwise specified from Bolognia et al.
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Diagnose dermatologic conditions affecting
the lower leg
Discuss management options
Understand the limitations of biopsies,
especially shave biopsies, using standard
breadloaf histologic grossing methods
Describe a lesion and consult dermatology
appropriately
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Immune-mediated destruction of vessels
Often classified by vessel size involved
 Small:
▪ Sometimes renal involvement
▪ Palpable purpura
 Medium/large:
▪ +/- systemic symptoms
▪ Ulcers
▪ Livedo reticularis
▪ Nodules
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Dermatology and/or rheumatology consult to
help rule out systemic involvement
If systemic involvement (or severely
symptomatic small vessel disease without
renal involvement)
 Steroids or other immunosuppressants
 Compression stockings for small vessel vasculitis
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Capillaritis
Various morphologies
 Annular telangiectasias (Majocchi)
 Cayenne pepper petechiae and macules
(Schaumberg)
 Eczematoid patches (Ducas and Kapetanakis)
 Lichenoid patches (Gougerot and Blum)
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Treatment
 Observation
 Topical steroids rarely helpful
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Clinical features
 Pathergy (sterile pustule at sites of trauma)
 Wound or ulcer that keeps getting “infected”
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despite debridement
Undermining and rolled borders
Cribiform healing
Erythematous margins
Bullous and granulomatous variants
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Associated conditions
 Inflammatory bowel disease
 Hematologic malignancy (bullous variants)
 Paraproteinemia
 Up to 50% idiopathic
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Diagnosis of exclusion
 Infectious etiology workup needed
 Biopsy will not RULE IN diagnosis but RULES OUT
other causes of chronic ulcer
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Treatment
 NO DEBRIDEMENT!!!
 NO DEBRIDEMENT!!!
 NO DEBRIDEMENT!!!
 Dermatology consult
 Steroids (often systemic)
 Immunosuppressives
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Kaposi’s sarcoma
Squamous cell carcinoma
Melanoma
Basal cell carcinoma
Cutaneous lymphoma
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Abnormal endothelial neoplasm caused by
human herpes virus 8 (HHV-8)
Pink, black-violet nodules, plaques, or polyps
4 variants
 Chronic/classic (Mediterranean)
 African endemic
 Iatrogenically immunocompromised (CyA)
 AIDS related
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Childhood lymphadenopathic variant is
fulminant and fatal
Chemotherapy +/- XRT usually before surgery
due to multifocality
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Malignant infiltration of keratinocytes
Risk factors:
 Immunosuppression (transplant)
 Sun damage
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Can follow nerves, invade into bone, and
metastasize
Refer to dermatology to discuss treatment
options, regardless of biopsy “margins”
Answers.com
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Rarer type of melanoma
Significant proportion of melanoma type in
Asian and African skin
Brown to black macule with irregular borders,
color variegation, longitudinal melanonychia
Consider biopsy
 Fair-skinned individuals
 Width >=3mm
 Changing lesion
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Staging / prognosis depends upon
 Histologic Breslow depth
 Lymph node involvement
 Mitotic rate
 Ulceration
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Treatment
 Wide local excision
 Sentinel lymph node biopsy for melanomas > 1 mm
 Adjuvant treatments and clinical trials
dermoscopic.blogspot.com/
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Most common skin cancer
Least likely to metastasize
Recommend referral to dermatology,
regardless of biopsy “margins”
Surgical management depends upon
histologic appearance
An Bras Dermatol 2005
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Abnormal, clonal T or B cell proliferation
Violaceous nodules (B cell) or widespread
eczematous-like plaques (T cell)
Differential includes “pseudolymphoma”
benign lymphocytic hyperplasia
Referral to dermatology and
hematology/oncology for treatment options
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Dermatofibroma
Disseminated superficial actinic
porokeratosis
Kyrle’s disease
Poroma
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Pink to brown dome shaped papules
(sometimes flatter) that dimples when
squeezed
Thought to be reactive to trauma
Management options
 Expectant (watchful neglect)
 Punch / excise
 Triamcinolone injection
 Cordran tape
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Multiple flesh colored, scaly papules or
plaques with double edge rim of scale
Malignant transformation risk is low
Treatment is generally unsatisfactory
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Expectant (watchful neglect)
Cryotherapy
Topical 5-FU or imiquimod
Topical retinoids
Curettage
VGDR.com
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Keratin perforates through skin
? form of prurigo nodularis associated with
renal disease
Treatment (difficult)
 Topical steroids
 Antipruritic lotions
 UV light
 Laser
Emedicine.com
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Benign tumor of eccrine > apocrine duct
origin
Palmo-plantar vascular papules, nodules,
plaques
No treatment indicated (or excise if
symptomatic)
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Lichen planus
Psoriasis
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Purple polygonal papules and plaques,
sometimes with lacy netlike Wicham’s striae
Affects wrists, arms, genitals, buttocks, oral
mucosa
Association with hepatitis C, metal contact
allergies, hepatitis B vaccine, medications
Can be difficult to treat
 Topical steroids
 Light
 Antimalarials (hydroxychloroquine)
Photos AAFP.org
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Oil spot
Nail pit
Polygenetic disorder
Itchy, red, well-demarcated plaques with
silvery scale involving the scalp, torso,
umbilicus, gluteal fold, extensor extremities
Often nail pitting and oil spots
Sometimes involving genitals, axillae
Rarely palmar or plantar distribution
Uncommonly pustular or erythrodermic
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Triggers
 Trauma
 Infection (streptococcal, HIV)
 Hypocalcemia
 Drugs (lithium, interferon, beta blocker, systemic
steroid, antimalarials)
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Major comorbidity: metabolic syndrome!
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Enthesitis
Morning stiffness lasting at least 1 hour
5-30% of all psoriasis patients
15% of cases arthritis precedes skin lesions
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Categories
 Classic (DIP)
 Mono/asymmetric arthritis
 RA-like (small and medium joints)
 Arthritis mutilans
 Spondyloarthritis
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Depends upon extent/sites of skin disease,
arthritis, comorbidities, lifestyle
Topical steroids and vitamin D analogs
Light
Methotrexate
Biologics (e.g., etanercept, infliximab,
adalimumab, ustekinumab)
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Necrobiosis lipoidica (diabeticorum)
Erythema nodosum
Pretibial myxedema
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Yellow-red-brown plaques +/- atrophy or
ulceration on shins
NOT strictly associated with diabetes or
glucose control
Treatment
 Potent topical or intralesional steroid into active
borders
 Niacinamide
 Light
 Surgery as last line
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Associated with hepatitis C
Obtain hepatitis C antibody study and refer to
hepatology
eMedicine.com
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Tender, red, poorly demarcated,
subcutaneous deep-seated nodules on
anterior shins resolving like a bruise
+/- arthralgias and fevers
Typically young adults
RARELY (if ever) ulcerates
Usually acute and self-limited
eMedicine.com
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Etiologies
 Infections (streptococcal and coccidioidomycosis)
 Inflammatory bowel disease
 Sarcoid
 Sulfonamides, halides, gold, sulfonylureas
 Behçet disease
 Pregnancy (2nd trimester)
 Lymphomas
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Treatments
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NSAIDs
Elevation
Compression
Rest
SSKI
Colchicine
Referral to internist or dermatologist to look
for underlying etiologies
www.Woundsresearch.com
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Excessive hyaluronic acid deposition in
dermis, often pretibial legs
Almost always associated with Graves
disease (though only 0.5-4.3% of Graves
patients)
Firm, bilateral, nonpitting, pink-purple-brown
plaques or nodules with follicular prominence
+/- hyperhidrosis or hypertrichosis
Rarely elephantiasis presentation
Women > men
eMedicine.com
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Dermatitis herpetiformis
Bullous pemphigoid
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Pruritic pink eroded papules on extensor
elbows and knees, buttocks
Rare to see an intact blister because so itchy
Gluten-allergy of skin
Diagnosis by serology, skin biopsy for direct
immunofluorescence
Treatments
 Gluten-free diet
 Dapsone
dermimages.med.jhmi.edu
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Often in older individuals
Pruritic or painful, tense subepidermal bullae,
sometimes affecting mucosa
Sometimes presents as eczematous or
urticarial lesions WITHOUT blisters
Sometimes precipitated by medications
(vancomycin, gold, furosemide, aldosterone
antagonists)
Diagnosis by serology, skin biopsy for direct
immunofluorescence
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Treatments
 Remove offending medication, if identified
 Steroids
 Steroid sparing agents
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Tungiasis
Larval migrans
Purpuric glove and sock syndrome
Mycetoma
CDC
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Tunga penetrans flea infestation
Caribbean, Africa, India, Pakistan, Central
America, South America
Invade through unprotected feet
Edematous, painful, hyperkeratotic pustules
and nodules
Secondary infection, lymphangitis common
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Cryotherapy
Electrodesiccation
Antiparasitics (ivermectin, niridazole)
Occlusive petrolatum
Surgical
eMedicine.com
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Hookworm “accidentally” infests barefoot
human
Ancylostoma, Uncinaria, Bunostomum
Tingling and pruritic, serpiginous
erythematous plaques
Self-limited
Prevention
Thiabendazole
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Painful erythematous and petechiae/purpuric
palmoplantar eruption +/- enanthem
Unique viral eruption in children and young
adults, often in springtime
 Parvo B19
 Coxsackie B6
 Human herpesvirus 6 (HHV-6)
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Symptomatic treatment
Still (probably) contagious during rash
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Deep seated skin / soft tissue infection with
draining sinuses and extruding grains
Often from direct innoculation from dirt
3 delicious flavors
 Botryomycotic (true bacteria, staph,
pseudomonas)
 Actinomycotic (filamentous organisms)
 Eumycotic (true fungi)
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Treatment
 Excision
 Appropriate antimicrobials based upon cultures
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Thanks to Dr. Jason Hadley for providing
content
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Nails
 Learn to identify some common causes of nail
disease
 Recognize concerning nail lesions
 Understand nails are a window to diagnosis of
systemic disease
A.
B.
C.
D.
Traumatic nail dystrophy
Melanoma
Drug induced pigment deposition
Benign melanonychia
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New pigmented streak in light-skinned
individuals
Nail plate destruction
Pigment on proximal nailfold (Hutchinson’s
sign)
Widening of existing streak
A.
B.
C.
D.
E.
Myxoid cyst
Glomus tumor
Traumatic nail dystrophy
Onychomycosis
Psoriasis
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Clinical features
 Proximal nail fold swelling
 Depression of nail plate
 Periodic clear drainage
 Connection to DIP joint
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Treatment
 Referral for excision
 Higher rate of recurrence with puncture and
drainage
 Sclerotherapy
 Cryosurgery
 Intralesional steroid injections
A.
B.
C.
D.
E.
Chronic paronychia
Pseudomonas infection
Verruca
Pyogenic granuloma(s)
Periungual fibroma
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Key Points
 Bleeding angiomatous nodule
 Often related to trauma
 Associated with zidovudine and isotretinoin
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Treatment
 Excision
 Electrodessication and curettage
A.
B.
C.
D.
E.
Onychomycosis
Lichen planus
Trachyonychia
Brittle nail syndrome
Nail-patella syndrome
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Key points:
 Nails are thin with rough appearance
 Most often associated with alopecia areata
 Rarely associated with lichen planus and psoriasis
 Etiology not understood
 No effective treatment
 Self limited
A.
B.
C.
D.
E.
F.
Psoriasis
Nail findings of alopecia areata
Pseudomonas infection
Epidermolysis bullosa
Lichen planus
Darier’s disease
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Key points
 Nail pits seen in psoriasis, alopecia areata, atopic
dermatitis
 Oil spots = psoriasis of nail bed
 Onycholysis
 Toenail findings indistinguishable from
onychomycosis
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Treatment
 Systemic psoriasis treatments
 Intralesional triamcinolone to proximal nail fold
A.
B.
C.
D.
E.
Benign longitudinal melanonychia
Minocycline-induced nail pigmentation
Pseudomonas infection
Laugier–Hunziker syndrome
Post-inflamatory hyperpigmentation
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Key points:
 When drug-induced cause suspected, multiple
nails should be involved
 Slate gray color is reassuring
 Rule out melanocytic process
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Treatment
 Color will return to normal 1-3 months after
discontinuing drug
A.
B.
C.
D.
E.
Lichen planus
Psoriasis
Onychomycosis
Chemotherapy-induced nail changes
Trachyonychia
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Key points
 Lichen planus rarely affects nails
 Characteristic “pterygium” blunts lateral nail fold
 Nail thinning
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Treatment
 Triamcinolone
 Methotrexate
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Beau’s lines
• Transverse depression on nail
plate
• Stressors
Onycholysis
• Splitting of distal nail plate
from nailbed
• Trauma, irritants, fungal
infection
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Onychorrhexis
• Brittle nail
Onychomadesis
• Complete proximal nailplate
shedding
• Systemic illness
Emedicine.com
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Onychoschizia
• Distal nailplate layer splitting
• Fragility / trauma
Darier-White
• Hereditary
• Red-white alternating
longitudinal nailplate
• V-nicking
dermatology.cdlib.org
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Yellow nail syndrome
• No cuticle, arrested growth
• Lymphedema, respiratory
tract disease
• Vitamin E, itraconazole
Koilonychia
• Spooned nail
• Anemia
Dermatology.cdlib.org
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Muehrcke
 Paired white lines that do not grow outward
 Hypoalbuminemia
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Mees’
 White band that grows out
 Heavy metal, renal failure
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Terry’s
 White proximal nail plate, red distally
 CHF, liver, diabetes
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Half & half
 White proximal nail plate, brown distally
 Renal failure
Aafp.org
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Nail-patella syndrome
 LMX1B autosomal dom
 Dysplastic nails
 Patellar aplasia
 Elbow arthrodysplasia
 Iliac horns
 Proteinuria
Emedicine.com