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Dermatology: Lecture 3 (Chapter 6, Part 2)

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- Soft, flat-topped, well-demarcated yellow macules, papules, or nodules
- Usually asymptomatic, but rarely itchy or tender
What is the presentation of Xanthamos?
Palpebrarum- papules around the eyelids
Tuberous- firm nodules on extensor surfaces
Tendinous- nodules near tendons/ligaments
Eruptive- crops of papules on the body
Plane- macular lesions on the body
What are the types of Xanthomas?
Associated with underlying blood lipid disorder
What is the etiology of Xanthomas?
Clinical. Or biopsy. Blood lipid panel helps.
How do we diagnose xanthomas?
1. Treat underlying lipid disorder
if present
2. Soluble fiber, B vitamins, phytosterols, niacin, diet changes, exercise, medications
3. Treatment of lesions is considered cosmetic unless symptomatic
4. Surgical excision; may recur
How do we treat Xanthomas?
Xanthomas
Large, hypertrophic scars at sites of
skin trauma
Firm, rubbery texture
Range in color from white, pink,
flesh-colored, hyperpigmented
Often inflamed, pruritic
What is the presentation of Keloids?
Excessive fibroblast proliferation beyond
that of normal wound healing

Risk factors:
Family history
African American or Asian descent
Wound infection, repeated trauma,
excessive skin tension, foreign body
What is the etiology of Keloids?
Diagnosis: Clinical
Treatment:
Avoid skin trauma, unnecessary surgeries
Steroids (topical, intralesional)
Compression, radiation, excision, cryotherapy, laser
Intralesional chemo, imiquimod, tacrolimus, methotrexate
How do we diagnose and treat keloids?
Keloids
Keloids
Most common benign childhood tumor
Red-blue vascular macule, papule, or nodule
83% located on head/neck
Generally appears at birth or shortly after, proliferates to 9-12 months of age, then involutes
What is the presentation of hemangiomas?
Proliferation of endothelial cells expressing GLUT-1 receptors
Etiology of Hemangiomas?
Diagnosis: Clinical; ultrasound can help
Treatment:
Topical steroids, interferons, propranolol, laser, compression
Psychosocial support
What is the diagnosis and treatment of Hemangiomas
Hemangiomas
Cysts filled with cheesy, keratinous material
Typically appear on the scalp (pilar), back, neck, extremities (EIC)
EICs have a central punctum
May become intermittently inflamed
What is the presentation of epidermal and pilar cysts?
Epidermal cysts (EICS) have a central punctum. Pilar cysts are generally on the scalp whereas EICS are everywhere else.
What is the difference between pilar and epidermal cysts?
Subcutaneous keratin-filled cysts originating from hair follicles.
What is the etiology of Epidermal and Pilar cysts?
Diagnosis: Clinical
Treatment:
Asymptomatic lesions do not require treatment
Surgical excision with sac removal
How do we diagnose and treat epidermal and pilar cysts?
Sign of colon cancer (Gardener's Syndrome)
If a patient has multiple Epidermal and Pilar Cysts what do we suspect?
Epidermal cyst
Soft, pedunculated, flesh-colored papules
Most common sites are the axillae, neck,
eyelids, and groin folds
Asymptomatic unless traumatized
What is the presentation of skin tags?
Risk factors include friction, age >30, obesity, family history
What is the etiology of skin tags?
Diagnosis: Clinical
Treatment: Considered cosmetic. Snip with scissors, electrocautery, cryotherapy.
What is the diagnosis and treatment of skin tags?
Skin Tags
Caused by neurofibrin gene
mutations
Autosomal dominant, 50% new
mutations
What is the etiology of Neurofibromatosis?
Types:
NF1 (classic, von Recklinghausen's)
NF2 (acoustic)
What are the types of neurofibromatosis?
Café au lait lesions: well-demarcated,
uniform, hyperpigmented macules or patches
Cutaneous neurofibromas: pink/brown/flesh-colored papules or nodules with +buttonhole sign, often pedunculated
Plexiform neurofibromas: large subcutaneous tumors, "doughy", "bag of worms"
Freckling: small round brown macules in the axillae and groin
What are the skin findings of neurofibromatosis?
Neurofibromatosis
Highly variable: many cases are limited to skin findings, but CNS/optic/MSK lesions can be debilitating
3-5% of tumors become malignant
What is the prognosis of neurofibromatosis?
Diagnosis: Clinical. We will monitor with regular exams. (Genetic testing can help as well).
Treatment:
Surgical intervention when necessary
Chiropractic care
Healthy diet, physical activity, and supplements (White willow bark, bromelain, fish oil, glutathione, selenium, Vitamins A/E/C, calcium and magnesium)
What is the diagnosis and treatment of neurofibromatosis?
Expanding erythematous papules,
nodules, or plaques with scaly, crusty,
and/or ulcerated surface
May be painful or tender
Rarely metastasizes (3-4%)

Risk Factors: Large lesion, lesions on
ears, mouth, or irradiated area,
immunosuppression
What is the presentation of Squamous Cell Carcinoma?
2nd most common type of skin cancer
Malignant tumor of the keratinocytes
Actinic keratosis SCC in situ SCC
Risk factors: fair skin, sun damage, family or personal history, immunosuppression, chronic inflammation, HPV, radiation
What is the etiology of Squamous Cell Carcinoma?
Diagnosis: Skin Biopsy
Treatment:
ED&C or cryosurgery for early lesions
Excision, Mohs surgery
Radiation in advanced cases
Can supplement with antioxidants
What is the diagnosis and treatment of Squamous Cell Carcinoma?
Squamous Cell Carcinoma
Squamous Cell Carcinoma
>90% are on the face

5 TYPES:
Superficial: thin pink or red plaque; may
have scale, telangiectasias
Nodular: translucent pearly pink papule or nodule; may have rolled borders,
telangiectasias
Ulcerating: similar to nodular, but
w/ulceration
Morpheaform: scar-like
Pigmented: contains brown-black pigment
What is the presentation of Basal Cell Carcinoma?
Most common form of skin cancer
Malignancy of the basal cell layer
Fair skin, extensive sun exposure, PTCH gene mutations, family or personal history
What is the etiology of Basal Cell Carcinoma?
Virtually never metastasize, but can be locally destructive
Many treatment options including surgical excision, Mohs surgery, ED&C, cryosurgery, topicals, radiation, CO2 laser
Controlled amino acid therapy, supplements (i.e. antioxidants)
What is the treatment and prognosis of Basal Cell Carcinoma?
Basal Cell Carcinoma (Nodular)
Malignant tumor of the melanocytes
Least common type of skin cancer, but on the rise
Risk factors: many nevi, dysplastic nevi (precursors in ~30% of cases), fair skin, red hair, freckles, severe sunburns, tanning, family or personal history
What is the etiology of Melanoma?
Asymmetry
Border Irregularity
Color
1/4 inch diameter
What is the ABCDEs of melanoma?
Lentigo Maligna: 5%. Older patients with chronic sun exposure. Face, neck, dorsal hands. Prolonged vertical growth phase.
Superficial Spreading: 70%. All Ages and sites. (Most common: back in men, posterior thighs in women). VGP: Months-2 years.
Nodular: 15%. Back, extremities most common sites. Immediate horizontal growth phase. Elevated uniform pigment.
Acral Lengtiginous: 10%. Palms, soles, nail beds. Most common in darker skin types.
What are the types of Melanoma?
Diagnosis: Skin
Treatment:
Wide local excision is all that is needed in early stages
Chemotherapy and radiation in advanced cases, although minimal survival benefit
New targeted immunotherapies in trial stage
Anecdotal evidence for acupuncture, herbs, biofeedback, meditation, yoga, diet changes, vitamins, antioxidants, and other supplements
How do we diagnose and treat melanoma?
Comedones, inflamed papules,
pustules, and nodules
Severe cases can result in permanent
scarring
Face > chest, back
Common in adolescents, but also
seen in babies and adults
What is the presentation of Acne Vulargis?
Follicular plugging
Cause is multifactorial (excess sebum,
androgen hormones, P. acnes, stress, cosmetics)
What is the etiology of Acne Vulgaris?
Diagnosis: Clinical
Treatment:
Topicals (salicylic acid, benzoyl peroxide, retinoids, antibiotics)
Oral antibiotics
Hormone therapy for women (OCPs, spironolactone)
Oral retinoids in severe cases (isotretinoin)
Comedone extraction, intralesional steroids, peels, laser
Natural remedies (tea tree oil, apple cider vinegar, zinc, vitamin A, B5/B6)
Acupuncture, chiropractic adjustments
Chocolate and greasy foods don't worsen acne, but dairy products and high glycemic index foods may
How do we diagnose and treat Acne Vulgaris?
Acne Vulgaris
Facial redness, flushing, and telangiectasias
Inflamed papules and pustules but no comedones
Rhinophyma in severe, chronic cases (M>F)
Can affect the eyes (ocular rosacea)
What is the presentation of Rosacea?
Unknown (?vascular dysfunction, D.folliculorum mite,
H. pylori)
Triggers include heat, alcohol, spicy foods, stress
What is the etiology of Rosacea?
Rosacea
Rosacea
Rhinophyma caused by Rosacea
Diagnosis: Clinical
Treatment:
Topicals (sulfa, antibiotics, retinoids,
azelaic acid)
Oral antibiotics
Cosmetic procedures for telangiectasias & rhinophyma
Riboflavin, lipase
Avoid triggers, wear sunscreen
What is the diagnosis and treatment for Rosacea?
Red papules +/- pustules around the lips
Sometimes itchy
Most common in women
What is the presentation of Perioral Dermatitis?
Thought to be multifactorial

Fusiform bacteria, hormones,
lotions/cosmetics, steroids, fluoride
What is the etiology of Perioral Dermatitis
Diagnosis: Clinical
Treatment:
Topical antibiotics, azelaic acid,
calcineurin inhibitors
Oral antibiotics
Glycolic acid peel
What is the diagnosis and treatment of Perioral Dermatitis?
Perioral Dermatitis
Comedones, inflammatory papules and pustules, nodules, abscesses, draining fistulae, and scarring affecting intertriginous areas
Often very painful & debilitating
Prone to secondary infections
A/w acne, pilonidal cyst, scalp folliculitis,
PCOS, inflammatory arthritis
What is the presentation of Hideradenitis Suppurativa?
Chronic auto-inflammatory
disease that runs in families
Follicular plugging
Hormones, sweating, friction, obesity, smoking, & shaving all contribute
What is the etiology of Hidradenitis Suppurativa?
Diagnosis: Clinical; biopsy rarely needed
Treatment:
Antiseptic washes, zinc shampoos
Topical and oral antibiotics, steroids
Hormone therapy (F)- OCPs, spironolactone
Oral retinoids, oral/injectable immunosuppressants
Radio-/laser therapy, I&Ds, surgical excision
Lifestyle changes including smoking cessation, diet/weight loss, avoiding shaving, and minimizing sweating & friction
What is the diagnosis and treatment of Hidradenitis suppurativa?