DERMATOLOGY RESEARCH ASSIGNMENT
Diana T. Binoya
SWU-MHAM CM - PBL III

1.)	Skin Lesions

1.1	cues for ACUTE vs. CHRONIC

acute			chronic

	speed of occurrence		abrupt			slow progressing
	duration			short (days-weeks)	long (mos.- year(s))

1.2	cues for EXANTHEM vs. NON-EXANTHEM

exanthem			non-exanthem

		cause			bacteria			trauma
virus				infection
drugs

		numbering accdg	1st dis. - measles
		to their historical	2nd       - scarlet fever
		appearance and	3rd        - rubella
		discription		4th        - Duke’s disease
					5th	- roseola infantum

		characterized by	widespread, symmetric,	may not be wide-
					erythematous, discrete or	spread, asymmetrical,
					confluent macules and 	lesions that may have
					papules that initially do not	scales
					form scale

		characteristic feature	common primary lesion	no primary lesion
					distribution			may or may not have
					duration			   systemic symptoms
					systemic symptoms

2.)	Information about the following diseases:

•	Atopic Dermatits

			   most cost-effective		most effective 
	clinical cues		paraclinical diagnostic	    treatment
				          procedure

•	Acute			Bacterial Culture 	      *  Acute
-  poorly defined ery-	 -  almost 90% of		pharmacologic
    thematous patches,	  patients with severe	         -  wet dressing and  
    papules, & plaques 	  AD are secondarily		topical cortico-
    w/ or w/o scale		  colonized/infected		steroid
-  skin appears puffy 
   & edematous					      *  Subacute and Chronic
-  moist, crusted ero-				        -  topical anti-inflamma-
   sions							tory (corticosteroids,
-  pustules if w/ secon-					hydroxyquinoline 
   dary infection w/ 					prep. and tar)	
   S. aureus
•	Chronic
	      -  lichenification
	      -  painful fissures espe-
         cially of palms, fingers,
         & soles
	      -  alopecia on the lateral
         one third of the eye-
         brows as a result of 
         rubbing the eyelids
	      -  w/ Dennie-Morgan 
         sign (characteristic 
   infraorbital fold in the 
   eyelids)
•	Distribution of the lesions
	     -  flexures
     -  front and sides of the 
neck
     -  eyelids
     -  forehead
     -  face
     -  wrists
     -  dorsa of the feet and
hands

•	Contact Dermatits

 most cost-effective		most effective
		Clinical cues		paraclinical diagnostic	   treatment
					        procedure

•	Acute			Patch tests (application	*  Acute
-  well-demarcated 	of the allergen to any		wet dressings using
plaques of erythema 	area of the normal skin)	gauze soaked in
& edema on w/c are	-  (+) result:			Burow’s solution
superimposed closely 	    erythema & papules	changed every 2 to
spaced, nonumbilica-	    as well as vesicles on	3 hrs.
ted vesicles, punctate	    the test site w/in 48
erosions exuding serum	    to 72 hrs.			*  Subacute and
and crusts			-   used to document &		Chronic
•	Subacute			    validate a diagnosis		short course of 1 of
-  plaques of mild ery-	    of allergic contact		the potent topical 
thema showing small, 	   sensitization & identi-	corticosteroid prep.
dry scales or superficial 	    fying the causative		if lesions are not
desquamation, sometimes     agent			bullous
associated with small red, 
pointed or rounded, firm 
papules
•	Chronic
-  plaques of lichenifica-
tion (thickening of the 
epidermis w/ deepening 
of the skin lines in parallel 
or rhomboid pattern) w/ 
satellite, small, firm, 
rounded or flat-topped 
papules, excoriations and 
pigmentation or mild ery-
thema
•	Arrangement
-  often linear with artificial 
patterns, an “outside job”
-  plant contact often results
in linear lesions
•	Distribution
-  extent:  isolated, localized 
to one region (e.g., shoe 
dermatitis) or generalized 
(e.g., plant dermatitis)
-  pattern:  random or on 
exposed areas (as in airborne 
allergic contact dermatitis)

•	Scabies

  most cost-effective		most effective
		clinical cues		paraclinical diagnostic	   treatment
					         procedure

•	Lesion at site of		microscopic examination	pharmacologic 
Infestation		of the scraped skin		-  scabicides
-  intraepidermal 		-  3 diagnositic findings:	  a.  permethin (effec-
    burrows:		   1.  S. scabiei mites		       tive and safe but
    	gray or skin-		   2.  their eggs			       cost more than
colored ridges, 	   3.  their fecal pellets		       lindane)cream5% 
0.5 to 1.0 cm in 					  b.  lindane (effective
length, either linear 					       in most areas of 
or warry (serpigi-					       the world but 
nous) w/ minute 					       resistance has 
vesicle or papule 					       been reported)1%
at end of tunnel
-  distribution of 
    burrows:
    	areas w/ few or no 
hair follicles, usually 
where stratum cor-
neum is thin and soft, 
i.e., interdigital webs 
of hands>wrist>shaft 
of penis>elbows>feet 
>genitalia>buttocks
>axillae > elsewhere
-  in infants, infestation 
   may occur on the head 
   and neck
•	Lesion of hyper-
sensitivity to mite
-  pruritus without any 
   cutaneous findings
-  “Id” or autosensitization-
   type reactions charac-
   terized by wide-spread 
   small urticarial edematous 
   papules mainly on anterior 
   trunk, thighs, buttocks, 
   and forearms
-  urticaria
-  eczematous dermatitis 
    at sires of heaviest 
    infestation: hand, axillae
•	Variants of Scabies in 
special hosts
1.	nodular scabies
-  nodules 5-20 mm in 
diameter, red, pink, tan, 
or brown in color, smooth
-  burrow may be seen 
on the surface of the early 
nodule
-  distribution:  penis, 
scrotum, axillae, waist, 
buttocks, areolae
2.	Crusted or Norwegian scabies
-  may begin as ordinary 
scabies
-  in others, clinical 
appearance is of chronic 
eczema, psoriasiform dermati-
tis, seborrheic dermatitis, 
or erythroderma
-  lesions often markedly 
hyperkeratotic and/or crusted
-  distribution:  generalized 
(head and neck in adults) or 
localized scale or crusts 
found on dorsal surface of 
hands, wrists, fingers, meta-
carpaphalangeal joints, palms, 
externsor aspects of elbows, 
scalp, ears, soles, and toes
-  in patients with neurologic 
deficit, crusted scabies may 
occur only in affected limb

•	Psoriasis

  most cost-effective		most effective
		clinical cues		paraclinical diagnostic	    treatment
					        procedure

•	skin lesion			dermatopathology		*  to the elbows, knee
-  type:			-  result:			    and isolated plaque
	=  papules and 	  a.  marked thickening	    -  topical agents:
plaques, sharply 	       and also thinning		      a.  topical fluori-
marginated with 	       of the epidermis with		nated cortico-
marked silvery-	       elongation of the rete		steroids in 
white scale; remo-	       ridges				ointment
val of scale results 	  b.  increased mitosis of	      b.  hydrocolloid 
in the appearance 	       keratinocytes, fibro-		dressing left 
of minute blood 	       blasts, and endothelial		on for 24-48h
droplets (Auspitz sign)      cells			      c.  triamcinolone 
	=  pustules, erythro-	  c.  parakeratotic hyper-		acetonide 
derma			       keratosis			            aqueous sus-
-  color: 			  d.  inflammatory cells in the		pension
	salmon pink		       dermis (usually lympho-	      d.  topical anthra-
-  shape:			       cytes and monocytes)		lin preparation
	round, oval, polycyclic,     and in the epidermis 	          (excellent when 
annular, linear		       (polymorphonuclear cells)	used properly)
-  arrangement:		       forming microabscesses	      e.  vit. D analogue
	zosteriform, arciform,        of Munro in the stratum
serpiginous, scattered 	       corneum			*  to guttate type
discrete lesions, erythro-				    -  UVB therapy
derma (involvement of 
almost the entire skin)					*  to trunk
•	arthritis							    - combination treat-
•	distribution						       ment with etreti-
extent – single lesion or 					       nate or methotre-
lesion localized to one 				       xate with PUVA
area (e.g. penis. nails), 
regional involvement 					*  for males
(scalp), generalized or 					Re-PUVA
universal (entire skin)
pattern – (1) bilateral but 					*  for females
rarely symmetrical, often 					isotretinoin &
spares exposed areas; 						contraception
favors elbows, knees, scalp, 
and intertriginous areas; 				*  in older patients or
facial region (uncommonly 				    when combination
involved and usually asso-				    phototherapy or 
ciated with refractory type 				    photochemotherapy 
of psoriasis); (2) dissiminated 			    failed:  
small lesions without publi-					methotrexate
cation of site

•	Leprosy

  most cost-effective		most effective
		clinical cues		paraclinical diagnostic	   treatment
					         procedure

•	Tuberculoid (TT)		slit skin smear			pharmacologic
-  single or few anes-	  -  result:			  -  miltidrug therapy
thetic macules or 		      (+) acid fast bacilli		(MDT)
plaques; borders well 					   1. Paucibacillary
defined; peripheral 					       patients ( I, TT,
nerve involvement 					       and BT)
common								-  Rifampin
-  color: erythematous 						600 mg once a
or purple border and 						month plus
hypopigmented center						-  Dapsone100
-  distribution: any site 						mg daily for 6
including face							months
•	Borderline Tuber-							- Follow-up
culoid (BT)							every 3-6 mos.
-  lesions similar to 						-  Relapsing 
TT but more numerous; 						patients must
borders of lesions less 						betreatedagain
distinct; satellite lesions 					   2.  Multibacillary
sometimes present 					        patients (LL,BL,
around larger lesions; 					        BB)
peripheral nerve 							-  Rifampin 
involvement common				           	            600mg month-
•	Borderline (BB)							ly plus
-  more lesions than BT; 						-  Dapsone100
borders more vague; 						mg daily plus 
satellite lesions often 						-  Clofazimine
seen; peripheral nerve 						50 mg daily
involvement common; 						for at least 2
decreased sweating 						years and con-
prominent in the lesion						tinued until 
•	Borderline Lepro-							skin smears 
matous (BL)							are negative
-  lesions are numerous 					  3.  Reactional states
and similar to BB; some 						-  Prednisone
nerve damage							1 mg/kg/day,
•	Lepromatous (LL)							orally, high
-  multiple, nonanesthetic, 					doses at 1st
macular or papular, 						then tapered to
symmetrically distributed 						minimum 
lesions until late; late 						effective dose
complications of madarosis, 					until reactions
leonine facies, testicular 						subside; alter-
damage, etc.							nate day ste-
-  color: normal skin color 					roid regimen
or erythematous or slightly 					should be 
hypopigmented							attempted 
•	Indeterminate (I)							when long
-  vaguely defined hypo-						treatment is
pigmented or erythematous 					needed.
Macule								-  analgesics
•	Reactional Phenomenon						-  Clofazimine 
-  Lepra type 1 reaction:						in patients 
skin lesion acutely 						with chronic
inflamed associated 						ENL
with edema and pain; 						-  Thalidomide 
may ulcerate; edema 						for severe 
most severe on face, 						ENL; terato-
hands and feet							genic hence 
-  Lepra type 2 reaction (ENL)					absolutely 
painful red skin nodule					contraindica- 
arising superficially and 					ted in women
deeply; lesions commonly 					of child bearin
on face and extensor limbs					age
-  Lucio’s reation							-  rest of 
irregularly shaped						affected area
 erythematous plaques; 					in reversal 
lesions may resolve 						reactions
spontaneously or undergo 
necrosis with ulceration

•	Pediculosis

clinical cues:	*  Pediculosis capitis
			-  head lice on the scalp, on the back of the head and neck, 
   and behind the ears
			-  nits cemented on the hair
			-  pruritus causing inflammation and secondary bacterial 
    infection
			-  posterior cervical adenopathy without obvious disease
			-  redness and swelling on the eyelashes when involved
		*  Pediculosis corporis
			-  pruritus that leads to scratching and secondary infection
		*  Pediculosis pubis
			-  pruritus
			-  little inflammation, but if not treated would develop 
wide-spread inflammation and infection of the groin with regional adenopathy
			-  gray-blue macules varying in size from 1 to 2 cm on the 
    groin and at sites distant from the infestation

most cost-effective
paraclinical diagnostic	Wood’s light examination
	procedure			-  result:  (1) fluoresce white for nits that contain an 
   unborn louse
						    (2) fluoresce gray for nits that are empty

	most effective treatment:	pharmacologic
						Lindane (Kwell) and Pyrethrins (RID)	
						-  effective for treating lice

•	Skin Cancer

Malignant Melanoma

	clinical cues:	*  ABCDs
A – asymmetry;  B-  border irregularity;  C- color 
variegation;  D- diameter enlargement (>6mm in diameter)
Changes in shape and color are important early signs.

				*  Superficial Spreading Melanoma (SSM)
					-  location:  anywhere on the body; frequently on 
the upper back of both sexes and on the legs of women
-  hallmark:  haphazard combination of many  
   colors; may be uniformly brown or black
-  lesion:  begins in a nonspecific manner and then 
   changes shape by radial spread and regression
					-  shape:  bizarre if left untreated
					-  age of patient:  most common in middle age (4th-
   5th decade of life)

				*  Nodular Melanoma (NM)
					-  location:  anywhere in the body
					-  age of patient:  5th or 6th decades of life
					-  characteristics:
						>  most commonly dark brown, red-brown, 
    or red-black
						>  dome-shaped, polypoid, or pedunculated
						>  amelanotic (fresh colored) at times
						>  resembles a blood blisters, hemangioma, 
    dermal nevus, or polyp

				*  Lentigo Maligna Melanoma (LMM)
					-  age of patient:  6th or 7th decades of life
					-  location:  mostly on face;  other exposed sites like 
   arms and legs
					-  shape:  more varied and bizarre than that of SSM
					-  color:  more uniform than SSm; red and white 
    may later occur
					-  other characteristics:
						>  tumors generally located in the center of 
    the lesion, away from the border
						>  may ulcerate or undergo charges similar 
to other lesions when they enter the tumor stage
						>  nodules usually single and generally 
appear when the lesion has assumed a size of 5 to 7 cm

				*  Acral-lentiginous Melanoma (ALM)
					-  location:  palms, soles, terminal phalanges, and 
   mucous membrane
					-  clinical presentation:  similar to LM and LMM
					-  with some colors and tendency to remain flat
					-  with small areas of elevation

		most cost-effective
		paraclinical diagnostic	-  Excisional biopsy if not contraindicated
		procedure			-  Incisional or punch biopsy for surgically 
sensitive areas like the nose and periorbital or digital regions

		most effective treatment:	Stage I -  surgical
							-  resection margins:
								=  1 cm margin for most thin 
     melanomas
								=   2 cm margin for lesion 1 
     to 4 mm thick
						Stage II – stage I plus therapeutic lymph 
node dissection
						Stage III

	Malignant Nonmelanoma

		Basal Cell Carcinoma (BCC)

		clinical cues:	*  Nodular BCC
					-  lesion begins as a pearly white or pink, dome-
shaped papule resembling a molluscum contagiosum or dermal nevus
					-  mass extends peripherally
					-  may remain flat
					-  with traction on the surrounding skin  that 
   accentuates the pearly border
					-  prominent telangiectatic vessels as lesion enlarges
					-  irregular growth pattern
					-  center frequently ulcerates and bleeds and 
  					    subsequently accumulates crust and scale
					-  common presentation :  nonhealing leg ulcers
				*  Pigmented BCC
					-  brown, black, or blue color lesion through all or 
    part of the lesion
					-  lesion clinically resembles a melanoma or 
    pigmented seborrheic keratosis
					-  characterized by elevated, pearly white, 
    translucent border
				*  Cystic BCC
					-  appears as smooth, round, cystic mass
					-  behaves like nodular BCC
				*  Sclerosing or morpheaform BCC
					-  waxy, firm, flat-to-slightly raised, either pale 
    white or yellowish tumor
					-  borders distinct and blend with normal skin
					-  depressed and firm lesion resembling a scar
				*  Superficial BCC
					-  location:  trunk and extremities, face
					-  number of lesion:  one or more
					-  spreads peripherally, sometimes for several 
    centimeters, and invades after considerable time
					-  circumscribed, round-to-oval, red scaling plaque 
resembling a plaque of eczema, psoriasis, extramammary Paget’s disease, or Bowen’s disease
-  characteristic features:  thin, raised, pearly white 
    nature
				*  Nevoid BCC syndrome (Gorlin’s syndrome)
					-  major features:
						multiple BCCs appear at birth or in early 
childhood; numerous small pits on the palms and soles; epithelium-lined jaw cysts, which commonly cause symptoms; ectopic calcification with lamellar calcification of falx cerebri; and a variety of skeletal abnormalities, especially of the ribs, skull, and spine

		most cost-effective
		paraclinical diagnostic	biopsy
		procedure			  

		most effective treatment	*  Nodular and Superficial BCCs
							-  simple surgical excision
						*  Micronodular, infiltrative, and 
morpheaform
							-  wide excision or microscopically 
    controlled surgery
						*  Sclerosing BCC
							-  Mohs’ micrographic surgery

		Squamous Cell Carcinoma

		clinical cues:	*  arising from actinic keratosis
					-  thick, adherent scale
					-  soft and freely movable tumor; may have red, 
   					    inflamed base
					-  location:  bald scalp, forehead, and backs of the 
 					    hands
				*  arising from actinically damaged skin
					-  firm, movable, elevated mass with sharply 
   defined border and little surface scale
	
		most cost-effective
		paraclinical diagnostic	biopsy
		procedure

		most effective treatment	*  small Sccs (from actinic keratosis)
							-  electrodesiccation and curettage
						*  larger tumors or those on or near the 
vermilion border of the lips
							-  excision including the 
    subcutaneous fat
						*  tumors thinner than 4 mm
							-  simple local removal
						*  lesions between 4 and 8 mm thick or that 
exhibit deep dermal invasion
							-  excision
						*  tumors that penetrate through the dermis
							-  excisional and Mohs’ surgery

3.)	Indications for	

A.	Topical medicines vs. Oral Medicines in skin lesion

topical medicines			oral medicines

		          for localized cutaneous		for generalized lesions
lesion			if localized drug would cause
systemic toxicity

B.	Cream vs. Ointment

cream				ointment

		       for wet lesions		        for dry lesions
		       for acute exudative lesions      for chronic lesions
		       if the wet phase of the 	        for the other areas with the lesion
disease has been controlled	except on intertriginous areas
		       for lesions found in the 
intertriginous areas 
(e.g., groin, rectal area 
and axilla)

4.)	Prescribe medicines

A.	Cellulitis

Name:  Ronnie P. Cucharo	sex:  M	age:  24	date: Oct. 22,1999
Address:  679 Brgy. San Francisco, Panabo, Davao del Norte

Rx

		CEFALEXIN	500 mg  cap # 28
		   (Cefalin) 

Sig.	Take 1 capsule every 6 hrs. for 7 days.

						M.D.  Diana T. Binoya
						Lic. No.  000091275

B.	Scabies

Name:  Ronnie P. Cucharo	sex:  M	age:  24	date:  Oct. 22,1999	
	Address:  679 Brgy. San Francisco, Panabo, Davao del Norte

	Rx

		LINDANE	1%  lotion   # 1
		  (Kwell)

	Sig.	Apply thinly to all areas of the body from neck to toe; 
wash off thoroughly after 8 hrs.

							M.D.   Diana T. Binoya
							Lic. No.  000091275

C.	Contact dermatitis – foot

Name:  Ronnie P. Cucharo	sex:  M	age:  24	date:  Oct. 22, 1999
Address:  679 Brgy. San Francisco, Panabo, Davao del Norte

Rx

	CLOBETASOL DIPROPIONATE  0.05%  cream  # 1
		   (Dermovate)

	Sig.  	Apply thin film 1 or 2 times a day until improvement occurs.

							M.D.   Diana T. Binoya
							Lic. No.  000091275

D.	Pimples

Name:  Ronnie P. Cucharo	sex:  M	age:  24	date:  Oct. 22,1999
Address:  679 Brgy. San Francisco, Panabo, Davao del Norte

Rx

	BENZOYL PEROXIDE   5% lotion  # 1
		(Benoxyl)

Sig.	Apply 1 or 2 times a day.

						M.D.   Diana T. Binoya
						Lic. No.  000091275

5.)	Short Referral Letter

October 30, 1999

Department of Internal Medicine
Sacred Heart Hospital

Department of Surgery
Sacred Heart Hospital

To Whom It May Concern:

	My patient, James Howard, 23 years old, male, single, Filipino, Roman Catholic, a banker, recently residing at A. Lopez St. Labangon, Cebu City, admitted for the frist time at SHH last October 30,1999 due to a tumor at the right antero-lateral arm.

	Patient noticed the mass a month ago to be increasing in size. No associated symptoms accompany the mass.  It is nontender, non-erythematous, and nonpruritic mass. No work up done yet. 

	Patient needs your assistance and further management for his complaint.

	Thank you and may the good Lord bless you always!

Diana T. Binoya, M.D.
Admitting physician

REFERENCE

	Fitzpatrick, T.B. et al., Color Atlas and Synopsis of Clinical Dermatology: 
Common and Serious Diseases. 3rd edition. copyright 1997 

	Habif, T. P. . Clinical Dermatology: A Color Guide to Diagnosis and Therapy. 
3rd edition.  copyright 1996 Mosby-Year Book, Inc.

	Hardman, J. G., et al., Goodman and Gilman’s The Pharmacological Basis of 
Therapeutics.  9th edition.  copyright 1996 McGraw-Hill Companies, Inc.

	Jacob, L. S.  NMS: Pharmacology.  4th edition.  copyright 1996 Williams and 
Wilkins

	Tierney, L. M. Jr., et al.  Current Medical Diagnosis and Treatment. 1998 
edition.  copyright 1998 Appletone Lannge.

	MIMS. Philippines – PIMS.  Volume 26 number 1 of 1997.