SKIN AND SOFT TISSUE PROBLEMS

I.	Skin lesions

I.1.  Cues for acute vs. chronic 

				Acute				Chronic

Onset				rapid 				insidious

Duration		     short-course, 		         long-course,
     < 6 months		         > 6 months
								recurrent

Quality of		severe, pronounced 	less severe, less pronounce
Symptoms

I.2.  Cues for exanthem vs. non-exanthem

				Exanthem			Non-exanthem

Characteristics	generalized eruption		non-eruptive

I.3.  Clinical cues for:

	
   History	
       P.E.	
Paraclinical	
Treatment

Atopic
Dermatitis	
Pruritus and scratching

Course marked by exacerbations and remissions

Personal or family history of atopy(asthma, allergic rhinitis,
Food allergies, or eczema)

Clinical course lasting longer than 6 weeks
	
Patches and plaques of erythema, scaling, and lichenification

Extrafold beneath the lower eyelid (Dennie’s line), increased palmar markings	
Patch testing	
Avoidance of cutaneous irritants, adequate cutaneous hydration, wet dressings with topical glucocorticosteroids, antihistamines
Topical antibiotics	

Contact Dermatitis

	
Direct contact with irritant chemicals at home or at work; previous contact with plants with plant derived antigens (e.g. poison ivy)	
Acute: wet and edematous lesions, strictly demarcated , localized to areas  of contact with the irritant
Chronic: dry, thickened and scaly lesions depending on the persistence of the insult
	
Patch testing	
Wet dressings using gauze soaked in Burrow’s solution and changed every 2-3 hours
Topical class I corticosteroids

Scabies

	
History of family members having the same manifestations	
Linear lesions called “burrows” where the mites are found;
Many papulovesicles seen in sites of predilection like wrists, elbows, webs of fingers, genitalia and knees; can be very pruritic	
Open up the burrows with the tip of an eleven blade with a drop of mineral oil and place on a clean glass slide. Cover with a cover slip. Actual mites, ova and feces (scybala) are seen on scanning power of the microscope
	
Scabicides – Permethrine is effective and safe

Antihistamines for itchiness

Lindane (Kwell) lotion applied for 4-5 hours once a day	

Psoriasis

	
Family history:
I parent = 8% possibility for the offspring
Both parents = 41% possibility for the offspring

Factors that trigger psoriatic attacks:
Stress, infections, physical trauma, certain drugs	
Sharply demarcated, pink-red, plaques with silvery scale; predominantly on the elbows, knees and scalp

Auspitz sign – minute, multiple bleeding points when the scale is lifted from the plaque.

Other findings:
Nail dystrophy: pitting, onycholysis, yellow discoloration
Arthritis: primarily small joints ( hands and feet
	
DERMATOPATHOLOGY
Histologic features:
Acanthosis, vascular proliferation;

The stratum granulosum is thinned or absent, and extensive overlying parakeratotic scale is seen	
Topical fluorinated corticosteroids (Bethamethasone valerate, Flucinolone) in ointment base applied after 

removing the scales by soaking in water. The ointment is applied to the wet skin, covered with plastic wrap, and left overnight.

Methotrexate is effective especially in patients with associated psoriatic arthritis

Ultraviolet light ( UV-B ) is an effective therapy for patients with widespread psoriasis

Leprosy

	
Risk factors:
•	Resident in an endemic area

•	having a blood relative
•	poverty	
Tuberculoid Leprosy:
Type of lesion- well defined hypopigmented anesthetic macules with raised edges and varying in size 
Color of lesion- erythematous or purple border and hypopigmented center

Border of lesion- shaping defined raised Shape- annular
Distribution- any site including the face 
Nerve-involvement- thickened nerve on the edge of the lesion.

Lepromatous leprosy:
Type of lesion- small erythematous or hypopigmented macules that are anesthetic; later papules, plaques, nodules and diffuse thickening of the skin with loss of hair ( eyebrows, eyelashes) 
Color- normal skin color or erythematous or slightly hypopigmented distribution- bilateral symmetric involving earlobes, face, arms and buttocks or less frequently the trunk and lower 
 Ext. mucous, plaques, tissues
	
Slit–skin smears	
Anti Lepromatous Therapy:
Multidrug Regimen:

Paucibacillary disease (TT & BT) 
>Monthly , supervised Rifampin/600mg 
>Daily, unsupervised Dapsone, 100mg 
Duration 6 months, all treatment then stop

>Follow –up after  stopping treatment- Minimum of 2 yrs. With clinical examinations at least 9 – 12 months

Multibacillary Disease(LL, BL & BB)
>Monthly, supervised medication- Rifampin, 600 mg Clofazamine, 50 mg
>Duration – A minimum of 2 yrs, but whenever possible until  slit-skin smears are negative
>Follow-up after stopping treatment- A minimum of 5 yrs. With clinical and bacteriologic exam at least 12 months	

Pediculosis
	
Exposure to persons with pediculosis

Pediculosis capitis infects the scalp, eyebrows and eyelashes;
	
Presence of lice and nits 
Pruritus on the affected area

Microscopy  -  the louse or a nit on a hair shaft can be examined to confirm the gross exam of the scalp or hair
	
Permetrine or pyrethrins applied to area

Pediculocides like Lindane (Kwell): one application of Kwell shampoo for 5 minutes, rinsed off and reapplied after 2 weeks when the nits hatch

Melanoma
	
Malignant melanoma

Precipitating factors:
•	exposure to sunlight
•	(+) family history

	
Six signs of malignant melanoma:
A-	Asymmetry in shape – ½  unlike the other half
B-	 Border is    irregular- edges irregular scalloped 
C-	Color is mottled- haphazard display of colors; shades of brown, black, gray, red and white
D-	diameter is usually large –greater
      than the tip
      of pencil                      
      eraser
      (6.0 mm)

E -  elevation is
      almost
always          present- surface distortion is assessed by side lighting.
 -   enlargement             a history of an   increase
In the size     of lesions

	
Dematopatho
logy
>Hyperplasia and proliferation of melanocytes	
Prophylactic excision periodic follow-up for life

	
Non-melanoma

	
Skin lesion:
Type-papule or nodule, texture of surface may be dull, shiny, or scaling. Top may be crusted or scarred 

secondary to 
excoriation or shaving. Borders - ill defined.

Color- variable: skin color, pink, brown, tan, dark, chocolate brown. Usually darker at center, fading to normal skin color at margin Palpation – firm dermal button- or pealike papule or nodule
Distribution- legs>arms>trunk	
Dematopatho
Logy:
whirling fascicles of spindle cells with small amounts of pale blue 

cytoplasm and 
elongated nuclei	
Cryosurgery with liquid nitrogen spray 	

2.	Indications for:

2.1	Topical Meds vs. Oral Meds

Topical  
	Topical application is used when a local effect of the drug is desired

Oral  	
	It is the most common route of administration; most convenient and economical. It is used when a systemic effect is desired

2.2	Cream  vs. Ointment

Cream  
 Used for wet/moist lesions

Ointment  
Used for dry lesions
	
3.	Prescribe Medicines for:

3.1. Cellulitis

Name: Lee, Anne				Date:  October 31, 1999
Age:  26 years old

Rx:	 Amoxicillin (Termox) 500 mg capsule   #  28 caps
		
Sig. Take 1 capsule 3x a day for 7 days.

Lilibeth Neri Macarine, M.D.
					License No.: 25324

			
3.2 Scabies

Name: Lee, Anne				Date:  October 31, 1999
Age:  26 years old

Rx:	 Lindane ( Kwell )  Lotion  # 1

Sig. apply once a day for 4-5 hours on affected areas.

Lilibeth Neri Macarine, M.D.
					License No.: 25324

3.3	Contact  Dermatitis – foot

Name: Lee, Anne				Date:  October 31, 1999
Age:  26 years old

Rx: Fluocinonide gel 0.05%  #  1 tube

Sig. Apply a thin film over the affected area 3 x a day for 7 days

Lilibeth Neri Macarine, M.D.
					License No.: 25324

3.4	Pimples

Name: Lee, Anne				Date:  October 31, 1999
Age:  26 years old

Rx:	 Tetracycline 500 mg capsules # 21

      Sig.  Take one capsule 3x a day for 3 weeks

Lilibeth Neri Macarine, M.D.
						License No.: 25324

4.	Short Referral Letter for patient with soft tissue tumor

October 31, 1999

Glenda E. Caballero, M.D.
OB-Gyne Department
Chong Hua Medical Center
J. Llorente St., Cebu City

Dear Glenda, 

	I would like to refer my patient, Lee, Ann; 26 y.o., female, single, 3rd year student in medicine, from Urgello, Cebu, City. She has multiple papules/pustules on the face and back, (+) mild hirsutism, noted 5 months ago. My diagnosis is Acne vulgaris and I am suspecting it is secondary to a gynecologic problem.
	I am referring her to you for gynecologic evaluation and management.		
Thank you very much. God bless you.

Referring Physician,

Lilibeth Neri Macarine, M.D.
Dermatologist
Cebu Derm Clinic
Colon St., Cebu City

Reference:
							 
Braunwald, E., Fauci, A.S., Isselbacher, K.J., et al; Harrison’s Principles of Internal 		Medicine, 14th Edition, 1998; McGraw-Hill Companies, USA; vol., pp. 298-311 

Del Mundo, F., Estrada, F.A., Navarro, X.R., et al; Textbook of Pediatricks and Child Health, 3rd edition, 1990; JMC Press Inc., Philippines;pp. 1020-1025

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