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CHAPTER 2 TRANSLATING RESEARCH INTO CLINICAL PRACTICE
CHAPTER 38 SCREENING FOR SKIN CANCER
Monthly self-skin examinations Benefits of skin cancer screening is greatest amongst subgroups most likely to develop fatal melanoma Basal cell carcinoma [most common form of skin cancer] Malignant melanoma [most fatal] o Incidence rates higher in women than in men before age 50 o Incidence rates in men vs women are twice as high after 65 and triple after 80 90% all skin cancers are caused by the sun [UV radiation] o Sunburns increase risk Skin cancers have hereditary component Endogenous risk factors o Phototype o Skin and eye color o Individual and family history o Number of nevi Exogenous risk factors o Type and degree of cumulative sun exposure o History of sunburn o Sun protection behavior UV radiation o DNA damage o Gene mutations o Immunosuppression o Oxidative stress o Inflammatory responses o Initiates tumorigenesis and promotes tumor development History and physical o Individual, social, and family history o Use of sunscreen [tendency to burn] o Outdoor employment Warning signs for skin cancer o Open sore that does not heal for 3 weeks o Spot or sore that burns, itches, stings, crusts, or bleeds o Any mole or spot that changes in size, texture, develops irregular borders, or is pearly, translucent, or multicolored o Non-healing skin areas, ulceration, bleeding, and weeping sores Detection of suspicious lesions warrants a biopsy Changes that occur in a few days usually not cancer [over a month or more should be evaluated] Basal cell carcinoma [raised shiny appearance often with pearly borders]
o Treated with electrosurgery and curettage Squamous cell carcinoma [roughened, scaling area that does not heal and readily bleeds with scraped] o Definitive treatment is total excision Malignant melanoma [ABCDE] Diagnostics o Skin biopsy [shave, punch, or excisional] is the definitive diagnostic test Actinic Keratosis o Persistent or reoccurring reddened and roughened area that scales or crusts o Treated with liquid nitrogen by freeze-thaw technique Education o Sun exposure longer than 15 min requires at least SPF15 applied before sun exposure and every 2 hours
CHAPTER 46 ECZEMATOUS DERMATITIS
Atopic dermatitis is the most common form of dermatitis Usually presents at a young age 3-6 months Associated with IgE diseases o Asthma o Allergic Rhinitis o Urticaria o Acute reactions to foods Etiology: Primary immune dysfunction resulting in IgE sensitization Eczema Presentation o Pruritic, erythematous, dry patches, often with scale o Borders are not well defined o Crusting and oozing common o Lichenification may result from scratching o Infants [cheeks, scalp, forehead, extensor extremities] o Adults [face, neck, flexural folds, wrists, and dorsa of feet] Nummular eczema o Coin shaped and on upper and lower extremities Dyshidrotic eczema o Dryness, patches, or fissures on palms of hands and soles of feet Id reactions o Acute onset of pruritic, erythematous, and papulovesicular eruption on upper and lower extremities o Occur as the result of infection elsewhere in the body [particularly fungal infections] Asteatotic dermatitis o Pruritic dry cracked skin with irregular scaling o Commonly occurs on the shins of older adults but can occur on hands and trunk Stasis dermatitis o Erythematous inflamed skin with areas of edema
Group A β-hemolytic Streptococci and Staphylococci are the most common bacterial organisms and should be cultured when indicated – Treatment with Cephalexin [Keflex] is well tolerated Dilute bleach baths twice weekly and intranasal mupirocin for 3 months can lead to reduction in bacterial superinfections o Patients with eczema have higher incidence of herpes simplex, molluscum contagiosum, and warts o Eczema herpeticum [viral complication] Widespread eruption of vesicles and erosions when experiencing a primary herpes infection
CHAPTER 47 SCABIES
Poor defined pruritic eruption often with linear burrows in the web spaces of fingers Can affect all ages [most commonly young and old] Common in crowded living conditions and institutional facilities [nursing homes, LTAC] More prevalent in hot humid environments Transmitted through direct skin-to-skin contact with infected person Diagnostics o Dermoscopy o “Adhesive tape test” Tape is applied to site then rapidly removed and placed on microscope slide for examination o “Scabies prep” Drop of mineral oil is placed on burrow, lesions are then scraped or shaved off and placed under a microscope for identification of mites, eggs, or feces [mite is not visible to the unaided eye] Scabies Crustosa o Highly contagious and should be treated immediately o Difficult to treat; requires prolonged course of combination therapy until all scales and crusts are gone Permethrin 5% or Benzyl Benzonate 25% applied from neck down repeating every 2- 3 days for 1-2 weeks Urea cream BID will help decrease hyperkeratosis o Affects immunocompromised or those with reduced sensation and/or immobility to scratch Presentation o Intractable pruritus [especially at night] o Lesions have 2 categories site of infestation vs lesions secondary to hypersensitivity o Common sites are interdigital spaces of hands, flexures of the wrist and arms, genitals, feet, buttocks, and axillae Pharmacological Management o Primary treatment 5% Permethrin cream [Elimite] applied from neck down Should be left on for 8-12 hours then washed off
Treatment must be repeated after 7-14 days Safe to use during pregnancy and in children 2 months and older Benzyl benzoate 10% - 25% Can be applied each night for 2 days in a row with reapplication after 7 days Crotamiton [not first line [has been associated with resistance issues] Oral ivermectin 200mcg/kg once daily but may be repeated in 14 days Off label used to treat crusted scabies or if topical treatment isn’t effective Not safe during pregnancy or in children weighing less than 15kg o Secondary Treatment Sulfur ointment Applied for 3 consecutive days Ivermectin ointment 1% [just as effective as 5%] Malathion 0.5% o Medication for Recalcitrant Scabies Lindane [Kwell] used as last resort No longer considered first line treatment toxicity concerns and side effects Used if other treatments are unavailable or have failed Absorbed through skin at rate of 10%; accumulates in fat and binds to the brain tissue. Education o Wash all clothing in hot water and dry on hot cycle o Items that cannot be washed should be placed in plastic bag for 1 week o Symptoms may continue 2 weeks after treatment o Avoid close contact
CHAPTER 47 HERPES ZOSTER
Eruption caused by reactivation of VZV that often follows [by decades] chicken pox infection Incidence increased with age Contagious Presentation o Prodrome of pain or dysesthesia [tingling] may occur prior to outbreak o Vesicular eruption in unilateral dermatomal pattern that does not cross midline o Burning pain Diagnostics o Based on clinical presentation o Tznack test [does not distinguish between VZV and HSV] o PCR test o DFA test Pharmacological Management o Antiviral Therapy Initiation within 72 hours reduces duration and severity of rash and pain Valacyclovir 1000mg PO TID for 7 days
Guatte Psoriasis
o Less than 1cm usually seen after strep infection
Psoriatic Arthritis
o Causes joint effusions, pain at insertion point of tendons to bone, swelling of fingers
and toes, and nail changes
Diagnostics
o Based on presentation
o Biopsy useful in pustular or difficult cases
o Nail cultures to determine fungal disease
o No diagnostic lab test for Psoriatic arthritis
Pharmacological Management
o Topical Therapy
Can be used when psoriasis covers small area [less than 3% body surface]
Larger surfaces require systemic therapy
High-potency topical glucocorticoids twice daily [results in 2-3 weeks]
Facial psoriasis requires low-potency steroids
Vitamin D analogues
Calcineurin inhibitors
Shampoos with salicylic acid used to reduce scale build up
o Intralesional Injection
Corticosteroid suspension
o Systemic Medications
Oral Retinoids
Teratogenic [use caution if childbearing age]
Methotrexate [for severe cases that have failed other treatment]
Cyclosporine [Neoral]
Limited use due to nephrotoxicity
o Biologic Agents
TNF antagonists [Etanercept, Infliximab, Adalimumab]
Costly [used when other methods have failed]
Phototherapy is effective treatment
CHAPTER 47 BACTERIAL INFECTIONS
CELLULITIS
Superficial localized swelling, erythema, pain and warmth to the affected area, and pus o Systemic symptoms include fever, chills, and malaise Can occur on both non-intact skin and skin with no signs of trauma Lower extremity most common site [can occur anywhere]
Diagnostics o Gram stain and culture od drained purulent material [mild cases] o Radiography [for those with long standing disease or deep-seated infection] Pharmacological Management o Oral Antibiotics [MRSA] Trimethoprim-Sulfamethoxazole [TMP-SMX] Doxycycline Cephalosporin [Cephalexin] Anti-staphylococcal penicillin [Dicloxacillin] o Anti-inflammatory Agents Ibuprofen 400mg QID for 5 days Corticosteroids [nondiabetic patients] Prednisone 40mg daily for 7 days o Intravenous Severe purulent SSTIs [MRSA] Vancomycin [preferred for children] Daptomycin Linezolid Telavancin Ceftaroline MSSA Nafcillin Cefazolin Clindamycin Nonpharmacological Management o Postural drainage [elevation of limb] o Compression [when no contraindicated]
