Dr neil jaddou m. D board certified and professor of family medicine



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References

World Health Organization



http://www.who.int/mediacentre/factsheets/fs277/en/
American Migraine Foundation

http://americanmigrainefoundation.org
Migraine Research Foundation

http://migrainereserachfoundation.org
International Headache Society
http://www.ihs-headache.org/

Kasper DL, Braunwald E, Fauci AS, Hauser SL, Longo DL, Jameson JL, Loscalzo J. 18 ed. Harrison's principles of internal medicine: Headache. New York, NY: McGraw-Hill; 2012:118,119,121.New York, NY.



Somerset Family Medicine Clinical Module

Bread & Butter of Family Medicine:

Skin Rash


Type of Skin Rashes

Clinical presentation

Treatments

Acne vulgaris

  • Caused by hormonal imbalance.

  • Contributing organism: Propionibacterium acnes.

  • Rashes can appear as pustules and cysts that can erupt and release free fatty acids, causing further irritation.

  • Mild acne: Use topical antibacterial such as benzoyl peroxide. If ineffective, add topical antibiotics such as clindamycin or erythromycin.

  • Moderate acne: Add topical vitamin A derivatives such as tretinoin, adaphalene to topical antibiotics as mentioned above.
    If ineffective, use oral antibiotics such as minocycline or doxycycline.

  • Severe acne: Add oral vitamin A, such as isotretinoin to oral antibiotics as mentioned above.

Dandruff (seborrheic dermatitis)

  • Caused by Malassezia furfur.

  • An over secretion of sebaceous material and a hypersensitivity reaction to a superficial fungal organism underlie seborrheic dermatitis.

  • Scaly, yellowish, greasy dermatitis found on a red base on the scalp, eyebrows, and in the nasolabial fold.

  • Common association with Parkinson disease and AIDS.

  • Wash scalp with Selenium Sulfide shampoo or ketoconazole shampoo daily.

  • Rub in betamethasone or fluocinonide solution one to two times a day into the affected area for itchy skin if moderate or severe dandruff.

Eczema

(Atopic dermatitis: Type I IgE-mediated hypersensitivity reaction)

  • Inflammatory dermatoses characterized by pruritus.

  • In children: Dry skin and eczema on cheeks and extensor and flexural surfaces.

  • In adults: dry skin and eczema on hands, eyelids, elbows, and knees.

  • Acute eczema: weeping, erythematous rash with vesicles.

  • Chronic eczema: dry, thickened skin (hyperkeratosis) caused by continual scratching.

  • Emollients provide moisture to the skin and help prevent further water loss.

  • Use topical steroids for mild to moderate eczema. For the face use only low-potency hydrocortisone such as Hydrocortisone (DermAid cream/soft cream). For other sites, medium potency corticosteroids such as Clobetasone butyrate (Eumovate cream), triamcinolone or high potency corticosteroids such as Betamethasone dipropionate (Diprosone OV cream/ointment) are recommended.

  • Oral corticosteroids such as prednisone are often used in the short term management of severe eczema.

  • Use antihistamines such as claritine to control the itching.



Herpes zoster

  • Herpes zoster is caused by the reactivation of a latent VZV infection.

  • It is characterized by a prodrome of pain and dysesthesia in a dermatomal pattern, followed by an eruption of grouped vesicles on an erythematous base.

  • It most commonly occurs in older individuals.

  • Use acyclovir 800 mg 5x/daily for 7 to 10 days or valacyclovir 1000 mg 3x/daily for 7 days.

  • Use pain medication depending on the degree of pain: Acetaminophen, acetaminophen-hydrocodone, gabapentin or tricyclic antidepressants are recommended.

Impetigo

  • Bacterial infection of the skin caused by Streptococcus pyogenes and Staph. Aureus (bullous impetigo).

  • Starts as maculopapules and rapidly progresses to vesicular pustular lesions or bullae.

  • Superficial, pustular skin infection, seen mainly in children, with oozing, crusting, and draining of the lesions (honey colored lesions).

  • Can progress to cellulitis, acute glomerulonephritis.

  • It is highly contagious.

  • Use topical antibacterial such as mupirocin (bactroban) or retapamulin for mild cases of impetigo.

  • In adults: Use oral first gen. cephalosporin such as Cephalexin (Keflex) 250 mg to 1000mg , 4x/day for 7 to 14 days

  • In children, the dose can range from 25 mg to 100 mg /kg/day, 3-4x/day for 7 to 10 days.

  • For Penicillin-allergic patients: Use
    Macrolides such as clarithromycin (Biaxin) or azythromycin (Z-pack)

  • For MRSA: TMP/SMZ (bactrim).

  • If allergic to sulfa drugs, use doxycycline or clindamycin (cleocin)

Pityriasis rosea

  • Transient, pruritic, erythematous, salmon-colored eruption that starts out as a single lesion (herald patch) and then disseminates.

  • Can look like secondary syphilis, except that it spares the palms and soles.

  • Lesions on the back appear in a pattern like a Christmas tree.

  • Use topical steroids such as triamcinolone.

Poison Ivy (contact dermatitis: type IV hypersensitivity reaction)

  • A rash from poison ivy, poison oak or poison sumac is caused by Urushiol, an oil substance found in the sap of these plants.

  • The rash is very itchy and can be characterized by red streaks, hives, small or large blisters or crusting skin (after blisters burst).

  • No skin to skin spread.


  • Most rashes go away w/o treatments in about 1 to 3 weeks. However, some treatments are recommended based on the severity.

  • For mild rash: Use calamine lotion (Local anesthetic).

  • For moderate rash: Use cortisone cream such as triamcinolone 0.1% or clobetasone butyrate.

  • For severe rash: Use oral prednisone fr 10-14 days.

  • Use local antihistamines such as Benadryl cream or oral antihistamines such as Claritin to control the itching.

Psoriasis

  • Etiology is unknown.

  • Well-demarcated, flat, elevated, salmon-colored plaques covered by adherent white to silver-colored scales.

  • Rash common on the extensor surface of the elbows and knees, lower back and pitting of the nails.

  • Salicylic acid can be used to remove heaped-up collections of scaly material.

  • If localized disease, use topical steroids such as triamcinolone (Kenalog cream 0.1%).

  • To avoid the long term use of steroids which can cause skin atrophy, substitute with topical vitamin D (calcipotriene) and vitamin A derivatives.

Rosacea

(adult acne)

  • Inflammatory reaction of the pilosebaceous units of facial skin.

  • Characterized by pustules and flushing of the cheeks which causes enlargement of the nose (rhinophyma).

  • Mild disease: Use topical metronidazole gel (Metro gel 0.75%, 1 %), Metro cream or Metro lotion 0.75%. A thin film of metronidazole gel should be rubbed on affected areas once or twice daily.

  • Severe disease: Use oral antibiotics such as tetracycline (sumycin), doxycycline (oracea). Add isotretinoin if ineffective.

Note:

Side effects of doxycycline: phototoxicity, discoloration of the milk teeth and enamel hypoplasia. Decrease dose in liver dysfunction.



Scabies

  • Parasitic infection caused by mites, sarcoptes scabiei. It is characterized by superficial burrows, intense pruritus and secondary infections.

  • Rashes are found in web spaces between fingers and toes, at elbows or near the genitals. The infection often does not affect the scalp

  • Transmitted through skin-to-skin contact

  • Apply Elimite (Permethrin cream) from the neck down, usually before bedtime and leave it for about 8 to 14 hours; then washed off in the morning.

  • For patients with AIDS, the combination of Permethrin and Ivermectin is recommended.

  • One application is often sufficient for mild infections.

Tinea capitis

  • Superficial fungal infection of the scalp

  • Circular or ring patches of hair loss (alopecia)

  • One or more lesion present on the body surface, typically annular with an elevated red, scaly border, tendency for central clearing.

  • Patient may have a history of exposure to a cat or dog.

  • Use oral terbinafine (Lamisil) for 4 to 8 weeks.

Tinea cruris (jock itch)


  • It is a fungal infection of the groin.

  • Sweat is important in pathogenesis.

  • The rash begins in the groin fold, usually on both sides. The area may enlarge and other sores may develop. The rash has sharply defined borders that may blister and ooze.



  • Use topical antifungal medication from azole type such as miconazole (Monistat), clotrimazole (lotrimin) or from allylamine type such as terbinafine 1% cream (Lamisil) once daily for 7 days

  • Minimizing damp conditions can help treat and prevent the rash.

  • Steroids (such as 1% triamcinolone cream) may be combined with the anti-fungal drug to help prevent further irritation.

Tinea unguium (nail; onychomycosis)

  • Dermatophyte infection affecting the nails.

  • The nail is frequently discolored.

  • Oral therapy includes terbinafine (Lamisil) or itroconazole. At least 6 weeks for fingernails and 12 weeks for toenails.


Note:

Terbinafine is hepatotoxic. Check liver function periodically.



Tinea versicolor

  • Caused by the malassezia fungus.

  • Skin infection characterized by multiple, brown (hyper pigmented), or white (hypo pigmented) scaling macular lesions that tend to coalesce. Found on chest, abdomen, neck or face.

  • Diagnostic: skin scrapings examined with KOH under a microscope: spaghetti (short hyphae) and meatballs (yeast).

  • Use oral antifungal medications; 400 mg of ketoconazole (best treatment) or fluconazole in a single dose, or ketoconazole 200 g daily for 7 days.

  • Use topical antifungal medication containing 2.5 % selenium sulfide if the rash is localized.

  • Use Ketoconazole (Nizoral ointment and shampoo): it is normally applied to dry skin and washed off after 10 minutes, repeated daily for 2 weeks.

  • Terbinafine (Lamisil cream) can also be used.

Note:

The skin may remain discolored for several weeks or months following treatment.



Note:

Oral Vitamin A derivatives are extremely teratogenic (craniofacial, central nervous system, and cardiovascular defects). Do a pregnancy test first. Only treat patients on suitable hormonal and barrier birth control. Isotretinoin causes hyperlipidemia


Class of topical steroids:


Class 1

Very potent or superpotent (up to 600 times as potent as hydrocortisone)

  • Clobetasol propionate (Dermol™ cream/ointment/scalp lotion)

  • Betamethasone dipropionate (Diprosone™ OV cream/ointment)

Class 2

Potent (100-150 times as potent as hydrocortisone)

  • Betamethasone valerate (Beta™ cream/ointment/scalp solution, Betnovate™ lotion/C cream/C ointment, Fucicort™ cream)

  • Methylprednisolone aceponate (Advantan™ cream/ointment)

Class 3

Moderate (2-25 times as potent as hydrocortisone)

  • Clobetasone butyrate (Eumovate™ cream)

  • Triamcinolone acetonide (Aristocort™ cream/ointment, Viaderm KC™ cream/ointment, Kenacomb™ ear drops)

Class 4

Mild

  • Hydrocortisone (DermAid™ cream/soft cream)


Vehicles of topical steroids


  • Lotions are easy to apply

  • Creams rub in well

  • Ointments may be most effective for dry lesions

  • Gels and solutions are useful in hairy areas or for a drying effect

sedating antihistamines

Non-sedating antihistamines

Diphenhydramine (Benadryl)

Cetirizine (Zyrtec)

Promethazine (Phenergan)

Fexofenadine (Allegra)

Hydroxyzine (Atarax, Vistaril)

Loratadine (Claritin)

Cyproheptadine (Perlactin)

Desloratadine (Clarinex)

Clemastine (Tavist)





http://www.mayoclinic.org/~/media/kcms/gbs/patient%20consumer/images/2013/08/26/10/02/ds00464_im00400_sn7_impetigo_jpg.ashx

Impetigo

http://www.herpeszostertreatment.net/wp-content/uploads/2014/06/herpeszoster.jpg

Herpes zooster

http://ultimatepsoriasisprogram.com/wp-content/uploads/2015/04/psoriasis-male.jpghttp://www.healthline.com/hlcmsresource/images/psoriasis/sp_s_3.jpg

Psoriasis

http://www.globalskinatlas.com/upload/lg50_2.jpg

Scabies

Tinea cruris

http://www.huidziekten.nl/afbeeldingen/dermatomycosis-corporis-2.jpg

http://img.medscapestatic.com/pi/meds/ckb/50/28550tn.jpg

Tinea capitis



http://i.ytimg.com/vi/0hxj1a9g73y/maxresdefault.jpg

Acne Vulgaris



http://www.patienthelp.org/wp-content/uploads/2013/11/pityriasis-rosea-images.jpg

Pityriasis Rosea



http://hardinmd.lib.uiowa.edu/pictures22/dermnet/seborrheic_dermatitis_21.jpg

Seborrheic dermatitis



Clinical vignettes

  1. A 17 year-old boy comes to the physician because of a 4-year history of facial lesions. He says that some lesions begin as painful “bumps”, whereas others look like “pimples” and large pores. His medical history is

  2. unremarkable and he takes no medications. He drinks occasionally on weekends. He denies illicit drug use. He is sexually active and he uses condoms consistently. His temperature is 36.9C (98.4 F). The examination shows open and closed comedones. Numerous deep inflammatory nodules and ice pick-like scarring. What is the most appropriate pharmacotherapy for this patient’s condition?

  1. Oral acitretin

  2. Oral isotetinoin

  3. Oral minocycline

  4. Oral prednisone

  5. Oral spironolactone

  6. Topical tazarotene/benzoyl peroxide.



  1. A 32 y o woman comes to the physician because of a red rash on her cheeks, nose, and forehead for 1 year. She has had facial flushing and redness and occasionally small pimples. She states that the rash is worsened by sun exposure and drinking hot beverages. She has had dryness and stinging in her eyes for the past 3 months. Her medical history is unremarkable and she takes no medications. Temp. 36.8 C (98.2) and BP 115/70. Examination shows mild erythema and telangiectasias over the malar cheeks, nasal sidewalls, and forehead; there are few pustules. The lid margins are erythematous with mild crusting. Which of the following is the most likely diagnosis?

  1. Acne vulgaris

  2. Dermatomyositis

  3. Rosacea

  4. Sjoegren syndrome

  5. Systemic lupus erythematosus



  1. A 40 yo woman comes to the physician because of a 1-month history of a progressive, light-colored rash on her chest that has been spreading rapidly. Her medical history is unremarkable and she takes no medications. She recently started working as a cook in a local fast-food restaurant. Her husband and 2 school-aged children are in good health. Before that, she was a homemaker. Temp36.8 C (98.2 F), BP 114/76, Pulse 74/min, and respirations 14/min. Examination shows well demarcated, slightly scaly hypopigmented patches. The remainder of the examination shows no abnormalities.

Which of the following is the most appropriate next step in management?

  1. Monospot test

  2. Potassium hydroxide preparation

  3. Skin biopsy

  4. Skin culture

  5. Tzanck smear



  1. A 20 yo college student comes to student health services because of an itchy rash for 6 days that began as a large red mark and then spread to her back, upper arms, and thighs. She had a sore throat 2 weeks ago that lasted 4 days. She denies fever, vaginal discharge, abdominal pain, back pain, or joint pain. Current medications include OCP. She is sexually active and she and her partner use condoms inconsistently. Examination shows multiple pink oval patches on the back, proximal upper extremities, and proximal lower extremities. There is no lymphadenopathy. Which of the following is the most likely diagnosis?

  1. Acute HIV reaction

  2. Herpes zoster

  3. Lyme disease

  4. Pityriasis rosea

  5. Pityriasis versicolor

  6. Secondary syphilis



  1. A 71 yo man comes to the physician because of a 2 days history of painful rash. He has had no fevers, chills, or weight loss. His past medical history is unremarkable. He lives with his cousin who has AIDS. Temp 37.2 C (99.0 F). Examination shows an eruption of grouped vesicles on an erythematous base in the TH5 dermatomal distribution. There is no lymphadenopathy. Lab studies show Hb 14, MCV 90 , leucocyte count 11.500, platelet count 350.000. Which of the following is the most appropriate pharmacotherapy?

  1. Amitriptyline and gabapentin

  2. Dexamethasone

  3. Emtricitabine, tenofovir, and efavirenz

  4. Ganciclovir

  5. Valacyclovir



  1. A 14 yo girl is brought to dermatologist by her mother because of acne. The girl reports worsening of the lesions despite usage of an over-the-counter topical acne treatment. Examination shows open and closed comedones, especially on the forehead. In addition, there are some comedones and many papules and large pustules on the chin, in the nasolabial folds, and on the cheeks. There are a few lesions on the upper back, but none seen on the chest or deltoid regions. Which of the following is the most appropriate pharmacotherapy?

  1. Isotretinoin

  2. Oral doxycycline plus topical retinoid

  3. Topical azelaic acid

  4. Topical benzoyl peroxide plus clindamycin gel.

  5. Topical adapalene



  1. A previously healthy 17-year-old girl comes to the physician because of a 1-week history of itching and progressive rash. She has no history of skin problems or associated symptoms. She takes no medications. Her sister with whom she shares a room had similar symptoms during the previous week. The patient's temperature is 36.8°C (98.2°F). There are multiple 2- to 5-mm erythematous papules over the trunk, especially at the waistline, and over the , hands, and fingers. There is no lymphadenopathy or hepatosplenomegaly. Which of the following is the most likely causal organism?

  1. Epstein-Barr virus

  2. Group A streptococcus

  3. Measles virus

  4. Sarcoptes scabiei

  5. Zoster virus

  1. A 6-year-old girl is brought to the physician because of a 1-month history of a recurrent pruritic rash on her arms. She was born at term and has been healthy except for an episode of bronchiolitis 6 months ago treated with albuterol. The examination shows a dry skin and eczema on the flexor surface of the elbows bilaterally. Which of the following is the most appropriate next step in management?

  1. Coal tar therapy

  2. Oral antibiotic therapy

  3. Topical antibiotic therapy

  4. Topical corticosteroid therapy

  5. Vitamin supplementation

9. A 56 yo man has had a painful weeping rash on the right side of the forehead for 2 days. He underwent chemotherapy for non-Hodgkin lymphoma 1 year ago. His temperature is 36.7°C (98°F), pulse is 80/min, and blood pressure is 138/76 mm Hg. Examination shows no other abnormalities. Which of the following is the most likely diagnosis?

  1. Herpes zoster

  2. Impetigo

  3. Pyoderma gangrenosum

  4. Syphilis

  5. Systemic lupus erythematosus

10 . The first line of treatment recommended for contact of crusted scabies is:

  1. Permethrin

  2. Lindane

  3. Ivermectin

  4. Benzoyl benzoate

11. Seborrheic dermatitis (dandruff) is commonly associated with two diseases. Which one?

12. Is the poison ivy rash contagious between people?

Yes or No.

13. What kind of topical steroids do you prescribe for eczema of the face?



  1. Low potency

  2. Medium potency

  3. High potency

14. Give an example of a low potency, medium potency and high potency hydrocortisone?

15. Give two side effects of doxycycline.

16. What should the physician do before prescribing oral vitamin A derivatives such as isotretinoin?

17. What should you do as a physician before prescribing terbinafine to a patient?

18. What is the 1st and 2nd line treatment of a super infection of impetigo with community acquired MRSA?

19. In which patients should you avoid sulfa drugs?

20. Give one side effect of acyclovir. How do you prevent it?

Answers:


1.B

2.C


3.B

4.D


5.E

6.B


7.D

8.D


9.A

10.A


11. Parkinson disease and AIDS

12.No.


13.A

14. Hydrocortisone (DermAid cream), Clobetasone butyrate (Eumovate™ cream) , Betamethasone dipropionate (Diprosone cream/ointment.

15. Photosensitivity and discoloration of milk teeth.

16. Exclude pregnancy by doing a pregnancy test. PT should be on table hormonal and barrier birth control.

17. Check liver function.

18. 1st line Bactrim. 2nd line: doxycycline.

19. Sulfa drugs allergy, G6PD deficiency

20. Crystalluria (crystal nephropathy). Full hydration.


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