Pigmented/Scaly Dermatoses

Question 1

• General: benign papules and plaques, beige to brown or even black, 3–20 mm in diameter, with a velvety or warty surface
• They appear to be stuck or pasted onto the skin.
• They are extremely common—especially in the elderly—and may be mistaken for melanomas or other types of cutaneous neoplasms.
• “barnacles”
• Location: face, scalp, trunk, arms and back

Answer 1

Seborrheic Keratosis

Diff: Never have just one so look for melanoma–rare before age 30

• a lot appearing quickly is a sign of Lesser Trelat or organ malignacy

Tx: frozen with liquid nitrogen or curetted if they itch or are inflamed, no treatment is needed.

Question 2

• may be flat or raised, expect this in any pigmented skin lesion that has changed, varied color, borders irregular
• Irregular notched border where the pigment appears to be spreading into the normal surrounding skin
• “Asymmetry, Border Irregularity, Color Variegation, and Diameter”
• changing mole (evolution) is most important reason to watch
• ”ugly duck”

Answer 2

Malignant Melanoma

Tx: Excision, lymph biopsy in pts with lesions over 1 mm or high risk features

Prog: tumor thickness tells us this

Question 3

S/S: often none, itching maybe

• Red, sharply defined plaques covered with silvery scales
• Stippling “pitting” in nails
• Pink or red inter-gluteal fold

Loc: scalp, elbows, knees, palms and soles, and nails

• Glans penis and vulva maybe

Answer 3

Psoriasis

• Diff: red plaque with silver scles on elbows and knees, with scaliness in scalp or nail findings
  
  • Differ from intertrigo and candidiasis via culture
  • KOH to rule out fungal
• Tx: topical steroids and light therapy (UVB)
• Prog: chronic and unpredictable, can be resistant to treatment

Question 4

S/S: itching is key

• Ill-defined, scaly, red plaques
• Scaling and fissuring may come after blisters
• Lichenification, can be in only one area
• Loc: face, neck, upper trunk, flexural surfaces of elbows and knees
• Diff: increased IgE and Eosinophilla

Answer 4

Atopic dermatitis/Exsema

Tx: gentle skin care, corticosteroids topically

Question 5

• Gen: represents a self-perpetuating scratch-itch cycle that is hard to disrupt.
• S/S: Dry, hypertrophic, lichenified plaques appear on the neck, ankles, or perineum
• Itching may be so intense as to interfere with sleep
  
  • only itches because they scratch it
• patches are rectangular, thickened, and hyperpigmented

Answer 5

Lichen Simplex Chronicus

Diff:

• Psoriasis-redder lesions having whiter scales on the elbows, knees, and scalp and nail findings
• lichen planus-violaceous, usually smaller polygonal papules

Tx: topical corticosterioids, tape

Question 6

Gen: malassezia (yeast) infection

S/S: Lesions are asymptomatic

• Velvety, tan, pink, white macules from 4mm to 5mm to large confluent areas
• Doesn’t look scaly right away, but when scrape they come out

Lab: Large, blunt hyphae and thick walled budding spores are seen on KOH

Loc: Trunk, upper arms, neck and groin

Answer 6

Tinea Versicolor

• Diff: Vitiligo usually presents with larger periorificial and acral lesions and is also characterized by total depigmentation
  
  • KOH to differentiate from seborrheic dermatitis
• Tx: OTC selenium sulfide lotion, Rx ketoconazole shampoo, cicloprox shampoo, oral azole treatment
  
  • Use these shampoos as body wash

Question 7

• S/S: Herald patches “red patch” precedes eruption by 1-2 weeks-these are larger lesions
• Occasional mild pruritus
• Centers of the lesions have a crinkled or “cigarette paper” appearance and a collarette scale (thin scale bound at periphery and free in the center
• Loc: involves trunk and proximal extremities
• Christmas tree back pattern

Answer 7

Pityriasis Rosea

• Diff: Serologic test for syphilis
  
  • Tinea corpis- but this usually only has a few lesions
  • KOH to exclude fungal
• Prog: eruption usually lasts 6-8 weeks and heals without scarring, acute self-limiting
• Tx: often requires no treatmentàUVB if bothersome
  
  • In dark pigmented individuals you might want to treat because they stay hyper-pigmented for some time
  • Treatment is only there if patient is symptomatic
  • Severe: UVB, prednisone (corticosteroid)
  • Mild to moderate: topical corticosteroids and oral antihistamines if itching

Question 8

Gen: small (0.2–0.6 cm) macules or papules

• Flesh-colored, pink, or slightly hyperpigmented
• Feel like sandpaper and are tender when the finger is drawn over them.
• Occur on sun-exposed parts of the body in persons of fair complexion.

Answer 8

Actinic Keratoses

Tx: Application of liquid nitrogen is a rapid method of eradication.

• lesions crust and disappear in 10–14 days

Prog: Considered premalignant, but only 1:1000 lesions per year progress to become squamous cell carcinomas.