Common Dermatologic Issues in the Geriatric Population Steve

Common Dermatologic Issues in the Geriatric Population Steve Marchenko, Janelle Pavlis and Kristen M. Kelly, M. D. University of California, Irvine

• Objectives: q. List dermatologic diseases commonly seen in the elderly q Identify terms used to describe dermatologic lesions and/or rashes q. Identify treatment options for common dermatologic conditions seen in the elderly

Approach to Making Dermatologic Diagnoses • Obtain Focused History q Time/duration/change over time, initial site and spread/symptoms q General health, occupation, family history, medications, previous treatments, allergies • Characterize morphology of basic lesion q Primary-original lesion q Secondary-changes to lesion over time q Characterize shape, color, texture, & arrangement of the lesions • Determine distribution of lesions q Lesion distribution often provides important diagnostic clues

Approach to Making Dermatologic Diagnoses • Diagnostic Testing to consider q Shave, punch biopsy q KOH for fungal infections q Gram stain for bacterial infections q Tzanck preparations for herpetic infection (shown) q Oil mount of skin scrapings for scabies infection Image courtesy of www. visualdx. com © Logical Images, Inc Victor Newcomer, MD (UCLA). (Jan 2006). Herpetic Whitlow [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=50694&image. Index=11

Defining Skin Lesions q A primary lesion is the initial lesion that characterizes a dermatologic disorder q Being able to recognize primary skin lesions is critical in making the correct diagnosis q Over time, primary lesions may continue to develop or be modified, producing secondary lesions q Keep in mind, when examining a patient: • The primary lesion may have evolved • Any combination of primary and secondary lesions may be present

Primary Skin Lesions Lesion Description Example Macule Circumscribed, flat, <0. 5 cm (centimeter) freckle (ephelis) Patch Macule >0. 5 cm vitiligo Papule Elevated, solid lesion <0. 5 cm molluscum contagiosum Plaque Elevated, plateau-like lesion without substantial depth psoriasis Note multiple hyperpigmented macular lesions and a single patch found in this patient with neurofibromatosis type 1. A papule is seen above the patch. *the definition of these lesions vary by the dermatology reference, but usually is 0. 5 -1. 0 cm. Image courtesy of www. visualdx. com © Logical Images, Inc (NYU, Department of Dermatology). (Dec 2004). Neurofibromatosis [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52014& Image. Index=0

Primary Skin Lesions Lesion Nodule Wheal Vesicle Bulla Pustule Description Example Elevated, solid lesion >0. 5 cm with some depth rheumatoid nodule Firm, edematous plaque hives Circumscribed, elevated lesion with free fluid, Varicella <0. 5 cm Vesicle >0. 5 cm Bullous pemphigoid Circumscribed, elevated lesion with purulent material acne

Primary Skin Lesions Image courtesy of www. visualdx. com © Logical Images, Inc Note multiple pustulo-vesicles and plaques in a patient with subcorneal pustular dermatosis (University of Rochester, Department of Dermatology). Sneddon-Wilkinson Subcorneal Pustulosis. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=8&diagnosis. Id=52332&image. Index=5

Secondary Skin Lesions q Scale: White, dry flakes (e. g. dermatophyte infection) q Crust: A “scab” formed from dried serum, blood or exudate on skin (e. g. impetigo) q Erosion: Focal loss of epidermis not extending below dermal/epidermal junction; heals without scarring (e. g. following blister rupture)

Secondary Skin Lesions Image courtesy of www. visualdx. com © Logical Images, Inc In this patient with pemphigus, superficial blisters have ruptured and formed crusted erosions and scales (NYU, Department of Dermatology). Pemphigus Foliaceus. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52136&image. Index=0

Secondary Skin Lesions q Ulcer: Focal loss of epidermis & dermis extending into hypodermis; heals with scarring (e. g. decubitus ulcer) q Fissure: Linear loss of epidermis (+/-) dermis (e. g. “chapping” of fingers) q Lichenification: Area of thickened epidermis with accentuated skin lines due to chronic rubbing (e. g. long standing atopic dermatitis)

Benign Skin Growths q Benign skin growths are common, especially in older individuals q It is important to differentiate these lesions from skin cancer q A clinician should try to categorize any skin lesion as: • Most likely benign, most likely malignant, or unclear • The last 2 categories should be biopsied q Examples of common benign lesions include: • Seborrheic keratoses and cherry angiomas

Benign Skin Growths Seborrheic Keratoses (SKs) SKs are the most common benign tumor in the elderly • Clinical: q Brown or black raised, waxy spots or wart-like growths that appear “stuck-on” q Represent benign thickening of epidermis • Epidemiology: q Incidence increases with age and tendency to develop SKs can be inherited Image courtesy of www. visualdx. com © Logical Images, Inc Tindall JP, Smith JG Jr. Skin lesions of the aged and their association with internal changes. JAMA. Dec 21 1963; 186: 1039 -42 Victor Newcomer, MD (UCLA). (Aug 2006). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=51808&image. Index=1

Benign Skin Growths • Management of SKs: q. Always differentiate from cancer – can be confused with pigmented basal cell carcinoma, melanoma • SKs appear as multiple lesions q Managed with cryotherapy, curettage or shave biopsy if they become irritated or for cosmetic reasons Image courtesy of www. visualdx. com © Logical Images, Inc (University of Rochester, Department of Dermatology). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2001, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=51808&image. Index=8

Benign Skin Growths Cherry Angiomas q Benign dome-shaped capillary proliferations. q Usually appear in individuals over 35 on arms and trunk and tend to bleed when injured. q Successfully treated with laser or electrocautery Image courtesy of www. visualdx. com © Logical Images, Inc (NYU, Department of Dermatology). Cherry Hemangioma. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=11&diagnosis. Id=51676&image. Index=4

Pre-cancerous Skin Growths Actinic Keratoses • Clinical: q Ill-marginated, reddish, papules with rough, adherent scale q More easily felt than seen q Can involute or persist q Occur on sun-exposed areas as a result of cumulative UV damage q Precursors to squamous cell carcinomas (up to 10% may advance to SCC) Image courtesy of www. visualdx. com © Logical Images, Inc Criscione, VD, Weinstock, MA, Naylor, MF, Luque, C, Eide, MJ and Bingham, SF. Actinic keratoses natural history and risk of malignant transformation in the Veterans Affairs Tropical Tretinoin Chemoprevention Trial. Cancer 2009; 115: 2523 -2530 (University of Rochester, Department of Dermatology). Actinic Keratosis. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=51805&image. Index=5

Actinic Keratoses • Differential Diagnosis: q Squamous cell carcinoma, SK, superficial basal cell carcinoma • Management: q Depends on number of lesions and area of involvement q For few localized lesions, cryotherapy with liquid nitrogen q For multiple, widespread lesions treatment options include: q Photodynamic therapy q Chemical Peels q Topical antineoplastic agents Examples include • 5 -Fluorouracil (5 -FU) Cream • Imiquimod Cream

Skin Cancer q Skin cancer is the most common of all human cancers • It is diagnosed in more than 1 million people in the United States each year q Skin cancers are of three major types: • Basal cell carcinoma (BCC), squamous cell carcinoma (SCC) and melanoma q The majority of skin cancers are BCCs or SCCs • Although metastatic rate is low, may be locally destructive and disfiguring if not treated early • Solar UV radiation is responsible for the majority of BCCs and SCCs Rogers, HW, Weinstock, MA, Harris, AR, et al. Incidence estimate of nonmelanoma skin cancer in the United States, 2006. Arch Dermatol 2010; 146(3): 283 -287.

Skin Cancer Squamous Cell Carcinoma (SCC) • Epidemiology q Second most common skin cancer q Most frequently affects Caucasians with extensive sun exposure • Risk factors q Chronic environmental damage • UV/ionizing radiation • Tobacco • Arsenic exposure q History of actinic keratoses q HPV infection 6, 11, 16, 18 q Chronic immunosupression Image courtesy of www. visualdx. com © Logical Images, Inc Charles E. Crutchfield III, MD. (Nov 2007). Squamous Cell Carcinoma. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=11&diagnosis. Id=52735&image. Index=0

Skin Cancer Squamous Cell Carcinoma • Clinical q A scaly patch or warty growth that may crust, bleed, and ulcerate q Frequently develops on sun-exposed areas or at sites of chronic injury, e. g. , chronically draining sinuses or burns q Some types have greater metastatic potential than basal cell carcinoma • Management q Excision with margins q Mohs micrographic surgery in cosmetically sensitive areas Image courtesy of www. visualdx. com © Logical Images, Inc (University of Rochester, Department of Dermatology). (Augu 2009). [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=11&diagnosis. Id=52735&image. Index=42

Skin Cancer Basal Cell Carcinoma (BCC) • Epidemiology q Most common human malignancy q 800, 000 new cases every year in US • Risk factors q Skin type 1 q Blistering sunburns in childhood q Family history of skin cancer q Immunosuppression Image courtesy of www. visualdx. com © Logical Images, Inc Nodular BCC (NYU, Department of Dermatology). Basal Cell Carcinoma, Nodular. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=11&diagnosis. Id=51167&image. Index=0

Basal Cell Carcinoma Clinical Several subtypes are described • Nodulocystic: Øsingle shiny, red nodule w/ telangiectasia • Superficial: Øleast aggressive Ø erythematous plaques Øcan mimic psoriasis • Sclerotic/Morpheiform: Ø most aggressive Ø 5% of all BCC’s. ØIll-defined borders • Pigmented Superficial ØShiny, blue-black papule, speckled pigment, rolled borders. Image courtesy of www. visualdx. com © Logical Images, Inc Charles E. Crutchfield III, MD. (Jan 2007). Basal Cell Carcinoma, Superficial. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=11&diagnosis. Id=52756&image. Index=16 BCC

Skin Cancer Basal Cell Carcinoma • Management q. Depends on location, size, histopathology, and patient factors q. Very low risk/superficial: consider curettage + topical 5 -FU or imiquimod q. Most low risk lesions: curettage and electrodessication q. For higher risk or recurrent BCC: excision with margins or Mohs micrographic surgery q. Elderly patients or those in whom surgery contraindicated: consider radiation.

Basics of Dermatologic Surgery • Cryosurgery • Electrodessication and curettage • Excision • Mohs Micrographic Surgery

Basics of Dermatologic Surgery Cryosurgery q Liquid nitrogen -195. 8º C q To produce adequate treatment, tissue temperature -50º C is needed q Fast freeze, slow thaw ; generally 2 cycles q PROS: cost effective, no surgery, minimal equipment q CONS: no specimen for evaluation, skin discoloration may occur and may be permanent (especially in tanned skin or patients with darker skin types)

Basics of Dermatologic Surgery Electrodessication and Curettage q Only indicated for low-risk lesions q PROS: minimal blood loss, ease, convenience for the patient q CONS: no specimen for pathology, clinician experience influences cure rate Images courtesy of Margaret Mann, M. D.

Basics of Dermatologic Surgery Excision q PROS • Shorter procedure time • Closure performed at the same time • Less expensive q Margins depend on lesion Leffell DJ, Brown MD, eds. Basic excisional surgery. In: Manual of Skin Surgery: A Practical Guide to Dermatologic Procedures. 1997. New York, NY: Wiley-Liss; 149 -80.

Basics of Dermatologic Surgery Mohs Micrographic Surgery • Indications: q Recurrent or incompletely excised BCC or SCC q Primary BCC or SCC with indistinct borders q Lesions located in high-risk or cosmetically and functionally important areas (e. g. face) q Tumors with aggressive clinical behavior (i. e. , rapidly growing, >2 cm in diameter) or aggressive histologic subtype q Tumors arising in sites of previous radiation therapy q Tumors arising in immunosuppressed patients

Basics of Dermatologic Surgery • Advantages: Mohs Micrographic Surgery q Low risk of recurrence q Exceptionally high cure rates q Designed to remove tumor with smallest possible margins • Disadvantages: q Surgical risks q Requires special equipment and technician q More technically difficult q Not optimal for all tumors

Basics of Dermatologic Surgery Mohs Micrographic Surgery • Step 1: Clinical examination and determination of visible margins • Step 2: Visible tumor is surgically removed • Step 3: A layer of skin is removed and divided into sections, which are color coded with dyes; reference marks made on skin for orientation; map of surgical site drawn • Step 4: Undersurface and edges of each section are microscopically examined for evidence of remaining cancer Image courtesy of American College of Mohs Surgery The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http: //www. skincancermohssurgery. org/mohs-surgery/mohsprocedure. php

Basics of Dermatologic Surgery Mohs Micrographic Surgery • Step 5: If residual cancer is seen under the microscope, surgeon marks location on map and returns to patient to remove another layer of skin where cancer cells remain • The removal process stops when there is no longer any evidence of cancer remaining in the surgical site Image courtesy of American College of Mohs Surgery The Mohs Surgery Procedure. Step-by-Step Process. [illustration]. Retrieved Oct 3, 2011, from http: //www. skincancermohssurgery. org/mohs-surgery/mohsprocedure. php

Drug Eruptions • Epidemiology q. Drug eruptions are a frequent cause of skin lesions in the elderly population q. Drug eruptions occur in approximately 2 -5% of inpatients and in greater than 1% of outpatients q Older patients have an increased prevalence of drug eruptions due to high incidence of polypharmacy and decreased kidney function Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331: 1272

Drug Eruptions • Etiology q. Often classified as immune and non-immune • Immune: type I, III IV hypersensitivity reactions • Non-immune: cumulative toxicity, overdose, photosensitivity, drug interactions, and metabolic alterations q A drug reaction should be considered in any patient on medication with acute onset of an eruption (usually symmetric) Roujeau, JC, Stern RS. Severe adverse cutaneous reactions to drugs. N Engl J Med 1994; 331: 1272

Drug Eruptions • Common morphologies: qmorbilliform (95%) and urticarial (5%) q. Less common morphologies include: pustular, bullous and papulosquamous q. Drug reactions can also cause pruritis without an obvious eruption Image courtesy of www. visualdx. com © Logical Images, Inc Morbiliform eruption • Drugs most commonly implicated: qantimicrobial agents, nonsteroidal antiinflammatory drugs (NSAIDs), cytokines, chemotherapeutic agents, anticonvulsants, and psychotropic agents Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7 th ed. New York, NY: Mc. Graw-Hill; 2008: 355 -362

Drug Eruptions Drugs commonly implicated in each type of reaction Urticaria Morbilliform rash Lichenoid rash Cutaneous Vasculitis Antibacterial, nonsteroidal antiinflammatory drugs, antidepressants, opioids, imidazoles Antibacterial (penicillin, sulfonamides), anticonvulsants, gold, allopurinol, diuretics Antimalarials, gold, β-blockers, diuretics, sulfonylureas, hypoglycemic agents Diuretics (furosemide, thiazides), antibacterials, allopurinol, amiodarone Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209: 131 Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7 th ed. New York, NY: Mc. Graw-Hill; 2008: 355 -362

Drug Eruptions Drugs commonly implicated in each type of reaction Photosensitivity Drug-induced autoimmune rash Stevens Johnson Toxic Epidermal Necrolysis Amiodarone, phenothiazines, sulfonamides, tetracyclines, nonsteroidal antiinflammatory drugs Penicillamine, hydralazine, gold Anti-gout agents (allopurinol), NSAIDS, antibiotics, anticonvulsants Yawalkar N. Drug-induced exanthems. Toxicology 2005; 209: 131 Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7 th ed. New York, NY: Mc. Graw-Hill; 2008: 355 -362

Drug Eruptions • Benign drug reaction q Most patients with a drug eruption complain only of itching q Most drug eruptions are mild, self-limited, and usually resolve after the offending agent has been discontinued q Look for: absence of systemic manifestations and normal lab values • Warning signs of a more serious reaction q q q q Skin pain, skin necrosis Fever Conjunctivitis or mucous membrane involvement Blisters Angioedema Palpable purpura Elevated BUN/creatinine or liver function tests Shear NH, Knowles SR, Shapiro L. Cutaneous reactions to drugs. In: Fitzpatrick TB, Wolff K, eds. Fitzpatrick’s Dermatology in General Medicine. 7 th ed. New York, NY: Mc. Graw-Hill; 2008: 355 -362

Drug Eruptions Erythema Multiforme (EM) Target lesions q EM is a spectrum of diseases ( EM minor, EM major) q EM Minor (less often due to a drug eruption) • May be due to infection (e. g. herpes simplex virus) • Characterized by target lesions distributed predominantly on the distal extremities (including palms/soles) • Mucous membrane involvement may occur but is not severe • Patients recover, but relapses are common Image: Lee T Nesbitt, Jr. The Skin and Infection: A Color Atlas and Text, Sanders, CV, Nesbitt, LT Jr (Eds), Williams & Wilkins, Baltimore 1995. Auquier- Dunant A, Mockenhaupt M, Naldi L, et al. Correlations between clinical patterns and causes of erythema multiforme majus, Stevens-Johnson syndrome, and toxic epidermal necrolysis; results of an international prospective study. Arch Dermatol 2002; 138: 1019.

Erythema Multiforme Major q. Severe drug reaction requiring immediate medical attention q. Subcategories include: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) q. Characterized by epidermal necrosis and sloughing of the mucous membranes and skin q. In SJS, lesions affect less than 10 % of the body surface; In TEN, greater than 30% affected Victor D. Newcomer, MD (UCLA). Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52413&image. Index=29 Image courtesy of www. visualdx. com © Logical Images, Inc

Drug Eruptions Erythema Multiforme Major • Etiology: q Not completely understood q 80% of cases associated with adverse drug reaction Image courtesy of www. visualdx. com © Logical Images, Inc Victor D. Newcomer, MD (UCLA). Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52413&image. Index=29

Erythema Multiforme Major • Presentation q Prodrome of fever, malaise and pain (often like a sunburn) q Primary lesions include dusky red macules of irregular size that start on the trunk and spread q Always screen for mucosal symptoms including: painful eyes, painful swallowing, dysuria and diarrhea q Ocular, oral, and genital mucosa are affected in >90% of cases • Mortality q Varies with type q SJS 1 -5% mortality; TEN carries a 25 -30% mortality Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev. 2008 Sep; 7(8)598 -605.

Drug Eruptions • Work-up q. Consider alternative etiologies, e. g. viral exanthems and bacterial infections q. Take a good medication history • Review the complete medication list, including overthe-counter supplements • Note the interval between the introduction of a drug and onset of the eruption • Patients can develop drug eruptions to medications they have been on for prolonged periods • Document any history of previous adverse reactions to drugs or foods

Drug Eruptions • Work-up q. Biopsy can be helpful in confirming the diagnosis (e. g. , by showing eosinophils in morbilliform eruptions) q. CBC with diff, Liver function tests, immunoserology tests may be ordered for suspected drug induced autoimmune rash, cultures if infection is suspected

Drug Eruptions • Treatment of Common Drug Eruption q Stop all non-essential meds (for >1 month) q Monitor for signs of systemic involvement or SJS/TEN q Therapy for most drug eruptions is mainly supportive • Morbilliform eruptions can be treated with oral antihistamines and topical steroids • Prednisone may be used cautiously in the treatment of hypersensitivity syndrome with heart and lung involvement or severe serum sickness–like reaction q Slowly re-introduce other medications after suspected agent is identified French LE, Trent JT, Kerdel FA. Use of intravenous immunoglobulin in toxic epidermal necrolysis and Stevens-Johnson syndrome: our current understanding. Int Immunopharmacol. Apr 2006; 6(4): 543 -9.

Erythema Multiforme Major • Treatment of Erythema Multiforme Major q Transfer to a burn unit with aggressive supportive care is the most critical step in management q Consultation with Dermatology and Ophthalmology q Rapid identification and withdrawal of offending drug improves survival q IVIG may be indicated; efficacy is controversial Image courtesy of www. visualdx. com © Logical Images, Inc Borchers AT, Lee JL, Naguwa SM, Cheema GS, Gershwin ME. Stevens-Johnson syndrome and toxic epidermal necrolysis. Autoimmun Rev. 2008 Sep; 7(8)598 -605. Robert Chalmers, MD. Toxic Epidermal Necrolysis. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52413&image. Index=12

Other Dermatologic Conditions in the Geriatric Population q Several dermatologic conditions have a higher incidence in the geriatric population q Examples include: • • Herpes Zoster Bullous Pemphigoid Venous Stasis Sun - induced skin changes

Herpes Zoster • Etiology q Reactivation of Varicella Zoster Virus • Clinical Image courtesy of www. visualdx. com © Logical Images, Inc q Prodrome of radicular pain & pruritus followed by skin eruption consisting of grouped vesicles on erythematous base in dermatomal distribution q Postherpetic neuralgia may follow causing debilitating pain in the affected dermatome (University of Rochester, Department of Dermatology). Zoster. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52552&image. Index=4

Herpes Zoster • Diagnosis q Typically clinical. Can also perform Tzanck smear, viral culture, or direct immunofluorescence Image courtesy of www. visualdx. com © Logical Images, Inc Victor Newcomer, MD (UCLA). (Jan 2006). Herpetic Whitlow [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=50694&image. Index=11

Herpes Zoster • Prevention q Zostavax – live herpes zoster vaccine q Reduces Shingles by 51. 3% Image courtesy of www. visualdx. com © Logical Images, Inc q Reduces cases of postherpetic neuralgia by 66. 5% Oxman MN, Levin MJ et al. A vaccine to prevent herpes zoster and postherpetic neuralgia in older adults. N Engl J Med. 2005 Jun 2; 352(22): 2271 -84. Nancy Esterly, MD. Zoster. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52552&image. Index=8

Herpes Zoster • Treatment Image courtesy of www. visualdx. com © Logical Images, Inc q Best if initiated within 72 hours of start of symptoms q Antivirals: Acyclovir, Valcyclovir or Famciclovir q Supportive: pain control, sedatives, moist dressings to affected skin q Use of gabapentin may reduce the incidence of post-herpetic neuralgia Lapolla W, Di. Giorgio C, Haitz K et al. Incidence of portherpetic neuralgia after combination treatment with gabapentin and valacyclovir in patient with acute herpes zoster. Arch Derm; 147: 901 -907. Victor D. Newcomer, MD (UCLA). (Nov 2005) Zoster. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52552&image. Index=2

Bullous Pemphigoid • Etiology q Autoimmune disorder caused by autoantibodies to hemidesmosomes – attachment complexes anchoring basal keratinocytes to the basement membrane q Antibody deposition at the basement membrane leads to inflammatory response and formation of subepidermal blisters Image courtesy of www. visualdx. com © Logical Images, Inc (NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52132&image. Index=3

Bullous Pemphigoid • Clinical Image courtesy of www. visualdx. com © Logical Images, Inc q Begins as pruritic papular eruption evolving into large, tense oval bullae with serous or hemorrhagic fluid q Commonly affected areas include axillae, medial thigh, groin, abdomen and lower leg q Mucous membranes are seldomly involved. (NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52132&image. Index=0

Bullous Pemphigoid • Diagnosis q Based on clinical presentation, presence of subepidermal blisters on histology and demonstration of anti-hemidesmosome antibodies by direct and indirect immunofluorescence Image courtesy of www. visualdx. com © Logical Images, Inc (University of Rochester, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52132&image. Index=14

Bullous Pemphigoid • Treatment q Immunosupressive therapy with: o Prednisone o Azathioprine o Methotrexate q Tetracycline and nicotinamide q In refractory cases can use IVIG Image courtesy of www. visualdx. com © Logical Images, Inc (NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52132&image. Index=4

Venous Stasis Disease • Etiology q Risk factors include: • Age • Family History • Prolonged Standing • Increased BMI • Sedentary lifestyle q Venous hypertension develops due to one or combination of: • Poor muscle pump function • Incompetent venous valves • Venous obstruction Charles E. Crutchfield III, MD. (March 2007). Venous Ulcer. [photograph]. Retrieved Oct 3, Image courtesy of www. visualdx. com © Logical Images, Inc 2011, from http: //www. visualdx. com/visualdx 6/ get. Zoom. Image. do? module. Id=11&diagnosis. Id=52465& image. Index=0

• Clinical Image courtesy of Margaret Mann, M. D. q Severity of symptoms depends on degree of venous reflux. q In order of severity: • Telangiectasias and Reticular Veins • Varicose Veins – dilated, tortuous veins > 3 mm in size • Chronic Venous Insufficiency o Edema o Skin discoloration o Ulcers o Lipodermatosclerosis – fibrosing panniculitis with hyperpigmentation

Venous Stasis Disease • Diagnosis q Venography – gold standard, but invasive, expensive, associated with complications q Duplex ultrasound – most frequently used to assess for deep venous thrombosis, venous reflux q Ankle-brachial index – used to exclude arterial disease Image courtesy of Margaret Mann, M. D.

Venous Stasis Disease • Treatment q Conservative management: • Leg elevation, compression therapy • Skin cleansing, emollients, and topical steroids q Ablation therapy: • Liquid and foam sclerotherapy for treatment of telangiectasias, reticular veins and small varicose veins • Endovenous laser or radiofrequency ablation as well as mechanical ablation are used to destroy large veins

Sun-Induced Skin Changes Image courtesy of www. visualdx. com © Logical Images, Inc • “Sun spots” or “liver spots” are also called lentigines, often on backs of hands and shoulders • Caused by the sun and generally harmless, but can be confused with more serious skin growths • Can be treated with liquid nitrogen cryotherapy or melanin-targeting lasers (e. g. , the Q-switched ruby laser) Charles E. Crutchfield III, MD. (March 2007). Lentigo, Solar. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=51834&image. Index=8

Sun-Induced Skin Changes • Telangiectasias, or dilated blood vessels , can arise as a result of photodamage, rosacea, radiation exposure, long term topical steroid therapy or hereditary causes Image courtesy of www. visualdx. com © Logical Images, Inc • Mostly benign and can be effectively treated with pulsed dye lasers, other vascular targeting lasers or in some cases, electrocautery (NYU, Department of Dermatology). Telangiectasia. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=11&diagnosis. Id=52379&image. Index=1

Questions 1. Which 2 primary lesions are elevated: a) Macule and Plaque b) Macule and Papule c) Papule and Patch d) Papule and Plaque 2. True or False, drug eruptions occur more frequently in elderly patients? a) True b) False Answers: 1. d, 2. a

3. The patient is a 75 yo male with no history of skin cancer who presents because his wife became concerned about large “mole-like” growths on his back, which have increased in number over the years. The patient says some of them are itchy. On physical exam the lesions are dark brown symmetric papules and plaques of uniform color with stuck-on waxy appearance. What is the diagnosis? a) Actinic Keratosis b) Solar lentigo c) Seborrheic Keratosis d) Benign Nevus 4. In this patient, what is the most appropriate next step in management? a) Urgent referral to a dermatologist for biopsy b) Photodynamic therapy c) Full body CT scan to look for metastases d) Cryotherapy with application of liquid nitrogen to symptomatic lesions Answers 3. c, 4. d. Image courtesy of www. visualdx. com © Logical Images, Inc Victor Newcomer, MD (UCLA). (Aug 2006). Keratosis, Seborrheic. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=51808&image. Index=1

5. The patient is a 60 year-old male with a history of significant sun exposure who presents for a routine skin check. He has a history of multiple rounds of cryotherapy for “pre-cancerous” lesions. On physical exam there are multiple skin-colored papules with rough adherent scale located on his hands and face. What is the diagnosis? a) Actinic Keratosis b) Seborrheic Keratosis c) Basal cell carcinoma d) Melanoma 6. For the patient in question 5, besides cryotherapy what is an additional treatment option a) 5 - Fluorouracil cream b) Chemical peels c) Imiquimod Cream d) Photodynamic therapy e) All of the above Answers: 5. a, 6. e Image courtesy of www. visualdx. com © Logical Images, Inc (University of Rochester, Department of Dermatology). Actinic Keratosis. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=51805&image. Index=5

7. A 55 year old female with a history of a blistering sunburn as a child and family history of skin cancer presents with a lesion on her chest, which she first noticed 1 month ago. She denies any pain but reports the lesion bled with minor trauma last week. On physical exam the lesion is a shiny, red lesion with rolled borders and prominent telangiectasias. The most likely diagnosis is: a. Melanoma in-situ b. Squamous cell carcinoma c. Nodular BCC d. Superficial BCC e. Herpes Zoster f. Pigmented BCC Answer: c Image courtesy of www. visualdx. com © Logical Images, Inc (NYU, Department of Dermatology). Basal Cell Carcinoma, Nodular. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=11&diagnosis. Id=51167&image. Index=0

8. This patient is a 60 year old female who presents with a large, tense bullae, as shown below. Prior to the appearance of the bullae, she noted a pruritic papular eruption in the same distribution. A biopsy was performed, which revealed a subepidermal blister and immunofluorescence demonstrated presence of anti-hemidesmosome antibodies in the serum. What is the diagnosis? a) Herpes Zoster b) Bullous Pemphigoid c) Drug eruption d) Dermatomyositis Answer: b Image courtesy of www. visualdx. com © Logical Images, Inc NYU, Department of Dermatology). Bullous Pemphigoid. [photograph]. Retrieved Oct 3, 2011, from http: //www. visualdx. com/visualdx 6/get. Zoom. Image. do? module. Id=7&diagnosis. Id=52132&image. Index=4