DERM FINAL: other skin disorders and pigment disorders

population affected by hidradenitis suppurtiva

women of reproductive age (shortly after puberty)

cause of hidradenitis suppurtiva

-occlusion of hair follicle via hyperkeratosis

-TNF-alpha significantly increased

-hormones, comorbidities

manifestation of hidradenitis suppurtiva

-gradual onset, chronic flares

-persistent/recurrent boil-like lesions in axillae/inguinal area

-painful

-can progress to open "tombstone" comedones

hidradenitis suppurtiva diagnosis

hidradenitis suppurtiva

definitive hidradenitis suppurtiva diagnosis requires presence of 3 criteria:

typical lesion (1+)

typical distribution

chronic/recurrent sx

hidradenitis suppurtiva typical lesions

painful nodule

abscess

draining sinuses

double open comedones

bridged scars

hidradenitis suppurtiva typical distribution

axillae

groin

buttocks

perineal

inframammary

how to determine treatment for hidradenitis suppurtiva

hurley staging of severity

hurley stage 1

mild

recurrent abscesses without scarring or sinus tract formation (tunnels)

hurley stage 2

moderate

recurrent abscesses with scarring and sinus tract formation separated by normal skin

hurley stage 3

severe

recurrent abscesses with scarring and sinus tract formation with no intervening normal skin

why do GS and culture for hidradenitis suppurtiva?

if secondary infection (staph aureus) suspected

treatment hurley stage 1

topical clinda +

1) doxy

2) oral clinda + oral rifampin

3) spironolactone (females with comorbid pcos/premenstrual flares)

treatment hurley stage 2

same as hurley stage 1, plus:

1) immunosuppressives (humira, remicade)

2) other options: (dapsone, cyclosporin, acitretin)

treatment hurley stage 3

pharm tx for stages 1 and 2, then:

1) surgical interventions

2) pain control

pt's with hidradenitis suppurtiva are at an increased risk of

cardiovascular events and malignancies

hidradenitis suppurtiva remission is more common in

non-smokers, those who have quit smoking, non-obese individuals

acrochordon aka

skin tag

population affected by acrochordons

mid 40s-60s

weight gain

manifestation of acrochordons

asymptomatic, soft, flesh-colored papules on thin stalk (contains central BV)

acrochordon diagnosis

clinical

acrochordon biopsy would show

loose fibrous tissue in dermis of a polyp with thin epidermis

tx options for acrochordon

cryo

shave excision

scissors +/-cauterization

lipoma

benign localized overgrowth of fat cells under the skin (trunk, neck, arms, axillae)

lipoma diagnosis

clinical

lipoma histopathology results

well-circumscribed adipose tumor with a thin capsule

angiolipoma histopathology results

adipose collections containing a proliferation of capillary-sized vessels

epidermal inclusion cyst

benign growths of upper portion of hair follicle, capsule filled with keratin debris

cause of epidermal inclusion cyst

plugging of follicular openings, arise from infundibulum of hair follicle

epidermal inclusion cyst affect what areas (most commonly)

central trunk and face

hallmarks of inflamed epidermal inclusion cyst

swelling, pain, purulent drainage (cheesy, foul odor)

hallmarks of non-inflamed epidermal inclusion cyst

asymptomatic, central punctum (black)

epidermal inclusion cyst diagnosis

clinical

epidermal inclusion cyst biopsy results

cyst in dermis lined with stratified squamous epithelium and filled with keratin flakes

epidermal inclusion cyst culture of contents will be _____

sterile

standard of care for non-inflamed epidermal inclusion cyst

surgical removal of entire capsule

standard of care for inflamed epidermal inclusion cyst

hypertrophic scar

symptomatic scar, does not extend beyond border of original injury

keloid

type of hypertrophic scar that will grow beyond the borders of original injury

keloid biopsy results

whorls of fibroblasts, think bands collagen

(biopsy has risk of scarring!)

treatment of hypertrophic scars

will become more supple over the years

intralesional steroid injections

surgical correction

treatment of keloids

will not become more supple over the years

intralesional steroid infections

surgical correction

referral required for management

population affected by pilonidal disease

3:1 male: female

peak between 16-20 y/o

cause of pilonidal disease

hair follicles become blocked > foreign body granuloma reaction and drainage

manifestation of pilonidal disease

acute abscess midline in upper gluteal cleft

-+/- pain, drainage, systemic sx possible

pilonidal disease diagnosis

clinical

pilonidal disease culture

if purulence present to direct treatment

treatment of pilonidal disease painless cyst

monitor

treatment of pilonidal disease acute abscess

1) I&D

2) abx for concomitant cellulitis:

-1st gen ceph + metronidazole

3) refer to general surgery

post-inflammatory hyperpigmentation

acquired disorder causing darkening of the skin secondary to inflammation/trauma, epi or dermis

post-inflammatory hyperpigmentation diagnosis

clinical

post-inflammatory hyperpigmentation wood's lamp exam results

epidermal pigmentation will enhance

dermal pigmentation does not enhance

post-inflammatory hyperpigmentation biopsy

increase in epidermal melanin +/- dermal melanophages

post-inflammatory hypopigmentation

acquired disorder causing lightening of the skin secondary to inflammation/trauma, epi or dermis

post-inflammatory hypopigmentation wood's lamp

may be more visible but won't be as bright as other disorders

post-inflammatory hypopigmentation biopsy

non specific: decrease melanin in epi, decrease melanophages in upper dermis

melasma

acquired hypermelanosis characterized by symmetric hyperpigmented patches with irregular borders on sun exposed regions of face

causes of melasma

sun exposure and hormones

melasma dx

clinical

melasma biopsy (if atypical or dx uncertain)

epidermal: enlarged melanocytes

dermal: melanophages/somes in dermis, limited melanin in epidermis

acanthosis nigricans

cutaneous manifestation of insulin resistance (often secondary to DM)

manifestation of acanthosis nigricans

thick velvety brown/black plaques, symmetrical, gradual onset

("looks dirty but can't wash it off")

affected areas of acanthosis nigricans

neck, axillae, groin, intertriginous areas

acanthosis nigricans palmar involvement may be a sign of

malignancy

acanthosis nigricans diagnosis

clinical

acanthosis nigricans biopsy

hyperkeratosis with increased pigmentation of basal layers

acanthosis nigricans labs

to ID underlying etiology

treatment of acanthosis nigricans should focus on

ID and tx of underlying disease

manifestation of pityriasis alba

round/ovoid, scaly, hypopigmented macule/patches that fade over the course of weeks, usually asymptomatic

population affected by pityriasis alba

children/adolescents > adults (<12 y/o)

areas affected by pityriasis alba

face, neck, trunk

pityriasis alba diagnosis

clinical

pityriasis alba biopsy (if dx unclear)

decrease # active melanocytes, smaller/fever melanosomes, less melanin in basal layer

peak onset of vitiligo

10-20 y/o

manifestation of vitiligo

slow progression of white, well-circumscribed spots, smooth (most common type = generalized)

cause of vitiligo

CD8+ T cells destroy melanocytes > loss of pigment

vitiligo wood's lamp

accentuates areas of non-scaly depigmentation

vitiligo biopsy

absence of melanocytes

what are more likely to develop in areas of depigmentation

actinic keratoses and skin cancer

post-inflammatory hyperpigmentation conservative treatment

treat underlying cause

sun protection

post-inflammatory hyperpigmentation gold standard

hydroquinone (gold standard)

topical retinoids +/- low potency topical steroid

post-inflammatory hypopigmentation treatment

1) treat underlying inflammatory disorder

2) repigmentation from sun (caution)

melasma conservative treatment

sun protection

minimize exogenous hormone exposure

melasma 1st line treatment

topical lightening agents

-hydroquinone, topical tretinoin +/- low potency topical steroid

acanthosis nigricans treatment

1) treat underlying disease!

2) topical agents (retinoids, hydroxyquinone, topical steroids, etc)

pityriasis alba treatment

1) proper moisturization and sun protection

2) topical steroids prn

vitiligo pharmacological treatment options

1) topical steroids (high or super high potency)

2) topical calcineurin inhibitors

3) topical vitamin D analogs