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“Emergent and Urgent Dermatology, Eruptions and Wound Care” G. Scott Drew, DO POMA District VIII 32nd Annual Educational Winter Seminar January 31-February 3, 2019 1 #POMAD8 #ChoosePOMA Emergent and Urgent Dermatology, Eruptions, and Wound Care G. Scott Drew, DO, FAAD, FAOCD Dermatology Associates of Mid Ohio POMA District 8 February 3, 2019 #POMAD8 #ChoosePOMA Disclosures Dr. Drew is a consultant for AbbVie, Inc., Sun Pharmaceutical Industries, Ltd, Pfizer, Inc., Centocor Biopharmaceutical, Ortho Pharmaceutical Corp., Galderma Laboratories, LP, Medimetriks Pharmaceuticals, Inc., and Novartis Pharmaceuticals Corp. #POMAD8 #ChoosePOMA Acute Cutaneous Lupus 1 2 3

Emergent and Urgent Dermatology, Eruptions, and Wound Care · Tinea Capitis with Kerion #POMAD8 #ChoosePOMA Tinea Capitis with Kerion Epidermophyton, Microsporum and Trichophyton

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 1

#POMAD8#ChoosePOMA

Emergent and Urgent

Dermatology, Eruptions,

and Wound Care

G. Scott Drew, DO, FAAD, FAOCD

Dermatology Associates of Mid Ohio

POMA District 8

February 3, 2019

#POMAD8#ChoosePOMA

Disclosures Dr. Drew is a consultant for AbbVie, Inc., Sun

Pharmaceutical Industries, Ltd, Pfizer, Inc.,

Centocor Biopharmaceutical, Ortho

Pharmaceutical Corp., Galderma Laboratories, LP,

Medimetriks Pharmaceuticals, Inc., and Novartis

Pharmaceuticals Corp.

#POMAD8#ChoosePOMA

Acute Cutaneous Lupus

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 2

#POMAD8#ChoosePOMA

Acute Cutaneous Lupus

#POMAD8#ChoosePOMA

Acute Cutaneous Lupus

ANA positive, Anti Ro, La Positive

Photo distributive

Need Systemic Work up

Initial tx, systemic corticosteroids, SPF

Antimalarials following negative G6PD

#POMAD8#ChoosePOMA

Subacute Cutaneous Lupus

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 3

#POMAD8#ChoosePOMA

Subacute Sutaneous Lupus

Erythematosis

ANA negative, Ro and La positive

Fewer systemic symptoms

Less systemic co morbidities

Corticosteroids and steroid sparing agents, spf

#POMAD8#ChoosePOMA

Discoid Lupus

#POMAD8#ChoosePOMA

Discoid lupus

ANA, Ro and La negative

Usually not systemic

Scarring and Scaling alopecia

Photo distributed

Treatment include systemic, topical and

intralesional corticosteroids, steroid sparing agents

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 4

#POMAD8#ChoosePOMA

Acral Lentiginous Melanoma

#POMAD8#ChoosePOMA

Acral Lentiginous Melanoma Highest morbidity and Mortality of the Melanomas

Due to delay in Diagnosis

Bob Marleys demise

Breslow depth

Work up and wide excision based on Breslow depth

FSE monthly by patient, quarterly by physician

Excision, not biopsy

#POMAD8#ChoosePOMA

Congential Nevus

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 5

#POMAD8#ChoosePOMA

Congential (Hairy) Nevus

Very low malignant risk

High parental concern

Watch for changes

#POMAD8#ChoosePOMA

Bullous Pemphigoid

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Bullous Pemphigoid Differentiate from Pemphigus, a far more serious Dx

H & E and DIF biopsy

Systemic corticosteroids

Steroid Sparing agents

Often burns out

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 6

#POMAD8#ChoosePOMA

Stasis dermatitis

#POMAD8#ChoosePOMA

Stasis dermatitis

Chronic

Circulatory Compromise

Compression Essential

Work up for Co morbidities

Prevention of Ulcerations

#POMAD8#ChoosePOMA

Necrotic Ulcers

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 7

#POMAD8#ChoosePOMA

Leg Ulcers-

-Leg ulcers are symptoms, not diagnoses

-treatment based on etiology

-biopsy if treatment not effective

-work up for co morbidities (malignancy, trauma,

diabetes, PVD, abuse, et al

#POMAD8#ChoosePOMA

The magic changing ink

#POMAD8#ChoosePOMA

Dermatomyositis

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 8

#POMAD8#ChoosePOMA

Dermatomyositis Classic but subtle clinical presentation, including

Heliotrope rash, shawl sign, gottrons papule

Work up essential: CK, Aldolase, LDH, etc

50% with associated malignancy

Biopsy confirmation

Treatment systemic corticosteroids, steroid sparing

agents, spf, others

#POMAD8#ChoosePOMA

Pyogenic Granuloma

Etiology often trauma and microtrauma. Surgical treatment

asap

#POMAD8#ChoosePOMA

Foreign Body Granuloma

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 9

#POMAD8#ChoosePOMA

Foreign Body Granuloma

History of injury important

Can be recent, usually remote

#POMAD8#ChoosePOMA

Erythema Multiforme Minor

#POMAD8#ChoosePOMA

Erythema Multiforme Minor Usually due to Drug reactions or HSV

Treatment directed at etiology

Palms, soles, mucous membranes.

Often recurrent, esp if HSV induced

Avoidance of offending drug (sulfonyl ureas,

bactrim) and/or supressive anti virals

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 10

#POMAD8#ChoosePOMA

EM Major/SJS

#POMAD8#ChoosePOMA

Molluscum contagiosum

#POMAD8#ChoosePOMA

Molluscum contagiosum

In toddlers, almost always associated with atopic

dermatitis.

If fewer than 10, treat the AD first

If greater than 10, treat the MC

If associated with wrestling, sports, STD, treat the

MC

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 11

#POMAD8#ChoosePOMA

Atopic dermatitis

#POMAD8#ChoosePOMA

Atopic Dermatitis

A lifestyle, not a tube of hydrocortisone

Increased risk of Bacterial, viral, fungal and

parasitic skin infections

Associated allergy, otitis, asthma

Treatment: steroid sparing agents, emollients, mild

cleaners, food, mild detergents, anti pruritics,

bleach baths. Limited corticosteroids

#POMAD8#ChoosePOMA

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 12

#POMAD8#ChoosePOMA

#POMAD8#ChoosePOMA

#POMAD8#ChoosePOMA

Pityriasis alba

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 13

#POMAD8#ChoosePOMA

#POMAD8#ChoosePOMA

Cellulitis

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Cellulits

Usually staph or strep

Community acquired vs Hospital acquired MRSA

Topical, oral, systemic antibiotics

History of prior manipulation, puncture,

penetration with home sterilized safety pins, awls,

needles, razors

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 14

#POMAD8#ChoosePOMA

Pityriasis Rosea

#POMAD8#ChoosePOMA

Pityriasis Rosea Herald Patch

Self limited

Pruritis variable

Rx supportive, accurate diagnosis

DDX includes parapsoriasis, guttate psoriasis,

tinea, et al

#POMAD8#ChoosePOMA

Hidradenitis supprativa

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 15

#POMAD8#ChoosePOMA

Hidradenitis supprativa

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Hidradenitis Supprativa Symptoms progressive and can be debilitating

Surgical tx as a LAST resort

TNF alfa inhibitors are first line treatment

Alternative tx include isotretinoin, rifampin,

minocyline, spirinolactone, surgery

#POMAD8#ChoosePOMA

Basal Cell Carcinoma

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 16

#POMAD8#ChoosePOMA

Basal Cell Carcinoma

Most common Human Malignancy >

1,000,000/year

Rare metastasis

Surgical excision is ToC

Radiation, MOHS, ED&C, Imiquimod, vismodegib

#POMAD8#ChoosePOMA

SCC

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Squamous Cell Carcinoma Slightly higher risk of metastasis, particularly of

hands, face, scalp and neck

Surgical treatment ASAP

Clean margins

SPF

Frequent FSE

In immunocompent host, usually sun exposed

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 17

#POMAD8#ChoosePOMA

Squamous Cell Carcinoma

#POMAD8#ChoosePOMA

Squamous Cell Carcinoma

#POMAD8#ChoosePOMA

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 18

#POMAD8#ChoosePOMA

#POMAD8#ChoosePOMA

Systemic Malignancy

Metastatic to Skin

#POMAD8#ChoosePOMA

Systemic Malignancy

Metastatic to skin

Occasionally primary malignancy is previously

unknown

Almost all systemic malignancies known to

metastasize to skin

History is irregularly irregular

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 19

#POMAD8#ChoosePOMA

Squamous Cell Carcinoma in the

immunocompromised patient

#POMAD8#ChoosePOMA

SCC in Immunocompromised

patients

Often in solid organ transplant patients, those on

chemotherapy, or systemic immunosuppressants

Metastatic rate higher

Clinical presentation often more aggressive

#POMAD8#ChoosePOMA

Granuloma Annulare

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 20

#POMAD8#ChoosePOMA

Granuloma Annulare

Distinct presentations in pediatrics vs adult pts

Often confused with tinea (no scale with GA)

Can be associated with DM

#POMAD8#ChoosePOMA

Tinea Capitis with Kerion

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Tinea Capitis with Kerion Epidermophyton, Microsporum and Trichophyton

spp are causative organisms

Usually associated with regional adenopathy

Tinea capitis requires oral treatment

Griseofulvin 20mg/kg x 6 weeks, terbinafine by

weight

Kerion is a late sequellae.

Power of a Nickel (Powerofanickel.org) and DOcare

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 21

#POMAD8#ChoosePOMA

Epidermal Inclusion cyst

Topical therapy, vs ILK, vs Excision

#POMAD8#ChoosePOMA

Plaque Psoriasis

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Plaque Psoriasis

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 22

#POMAD8#ChoosePOMA

Treatment Options

for BSA > 10%

Narrowband UVB

Methotrexate

Acetretin

Apremilast (PDE 4 inhibitors)

Biologics

Combinaiton theraby

#POMAD8#ChoosePOMA

Sebopsoriasis with Isomorphic

phenoenon

#POMAD8#ChoosePOMA

Pediatric psoriasis

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 23

#POMAD8#ChoosePOMA

One month of adalimumab

#POMAD8#ChoosePOMA

Compulsive excoriation

#POMAD8#ChoosePOMA

Compulsive

Excoriation/Neurodermatitis

Rarely a primary dermatitis

Often require multidisciplinary approach

Recognition of the patients participation in the

disease

Elimination of the picking/scratching/digging

Often requires psychoactive agents (doxepin,

fluvoxamine, benzodiazapines)

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Emergent and Urgent Dermatology, Eruptions and Wound CareG. Scott Drew, DO

POMA District VIII 32nd Annual Educational Winter SeminarJanuary 31-February 3, 2019 24

#POMAD8#ChoosePOMA

Cutaneous Sarcoid

#POMAD8#ChoosePOMA

Diabetic foot disease

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