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A. Seborrheic Dermatitis [1]navigator

  1. Waxy, Inflammatory dermatitis
    1. Waxy scales, "dandruff", redness in nasolabial fold and eyebrows
    2. Most common in persons 30-60 years of age
    3. Also occurs in infants
    4. Common in Parkinson's patients
    5. AIDS patients may have severe seborrheic dermatitis
    6. Occurs in areas of dense distribution of sebaceous glands
  2. Differential Diagnosis
    1. Psoriasis
    2. Atopic dermatitis
    3. Tinea capitis
    4. Candidiasis
  3. Treat with topical anti-fungal agents
    1. Ketoconazole (Nizoral®) cream on eyebrows and nasolabial areas
    2. Nizoral® shampoo for dandruff (may try selenium / zinc shampoos)
    3. Low potency topical steroids may be added for brief (<1 week) periods

B. Eczematous Dermatitis [2] navigator

  1. Definition: ill defined erythematous scaly plaques ± pruritus
  2. Symptoms
    1. Erythema with irritation and dryness
    2. Pruritus may be prominent
    3. Localized edema
  3. Types of Eczematous Dermatitis
    1. Allergic / Atopic Dermatitis
    2. Nummular - coin shaped
    3. Contact Dermatitis
    4. Asteototic Eczema - cracked like apearance, "eczema craquely"
    5. Fungal Dermatitis - KOH preparations done on perimeter of lesion to rule out fungus
    6. Idiopathic
  4. Treatment
    1. Moisturizing, non-allergic soaps
    2. Topical glucocorticoids (for <1 week) unless fungal disease is present
    3. Oral anti-histamines - such as hydroxazine 10-40mg po qid
    4. Tar effective in some
    5. Atopic dermatitis responds to topical tacrolimus without major irritation [5]
  5. Perinatal administration of probiotic Lactobacillus rhamnosus strain GG appears to reduce risk of developing atopic eczema by >40% [18]
  6. Dermatophyte Infections
    1. Diagnosis made with KOH (potassium hydroxide) preparation of skin scarping
    2. Athlete's Foot - Tinea pedis; use topical agents such as clotrimazole
    3. Jock Itch - Tinea cruris; treat similar to T. pedis
    4. Scalp Infection - Tinea capitis; treat with itraconazole or griseofulvin

C. Actinic Keratosis (AK) navigator

  1. Synonyms: Solar Keratosis, Solar Elastosis, Senile Keratosis
  2. Types
    1. Pigmented AK
    2. Non-pigmented AK
  3. Appearance
    1. Rough, faintly erythematous, slightly raised skin lesions
    2. Most frequently on face and hands (sun exposed area)
    3. Progression of lesions to neoplasia is very slow
    4. 0.25-1.0% progress to squamous cell cancer each year
  4. Treatment [3,19]
    1. 5-Fluorouracil (Efudex®, Fluoroplex®, Carac®) 2-5% solution or 0.5-5% cream [16]
    2. Aminolevulinic Acid (Levulan Kerastick®) - 20% solution
    3. Diclofenac Gel (Solaraze®) - 3% gel
    4. Imiquimod (Aldara®) 5% cream now approved for AKs on face and scalp [19]
    5. Fluorouracil generic is least expensive; imiquimod is most expensive

D. Lice (Pediculosis) [4,8] navigator

  1. Distinct syndromes caused by related, blood-sucking, ectoparasites
    1. Head Lice - Pediculus humanus variant corporis
    2. Body Lice - P. humanus variant pubis
    3. Pubic (crab) Lice - P. humanus variant pubis
  2. Hundreds of millions of cases annually worldwide
    1. Transmission is between individuals or indirectly with contact with linens, other
    2. Head lice are most common, particularly in age 3-11 years
    3. Body lice are mainly associated with poor socioeconomic conditions
    4. Increased risk of body and pubic lice with increasing sexual contacts
    5. Pubic lice are transmitted sexually, often with other sexually transmitted diseases
    6. Nonsexual transmission of pubic lice reported in homeless persons
  3. Symptoms and Diagnosis
    1. Pruritus occurs in <20% of schoolchildren with head lice
    2. Pruritus is common with body lice and is prominant with pubic lice
    3. Diagnosis by finding live adult lice in hear or on skin, clothing
  4. Treatment Overview [7]
    1. Reasonable initial treatment with 1% permethrin (over the counter, OTC)
    2. Malathion (prescription) is used for permethrin failures
    3. Ivermectin is a reasonable 3rd line therapy (or consider for second line)
  5. Pyrethrins [7]
    1. Combined with piperonyl butoxide are available over the counter
    2. Safe agents; apply to hair for 10 minutes
    3. Pyrethrins or malathion are currently recommended first line
  6. Permethrin [7]
    1. Synthetic agent based on natural pyrethrin
    2. Safe and more effective than pyrethrin
    3. 1% Solution is available OTC (Nix®)
    4. 5% Solution requires prescription, is effective, usually for scabies (Elimite®)
    5. The 5% solution may be applied to clean, dry hair and left overnight
  7. Malathion (Ovid®) [9,10]
    1. Organophosphate compound based on pesticides
    2. Irreversible cholinesterase inhibitor
    3. Now available in USA, as 0.5% shampoo in isopropanol
    4. Label recommends leaving on hair x 12 hours, then wash off
    5. Recent studies indicate that 1 or 2 treatments of 20 minutes are sufficient [7]
    6. Typically effective after one treatment, including in permethrin resistant lice
    7. Two treatments much more effective than mechanical removal of lice [10]
  8. Ivermectin (Mectizan®)
    1. Very potent, broad range antiparasitic agent
    2. Oral doses 200µg/kg on days 1 and 10 are very effective for head lice [7]
    3. Ivermectin 0.8% lotion is also effective for head lice
    4. Very well tolerated
  9. Lindane (Kwell®) [14]
    1. Organochlorine insecticide based compound
    2. Shampoo 1% requires 4 minute application; repeat 1 week later
    3. Lindane resistant lice have been reported
    4. Should not be overused or likely to cause systemic toxicity
    5. Use of lindane for head lice should be considered fourth line only
  10. Trimethoprim-Sulfamethoxazole [13]
    1. TMP/SMX (Bactrim®, Septra®)
    2. Active even in resistant head lice
    3. Dose is 5mg/kg po bid x 10 days for resistant head lice
    4. May be more effective when combined with permethrin
    5. Increased side effects over topical agents (transient pruritis or nausea/vomiting)

E. Annular (Ringed) Lesions [12]navigator

  1. Pityriasis rosea
  2. Granuloma annulare
    1. Idiopathic, self-limited cutaneous eruption
    2. Common in adults and children, typically <40 years
    3. Smooth, skin-colored annular plaques and papules
    4. Lesions usually on hands, feet, wrists, ankles but can occur anywhere
    5. Usually asymptomatic, but mild pruritus may occur
    6. Localized (75%), generalized, perforating, subcutaneous, actinic forms
    7. Spontaneous resolution within 2 years in ~50% of patients with localized form
    8. Diagnosis based on clnical apparance and pathology
    9. Best treatment is usually no treatment
  3. Sarcoidosis
  4. Subacute cutaneous lupus erythematosus
    1. Presents as annular or papulosquamous forms
    2. Photosensitivity is major component
    3. Lesions generally confined to sun-exposed surfaces
    4. ~50% of patients meet criteria for SLE
    5. Over 60% of patients have antibodies to SSA/Ro Antigen
    6. Of the SSA+ patients, ~10% have Sjogren's Syndrome
    7. Topical glucocorticoids and/or oral hydroxychloroquine (Plaquenil®) are effective
  5. Erythema annulare centrifugum
    1. Non-indurated, annular patches with associated trailing scale
    2. Erythematous borders
    3. Perivascular dermal lymphocytic infiltrates gathered in dermis
    4. Papillary edema, spongiosis and parakeratosis occurs
    5. Likely a cutaneous hypersensitivity reaction
    6. Most cases do not require treatment
    7. Topical or systemic glucocorticoids or antihistamines are used for symptoms
  6. Leprosy
  7. Urticaria or Urticarial Vasculitis
  8. Less Common Presentations
    1. Erythema chronicum migrans
    2. Erythema multiforme
    3. Psoriasis - uncommon anular lesions with white borders
    4. Numular eczema

F. Xanthomatous Diseases [6] navigator

  1. Xanthomas are deposits of lipid
  2. Usually papules, yellowish to yellow-tan in appearance
  3. Congenital versus acquired disorders
  4. Diseases usually associated with abnormal lipid metabolism
    1. Typical severe hypercholesterolemia
    2. Inherited disorders of lipoprotein and lipid metabolism
    3. Tendinous xanthomas are most common
    4. Hyperlipidemia is always present
  5. May include an inflammatory component
  6. Other Causes of Yellow-Tan Papules
    1. Pseudoxanthoma elasticum - abnormal elastic fibers in the dermis
    2. Lipoid proteinosis
    3. Necrobiosis lipoidica
    4. Giant Cell (Histiocytic) diseases - sarcoidosis, Langerhans' histiocytosis, fungal disease
    5. Disseminated tuberculosis ("lupus vulgaris", granulomatous form of TB)
    6. Normolipemic xanthomatous disorders
  7. Inherited Disorders
    1. Lipoid Proteinosis - mutations in extracellular matrix protein 1 (ECM 1)
    2. Lipogranulomatosis (Farber's Disease)
  8. Normolipemic Xanthomatous Disorders
    1. Also called non-X histiocytosis
    2. Erdheim-Chester Syndrome - bone lesions, periorbital yellow papular lesions
    3. Normolipemic plane xanthoma - no inflammation, macular (not papular) lesions
    4. Necrobiotic xanthogranuloma - yellow lesions, associated with paraproteinemias
    5. Xanthoma disseminatum - no bone lesions, flexural area yellow lesions

G. Hyperhidrosis (Excessive Sweating) [11]navigator

  1. Sweating is normally a part of thermoregulation
  2. Normal sweating is induced by exercise or heat
  3. Primary Hyperhidrosis
    1. Excessive, uncontrollable sweating without any discernable cause
    2. Usually involves axillae, palms and soles
  4. Complications of Severe Hyperhidrosis
    1. Skin maceration
    2. Secondary bacterial infections
    3. Drenched clothing (social stigmata)
  5. Treatment
    1. Iontophoresis
    2. Topical aluminum chloride
    3. Anticholinergic agents
    4. ß-adrenergic blockers
    5. Surgical removal of sweat glands
    6. Sympathectomy - usually of limited benefit
    7. Botulinum toxin A (intradermal) - 50 units/axilla effective for axillary hyperhidrosis [20]

H. Hemangioma (Superficial) [15] navigator

  1. Typically occur in children, often called strawberry nevi
  2. Most common soft tissue tumors of infancy, ~10% of children <1 year
  3. <30% present at birth
  4. 90% appear within 1 month
    1. Reach maximum size at 6-8 months
    2. 50% resolve by 5 years; 90% by 10 years
    3. Thus, 50% are present when child starts primary school
  5. Initial rapid phase followed by slower involutional phase
    1. Blanched macule, telangiectasia, surrounded by blanced halo or red macule
    2. Vascular tumor of variable size then develops
  6. Complications
    1. Generally mild, though very location dependent
    2. Infection, bleeding, occlusion or obstruction of vital structures can occur
    3. Eyes, nose, mojuth, auditory canal can be affected
    4. Facial lesions in particular can cause significant cosmetic disfigurement
    5. Resolution may leave ~30% of children with residual skin changes
    6. These skin changes include epidermal atrophy, telangiectasia, hypopigmentation
  7. Treatment
    1. Usually "wait-and-see" policy
    2. Intralesional or systemic glucocorticoids, particularly in rapid growth phase
    3. Pulse dye laser has also been used
    4. No overall benefit to pulse dye laser over wait-and-see policy in children [15]

I. Frown Linesnavigator

  1. Frown lines due to tonic muscle contractions
  2. Increase with age
  3. Botulinum toxin (Botox Cosmetic®, similar to Botox®) [17]
    1. Toxin derived from Clostridium botulinum
    2. Blocks neuromuscular conduction
    3. Cleaves proteins needed for acetylcholine release
    4. Injection into frown line areas paralyzes muscles
    5. Overlying skin smooths
    6. Response lasts 3-6 months
    7. Generally well tolerated with some weakness at injection site and surrounding muscles
    8. Also effective for hyperhidrosis (see above) [20]

References navigator

  1. Janniger CK and Schwartz RA. 1995. Am Fam Phys. 52(1):149 abstract
  2. Leung DYM, Diaz LA, DeLeo V, Soter NA. 1997. JAMA. 278(22):1914 abstract
  3. New Treatments for Actinic Keratosis. 2002. Med Let. 44(1133):57 abstract
  4. Roberts RJ. 2002. NEJM. 346(21):1645 abstract
  5. Ruzicka T, Bieber T, Schopf, et al. 1997. NEJM. 337(12):817
  6. Heald P and Duncan LM. 1998. NEJM. 338(16):1138
  7. Drugs for Head Lice. 2005. Med Let. 47(1215):68
  8. Chosidow O. 2000. Lancet. 355(9206):819 abstract
  9. Malathione for Head Lice. 1999. Med Let. 41(1059):73 abstract
  10. Roberts RJ, Casey D, Morgan DA, Petrovic M. 2000. Lancet. 356(9229):540 abstract
  11. Heckmann M, Ceballos-Baumann AO, Plewig G. 2001. NEJM. 344(7):488 abstract
  12. Hsu S, Le EH, Khoshevis MR. 2001. Am Fam Phys. 62(2):289
  13. Hipolito RB, Mallorca FG, Zuniga-Macaraig ZO, et al. 2001. Pediatrics. 107:E30 abstract
  14. Lindane. 1997. Med Let. 38(992):6
  15. Batta K, Goodyear HM, Moss C, et al. 2002. Lancet. 360(9332):521 abstract
  16. Efudex. 1993. Med Let. 35(907):97
  17. Botox Cosmetic. 2002. Med Let. 44(1131):47 abstract
  18. Kalliomaki M, Salminen S, Poussa T, et al. 2003. Lancet. 361(9372):1869 abstract
  19. Imiquimod for Actinic Keratoses. 2004. Med Let. 46(1183):42 abstract
  20. Botulinum Toxin for Axillary Hyperhidrosis. 2004. Med Let. 46(1191):76 abstract