Transcript Dark Rashes - American Academy of Dermatology
Blotches: Dark rashes
Medical Student Core Curriculum in Dermatology Last updated April 18, 2011 1
Module Instructions
The following module contains a number of blue, underlined terms which are hyperlinked to the dermatology glossary , an illustrated interactive guide to clinical dermatology and dermatopathology.
We encourage the learner to read all the hyperlinked information.
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Goals and Objectives
The purpose of this module is to help medical students develop a clinical approach to the evaluation and initial management of patients presenting with hyperpigmented rashes.
After completing this module, the medical student will be able to: • Identify and describe the morphology of common hyperpigmented rashes • Provide an initial treatment plan for selected dark rashes • Determine when to refer a patient with a dark rash to a dermatologist 3
Case One
Scott Goff 4
Case One: History
HPI: Scott Goff is a 28-year-old male who presents with “blotches” on his upper back and chest for several years. They do not cause any symptoms other than anxiety because he has these dark spots.
PMH: no major illnesses or hospitalizations Allergies: none Medications: protein supplements Family history: none Social history: accountant; weightlifter ROS: negative 5
Case One: Skin Exam
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Case One: Skin Exam
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Case One, Question 1
Mr. Goff’s chest shows hyperpigmented , scaly macules on his upper chest and back. Which is the best test to confirm the diagnosis?
a. Bacterial culture b. Direct fluorescent antibody (DFA) test c. Potassium hydroxide (KOH) exam d.
Wood’s light 8
Case One, Question 1
Answer: c
Mr. Goff’s chest shows hyperpigmented, scaly macules on his upper chest and back. Which is the best test to confirm the diagnosis?
a. Bacterial culture b. Direct fluorescent antibody (DFA) test
c. Potassium hydroxide (KOH) exam
d.
Wood’s light 9
Case One, KOH exam
Spores (yeast forms) Short Hyphae The KOH exam shows short hyphae and small round spores. This is diagnostic of tinea (pityriasis) versicolor.
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Diagnosis: Tinea versicolor
Based on his skin findings and KOH exam, Mr. Goff has tinea versicolor It’s called “versicolor” because it can be light, dark, or pink to tan Let’s look at some examples of the various colors of tinea versicolor 11
Tinea versicolor: lighter
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Tinea versicolor: darker
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Tinea versicolor: pink or tan
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Case One, Question 2
What is the best treatment for Mr. Goff?
a. Ketoconazole shampoo b. Narrow band UVB phototherapy c. Oral griseofulvin d. Tacrolimus cream e. Triamcinolone cream 15
Case One, Question 2
Answer: a
What is the best treatment for Mr. Goff?
a. Ketoconazole shampoo
b. Narrow band UVB phototherapy (may worsen appearance by increasing contrast) c. Oral griseofulvin (does not work for
Malassezia
species) d. Tacrolimus cream (does not fight yeast) e. Triamcinolone cream (does not fight yeast) 16
Case One, Question 3
Which of the following statements is
true
about the treatment of tinea versicolor?
a. Normal pigmentation should return within a week of treatment b. Oral azoles should be used in most cases c. When using shampoos as body wash, leave on for ten minutes before rinsing 17
Case One, Question 3
Answer: c
Which of the following statements is true about the treatment of tinea versicolor?
a. Normal pigmentation should return within a week of treatment (usually takes weeks to months to return to normal) b. Oral azoles should be used in most cases (mild cases can be treated with topicals)
c. When using shampoos as body wash, leave on for ten minutes before rinsing
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Case Two
Melinda Kinsley 19
Case Two: History
HPI: Melinda Kinsley is a 48-year-old Guatemalan woman who presents with ten years of dark spots on her face. She tried a bleaching cream she got from Mexico but her friend told her it could make the spots worse.
PMH: three normal pregnancies; s/p tubal ligation Allergies: none Medications: supplements black cohosh, evening primrose Family history: noncontributory Social history: lives with husband and children ROS: negative 20
Case Two: Skin Exam
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Case Two, Question 1
Which of the following is most likely associated with this symmetric hyperpigmentation?
a. Ginseng b. Limes c. Minocycline
d. Malassezia furfur
e. Pregnancy 22
Case Two, Question 1
Answer: e
Which of the following is most likely associated with this symmetric hyperpigmentation?
a. Ginseng b. Limes c. Minocycline
d. Malassezia furfur
e. Pregnancy
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Melasma
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Melasma (aka Chloasma)
Melasma is characterized by patchy light to dark brown hyperpigmentation of the face Usually affects women, runs in families Associated with hormonal changes • Called the “mask of pregnancy” • May occur with pregnancy, birth control pills, and hormone replacement therapy 25
Melasma (aka Chloasma)
Worse with exposure to UV radiation Treatments • Strict sun avoidance,
daily sunscreen with broad spectrum coverage and SPF > 30
• Hydroquinone 4% cream BID • If this fails, may refer to dermatology for cosmetic treatments like triple topical therapy, lasers, or chemical peels, but these will usually be at the patient’s expense 26
Case Three
Henry Fontana 27
Case Three: History
HPI: Henry Fontana is a 78-year-old man who presents with of darkening of his arms and neck over the past few years. He recently underwent knee replacement surgery, and the orthopedist noticed a greenish pigmentation of his bones.
PMH: hypertension, GERD, osteoarthritis, BPH, basal cell and squamous cell carcinomas, rosacea Allergies: none Medications: atenolol, felodipine, celecoxib, oxybutinin, rabeprazole, minocycline Family history: noncontributory Social history: widower; lives alone ROS: negative 28
Case Three: Skin Exam
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Case Three, Question 1
Which of the following medications is most likely associated with this pigmentation?
a. Atenolol b. Celecoxib c. Minocycline d. Oxybutinin e. Rabeprazole 30
Case Three, Question 1
Answer: c
Which of the following medications is most likely associated with this pigmentation?
a. Atenolol b. Celecoxib
c. Minocycline
d. Oxybutinin e. Rabeprazole 31
Minocycline pigmentation
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Minocycline pigmentation
Deposition appears after months to years in a small percentage of patients First noticeable on the alveolar ridge, palate, sclera May involve bones, thyroid, but this is harmless Skin deposition can be brown or blue-grey Blue-grey pigmentation may occur in scars Skin pigmentation may not fade after discontinuation Patients on long-term minocycline should be screened; if seen on gums or sclerae, discontinue 33
Other causes of medication-related hyperpigmentation
Amiodarone Antimalarials • Hydroxychloroquine • Chloraquine Calcium channel blockers • Verapamil • Diltiazem Zidovudine Imipramine • Some antipsychotics Some chemotherapy agents 34
Case Four
Elaine Gosnel 35
Case Four: History
HPI: Elaine Gosnel is a 66-year-old woman with a two-year history of an itchy rash on her legs that has resulted in dark spots.
PMH: hypertension, diabetes, hyperlipidemia Allergies: none Medications: metoprolol, simvastatin, metformin Family history: noncontributory Social history: widowed; lives in a retirement community ROS: edematous legs 36
Case Four: Skin Exam
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Case Four, Question 1
The patient’s legs show scaly brown plaques on her lower legs bilaterally. Pedal pulses are normal. What is the most likely diagnosis for Mrs. Gosnel’s rash?
a. Atopic dermatitis b. Erysipelas c. Irritant contact dermatitis d. Stasis dermatitis e. Tinea corporis 38
Case Four, Question 1
Answer: d
The patient’s legs show scaly brown plaques on her lower legs bilaterally. Pedal pulses are normal. What is the most likely diagnosis for Mrs. Gosnel’s rash?
a.
b.
c.
Atopic dermatitis (wrong location, no history) Erysipelas (usually unilateral, acute not chronic) Irritant contact dermatitis (not good location, no history)
d. Stasis dermatitis
e.
Tinea corporis (more superficial) 39
Stasis dermatitis
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Case Four, Question 2
You correctly diagnose Mrs. Gosnel with stasis dermatitis. What do you recommend?
a. Bacitracin ointment twice daily b. Daily oral trimethoprim-sulfamethoxazole c. Debridement of superficial erosions d. Elevation and compression stockings e. Immediate referral to vascular surgery 41
Case Four, Question 2
Answer: d
You correctly diagnose Mrs. Gosnel with stasis dermatitis. What do you recommend?
a. Bacitracin ointment twice daily (likely to cause allergic contact dermatitis) b. Daily oral trimethoprim-sulfamethoxazole (no active infection) c. Debridement of superficial erosions (may worsen)
d. Elevation and compression stockings
e. Immediate referral to vascular surgery (not indicated for most stasis dermatitis) 42
Stasis dermatitis
Venous stasis dermatitis is an eczematous eruption that occurs in venous insufficiency and leg edema • Acute eczematous dermatitis (itchy red scaly plaques) leads to chronic eczematous dermatitis; may be weepy • Extravasation leads to brown pigmentation and petechiae • Venous ulcers may result, especially on medial malleolus
Refer to the module on Stasis Dermatitis and Leg Ulcers for more information
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Stasis dermatitis: Treatment
Reduce edema with
elevation compression stockings
and Wet compresses may aid in healing erosions or ulcers
Mid-potency topical steroids
control inflammation Avoid topical antibiotics
because up to half develop allergic contact dermatitis
, especially to
neomycin and bacitracin
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Quick Case: Dark spot on the leg
This 32-year-old man who had a small laceration two years ago and presents with a dark spot He’s worried it might be something bad 45
Quick Case: Diagnosis?
What is the most likely diagnosis?
a. Drug-induced pigmentation b. Melanoma c. Postinflammatory hyperpigmentation d. Post-traumatic fungal infection 46
Quick Case: Diagnosis?
Answer: c
What is the most likely diagnosis?
a. Drug-induced pigmentation b. Melanoma
c. Postinflammatory hyperpigmentation
d. Post-traumatic fungal infection 47
Postinflammatory hyperpigmentation
Postinflammatory hyperpigmentation describes a common phenomenon of darkening of the skin at or around sites of injury or inflammation • Individuals with olive or slightly darker complexion are at particular risk • The pigmentation takes months to years to fade but usually improves gradually over time 48
Postinflammatory hyperpigmentation
Reassure patients this is normal • This is not a scar; it’s just increased pigment • Use sunscreen after injuries or surgical procedures • For significant or problematic hyperpigmentation, refer to a dermatologist 49
Postinflammatory hypopigmentation
Some patients heal with light spots instead Stigma may be caused by fear of infectious diseases Social impact can be more severe than original rash Pigmentation may return slowly It is important to treat rashes aggressively to avoid this if possible 50
Common dark rashes
Tinea versicolor Melasma Drug pigmentation Stasis dermatitis Postinflammatory hyperpigmentation 51
Take Home Points: Dark Rashes
Tinea versicolor may be hyperpigmented Symmetric brown patches on the zygomatic, buccal, and mandibular cheeks of adult women are usually melasma Some medications (especially minocycline) cause hyperpigmentation; warn patients and monitor for it Venous stasis can cause hyperpigmentation Postinflammatory hyperpigmentation and hypopigmentation are very common in darker skin types, so treat skin conditions aggressively 52
Acknowledgements
This module was developed by the American Academy of Dermatology Medical Student Core Curriculum Workgroup from 2008-2012.
Primary author: Patrick McCleskey, MD, FAAD.
Peer reviewers: Timothy G. Berger, MD, FAAD; Peter A. Lio, MD, FAAD; Jennifer Swearingen, MD; Sarah D. Cipriano, MD, MPH.
Revisions: Patrick McCleskey, MD, FAAD. Last revised April 2011.
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References
Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The Web Based Illustrated Clinical Dermatology Glossary. MedEdPORTAL; 2007. Available from: www.mededportal.org/publication/462.
Habif TP. Clinical Dermatology: a color guide to diagnosis and therapy, 4 th ed. New York, NY: Mosby; 2004.
Layton AM, Cunliffe WJ. Minocycline induced skin pigmentation in the treatment of acne —a review and personal observations. J Dermatol Treatment 1989;1:9-12.
Lio PA. Little white spots: an approach to hypopigmented macules. Arch Dis Child Pract Ed 2008;93:98-102.
Marks Jr JG, Miller JJ. Chapter 13. White Spots (chapter). Lookingbill and Marks’ Principles of Dermatology, 4 th ed. Elsevier; 2006:187-197. Wolverton SE. Systemic drugs for infectious diseases (Chapter 5) and Topical Antifungal Agents (Chapter 29). Comprehensive Dermatologic Drug Therapy, 2 nd ed. Elsevier; 2007: 80-99, 547-559.
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