Contents
This edition first published 2009, © 2009 by Margaret W. Mann, David R. Berk, Daniel L. Popkin, and Susan J. Bayliss
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Library of Congress Cataloging-in-Publication Data
Handbook of dermatology: a practical manual/Margaret W. Mann… [et al.].
p.; cm.
Includes bibliographical references and index.
ISBN 978-1-4051-8110-5 (pbk.: alk. paper) 1. Dermatology—Handbooks, manuals, etc. 2. Skin— Diseases—Handbooks, manuals, etc. I. Mann, Margaret W.
[DNLM: 1. Skin Diseases—diagnosis—Handbooks. 2. Skin Diseases—therapy—Handbooks. 3. Dermatologic Agents—therapeutic use—Handbooks. WR 39 H2357 2008]
RL74.H36 2008
616.5—dc22
2008015533
ISBN: 978-1-4051-8110-5
Preface
Welcome to the first edition of Handbook of Dermatology: A Practical Manual, a pocket guide designed for practicing dermatologists, dermatology residents, medical students, and physicians in other fields who may be interested in dermatology. Written and edited by former residents and attending physicians in the Division of Dermatology at Washington University School of Medicine, this book is based on an in-house resident handbook which has been used by our department for the past five years. Our goal was to compile and consolidate need-to-know dermatologic information for daily use in patient care and resident and fellow education. As such, it represents the indispensable pocket-sized quick reference which we had wanted during our training and which we now use in our practices.
Currently, there are multiple in-depth dermatology textbooks and atlases, most of which are too bulky to be carried around in the clinic. Our manual concisely presents data in outline, bullet-point, and table formats such that information is manageable and easily retrievable. The compact design is lightweight, allowing information to be accessible in seconds during clinics, facilitating patient care. We have tried to balance space limitations with the need to cover a subject in sufficient detail.
Our manual has three main sections – medical dermatology, surgical dermatology, and pharmacology/treatment. Each section is designed to provide the reader with up-to-date, comprehensive yet concise information for patient care. In addition to core material, we sought to consolidate the information which we found ourselves most often looking up, which our attendings most frequently quizzed us on, and which were emphasized on the dermatology board exam. The manual consolidates the dermatologic algorithms, protocols, guidelines, staging and scoring systems which we find most essential. Each section is designed for easy reference, with tabular and graphic information throughout. The diseases covered are those which we frequently encountered in clinic, on call, during teaching conferences, and on board exams.
We hope you will find this manual helpful to you in providing care to your patients. We welcome your input as this manual continues to evolve.
Margaret W. Mann
David R. Berk
Daniel L. Popkin
Susan J. Bayliss
Dedication
We wish to express our thanks to the many people who have inspired us to write this book and supported us in our careers. Special thanks to the following physicians who contributed to the manuscript: Drs. Paul Klekotka, Alison Klenk, and Neel Patel – who helped make the prototype possible – without you, this manual would never have happened; Drs. Milan Anadkat, Grace Bandow, Amy Cheng, Michael Heffernan, Yadira Hurley, and David Smith for their valuable contributions; Drs. Stacey Tull and Quan Vu for the beautiful drawings; Drs. Senait Dyson, Kristen Kelly, and Anne Lind for their proofreading and comments; and finally Drs. Lynn Cornelius, Arthur Eisen, and all the faculty in the Division of Dermatology at Washington University for their support and encouragement.
Margaret Mann would like to thank her parents and her ever-patient husband, Daniel, for all the love and support over the years.
David Berk wishes to thank his family, especially his wife Melissa and his parents, for their constant support and patience.
Daniel Popkin would like to thank his parents and his wife Margaret.
Susan Bayliss wishes to thank her grandsons Cai and Eli Kenemore, and her daughters Elizabeth Kenemore and Meredith Mallory for all the joy they constantly bring her.
Abbreviations
ACD | allergic contact dermatitis |
AD | autosomal dominant |
AFB | acid fast bacilli |
AK | actinic keratoses |
ANA | anti-nuclear antibody |
ANCA | anti-neutrophilic cytoplasmic antibody |
APS | antiphospholipid syndrome |
AR | autosomal recessive |
ASO | antistreptolysin O titer |
asx | asymptomatic |
BCC | basal cell carcinoma |
BID | twice daily |
BM | bone marrow |
BMP | basic metabolic panel |
BMZ | basement membrane zone |
BP | bullous pemphigoid |
BP | blood pressure |
Bx | biopsy |
Ca++ | calcium |
CAD | coronary artery disease |
CBC | complete blood count |
CCB | calcium channel blocker |
CF | cystic fibrosis |
cGVHD | chronic graft-versus-host disease |
CH50 | total hemolytic component |
CMP | complete metabolic panel |
CMV | cytomegalovirus |
CN | cranial nerve |
CNS | central nervous system |
CP | cicatricial pemphigoid |
CR | creatinine |
CRF | chronic renal failure |
CRP | C-reactive protein |
Cryo | cryoglobulinemia |
CT | computed tomography |
CTCL | cutaneous T-cell lymphoma |
CTD | connective tissue disease |
CVA | cerebral vascular accident |
Cx | culture |
CXR | chest X-ray |
DCN | doxycycline |
DEJ | dermal–epidermal junction |
DF | dermatofibroma |
DFA | direct fluorescent antibody |
DFSP | dermatofibrosarcoma protuberans |
DH | dermatitis herpetiformis |
DHEA-S | dehydroepiandrosterone sulfate |
DI | diabetes insipidus |
DIF | direct immunofluorescence |
DM | dermatomyositis |
DM2 | diabetes mellitus type II |
Dsg | desmoglein |
Dz | disease |
EBA | epidermolysis bullosa acquisita |
EBV | Epstein–Barr virus |
EDS | Ehlers–Danlos syndrome |
EED | erythema elevatum diutinum |
EKG | electrocardiogram |
EM | electromicroscopy |
EMG | electromyogram |
ENA | extractable nuclear antigen |
eos | eosinophils |
ESR | erythrocyte sedimentation rate |
ETOH | alcohol |
F | fever |
FLP | fasting lipid panel |
FMF | Familial Mediterranean fever |
G6PD | glucose-6-phosphate dehydrogenase |
GA | granuloma annulare |
GF | granuloma faciale |
GI | gastroenterology |
GVHD | graft-versus-host disease |
h/o | history of |
HA | headache |
HBV | hepatitis B virus |
HCV | hepatitis C virus |
HDL | high density lipoprotein |
Hep | hepatitis |
HSM | hepatosplenomegaly |
HSV | herpes simplex virus |
HTN | hypertension |
IBD | inflammatory bowel disease |
IIF | indirect immunofluorescence |
IL | intralesional |
IM | intramuscular |
IV | intravenous |
IVIG | intravenous immunoglobulin |
KOH | potassium hydroxide |
LAN | lymphadenopathy |
LCH | Langerhans Cell Histiocytosis |
LCV | leukocytoclastic vasculitis |
LDH | lactate dehydrogenase |
LDL | low density lipoprotein |
LE | lupus erythematosus |
LFT | liver function test |
LN | lymph nodes |
LP | lichen planus |
MCN | minocycline |
MCTD | mixed connective tissue disease |
MEN | multiple endocrine neoplasia |
MF | mycosis fungoides |
MM | malignant melanoma |
MR | mental retardation |
MRI | magnetic resonance imaging |
MTX | metrotrexate |
nl | normal |
NLD | necrobiosis lipoidica diabeticorum |
NSAIDs | non-steroidal anti-inflammatory drugs |
NXG | necrobiosis xanthogranuloma |
OCP | oral contraceptive pill |
OTC | over the counter |
PAN | polyarteritis nodosa |
PCN | penicillin |
PCR | polymerase chain reaction |
PCT | porphyria cutaneous tarde |
PET | positron emission tomography |
PFTs | pulmonary function tests |
PIH | post inflammatory hyperpigmentation |
PMLE | polymorphous light eruption |
PMNs | polymorphonuclear leukocytes |
po | per oral |
PPD | tuberculosis skin test |
PT/PTT | prothrombin time/ partial thromboplastin time |
PUVA | psoralen + ultraviolet A |
PV | pemphigus vulgaris |
QD | once a day |
QHS | every night |
QOD | every other day |
RA | rheumatoid arthritis |
RF | rheumatoid factor |
ROS | review of systems |
RPR | rapid plasma reagin (screening test for syphilis) |
Rxn | reaction |
SCC | squamous cell carcinoma |
SCM | sternocleidomastoid |
SJS | Stevens–Johnson syndrome |
SLN | sentinal lymph node |
SPEP | serum protein electrophoresis |
SQ | subcutaneous |
SS | systemic sclerosis |
SSRI | selective serotonin reuptake inhibitor |
SSSS | staphylococcal scalded skin syndrome |
Sxs | symptoms |
szs | seizures |
TB | tuberculosis |
TBSA | total body surface area |
TCA | tricyclic antidepressant |
TCN | tetracycline |
TEN | toxic epidermal necrolysis |
TG | triglycerides |
TIBC | total iron binding capacity |
TID | three times a day |
TNF | tumor necrosis factor |
TSH | thyroid stimulating hormone |
Tx | treatment |
UA | urinalysis |
UPEP | urine protein electrophoresis |
VLDL | very low density lipoprotein |
WBC | white blood cell count |
WLE | wide local excision |
XD | x-linked dominant |
XR | x-linked recessive |
X-RXN | cross reaction |
XP | xeroderma pigmentosa |
yo | year old |
Part 1
General Dermatology
Work-up Quick Reference
CTCL | CBC, LDH, Sezary prep, flow cytometry, CXR |
Vasculitis | CBC, ESR, BMP, UA, consider drug-induced vasculitis, further testing guided by ROS and type of vasculitis suspected (CRP, SPEP, UPEP, cryo, LFT, HBV, HCV, RF, C3, C4, CH50, ANA, ANCA, ASO, CXR, guaiac, cancer screening, HIV, ENA, echo, electromyogram, nerve conduction, biopsy (nerve, respiratory tract, kidney)) |
Urticaria | In children, often due to Strep Consider ASO, Rapid Strep |
Urticarial vasculitis | CBC, UA, ANA, C1, C3, C4, CH50, anti-C1q, ESR |
Lupus | ANA, ENA (Ro/La), CBC, BMP, ESR, C3, C4, UA, G6PD |
Sarcoid | BMP, Ca++, CXR, PFTs, G6PD, EKG, ophtho consult |
Angioedema | CBC, C1 est inhib, C1,C2,C4; Hereditary: C1-nl; C2,C4 and C1 est inhib-↓ (C1est inhib levels may be nl but non-functional); Acquired: C1--↓; C2,C4 and C1 est inhib-↓ |
Photosensitivity | ENA (Ro/La) |
Hypercoagulable | CBC, PT/PTT, Factor V Leiden, |
Anti-phospholipid Ab, protein C&S, prothrombin G20210A, anti-thrombin III activity, homocysteine | |
TEN | Tx: IVIG 2–4 gm/kg (total dose, divided over 2–5 days) use GammaGard if possible (low IgA) Check for IgA deficiency. See TEN protocol p. 282–283 |
Direct immunofluorescence – where to biopsy?
Source:
Diseases | Where to biopsy |
LE, MCTD, PCT, LP, Vasculitis | Erythematous border of active lesion/involved skin (avoid old lesions, facial lesions, ulcers) |
Pemphigus group, Pemphigoid group, Linear IgA | Erythematous perilesional skin (avoid bullae, ulcers, erosions) |
DH | Normal-looking perilesional skin (0.5–1 cm away) |
Lupus band | Uninvolved, non-photoexposed skin (buttock) |
False positive/negative DIFs
False negative in BP: (1) low yield of biopsy on distal extremity (esp. legs) (controversial), (2) predominantly IgG4 subclass of auto-antibody (poorly recognized on DIF)
False positive in LE: chronically sun-exposed skin of young adults
To increase DIF yield: transport in saline (reduces dermal background) – cannot do DIF on formalin-fixed specimen
Biopsy for GVHD
Biopsy for GVHD vs. lymphocyte recovery vs. drug eruption
Marra DE et al. Tissue eosinophils and the perils of using skin biopsy specimens to distinguish between drug hypersensitivity and cutaneous graft-versus-host disease. JAAD. 2004; 51(4):543–545.
Zhou Y et al. Clinical significance of skin biopsies in the diagnosis and management of graft vs host disease in early postallogeneic bone marrow transplantation. Arch Derm. 2000; 136(6):717 –721.
The Dermatologic Differential Algorithm
1. Is it a rash or growth?
2. If it is a rash, is it mainly epidermal, dermal, subcutaneous, or a combination?
3. If the rash is epidermal or a combination, try to define the characteristics of the rash. Is it mainly papulosquamous? Papulopustular? Blistering?
4. After defining the characteristics, then think about causes of that type of rash (CITES MVA PITA):
Congenital, Infections, Tumor, Endocrinologic, Solar related, Metabolic, Vascular, Allergic, Psychiatric, Iatrogenic, Trauma, Autoimmune. When generating the differential, take the history and location of the rash into account.
5. If the rash is dermal or subcutaneous, then think of cells and substances that infiltrate and associated diseases (histiocytes, lymphocytes, mast cells, neutrophils, metastatic tumors, mucin, amyloid, immunoglobulin, etc.).
6. If the lesion is a growth, is it benign or malignant in appearance? Think of cells in the skin and their associated diseases (keratinocytes, fibroblasts, neurons, adipocytes, melanocytes, histiocytes, pericytes, endothelial cells, smooth muscle cells, follicular cells, sebocytes, eccrine cells, apocrine cells, etc.).
Alopecia Work-Up
Associations
1. Medications? Telogen effluvium-associated meds: anticonvulsants, anticoagulants, chemotherapy, psychiatric meds, antigout, antibiotics, beta-blockers
2. Hormones (pregnancy, menstruation, OCPs)?
3. Hair care/products?
4. Diet (iron or protein deficiency)?
5. Systemic illness/stress?
Cicatricial or non-cicatricial?
1. Non-cicatricial: Is hair breaking off or coming out at the roots? Is hair loss focal or diffuse?
Breakage | Coming out at roots |
Hair shaft defects, trichorrhexis nodosa, hair care (products, traction, friction), tinea capitis, trichotillomania, anagen arrest/chemotherapy | Telogen effluvium, alopecia areata, androgenetic, syphilis, loose anagen, OCPs |
Focal loss | Diffuse loss |
Hair care (traction), tinea capitis, trichotillomania, alopecia areata, syphilis, hair shaft defects | Telogen effluvium, anagen effluvium, androgenetic alopecia, hair shaft defects |
2. Cicatricial: Is biopsy predominantly lymphocytic, neutrophic, or mixed?
Classification of cicatricial alopecia
Lymphocytic | Neutrophilic | Mixed |
• LPP (including classic, frontal fibrosing, Graham-Little) | • Folliculitis decalvans | • Folliculitis/acne keloidalis |
• Dissecting cellulitis/folliculitis | • Folliculitis/acne necrotica | |
• Erosive pustular dermatosis | ||
• Central centrifugal | ||
• Alopecia mucinosa | ||
• Keratosis follicularis spinulosa decalvans | ||
• Chronic cutaneous LE | ||
• Pseudopelade (Brocq) |
Adapted from Olsen EA et al. North American hair research Society Summary of sponsored Workshop on Cicatricial Alopecia. J Am Acad Dermatol 2003; 48:103–10.
Structural hair abnormalities classified by hair fragility
Increased fragility | No increased fragility |
Trichorrhexis invaginata (bamboo) | Loose anagen |
Monilethrix | Pili annulati |
Trichorrhexis nodosa | Uncombable hair (spun-glass) |
Trichothiodystrophy | Woolly hair |
Pili torti | Pili bifurcati |
Pili multigemini | |
Acquired progressive kinking |
Adapted from Hordinsky MK. Alopecias. In: Bolognia JL, Jorizzo JL, Rapini RP. Dermatology Vol. 1, Mosby; London. 2003, p. 1042.
Pull test and hair mount
1. Pull test – reveals telogen hairs in telogen effluvium, and anagen hairs in loose anagen syndrome. Helpful to identify active areas in cicatricial alopecia or alopecia areata.
2. Hair mount
Disorder | Hair mount findings |
Monilethrix | Beaded, pearl necklace, knots |
Trichorrhexis nodosa | Fractures, paint brushes |
Trichorrhexis invaginata | Bamboo/golf tee hair |
Trichothiodystrophy | Trichoschisis, tiger-tail on polarization |
Loose anagen | Anagen hairs with ruffled cuticles and curled ends and lacking root sheaths |
Pili torti | Flattened, 180º irregularly spaced twists |
Uncombable hair | Pili canaliculi et trianguli, triangular in cross section |
Pili annulati | Abnormal dark bands on polarization, air bubbles in cortex |
Elejalde | Pigment inclusions |
Griscelli | Pigment clumping |
Menkes | Multiple – pili torti, trichorrhexis nodosa, trichoptilosis |
Hair count – helpful in quantifying hair loss
1. Daily hair count: collect all hairs before shampooing (Normal is <100)
2. 60 second hair count: comb for 60 seconds (Normally yields 10–15 hairs).
Biopsy – helpful in persistent alopecia, may help determine if an alopecia is cicatricial
1. 4 mm punch biopsy for horizontal sectioning
a. Hair count: Caucasians should have ~40 total hairs (20–35 terminal, 5–10 vellus) while African Americans should have fewer (18 terminal, 3 vellus) – assess catagen vs. telogen at isthmus level and terminal vs. vellus at infundibular level.
b. Look at terminal to vellus* hair ratio:
Normal | >4 (~7–10T: 1V) |
Androgenic | <2–4T: 1V |
c. Look for characteristic findings:
Alopecia areata: lymphocytes around anagen bulbs
Trichotillomania: pigment casts, trichomalacia, catagen hairs, dermal hemorrhage
Androgenetic alopecia: miniaturized follicles.
Labs – TSH, CBC, iron, TIBC, ferritin; consider RPR, ANA; check hormones (testosterone, DHEAS, prolactin) if irregular menses, infertility, hirsutism, severe acne, galactorrhea, or virilization.
* Vellus hairs – true vellus hairs (small and lack melanin) and miniaturized terminal hairs are histologically identical.
Management of Acne