• Primary vs. secondary changes
  
• Color
  
• Consistency and texture
  
• Mobility
  
• Configuration
  
• Shape
  
• Well vs. ill-defined
  
• Arrangement
  
• Discrete
  
• Localized
  
• Grouped
  
• Disseminated

• Symmetry
  
• Dermatomal
  
• Photodistribution
  
• Mucous membrane involvement
  
• Contact areas
  
• Flexor vs extensor surfaces
  
• Koebner phenomenon: areas of previous trauma

• How long?
  
• Since birth?
  
• Recurrent?

• Sick contacts
  
• Recent travel
  
• Medications
  
• Personal care products
  
• Environmental exposures
  
• Occupational exposures
  
• Recreational exposures
  
• Seasonal variation
  
• Family history

• Local
  
• Pruritus
  
• Pain and tenderness
  
• Paresthesias
  
• Bleeding
  
• Systemic
  
• Fever or chills
  
• Malaise or fatigue
  
• Arthritis or arthralgias

S. aureus superinfection

Honey-crusted erosions, pustules, weeping, acute increase in erythema

• Topical or oral antibiotic
  
• Obtain culture

Eczema herpeticum (HSV superinfection)

• Source of contact often adult caretaker with “cold sore”

• First-degree lesions: Crops of vesicles on inflamed base at sites of eczema
  
• Late: “punched-out” erosions
  
• Common associated symptoms: Fever, malaise, irritability, intense itching, eczema flare
  
• Severe: Widespread viral dissemination with multiorgan involvement

• Stop TCS or TCI
  
• Acyclovir or valacyclovir
  
• Treat for secondary bacterial infection if indicated
  
• Treat known contacts
  
• Eye exam for periorbital involvement
  
• Obtain culture &/or DFA

Long-term TCS use

• Skin atrophy, ecchymoses, striae, telangiectasias, poor wound healing, perioral dermatitis or steroid rosacea, hypothalamus–pituitary axis suppression with systemic absorption

• Limit use for flares only (usually <1- 2-wk intervals)
  
• Use lower potency TCS for face, underarms, and groin
  
• If indicated, evaluate for adrenal suppression and treat appropriately

Postinflammatory pigment changes

• Hypo- or hyperpigmented macules or patches in areas of previous involvement
  
• Fades over months to years

Sun protection and continued treatment of flares of dermatitis

Irritant

• Acute: Erythema, scaling, edema, vesicles, pustules, erosions
  
• Chronic: Lichenification, fissures

Results from contact with a substance that chemically or physically damages skin

• Urine or feces → diaper rash
  
• Lip licking or thumb sucking
  
• Detergents or solvents
  
• Topical medications
  
• Battery acid

• May occur after single contact with a strong irritant or after repeated contact with milder irritants
  
• Rash minutes to hours after exposure

• Avoidance of irritants
  
• Emollients, barrier creams
  
• May consider TCS if no improvement (controversial)

Allergic (type IV cell- mediated immune reaction)

• Acute: Erythematous, scaly, vesicular, crusted, weeping
  
• Chronic: Lichenification, fissuring, excoriations

• Poison ivy, oak, sumac
  
• Nickel (jewelry, metal clasps, glasses)
  
• Rubber (shoes, clothing)
  
• Paraphenylenediamine (hair dyes, leather, black-dyed henna)
  
• Topical antibiotics (eg, neomycin, bacitracin)
  
• Emollients
  
• TCS

• 1° exposure → rechallenged by allergen → dermatitis
  
• Rhus (poison ivy, oak, sumac): patchy or linear vesicles or bullae on exposed surfaces 2–7 days after exposure, lasting 3–4wk

• May use patch testing to confirm diagnosis
  
• Avoidance of allergen (may take >6 wk for complete clearing of rash)
  
• Topical or systemic corticosteroids

Seborrheic dermatitis (infantile form)

• “Cradle cap”: Greasy scales on scalp
  
• Disseminated: Bilateral, well-demarcated, symmetric pink patches and plaques with scaling in diaper area, retroauricular areas, neck, trunk, and proximal extremities, prominent in skin creases/folds

• Usually begins 1wk after birth
  
• May persist for months

• Bathing
  
• Frequent moisturization
  
• Ketoconazole 2% cream if extensive or persistent
  
• Short course of low-potency TCS if inflamed

• Linked with sebum overproduction and Malassezia spp. infection

Keratosis pilaris*

• Skin-colored follicular hyperkeratotic or erythematous papules on the upper arms, thighs, cheeks

• May become more pronounced at puberty (some may improve at puberty)
  
• Often improves with age
  
• Improvement in summer; worsening in winter

• No definitive treatment
  
• May try emollients, lactic acid or glycolic acid creams, urea cream, salicylic acid, short course of TCS for inflamed areas

• Can be associated with ichthyosis vulgaris, atopic dermatitis

Pityriasis alba

• Small, ill-defined, symmetric, hypopigmented patches with fine scales, often on cheeks; may be seen on upper extremities

• May become more obvious in summer on tanned skin
  
• May last for months to years
  
• Resolves spontaneously

Emollients, low-potency TCS, sunscreen

Pityriasis rosea

• “Herald” patch: Initial 1- to 10-cm salmon-colored oval patch or plaque with collarette of fine scale, usually on trunk
  
• Within days: “Christmas tree” distribution of oval, hyperpigmented, smaller, thin plaques or papules similar to a herald patch on trunk
  
• Face, palms, soles usually spared
  
• May see oral erosions
  
• Inverse pityriasis rosea: Variant involving axillae and inguinal areas; more common in younger children and darker-skinned patients

• Most common in adolescents and young adults
  
• More common in spring

• Reassurance
  
• TCS ± PO antihistamine PRN for pruritus
  
• Possible benefit of 14-day course of erythromycin† (controversial)
  
• UVB light treatment for severe cases

• May have mild prodrome: Fever, HA, malaise
  
• May be pruritic
  
• Lasts 6–8 wk; sometimes months
  
• May be mimicked by syphilis (check RPR if indicated)
  
• Possible association with HHV-6, HHV-7

Psoriasis‡

• Well-demarcated erythematous papules and plaques with thick, silvery scales; often on elbows, knees, scalp, trunk, but can occur anywhere
  
• Diaper area in infants
  
• Scalp scaling, papules & plaques
  
• Nail dystrophy pitting, other

• Guttate type: Drop-like lesions on trunk, often after streptococcal infections, URI
  
• Localized pustular type: Discrete pustules, scaly plaques on palms or soles
  
• Generalized pustular type: Erythema with sheets of small pustules, migratory annular erythematous plaques on tongue, possible after corticosteroid withdrawal, fever, arthralgias
  
• Koebner phenomenon

• Topical corticosteroids, calcipotriene, coal tars, phototherapy, methotrexate, cyclosporine, acitretin, TNF-α inhibitors, mycophenolate mofetil
  
• Never use systemic steroids because of psoriasis flares when stopped

• Inverse psoriasis: Variant involving flexural areas

Mild comedonal

Open comedones (blackheads) or closed comedones (whiteheads)

Accumulation of keratinous debris in pilosebaceous unit → occlusion of follicles → sebum accumulation

Topical retinoid ± BPO

Continue treatment for at least 2–3 mo

Moderate to severe comedonal

Same but more extensive

Mild inflammatory

Scattered small papules or pustules

Proliferation of Propionibacterium acnes → inflammation

Topical retinoid ± topical antibiotic ± BPO

• Until no new lesions, then taper off antibiotics
  
• Usually 2–4 mo

Moderate inflammatory

Generalized papules or pustules on face or trunk

Topical retinoid ± oral antibiotic ± BPO

Nodulocystic

Large, deep inflammatory nodules, cysts

Isotretinoin

• 4–6+ mo
  
• Total dose: 120–150 mg/kg

BPO

Bactericidal

2.5%, 5%, and 10% gel, liquid, cream

Dryness, irritation, desquamation, may bleach clothing

Topical retinoid (tretinoin, adapalene, tazarotene)

Normalizes keratinocyte desquamation, anti-inflammatory

Use highest concentration tolerated, pea-sized amount every evening

Dryness, desquamation, irritation, photosensitivity

Topical antibiotics

Eliminate P. acnes from follicles

Erythromycin 2% solution, clindamycin 1% solution

Rarely pseudomembranous colitis with clindamycin

Systemic antibiotics

Reduce resident skin bacteria, inhibit neutrophil chemotaxis, alter macrophage and cytokine production

• Doxycycline 50–200 mg/d
  
• Minocycline 50–200 mg/d
  
• Tetracycline 250–1500 mg/d
  
• Trimethoprim/Sulfamethoxazole

• Candidiasis, photosensitivity, GI upset, pseudotumor cerebri
  
• Minocycline: Drug-induced lupus, blue-gray hyperpigmentation, drug hypersensitivity

Use Tetracycline, Doxycycline, Minocycline only in patients >8 yo

Isotretinoin

Reduce sebum secretion → decreased P. acnes proliferation, inhibits comedogenesis, anti-inflammatory properties

Total treatment course of 120–150 mg/kg over 4-6+ mo

Teratogenicity, cheilitis, dryness, peeling, photosensitivity, pruritus, hypertriglyceridemia, possible association with depression or suicide,* hepatoxicity, bone marrow suppression, pseudotumor cerebri, IBD†

• Registration with IPLEDGE and two forms of birth control (one may be abstinence)
  
• Check monthly: pregnancy test, CBC, liver enzymes, lipid profile

Hormonal

Blocks androgen production → reduces sebum production

• FDA approved: Estrostep, Ortho Tri-cyclen, Yaz
  
• Spironolactone 50–100 mg BID

• OCPs: Nausea, abnormal menses, weight gain, breast tenderness, thrombophlebitis, pulmonary embolism, hypertension
  
• Spironolactone (dose related): Hyperkalemia, abnormal menses, breast tenderness, HA, fatigue

• Especially useful for those who have premenstrual flares or in PCOS patients
  
• Consultation with gynecologist or endocrinologist

Hemangioma

• Circumscribed, bright red masses; blue if deeper
  
• More common in girls, preterm or LBW infants, infants from multiple gestations

• Usually appear within days to few weeks of age
  
• Growth phase: First 6–9 mo
  
• Slow involution: 50% resolve by 5 yr, 70% by 7yr, 90% by 9 yr

• Observation for most
  
• Vaseline and topical antibiotics for minor ulceration or bleeding
  
• Treatment decision based on size, location, functional problems
  
• Prednisone, intralesional corticosteroids, vincristine, IFN-α propanolol (isolated reports)*

• Kasabach-Merritt syndrome: Tufted angioma, kaposiform hemangioendothelioma, platelet sequestration → thrombocytopenia with risk of severe hemorrhage
  
• PHACES: Posterior fossa malformation, segmental hemangioma, arterial anomalies, cardiac anomalies, eye anomalies, sternal cleft or supraumbilical raphe
  
• Lumbosacral: May be associated with tethered spinal cord or GU abnormalities

Capillary malformation (port wine stain, nevus flammeus)

• Pink to purple, sharply demarcated patches

• Present at birth
  
• Darken with age
  
• Some expand at puberty, with illness or trauma
  
• Regression is not expected

• Observation, symptomatic care, laser, surgery

• Sturge-Weber syndrome: Port wine stain in V1 distribution, ipsilateral meningeal and cortical vascular malformations, seizures, mental retardation, glaucoma
  
• Klippel-Trenaunay syndrome: Ipsilateral hypertrophy of limb or body part (caused by bone and soft tissue hypertrophy) in association with varicose veins, capillary malformation, ± arteriovenous fistulas (Parkes-Weber)