DERMATOLOGY LOOK‐A‐LIKES
PEGGY VERNON, RN, MA, C‐PNP,FAANP
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
1
DISCLOSURESDISCLOSURES
• There are no financial relationships with
l d lcommercial interests to disclose
• Any unlabeled/unapproved uses of drugs or • Any unlabeled/unapproved uses of drugs or
products referenced will be disclosed
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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RESTRICTIONSRESTRICTIONS
P i i t d t th N ti l N • Permission granted to the 2019 National Nurse
Practitioner Symposium and its attendees
• All rights reserved. No part of this presentation may
b d d d d fbe reproduced, stored, or transmitted in any form or
by any means without written permission of the
author
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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ObjectivesObjectives
b d l h fI. Describe and list two treatment choices for
tinea capitus p
II. Identify two clinical differences between
pityriasis rosea and tinea corporis.
III D ib h diff i l b III. Describe the difference in scale between
atopic dermatitis and psoriasis©PVernon2019
p p
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Alopecia Areatap
• Localized area of hair loss in round, oval, or reticulated, diffuse patterns
• Noninfectious, nonscarring
• Scalp is the most Scalp is the most common site
• Can occur at any age, but most common <25 years most common <25 years of age
• 10‐20% have family history of AA
©PVernon2019
history of AA
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Diagnosis Alopecia Areatag p
l d• Visual diagnosis
• KOH and fungal cultures
negative
• ANA to rule out SLE• ANA to rule out SLE
• RPR to rule out
secondary syphilis
• Biopsy
©PVernon2019
p y
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Treatment Alopecia Areatap
• Systemic topical • Systemic, topical,
intralesional
corticosteroidscorticosteroids
• Off label: Imiquimod
(Aldara®), anthralin,
squaric acid,
immunomodulators
• Psychological support
©PVernon2019
g
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Associated Disorders
• Associated autoimmune disorders: thyroiditis, y ,
Down syndrome, autoimmune
polyendocrinopathy‐candidiasis‐ectodermal
dysplasia syndromedysplasia syndrome
• Nails: fine pitting (hammered brass), mottled
lunula, rough nails, separation of nail from matrix
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Tinea Capitus• Most common fungal
infection in children• More common in black
boys• Noninflammatory scaling Noninflammatory scaling
and broken‐off hairs• Severe, painful
inflammation with boggy inflammation with boggy nodules (kerion) can result in scaring
• Palpable lymph nodes• Palpable lymph nodes• Contagious
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Treatment Tinea Capitusp• Topical antifungal agents
ineffective• Griseofulvin: Microsized
15mg/kg/day for at least 6 weeks to several months; better with high fat mealbetter with high fat meal
• Terbinafine: 250 mg/day (10mg/ml solution) 4‐6 weeks
• Itraconazole: 100mg capsules Itraconazole: 100mg capsules or oral solution (10 mg/ml) 3‐4 weeks
• Fluconazole: 6mg/kg/day 2 k kweeks, repeat at 4 week
intervals• Ketoconazole: 5mg/kg/day
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Adjunctive Therapyj py
P d i /k /d • Prednisone 1mg/kg/day
for 14 days for painful
kerion
• Systemic antibiotics for • Systemic antibiotics for
culture positive for
s.aureus or GAS
• Surgery to drain kerion©PVernon2019
Surgery to drain kerion
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Wooly Hair SyndromeWooly Hair Syndrome
• Light colored
• Sparse distribution
• Coarse woolly hair• Coarse, woolly hair
• Short, kinky, slow
growing
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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ASSOCIATED ABNORMALITIESASSOCIATED ABNORMALITIES
• Autosomal recessive: palmoplantar
h k h l hhyperkeratosis, heart anomalies, right
ventricular cardiomyopathyventricular cardiomyopathy
• Present at birth
• Autosomal dominant most common
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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TREATMENTTREATMENT
l l bl• No treatment currently available
• Screen for heart anomalies• Screen for heart anomalies
• Genetic counselingg
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Pityriasis AmiantaceaPityriasis Amiantacea• Distinct scalp disorderp• Female predilection: young
adults, adolescents, and childrenchildren
• Clinical diagnosis: Adherent thick silver scales which
d d bi d d h i surround and bind down hair tufts. Scale attached to hair shaft and scalp
• Scale resembles asbestos• Fungal cultures usually negative• Staph most common
©PVernon2019
• Staph most common
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Pityriasis Amiantacea TreatmentPityriasis Amiantacea Treatment
• Mineral oil soaks prior to • Mineral oil soaks prior to
shampoo
• Keratolytic shampoo:
Salicylic acid, Clobetasol,
Silver sulfadiazine,
ketoconazole
• Topical corticosteroids
• Oral Antibiotics©PVernon2019
Oral Antibiotics
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Papulosquamous Disorders
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Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Tinea Versicolor
• Latin: “Tinea of various • Latin: Tinea of various colors”
• Yeast Malassezia furfurYeast Malassezia furfur• Multiple oval macules• Fine scale• Fine scale• Neck, shoulders, chest,
upper back armsupper back, arms• Color dependent on
season and pigmentation©PVernon2019
season and pigmentation
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Diagnosis and Treatment• KOH: multiple short, curved
hyphae and circular spores‐‐‐spaghetti and meatballs
• Wood’s light: orange fluorescence
• Topical antifungal creams: costly
• Ketoconazole or selenium • Ketoconazole or selenium sulfide shampoo 30 minutes daily for one week then monthly for 3 monthsmonthly for 3 months
• Oral ketoconazole, fluconazole, or itraconazole daily for 2
f ff©PVernon2019
weeks for difficult cases
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Pityriasis Roseay
• Herald patch: oval, Herald patch: oval, salmon colored patch with fine collarette of scale; develops over 1‐2 ; pweeks
• Smaller oval plaques follow lines of Blashko in follow lines of Blashko in “christmas tree”configuration
• Usually confined to trunk • Usually confined to trunk, proximal arms and legs, rarely on face; never on palms and soles
©PVernon2019
palms and soles
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Diagnosis and Treatmentg
• Biopsy if unclear• Biopsy if unclear
• Spontaneous remission in
6‐12 weeks
• Treat symptomatically:Treat symptomatically:
– Antihistamines for itching
– Topical glucocorticoids
– UVB
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Nummular Dermatitis• Latin: nummularis “like
”a coin”
• Plaques and papulesaques a d papu es
• Erythema, scale, often
crusted
• Pruritus often intense• Pruritus often intense
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Diagnosis and Treatmentg
• Bacterial culture of crusts
• Topical steroids• Antihistamines for
itching• Moisturizers• Systemic antibiotics if
S.aureus is present
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Tinea Corporisp
O l • One or several circular
th t erythematous patches
• Central clearing, occasionally follicular pustules
• Usually unilateral©PVernon2019
y
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Diagnosis and Treatment• Visual diagnosis• KOH: scrapings of the border
of the lesion• Fungal culture• Misdiagnosed cases treated g
with topical steroids will not display scaling; annular border may be obscured (tinea incognito)
• Treat with topical antifungal agents BID for 2‐3 weeks to
l lensure complete resolution• Occasionally oral antifungal
agents for severe or l
©PVernon2019
recalcitrant cases
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Psoriasis
• Erythematous/violaceous plaques and papules with thick silvery‐white scale, sharply marginated
• Scalp, ears, elbows, knees, gluteal crease
• Guttate: Latin guttata “dew drop”• Guttate: Latin guttata dew drop
– Discrete papules mostly on trunktrunk
– Follows URI, Strep
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Diagnosis and Treatmentg• Visual Diagnosis• Culture for oral and rectal strep;
ASOASO• Treat with oral antibiotics for
guttate • Moderate to high potency
steroidssteroids• Topical calcipotriene (Vitamin D3
analog)• Topical tazoratene (Vitamin A)
UVA UVB• UVA;UVB• Systemic steroids
contraindicated• Educate: chronic nature of
didisease• Guttate: likely to develop plaque
psoriasis within 5 years
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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F D i iFoot Dermatitis
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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PsoriasisPsoriasis
• Thick scale• Fissures and Bleeding• Only on the soles of
feet• Previously treated with
topical anti‐fungal creams
• Long‐standing history
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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PSORIASIS DIFFERENTIALPSORIASIS DIFFERENTIAL
• Tinea Pedis
• Atopic Dermatitis
• Contact Dermatitis
• Psoriasis
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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PSORIASIS
• 1‐3% of the population
• 25‐45 & after age ten
• one third of adults with psoriasis developed before • one‐third of adults with psoriasis developed before
age 16
• Both sexes affected equally in adults
• Familial tendency
• Up to 42% have psoriatic arthritis©PVernon2019
Up to 42% have psoriatic arthritis
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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PSORIASIS PATHOPHYSIOLOGYPSORIASIS PATHOPHYSIOLOGY
Ch i i fl t t i di• Chronic, inflammatory, systemic disease
• Epidermis thickened, silver‐white scaleEpidermis thickened, silver white scale
• Transit time from basal cell layer to surface of
skin in 3‐4 days, compared to normal cell
t it ti f 8 dtransit time of 20‐28 days
• Itching variable©PVernon2019
Itching variable
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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PSORIASIS TREATMENT• Ultraviolet B (UVB)
• Ultraviolet A (UVA) • Systemic DrugsA it ti (S i t ®)• PUVA (psoralens with UVA)
• Home UVB
– Acitretin (Soriatane®)– Methotrexate (MTX)– Cyclosporine (CsA)– Apremilast (Otezla®)– Adjunct Therapies
– Topical Steroids
Vit i A d D d i ti
– Apremilast (Otezla®)• Biologic Therapy
– Alefacept (Amevive®)– Etanercept (Enbrel®)– Vitamin A and D derivatives
– Topical calcineurin inhibitors
Intralesional steroid
ta e cept ( b e )– Adalimumab (Humira®)– Infliximab (Remicade®)– Ustekinumab (Stelara®)– Intralesional steroid
injections
– Coal Tar (Scytera®)
– Ixekizumab (Taltz®)– Secukinumab (Cosentyx®)– Tildrakizumab (Ilumya®)
©PVernon2019
Coal Tar (Scytera )
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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PITTED KERATOLYSIS• Superficial bacterial infection
of the soles of the foot, lateral toes, occasionally , ypalms
• Asymptomatic erythematous plaques and circular shallow p qpits on weight‐bearing areas; occasionally painful
• Often misdiagnosed as tineag• Hyperhidrosis, moist socks,
humid environment, occlusive shoes and
l dprolonged immersion in water are predisposing factors
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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TreatmentTreatment• Remove environment, promote drynessRemove environment, promote dryness
• 20% aluminum chloride (Drysol®) BID
• Alcohol‐based benzoyl peroxide
• Topical erythromycin or clindamycin
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Warts• HPV induced benign
epidermal tumorsS li l i l ki• Solitary or multiple, skin‐colored to light tan
• Grouped appear within • Grouped, appear within sites of trauma
• Variable history, incubation y,unknown, transmission to others well‐documented
• Spontaneous remission within 24 months
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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TreatmentHIn‐office
• Cryotherapy
Home
• Cantharidin
• Injection therapy
• OTC products
• Injection therapy
– Candida• Squaric Acid
• Immiquiod – Bleomycin
• Laser therapy
q
• Retinoids py
• Surgical excision• Cimetidine
• Watchful Waiting©PVernon2019
Watchful Waiting
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Tinea Pedis
• Most common in post‐Most common in postpubertal
• Vesicles and erosions on instep
• Occasional fissuring between toes with erythema and scale f d kof surrounding skin
• Dorsum of toes and feet sparedspared
• Often unilateral
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Diagnosis and Treatment
• Visual diagnosis
• KOH
• Fungal culture
• Treat: topical Treat: topical
antifungal creams BID
for 2‐4 weeks
• Rarely oral medications©PVernon2019
Rarely oral medications
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Dyshidrotic Eczemay
• Recurrent eruption of palms soles lateral palms, soles, lateral aspects of digits
• Inflammatory vesicles, Inflammatory vesicles, pruritic, burn
• Symmetricaly• Hyperhidrosis
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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TreatmentTreatment• Dry environment
• Aluminum chloride 12% (Certain Dry®) or
20% (Drysol®)
• Topical steroids• Topical steroids
• Tacrolimus (Protopic) ointment; p
Pimecrolimus (Elidel)
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Juvenile Plantar Dermatosis
• Cracked, shiny, dry on , y, y
weight‐bearing surface
• Painful fissures
• Common in children • Common in children
and preadolescents
• Symmetrical
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Treatment• Ointments (Aquaphor,
Vaseline) immediately Vaseline) immediately
after removing shoes
d kand socks
• Cotton socks
• Topical steroids for
inflammationinflammation
• Immunomodulators
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Nail DisordersNail Disorders
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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LICHEN PLANUS
• Unique inflammatory cutaneous and mucocutaneous eruption
• Unknown etiology• Unknown etiology• Purple, flat‐topped
polygonal papules• Oral lesions on buccal
mucosa (wickham’s striae)N i f th il ith • Narrowing of the nails with overgrowth of fibrous tissue proximally to distally
©PVernon2019
©Pvernon 2015
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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LICHEN PLANUS: TREATMENT
• Topical corticosteroids p
• Antihistamines for
pruritus
• Immunomodulators• Immunomodulators
• Permanent damage g
rare
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Twenty Nail Dystrophy(T h h )(Trachyonychya)
• Longitudinal ridgingg g g
• Pitting
• Loss of Lustre
R h i f il • Roughening of nail
surface
• Change in color:
dd h©PVernon2019
muddy, grey‐white
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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PSORIASIS NAILS
• Pittingg
• Yellowing of distal
tiportion
• Separation of nail plate
(onycholysis)
• Thickening of entire Thickening of entire
nail (hyperkeratosis)
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Psoriasis Nails Treatment• Corticosteroids
• Tazorac gel .05‐.1%
C l i i • Calcipotriene
• Moisturizers
• Treat underlying
disease
• Keep nails trimmed©PVernon2019
• Keep nails trimmed
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Onychomycosis (Tinea unguium)
• Fungal infection of the nail
• Hyperkeratotic brittle nails with Hyperkeratotic brittle nails with
thick sub‐ungual debris
• Caused by dermatophytes, Caused by dermatophytes,
Candida, or molds
• Risk Factors: poor circulation, p ,
diabetes, perspiration, humid
environment, damp public
places (gyms, swimming pools,
shower rooms), presence of
h f l f©PVernon2019
other fungal infections
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Onychomycosis Diagnosis and T t tTreatment
• Diagnosis: clinical, KOH smear, l b h dculture, biopsy with PAS (periodic
acid‐Schiff stain)• Treatment:
– Topical: Ciclopirox (Penlac, Loprox TS) daily, amorolfine weekly efinaconazole (Jublia®) weekly, efinaconazole (Jublia ) daily
– Oral: Terbinafine (Sporonox®) 6% ff ti It l 76% effective, Itraconazole (Lamisil®) 60% effective, Fluconazole 48% effective
©PVernon2019
– Laser therapy: low quality
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Alopecia Areata Nailsp
• Disorder of
keratinkeratin
• Treat underlying • Treat underlying
disorderd so de
• Moisturizers©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Nail Tic
• Repeated trauma to
il t inail matrix
• Transverse ridgesTransverse ridges
• Central depressionp
• Cuticle hypertrophy
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Nail Tic
• Repeated trauma to Repeated trauma to
nail matrix
• Transverse ridges
• Central depression
• Cuticle hypertrophy
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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OnychomadesisOnychomadesis
• Painless Painless
spontaneous
separation of
i l il lproximal nail plate
©PVernon2019
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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Onychomadesisy
• Trauma (e g subungual • Trauma (e.g. subungual haematoma)
• Inflammation or infection (fever, HFM disease)
• Peripheral vascular diseaseR d’• Raynaud’s
• Familial trait
©PVernon2019
©Pvernon 2015
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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MelanomaMelanoma
©PVernon2019
©Pvernon 2015
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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ReferencesBobonich, M, Nolen, M. Dermatology for Advanced Practice Clinicians. Wolters Kluwer, 2015. First Edition.
• Bolognia, Jean L., et al. Dermatology. Mosby, 2003.• Habif, Thomas. Clinical Dermatology. Fourth Edition, Mosby,
2004.4• Schachner, Lawrence A. & Hansen, Ronald C. Pediatric
Dermatology, Third Edition, Mosby, 2003. • Wolff Klaus & Hohnson Richard A Fitzpatrick’s Color Atlas & Wolff, Klaus & Hohnson, Richard A. Fitzpatrick s Color Atlas &
Synopsis of Clinical Dermatology, Sixth Edition, McGraw Hill, 2009
• Pediatric Annals, Vol. 36, No 12, Dec. 2007; Persistent Facial Pediatric Annals, Vol. 36, No 12, Dec. 2007; Persistent Facial Dermatitis: Pediatric Perioral Dermatitis.
• Consultant for Pediatricians, Vol. 8, No. 3, March 2009; Dermclinic.
©PVernon2019
Dermclinic.
Dermatology Look-a-Likes Peggy Vernon, RN, MA, C-PNP, DCNP, FAANP Pre 2
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