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CURRENT medical diagnosis treatment study g


CURRENT
Me dica l Dia gnos is
& Tre a tme nt
S tudy Guide
S e cond Edition
Edited by
Gene R. Quinn, MD, MS
Division of Cardiovascular Disease
Department of Medicine
Beth Israel Deaconess Medical Center
Boston
Nathaniel W. Gleason, MD
Maxine A. Papadakis, MD
Stephen J. McPhee, MD
Department of Medicine
University of California
San Francisco

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Contents
Preface

v

Skin Disorders
1. Atopic Dermatitis
2. Contact Dermatitis
3. Psoriasis

Pulmonary/Ear, Nose,
and Throat Disorders
4. Asthma
5. Chronic Obstructive
Pulmonary Disease
6. Cough
7. Dyspnea
8. Lung Cancer
9. Pharyngitis
10. Pneumonia
11. Pulmonary Embolism
12. Sinusitis (Bacterial)

1
2
7
12

17

13. Acute Myocardial In arction
14. Aortic Regurgitation
15. Aortic Stenosis
16. Chest Pain
17. Dyslipidemia
18. Heart Failure
19. Hypertension
20. Mitral Regurgitation
21. Mitral Stenosis
22. Shock

86
94
99
105
111
117
126
140
145
149

Hematologic Disorders

155

27. Acute Cholecystitis
28. Cirrhosis
29. Colorectal Cancer

38. Breast Cancer
39. Benign Prostatic Hyperplasia
40. Dysmenorrhea
41. Prostate Cancer

29
37
43
48
56
60
70
79

85

Gastrointestinal/Liver/
Pancreas Disorders

Gynecologic/Urologic
Disorders

18

Heart/Hypertension/Lipid
Disorders

23. Hypercoagulable States
24. Iron De ciency Anemia
25. Deep Venous T rombosis and
T romboembolism
26. Vitamin B12 De ciency Anemia

30. Crohn Disease
31. Diarrhea
32. Lower Gastrointestinal Bleeding
33. Upper Gastrointestinal Bleeding
34. Viral Hepatitis
35. Acute Pancreatitis
36. Chronic Pancreatitis
37. Ulcerative Colitis

Musculoskeletal Disorders
42. Low Back Pain
43. Gout
44. Knee Pain
45. Rheumatoid Arthritis
46. Systemic Lupus Erythematosus

Kidney/Electrolyte Disorders
47. Glomerulonephritis
48. Hypokalemia
49. Hyponatremia
50. Acute Kidney Injury
51. Chronic Kidney Disease
52. Kidney Stone Disease
53. Metabolic Acidosis
54. Nephrotic Syndrome

Nervous System/Psychiatric
Disorders

156
164

55. Altered Mental Status
56. Dementia
57. Depression
58. Epilepsy
59. Bacterial Meningitis
60. Myasthenia Gravis
61. Parkinson Disease
62. Stroke
63. Smoking Cessation
64. Substance Abuse

168
175

179
180
185
193

iii

199
205
216
221
226
241
248
255

263
264
274
280
284

291
292
298
304
313
321

329
330
338
342
349
354
361
367
373

379
380
387
394
401
408
415
420
426
435
441


iv

CONTENTS

Endocrine/Metabolic
Disorders
65. Adrenocortical Insu ciency
66. Cushing Syndrome
67. ype 1 Diabetes Mellitus
68. ype 2 Diabetes Mellitus
69. Hyperaldosteronism (Aldosteronism)
70. Hypercalcemia
71. Primary Hyperparathyroidism
72. Hyperthyroidism
73. Hypothyroidism

447
448
456
463
470
482
487
492
499
506

74. Obesity
75. Osteoporosis

Infectious Disorders

512
518

525

76. Fever
77. HIV-AIDS
78. Healthcare-Associated In ections
79. In ective Endocarditis
80. Sepsis

526
532
547
553
561

Index

567


Preface
• Medical and nursing students, physician’s assistants,
nurse practitioners, house o cers, and practicing physicians will nd the clear organization and current literature re erences use ul in devising proper management
or patients with these conditions

Purpose
Current Medical Diagnosis and Treatment (CMDT) is the
leading internal medicine textbook known or its comprehensive coverage o current inpatient and outpatient
care with diagnostic tools relevant to day-to-day practice.
Facilitating its use ulness, this CMDT Study Guide, second
edition, directs readers through a case analysis o 80 o the
most common topics in internal medicine. T e CMDT
Study Guide provides a comprehensive and clearly organized synopsis o each medical topic that helps the reader
review and study or a variety o examinations, such as the
medicine clerkship shel exam, USMLE Step 2 examinations, ABIM internal medicine boards, and recerti cation
examinations. As such it will be very use ul to medical,
nursing (Adult and Family Nurse Practitioner Certi cation
Exam), pharmacy, and other health pro essional students,
Physician Assistant National Certi ying Exam (PANCE),
to house o cers, and to practicing physicians. T e CMDT
Study Guide is engaging and patient-centered since each o
the 80 topics begins with presentation o a typical patient
to help the reader think in a step-wise ashion through the
various clinical problem-solving aspects o the case. For
each topic, the CMDT Study Guide provides PubMed’s
re erences to the most current and pertinent MEDLINE
articles or that topic. Each re erence provides PMID numbers to acilitate retrieval o the relevant articles.

Organization
T e CMDT Study Guide provides comprehensive yet
succinct in ormation. Each CMDT Study Guide topic
begins with a patient presentation, ollowed by Learning
Objectives and 9 Questions to help the learner work
through the topic in the context o the patient presented.
Answers to the 9 questions are organized as Salient
Features, How to T ink T rough the Problem, Key
Features (which contain Essentials o Diagnosis, General
Considerations, and Demographics), Symptoms and
Signs, Dif erential Diagnosis, Laboratory, Imaging, and
Procedural Findings, reatments, Outcomes, and When
to Re er and When to Admit. Re erences are then provided that contain current literature citations complete
with PubMed (PMID) numbers. T e CMDT Study Guide
is a complete source o patient care in ormation or these
80 most common clinical problems! T e 80 topics in the
CMDT Study Guide were selected as the core topics or
the learner because o their importance to the eld o
internal medicine.
T e CMDT Study Guide ollows the organization
o Quick Medical Diagnosis and Treatment (QMDT)
(or Quick Dx & Rx at www.accessmedicinemhmedical.
com) and the QMDT App, and is divided into 11 sections:
• Skin Disorders
• Pulmonary/Ear, Nose, & T roat Disorders
• Heart/Hypertension/Lipid Disorders
• Hematologic Disorders
• Gastrointestinal/Liver/Pancreas Disorders
• Gynecologic/Urologic Disorders
• Musculoskeletal Disorders
• Kidney/Electrolyte Disorders
• Nervous System/Psychiatric Disorders
• Endocrine/Metabolic Disorders
• In ectious Disorders

Outstanding Features
• Eighty common internal medicine topics use ul to
learners and practitioners or patient care and to prepare or examinations
• Material drawn rom the expert source, Current Medical
Diagnosis and Treatment 2016, including tables about
laboratory tests and treatments
• In-depth, consistent, and readable ormat organized
in a way that allows or quick study and easy access to
in ormation
• Emphasis on a standard approach to clinical problemsolving with Learning Objectives, Salient Features,
Symptoms and Signs, reatment, Outcomes, When to
Re er and When to Admit, and Re erences

v


vi

PREFACE

Intended Audience

Acknowledgments

Medical students on their internal medicine clerkship will
nd this Study Guide a use ul aid as they care or patients
with these common medical problems. T e Study Guide
will assist medical students, PA students, and NP students
taking their internal medicine rotation and house o cers
to review the core topics as they prepare or standardized
examinations. Practicing physicians, physician assistants
and nurse practitioners will similarly nd the CMDT Study
Guide use ul in order to stay current in clinical problemsolving, while providing a concise summary o relevant
diagnostic laboratory, microbiologic, and imaging studies
and treatments, and recent relevant publications.

We thank our Current Medical Diagnosis and Treatment
authors or their contributions to it and we are grate ul to
the many students, residents, and practitioners who have
made use ul suggestions to this book. We hope that you
will share with us your comments about the CMDT Study
Guide.
Gene R. Quinn, MD, MS
Nathaniel W. Gleason, MD
Maxine A. Papadakis, MD
Stephen J. McPhee, MD


Skin Disorders

Musculoskeletal
Disorders

Pulmonary/Ear,
Nose and Throat
Disorders

Kidney/Electrolyte
Disorders

Heart/
Hypertension/
Lipid Disorders

Nervous System/
Psychiatric
Disorders

Hematologic
Disorders

Endocrine/
Metabolic
Disorders

Gastrointestinal/
Liver/Pancreas
Disorders

Infectious
Disorders

Gynecologic/
Urologic
Disorders


Skin Disorders
Pulmonary/Ear, Nose, and Throat Disorders
Heart/Hypertension/Lipid Disorders
Hematologic Disorders
Gastrointestinal/Liver/Pancreas Disorders
Gynecologic/Urologic Disorders
Musculoskeletal Disorders
Kidney/Electrolyte Disorders
Nervous System/Psychiatric Disorders
Endocrine/Metabolic Disorders
Infectious Disorders


2

1

Atopic Dermatitis

A 30-year-old woman presents to her primary care clinician with
an itchy rash on her hands, wrists, and arms. She states she has had
similar rashes before, which had gone away with over-the-counter
hydrocortisone cream, the rst episode occurring when she was very
young. Her past medical history includes asthma. She takes loratadine
occasionally for allergic rhinitis. Physical examination reveals plaques on
the hands, wrists, and antecubital folds, which are mildly exudative and
without scale. Laboratory testing shows eosinophilia on a complete blood
count with di erential and an elevated serum immunoglobulin E (IgE)
level.

LEARNING OBJECTIVES
Learn the clinical mani estations and objective f ndings o atopic dermatitis, and the
f ndings that distinguish it rom other skin conditions
Understand the associated diseases that predispose to atopic dermatitis
Know the di erential diagnosis o atopic dermatitis
Learn the treatments or each clinical pattern o atopic dermatitis
Know which patients are likely to have recurrent atopic dermatitis and how to prevent ares

QUESTIONS
1. What are the salient eatures o this patient’s problem?
2. How do you think through her problem?
3. What are the key eatures, including essentials o diagnosis and general considerations,
4.
5.
6.
7.
8.
9.

o atopic dermatitis?
What are the symptoms and signs o atopic dermatitis?
What is the di erential diagnosis o atopic dermatitis?
What are the laboratory f ndings in atopic dermatitis?
What are the treatments or atopic dermatitis?
What are the outcomes, including complications, prognosis, and prevention, o atopic
dermatitis?
When should patients with atopic dermatitis be re erred to a specialist?


CHAPTER 1 • ATOPIC DERMATITIS

ANSWERS
1. Salient Features
Pruritic rash in distribution o hands, wrists, antecubital olds; similar symptoms starting
in childhood; personal history o atopic conditions (asthma, allergic rhinitis); plaques with
exudates and without scale; eosinophilia; and elevated serum IgE levels

2. How to Think Through
It is important to think broadly about possible causes o rash in this patient, despite her
strong atopic history. Might this be seborrheic dermatitis? (Seborrheic dermatitis typically
looks like greasy, scaly lesions on the central ace and scalp.) A ungal in ection? (Prior
similar mani estations have resolved with topical corticosteroid treatment, making this
unlikely.) Psoriasis? (T e distribution and absence o silvery scale makes this unlikely.)
Contact dermatitis? (T is is a reasonable consideration. Contact dermatitis can be indistinguishable rom atopic dermatitis, and in this case, the rash is similarly conf ned to exposed
areas o the body.) What would raise your suspicion or contact dermatitis? (A history o
new potential allergen or irritant exposure.)
A er considering the above, a diagnosis o atopic dermatitis is most likely, given
the prior atopy (asthma and allergic rhinitis), the recurrence o similar symptoms since
childhood, the eosinophilia, and elevated IgE. How should she be treated? (Mid-potency
topical corticosteroids twice daily with subsequent tapering to low-potency corticosteroids,
and with emollient applied requently. T is patient’s presentation is unlikely to require oral
corticosteroid treatment. An oral antihistamine or itching may be help ul.) How would you
counsel this patient to prevent uture ares? (Avoid excessive bathing and hand washing.
Use mild soaps. Apply emollient a er washing. rim f ngernails and wrap a ected areas at
night to prevent scratching.)

3. Key Features
Essentials of Diagnosis
• Pruritic, exudative, or lichenif ed eruption on ace, neck, upper trunk, wrists, hands, and
antecubital and popliteal olds
• Personal or amily history o allergies or asthma
• endency to recur
• Onset in childhood in most patients; onset a er age 30 is very uncommon
General Considerations
• Also known as eczema
• Looks di erent at di erent ages and in people o di erent races
• Diagnostic criteria include
— Pruritus
— ypical morphology and distribution ( exural lichenif cation, hand eczema, nipple
eczema, and eyelid eczema in adults)
— Onset in childhood
— Chronicity
• Also diagnostically help ul are
— Personal history o asthma or allergic rhinitis
— Family history o atopic disease (asthma, allergic rhinitis, atopic dermatitis)
— Xerosis ichthyosis
— Facial pallor with in raorbital darkening
— Elevated serum IgE
— Repeated skin in ections

3


4

SKIN DISORDERS

4. Symptoms and Signs
• Itching may be severe and prolonged
• Rough, red plaques usually without the thick scale and discrete demarcation o psoriasis
a ect the ace, neck, and upper trunk; may be pruritic or exudative
• Flexural sur aces o elbows and knees are o en involved
• In chronic cases, the skin is dry, leathery, and lichenif ed
• In black patients with severe disease, pigmentation may be lost in lichenif ed areas
• During acute ares, widespread redness with weeping, either di usely or in discrete
plaques

5. Di erential Diagnosis
• Seborrheic dermatitis
• Impetigo
• Secondary staphylococcal in ections
• Psoriasis
• Lichen simplex chronicus (circumscribed neurodermatitis)

6. Laboratory Findings
Laboratory ests
• Eosinophilia and increased serum IgE levels may be present

7. Treatments
Medications
Local reatments
• Corticosteroids
— For treatment o lesions on the body (excluding genitalia, axillary or crural olds),
begin with triamcinolone 0.1% ointment or a stronger corticosteroid, then taper
to hydrocortisone 1% ointment or another slightly stronger mild corticosteroid
(alclometasone 0.05% or desonide 0.05% ointment)
— Apply sparingly once or twice daily
— aper o corticosteroids and substitute emollients as the dermatitis clears to avoid the
side e ects o corticosteroids and rebound
• acrolimus and pimecrolimus
— Do not appear to cause corticosteroid side e ects
— Sa e on the ace and eyelids
— Use sparingly and or as brie a time as possible
— Avoid in patients at high risk or lymphoma (ie, those with HIV, iatrogenic immunosuppression, prior lymphoma)
— acrolimus 0.03% and 0.1% ointment applied twice daily
E ective as a f rst-line steroid-sparing agent
Burning on application occurs in about hal but may resolve with continued
treatment
— Pimecrolimus 1% cream applied twice daily is similar but burns less
Systemic and Adjuvant T erapies
• Prednisone
— Start at 40 to 60 mg orally daily
— aper to nil over 2 to 4 weeks
— Use as long-term maintenance therapy is not recommended
• Bedtime doses o hydroxyzine, diphenhydramine, or doxepin may be help ul via their
sedative properties in reducing perceived pruritus


CHAPTER 1 • ATOPIC DERMATITIS

• Antistaphylococcal antibiotics
— Should only be used i indicated by bacterial culture
— First-generation cephalosporins may be help ul
— Doxycycline, i methicillin-resistant Staphylococcus aureus is suspected
• Phototherapy
• Oral cyclosporine, mycophenolate mo etil, methotrexate, inter eron gamma, dupilumab,
or azathioprine may be used or the most severe and recalcitrant cases
reatment by Pattern and Stage of Dermatitis
• Acute weeping lesions
— Staphylococcal or herpetic superin ection should be excluded
— Use saline or aluminum subacetate solution (Domeboro tablets) or colloidal oatmeal
(Aveeno) as soothing or wet dressings or astringent soaks or 10 to 30 minutes two to
our times a day
• Lesions on the extremities may be bandaged or protection at night
— Use high-potency corticosteroids a er soaking but spare the ace and body olds
— acrolimus may not be tolerated; systemic corticosteroids are last resort
• Subacute or scaly lesions (lesions are dry but still red and pruritic)
— Mid- to high-potency corticosteroids
In ointment orm i tolerated—creams, i not
Should be continued until scaling and elevated skin lesions are cleared and itching is
decreased
T en, begin a 2- to 4-week taper with topical corticosteroids
• Chronic, dry lichenif ed lesions (thickened and usually well demarcated)
— High-potency to ultrahigh-potency corticosteroid ointments
— Nightly occlusion or 2 to 6 weeks may enhance the initial response
— Occasionally, adding tar preparations such as liquor carbonis detergens 10% in
Aquaphor or 2% crude coal tar may be benef cial
• Maintenance treatment
— Constant application o e ective moisturizers is recommended to prevent ares
— In patients with moderate disease, topical anti-in ammatory agents can be used on
weekends only or three times weekly to prevent ares

8. Outcomes
Complications
• reatment complications
— Monitor or skin atrophy
— Eczema herpeticum, a generalized herpes simplex in ection mani ested by monomorphic
vesicles, crusts, or scalloped erosions superimposed on atopic dermatitis or other
extensive eczematous processes
• Smallpox vaccination is absolutely contraindicated in patients with atopic dermatitis or a
history thereo because o the risk o eczema vaccinatum
Prognosis
• Runs a chronic or intermittent course
• A ected adults may have only hand dermatitis
• Poor prognostic actors or persistence into adulthood: onset early in childhood, early
generalized disease, and asthma; only 40% to 60% o these patients have lasting remissions
Prevention
• Avoid things that dry or irritate the skin: low humidity and dry air
• Other triggers: sweating, overbathing, animal danders, scratchy abrics
• Do not bathe more than once daily and use soap only on armpits, groin, and eet
• A er rinsing, pat the skin dry (not rub) and then, be ore it dries completely, cover with a
thin f lm o emollient such as Aquaphor, Eucerin, petrolatum, Vanicream

5


6

SKIN DISORDERS

9. When to Refer
• I there is a question about the diagnosis, recommended therapy is ine ective, or
specialized treatment is necessary

SUGGESTED REFERENCES
Beck LA et al. Dupilumab treatment in adults with moderate-to-severe atopic dermatitis. N Engl J Med.
2014 Jul 10;371(2):130–139. [PMID: 25006719]
Coenraads PJ. Eczema. N Engl J Med. 2012 Nov;367(19):1829–1837. [PMID: 23134383]
Eichen ield LF et al. Guidelines o care or the management o atopic dermatitis: section 1. Diagnosis
and assessment o atopic dermatitis. J Am Acad Dermatol. 2014 Feb;70(2):338–351. [PMID:
24290431]
Eichen ield LF et al. Guidelines o care or the management o atopic dermatitis: section 2. Guidelines
o care or the management and treatment o atopic dermatitis with topical therapies. J Am Acad
Dermatol. 2014 Jul;71(1):116–132. [PMID: 24813302]
Kwatra SG et al. he in ra-auricular issure: a bedside marker o disease severity in patients with atopic
dermatitis. J Am Acad Dermatol. 2012 Jun;66(6):1009–1010. [PMID: 2258371]
Roekevisch E et al. E icacy and sa ety o systemic treatments or moderate-to-severe atopic dermatitis:
a systematic review. J Allergy Clin Immunol. 2014 Feb;133(2):429–438. [PMID: 24269258]
Sidbury R et al. Guidelines o care or the management o atopic dermatitis: section 3. Management and
treatment with phototherapy and systemic agents. J Am Acad Dermatol. 2014 Aug;71(2):327–349.
[PMID: 24813298]
Sidbury R et al. Guidelines o care or the management o atopic dermatitis: Section 4. Prevention o
disease lares and use o adjunctive therapies and approaches. J Am Acad Dermatol. 2014 Dec;
71(6):1218–1233. [PMID: 25264237]
Sugerman D . JAMA patient page. Atopic eczema. JAMA. 2014 Feb;311(6):636. [PMID: 24519314]


7

Contact Dermatitis

A 30-year-old woman presents to the clinic complaining that she has “an
itchy rash all over the place.” She noticed that her legs became red, itchy,
and blistered about 2 days after she had been hiking in a heavily wooded
area. She says that scratching broke the blisters and afterward the rash
became much worse and spread all over. She is convinced that the rash
could not be poison ivy because once before she was exposed to that
plant and did not develop a rash. On examination, there are erythematous
vesicles and bullae in linear streaks on both of her legs. Some areas are
weepy, with a yellowish crust. There are ill-de ned erythematous plaques
studded with papulovesicles on the trunk and arms.

LEARNING OBJECTIVES
Learn the clinical mani estations and morphologic type o eruption in contact dermatitis
Understand the actors that predispose to contact dermatitis
Know the dif erential diagnosis o contact dermatitis
Learn the treatments or contact dermatitis by its severity
Understand how to prevent contact dermatitis rom recurring

QUESTIONS
1. What are the salient eatures o this patient’s problem?
2. How do you think through her problem?
3. What are the key eatures, including essentials o diagnosis and general considerations,
4.
5.
6.
7.
8.
9.

o contact dermatitis?
What are the symptoms and signs o contact dermatitis?
What is the dif erential diagnosis o contact dermatitis?
What are the laboratory and procedural ndings in contact dermatitis?
What are the treatments or contact dermatitis?
What are the outcomes, including prognosis and prevention, o contact dermatitis?
When should patients with contact dermatitis be re erred to a specialist?

2


8

SKIN DISORDERS

ANSWERS
1. Salient Features
Itchy erythematous rash; history o pre-eruption exposure to the outdoors; previous initial
exposure to same antigen; weeping, vesicles, and bullae in allergic type

2. How to Think Through
T is patient’s rash is severe, so it is important to think broadly about other causes besides
those linked to the outdoor exposure. No symptoms or signs o systemic illness are
mentioned, but a complete review o systems and physical examination (with vital signs) are
essential. Could this be atopic dermatitis? (Unlikely—there is no history o atopy or prior
similar symptoms.) Might this be seborrheic dermatitis? (No, since it typically involves the
ace and scalp.) A ungal in ection? (T e pace is too rapid and the rash is more consistent
with dermatitis). Scabies? (No, due to the rapid pace and lack o ocus in intertriginous
areas.) Could this be impetigo? (Yes, care ul examination is warranted to exclude impetigo.)
What eatures o this case provide the strongest evidence or contact dermatitis? (Streaked
appearance, a pattern con ned to exposed areas o the body, recent possible exposure to
poison ivy with prior contact with this antigen.) What are the two classes o causative agents
in contact dermatitis? (Irritants and antigens.) What are common irritants or antigens?
How should she be treated—topically or systemically? (T e weeping and bullae
suggest that she may need systemic corticosteroids.) What complications may develop?
(Superin ection, especially with Streptococcus spp and Staphylococcus aureus.)

3. Key Features
Essentials of Diagnosis
• Erythema and edema, with pruritus, o en ollowed by vesicles and bullae in an area o
contact with a suspected agent
• Later, weeping, crusting, or secondary in ection
• A history o previous reaction to suspected contactant
• Patch test with agent positive
General Considerations
• An acute or chronic dermatitis that results rom direct skin contact with chemicals or
allergens
• Irritant contact dermatitis
— Eighty percent o cases are due to excessive exposure to or additive ef ects o universal
irritants such as soaps, detergents, or organic solvents
— Appears red and scaly but not vesicular
• Allergic contact dermatitis
— Most common causes are poison ivy, oak, or sumac; topically applied antimicrobials
(especially bacitracin and neomycin), anesthetics (benzocaine); haircare products;
preservatives; jewelry (nickel); rubber; essential oils; propolis ( rom bees); vitamin E;
and adhesive tape
— Occupational exposure is an important cause
• Weeping and crusting are typically due to allergic and not irritant dermatitis

4. Symptoms and Signs
• T e acute phase is characterized by tiny vesicles and weepy and crusted lesions
• Resolving or chronic contact dermatitis presents with scaling, erythema, and possibly
thickened skin; itching, burning, and stinging may be severe
• T e lesions, distributed on exposed parts or in bizarre asymmetric patterns, consist o
erythematous macules, papules, and vesicles
• T e af ected area is o en hot and swollen, with exudation and crusting, simulating and, at
times, complicated by in ection


CHAPTER 2 • CONTACT DERMATITIS

• T e pattern o the eruption may be diagnostic (eg, typical linear streaked vesicles on the
extremities in poison oak or ivy dermatitis)
• T e location will o en suggest the cause
— Scalp involvement suggests hair dyes or shampoos
— Face involvement, creams, cosmetics, soaps, shaving materials, nail polish; neck
involvement, jewelry, hair dyes

5. Di erential Diagnosis
• Impetigo
• Cellulitis
• Scabies
• Dermatophytid reaction (allergy or sensitivity to ungi)
• Atopic dermatitis
• Pompholyx
• Asymmetric distribution, blotchy erythema around the ace, linear lesions, and a history
o exposure help distinguish contact dermatitis rom other skin lesions
• T e most commonly con used diagnosis is impetigo, in which case Gram stain and culture
will rule out impetigo or secondary in ection (impetiginization)

6. Laboratory and Procedural Findings
Laboratory ests
• Gram stain and culture will rule out impetigo or secondary in ection (impetiginization)
• A er the episode o allergic contact dermatitis has cleared, patch testing may be use ul i
triggering allergen is not known
Diagnostic Procedures
• I itching is generalized, then consider scabies

7. Treatments
• able 2-1
• Vesicular and weepy lesions o en require systemic corticosteroid therapy
• Localized involvement (except on the ace) can o en be managed with topical agents
• Irritant contact dermatitis is treated by protection rom the irritant and use o topical
corticosteroids as or atopic dermatitis
Local Measures
• Acute weeping dermatitis
— Compresses are most o en used
— Lesions on the extremities may be bandaged with wet dressings or 30 to 60 minutes
several times a day
— Calamine or zinc oxide paste can be used between wet dressings, especially or intertriginous areas or when oozing is not marked
— High-potency topical corticosteroids in gel or cream orm ( uocinonide, clobetasol, or
halobetasol) may help suppress acute contact dermatitis and relieve itching
— T en, taper the number o high-potency topical steroid applications per day or use a
mid-potency corticosteroid, such as triamcinolone 0.1% cream to prevent rebound o
the dermatitis
— A soothing ormulation is 2 oz 0.1% triamcinolone acetonide cream in 7.5 oz Sarna
lotion (0.5% camphor, 0.5% menthol, 0.5% phenol)
• Subacute dermatitis (subsiding)
— Mid-potency (triamcinolone 0.1%) to high-potency corticosteroids (clobetasol 0.05%,
uocinonide 0.05%, desoximetasone 0.05%–0.25%) are the mainstays o the therapy
• Chronic dermatitis (dry and licheni ed)
— High- to super-potency corticosteroids are used in ointment orm

9


10

SKIN DISORDERS

Table 2-1. Useful topical dermatologic therapeutic agents for contact dermatitis.
Agent
Corticosteroids
Hydrocortisone acetate

Formulations,
Strengths, and Pricesa

Apply

Potency Class

Comments

Cream1%
Ointment 1%
Lotion 1%

Twice daily

Low

Cream2.5%

Twice daily

Low

Twice daily

Low

Twice daily

Low

Three times
daily
Twice daily

Medium

Triamcinolone acetonide Cream0.1%
Ointment 0.1%
Lotion 0.1%
Cream0.025%
Ointment 0.025%
Fluocinolone acetonide Cream0.025%
Ointment 0.025%
Solution 0.01%
Mometasone furoate
Cream0.1%
(Elocon)
Ointment 0.1%
Lotion 0.1%
Diflorasone diacetate
Cream0.05%
Ointment 0.05%
Amcinonide (Cyclocort) Cream0.1%
Ointment 0.1%
Fluocinonide (Lidex)
Cream0.05%
Gel 0.05
Ointment 0.05%
Solution 0.05%
Betamethasone
Cream0.05%
dipropionate
Ointment 0.05%
(Diprolene)
Lotion 0.05%
Clobetasol propionate
Cream0.05%
(Temovate)
Ointment 0.05%
Lotion 0.05%

Twice daily

Medium

Twice daily

Medium

Twice daily

Medium

Once daily

Medium

Twice daily

High

Twice daily

High

Twice daily

High

Economical generics
Lidexcreamcan cause stinging on eczema
Lidexemollient creampreferred

Twice daily

Ultra-high

Economical generics available

Twice daily

Ultra-high

Halobetasol propionate
(Ultravate)

Cream0.05%
Ointment 0.05%

Twice daily

Ultra-high

Flurandrenolide
Tape: 3”roll
(Cordran)
Lotion 0.05%
Nonsteroidal Anti-Inflammatory Agents
Tacrolimusa (Protopic)
Ointment 0.1%
Ointment 0.03%
Pimecrolimusa (Elidel)
Cream1%

Every12 h

Ultra-high

Somewhat more potent than diflorasone
Limited to 50 g or less per week
Limited to 2 continuous weeks of use
Creammaycause stinging; use“emollient cream”formulation
Generic available
Same restrictions as clobetasol
Creamdoes not cause stinging
Compatible with calcipotriene (Dovonex)
Protects the skin and prevents scratching

Twice daily

N/A

Twice daily

N/A

Alclometasone
Cream0.05%
dipropionate (Aclovate) Ointment 0.05%
Desonide
Cream0.05%
Ointment 0.05%
Lotion 0.05%
Clocortolone (Cloderm) Cream0.1%
Prednicarbate
(Dermatop)

Emollient cream0.1%
Ointment 0.1%

Medium

Not the same as hydrocortisone butyrate or valerate
Not for poison oak
OTClotion (Aquanil HC)
OTCsolution (Scalpicin, TScalp)
Perhaps better for pruritus ani
Not clearlybetter than 1%
More expensive
Not OTC
More efficacious than hydrocortisone
Perhaps causes less atrophy
More efficacious than hydrocortisone
Can cause rosacea or atrophy
Not fluorinated
Does not cross-react with other corticosteroids chemicallyand can be used in patients
allergic to other corticosteroids
Maycause less atrophy
No generic formulations
Preservative-free
Caution in bodyfolds, face
Economical in 0.5-lb and 1-lb sizes for treatment of large bodysurfaces
Economical as solution for scalp
Possiblyless efficacyand fewadvantages over 0.1%formulation

Often used inappropriatelyon the face or on children
Not fluorinated

Steroid substitute not causing atrophyor striae
Burns in ≥ 40%of patients with eczema
Steroid substitute not causing atrophyor striae

N/A, not applicable; OTC, over-the-counter.
a
Topical tacrolimus and pimecrolimus should only be used when other topical treatments are ineffective. Treatment should be limited to an area
and duration to be as brief as possible. Treatment with these agents should be avoided in persons with known immunosuppression, HIVinfection,
bone marrow and organ transplantation, lymphoma, at high risk for lymphoma, and those with a prior history of lymphoma.


CHAPTER 2 • CONTACT DERMATITIS

Systemic T erapy
• For acute severe cases, give oral prednisone or 12 to 21 days
• Prednisone, 60 mg or 4 to 7 days, 40 mg or 4 to 7 days, and 20 mg or 4 to 7 days without
a urther taper is one use ul regimen or dispense 78 prednisone 5-mg pills to be taken 12
the rst day, 11 the second day, and so on
• T e key is to use enough corticosteroid (and as early as possible) to achieve a clinical ef ect
and to taper slowly enough to avoid rebound
• A Medrol Dosepak (methylprednisolone) with 5 days o medication is inappropriate on
both counts

8. Outcomes
Prognosis
• Sel -limited i reexposure is prevented but o en takes 2 to 3 weeks or ull resolution
Prevention
• Prompt and thorough removal o the causative oil by washing with liquid dishwashing
soap (eg, Dial Ultra) may be ef ective i done within 30 minutes a er exposure to poison
oak or ivy
• Goop and ecnu oil-removing skin cleansers are also ef ective but much more costly
without increased e cacy
• T e most ef ective over-the-counter barrier creams that are applied prior to exposure and
prevent or reduce the severity o the dermatitis are
— Stokogard
— Hollister Moisture Barrier
— Hydropel
• T e mainstay o prevention is identi cation o the agent causing the dermatitis and
avoidance o exposure or use o protective clothing and gloves

9. When to Refer
• Occupational allergic contact dermatitis should be re erred to a dermatologist

SUGGESTED REFERENCES
Fonacier LS et al. Allergic contact dermatitis. Ann Allergy Asthma Immunol. 2014 Jul;113(1):9–12.
[PMID: 24950843]
Holness DL. Occupational skin allergies: testing and treatment (the case o occupational allergic contact
dermatitis). Curr Allergy Asthma Rep. 2014 Feb;14(2):410. [PMID: 24408535]
an CH et al. Contact dermatitis: allergic and irritant. Clin Dermatol. 2014 Jan–Feb;32(1):116–124.
[PMID: 24314385]
Wol R et al. Contact dermatitis: acts and controversies. Clin Dermatol. 2013 Jul–Aug;31(4):467–478.
[PMID: 23806164]
Wol R et al. Patch testing: acts and controversies. Clin Dermatol. 2013 Jul–Aug;31(4):479–486. [PMID:
23806165]

11


12

3

Psoriasis

A 25-year-old woman presents with a complaint of rash that has
developed over the last several weeks and seems to be progressing.
She describes the involved areas as mildly itchy. On examination, she
is noted to have several plaque-like lesions over the extensor surfaces
of both upper and lower extremities as well as similar lesions on her
scalp. The plaques are erythematous, with silvery scales, and are sharply
marginated.

LEARNING OBJECTIVES
Learn the clinical mani estations and morphologic type o eruption in psoriasis
Understand the actors that predispose to psoriasis
Know the dif erential diagnosis o psoriasis
Learn the treatments or psoriasis by its severity
Understand the complications and prognosis o psoriasis

QUESTIONS
1. What are the salient eatures o this patient’s problem?
2. How do you think through her problem?
3. What are the key eatures, including essentials o diagnosis and general considerations,
4.
5.
6.
7.
8.
9.

o psoriasis?
What are the symptoms and signs o psoriasis?
What is the dif erential diagnosis o psoriasis?
What are the procedural ndings in psoriasis?
What are the treatments or psoriasis?
What are the outcomes, including complications and prognosis, o psoriasis?
When should patients with psoriasis be re erred to a specialist?

ANSWERS
1. Salient Features
Progressive rash; mild itching; plaque-like lesions; extensor sur aces o extremities and
scalp distribution; sharp margins with silvery scales


CHAPTER 3 • PSORIASIS

2. How to Think Through
What are the common skin diseases in the dif erential diagnosis o this woman’s eruption and
what eatures about her presentation make psoriasis the most likely diagnosis? (Candidiasis,
tinea, and atopic dermatitis are characterized by poorly demarcated lesions and typically present on the extensor sur aces. Candida, in particular, is ound in the moist body olds and exural sur aces. T is patient’s lesions are described as mildly pruritic, which is more typical o
psoriasis than these alternative diagnoses. T e scaly scalp plaques are particularly characteristic
o psoriasis.) How does her presentation dif er rom that o seborrheic dermatitis?
What other mani estations should you explore? (Nail pitting is common in psoriasis and
will help con rm your diagnosis. Joint pain and in ammation would raise the possibility
psoriatic arthritis.)

3. Key Features
Essentials of Diagnosis
• Silvery scales on bright red, well-demarcated plaques, usually on the knees, elbows, and scalp
• Nail ndings include pitting and onycholysis (separation o the nail plate rom the bed)
• Mild itching (usually)
• May be associated with psoriatic arthritis
• Patients with psoriasis are at increased risk or metabolic syndrome and lymphoma
• Histopathology is not o en use ul and can be con using
General Considerations
• A common benign, chronic in ammatory skin disease with both a genetic basis and
known environmental triggers
• Injury or irritation o normal skin tends to induce lesions o psoriasis at the site (Koebner
phenomenon)
• Obesity worsens psoriasis, and signi cant weight loss in persons with high body mass
index may lead to substantial improvement
• Psoriasis has several variants—the most common is the plaque type

4. Symptoms and Signs
T ere are o en no symptoms, but itching may occur
• Although psoriasis may occur anywhere, examine the scalp, elbows, knees, palms and
soles, umbilicus, intergluteal old, and nails
• T e lesions are red, sharply de ned plaques covered with silvery scales; the glans penis
and vulva may be af ected; occasionally, only the exures (axillae, inguinal areas including
genitalia) are involved (“inverse psoriasis”)
• Fine stippling (“pitting”) in the nails is highly suggestive; onycholysis (separation o the
nail plate rom its bed) may occur
• Patients with psoriasis o en have a pink or red intergluteal old
• T ere may be associated seronegative arthritis, o en involving the distal interphalangeal
joints
• Eruptive (guttate) psoriasis, consisting o myriad lesions 3 to 10 mm in diameter, occurs
occasionally a er streptococcal pharyngitis
• Plaque-type or extensive erythrodermic psoriasis with abrupt onset may accompany HIV
in ection

5. Di erential Diagnosis
• Atopic dermatitis (eczema)
• Contact dermatitis
• Nummular eczema (discoid eczema, nummular dermatitis)
• inea
• Candidiasis
• Intertrigo

13


14

SKIN DISORDERS

• Seborrheic dermatitis
• Pityriasis rosea
• Secondary syphilis
• Pityriasis rubra pilaris
• Onychomycosis (nail ndings)
• Cutaneous eatures o reactive arthritis
• Cutaneous eatures o reactive lupus
• Cutaneous -cell lymphoma (mycosis ungoides)

6. Procedural Findings
Diagnostic Procedures
• T e combination o red plaques with silvery scales on elbows and knees, with scaliness in
the scalp or nail pitting or onycholysis, is diagnostic
• Psoriasis lesions are well demarcated and af ect extensor sur aces—in contrast to atopic
dermatitis, with poorly demarcated plaques in exural distribution
• In body olds and groin, scraping and culture or Candida and examination o scalp and
nails will distinguish inverse psoriasis rom intertrigo and candidiasis

7. Treatments
• Certain drugs, such as β-blockers, antimalarial agents, statins, and lithium, may are or
worsen psoriasis
• Even tiny doses o systemic corticosteroids given to psoriasis patients may lead to severe
rebound ares o their disease
• Never use systemic corticosteroids to treat ares o psoriasis
Medications
• opical corticosteroid cream or ointment ( able 3-1)
• Limited disease (< 10% o the body sur ace)
— Restrict the highest potency corticosteroids to 2 to 3 weeks o twice daily use; then
three or our times on weekends or switch to a mid-potency corticosteroid
— Rarely induce a lasting remission
• Calcipotriene ointment 0.005% or calcitriol ointment 0.003%, both vitamin D analogs, is
used twice daily
— Initial treatment regimen: corticosteroids twice daily plus a vitamin D analog twice daily
— Once lesions are cleared, vitamin D analog is used alone, once daily, and with corticosteroids, once daily, or several weeks
— T en, once- or twice-daily application o the vitamin D analog is continued long term
and topical corticosteroids are stopped
— Calcipotriene usually cannot be applied to the groin or the ace because o irritation
— Calcipotriene is incompatible with many topical corticosteroids; it must be applied at
a dif erent time
— Maximum dose or calcipotriene is 100 g/week and or calcitriol is 200 g/week
• Occlusion alone clears isolated plaques in 30% to 40% o patients
— T in, occlusive hydrocolloid dressings are placed on the lesions and le undisturbed
or 5 to 7 days and then replaced
— Responses may be seen within several weeks
• For the scalp
— Start with a tar shampoo once daily
— T ick scales: 6% salicylic acid gel (eg, Keralyt), P & S solution (phenol, mineral oil,
and glycerin), or oil-based uocinolone acetonide 0.01% (Derma-Smoothe/FS) under
a shower cap at night, ollowed by a shampoo in the morning
— In order o increasing potency, triamcinolone 0.1%, or uocinolone, betamethasone
dipropionate, uocinonide or amcinonide, and clobetasol are available in solution
orm or use on the scalp twice daily


CHAPTER 3 • PSORIASIS

Table 3-1. Useful topical dermatologic therapeutic agents for psoriasis.
Agent

Formulations, Strengths

Application

Potency Class

Comments

Diflorasone
diacetate

Cream0.05%
Ointment 0.05%

Twice daily

High

Amcinonide
(Cyclocort)

Cream0.1%
Ointment 0.1%

Twice daily

High

Fluocinonide (Lidex)

Cream0.05%
Gel 0.05%
Ointment 0.05%
Solution 0.05%

Twice daily

High

Economical generics
Lidexcreamcan cause stinging on
eczema
Lidexemollient creampreferred

Betamethasone
dipropionate
(Diprolene)

Cream0.05%
Ointment 0.05%
Lotion 0.05%

Twice daily

Ultra-high

Economical generics available

Clobetasol
propionate
(Temovate)

Cream0.05%
Ointment 0.05%
Lotion 0.05%

Twice daily

Ultra-high

Somewhat more potent than
diflorasone
Limited to two continuous weeks of
use
Limited to 50 g or less per week
Creammaycause stinging; use
“emollient cream”formulation
Generic available

Halobetasol
propionate
(Ultravate)

Cream0.05%
Ointment 0.05%

Twice daily

Ultra-high

Same restrictions as clobetasol
Creamdoes not cause stinging
Compatible with calcipotriene (Dovonex)

Flurandrenolide
(Cordran)

Tape: 80”× 3”roll
Lotion 0.05%: 60 mL

Every12 hours

Ultra-high

Protects the skin and prevents
scratching

• Psoriasis in the body olds
— Potent corticosteroids cannot be used
— acrolimus ointment 0.1% or 0.03% or pimecrolimus cream 1% may be ef ective in
penile, groin, and acial psoriasis
• Moderate disease (10%–30% o the body sur ace) to severe disease (> 30% o the body
sur ace)
— Methotrexate is very ef ective in doses up to 25 mg once weekly orally
— Acitretin, a synthetic retinoid, is most ef ective or pustular psoriasis at 0.5 to 0.75 mg/
kg/day orally
Liver enzymes and serum lipids must be checked periodically
Acitretin is a teratogen and persists or 2 to 3 years in at tissue. Women must wait at
least 3 years a er completing treatment be ore considering pregnancy
— Cyclosporine dramatically improves severe cases o psoriasis
— umor necrosis actor ( NF) inhibitors (etanercept, 50 mg twice weekly subcutaneously ×12, then once weekly; in iximab, 5 mg/kg once weekly intravenously at weeks
0, 2, and 6; and adalimumab, 40 mg every 2 weeks subcutaneously) can be ef ective; all
three can also induce or worsen psoriasis
— IL-12/23 monoclonal antibodies (ustekinumab [Stelara]) and IL-17 monoclonal
antibodies (brodalumab, secukinumab, and ixekizumab)
Are ef ective in psoriasis
May be considered instead o using a NF inhibitor
T erapeutic Procedures
• Limited to moderate disease: UV phototherapy
• Moderate-to-severe disease
— T e treatment o choice is narrow-band UVB light exposure three times weekly;
clearing usually occurs in ~7 weeks; maintenance may be needed since relapses are
requent

15


16

SKIN DISORDERS

— Severe disease unresponsive to UV light may be treated in a psoriasis day care center
with the Goeckerman regimen, using crude coal tar or many hours and exposure to
UVB light; this of ers the best chance or prolonged remissions
— PUVA (psoralen plus ultraviolet A) may be ef ective even i standard UVB treatment
has ailed; may be used with other therapy, eg, acitretin

8. Outcomes
Complications
• reatment with calcipotriene may result in hypercalcemia
• Long-term use o PUVA (> 250 doses) is associated with an increased risk o skin cancer
(especially squamous cell carcinoma and perhaps melanoma)
Prognosis
• T e course tends to be chronic and unpredictable, and the disease may be re ractory to
treatment
• Patients (especially those > 40 years o age) should be monitored or metabolic syndrome,
which correlates with the severity o skin disease

9. When to Refer
• I there is a question about the diagnosis, i recommended therapy is inef ective, or i
specialized treatment is necessary

SUGGESTED REFERENCES
Armstrong AW et al. Combining biologic therapies with other systemic treatments in psoriasis:
evidence-based, best-practice recommendations rom the Medical Board o the National Psoriasis
Foundation. JAMA Dermatol. 2015 Apr;151(4):432–438 [PMID: 25517130]
Armstrong AW et al. Psoriasis and the risk o diabetes mellitus: a systematic review and meta-analysis.
JAMA Dermatol. 2013 Jan;149(1):84–91. [PMID: 23407990]
Coumbe AG et al. Cardiovascular risk and psoriasis: beyond the traditional risk actors. Am J Med. 2014
Jan;127(1):12–18. [PMID: 24161194]
Debbaneh M et al. Diet and psoriasis, part I: impact o weight loss interventions. J Am Acad Dermatol.
2014 Jul;71(1):133–140. [PMID: 24709272]
Gel and JM et al. Comparative e ectiveness o commonly used systemic treatments o phototherapy or
moderate to severe plaque psoriasis in the clinical practice setting. Arch Dermatol. 2012
Apr;148(4):487–494. [PMID: 22508874]
Hendriks AG et al. Combinations o classical time-honoured topicals in plaque psoriasis: a systematic
review. J Eur Acad Dermatol Venereol. 2013 Apr;27(4):399–410. [PMID: 22779910]
Hsu S et al. Consensus guidelines or the management o plaque psoriasis. Arch Dermatol. 2012
Jan;148(1):95–102. [PMID: 22250239]
Kim IH et al. Comparative e icacy o biologics in psoriasis: a review. Am J Clin Dermatol. 2012 Dec
1;13(6):365–374. [PMID: 22967166]
Kupetsky EA et al. Psoriasis vulgaris: an evidence-based guide or primary care. J Am Board Fam Med.
2013 Nov–Dec;26(6):787–801. [PMID: 24204077]
Lynch M et al. reating moderate to severe psoriasis—best use o biologics. Expert Rev Clin Immunol.
2014 Feb;10(2):269–279. [PMID: 24372444]
Mason A et al. opical treatments or chronic plaque psoriasis: an abridged Cochrane Systematic
Review. J Am Acad Dermatol. 2013 Nov;69(5):799–807. [PMID: 24124809]
Reich K et al. E icacy o biologics in the treatment o moderate to severe psoriasis: a network metaanalysis o randomized controlled trials. Br J Dermatol. 2012 Jan;166(1):179–188. [PMID: 21910698]
Richard MA et al. Evidence-based recommendations on the role o dermatologists in the diagnosis and
management o psoriatic arthritis: systematic review and expert opinion. J Eur Acad Dermatol
Venereol. 2014 Aug;28(suppl 5):3–12. [PMID: 24985557]
Samarasekere EJ et al. opical therapies or the treatment o plaque psoriasis: systematic review and
network meta-analyses. Br J Dermatol. 2013 May;168(5):954–967. [PMID: 23413913]
Weigle N et al. Psoriasis. Am Fam Physician. 2013 May;87(9):626–633. [PMID: 23668525]


Skin Disorders
Pulmonary/Ear, Nose, and Throat Disorders
Heart/Hypertension/Lipid Disorders
Hematologic Disorders
Gastrointestinal/Liver/Pancreas Disorders
Gynecologic/Urologic Disorders
Musculoskeletal Disorders
Kidney/Electrolyte Disorders
Nervous System/Psychiatric Disorders
Endocrine/Metabolic Disorders
Infectious Disorders


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