#285 Common Skin Complaints in Primary Care (Dermsiders)

July 19, 2021 | By Beth Garbitelli

Tinea Versicolor, Pruritus, and Oh So Many Trunk and Extremity Complaints  with Dr. Helena Pasieka

Walk with us through common skin complaints in primary care, focusing on the trunk and extremities. Our favorite skinternist, Dr. Helena Pasieka (Chief of Dermatology at Kashlak) schools us on tinea versicolor, the fluff test, treatment of skin tags, how to work up and manage generalized pruritus, venous insufficiency, and how to get ready for sandal season in the face of onychomycosis. #dermismedicine!

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Credits

• Producers: Maddie “Mad Dog” Morgan, Edison Jyang 
• Infographic and Cover Art: Edison Jyang 
• Writer: Beth Garbs Garbitelli 
• Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP 
• Reviewer: Emi Okamoto MD, FACP 
• Editor: Emi Okamoto MD, FACP (written materials); Clair Morgan of nodderly.com
• Guest: Dr. Helena Pasieka 

CME Partner: VCU Health CE

The Curbsiders are partnering with VCU Health Continuing Education to offer FREE continuing education credits for physicians and other healthcare professionals. Visit curbsiders.vcuhealth.org to claim credit. 

Show Segments

• Intro, disclaimer, guest bio
• Guest one-liner
• Picks of the Week*
• Tinea (pityriasis) versicolor and the fluff test, bumps, and lesions 
• Generalized Pruritus: clinical features, work-up and supportive care  
• Lower Extremity Venous Insufficiency and Lipodermatosclerosis
• Onychomycosis
• Take-Home Points 
• Outro

Common Skin Complaints Pearls

1. Fluff test (aka stretch test) can be used to diagnose tinea. Look for the furfuraceous scale!
2. Method of removal of skin tags is dependent on the diameter of the stalk. 
3. The two buckets of generalized pruritus are with and without a rash. Initial work up includes labs like CBC, CMP, and LFTs to rule out other etiologies, eg thyroid issues or lymphoma. 
4. Avoid antihistamines for generalized pruritus, as the majority of itch is not histamine-mediated. Consider ointments with ceramide or petrolatum and things that are scooped out, not pumped out!
5. In patients with chronic venous stasis or lipodermatosclerosis, use steroid creams with a goal of resolution of itch (rather than rash), making sure to use ceramide-containing emollients during steroid holidays.
6. Figure out what the goals of a patient with onychomycosis are, sometimes all they want is a thinner nail they can paint over. To thin out onychomycotic nails, use urea 40%.

Common Skin Complaints for Primary Care Notes 

Neck and Trunk

Use the z-axis to differentiate

Dr. Pasieka shares the hint of identifying if the lesion is raised or has a ‘z-axis’ by feeling (sometimes with closed eyes!). Remember, macules have no z-axis, therefore if you cannot tell if you are on or off the lesion with your eyes closed.

Tinea (pityriasis) versicolor

This image of tinea versicolor is from DermNetNZ.org, and displayed here for non-commercial use per Creative Commons License. 

Important clinical clues and presentation of tinea (a.k.a. pityriasis) versicolor include skin exposure, tan skin, macules of various sizes that may or may not be hypopigmented relative to skin tone, often in the sebaceous or sweatier areas of the skin.  These macules tend to be uniform in size and shape and are caused by yeast in the environment and the host’s reaction to the yeast. 

Tinea versicolor macules should have scale or flake (furfuraceous scale), which can be distinguished at the border of the lesion. It can be diagnosed via the “fluff test” or “stretch test” (check out the video below). To perform this, push down and stretch around the lesion in all directions with both index fingers, like zooming in on a smartphone, to fluff/puff up the lesion. The KOH test (showing ‘spaghetti and meatballs’ of the Malassezia globosa or M. furfur) can also be done but is now largely only used for teaching purposes per Dr. Pasieka. 

These macules present as hypopigmented because they create enzymes that inhibit melanocytes.

Predisposing factors to tinea versicolor include steroids, tropical climates, and genetics and treatments include azole creams, selenium sulfide or ketoconazole shampoo used as a body wash. Prescription strengths can be used as they are higher potency than over-the-counter options. Maintenance to prevent recurrence entails weekly rather than daily use of ketoconazole shampoo. 

Acrochordons (skin tags)  

This image of skin tags is from DermNetNZ.org, and displayed here for non-commercial use per Creative Commons License. 

These are papules (raised) and have a stalk, and are located in areas of friction/areas of skin touching skin (intertriginous areas).They are often skin-toned or hyperpigmented. Skin tags can get inflamed, thrombosed and be symptomatic. When symptomatic (i.e. necklace gets caught, razor knicks it, gets inflamed/traumatized), removal can be covered by insurance when documented appropriately. Per expert opinion, consider sending rapidly growing or symptomatic skin tags to pathology, or if the stalk is >4mm. 

Removal of skin tags depends on the diameter of the stalk. Expert opinion: a thin stalk can be removed with liquid nitrogen, but it is important to note that this treatment in darker skin tones could kill melanocytes and cause hypopigmentation. It can also be removed by a straight blade or iris scissors. 

Cherry Angiomas 

This image of Cherry angiomas is from DermNetNZ.org, and displayed here for non-commercial use per Creative Commons License. 

Cherry angiomas are genetically predisposed, best treated with pulsed dye laser (vascular laser), hyfrecation (electric needle), or shave biopsy. They do not respond well to freezing per Dr. Pasieka. 

Generalized Pruritus

Pruritus should always be separated by the presence or lack of rash. Generalized pruritus without a rash has a greater differential diagnosis, may be multifactorial, and will be discussed in greater detail here.

Work-up

Dr. Pasieka breaks down pruritus into two separate buckets, with and without a rash. For older patients, without a rash pruritus presentation is often multifactorial. The threshold for chronic pruritus is 6 weeks. Common clinical presentation includes “itchiness” all over the body and in the winter months. You want to consider pruritus caused by comorbidities, showering routines, or medications such as statins, opioids, aspirin, and chemotherapy/immunotherapy (e.g. PD-1 inhibitors) drugs. 

Dr. Pasieka asks all her residents to read this 2013 NEJM paper discussing chronic pruritus workup and treatment by Gill Yosipovitch.

Common things are common

Xerosis, or dry skin, is the most common cause of generalized pruritus without a rash. Dr. Pasieka uses the analogy of skin as a brick wall: keratinocytes as bricks; free fatty acids, ceramides, cholesterol and other lipids as the mortar; and as you age you become less efficient at patching the mortar, leading to xerosis and pruritus.

Basic labs to rule out other etiologies 

• CMP (with LFTs), thyroid panel, CBC
• If in the 65 + age group, LDH check to check for lymphoma 

General advice for dry skin 

• Unscented does not mean fragrance free, use bland soaps. 
• Apply moisturizer when skin is still slightly damp.
• Ointments are better than creams for sensitive skin.
• Things that are scooped out of a jar are better than the ones that pump out (due to added alcohols to thin the product) 
• Hot vs. cold showers: hot showers provide immediate relief but the transepidermal water loss causes post shower increase in pruritus. 

Supportive Care 

Dry skin is itchy skin – for most complaints of generalized pruritus, Dr. Pasieka starts with a ceramide containing moisturizer twice a day. A cheaper non-ceramide alternative would be to use petrolatum. Supportive care could include menthol, camphor, pramoxine (topical neuromodulator, over the counter), capsaicin (needs proper counseling), or compound neuromodulators (by a dermatologist). For medication-induced pruritus, consider adjusting medication when possible (eg reduce narcotics). 

Trial a few different products to find the tactile feel desired, then prescribe a 1-lb (454 gm) jar, especially if covering a large surface area. Avoid antihistamines, especially in older patients. Other treatment options include antidepressants, opioid antagonists, and phototherapy. Dr. Pasieka prefers not to use topical steroids unless there is specifically inflammation of the skin (presence of a rash).   

Lower Extremity Venous Insufficiency and Lipodermatosclerosis

This image of Lipodermatosclerosis is from DermNetNZ.org, and displayed here for non-commercial use per Creative Commons License. 

Are we looking at bilateral cellulitis? Unlikely! (Also discussed on Episode #246 on cellulitis). Try to take note of any loss of leg hair and shiny skin, more characteristic of chronic venous stasis changes.

Chronic venous stasis changes vs. chronic lymphedema of the legs?

• Venous stasis: skin changes from patella to above the malleoli (“think flash dance leg warmers”).
• Lymphedematous changes: skin changes include the puffy dorsum of the foot.

Treatment

• Compression stockings are key
• Emollients and topical steroids (Dr. Pasieka recommends steroids when the skin is pink and itchy) 
  • Creams are preferred over ointments, as they can be rubbed in and are less greasy.
  • Expert opinion: Use the steroids for resolution of itch rather than rash, and to switch to ceramide creams during steroid holidays (keeping in mind steroids will likely have to be used again).
  • There are charts (table 3) and apps (CorticoCalc) that assist in calculating how much topical medication to prescribe based on body parts.
• Treat any concomitant tinea pedis
  • Skin lesions/breakdown from tinea pedis can increase likelihood of developing cellulitis.

Onychomycosis

This image of Onychomycosis is from DermNetNZ.org, and displayed here for non-commercial use per Creative Commons License. 

There is a difference between mycological clearance and an aesthetic improvement of the nail. Mycological clearance may not lead to a visually normal nail, and some patients are satisfied with just an aesthetic improvement. Try to ascertain what the goals of the patient are, reminding them that this is a common condition due to the ubiquity of the fungus, and is likely to recur. Reinforce that onychomycosis is only a cosmetic problem, unless it is turning into an ingrown toenail.

Is this onychomycosis or something else?

Mimickers include: onycholysis (e.g. chronic trauma), disappearing nail bed, warts, and squamous cell carcinoma.

Tips for non-projectile toenail clipping!

1. Poke a hole in the bottom of a biohazard bag.
2. Place toe of interest through the hole.
3. Open the bag from the zip side and clip the toenail inside the bag.
4. Remove the toe (from the bag).
5. Acquire the specimen from inside the bag.

Treatment

Some topical low risk treatments are available, though they are more effective earlier in the disease: mentholated ointment (Vick’s VapoRub), vinegar soaks, compounded thymol in alcohol, antifungal nail lacquers.

If a patient is bothered by the thickness of the nail, you can prescribe urea 40% ointment or cream, applied to the nail plate until desired thinness. Highly effective for patients who seek to have nails of normal thickness that they can then paint over.

Oral therapy such as azoles or terbinafine can be used. Check LFTs and discuss risk/benefit/recurrence of treatment with the patient (be sure to mention interactions of these medications with alcohol consumption). There is growing evidence on the efficacy of pulse therapy (Gupta et al., 2019), where prolonged contiguous treatment may not be needed.

There are more novel treatments like lasering, but results have not been as promising.

Links

1. #dermismedicine – a new hashtag to use 
2. Measure What Matters by John Doerr 
3. Red Fang (Band from Portland Oregon) Arrows Album 
4. Society of Dermatology Hospitalists website

Goal

Listeners will explain the basic presentation, diagnosis, and treatment of common skin complaints involving the trunk and extremities to improve primary care management of these skin conditions. 

Learning objectives

After listening to this episode listeners will…  

1. Be familiar with tinea (pityriasis) versicolor, the fluff test and predisposing and diagnostic factors. 
2. Recognize the difference in treatment and presentation of common conditions like skin tags and cherry angiomas. 
3. Learn the work up, common causes and supportive care associated with generalized pruritus. 
4. Describe the typical presentation of varicose veins and venous insufficiency vs. bilateral cellulitis. 
5. Feel comfortable with onychomycosis, both treatment and distinguishing mimics. 

Disclosures

Dr Pasieka reports no relevant financial disclosures. The Curbsiders report no relevant financial disclosures. 

Citation

Morgan, MA, Jyang, E, Pasieka H, Williams PN, Okamoto E, Watto MF. “#285 Common Skin Complaints in Primary Care – Trunk and Extremities (Dermsiders)”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list Final publishing date July 19, 2021.