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This publication is printed on acid-free paper.

ANSI Z39.48-1984 (American Standards Institute) Permanence of Paper for Printed Library Materials. Cover design by Daniel J. Trozak, md

Left Photo: Bullous Impetigo (see color photo section, Part VI) Right Photo: Vesicle/Bulla (see p. 10, Fig. 11)

Production Editor: Robin B. Weisberg

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Printed in the United States of America. 10 9 8 7 6 5 4 3 2 1 eISBN: 1-59259-906-0

Library of Congress Cataloging-in-Publication Data Trozak, Daniel J.

Dermatology skills for primary care : an illustrated guide / by Daniel J. Trozak, Dan J. Tennenhouse, John J. Russell. p. ; cm. -- (Current clinical practice) Includes bibliographical references and index. ISBN 1-58829-489-7 (alk. paper)

I. Skin--Diseases. 2. Dermatology. 3. Primary care (Medicine) [DNLM: 1. Skin Diseases—diagnosis. 2. Skin Diseases--therapy. 3.

Primary Health Care--methods. WR 140 T864d 2005] I. Tennenhouse, Dan J.

II. Russell, John J., MD. III. Title. IV. Series. RL71.T76 2005



Series Editor's Introduction

The diagnosis and treatment of common dermatologie problems is a critical area of skill and knowledge for primary care physicians. According to the US Department of Health and Human Services,1 patients present to their physicians a skin rash as their chief concern for nearly 12 million office visits each year. In 73% of these office visits, patients see their internist, family physician, or pediatrician. In this respect, astonishingly, primary care clinicians see far more skin disease in their offices than dermatologists. Dermatology Skills for Primary Care: An Illustrated Guide advances the targeted skill and knowledge base of primary care physicians, as well as the collaboration between dermatologists and primary care physicians, by its wise choice of organization, scope, and approach.

Dermatology Skills for Primary Care: An Illustrated Guide by Drs. Trozak, Tennenhouse, and Russell is an important addition to the dermatology literature because it has been written collaboratively by a skilled dermatologist and two excellent academic family physicians. As such, the book superbly targets the depth and scope of needs of primary care practitioners in the field of dermatology.

Dermatology Skills for Primary Care: An Illustrated Guide is unique in its approach by opening each chapter with the clinical questions that physicians must answer in approaching patients, and then giving the history, physical examination findings, differential diagnosis, therapeutic options for treatment, and finally explicitly answering the opening questions in each chapter. The book is important in scope, providing in-depth discussions of the most common skin conditions that primary care clinicians encounter.

If a physician knows the contents of this book, he or she will be able to competently take care of more than 90% of the dermatologic problems that are seen in a busy office practice.

That is an accomplishment.

Neil S. Skolnik, md

Associate Director Family Practice Residency Program Abington Memorial Hospital Abington, PA

Professor of Family and Community Medicine Temple University School of Medicine Philadelphia, PA

1Source: US Department of Health and Human Services, Public Health Service, Centers for Disease Control and Prevention, National Center for Health Statistics, 2002 data. Public Use data file. Table 35a. x24579.xml (accessed May 2, 2005).


Skin diseases are a very substantial part of any primary care practice. Unlike most internal conditions, dermatological lesions are apparent to the patient from their inception and the progression is usually readily evident. Accurate prompt diagnosis and appropriate treatment will alleviate a great deal of suffering and reinforce the patient's confidence in the practitioner's skills.

Dermatology Skills for Primary Care: An Illustrated Guide is designed to teach basic skills and to offer an inclusive approach to skin diseases so that primary practitioners can acquire the basic diagnostic and therapeutic skills used by their dermato-logic colleagues. Part I reviews the basic skills and tools used in dermatologic diagnosis and also discusses basic principles of topical therapy. The ensuing five parts put these skills into practical scenarios and cover the treatment of specific skin conditions that are frequently encountered in everyday general medicine.

Although Dermatology Skills for Primary Care: An Illustrated Guide is not a comprehensive dermatologic reference, practitioners who master the skills in Part I and apply them to the 33 commonly encountered skin conditions in Parts II-VI should be able to practice very credible general dermatology.

Daniel J. Trozak, md Dan J. Tennenhouse, md, jd John J. Russell, md

About the Authors

Daniel J. Trozak, md, faad, is a graduate of the University of Michigan School of Medicine and completed his postgraduate training in dermatology at University of Oregon Health Sciences University. He served as a clinical associate professor of dermatology at Stanford University from 1974 to 1992. He has been a consultant in pharmacological research to the Psoriasis Research Institute (Palo Alto, CA) and a consultant in product research to Product Investigations Inc. (Conshohocken, PA). Dr. Trozak has authored and co-authored publications in the areas of melanoma, contact dermatitis, delayed cutaneous hypersensitivity, neuropeptides, and psoriasis. Dr. Trozak has been in the private practice of dermatology in Modesto, California since 1973 and is familiar on a firsthand basis with the dermatological problems that confront primary practitioners on a daily basis.

Dan J. Tennenhouse, MD, JD, FCLM, is a graduate of the University of Michigan School of Medicine and the University of California Hastings College of the Law. Dr. Tennenhouse is a nationally recognized medico-legal consultant, author, and lecturer and has 25 years experience in the practice of primary care medicine at the University of California San Francisco School of Medicine plus more than 30 years experience on the medical school faculty teaching lecture courses. He is the author or co-author of more than 30 references on risk management and medical law.

John J. Russell, md, aafp, is a graduate of Pennsylvania State College of Medicine and completed his postgraduate training in family medicine at Abington Memorial Hospital, Abington, Pennsylvania. Since 1993, Dr. Russell has served as assistant and associate director of the Abington Memorial Hospital Family Medicine Program. He is a clinical associate professor of family and community medicine at Temple University School of Medicine and lectures nationally on a variety of medical subjects including asthma, hyperlipidemia, and various aspects of dermatology. He serves as a contributing editor and reviewer for several primary care journals and has authored or co-authored several papers in the areas of dermatology and general medicine.


Series Editor's Introduction v

Preface vii

About the Authors ix

Part I: Basic Skills

1. Specific History 3

2. Dermatologic Physical Examination 7

3. Indicated Supporting Diagnostic Data 29

4. Therapy 37

References for Part I 47

Part II: Papular, Papulosquamous, and Papulo-Vesicular Skin Lesions

5. Molluscum Contagiosum (Dimple Warts) 51

6. Verruca Vulgaris (Common Warts) 59

7. Seborrheic Dermatitis (Dandruff) 67

8. Pityriasis Rosea 77

9. Psoriasis Vulgaris 83

10. Lichen Planus 93

11. Miliaria Rubra (Prickly Heat) 101

12. Scabies 105

References for Part II 113

Part III: Epidermal, Dermal, and Epidermal/Dermal Lesions

13. Erythrasma 117

14. Tinea (Superficial Fungi, Dermatophytosis, Ringworm) 121

15. Urticaria (Urticaria Simplex, Common Hives) 135

16. Fixed Drug Eruption 147

17. Erysipelas/Cellulitis 153

18. Erythema Multiforme 161

References for Part III 169


Part IV: Epidermal and Dermal Lesions, Eczematous Lesions, and Atrophies

19. Lupus Erythematosus 175

20. Toxicodendron Dermatitis (Poison Oak, Poison Ivy, Poison Sumac;

Also Known as Rhus Dermatitis) 191

21. Atopic Dermatitis (Atopic Eczema, Disseminated Neurodermatitis,

Besnier's Prurigo) 199

22. Asteatotic Eczema (Xerosis, Xerotic Eczema, Eczema Craquelé, Eczema Cannalé,

Eczema Hiemalis, Winter Itch) 213

23. Senile Purpura (Bateman's Purpura) 219

24. Striae Distensae (Striae Atrophicans, Striae Gravidarum, Stretch Marks) 223

References for Part IV 231

Part V: Pigmented, Pre-Malignant, and Common Malignant Skin Lesions

25. Seborrheic Keratosis (Old Age Spots, Liver Spots) 235

26. Ephelides (Freckles) 241

27. Lentigines 245

28. Melanocytic Nevi 251

29. Malignant Melanoma 271

30. Actinic Keratosis (Solar Keratosis) 287

31. Keratoacanthoma (Molluscum Sebaceum) 293

32. Common Skin Cancers 299

References for Part V 311

Part VI: Vesiculo-Bullous and Papulo-Pustular Disorders

33. Impetigo (Impetigo Contagiosa) 317

34. Herpes Simplex Recidivans (Herpes Labialis, Cold Sores, Fever Blisters,

Herpes Genitalis) 325

35. Herpes Zoster (Shingles) 335

36. Acne Vulgaris (Acne, Zits) 345

37. Rosacea (Acne Rosasea) 359

References for Part VI 367

Appendix A: Table of Primary Lesions and Related Disorders 369

Appendix B: Table of Secondary Lesions and Related Disorders 373

Color Photographs 377

Index 441

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