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General lnternal Medicine Melanoma Diagnosis 57UDY ?ABLE: "ABCDE" Rule to Diagnose Melanoma Characteristic Description Asymmetry Not regularly round or oval Border irregularity Notching, scalloping, or poorly defined margins Color variegation Shades of brown, tan, red, white, blue-black, or combinations Diameter Size >6 mm (early melanomas may be diagnosed at a smaller size) Evolution Lateral expansion or vertical growth There are several subtypes of melanoma: o Lentigo maligna begins as a uniformly pigmented, light brown patch on the face or upper trunk that is confined to the epidermis and resembles a solar lentigo. Over time, the lesion expands and becomes more variegated in color. . Superficial spreading melanoma presents as a well-defined asymmetric patch or plaque with an irregular border, varia- tion in color, and an expanding diameter. This type tends to occur on the back in men and the legs in women (areas that receive intermittent sun and are prone to sunburn). o Nodular melanomas are the most aggressive form (invading deeper structures); they are responsible fbr most deaths from melanoma. lentigo Maligna: This melanoma in situ appears as a brown patch on sun- . Acral lentiginous melanomas are the most common type of exposed skin. melanoma seen in patients with dark skin. ..\ *r''I'':'o*''' -*illlllllllllllllllllllll Melanoma: This asymmetric pigmented skin lesion has irregular, scalloped, notched, and indistinct borders with variegated coloration. Acral Melanoma: Acral melanoma 0n the toe. Treatment Complete excision is the preferred biopsy technique fbr most varieties of melanoma, ancl sentinel lymph node biopsy is indi cated for melanomas >1 mm thick. The extent of the surgical excision clepends on the thickness of the primary melanoma. 186

General lnternal Medicine DO]I'T BE TRICKED I o Routine blood tests are not recommended in patients with nonmetastatic melanoma treated with complete excision, I and the value ofscreening radiography, CT, or pET CT scanning is questionable. Other Papulosquamous Disorders l STUDY TABLE: Other Papulosquamous Disorders Condition Presentation Therapy Lichen planus Acute eruption of purple, pruritic, polygonal papules that Topical glucocorticoids most commonly presents on the wrists and ankles Can also present in the mouth, vaginal vault, penis, and in the nails (leading to thickening and distortion of the nail plate) Pityriasis rosea Presents with one herald patch that is a few centimeters wide, Topical glucocorticoids and a ntihistami nes for followed by many 0.5- to 2.O-cm red, scaling pruritic patches p ru ritus along the skin cleavage lines in a "Christmas tree" distribution on the trunk that last 1-3 months Can mimic syphilis except for sparing the palms and soles DOI{'T BE TRICKED . Pityriasis rosea can resemble secondary syphilis but does not involve the palms and soles; obtain RPR in sexually .*; active persons.

DOI{'T BE TRICKED . Pityriasis rosea can resemble secondary syphilis but does not involve the palms and soles; obtain RPR in sexually .*; active persons. Psoriasis Diagnosis Typical findings of chronic plaque psoriasis are erythema, scaling, d and induration on the extensor surfaces, scalp, ears, intertrigi nous folds, and genitalia. The nails may be pitted, thickened, or Pityriasis Rosea: Pityriasis rosea, presenting with an oval herald patch on the abdomen, followed by a more generalized rash. Reprinted from the Centers for yellow with subungual debris and may be the only manifestation Disease Control and Prevention Public Health lmage Library; https://phil.cdc.gov/ of psoriasis. Psoriatic arthritis and spondylitis may coexist in defau lt.aspx. approximately 25'2, of patients. Psoriasis is exacerbated by systemic glucocorticoids, lithium, antimalarial drugs, tetracyclines, p-blockers, NSAIDs, and ACE inhibitors. STUDY TABLE; Clinical Appearance of Common Psoriasis Subtypes Subtype Description Chronic plaque psoriasis Thick, erythematous lesions with silvery, adherent scale anywhere on the body Guttate psoriasis Many small drop-like papules and plaques on the trunk often developing after infection with B-hemolytic Streptococcus Pustular psoriasis Abrupt onset of generalized erythema and "lakes of pus," typically following abrupt discontinuation of glucocorticoids lnverse psoriasis Red, thin plaques with a variable amount of scale in the axillae, underthe breasts or pannus, intergluteal cleft, and perineum

STUDY TABLE; Clinical Appearance of Common Psoriasis Subtypes Subtype Description Chronic plaque psoriasis Thick, erythematous lesions with silvery, adherent scale anywhere on the body Guttate psoriasis Many small drop-like papules and plaques on the trunk often developing after infection with B-hemolytic Streptococcus Pustular psoriasis Abrupt onset of generalized erythema and "lakes of pus," typically following abrupt discontinuation of glucocorticoids lnverse psoriasis Red, thin plaques with a variable amount of scale in the axillae, underthe breasts or pannus, intergluteal cleft, and perineum l*" il psoriasis lndentations, pits, and oil spots often involving multiple nails 187