ABIM 2015 - Derm Flashcards
Which areas of the body are sites that are most commonly diagnosed with melanoma?
Backs of MEN, legs of WOMEN
What are the dermatologic risks of phototherapy and immunosuppression?
Skin cancers
What type of care is required by patients whom exhibit widespread erythema, peeling, sloughing or painful skin, acute onset of mucosal erosion (mouth, eyes, genitals), rapidly-progressing blisters/pustules, skin necrosis, purpura in patients with systemic illness or fever?
Emergent Dermatologic Consultation
What patient population is at an especially high risk of developing aggressive Squamous Cell Carcinoma, other skin cancers, deep fungal infections and rapidly-growing nodules or plaques?
TRANSPLANT recipients (immunosuppressed)
Clobetasol Propionate
Superpotent Topical Steroid
Triamcinolone
High-Potency Topical Steroid
Hydrocortisone
Low-Potency Topical Steroid
These topical steroids MUST be avoided on the face, groin, axilla or atrophic skin and only used for short-term elsewhere?
Superpotency and High-Potency topical steroids
How is Vulvar Lichen Sclerosus treated?
Superpotent (Clobetasol) Topical Steroids
Best steroid for patients with WIDE-SPREAD (large surface area) dermatoses?
Triamcinolone
Why do corticosteroids thin-out the skin if used long-term?
Because they inhibit collagen production
Cigarette paper skin, skin atrophy and striae (stretch marks) are all caused by prolonged use of these medications?
Topical Corticosteroids
What is a rare SYSTEMIC adverse effect of chronically used Superpotent Topical Corticosteroids?
Hypothalamic-Pituitary Axis suppression (>50 g/week of superpotent or >100 g/week of high-potency)
Skin findings worsen in a patient after receiving appropriate topical corticosteroid therapy?
Allergic contact dermatitis to corticosteroid formulation
What dermatologic therapy can lead to easy bruising from minimal trauma?
Chronic use of SYSTEMIC corticosteroids
Topical and Systemic corticosteroids are considered Category C, are these safe for use in pregnancy?
YES
Of ALL antihistamines, which is contraindicated for use during the first trimester?
Hydroxyzine
Tetracyclines in pregnancy?
NO! can cause staining of teeth and affect developing bones, especially skull fontanelles (bulging)
Isotretinoin, Methotrexate, Thalidomide, Flutamide, 5-FU, finasteride, Danazol, Estrogens?
Pregnancy Category X (DO NOT USE)
Which TWO medications have their own government-mandated Pregnancy Prevention Programs?
Isotretinoin and Thalidomide
Pregnancy Category D?
Human studies confirm risk to fetus however benefits of treatment may outweigh potential risk
Skin findings of linear excoriations, small scattered erosions, scarring, hyper/hypo pigmentation, firm, hyperpigmented dome-shaped nodules with superficial erosions indicate what?
Clues that a patient has pruritus and has been scratching
A non-immunologic, toxic-injury to the skin is called?
“IRRITANT” Contact Dermatitis (chronic hand-washing)
Delayed-Hypersensitivity Reaction (TYPE-IV) caused by allergen-specific T-lymphocytes with rash with specific pattern of substance usually seen on skin (squares, etc.)?
“ALLERGIC” Contact Dermatitis (poison ivy, metals, bandaid, etc.)
How do you diagnose ALLERGIC Contact Dermatitis?
Epicutaneous Patch Testing
Why is patch testing NOT done with “IRRITANT” contact dermatitis?
Because it can scar and cause pigmentation changes
How is Prick or Scratch testing different than Patch testing?
RAST (prick/scratch) testing is for Type-I or IgE-mediaed allergies, NOT Type-IV (delayed hypersensitivity) testing
How are IRRITANT and ALLERGIC contact dermatitis treated?
Mid-to-High potency topical corticosteroids and avoidance of the offending substance
When would you opt to use systemic corticosteroids for the treatment of contact dermatitis?
If severe reaction (facial swelling, severe pruritus, extensive area affected, impairment of function or sleep
What testing best identifies the etiology of hand-eczema (most often work-related exposure)?
Patch testing
How do you best treat hand-eczema besides avoidance of causative substance?
Wearing rubber gloves and using a mid-to-high potency topical corticosteroid twice daily until it clears
Patients with recalcitrant (refractive) dermatitis to topical/systemic corticosteroids must be treated with what?
Immunosuppressant agents or PSORALEN + PUVA (UV A or B light therapy)
Erythematous patches on the lower leg with dry scale and fine fissures that occur usually in the winter on dry skin? How do you treat?
Xerotic eczema; non-soap cleansers, thick moisturizers and 2-3 weeks of low-to-mid potency topical corticosteroids if significant pruritus
Distinguished from Tinea Corporis by negative KOH test and no hyphae under the microscope, presents with coin-shaped patches that are very itchy, usually in patients with history of atopic eczema?
Nummular dermatitis
A dermatitis that occurs often on the lower legs of patients with venous insufficiency, >50 yo, with edema, erythema, brown discoloration, scaling and petechiae, however is CHRONIC, BILATERAL and often with PRURITUS?
Stasis Dermatitis
How is cellulitis different than Stasis Dermatitis?
Cellulitis is NOT pruritic, usually UNILATERAL, smooth not scaly, ACUTE, rapidly spreading and PAINFUL
Why should biopsy of stasis dermatitis be used only as a last resort (unusual location, recalcitrant to therapy or with normal venous studies?
Because the ulcer created by the biopsy may not heal (due to the poor blood flow of venous stasis)
How is stasis dermatitis treated?
Leg elevation, graduated support stockings, ORAL antibiotics if infection present
A chronic, pruritic skin condition that begins in childhood, with intermittent flares involving the wrists, hands, antecubital and popliteal fossae?
Atopic Dermatitis
Dermatitis flares caused by heat, stress, infection with red skin with serous crusting and erosions, commonly seen in patients with a history of environmental allergies, asthma?
Atopic Dermatitis
Type 2 T-helper (TH2) response with elevated IgE and eosinophils and dysregulation of (TH1) response - type of dermatitis?
Atopic Dermatitis
How is atopic dermatitis treated?
Topical Corticosteroids
What types of topical corticosteroids are used for the face and other thin-skin areas such as intertriginous (skin folds) areas?
Low-potency topical steroids (to avoid thinning of skin)
What are topical pimeCROLIMUS and taCROLIMUS used for?
Topical calcineurin inhibitors that CAN be used on the face and intertriginous (skin folds) areas when superpotent and high-potency corticosteroids can’t
What is a disadvantage of soaps?
They dry the skin
What is a disadvantage of creams, lotions, solutions and gels?
Contain water, preservatives and alcohols that can sting and burn open skin
Best thick moisturizer?
Petroleum jelly
Recalcitrant dermatitis, eczema, vitiligo, cutaneous T-cell lymphoma can be treated how?
PSORALEN + UV A/B light or systemic immunosuppressants
What bacteria colonizes areas affected by chronic skin conditions including dermatitis?
Staphylococcus Aureus
A chronic, multisystem inflammatory disease with both genetic and environmental factors, exacerbated by stress, infections, medication (interferons, TNF-alpha, lithium & ß-blockers)?
Psoriasis
The second most common type of psoriasis after plaque psoriasis which is often diagnosed in childhood and is triggered by this respiratory illness?
Streptococcal pharyngitis (strep throat)
What is the “Koebner” phenomenon experienced by patients with psoriasis, lichen, vitiligo and keratosis?
Development of PSORIATIC, LICHEN, VITILIGO or KERATOSIS lesions in the scars that develop following injury to the skin as it heals
Nail involvement in psoriasis indicates what condition?
Psoriatic arthritis
What dermatologic conditions mimic the appearance of psoriasis and erythema often necessitating skin biopsy for diagnosis?
Cutaneous T-cell lymphoma, Lupus, Dermatomyositis
When is SYSTEMIC (methotrexate, acitretin, TNF-alpha) rather than topical therapy recommended for patients with psoriasis?
When >10% body surface area is affected
An idiopathic, inflammatory disease that can affect the hair follicles, skin (wrists, ankles, back and trunk), nails and mucous membranes (oral/buccal and genital) with INTENSE pruritus and Wickham striae (fine white lines on lesions)?
Lichen Planus
What has a similar appearance to Lichen Planus but is caused by meds like ACE-I, thiazide diuretics, furosemide, ß-blockers and antimalarials?
Lichenoid Drug Eruption (LDE)
How is mild psoriasis treated?
Topical Corticosteroids or Topical Vit D analogues
How are psoriasis, lichen planus, pityriasis rosea and seborrheic dermatitis diagnosed?
KOH prep/Biopsy if needed
How are mild cases of psoriasis, lichen planus, pityriasis rosea and seborrheic dermatitis treated?
Topical corticosteroids
Patients allergic to metals (mercury, gold, palladium) can have what types of changes directly adjacent to their dental fillings?
Lichenoid (Lichen Planus)
What is the most serious risk of a chronic mucosal (oral/buccal, genital) lesion of Lichen Planus?
Squamous Cell Carcinoma
What dermatological disorder can cause scarring alopecia?
Lichen Planus (can affect hair follicles)
What maintenance therapy is used for Lichen Planus?
Topical Calcineurin Inhibitors
What is the ONLY medication that CAN result in REMISSION in Lichen Planus?
PSORALEN + PUVA (UV A)
A common dermatosis seen in 10-35 year olds, seen in fall and spring, begins with one, annular patch with trailing scale, days to weeks BEFORE onset of numerous, smaller patches on the trunk and proximal extremities?
Pityriasis rosea (herald patch, Christmas Tree distribution)
As Pityriasis Rosea is self-limited and spontaneously resolves, when do you treat with topical corticosteroids or UV-B light therapy?
If extensive or persistent (beyond 1-3 months)
A dermatitis seen commonly in HIV/AIDS and patients with neurologic diseases (Parkinson) that involves the scalp, eyebrows, side of nose and ears?
Seborrheic dermatitis
Is a biopsy helpful in a morbilliform (a combined macular/papular skin eruption) caused by medications?
NO
How is a MORBILLIFORM (coexistent macules & papules) drug reaction different than a drug HYPERSENSITIVITY syndrome?
Drug HYPERSENSITIVITY syndrome involves FACIAL EDEMA with papules coalescing into plaques and is treated with SYSTEMIC not topical corticosteroids
Puffy pink plaques with an annular configuration that occur within DAYS of initiation (antibiotics, contrast dye) with possible ANAPHYLAXIS is what type of a cutaneous drug reaction and how is it treated?
URTICARIAL; antihistamines AND possibly systemic corticosteroids (if severe) or EPINEPHRINE (if anaphylaxis)
Swollen, painful plaques on palms and soles after chemotherapy?
Hand-Foot syndrome (treat with analgesics)
Skin reaction that looks like acne but is NOT (does not respond to retinoids) that is seen with CETUXIMAN and SORAFENIB and is treated with antibiotics and low-potency topical corticosteroids?
ACNEIFORM reaction
What is the DANGER with use of Tyrosine Kinase Inhibitors (“inib”), Hydroxyurea and Voriconazole?
Cutaneous Squamous Cell Carcinoma
What is the DANGER with VORICONAZOLE?
Associated with Squamous Cell Carcinoma and Melanoma
Which drugs are the MOST COMMON cause of “Drug-Induced Hypersensitivity Syndrome” or “Drug-Induced Systemic Reactions” or “Drug Reaction With Eosinophilia and Systemic Symptoms?”
Anticonvulsants (anti-epileptic)
Epileptic patient took his medication and developed facial edema, fever, lymphadenopathy, wide-spread rash with purpura and skin necrosis?
Drug-Induced Hypersensitivity Syndrome
Severe drug reaction with SUDDEN onset of wide-spread erythema studded by small pustules with fever, leukocytosis and eosinophilia caused by antibiotics, antimalarials, diltiazem and terbinafine?
Acute Generalized Erythematous Pustulosis (AGEP)
How is Acute Generalized Erythematous Pustulosis (AGEP) treated?
Self-limited (2 weeks) or can use topical/systemic corticosteroids depending on severity
What is the preferred treatment of drug-induced SYSTEMIC reactions?
Systemic corticosteroids
A combination of new and resolving, NON-PRURITIC red-brown patches with “cayenne pepper” petechiae on the lower extremities mistaken for stasis dermatitis or vasculitis?
Pigmented Purpuric Dermatoses (mixed cryoglobulinemia)
Blockage and rupture of sweat glands when skin is occluded and hot such as in swaddled neonates, immobile, febrile or post-op patients or under pannus or breasts?
Miliaria (heat rash)
What is generally seen in combination with Miliaria (heat rash)? How is it treated?
Candida infection; cooling the patient, talctum powder, antifungal if candida
Erythematous papules on chest, back or flanks of hospitalized patients due to occlusion of the skin from fever and sweating?
Acantholytic Dermatosis (Grover Disease)
What are the two main types of acne?
Inflammatory and non-inflammatory
What is the presentation of non-inflammatory acne?
Comedones (white/blackheads)
What is the presentation of inflammatory acne?
PAINFUL erythematous pustules, nodules or cysts
What MUSt be done for a woman presenting with acne and a history of irregular menses, hirsutism, deepening voice or clitoromegaly?
Prompt endocrine screening (DHEA-S, testosterone and 17-hydroxyprogesterone)
A severe type of acne that presents with ABRUPT onset of widespread, severe, painful inflammatory cysts with a febrile and ill-feeling patient with sterile osteomyelitis presenting as bony lesions in the sternum and clavicle?
Acne Fulminans
How do you treat Acne Fulminans?
Referral to dermatology and Isotretinoin with systemic corticosteroids to minimize severe scarring
Young body builder presents with hundreds of small follicular papules and pustules in the SAME STAGE of evolution WITHOUT comedones, on the upper trunk, arms or face?
Corticosteroid-induced acneiform eruption
Bacterial folliculitis in HAIR-bering areas in athletes is caused by?
Staphylococcus Aureus
When is folliculitis on the face caused by E.coli (Gm neg)?
When overgrowth of the bacteria occurs during prolonged antibiotic treatment of acne
How is MILD (comedomal) acne treated?
Topical antibiotic + Benzoyl peroxide AND topical retinoid
How is MODERATE acne (comedomes and papules/pustules) treated?
Topical AND oral antibiotic + Benzoyl peroxide AND topical retinoid
How is SEVERE (nodular/cystic) acne treated?
Oral antibiotics
How is SEVERE RECALCITRANT acne treated?
Oral Isotretinoin with referral to dermatologist
What are the typical skin washes used for acne?
Benzoyl peroxide, Salicylic/Azelaic acid
What are the typical TOPICAL antibiotics used to treat acne?
Clindamycin, Erythromycin
What are the typical ORAL antibiotics used to treat acne?
Doxycycline, Tetracycline, Minocycline, Erythromycin
Why is the use of Benzoyl peroxide important in the treatment of acne with TOPICAL or ORAL antibiotics?
Because it reduces the resistance of Propionibacterium acnes to the antibiotics used
What agent is used in combination with Oral Contraceptive pills to improve their effect on acne treatment?
Spironolactone (drospirenone)
What can painful acne cysts be treated with at the dermatologist’s office?
Injection of cyst with Triamcinolone
Inflammatory vascular condition causing acneiform eruption presenting as flushing of the face with bulbous nose and dry, gritty feeling in the eyes with conjunctival injection triggered by hot liquids, spicy foods, exercise, stress and alcohol?
Rosacea
How are vascular rosacea and periorificial dermatitis treated?
TOPICAL metronidazole, azelaic acid or sodium sulfacetamide
How is pustular rosacea treated?
Oral Tetracycline
Follicular occlusion with painful, draining nodules and sinuses in the axilla, groin and under breasts with sterile abscesses?
Hidradenitis Suppurativa
How is Hidradenitis Suppurativa treated?
Oral Tetracycline
What treatment allows for analgesia of painful dermatological nodules and cysts?
Intra-lesional injection of Triamcinolone
What dermatological condition is very strongly worsened by smoking and obesity?
Hidradenitis Suppurativa
What therapy is definitive for Hidradenitis Suppurativa?
Surgical excision and grafting
Folliculitis, furuncles, carbuncles, impetigo, cellulitis, ecthyma, scalded skin syndrome and erysipelas are all caused by?
Staph aureus OR Strep pyogenes
When is culture of folliculitis important?
When suspecting MRSA
How is folliculitis treated?
TOPICAL antibacterial washes (clorhexidine), TOPICAL antibiotics (mupirocin) or ORAL antibiotics
What is suspected in recurrent folliculitis?
MRSA (check nares and perianal area)
Besides bacteria, what else can cause folliculitis?
Fungi and HSV
When an abscess involves a follicle, it is called? When these coalesce into larger lesions they are called?
Furuncle; Carbuncles
When are skin abscesses treated with antibiotics?
If cellulitis is present, if systemic symptoms exist (fever) and in immunosuppressed or patients with heart valves or joint prostheses
What are first-line therapies for MRSA?
Tetracyclines (doxycycline, minocycline), clindamycin or TMP-SMX
What is an excellent medication to use in a patient with jaundice-caused pruritus not responsive to cholestyramine?
Rifampin
A CONTAGIOUS and pruritic skin infection caused by Staph aureus or Strep pyogenes in healthy people that has a bullous and non-bullous form?
Impetigo
How is impetigo treated?
Topical (mupirocin) or Oral antibiotics
What is cellulitis?
Infection of deeper layers of the skin (scratching, injury or hematogenous spread)
How do you treat cellulitis?
ß-lactam antibiotic (cephalexin or dicloxacillin) or same as MRSA antibiotics (clindamycin, TMP-SMX, tetracycline)
What bacteria are suspected in cellulitis BESIDES Staph aureus?
ß-hemolytic strep (thus requiring ß-lactam antibiotics for treatment)
How do you treat an immunocompromised patient with cellulitis?
Broad-spectrum antibiotics as with MRSA (clindamycin, TMP-SMX, tetracyclines, linezolid)
What should be done preventatively in patients with lower extremity cellulitis?
Check for DVT with US
DEEPER skin infection than Cellulitis is called?
Erysipelas (dermis and lymphatics)
What bacteria is involved in Erysipelas (FACE) in the young, women and elderly and how is it treated?
Group A Strep; PENICILLIN
Infection in intertriginous areas (axilla, groin), caused by Corynebacterium and fluoresces coral red on wood lamp?
Erythrasma
How is erythrasma treated?
Clindamycin, erytheromycin (macrolides) or topical antifungals (azoles)
Stinky feet with pitted lesions caused by excess sweat and bacteria (Corynebacterium, Kytococcus, Actinomyces)? How is it treated?
Keratolysis (topical erythromycin or clindamycin
Moccasin distribution of SCALING fungal infection?
Tinea Pedis
How are all Tineas treated?
Topical (azole) antifungals (oral only if recurrent)
Dry SCALING on one hand and two feet?
Tinea Manum
Dry SCALING of scalp and hair loss, usually in children?
Tinea Capitis
Symmetrical SCALING in the inguinal folds sparing the scrotum?
Tinea Cruris
How can you test for Tinea if needed?
KOH prep of advancing edge of lesion demonstrating hyphae (fungus)
How long are tineas treated for?
Until COMPLETELY cleared
SCALED oval patches either hyper or hypo pigmented involving skin and hair follicles usually on chest, upper back and abdomen (high sebaceous gland concentration) with hyphae and spores on KOH prep?
Tinea Versicolor (pityriasis versicolor)
How is Tinea Versicolor treatment DIFFERENT than the other Tineas?
Selenium; or topical/oral antifungals if very limited involvement or very wide spread
Besides AZOLE antifungals, what can be used for cutaneous candidiasis treatment? Prevention?
Nystatin; Zinc Oxide paste (barrier cream)
Grouped, PAINFUL, BURNING vesicular lesions that recur, generally found in oral mucosa?
HSV-1
Grouped, PAINFUL, BURNING vesicular lesions with ulceration that recur, generally found in genital region?
HSV-2
Grouped, PAINFUL, BURNING vesicular lesions that recur, generally found in dermatomal distribution?
Herpes Zoster (varicella zoster) - chicken pox reactivation
What CAN occur ONLY during INITIAL infection with HSV besides severe local pain and burning?
Fever, malaise, tender lymphadenopathy
What are the prodromal symptoms of HSV recurrence?
Burning and stinging at site of eruption before eruption
Which HSV type can cause pharyngitis and aseptic meningitis?
HSV-2
What is common with HSV-2, Syphilis, Chancroid, Lymphogranuloma Venerum and Granuloma Inguinale?
ALL cause GENITAL ULCERS
What can test for but not differentiate HSV type?
Tzank smear
What can rapidly test for AND differentiate HSV?
PCR or DFA (direct fluorescent antibody)
What is the gold standard for HSV type diagnosis but takes 2 weeks for result?
Viral culture
What is recommended for treatment of HSV infection when lesions occur and when is the BEST time to treat?
ORAL agents (acyclovir, valcyclovir, famcyclovir); at onset of PRODROME symptoms
Recurrent herpes zoster infection should raise suspicion of?
HIV infection or malignancy
When should treatment of herpes zoster begin?
Within 24-72 hours of ERUPTION
What should be done if herpes zoster (shingles) involves the face (1st distribution of trigeminal nerve)?
Emergent ophthalmology evaluation
What are warts caused by?
HPV
What are anogenital warts called?
Condylomata acuminata
Does surgical removal of warts treat HPV?
NO
Do women with genital warts require more frequent PAP smears than the regular population?
NO
What should be suspected if genital warts appear to be bizarre or recalcitrant to therapy?
Transformation into Squamous Cell Carcinoma
Besides surgery, what are other good treatments for warts?
Salicylic acid, cryotherapy, Topical IMIQUIMOD
What HPV strains are covered by the HPV vaccine?
Cancer types (6, 11, 16, 18)
What TOPICAL immunomodulatory medication works well for warts, molluscum contagiosum, actinic keratosis and Squamous Cell Carcinoma in Situ (Bowen Disease)?
IMIQUIMOD
Asymptomatic, small firm papules with with central depression caused by a poxvirus and can occur on ANY skin surface?
Molluscum Contagiosum
Adults and children with this disease can have EXAGGERATED responses to mosquito bites, with blisters and wheals?
CLL
How is scabies diagnosed?
Scraping of lesions and examination with KOH or mineral oil
What is used to treat scabies infestation (person affected and ALL family members who live with patient and close contacts)
Topical PREMETHERIN cream, applied neck to toe, repeated again in 7-10 days; Oral IVERMECTIN (for persistent infection)
What dermatologic condition is a risk factor for Bartonella quintana endocarditis?
Body lice (homeless)
How is lice treated initially? If not resolved?
Topical Premetherin, malathione or Oral Ivermectin; Lindane (neurotoxic)
Best medication for head lice?
SPINOSAD (topical insecticide)
“Breakfast, Lunch and Dinner” bites, treatment is symptomatic only with topical corticosteroids and antihistamines?
Bed Bugs
Spider bite with nausea, vomiting, fever, myalgia and can develop a painful necrotic wound? How is it treated?
Brown Recluse Spider; Supportive with wound care
What is the best management for wound healing?
Keeping them MOIST and OCCLUDED (petroleum jelly)
Why is petroleum jelly better than topical antibiotics for NON-INFECTED cuts, scrapes and burns?
Same outcome WITHOUT possibility of allergic reactions/contact dermatitis from antibiotics
What topical antibiotics are recommended for SECONDARILY INFECTED cuts, scrapes and burns?
Mupirocin
What is the difference between a 1st degree burn and a second degree burn?
1st degree burn is DRY; 2nd degree burn is MOIST
What is the initial treatment for both 1st and second degree burns?
Outpatient analgesia, NSAIDS, cool compresses and gentle skin care
What is done with open blisters from a burn?
Gentle debridement and non-adherent gauze (petrolatum)
How are 2nd degree burns treated differently than 1st degree burns?
2nd degree burns are monitored for infection and tetanus prophylaxis is given if immunization is unknown
What is done with patients who present with burns >10% body surface area, burns involving the face, hands/feet, genitals, perineum or major joints, 3rd degree burns, electrical/chemical burns, inhalation injury and burns+trauma?
Referral to a BURN CENTER
What are the three most common types of skin cancer?
Basal Cell Carcinoma, Squamous Cell Carcinoma and Melanoma
This skin cancer does not metastasize however causes significant local tissue destruction and has telangiectasias?
Basal Cell Carcinoma
What is REQUIRED for diagnosis of basal cell carcinoma?
BIOPSY
What is the best treatment for Basal Cell carcinoma and is especially used on the face?
Mohs surgery
How are less aggressive subtypes of basal cell carcinoma treated?
Simple excision, cryotherapy, electrodessication and curettage, pthotodynamic therapy or topical imiquimod
What is morpheaphorm basal cell carcinoma?
A more aggressive type of basal cell carcinoma
Very SCALY macules or papules usually found on face or dorsum of hands usually easier to feel rather than see, due to sun exposure?
Actinic Keratosis
What is actinic keratosis a precursor for?
Invasive Squamous Cell Carcinoma
Besides Topical imiquimod, cryotherapy and photodynamic therapy, what else is used to treat actinic keratosis?
5-FU
What is Bowen Disease?
Squamous Cell Carcinoma in Situ, a non-invasive form of Squamous Cell Carcinoma
How is Bowen disease treated?
Same as actinic keratosis, cryotherapy, topical imiquimod, 5-FU or excision
A red, volcano-like nodule with a central keratinic plug, a subtype of squamous cell carcinoma, which grows rapidly treated by excision?
Keratoacanthoma
A history of blistering sunburns, especially before 18 yo, presence of multiple nevi, having fair skin and freckles are all risk factors for?
Melanoma
A skin lesion with asymmetry, irregular borders, multiple colors, diameter >6 mm with enlargement over time is likely?
Melanoma
What is the MOST important prognostic feature of melanoma?
Tumor depth (Breslow depth)
What is an Acral Lentiginous Melanoma and where is it found?
Melanomas found on the nails or hands and feet of patients with dark skin types
What is the diagnostic technique of choice for melanoma?
Excisional Biopsy
This type of skin cancers are much more aggressive in immunosuppressed patients?
Squamous Cell Carcinoma
Exposure to UV light, arsenic, ionizing radiation, HPV, cigarette smoke and being immunosuppressed places a patient at high-risk of?
Squamous Cell Carcinoma
What is a Marjolin ulcer?
An aggressive form of Squamous Cell Carcinoma which can arise from a burn injury scar, years after burn
How is Squamous Cell Carcinoma treated?
Radiation and Mohs surgery/excisional surgery
What else is done for patients with melanoma besides excision of tumor if higher-risk lesion?
Sentinel lymph node biopsy
How is METASTATIC melanoma treated?
Interferon + Chemotherapy
Benign pigmented lesions usually found in older adults and have a “stuck-on” appearance?
Seborrheic Keratosis
How and when is seborrheic keratosis treated?
Curettage or cryotherapy, only necessary if inflamed
What type of nevi appear in hoards on back/chest/arms, are darkly pigmented (melanocytic) and pose a higher risk of transformation into melanoma?
Dysplastic nevi
What is recommended for Dysplastic Nevi?
Rigorous screening, surveillance, self-examination and regular physician examinations, NOT routine removal
What are HALO Nevi and why are these important?
Nevi that are undergoing a process of destruction by an immune-mediated response leaving a white halo around them; because melanoma can undergo a similar process
Single or multiple small, pink or yellowish papules on the face WITHOUT telangiectasias and WITHOUT translucency, often associated with rosacea?
Sebaceous Hyperplasia
Small, flesh-colored asymptomatic papules that are common and benign however can present as multiple in conjunction with axillary freckling, cafe-au-lait spots and Lisch (brownish) nodules on the iris?
Neurofibromas; Neurofibromatosis-I
Benign, soft, fleshy and pedunculated papules occurring in areas of friction such as neck, axillae and groin and the presence of multiple such lesions is associated with insulin resistance, obesity and DM-II. Often found in patients with acanthosis nigricans?
Acrochordons (Skin Tags)
Benign vascular lesion (usually red and non-blanching) found in adults and mainly on the trunk?
Cherry Hemangioma
Firm pink to brown papule on skin with darker brown ring on periphery, found after insect bites or shaving injury and dimples when squeezed?
Dermatofibroma (benign)
Brown macules found in older people especially in sun-exposed areas, benign but if found on face and have irregular pigmentation these need to be biopsied, why?
Solar Lentigines “liver spots”; because may be lentigo maligna
How are hypertrophic scars and keloids treated?
Intra-lesional corticosteroid injections
Friable, red vascular papules that are often painful and bleed easily, arise spontaneously especially in pregnant women and grow very rapidly that consist of a collection of capillaries?
Pyogenic granulomas (not actually pyogenic nor granulomas)
Subcutaneous nodule that is benign, has a central punctum and if drained, contains a white, cheesy and malodorous keratinaceous material?
Epidermal Inclusion Cysts (must remove cyst wall if treated)
What is the main cause of pruritus?
Dry Skin
A condition in which stroking or rubbing your skin causes a pruritic acute wheal and flare reaction?
Dermatographism
What should be done for diffuse itching without a rash?
Search for underlying systemic cause
Malignancies (especially hematologic or lymphomas), cholestatic liver disease, renal disease, iron deficiency, hypo/hyper thyroid disease, certain medications and HIV infection can all cause what common symptom?
Pruritus
What are notalgia paresthetica and brachioradial pruritus?
Neuropathic itching conditions resulting from inflammation or damage to sensory nerves
Which antihistamines are best for treatment of pruritus?
The most sedating types
Which are the two common topical antihistamines?
Doxepin and Diphenhydramine
What agents are used for neuropathic pruritus?
Gabapentin, Pregabalin and UV-B therapy
How long do urticarial lesions (wheals) last for?
No longer than 24 hours
Uritcarial lesions that last LONGER than 24 hours, resolve leaving a bruise and present with burning or tingling are what and what do they require?
Urticarial Vasculitis; must be biopsied for diagnosis
What must be done for patients whom have extensive urticarial eruptions around the mouth?
Monitored closely for possible admission in case of airway obstruction
What is the predominant cause of urticaria?
Viral URI’s
What is considered acute vs chronic urticaria?
6 weeks
What MUST ALL patients with ACUTE urticaria be evaluated for?
Anaphylaxis
What are the three (3) most common triggers for anaphylaxis?
Bee stings, food allergies, medications
What are known mast-cell degranulators that can make urticaria worse?
Exercise, heat/cold, friction, vibration, pressure and venoms
What are common medications that induce mast-cell degranulation?
Aspirin, alcohol, narcotics (codeine and morphine), scopolamine and some anesthetics
What is first-line therapy for urticaria?
Anti-histamines 4-8 weeks NOT just for flare-ups
What is second-line treatment for urticaria if antihistamines fail?
Tapered oral corticosteroids
Patients who fail to respond to antihistamine therapy should be diagnosed with what?
CHRONIC urticaria
What is CHRONIC urticaria treated with?
Colchicine, Dapsone, Hydroxychloroquine, mycophenolate mofetil, methotrexate
What should ALL patients with angioedema be trained to do?
Be able to use an Epi-Pen
What should be considered when an adult presents with unexplained BLISTERING or erosions of the skin, especially of the MOUTH, EYES or VULVA?
Autoimmune blistering disease
How are autoimmune blistering diseases diagnosed (3 tests)?
- BIOPSY
- Blood tests for circulating Ab’s
- Direct Immunofluorescence Microscopy
What is a symblepharon?
Fusion of the eyelid to the eye globe in autoimmune blistering disease involving the eye
Tender, fragile blisters and erosions involving skin and mucous membranes, biopsy shows suprabasilar clefting and DESMOGLEIN 3 Auto-Ab with INTERcellular deposition of IgG
Pemphigus Vulgaris
Scaling and crusted lesions on face and upper trunk, NO mucosal involvement with DESMOGLEIN 1 Auto-Ab?
Pemphigus foliaceus
Bullous disease associated with underlying neoplasms (NHL, CLL) involving mostly mucous membranes (oral, conjunctival, esophageal, laryngeal)?
Paraneoplastic pemphigus
No mucous membrane involvement however this vesicopustular eruption with clear blisters transforms to pustules, involves trunk and proximal extremities with IgA antibodies and deposition of intracellular IgA at the epidermal surfaces?
IgA Pemphigus
Presents in the elderly on trunk and limbs with tense blisters after INTENSE pruritus or urticarial lesions with linear IgG deposition in basement membranes without mucosal involvement?
Bullous Pemphigoid
Bullae usually seen in elderly on conjunctiva, affects mucous membranes including oral mucosa and is associated with CANCER?
Cicatricial Pemphigoid
Involves ELBOWS, KNEES, BACK, SCALP and BUTTOCKS with SEVERELY pruritic grouped vesicles with neutrophilic infiltrate and granular IgA deposition in the DERMIS?
Dermatitis Herpetiformis
ALL patients with Dermatitis Herpetiformis have this disease?
Celiac Disease
Mechanically-induced bullae on extensor areas that heal with scarring, associated with SLE and IBD?
Epidermolysis Bullosa Acquisita
How are autoimmune blistering diseases treated?
Systemic corticosteroids or immunosuppressants (azathioprine, mycophenolate mofetil, methotrexate, cyclophosphamide), RITUXIMAB and Dapsone
What autoimmune dermatologic disease is associated with LYMPHOMA?
Paraneoplastic Pemphigus
Patients with Dermatitis Herpetiformis ALL have Celiac Disease, this places them at risk for what GI malignancy?
GI tract LYMPHOMA (treatment is gluten-free diet)
Malar rash is seen in? What is Discoid rash seen in?
SLE; Cutaneous Lupus
What is SUBACUTE Cutaneous Lupus Erythematosus (SCLE) caused by?
Medications
What medications typically cause Subacute Cutaneous Lupus Erythematosus?
HCTZ, Calcium Channel Blockers, ACE-I, terbinafine and TNF-alpha inhibitors
What does the presence of Anti-Histone Ab’s suggest?
Medication-Induced Lupus
What antibodies are Subacute Cutaneous Lupus Erythematosus positive for?
anti-Ro/SSA, anti-La/SSB and anti-histone Ab’s
Do the lesions of Cutaneous Lupus (Discoid Lupus) scar?
NO
What is the lupus band test?
Biopsy of a lupus lesion demonstrating Ig deposition
Patients with long-standing lupus with scarring are at an increased risk of what?
Skin cancer within the lupus lesion - any change in lesions warrants close evalaution
What should you do if you notice a change in a scar or chronic cutaneous lesion of lupus?
Closely evaluate for possible cancer transformation
What is an ESSENTIAL part of therapy for ALL lupus forms?
Protection from UV-light as this EXACERBATES lupus
What must lupus patients be monitored for as a result of their aggressive protection from sun light?
Vitamin D deficiency
What is first-line systemic therapy for lupus?
Hydroxychloroquine
If Hydroxychloroquine does not work for lupus, what else can be used?
Other anti-malarial agents as well as mycophenolate mofetil, methotrexate, dapsone, cyclosporine, thalidomide
Heliotrope Rash, Gottron Papules, telangiectasias of proximal nail folds with frayed cuticles, positive ANA and muscle inflammation?
Dermatomysositis
Erythematous papules over the bony prominences of the hands and fingers are found in?
Dermatomyositis - Gottron Papules
The presence of antisynthetase antibodies in patients with dermatomyositis, usually found in those who also have mechanic hands (thickened hyperkeratotic scale of lateral aspects of digits) correlates with what other disease?
Interstitial lung disease (anti-Jo-1 & anti-Mi-2)
Violaceous erythema over the “V” of the neck, upper back and deltoids “shawl sign” is seen in what disease?
Dermatomyositis
What symptom can differentiate dermatomyositis from lupus?
Intense pruritus (shawl sign, Gottron papules, heliotrope rash)
20%-25% of patients with dermatomyositis have what?
AN UNDERLYING CANCER
What should you ALWAYS check for in a patient with dermatomyositis?
Underlying CANCER (age-related cancers, ovarian cancer)
What is the MOST common type of cancer found in women with dermatomyositis?
OVARIAN CANCER
How is dermatomyositis treated?
Like lupus (aggressive sun-light protection, anti-malarial drugs, other immunosuppressant drugs)
For how long after diagnosing dermatomyositis is a patient at risk for cancers if none are found at diagnosis?
3 years
A discoloration of the vasculature attributed to SLOW blood flow, usually on the lower extremities and associated with the medication AMANTADINE?
Livedo Reticularis
Patients with Livedo Reticularis and Migraines are at an increased risk of what?
STROKE
A dermatologic representation of abnormal platelet quantity, function, infectious process or abnormal vasculature with pin-point foci of extravasated erythrocytes?
Petechiae
What congenital syndrome and vitamin deficiency both present with purpura (coalesced petechiae)?
Ehlers-Danlos syndrome and Vitamin C deficiency
Cutaneous small vessel vasculitis, due to the injury of small vessels and resultant bleeding into the dermis, presents as what cutaneous manifestation?
Palpable purpura
How is the underlying vasculitis causing palpable purpura diagnosed?
By skin biopsy
What is urticarial vasculitis (persistent urticarial plaques lasting longer than 24 hours and presenting with pain and burning rather than pruritus) associated with in >50% of cases?
Autoimmune disease
What medications are associated with cutaneous small vessel vasculitis causing palpable purpura?
NSAIDS, ß-lactam antibiotics and diuretics
The pathologic process in cutaneous small vessel vasculitis causing palpable purpura is mediated by what?
Neutrophils
How do you treat cutaneous small vessel vasculitis?
Limb elevation, Topical corticosteroids, NSAIDS, colchicine, dapsone and antihistamines
A variant of leukocytoclastic vasculitis seen in children and young adults with IgA in the affected vessels, follows an infection with palpable purpura on the lower legs and buttocks, associated with arthritis, arthralgia and abdominal pain with patients being at risk of kidney disease months after the initial eruption?
Henoch-Schonlein Purpura (HSP)
What is the most common cutaneous manifestation of Rheumatoid Arthritis (RA)?
Rheumatoid nodules (firm, asymptomatic and found over extensor joints)
What RA medication exacerbates the nodules seen in RA?
Methotrexate
A rare complication of chronic RA with severe, seropositive RA presenting as purpura, livedo reticularis or cutaneous ulcerations?
Rheumatoid vasculitis
What is the most common cutaneous issue in patients with chronic kidney disease and/or ESRD?
Intense, refractory, unremitting pruritus as well as very dry skin
How do you treat the dry skin and pruritus in chronic kidney disease/ESRD patients?
Topical emollients, petrolatum, topical corticosteroids and phototherapy
What can occur in patients with ESRD in states of extremely dysfunctional calcium and phosphorus balance leading to calcification of the lumen of arteries with ischemia and necrosis?
Calciphylaxis
Intensely painful necrosis in ESRD patients with high risk of sepsis and mortality?
Calciphylaxis - arterial calcification
What treatments are there for ESRD patients with calciphylaxis?
Sodium thiosulfate, wound care and surgical debridement
How is hyperparathyroidism treated?
Cinacalcet or parathyroidectomy
A patient undergoes MRI with gadolinium and experiences distal extremity skin thickening with fibrosis, limited mobility and distal edema that becomes fixed and indurated with a woody-feel with erythematous plaques and nodules?
Nephrogenic Systemic Fibrosis
How is Nephrogenic Systemic Fibrosis diagnosed?
Skin biopsy
What is the only effective treatment for Nephrogenic Systemic Fibrosis?
Kidney transplant
What two cutaneous malignancies are organ transplant recipients at risk for?
Basal Cell Carcinoma and Squamous Cell Carcinoma
What cutaneous malignancy are renal transplant recipients at a high-risk for?
Squamous-Cell Carcinoma
Violaceous papules, nodules and plaques of this disease occur at sites of trauma, surgical scars or tattoos?
Cutaneous sarcoidosis
What is cutaneous sarcoidosis treated with?
Antimalarial drugs, methotrexate or systemic corticosteroids
What is the most common infection associated with Erythema Nodosum?
Streptococcus
What are the most common medications associated with triggers of Erythema Nodosum?
Antibiotics, oral contraceptives and hormone therapy
What two systemic diseases are associated with Erythema Nodosum?
Sarcoidosis and IBD
Patient with systemic disease or with strep infection or was on hormonal therapy or antibiotics or took oral contraceptives and after a low-grade fever, malaise and arthralgia, developed barely-noticeable tender subcutaneous nodules on their lower extremities leaving a dull, brown circular patch as they resolved?
Erythema Nodosum
What condition does a patient have that presents with Erythema Nodosum, Arthritis, B/L Hilar Lymphadenopathy with fever and uveitis?
An acute form of Sarcoidosis called Lofgren syndrome which resolves in 2-3 years
How is Erythema Nodosum treated?
NSAIDS or systemic immunomodulatory drugs if resistent
Inflammation of the SEPTAE of fat lobules?
Erythema Nodosum
What two cutaneous manifestations are seen in IBD?
Erythema Nodosum (more in UC) and Pyoderma Gangrenosum
Rapidly ulcerating painful pustules with a “juicy” edematous rolled border that also exhibits pathergy (new lesions occur at sites of trauma) associated with IBD and ALL?
Pyoderma Gangrenosum
What is the first-line treatment of pyoderma gangrenosum?
Corticosteroids
How do you treat refractory pyoderma gangrenosum?
Immunomodulators such as cyclosporine, infliximab, thalidomide, mycophenolate mofetil, azathioprine, methotrexate, IVIG, dapsone, colchicine
How is Pyoderma Gangrenosum diagnosed?
By exclusion
Besides Rifampin and Cholestyramine, what other agent is used for treatment of refractory pruritus in end-stage liver disease patients?
Naltrexone
Patients with end-stage liver disease, extensive alcohol use, HCV and hemochromatosis are at a great risk of developing skin fragility with small vesicles developing in sun-exposed areas (dorsum of hands) with small milia, hyperpigmentation and small scars?
Porphyria Cutanea Tarda (treat with phlebotomy and anti-malarial agents)
How is porphyria cutanea tarda (associated with HCV) diagnosed?
Urine porphyrins are elevated
Palpable purpura in the lower extremities of patients with HCV, Waldenstrom macroglobulinemia, Multiple Myeloma and SLE?
Cryoglobulinemia
This disease, associated with HCV and can cause glomerulonephritis, neuropathy, arthritis, pulmonary inflammation. Patients have elevated Rheumatoid Factor low and complement (C4)?
Cryoglobulinemic vasculitis
Besides addressing the underlying disorder, how is cryoglobulinemia treated?
Cyclophosphamide, plasmapharesis, high-dose corticosteroids and rituximab
Painful erythema of the distal hands and feet however can also involve intertriginous areas and can blister, caused by this type of drug therapy?
Hand-Foot Syndrome caused by chemotherapy with cytarabine, 5-FU, capecitabine, methotrexate, docetaxel, paclitaxel and anthracyclines (“rubicin”)
Which chemotherapeutic drug can induce cutaneous lupus?
5-FU and capecitabine (5-FU prodrug)
Seen in AML, IBD, infections as well as caused by medications such as granulocyte colony stimulating factor, trans-retinoic acid, TMP-SMX and minocycline and presents with fever, arthralgia, myalgia and juicy, indurated plaques with sharp borders and vigorous edema that can ulcerate and demonstrates pathergy?
Sweet Syndrome
All patients with Sweet Syndrome should be evaluated for what?
Underlying malignancy, especially AML and myelodysplastic syndrome
In patients with myelodysplastic sydrome, developing Sweet Syndrome signifies what?
Transformation to AML
How do you treat Sweet Syndrome?
Corticosteroids
What chemotherapeutic medication can induce Sweet Syndrome?
Thalidomide (and lenalidomide)
Pigmentation of the oral mucosa signifies what disease?
Addison disease (adrenal insufficiency)
Acanthosis nigricans can signify what two conditions?
Insulin resistance and underlying internal malignancy
What cutaneous condition can be seen in Type-I DM?
Vitiligo (cross autoimmune response against melanocytes)
Why should tenia pedis be treated aggressively in patients with DM?
Because it can lead to ulcers (ketoconazole)
Thinning of the skin which feels warm, moist and smooth with generalized hyperhidrosis, thin and softer-than-normal hair as well as “plummer nail” (nail plate concavity with distal nail separation) are seen in?
HYPERthyroidism
Cool, dry, pale skin with dry and brittle hair and hair loss with lateral thinning of the eyebrows and generalized myxedema?
HYPOthyroidism
What is the most common cutaneous issue with patients with HIV and low CD4 counts (
Photosensitivity
Which patients are at high-risk of secondary skin infections with molluscum, herpes simplex and herpes zoster as well as cutaneous malignancies such as cutaneous lymphoma, Kaposi sarcoma and squamous cell carcinoma?
HIV patients with low CD4 counts
An acute painful and scarring dermatosis with target/”iris” lesions that favors the extremities, affects ONLY one or two mucosal sites and although it can be caused by medications, it is usually caused by INFECTION (HERPES)?
Erythema Multiforme (EM)
Target or “IRIS” lesions on the palms and soles of a 20-40 year old patient, 1-3 weeks after infection with HERPES?
Erythema Multiforme (EM)
What is the difference between SJS and TEN?
SJS affects 30%
What is the most common cause of SJS and TEN?
Medications
Which medications cause SJS/TEN?
Anti-seizure (carbamazepine, lamotrigine, phenytoin), sulfonamides, ß-lactams, pantoprazole, NSAIDS, sertraline, tramadol and allopurinol
How long after taking an offending medication can patients develop SJS/TEN?
4-28 days (within 8 weeks)
Skin pain with coalescing vesicles, bullae and erosions with shearing off of the epidermis with lateral pressure involving ≥2 mucosal surfaces (eyes, mouth, genitals, nasopharynx)?
SJS/TEN
What is used to measure the severity (mortality) of SJS/TEN?
The SCORTEN test (blood gluc, presence of CA, age >40, HR >120, >10% body surface area on day 1, HCO3 28)
What viral and what bacterial infection is implicated in Erythema Multiforme (EM)?
Virus: HSV; Bacteria: Mycoplasma pneumoniae
Short courses of systemic corticosteroids and immunosuppressive therapy works for which of EM/SJS/TEN?
Only for Erythema Multiforme (EM)
How are SJS/TEN treated?
Aggressive supportive skin care as in a BURN UNIT with fluid, electrolyte and nutrition
What is the significant cause of mortality in SJS/TEN which is why dermatologist consultation is recommended?
Infection - treat with EMPIRIC antibiotics
Inflammation of 80-90% of the skin surface with edema, severe pruritus, erosions and scaling with lymphadenopathy?
Erythroderma
What are the causes of erythroderma?
Uncontrolled existing dermatosis, medication reaction or idiopathic
Erythematous reaction that begins on the scalp and becomes generalized with small islands of normal skin in between?
Erythroderma
Scabies, lymphoma, medications, dermatosis can all cause this severe erythema of 80-90% of the skin?
Erythroderma
What is found in a CBC with differential of a patient with a reaction to medication?
Eosinophilia
How is erythroderma treated besides electrolytes, hydration and treatment of any underlying infection or cessation of offending drug?
Topical/oral corticosteroids, systemic antihistamines, oral retinoids, UV-therapy, and if severe, immunosuppressants such as azathioprine, methotrexate, mycophenolate mofetil
Signs such as alopecia, nail dystrophy, thickening of the palms and soles in a patient with erythroderma suggest what?
Chronic underlying condition such as cutaneous T-cell lymphoma, graft-vs-host disease or psoriasis
What type of alopecia is permanent?
The one that occurs with SCARING
How is the etiology of alopecia diagnosed?
Scalp biopsy
What do polycystic ovarian syndrome (hormonal imbalance), thyroid dysfunction, iron deficiency, side effects of ß-blockers, anticonvulsants, oral retinoids and warfarin all have in common?
Non-scaring, reversible alopecia
What are the three best available treatment for male and female-pattern balndess?
Topical minoxidil, oral finasteride, hair transplantation
Asymptomatic round/oval areas of total hair loss without erythema or scale, with tapered “exclamation point” hairs (shafts are thicker distally and narrower near the scalp) where the melanocyte is the target being destroyed thereby causing regrowth of white hairs at first?
Alopecia Aerata
What is the treatment of alopecia aerata (autoimmune disease)?
Intralesional triamcinolone injections
What autoimmune hair-loss disease suggests that these patients have a higher risk for type 1 DM and autoimmune thyroiditis as well as other autoimmune conditions?
Alopecia aerata
A diffuse, non-scaring alopecia triggered by a stressful event such as serious illness, surgery or childbirth and is commonly seen in women postpartum?
Telogen Effluvium
How is telogen effluvium treated?
It is not, it resolves on its own
This scaring alopecia begins on the crown of the head and expands outward, is most commonly seen in black women and is caused by thermal or chemical trauma?
Central Centrifugal Cicatricial Alopecia
How is Central Centrifugal Cicatricial Alopecia treated?
Topical and intralesional corticosteroids
This scaring alopecia presents with perifollicular inflammation involving the superior scalp which progresses slowly over years?
Lichen Planopilaris
What type of psoriasis is common in patients whom present with nail findings (onycholysis, pitting, oild drop)?
Psoriatic arthritis
What disease causes “20-nail dystrophy” with nail pterygium formation?
Lichen planus
This disease can have all of the nail findings of psoriatic arthritis as well as “20-nail dystrophy” and nail pterygium formation?
Lichen planus
A SINGLE nail, with longitudinal melanonychia is suggestive of what?
An underlying melanocytic lesion such as Subungual melanoma
What is the most common type of melanoma in Asians and Blacks?
Subungual Acral Lentiginous Melanoma
What nail changes are seen in patients undergoing chemotherapy?
Beau Lines - as chemotherapy halts the growth process
Invasion of the nail plate by dermatophytes causing thickening and discoloration, does NOT usually affect all the nails?
Onychomycosis
How does treatment of Onychomycosis differ for fingers and toes?
Terbinafine (lamisil) for both, for toes its a longer duration
When is treatment medically INDICATED for onychomycosis?
When symptomatic (bothersome, painful) AND if other comorbidities are present such as DM
What is REQUIRED prior to starting antifungal therapy for onychomycosis?
Confirmation by either KOH, fungal culture or histology of scrapings
What must be tested for PRIOR to starting TERBINAFINE (lamisil) for treatment of onychomycosis?
Liver chemistries
Mucosal membrane malignancies are seen more frequently in patients with what history?
Those who use tobacco (smoke or chew) and those who drink alcohol
What is the most common location for oral melanoma?
The palate
When should pigmented macules on the lower lips, buccal mucosa, gingivae and palate be biopsied?
When they appear irregular in pigmentation or atypical
Buccal, tongue or genital lesions that are inflammatory, ulcerate and become tender with Wickham striae (white lacy streaks) ?
Lichen Planus
How is lichen planus diagnosed when it affects mucosal surfaces?
Biopsy
How is lichen planus treated when it affects mucosal surfaces?
Topical corticosteroids or calcineurin inhibitors (cyclosporine, tacrolimus)
Lichen planus carries a risk of what cancer?
Squamous cell carcinoma
Well demarcated, ISOLATED, painful, shallow ulcers on the tongue, gingivae and oral mucosa that are usually self-limited, also seen in IBD?
Aphthous Ulcers
Recurrent aphthous ulcers in the mouth and genital areas accompanied by ocular symptoms, joint pain and systemic symptoms (fever)?
Behçet Disease
Asymptomatic white plaques with a wavy, wrinkled appearance on the lateral aspects of the tongue that are adherent and CANNOT be scraped off, caused by EBV and is typically seen in HIV patients and is a PRE-CANCEROUS condition?
Oral Hairy Leukoplakia
Asymptomatic erythematous red plaques on the lateral aspects of the tongue that are adherent and CANNOT be scraped off and is a severely dysplastic if not already a CANCEROUS condition?
Erythroplakia
Erythema, scaling and fissuring of the lower lip due to chronic sun damage is a precancerous condition known as?
Actinic Cheilitis
How is actinic cheilitis treated (precancerous condition of the lip)?
Cryotherapy, topical 5-FU, imiquimod, photodynamic and laser therapy
Black patches on the dorsum of the tongue caused by hypertrophied papillae with bacterial and yeast overgrowth however is benign?
Black Hairy Tongue
How is Black Hairy Tongue (benign) treated?
Gentle scraping of the tongue with toothbrush or tongue scraper
What is the most COMMON malignancy of the mouth and vermilion lip in a person with chronic sun exposure, tobacco and alcohol use?
Squamous Cell Carcinoma
Patients who wear dentures are particularly prone to what oral disease that causes burning and alteration of taste?
Oral Candidiasis
What are the three common type of foot and leg ulcers?
Venous stasis, arterial or neuropathic
Lower extremities below the knees with visible or palpable varicose veins with presence of acute or chronic edema, with sclerotic and discolored skin (yellowish-brown)?
Venous stasis
What is essential treatment for VENOUS stasis ulcers?
COMPRESSION (elastic support stockings or UNA boot) and hydrocolloid or foam dressings (debridement)
What should be assessed PRIOR to using compression for treating venous stasis ulcers?
Arterial status (don’t want to compress arteries)
What should you suspect if in treating a venous stasis ulcer you detect a foul odor or patient experiences increased erythema and pain?
Infection
What is infection of a venous stasis ulcer treated with?
First generation cephalosporin (cephalexin, cephazolin)
What is considered maintenance treatment to prevent recurrence of venous stasis ulcers?
Elastic compression stockings
In patients with SEVERE peripheral vascular disease, where do arterial ulcers generally form?
Over bony prominances
These types of lower extremity ulcers are sharply demarcated and “punched out” extremely painful and pain worsens with leg elevation, area is cool to touch?
Arterial ulcers
What Ankle-Brachial Index (ABI) score is considered positive for arterial compromise?
What is a normal Ankle-Brachial Index (ABI)?
1.0-1.4
What does the Ankle-Brachial Index score predict?
Presence of Peripheral Artery Disease (PAD)
What is considered an ABNORMAL Ankle-Brachial Index?
1.4
How are arterial ulcers treated?
Gentle wound care, moist dressings, debridement
What is done to save a limb when arterial ulcers are refractory to medical treatment?
Revascularization surgery to avoid amputation
Ulcers that occur under the metatarsal heads in patients with poor sensation in those limbs, are painless and if not treated early can cause osteomyelitis?
Neuropathic ulcers
How are neuropathic ulcers treated?
By debridement and offloading of pressure
In what patients are dry skin (xerosis) causing pruritus, herpes zoster, chronic tenia pedis, onychomycosis, seborrheic keratoses, cherry angiomas and lentigines commonly found?
Elderly
Where are actinic keratoses found mostly and why are these important in elderly?
Sun-exposed areas (face, dorsal hands, arms); because of prevalence and pre-cancerous nature
What can occur in a dark-skinned individual after an inflammatory skin condition?
Hyper or Hypo pigmentation
How is hyper/hypo pigmentation of the skin REDUCED after an inflammatory skin condition in dark-skinned individuals?
Hydroquinone
How are keloids treated?
Intralesional corticosteroid injections, surgical resection followed by radiation therapy
What is Pseudofollicular Barbae?
Ingrown hairs with inflammation and papules with scarring in individuals with very small, tightly-curled hairs after shaving
What is Dermatosis Papulosa Nigra?
The equivalent of seborrheic keratosis but seen in dark-skinned individuals as benign stuck-on papules, usually on the face
What are the two most commonly-found skin cancers in dark-skinned individuals?
Squamous Cell Carcinoma and Acral Melanoma
Autoimmune disease that causes destruction of the melanocyte with depigmentation and is associated with other autoimmune diseases, especially thyroid disease?
Vitiligo
What should ALWAYS be checked for in a patient with Vitiligo?
Thyroid function tests (TSH)
How is vitiligo treated?
Phototherapy, topical corticosteroids, topical calcineurin inhibitors (tacrolimus, cyclosporine), total chemical destruction of remaining skin pigment
When you see “PALPABLE PURPURA” think of what process?
VASCULITIS
What is indicative on biopsy that the diagnosis is Sweet Disease?
Neutrophilic infiltrate and edema
What is indicative on biopsy that the diagnosis is Henoch-Schonlein Purpura (HSP)?
IgA deposition
