Acneform Eruptions/ Skin Adnexal Disease

Question 1

Answer 1

• Acne Vulgaris
  
  • ​caused by Cutibacterium acnes
• Mild: comedones, small amounts of papules or pustules
  
  • tx: azelauc acid, salicylic acid, benzoyl peroxide, retinoids or topical abx
• Moderate: comedones, large amounts of papules or pustules
  
  • tx: as above + oral antibiotics (minocycline or doxycyline)
• Sever: nodular >5mm or cystic acne
  
  • tx: Oral Isotretinoin

Question 2

Answer 2

Acne Rosacea

• acne-like rahs + central facial erythema, facial flushing, telangiectasias
• **NO COMEDONES**
• Rhinophyma (red enlarged nose with edema)
• women age 30-50 = most common
• tx:
  
  • sunscreen (not chemical), avoid irritants
  • mild/moderate:
    
    • topical metronidazole for papulopustules, azelaic acid, ivermectin for demodex mite)
  • Severe:
    
    • oral abx (tetracycline, doxycyline, minocycline)
    • Oral Isotretinoin can be used for refractory cases

Question 3

Answer 3

Perioral dermatitis

• monomorphic pink papules
• hx of topical corticosteroid use
• tingling/burning sensation
• no comedones
• tx:
  
  • clindamycin, sodium sulfacetamide (excellent for kids)
  • oral abx: doxycyline, azithromycin
    
    • in children: amoxicillin or azithromycin if PCN allergy

Question 4

Answer 4

Hot tub folliculitis

• caused by pseudomonas:
  
  • tx: abx soap, CLN, BPO and fix hot tub chlorine levels
  • Immune compromised? fluoroquinolones

Question 5

Answer 5

folliculitis

• inflammation/infection of air follicile
• common cause: MRSA
• tx: doxycycline or cephalexin
• CLN wash (bleach wash)
• topical mupirocen ointment

Question 6

Answer 6

hydradentitis supparativa

• **double comedones**
• favors female > males, smoking and obesity = risk factor
• targets hair follicle and apocrine glands found in skin folds
• tx: weight reduction
  
  • reduce friction and moisture
  • stop smoking
  • topical clindamycin, intralesional injections of triamcinolone
  • systemic: tetracyclines, clindamycin, rifampin

Question 7

Hyperhidrosis

Answer 7

• focal visible sweat present for at least 6 months with no apparent secondary cause
• tx:
  
  • topical aluminum chloride hexahydrate (e.g. Dryol)
  • second line:
    
    • botulinum toxin A

Question 8

Answer 8

Lipoma

• common tumor of mature fat
• diagnosis:
  
  • u/s can be helpful in early eval
  • consider incisional biopsy
• tx:
  
  • excision

Question 9

Answer 9

Epidermal Incluysion Cyst

• build up of keratin
• considered a true cyst b/c it contains epithelial lining
• diagnosis: clinical
  
  • incisional biopsy or punch
• tx:
  
  • if inflamed: I&D
  • non inflamed: observe, steroid injection, excision

Question 10

Answer 10

Androgenic Alopecia

• **most common cause of progressive balding
• action of androgen at the hair follicle
• often autosomal dominant or polygenic
• miniaturization of hair follicles due to increased levels of DHT
• tx:
  
  • minoxidil 2-5% cream
  • finasteride for men only
  • consider OCP and spironolactone (antiandrogen, antiduretic) in women
  • hair transplant
  • wigs

Question 11

**sudden hair loss**

Answer 11

telogen effluvium

• non-cicatricial alopecia
• major life event that causes hair loss 3-6 months after the event
  
  • high fevers, postpartum, medications
• Diagnosis:
  
  • positive pull test
  • consider biopsy (to ease mind of pt)
  • check TSH, ferritin, CBC, consider chem panel/sed rate
  • review medication and life events
• Tx: treat the underlying cause
• should resolved over next few months
  
  • TAKE PICTURES to reassure pt

Question 12

Answer 12

Alopecia Areata

• ophiasis pattern: first pic; exclamation points: second pic; Nail pitting
• can be indicative of hashimoto, thyroiditis, and vitiligo
• most common in children
• Diagnosis:
  
  • positive pull test at periphery of oval areas of loss
• tx: <10yo:
  
  • topical corticosteroids mometasone
  • minoxidil 5%
• >10 yo: if <50% scalp involvement:
  
  • topical corticosteroids
  • intralesional corticosteroids (inject Kenalog into upper dermal layer of skin)
  • topical minoxidil 5%
• if >50% scalp involvement: JAK inhibitors

Question 13

Answer 13

Trichotillomania

• may be related to psychological disorder or stress
• different length of hairs, occipital region is usually involved
• diagnosis:
  
  • can shave a small area of hair and cover it to see if normal growth occurs
• tx:
  
  • couseling and eval for psych problem
  • common in childhood/infancy boys > girls
    
    • will usually resovle on its own

Question 14

Answer 14

Onychomycosis

• fungal or dermatophyte infection of the nail
• toenails >> fingernails
• Diagnosis: KOH wet prep
  
  • periodic acid-Schiff Test = most rapid and sensitivie
  • fungal cx
• tx: systemic is most effective:
  
  • terbinafine = first line for dermatophytes
  • itraconazole for dermatophytes and candida
    
    • be careful of hepatotoxicity and DDIs
  • topicals:
    
    • efinaconazole
    • tavaborole for 12 months

Question 15

Answer 15

Paronychia

• Most commonly caused by staph or strep
• if recurrent consider HSV
• acute tx:
  
  • cefalexin (Keflex)
  • doxycyline
• Chronic:
  
  • avoid water and chemicals
  • topical steroids
  • topical antifungals

Question 16

Answer 16

Onycholysis

• risk factors: psoriasis, lichen planus, atopic dermatitis, nail tumor, overzealous manicure
• tx: keep nails short
• avoid irritants
• consider topical antifungal
• tx underlying condition

Question 17

Answer 17

Subungual Debris

• often hyperkeratotic
• diagnosis:
  
  • nail clipping for fungal cx
• tx of infection or psoriasis

Question 18

Answer 18

Chloronychia

• green nail caused by pseudomonas
• tx: **dilute vinegar or bleach soaks** (1:3 vinegar :water)
• topical abx:
  
  • gentamicin, tobramycin, or ciprofloxacin