Ch 3 MDT Flashcards
Inflammation of a hair follicle that can occur anywhere on the body where hair is found
Folliculitis
Most common infectious etiology of bacterial Folliculitis
Staph aureus
Most common etiologies of non-infectious Folliculitis
Pseudo-folliculitis barbae (PFB)
Mechanical Folliculitis (Skinny Jean Syndrome)
Folliculitis Risk Factors
Hair removal (shaving, plucking, waxing, epilating agents)
Other pruritic skin conditions: eczema, scabies
Occlusive dressing or clothing
Personal carrier or contact with MRSA-infected persons
Diabetes
Immunosuppression
Use of hot tubs or saunas
Chronic antibiotic use
Tattoos
Poor Hygiene
Abrupt onset of follicular erythematous papules or pustules, with pruritus and pain in hairy areas
Rash occurs on hair-bearing skin, especially the face (beard, proximal limbs, scalp, and pubis
Folliculitis
Pseudomonal folliculitis appears as a widespread rash, located mainly at:
Trunk and limbs
Clinical hallmark of folliculitis
Hair emanating from the center of the pustule
General treatment and prevention of Folliculitis
Antiseptic and supportive care is usually enough
MRSA drugs
Bactrim
Clindamycin
Doxycycline
Complications of Folliculitis
Recurrent Folliculitis (PRIMARY)
Progression to furunculosis or abscesses
Cellulitis
Condition caused by ingrowing hairs, mostly in the beard area
Affects people with curly hair or those with hair follicles oriented at an oblique angle to the skin surface
Pseudofolliculitis Barbae
PFB
What is often a problem in affected skin, especially in African-American people?
Keloid formation
What may result from PFB?
Scarring and hyperpigmentation
PFB affects ____% of black people
and ___% of white people
50-75%
3-5%
Treatment for mild to moderate PFB
Medical treatment with grooming modifications
Treatment for moderate to severe PFB
Laser hair reduction with grooming modifications
PFB Laser Treatment
A series of at least ____ treatments is usually needed, with ____ days in between
Three
30-45 days
A contagious, superficial, intra-epidermal infection occurring prominently on exposed areas of the face and extremities
Impetigo
A deeper, ulcerated impetigo infection often with lymphadenitis
Ecthyma
Most common form of impetigo.
Formation of vesiculopustular that rupture, leading to crusting with a characteristic golden appearance
Local lymphadenopathy may occur
Nonbullous impetigo
Staphylococcal impetigo that progresses from small to large flaccid bullae
Ruptured bullae leaves brown crust
Less lymphadenopathy
Trunk more affected
Bullous impetigo
Impetigo risk factors
Warm, humid environment
Tropical or subtropical climate
Summer or fall season
Minor trauma, insect bites, breaches in skin
Poor hygiene, poverty, crowding, epidemics, wartime
Familial spread
Complication of pediculosis, scabies, chickenpox, eczema /atopic dermatitis
Contact Dermatitis
Burns
Contact sports
Children in daycare
Carriage of group A streptococcus and Staph aureus
Cutaneous pyoderma characterized by thickly crusted erosions or ulcerations.
Usually a consequence of neglected impetigo and classically evolves in impetigo occluded by footwear and clothing
Ecthyma
What is the key to avoid infection of impetigo?
Avoidance of spreading
HAND WASHING
Treatment for impetigo
Mupirocin ointment
Remove crusts clean with gentle washing 2-3 times daily; clean with antibacterial soap, chlorhexidine, or betadine
Severe impetigo treatment may require:
Nafcillin or Cefazolin IV antibiotics
Complications of Impetigo
Ecthyma
Cellulitis
Resistance to treatment
Lymphangitis
Furunculosis
An acute bacterial infection of the dermis and subcutaneous tissue
Typically caused by bacterial penetration through a break in the skin
Cellulitis
Most common etiologies of cellulitis
Hemolytic streptococci
Staph aureus
Gram-negative aerobic bacilli
Cellulitis is present with what four classic signs of inflammation?
Erythema
Edema
Tenderness
Elevated skin temperature
Most common portal of entry for lower leg cellulitis
Toe web intertrigo with fissuring
Secondary to interdigital tinea pedis
History
- Previous trauma, surgery, animal/human bites, dermatitis, and fungal infection are portals of entry for bacterial pathogens
- Pain, itching, and/or burning
- Fever, chills, and malaise
Cellulitis
Physical Exam
- Localized pain and tenderness with erythema, induration, swelling, and warmth
- Regional lymphadenopathy
- Purulent drainage from abscesses
Cellulitis
Labs considered for cellulitis when:
Signs of systemic disease (Fever, HR >100, SBP <90 mm Hg)
What needs to be ruled out in a patient with cellulitis?
DVT
Cellulitis treatment
Mark borders with a permanent marker
Immobilize and elevate limb
Pain relief
Compression for edema
Antibiotics
Antibiotics of choice for Human and Animal bites
Amoxicillin & clavulanic acid (Augmentin)
Complications of Cellulitis
Local abscess or bacteremia, sepsis
Superinfection with gram-negative organisms
Lymphangitis
Gangrene
Medical Emergency
Rare and rapidly progressing infection involving any layer of soft tissue including skin, subcutaneous fat, fascia, and/or muscle
Extensive tissue destruction, systemic toxicity, limb loss and are potentially fatal
Necrotizing Fasciitis
Risk factors for necrotizing fasciitis
Major penetrating trauma
Minor laceration or blunt trauma
Skin breach
Recent surgery
Mucosal breach
Immunosuppression
Malignancy
Obesity
Alcoholism
Most frequently occurs in the extremities and may mimic DVT
Pain, erythema, edema, cellulitis and high fever
Pain is out of proportion to the severity of the physical findings
Necrotizing Fasciitis
Labs for Necrotizing Fasciitis
MRI: Edema along the fascial plane
X-ray, CT or US are useful in demonstrating the air bubble in soft tissues
Cultures: Group A strep and mixed aerobic and anaerobic bacteria
Treatment for Necrotizing Fasciitis
Prompt and wide surgical debridement is the cornerstone
Broad-spectrum antibiotics
MEDEVAC
Complications of Necrotizing Fasciitis
Toxic shock syndrome
Amputation
Septic Shock
Death
A well-circumscribed, painful, inflammatory nodule at any site that contains hair follicles. May extend into the dermis and subcutaneous tissues
Furuncle
A collection of pus within the dermis and deeper skin tissues. Manifests as painful, tender, fluctuant, and erythematous nodules
Typically do not present with systemic symptoms
Abscess
A coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles
Typically presents with systemic symptoms and fever
Carbuncle
Risk factors of abscesses (furuncle, abscess, carbuncle)
Carriage of pathogenic staphylococcus sp. in nares, skin, axilla, and perineum
Diabetes mellitus, malnutrition, alcoholism, obesity, atopic dermatitis
Deep subcutaneous erythematous papules enlarge to deep-seated nodules that can be stable or become fluctuant within several days
Multiple Hair Follicles. Most commonly occurs on the back of the neck, upper back and lateral thighs
Tender, perifollicular swelling, terminating in discharge of pus and necrotic plug
Malaise, chills, and fever may precede or occur during the height of inflammation
Carbuncle
Mainstay treatment for an abscess, furuncle, or carbuncle
Incision and Drainage
Carbuncles should be handled by dermatology or general surgery in all situations unless patient is:
Unable to be transferred
Most common benign cutaneous cysts
Sebaceous Cyst (epidermal)
The cyst wall consists of normal stratified squamous epithelium derived from:
Follicular infundibulum
Firm or fluctuant flesh-to-yellow colored solitary nodule (0.5-5 cm) which often connects with the surface by keratin-filled pores
Grow slowly over time and may remain stable for months to years
Commonly located on face, neck, upper back, chest; if due to trauma, on buttocks, palms, or plantar side of feet
Stable epidermal cyst
Warm, red and boggy and tender on palpation
Sterile, purulent material and keratin debris often point towards and drain to the surface
These lesions mimic and present very similarly to abscesses
Inflamed/Ruptured Epidermal Cyst
Biopsy of a cyst shows:
Encapsulated keratinocytes and cellular debris
Indications for removal of cysts
Inflamed/ruptured or infected epidermal cyst
Produces functional deficit
Cosmetic
Pain secondary to location and duties
Cysts
What must be removed to prevent further infection?
Capsule
The most common benign mesenchymal neoplasm in adults and are composed of mature white adipocytes
Lipoma
Lipomas can occur on any part of the body and usually develop superficially in the ______ tissue
Subcutaneous
Soft, painless subcutaneous nodule ranging in size from 1->10 cm
Occur most frequently on the trunk and upper extremities and can be round, oval, or multilobulated
Frequently patients have more than one
Lipoma
Transition of a preexisting lipoma to an atypical lipomatous tumor represents an exceeding rare phenomenon at ___%
<0.1%
Lipomas may be excised by dermatology for what reasons?
Cosmetic
Pain
Impedance of duties
Intramuscular lipoma recurrence rate is up to ___%
20%
Acute inflammatory process, with or without abscess formation, that involves the proximal and lateral nail folds and that has been present for less than 6 weeks
Paronychia
Paronychia is commonly caused by:
Manicuring, nail biting, thumb sucking, and picking at a hangnail
Acute paronychia of the toes is associated with:
Ingrown toenails
Most common infection of the hand, representing 35% of all hand infections in the U.S.
Paronychia
Paronychia treatment
Warm compresses or soaks
Drainage using a scalpel blade inserted between the nail and nail fold
Antibiotics if warranted
What is unnecessary in the treatment of paronychia?
Skin incision
Complications of paronychia
Further extension of infection with deeper involvement
Nail distortion in chronic infections
Abscess of the distal phalanx fat pad
Staph aureus is the most common pathogen
Painful and swollen distal pulp space
Felon
The digital pulp, the fleshy mass at the fingertips, is divided into multiple compartments by _____ _____ that provide structural support
Fibrous septae
Pyogenic infection of the distal digital pulp space, with pus collecting in the spaces formed by the vertical septa anchoring the pad to the distal phalanx
Nearly always follows minor finger injury (splinter or needle prick)
Felon
Felon treatment
Incision and drainage by a Dermatologist
Antibiotics
Labs/Studies/Imaging for a Felon
Imaging to evaluate for retained foreign body and to rule out involvement of the distal phalanx
Complications of a Felon
Osteitis & osteomyelitis
Ulcerative and tissue necrosis
Flexor tenosynovitis
Septic Arthritis
Grows best in warm, moist environments so infection is often confined to mucous membranes and intertriginous areas
Opportunistic pathogen when allowed to overgrow and predisposing conditions permit
Candida (fungal)
What layers of the epithelium does yeast infect?
Outer Layers only
Fungal infection Risk Factors
Hormonal alterations
-Pregnancy, oral contraceptives, diabetes
Elimination of competing microorganisms
-Antibiotics
Physical environment changes
-Skin maceration, increased humidity/temperature
Direct/Indirect Immunosuppression
-Corticosteroid therapy, immunosuppression
Candidiasis occurs most commonly in what type of areas?
Intertriginous areas (axillae, groin, digital web spaces, glans penis, beneath breasts, vulvovaginal)
Red, glistening surface with a long, cigarette paper-like, scaling and advancing border
Candidiasis
Treatment for Candidiasis
Skin kept dry and exposed to air as much as possible
Antifungals
What is not recommended in the treatment for Candidiasis?
Topical Steroids
Diagnosis for Candidiasis is based on:
Clinical Appearance
Location of Infection
Presence of predisposing factors
Candidiasis
Positive culture alone is usually meaningless because Candida is:
Omnipresent
Superficial fungal infections of the skin/scalp; various forms of dermatophytosis
Tinea
Infection of the crural fold and gluteal cleft
Tinea Cruris
Infection involving the face, trunk, and /or extremities often presents with ring-shaped lesions, hence the misnomer ringworm
Tinea corporis
Infection of the scalp and hair; affected areas of the scalp can show characteristic black dots resulting from broken hairs
Tinea capitis
Can subsist on protein, namely keratin and can cause disease in keratin-rich structures such as skin, nails, and hair
Dermatophytes
Infections acquired from animals
Zoophilic
Infections acquired from personal contact
Anthropophilic
Scaling, round or oval pruritic plaques characterized by a sharply defined annular pattern with peripheral activity and central clearing
Papules and occasionally pustules/vesicles present at border and, less commonly in center
Tinea Corporis
Treatment for Tinea Corporis
Antifungal creams for at least 2 weeks
Continue treatment 1 week after resolution of infection
Tinea corporis treatment that requires oral therapy
Extensive lesions or those with red papules
Tinea corporis
What medication may be considered for highly inflamed lesions to minimize scarring?
Short course of prednisone
Labs/studies/imaging for Tinea Corporis
KOH Prep
Woods lamp
Complications of Tinea Corporis
Extension of diease down to the hair follicles
Well-marginated, erythematous, halfmoon-shaped plaques in crural folds that spread to medial thighs; advancing border is well defined, often with fine scaling and sometimes vesicular eruptions
Lesions are usually bilateral and do not include scrotum/penis (unlike candida infections)
Tinea Cruris
First line treatment for Tinea Cruris
Topical antifungal cream
Absorbent powders
Treatment for refractory, inflammatory or widespread tinea cruris infections
Oral antifungals
Resume topical antifungals/powders once resolved
Complications of Tinea Cruris
Secondary Bacteria infections
Superficial infection in the interdigital web and soles of the feet caused by dermatophytes
Most common Dermatophyte infection
Tinea Pedis
Itching, burning, and stinging of interdigital webs and plantar surfaces
Pain may indicate secondary infection
Most present with asymptomatic scaling
Woods lamp exam with not fluoresce
Tinea Pedis
Treatment for Tinea Pedis
Open-toed shoes
Shower shoes
Dry between toes after showering & frequent sock changing
Cotten socks (absorbent, non-synthetic)
Antifungal powders
Wide shoes
Caused by Pityrosporum orbiculare
Organism is nourished by sebum
Very common in excess heat and humidity
-Prevalence can reach 50% in tropical areas
Not a dermatophyte infection
Tinea versicolor
Velvety tan, pink or white macules that do not tan
Fine scales that are not visible but are seen by scraping the lesion
Central upper back, chest, and proximal areas (highest concentration of sebum)
Asymptomatic; Appearance is often the patient’s main concern
Tinea Versicolor
Labs/Studies for Tinea Versicolor
Woods lamp will show hypo-pigmented areas of infections
-Faint yellow-green fluorescence
Complications of Tinea Versicolor
Relapses without any complications
Treatment for Tinea Versicolor
Selenium sulfide from neck to waist
Ketoconazole shampoo to chest and back
Oral treatment for Tinea Versicolor is reserved for patients with:
Extensive disease who do not response to topical treatment
Acquired through direct contact of the nail with dermatophytes, yeast, or non-dermatophyte molds in the environment or through spread of fungal infection from affected skin
Onychomycosis
Predisposing factors for onychomycosis
Tinea pedis, psoriasis, hyperhidrosis, obesity, advancing age, contact with infected household members
Trauma, poor nail grooming, sports and fitness activities, occlusive shoes
Most common onychomycosis presentation
Distal subungual onychomycosis
-Begins with white/yellow/brown discoloration of distal corner of the nail that gradually spreads moving proximally
Treatment for Onychomycosis
Confirm with KOH & fungal culture for potential liver toxicity
LFT
Oral antifungal (Gold Standard)
Required labs for onychomycosis
KOH and Fungal Culture to begin treatment
Disposition for onychomycosis
Consult to dermatology and/or podiatry
A contagious parasitic infection of the skin caused by the mite Sarcoptes scabiei
Scabies
Scabies is transmitted by:
Prolonged human to human direct skin contact
Scabies rash appears __ weeks after exposure
2-6 weeks
Cardinal feature of Scabies
Intense pruritus that worsens at night
Secondary lesions of Scabies
Impetigo
Eczema
Labs/Studies/Imaging for Scabies
Ink test
Treatment for Scabies
Permethrin 5% or Lindane 1% applied to entire skin surface from the neck down to include fingernails/toenails and in the umbilicus
After 12 hours, patient will bathe
Treatment regimen should be repeated in 1 week
Scabies
What may be used to control pruritus and inflammation after treatment with a scabicide?
Topical steroids
Obligate human parasites
Direct contact is source of transmission
Transmission via hats, brushes, or ear phones is common
Pediculus humanus capitis
Lice feed or suck blood every ___ hours (blood meal)
3-6 hours
Lice live for about _____
1 month
Female lice can lay __ eggs per day
7-10
Lice eggs (nits) are firm casts cemented to the hair shaft; hatch every __ days
8-10
Pediculosis pubis
Pubic louse
Pediculosis Corporis
Body louse
Pediculosis capitis
Head louse
Head lice are __ mm in length
3-4 mm
Pediculosis Capitis
Easier to see than lice and are fluorescent
Nits
Sky-blue macules on the inner thighs or lower abdomen
Pubic louse infestation
Treatment for Lice
Permethrin / Lindane
Remove nits
Clothes and sheets washed and dried on high temperature
What can ‘unglue’ nits?
50% vinegar and 50% water
Applied and removed in 15 minutes
Home remedies that can kill lice
Vaseline over scalp overnight (repeat for 3-4 weeks)
Hair Clean 1-2-3 hairspray
Common, acute, self-limited papulosquamous skin rash that is most commonly seen in individuals 10-35 years old
Viral etiology
“Pink Scales”
Sometimes preceded by a prodrome
Pityriasis Rosea
Pityriasis Rosea
Prodromal symptoms are reported in ___% of patients
-Malaise, mild fever, headache, sore throat, cough, or mild URI or GI symptoms
69%
Classic Pityriasis Rosea begins with a _____ ______ on the trunk or proximal limbs that precedes secondary eruption by 7-14 days
Herald Patch
2-5 cm round or oval, sharply delimited, pink or salmon-colored lesion on the chest, neck or back
Herald Patch (PR)
Lesions are distributed with long axes along cleavage
- Christmas tree pattern on back
- V-shaped pattern on upper chest
Resolve in 45 days
Pityriasis Rosea
Medications for Pityriasis Rosea
Antihistamines for pruritis relief
Labs/Studies/Imaging for Pityriasis Rosea
KOH if atypical presentation
Serologic Syphilis testing
Complications of PR
Long term skin pigmentary changes
Abortion during pregnancy
Herpes
Primary outbreaks manifest as:
Herpetic gingivostomatitis
Herpes
Recurrent episodes usually affect the:
Vermillion border of lips of mucosa of the hard palate
HSV-1 can be transmitted via:
Mucous membranes/secretions
Kissing/Sharing utensils or towels
HSV-1
__% infected by age 6
33%
__% of adults reported to have experienced oral herpes
60-90%
Herpes recurrences may be precipitated by:
Stress, sun, illness, fatigue, dental work, local trauma, menstruation, pregnancy, and immunodeficiency
Herpes
Recurrent episodes occur in older children and adults, frequently with a prodrome of:
Perioral tingling, itching, numbness, pain, or burning
Followed by papulovesicular lesions (cold sore) on the lip or vermilion border
Herpes
Antiviral medications may reduce duration by about how many days?
1 day
Complications of Herpes Simplex
Pyoderma
Eczema Herpeticum
Herpetic Whitlow
Ocular Keratitis
Diffuse pox-like eruption complicating atopic dermatitis; sudden appearance of lesions in typical atopic areas (upper trunk, neck, head); high fever, localized edema, adenopathy
Eczema herpeticum
Localized infection of affected finger with intense itching and pain, followed by vesicles that may coalesce with swelling and erythema
Mimics pyogenic paronychia; neuralgia and axillary adenopathy are possible; heals in 2-3 weeks
Herpetic whitlow
Clinical syndrome associated with reactivation of latent varicella zoster virus
Typically occurs years after primary Varicella Zoster Virus infection
Herpes Zoster (Shingles)
> __% of adults in United States are seropositive for varicella
95%
Herpes Zoster is most common at what age?
> 60 years old
What amount of people will contract herpes zoster in their lifetime?
One-third
Characteristic prodrome of Herpes Zoster that may precede rash by 1-5 days
Acute neuritis
Paresthesias with allodynia or hyperesthesia described by patient as deep burning, throbbing, or stabbing sensation
Unilateral dermatomal rash without midline crossing that favors the thoracic, cranial, lumbar, and cervical dermatomes
Herpes Zoster
Begins with red macules and papules that progress to clear vesicles within 1-2 days with new vesicles forming over 3-5 days
Vesicles evolve into pustules within 7 days; ulcerating and crusting of pustules by day 14
Herpes Zoster
Herpes Zoster
Lesions usually heal within ___ weeks
2-4 weeks
Medications for Herpes Zoster
Antivirals <72 hours after onset or if new lesions are appearing
Pain control
Occurrence of pain for months or years in the same dermatomal distribution as was affected by herpes zoster
Postherpetic Neuralgia
Acute herpetic neuralgia refers to pain preceding or accompanying the eruption of rash that persists up to __ days from its onset
30 days
Subacute herpetic neuralgia refers to pain that persists beyond healing of the rash but which resolves with ___ months of onset
4 months
Refers to pain persisting beyond four months from the initial onset of rash
Postherpetic Neuralgia
Reduces the incidence of Postherpetic Neuralgia by 50% when given within 72 hours of rash onset
Antivirals
Involves the Opthalmic division of the trigeminal nerve
Presents with malaise, fever, headache, and periorbital burning/itching
Herpes Zoster Opthalmicus
___% of patients with HZO experience direct ocular involvement if antiviral therapy is not used
50%
Vesicles on the tip/side of nose precedes the development of HZO
Hutchinson’s Sign
Disposition of patients with Herpes Zoster on the face
Medical officer for further evaluation
Warts is caused by what virus?
Human papillomavirus (HPV)
HPV
___ types
___ can infect humans
200 types
150 can infect humans
HPV
Infection occurs by:
Direct skin contact
HPV
Incubation period is approximately ___ months
2-6 months
Verruca vulgaris
Common warts
Verruca plantaris
Plantar warts
Verruca plana
Flat (plane) warts
Warts that are typically few in number
Hands, periungual skin, elbows, knees and plantar surface
Block dots are thrombosed capillaries
May occur singly, in groups, or as coalescing warts forming plaques
Verrucae Vulgaris
Warts, slightly elevated and flat-topped
Vary in size 0.1-0.3 cm
May be few or numerous and often occur grouped or in a line as a result of spread from scratching
Forehead, back of hands, chin, neck and legs
Typically asymptomatic, however, cosmetically distressing
Flat (plane) warts
Caused by HPV infection on the plantar foot
Occurs at points of maximal pressure, such as over the heads of the metatarsal bones
Cluster many warts is called a “mosaic wart”
Plantar Warts
How to differentiate between plantar warts and corn/callus
Black dots are seen in warts
Corns have a hard painful translucent central core
Treatment for warts
Salicylic acid
Cryotherapy
Duct tape
Complications of warts
Scarring and recurrence
Some types of HPV have higher risks for Carcinoma
Non-immunologic reaction to substance or action producing direct damage to skin by chemical abrasion or physical irritation
Causes: Chemical agents, alcohol, creams, powders, moisture, friction, and temperature extremes
Irritant Contact Dermatitis
Due to a delayed immunologic response to a cutaneous or systemic exposure to an allergen to which the patient has been previously sensitized
Allergic Contact Dermatitis
Most common cause of allergic contact dermatitis
Poison ivy
Poison sumac
Poison oak
Allergic contact Dermatitis
Latency period of ____ hours
12-48 hours
Most common cause of metal dermatitis
Nickel
Hands are most often affected
Erythema, dryness, painful cracking or fissuring and scaling are typically, Vesicles may be present
Tenderness and burning are common and predominate the itching
Open skin may burn on contact with topical products
Irritant Dermatitis
Irritant Dermatitis prevention
Avoidance of exposure
PPE
Irritant Dermatitis Treatment
Steroid ointments
Frequent application of a bland emollient is essential
Vesicles, edema, redness, and extreme pruritus
Strong allergens such as poison ivy produce bullae
Distribution first confined to the area of direct exposure
May spread beyond areas of direct contact
Itch and swelling are key components of the history
Allergic Contact Dermatitis
Most common sites of Allergic Contact Dermatitis
Hands, forearms and face
Allergic Contact Dermatitis treatment
Avoid allergic substance
Topical steroids
Patch testing for allergic contact dermatitis should be delayed until the dermatitis has subsided for at least __ weeks
2 weeks
Seborrheic Dermatitis
Dandruff
Chronic, superficial, recurrent inflammatory rash affecting sebum-rich, hair regions of the body, especially the scalp, eyebrows, and face
Prevalence: 3-5%
Seborrheic Dermatitis
Treatment for Seborrheic Dermatitis
Control rather than cure
-Shampoos: Zinc pyrithione, Selenium sulfide, Ketoconazole, Salicylic Acid, Coal tar
Chronic, inflammatory disorder most commonly characterized by cutaneous erythematous plaques with silvery scale
Complex immune-mediated disorder associated with flares related to systemic, psychological, infectious, and environmental factors
Psoriasis
Most common variant of Psoriasis at 80% of cases
Plaque (vulgaris) Psoriasis
Psoriasis
__% have psoriasis in a first-degree relative
40%
Well-demarcated salmon pink to red erythematous papules and plaques; silvery scale
Scalp, auricular, postauricular area; extensor surfaces (knees elbows); umbilicus, lower back, intergluteal cleft, and nails
Plaque Psoriasis
Nail findings of plaque psoriasis
Pitting, oil spots, onycholysis
Pinpoint bleeding with removal of scale
Auspitz sign (plaque psoriasis)
New psoriatic lesions arising at sites of skin injury/trauma
Koebner phenomenon
Plaque psoriasis
Genitals affected in up to ___% of patients
40%
Treatment for psoriasis
Topical corticosteroids/retinoids
Systemic therapy if >20% of the body or very uncomfortable
Phototherapy
Disposition for Psoriasis
Routine referral to dermatology for further evaluation and definitive treatment
Complications of Psoriasis
Psoriatic arthritis
Exfoliative dermatitis
Disorder of the pilosebaceous units
Notable for open/closed comedones, papules, pustules, nodules
Early to late puberty, may persist in 20-40% of affected individuals into 4th decade
Acne vulgaris
Ance vulgaris
___% of adolescents affected
80-95%
Open comedones
Blackheads
Closed comedones
Whiteheads
Treatment for comedonal (non-inflammatory) ance
Topical retinoid
Treatment for mild comedonal + papulopustular acne
Topical antimicrobial
Topical retinoid
Antibiotics for those who cannot tolerate retinoids
Treatment for moderate papulopustular and mixed acne
Topical retinoid
Oral antibiotics
Topical benzoyl peroxide
Treatment for severe acne (nodulocystic acne)
Oral isotretinoin monotherapy
Acne medication
Antibacterial properties and also comedolytic
Visible improvement typically occurs within three weeks, with maximum results evident after 8-12 weeks
Benzoyl peroxide
Acne Medication
Reduce the number of comedonal acnes in the sebaceous follicles and suppress inflammation. May cause skin irritation
Use with benzoyl peroxide to decrease the occurrence of bacterial resistance
Topical Antibiotics (erythromycin & clindamycin)
Most common topical antibiotics used for the treatment of acne
Erythromycin and clindamycin
Most frequently used oral antibiotics for acne therapy
Doxycycline and minocycline
Treatment for severe recalcitrant nodular acne who is unresponsive to conventional therapy, including systemic antibiotics
20 week course
Teratogenic
Only prescribed by clinicians who participate in iPLEDGE
Isotretinoin
What can be beneficial in the treatment of acne for women older than 15?
Contraceptives
Complications of Acne
Cyst formation
Pigmentary changes
Severe scarring
Psychological problems
Gram-negative folliculitis
An abscess, or sinus tract, in the upper part of the natal (gluteal) cleft
Pilonidal abscess
Means “nest of hair”
Pilonidal
Physical exam reveals one or more primary pores (pits) in the midline of the natal cleft and/or a painless sinus opening
No acute inflammation or infection
Asymptomatic pilonidal disease
Tender, swollen, and fluctuant nodule located along the superior gluteal fold
Acute pilonidal abscess
Treatment for an acute pilonidal abscess
Incision and drainage
Antibiotics in the presence of cellulitis
Complications of pilonidal abscess
Systemic infection
Recurrence
Active hair growth
80-85% of hairs are in this stage at a given time
Anagen (growth) Phase
Hair growth stops due to papilla detaching (removing blood supply)
1-3% of hairs are in this stage at a given time
Catagen (transitional) phase
Hair is resting phase for 1-4 months, up to 10-15% of hairs in a normal scalp.
Hair is no longer connected to anything but the follicle
Telogen (resting) Phase
In late telogen phase, the follicle begins to grow again and hair base breaks free from the root and is shed
2 weeks, new hair shaft begins to emerge
Exogen (shedding) Phase
Anagen phase for shorter hairs (eyelashes, eyebrows, leg/arm hair)
1 month
Anagen duration for scalp hair
> 6 years
= “hair loss”
Alopecia
Present follicular markings suggest a _______ alopecia
non-scarring
Absent follicular markings suggest a ______ alopecia
Scarring
Alopecia
Occur secondary to something else in the body (systemic disease, endocrine disorders, vitamin deficiencies, malnutrition)
Non-scarring alopecia
Most common form of male hair loss affecting 30-50% of men by age 50
Occurs in highly reproducible pattern, affecting the temples, vertex and mid frontal scalp
Androgenetic alopecia
Androgenetic alopecia
Familial tendency and racial variation and heredity account for __% of disposition
80%
Believed to be an immunologic process. Patches that are perfectly smooth and without scarring
Involvement may extend to all of the scalp hair or to all scalp and body hair
Alopecia Areata
Alopecia of all the scalp hair
Alopecia totalis
Alopecia of all scalp and body hair
Alopecia universalis
Temporary hair loss that usually happens after stress, a shock, or a traumatic event. Usually occurs on the top of the scalp
Telogen effluvium
May occur following any type of trauma or inflammation that may scar hair follicles
Chemical, physical trauma, bacterial or fungal infections, severe herpes zoster, chronic discoid lupus erythematosus, scleroderma, and excessive ionizing radiation
Cicatricial Alopecia
Treatment of alopecia
Most cases hair re-grows and no treatment is needed
Consider treatment on how to deal with emotional stress
Referral to dermatology for more intense treatment
Labs/Studies/Imaging for Alopecia
TSH
CBC
Complications of Alopecia
Depression/Anxiety
Mid-life crisis
Acute. delayed, and transient inflammatory response of the skin secondary to excessive exposure to ultraviolet radiation (UVR)
Depending on frequency and exposure time damage can be cause to melanocytes and keratinocytes
Sunburn
Susceptibility to sunburn =
Susceptibility to skin cancer; associated with an increased risk of melanoma at all ages
Risk factors of Sunburn
Near the equator
More likely to occur at noon
Altitude
Reflection from snow (90%), Sand (15-30%), Water (5-20%)
Fair skin, blue eyes, red & blond hair
Sunburn
Erythema is first noted at ___ hours
Peaks at ____ hours
Subsides at ____ hours
3-5 hours
12-24 hours
72 hours
Sunburn
Blisters heal without scarring in ____ days
7-10
Sunburn
Scaling, desquamation, and tanning are noted ____ days after exposure
4-7
Occur quickly and appear as a sunburn
Drug-induced phototoxic reactions
Rare, IgE-mediated, photodermatosis characterized by pruritis, stinging, erythema, and wheal formation after exposure to sunlight
Solar urticarial
Complications of Sunburn
Melanoma
Actinic Keratoses
The most important part of treatment for sunburn is:
Prevention
- Protective clothing (SPF 50+)
- Sunscreen (SPF 30+)
Measures the UV radiation required to produce sunburn on protected skin (with sunscreen) relative to UV radiation is required to produce sunburn on unprotected skin (no sunscreen)
SPF
SPF is related directly to:
Amount of Solar Exposure (not time)
Treatment for Sunburn
Cool compresses or soaks, calamine lotion, aloe vera
NSAIDs
Contraindicated in the treatment of Sunburn
Topical Corticosteroids
Caused by lateral pressure of poorly fitting shoes, by improper or excessive trimming of the lateral nail plate or by trauma
Pain, redness and swelling caused by the nail penetrating the surrounding nail tissue
Ingrown Nail
Virtually the only toe involved, with either the medial or lateral border of the nail may be affected
Great toe
Treatment of ingrown nail
Removing the penetrating nail with scissors and curetting the granulation tissue
Small areas of granulation tissue can be simply treated with silver nitrate
Podiatrists treat chronic recurrent ingrown nails by destroying the lateral nail matrix with:
Phenol
Most common of all injuries to the upper extremities; typically results from a direct blow to the fingernail or a squeezing type injury to the distal finger
Causes bleeding into the space between the nail bed and nail itself
Subungual hematoma
Separation of the nail from the nail bed
Onycholysis
Subungual hematoma
What must be done prior to draining/trephination?
Rule out additional/more severe injuries
Subungual hematoma
Drainage methods
Heated paperclip
Cautery Pen
Drill method
Needle method
Most common acquired benign epithelial tumor of the skin
Often mistaken for Melanoma
Typically develop after age 50
Usually Asymptomatic
Seborrheic Keratoses
Usually multiple lesions, which can arise anywhere except the lips, palms, and soles
Begin as circumscribed tan brown patches or thin plaques
Over time, may become more papular or verrucous with a greasy scale and a stuck-on appearance
Seborrheic Keratoses
Treatment for Seborrheic Keratoses
Cryotherapy
Curettage/shave excision
Electrodessication
Result from the proliferation of atypical epidermal keratinocytes
Represent early lesions on a continuum with squamous cell carcinoma
Precancerous lesions
Frequently occur in sun-exposed areas
Actinic Keratoses
Risk factors of Actinic Keratoses
Extensive sun exposure, history of sunburns, sunscreen usage
Fair Skin, Male, >40 years old, geography
Commonly described as having a “rough, sandpaper-like” feeling
Actinic Keratoses
Patients with multiple Actinic Keratoses lesions require:
Annual Follow-up
Malignant tumor arising from melanocytic cells
Most fatal form of skin cancer
Increasing faster than any other potentially preventable cancer in the United States
Melanoma
Strongest association of Melanoma
Intermittent exposure and sunburn that occurred in adolescence or childhood
Nearly 50% of melanoma deaths in the U.S. occur in:
White males, age >50
Lesion will be the “ugly duckling”, different than the other lesions
- Asymmetrical
- Irregular borders
- Color Changes
- Diameter >6 mm
Melanoma
Treatment for Melanoma
Dermatology:
-Biopsy, Complete excision of entire lesion into the subcutaneous fat
The goals of wound repair for lacerations and incisions are to:
Achieve Hemostasis
Prevent Infection
Preserve Function
Restore Appearance
Minimize patient discomfort
Wound Healing
Day 0-5: no Gain in wound strength
Phase I: Initial Lag Phase
Wound Healing
Days 5-14: Rapid increase in wound strength occurs.
Phase II: Fibroplasia Phase
Wounding Healing
Day 14 until healing is complete: Further connective tissue remodeling. Up to 80% of normal skin strength achieved.
Phase III: Final Maturation Phase
Indications for wound repair
Lacerations open for less than 12 hours
Repair of sites where a lesion has been surgically removed
Contraindications for wound repair
Wounds open more than 12 hours
Animal or human bites
Puncture wounds
Four principles that should be incorporated in the process of closing any wound
- Control all bleeding
- Eliminate “dead space”
- Accurately approximate tissue layers
- Approximate the wound with minimal skin tension
Stitch should be wide as it is deep
Equal distance from the wound margin and of equal depth
No closer than 2 mm of other sutures
Ideal for the scalp
Simple Interrupted Sutures
Quick and distributes tension evenly and provides excellent cosmetic results
Less desirable in traumatic lacerations because of the increased risk of contamination
Simple running stitch
Promotes eversion of the skin edges. It is useful when the natural tendency of lose skin is to create inversion of the wound margins, which is to be avoided
Appropriate when the skin is very thin and interrupted sutures have a tendency to pull through
Vertical Mattress Sutures
Suture technique is helpful in wounds under a moderate amount of tension; also promotes wound edge eversion
Useful on palms of hands or soles of feet and in patients who are poor candidates for deep sutures because of susceptibility to wound infections
Horizontal Mattress Sutures
Provide a rapid and simple alternative to other methods of skin closure and wound repair
Indicated for:
- Wounds whose edges are easily approximated and not under undue tension
- Long, Linear wounds of the scalp
- Proximal extremities or the torso where cosmetic is not a concern
Skin Staples
Skin staples are contraindicated for:
Facial or neck tissue
Areas where there is an inadequate subcutaneous base
Overall small mobile joints or wherever staples may interfere with normal function
Wounds that are macerated/infected or over large tissue loss
