Clin Med Derm Flashcards
1
Q
Excoriation
A
Picking or scratching
2
Q
Skin components (superficial to deep)
A
Epidermis,
dermis (appendages: sweat glands, oil glands, hair, nails)
subcutaneous fat
3
Q
Layers of epidermis
A
From bottom to top- basal cell, stratum spinosum, stratum granulosum, stratum corneum
(also contains melanocytes and Langerhans cells)
4
Q
Basal cell layer
A
Basement layer, undifferentiated proliferating cells takes 4 weeks to go from basement to roof
Skin cells divide in this layer
5
Q
Stratum spinosum
A
Layer above basal cells, contains keratinocytes.
6
Q
Stratum granulosum
A
Differentiated cells, have more keratin and become flatter, cells begin to stick together. Polysaccharides, glycoproteins, and lipids may also be found here
7
Q
Stratum corneum
A
Roof layer, stacked in layers. 15-25 most surfaces, 100 on palms/soles
Major physical barrier, cells are large, flat, filled with keratin
Cells die and shed in this layer
8
Q
Melanocytes
A
Pigment producing cells in basal cell layer, rise to surface when stimulated by sunlight
Provide protection from UV rays
9
Q
Langerhans cells
A
From bone marrow (found in epidermis) like macrophages and present antigens to lymphocytes (immune cells)
10
Q
Dermis
A
Tough, elastic support. Contains nerves, blood vessels and appendages. 1-4 mm thick (thinner in face, thicker in soles)
11
Q
Skin appendages
A
Eccrine sweat glands, apocrine sweat glands, hair follicles, sebaceous glands, nails
12
Q
Eccrine sweat glands
A
Sweat only, triggered by emotion and thermal stimuli(regulates body temp) , transported by duct in dermis to epidermis
13
Q
Apocrine sweat glands
A
No useful purpose, body odor only (caused by surface bacteria), glands in axillae and anogenital areas, located deep in dermis and reach surface by hair follicle
14
Q
Hair follicle
A
Protective and decorative
2 types: vellus (fine, light colored “peach fuzz”) and terminal (coarse, dark, most of the hair on our bodies)
15
Q
Hair growth
A
Occurs in cycles:
Anagen: active growth
Catagen: transition
Telogen: resting, when hair easily falls out
16
Q
Sebaceous glands
A
Produce sebum, located with hair follicles, size and activity controlled by androgen- full size at puberty
17
Q
Nails
A
Made of keratin,formed from matrix of dividing cells, grow at 0.1 mm/day
3 months for finger nails to grow out
6-12 months for toe nails to grow out
18
Q
Nail components
A
Proximal fold: protects matrix, contains cuticle
Matrix: produces nail plate (if damaged, can never be repaired and nail will always grow abnormally)
Hyponychium: distal edge of the nail
19
Q
Subcutaneous fat
A
Lies between dermis and fascia
Insulation, cushion, and energy reserve
20
Q
Macule
A
Flat Skin lesion, different color
Ex- freckle
21
Q
Papule
A
Small raised skin lesions, no fluid
ex-pimple
22
Q
Alopecia
A
Partial or complete hair loss. Can scar or not, determines if hair can grow back
Affects children and adults
Possible causes: Autoimmune and genetic
23
Q
Comedones
A
Blackheads (open), whiteheads (closed)
24
Q
Vesicle
A
Blister filled with clear fluid, less than .5 cm diameter
25
Bullae
Blister filled with clear fluid, greater than .5 cm diameter
26
Pustule
Raised fluid filled lesion, filled with pus or cloudy fluid
27
Wheal
Lesion of dermal edema, speed bump in skin (slightly raised) (Ex. Urticaria (hives))
28
Nodule
Raised marble like, diameter and depth greater than .5 cm
29
Ulcer
Epidermis is gone and part of dermis affected, from pressure (being in bed for a long time)
30
Lichenification
Thickening of epidermis, alligator skin, exaggerated skin lines visible. During inflammatory process, person scratches (intense excoriation), skin thickens
31
Polyp
Soft fleshy growth, skin tag
32
Fissure
Linear cracks and tears in epidermis, seen with swelling
33
Scale
Thickened stratum corneum, dry, easily flakes off
dandruff, eczema, psoriasis
34
Crust
Dried liquid (blood, serum, pus) on surface of skin, scab
35
Atrophy
Loss of skin tissue
Epidermal -skin looks thin/shiny (saran wrap)
Dermal- detectable depression (divot) “sunken in appearance”
36
Plaque
Elevated skin lesion but lacks depth, diameter greater than .5cm
37
Telangectasia
Squiggly, broken, enlarged superficial blood vessels
38
Depigmentation
Complete loss of pigment in an area (Vitiligo)
39
Hypopigmentation
Partial loss of pigment (Tinea versicolor)
40
Hyperpigmentation
Excessive pigment, darker than surrounding skin
Macule is considered a hyperpigmented lesion
41
Langer’s lines
Skin tension lines, guide for strongest scar and better cosmetic outcome
42
Pruritis
the sensation of itching
43
Papulosquamous diseases
Psoriasis, pityriasis rosea, drug eruptions, lichen planus
44
Psoriasis
Well demarcated erythematous plaque with silvery scale on extensor surfaces
No cure, epidermal cells produced 7x normal rate (thickened stratum corneum), "too many shingles on roof”
Elbow, knees, and scalp most common
May be autoimmune disease, comorbid disease
Chronic
45
Koebner phenomenon
Psoriasis can occur where there is trauma to the skin ex-where surgical incision occurs
46
Nail psoriasis
Pitting of nail bed, subungal discoloration, difficult to treat, differentiate from nail fungus
47
Guttate psoriasis
Many small red plaques peppered throughout body
associated with strep/upper respiratory infection
48
Pustular psoriasis
Small pustules, common on hands and feet
49
Palmar/plantar psoriasis
Confined to palms and soles
50
Inverse psoriasis
Occurs in skin folds, often mistaken for Tinea infections, under breasts, between buttocks, in axillae
51
Systemic effects of psoriasis
Psoriatic arthritis (30%), risk for cv disease, cancer, obesity, depression/alcoholism
52
Psoriasis treatment
No cure, goal of tx is control
Tx depends on severity, location, symptoms, insurance, pt preference
Can be topical, phototherapy, or systemic treatment
53
Topical steroids (psoriasis)
Decrease inflammation, use class appropriate for location
ointments work better than creams or lotions
54
Phototherapy (psoriasis)
Good for widespread disease
light causes a photochemical rxn that is anti-inflammatory
Never treat back-back days
2-3x/wk, build time then taper back
Average “clear” time= 3 months
55
Systemic medications (psoriasis)
Methotrexate: inhibits cell proliferation, labs needed to monitor liver regularly, hepatotoxic
Soriatane: no blood donation/pregnancy for three years after d/c (teratogenic), labs for cholesterol/triglycerides. Best used for palmar/plantar psoriasis.
Otezla (Apremilast): reduces production of cytokines, $
56
Pityriasis rosea (PR)
Unknown cause
Peaks in spring and fall in younger population
Possible Viral etiology
Herald patch (salmon pink, 1st to show up)
followed by red/pink/brown scaly patches at trunk and proximal extremeties (like Christmas tree)
Acute
Pruritis is usually intense
57
Treatment for PR
Topical steroids, oral antihistamines, phototherapy
TX won't stop eruption, will only control itch, Will last 6-12 weeks (resolve on its own), not contagious
NOT COMMON AND NOT RECURRENT
58
Lichen planus
Pruritic flat top violaceous (purple) papule (degree of pruritis varies)
Can affect skin, scalp, nails, and mucous membranes
test for Hepatitis C, may be associated with this
If oral only, monitor for cancer in mouth
Mostly seen in adults
4 P’s Purple, pruritic, polygonal, papules
Clinical features: Wickham’s Striae
Can lead to scarring alopecia and nail deformity
59
Wickham's striae
Fine white lines or grey streaks within lesions, can be in mouth
60
Lichen planus Tx
Diagnose with biopsy (punch), test for hepatitis
Can tx with intralesional steroids (IL)
Topical, systemic, photo tx
Spontaneously resolves between 6 months -2 years
Can flare up with stress or recur at any time
61
Drug eruptions
Systemic sudden onset, hives or bright papular rash
starts proximally and moves distally
usually seen within 1 week of new med
Caused by antibiotics(bactrim/sulfa,penicillins,cephalosporins), diuretics(furesomide-lasix), NSAIDs, blood products
IF IT HAPPENS TO ONE SIDE IT WILL HAPPEN TO THE OTHER (bilateral)
62
Drug eruptions treatment
Biopsy to diagnose (won’t tell you what medication the pt is allergic to)
D/C suspected drug, talk to PCP about replacing drug, may take 4 weeks for drug to clear system
63
Fixed drug eruption
Usually develop 1 annular or oval erythematous patch
More common with PRN meds
May see 2 week delay between drug intro and lesion
May recur at same site with reexposure (lighting up of the hyper-pigmented lesion)
Seen on lip, hip, sacrum, or genitalia
Nickel to quarter in size
May have itching, burning, and pain
64
Causes of acne
Clogged pores due to the epidermis not shedding dead skin cells fast enough coupled with the overproduction of oil in sebaceous glands.
Naturally occurring C. acnes can infect the clogged pore causing inflammation and lesions on the skin.
65
Acne
Chronic inflammatory condition affecting both genders mainly in face, chest, and back.
It consists of comedones, papules, pustules, and nodules
It can start as early as 8 years and last through adulthood
66
Mild acne
Classification of acne characterized by few papules, pustules, and comedones; small number of lesions; limited in location
67
Moderate acne
Classification of acne characterized by many papules, pustules, and comedones; can cause scarring; usually in more than one location
68
Severe acne
Classification of acne characterized by extensive papules, pustules, and nodules; will cause scarring; usually in more than one location
69
Papulopustular acne
Type of acne characterized by papules and pustules
70
Comedonal acne
Type of acne characterized by “whiteheads” if comedones closed, “blackheads” if comedones open
71
Nodulocystic acne
Type of acne characterized by nodules; feels like a hard or firm ball under the skin
Scarring will likely happen
72
Topical treatments for acne
Benzoyl peroxide, topical antibiotics (ex. Clindamycin), retinoids (Retin-A,differin,tazorac), witch hazel
73
Systemic treatments for acne
Oral antibiotics, birth control pills, spironolactone, isotretinoin (accutane)
74
Patient education points for acne
No cure for acne, treatment response can take up to 6 weeks, don’t pick, cleanse face 2x daily with warm water and hands, makeup and moisturizer should be oil free, avoid toners/scrubs/masks
Pitted acne scars are permanent
Topical tx may bleach fabrics
Avoid sun exposure while on most acne tx
75
Tx considerations for isotretinoin
Last resort tx for nodulocystic acne
Standard course is 6 months
Side effects include dry lips/skin, sun sensitivity, muscle/joint pain, alopecia, nose bleeds, depression, pseudocerebri tumor,
Frequent lab tests throughout tx to check liver
Must be seen by prescriber every 30 days throughout tx
Teratogenic
Females must choose 2 forms of birth control and must compete monthly quizzes about pregnancy prevention in order to refill monthly rx
76
Rosacea
Chronic inflammatory/neurovascular condition
Mainly affects face
Characterized by flares and remissions
No cure
Primarily adult disease
77
Symptoms of rosacea
Affects nose and medial aspect of cheeks; flat redness (flushing)
May have papules and pustules, telangiectasia, burning sensation, tenderness, blepharitis, keratitis(inflammation of the cornea)
C/o of dry eye or feeling of sand in eye
78
Common triggers of Rosacea
Temperature extremes, wind, stress, spicy food, alcohol (especially red wine), sun exposure, emotions
79
Topical Tx for rosacea
Gentle cleansers, sunscreen, topical antibiotics(metronidazole,clindamycin,sodium sulfacetamide)
topical retinoids (azaleic acid-can burn first few times), Mirvaso (vasoconstrictor) = for use episodically but rebound flaring: purple appearance can occur
AVOID BENZOYL PEROXIDE
80
Systemic Tx for Rosacea
Low dose doxycycline for its anti inflammatory properties
81
Verrucous lesion
Warty looking lesion
2 types:
-Seborrheic keratosis
-actinic keratosis
82
Seborrheic Keratosis (SK)
Benign warty stuck on growth
Adults only
May have hereditary factor
Appearance: Sharply defined, raised, stuck on, tan to black in color, biopsy if not clear
cut SK
Sx: asymptomatic, maybe itchy or tender if irritated
Tx: not necessary, only remove if irritated or hx of breast cx
Remove with cryotherapy for small lesion or surgery for large
Sign of Lester-Trelat = malignancy
83
Actinic (sun related) Keratosis
Premalignant (25% will develop into squamous cell)
Caused by excess sun exposure
Seen on face, ears, scalp, forearms, chest, upper back, hands
Initially may come and go, then stays
Appearance: Scaly, flaky, rough, red, pink, sensitive
Tx: destroy with liquid nitrogen freezing, topical chemotherapy, or photodynamic
therapy (depends on location, number, size)
84
Neoplasm
New and abnormal growth of tissue
85
Skin cancer facts
Risk of melanoma doubles after 1 burn as child
Risk of skin cancer doubles after 3-5 burns
1 person dies every hour from melanoma
Melanoma is more common form in age 25-29
1/5 develop
86
Skin cancer risk factors
Fair skin, light hair/eyes
Geographic location
Hx of UV exposure and radiation tx
Family hx of melanoma
50 or more moles on body
Chronically suppressed immune system (transplant pt)
More deadly in non-Caucasian due to delayed dx
87
Basal cell skin cancer
Most common skin cancer
Not life threatening
Caused by increase sun exposure
Sx: sore that doesn’t heal, pearly shiny bump, scar like appearance, red scaly crusted patch, lesion may bleed
Dx: made by biopsy
Tx: Cryotherapy, topical chemo, ED&C, MOHS Surgery, excision
Excellent cure rate
88
ED&C
Burn an scrape method for treatment
Blind test, not retesting to make sure cancer is gone
89
MOHS Surgery
Highest cure rate
Cut around skin cancer, put on a slide, and look under microscope to see if any left, continue until none is left
Better cosmetic outcome
90
Squamous cell skin cancer
Second most common skin cancer
700,000 dx/year
If untreated, can metastasize
Caused by excess sun exposure/radiation, lips often affected, can develop with immunodeficiency
Sx: Thick round horn like lesion, wart-like sore, may bleed, irregular rough red patch persists
Dx: made by biopsy
Tx: Cryotherapy, topical chemo, ED&C, MOHS surgery
Good prognosis
91
Facts about malignant melanoma
Most serious skin cancer- 4%
Causes most skin cancer related deaths
If dx and tx early, cure rate near 100%
Can be hereditary- 1st degree relative has it, 50% greater chance of developing
92
Signs of Malignant Melanoma
ABCD’s (EF)
A- Asymmetry
B- Borders (jagged edge)
C- Color (multi-colored, not good)
D- Diameter (6mm or less, pencil eraser)
E- evolving (changes)
F- failure to respond to tx
93
Diagnosis of Malignant Melanoma
Done by biopsy
Should use excision biopsy- gives a deeper test
and better plan for tx
94
4 types of Malignant Melanoma
1. Superficial spreading (in situ)
2. Lentigo Maligna- Elderly (in situ)
3. Acral Lentiginous (in situ)
4. Nodular (starts invasive)
95
Superficial Spreading
Most commonly
Trunk in men
Legs in women
upper back in both
96
Lentigo Maligna- Elderly
Chronically damaged skin
Common in face, ears, arms, upper trunk
*big freckle turns cancer from sun exposure
97
Acral lentiginous
Seen under nails or palms of hands/soles of feet
Common in African Americans and Asians, can advance quickly
98
Nodular
Most aggressive, starts invasive, presents with raised lesions
Seen on trunk, legs, scalp of men
Worse prognosis of the 4
99
Breslow’s Thickness
Measures the deepest point of tumor penetration in mm
In situ- confined to the epidermis, best prognosis
Thin tumor- <1 mm
Intermediate tumor- 1mm-4mm
thick tumor- >4mm
100
Staging of Melanoma
Stage 0- in situ
Stage 1- Up to 1mm thick, no spread
Stage 2- 1.01 mm-4mm thick, no spread
Stage 3- MM has spread to nearby lymph nodes or skin
Stage 4- MM has spread to internal organs, far away skin, and far away lymph nodes
101
After treatment for malignant melanoma
See ophthalmologist 1x/ year
See gynecologist 1x/year
See dermatologist every 3 months for first year, every 6 months for 2-5 years, and 1x/year after 5 years
102
Who does psoriasis affect?
Affects all ages
Most common onset is around the third decade of life
Strep infection, emotional stress, skin trauma, drugs and obesity can contribute to the onset
103
Onset of psoriasis
-Usually gradual, can be sudden
-strep can cause another form of this
-emotional stress/obesity/medications can aggravate
104
Atopic Dermatitis
Condition characterized by chronic, itchy, eczematous eruptions
It affects the face, neck, antecubital and popliteal spaces, and flexor surfaces
It is common in childhood
105
Symptoms of Atopic dermatitis
Pruritis, burning, erythema, scaling, crusting, lichenification
106
Basic treatments for atopic dermatitis
Moisturizer cream
Decrease bathing frequency
Gentle cleansers, humidifiers, sensitive skin laundry detergents
trim nails
107
Topical treatments for Atopic dermatitis
Topical steroids, calcineurin inhibitors-Immunomodulators; Rx moisturizers; phototherapy
108
Systemic treatments for Atopic dermatitis
Oral steroids, antihistamines, antibiotics
109
Irritant contact dermatitis
Condition caused by a substance that produces a direct toxic effect to the skin
It only affects the skin in contact with the substance (ex. nickel in a watch)
110
Allergic contact dermatitis
Condition caused by an immunologic reaction that triggers inflammation
It can be systemic and cause anaphylaxis (ex. Poison ivy)
111
Seborrheic dermatitis
Condition characterized by a superficial inflammatory response
It can be chronic and occurs in hairy areas of body
Organism causing this is Malassezia
112
Symptoms of Seborrheic dermatitis
On face: white or yellow skin, flaky, erythema, may be pruritic
On scalp: dandruff with no itch, erythema, or adherent scale
113
Shampoo treatments for Seborrheic dermatitis
3x per week: selenium sulfide, zinc pyrithione
(Head and Shoulders), or Ketaconazole (Nizoral)
114
Topical treatments for Seborrheic Dermatitis
Low potency topical steroids PRN, immunomodulators (elides and protopic), topical antifungals, and keratolytics for thick scale
For eyelids, baby shampoo
115
Treatment for Lichen Simplex Chronicus
Potent topical steroid (ointment or cordran tape),
Interlesional steroids, oral and topical anti pruritics, behavior modification
116
Name 3 functions of the skin
Temperature regulation
Insulation
Sensation
Protection
117
Where are Melanocytes and Langerhans cells located?
Epidermis
118
What is the possible explanation for why topical treatments take time and why patients should be given realistic expectations?
Takes 4 weeks for cells to migrate up
119
What epidermal layer does cell differentiation occur?
Stratum granulosum
120
What epidermal layer contains a lot of keratin?
Stratum corneum
121
Why might treatment of palmar/plantar pathology be more aggressive than other locations?
Thicker skin layers, need to penetrate deeper to treat the cause
122
T/F: People with darker skin have more melanocytes than someone with fairer skin
False
Same number of melanocytes, more melanin
123
Collagen and elastic fibers are contained within the
Dermis
124
How much sweat can the body produce per day?
10 liters
125
What locations will we not find any hair?
Palmar and plantar surfaces
126
What does the pilosebaceous unit consist of?
Hair follicle and sebaceous gland (amongst other things)
127
Why might toenail pathology be treated different than fingernail?
More distal, blood flow
128
What is one possible cause of skin atrophy?
Chronic topical steroid use
129
Name a skin condition where Telangiectasia can be seen
Rosacea
Basal cell carcinoma (BCC)
130
What is a dermatome?
An area of skin supplied by branches of a single spinal sensory nerve root
131
Name a condition where dermatomes can be clinically important
Herpes Zoster (shingles) Has a dermatomal pattern
132
How many dermatome groups are there? What are they divided into (general)?
5
-cervical (7)
-thoracic (12)
-lumbar (5)
-sacral (5)
-coccygeal (1)
133
What is the Fitzpatrick scale used for?
Classifies skin in reaction to sun exposure
134
A Fitzpatrick score of 1 is
Very little melanin, the fairest skin possible
135
A Fitzpatrick score of 6 is
The most melanin, dark skin
136
What is a possible etiology for psoriasis?
Possibly T-cell (immune) mediated
137
Is there a genetic predisposition for psoriasis?
Yes 30-50%
138
What is the most common type of psoriasis?
Plaque psoriasis
139
What age does psoriasis mostly affect?
3rd decade of life
140
What kinds of drugs can cause psoriasis flaring?
Lithium
Beta blockers
NSAIDS
141
What are some other predisposing factors for psoriasis?
Obesity
142
Symptoms of psoriasis can include
Pruritis
Pain
Arthralgias (**need to ask about joint symptoms)
143
Guttate psoriasis can be mistaken for
Tinea (fungal) infection
144
Ddx of Psoriasis
Candidiasis (inverse)
Atopic dermatitis (eczema)
Tinea (fungal, ringworm)
Pityriasis rosea
Seb. Dermatitis
Nummular eczema
145
Name 2 topical medications that we can use for treatment of psoriasis
Calcipotriene: topical steroid, alters keratinocyte proliferation
Tazarotene: topical retinoid, alters epidermal proliferation
146
Name alternative topical treatment we can use for psoriasis
Tar: anti inflammatory
147
What are some downsides of phototherapy?
Expensive, time-consuming, not widely available
Associated risks (photo aging, risk of skin cancer)
148
What labs do we monitor for when Methotrexate is used?
CBC, BUN, HFP, CREAT.
Not a good option for pts with alcoholic cirrhosis
149
Common symptom of Methotrexate
Nausea
150
What is an indication for starting systemic treatment for psoriasis?
Large BSA or presence of joint symptoms (indicating possible psoriatic arthritis)
151
Major symptom of soriatane?
Dryness (lips)
152
What is the preferred treatment for moderate to severe psoriasis?
Biologics- SQ injection/IV infusion
Immunosuppression causes inflammation interference
However increased risk of infection
Needs PPD
153
Herald patch
One 2-6 cm patch that shows up before rest of the rash blossoms
154
Pityriasis rosea DDx
Guttate psoriasis
Tinea
Secondary syphilis
Nummular eczema
155
What differentiates secondary syphilis from Pityriasis rosea?
Palmar/plantar rash seen in secondary syphilis, not in PR
156
What does lichen planopilaris refer to?
Lichen planus affecting the scalp, causing alopecia
157
Why is a thorough history so important in diagnosing a drug eruption?
Need to figure out the offending drug! Ask about all medications, not just prescription (otc, homeopathic, topicals)
158
What is onychomycosis?
A fungal infection of the nails
159
3 acneiform disorders
Acne
Rosacea
Folliculitis
160
You see a 6 year old with diffuse acne lesions. Why is this concerning?
Red flag
There could be an underlying endocrine issue
161
Frontline topical treatment for mild to moderate acne?
Benzoyl peroxide - bacteriostatic that reduces C. acne
162
Aczone Gel is used for_________ ___________ acne
Adult female
163
What are some ABx to treat mod to severe acne?
Tetracycline class
Ex. Minocycline, doxycycline
164
Why should minocycline be avoided in pregnant women?
Risks for tooth staining
165
What is the idea for using combination birth control pills for acne?
Lowering the estrogen levels can decrease oil production and therefore acne formation
166
What do we need to ask about in patients we are considering starting on combo birth control pills for acne?
Smoking history
167
What labs should we consider monitoring in acne patients being treated with spironolactone?
Potassium
168
What is iPLEDGE?
single pregnancy risk management program for prescribing and dispensing of all isotretinoin products
169
How can lupus be distinguished from rosacea
Lupus has a more purple appearance, constant and consistent (“doesn’t relent”)
Rule out lupus from our rosacea diagnosis by checking ANA (anti-nuclear antibody)
170
What is a complication associated with rosacea?
Rhinophyma - hyperplasia of the soft tissues of the nose
171
We may need a ______referral for rosacea patients
Ophthalmology
172
Clinical features of folliculitis
Follicular pustules
Follicular erythematous papules or nodules
173
What bacteria most commonly causes folliculitis?
S. aureus
174
For most cases of folliculitis, we could use the topical ABXs _______ or _________
Mupirocin, Clindamycin
175
What oral ABx could we use for extensive folliculitis?
Cephalexin
TMP sulfa
176
Two subtypes of folliculitis are
Hot tub folliculitis (pseudomonas)
Folliculitis barbae (shaving distribution)
177
What are the types of eczematous disorders we discussed?
Atopic dermatitis
Contact dermatitis
Seborrheic dermatitis
Dyshidrotic eczema
Lichen simplex chronicus
178
The atopic triad is composed of
Allergies, asthma, atopic dermatitis
179
Secondary bacterial infection in atopic dermatitis
Fever, chills, and purulent discharge could be a sign
180
Atopic dermatitis DDx
Contact dermatitis
Cellulitis
Seborrheic dermatitis
181
Contact dermatitis DDx
Atopic dermatitis
Psoriasis
Herpes zoster
182
What is patch testing and what is it used for?
Exposing skin to irritants to identify a possible cause for contact dermatitis
183
Treatment for contact dermatitis
Remove offender
Treat symptoms (topical and oral steroids)
Antihistamines
Prevention and avoidance
184
Seborrheic dermatitis DDx
Psoriasis
Rosacea
Contact dermatitis
185
There is a high rate of occurrence of seborrheic dermatitis in what special populations
HIV/AIDS
Parkinson’s
186
Dyshidrotic eczema (all ages) is also known as
and the cause?
Acute palmoplantar eczema
Caused by overexposure to moisture
187
Hallmark sign of dyshidrotic eczema
Small tapioca vesicles in high moisture area
188
Dyshidrotic eczema DDx
MRSA
Cellulitis
HSV
Pustular psoriasis
189
Treatment of dyshidrotic eczema is
Prevention
Topical or systemic steroids
phototherapy
190
Nummular eczema presents with
Erythematous, round patches that are very diffuse,
More prevalent in the winter time
191
How is nummular eczema different than a tinea infection?
More widespread/diffuse and solid red
192
Stasis dermatitis is secondarily caused by
Vascular disease
193
Skin in stasis dermatitis will have a __________ color
Brown-red
Extra info: texture may be shiny, edematous, may ulcerate
194
Neurodermatitis cause
Patients picking,
Real or perceived
195
What disease is described as a "chronic itch scratch cycle?"
Lichen simplex chronicus
196
What population does nummular eczema typically affect?
Older
197
Lichen simplex chronicus DDx
Psoriasis
198
What age does bullous pemphigoid usually affect?
65+ y/o, usually with comorbidities
199
Bullous pemphigoid is _______ mediated
Autoimmune
200
"Tense bullae arise on any part of the skin surface, with a predilection for the flexural areas of the skin”
Bullous pemphigoid
201
Symptoms of bullous pemphigoid
Prodrome
Intense pruritis
Lesions may occur intra-orally
Lesions heal without scarring
202
Diagnostic studies of choice for bullous pemphigoid
Skin biopsy (need 2 samples: one regular specimen from edge of blister and one normal appearing sample from peri-lesion skin for direct immunofluorescence)
Blood testing
203
Frontline treatment for bullous pemphigoid? Other treatments?
Oral steroids (prednisone) #1
STEROID WORKS FASTER but not for diabetics
Topical steroids (given in conjunction with systemic tx)
Oral ABx - tetracyclines (also first line)
Immunosuppressives (second line) - Methotrexate, dapsone, imuran
204
What is different about pemphigus vulgaris?
Blisters occur on skin and mucous membranes
Usually in younger population
Rare
Can be associated with cancer
205
Erythema multiforme has 2 types
Minor, major
206
Is erythema multiforme self-limiting?
Yes
207
What causes erythema multiforme?
HSV
208
Target lesions-clear center with erythematous ring indicative of
Erythema multiforme
209
Supportive measures for erythema multiforme
Topical steroids
Viscous lidocaine
210
What is the main difference between SJS and TEN?
SJS <10% BSA affected
TEN >30% BSA
211
Causes of SJS/TEN
Infection (HIV)
Medication- ABx, NSAIDS, Anti-gout
Psychoepileptics
Malignancy
Idiopathic
212
What is a clinical key to note about SJS/TEN in terms of onset of symptoms?
Prodromal symptoms (1-3 days before)
Including productive cough
Headache
Malaise
Arthalgias
213
What other body system (outside of the skin) can be affected in SJS/TEN?
Ocular symptoms: red eye, dry eye, pain, grittiness, decreased vision, diplopia
214
Why can SJS/TEN be considered life-threatening?
Risk of systemic infection
215
Treatment of patients with SJS/TEN should be in a ___________
burn unit/icu
216
#1 priority for SJS/TEN treatment is to
Remove the offending drug
217
What is cause of death attributed to in sjs/ten patients?
Sepsis and multi organ failure
218
Other considerations for SJS/TEN treatment
Fluid resuscitation
O2, intubation if can’t protect airway
Pain control
Treat secondary infections
Parenteral nutrition
219
What is a positive nikolsky sign?
Application of slight lateral pressure on the epidermal surface results in epidermis easily separating from its underlying surface
In SJS/TEN
220
Explain the rule of 9's
Head - 9
Anterior trunk - 18
Posterior trunk - 18
Legs - 18 each
Genitalia- 1
Palm - 1
Arms - 9 each
221
A female pt with lesions on the entire anterior trunk, anterior left arm, and anterior left leg has approximately __________ % BSA affected
32%
Anterior trunk was 18 plus ANTERIOR arm (9/2 = 4.5) plus ANTERIOR leg (18/2 = 9)
222
What is the sign of Leser-Trelat? What is it associated with?
Sudden onset of numerous SKs. Associated with various malignancies
223
What are two long term effects of freezing with liquid nitrogen?
1. Depression
2. White color
224
A nevi is another word for a
Mole
225
T/F An atypical mole should be excised.
True
226
T/F Melanoma results in more deaths per year than SCC
False
SCC results in more deaths because prevalence is also greater
Melanoma is still deadlier
227
Skin cancer capital of the world?
Australia
228
Commonly affected areas for SCC include
The lips, especially the bottom
229
“Meaty craterform lesion”
Warning sign for SCC
230
Lice is most commonly caused by _________parasite
Pediculus
231
What causes the irritation in a lice infestation?
Saliva of lice produces an irritant reaction
232
Nit
Empty egg shell
233
How can nits be differentiated from dandruff?
Nits don't come out easily, dandruff does
234
Severe lice infestation can cause
Local lymphadenopathy
235
Treatment for lice
Topical pediculicides
236
What should not be used for lice treatment?
Lindane
237
What can be used for lice with eyelash involvement?
Petroleum jelly
238
T/F the presence of nits doesn't necessarily mean an active lice infestation
True
239
Scabies is caused by
Sarcoptes species
240
Scabies spread by
Prolonged skin to skin contact
Frequently sexually acquired
Common in crowded conditions (nursing homes, jail)
Exposure to clothing, bedding, furniture used by infested person
241
Scabies may take ________ months to start itching
2
242
Pruritis in scabies is usually worse at
Night
243
Areas of predilection for scabies
Finger web spaces
Wrist
Elbows
Axillae
Penis
Nipples
Buttocks
244
What is always a concern with the intense scratching asociated with scabies?
Secondary infection
245
Diagnosis for scabies is made by
Skin scrapings
246
Treatment for scabies
Permetherin 5% cream (elimite)
247
Post scabetic pruritis
Can last up to 4 weeks after tx
Should become less dramatic with time
Tx with topical steroids and oral anti histamines
248
T/F most spider bites are minor
True
249
Brown recluse bite
Minimal pain initially
Symptoms usually delayed 2-8 hours,
fevers/chills, nausea/vomiting, joint pain, local tissue necrosis
Halo of red then white then red in the center
250
A black widow spider bite contains potent
Neurotoxins
251
Black widow bite
Usually no reaction, little or no redness or pain
Symptoms delayed 1/2 to 2 hours, systemic muscle pain, extreme abdominal pain, muscle cramping, chest tightness, dyspnea, abdominal rigidity, may develop hypertensive crisis, seizures
252
Complications to black widow bites usually more in what populations?
Elderly, young, sick
253
Treatment for black widow bite
Tetanus
Analgesics
Antispasmodic
Anti-venom (call medical toxicologist ~ may take awhile)
254
Impetigo is a common bacterial infection in
Children
255
Impetigo is highly
Contagious and autoinocuable
256
Offending organisms of impetigo
S. pyogenes or S. aureus
257
"Superficial pustule that ruptures and forms a yellow brown honey colored crust" classic of
Impetigo
258
Treatment for impetigo
Topical-mupirocin
Systemic-cephalexin
If MRSA, TMP Sulfa (bactrim) or clindamycin
259
Erysipelas
Bacterial skin infection caused by strep. pyogenes
260
Difference between erysipelas and cellulitis
Borders much more defined, sharply demarcated from heathy skin. Cellulitis is more diffuse
261
Treatment for erysipelas
5-14 day course of oral ABx
Penicillin mild
IV ceftriaxone for significant
262
Causative agents for cellulitis
S. aureus and S. pyogenes
MRSA on the rise
263
Predisposing factors for cellulitis
Tinea pedis
Vascular insufficiency
Diabetes
264
Pt’s with cellulitis are at risk for becoming
Septic
265
Workup for cellulitis includes
Labs - CBC with diff
Blood cultures if systemic illness is present
266
Cellulitis DDx
DVT
Stasis dermatitis
267
Treatment for cellulitis
Oral or IV ABx depending on severity
268
Tinea corporis
Ringworm
269
Tinea capitis
Ringworm of the scalp
270
Tinea faciei
Ringworm of the face
271
Tinea pedis
A ringworm fungus of the foot
272
Tinea mannum
Tinea on hands
273
Tinea ungium
Ringworm of the nail associated with onychomycosis
274
Tinea Cruris
Jock itch
Tinea of the groin
275
Treatment for tinea infection
Topical antifungal (azole) (not for nails or scalp)
Oral lamisil or griseofulvin
Treat scalp for 6 weeks at least
276
Tinea versicolor is caused by
Malassezia furfur
277
Tinea versicolor usually occurs in
Young adults
Neck, trunk, and upper arms
Summer recurrent
278
KOH of tinea versicolor will show
Spaghetti and meatballs
279
Tinea versicolor treatment
Topical antifungal (ketaconazole)
Oral fluconazole
Prevention: Selenium sulfide shampoo as a body wash
280
Causative organism for candidiasis?
Candida albicans
281
High risk patients for candidiasis
Diabetics
HIV/aids
Pregnancy
Obese
282
“ Denuded, beefy red skin with white curd like collections on mucosa, usually in the creases (inframammary, IG crease, axillae, groin)”
Candidiasis
283
Treatment for candidiasis
Keep skin dry
Azole topicals or nystatin powder
Oral fluconazole
284
HSV is commonly known as
Cold sores, fever blisters
285
What type of HSV most commonly causes oral lesions?
HSV 1 (80%)
286
Incubation period for HSV? Average?
HSV is highly contagious
2-12 days
4 days average
287
Duration of HSV infection?
5-8 days
288
HSV lesions are most contagious when they are in what form
Intact vesicles
289
Testing for HSV
PCR testing
Viral culture
Throat culture
HSV 1/2 serology
Tzanck smear
290
A positive Tzanck smear will show what under microscope
Giant multinucleate cells
291
Treatment for HSV
Oral acyclovir (famcyclovir, valacyclovir)
292
Recurrent HSV patients may get a __________ prior to onset
Prodromal of pain, tingling, burning
293
Acyclovir/valocycliovir prophylaxis has been shown to
Reduce number of HSV episodes
294
Herpes zoster also known as
Shingles
295
Lesions in herpes shingles occur in ________ pattern
Dermatomal
-unilateral
296
Shingles caused by
Reactivation of latent varicella zoster virus (chickenpox)
297
Shingles seen mostly after age
50
298
T/F shingles vaccine can cause shingles in someone without latent varicella zoster virus
True! Vaccine has live virus
299
Prodromal pain or burning in dermatome
Grouped, linear vesicles in unilateral dermatomal distribution
Classic sign of shingles infection
300
Herpes zoster patients with periorbital involvement require
Ophthalmology consult
301
Shingles treatment
Valtrez 1gm TID x 1 week
Pain meds (depending)
302
PHN
Post herpetic neuralgia, can persist beyond 4 months of initial eruption
Increased age increases risk for PHN (in Herpes Zoster)
Neurontin or Elavil may be helpful
303
Name of shingles vaccine
Indicated for?
Shingrex
50 yo+ or 19 yo+ immunocompromised
304
Molluscum contagiosum
Verrucous growths caused by poxvirus
305
Molluscum commonly seen in age
3-10
306
“Umbilicated dome shaped pink papules" hallmark of
Molluscum contagiosum
307
Tx for molluscum
Observation!
(Self-limiting)
308
Verruca vulgaris
Common wart
309
Condyloma acuminata
Genital warts
310
Verrucae are caused by
HPV (human papilloma virus)
311
Verrucae DDx
SCC ( biopsy if questioning)
312
Tx for verrucae
Liquid nitrogen
Laser therapy
Immunotherapy
313
Acanthosis nigricans
The presence of dark velvety patches of skin around the armpit, back, neck, and groin
Patients with this may complain of “dirty skin”
314
Acanthosis nigricans has been linked to
Insulin resistance and diabetes
These patients should be screened for diabetes: check plasma insulin level
315
Tx for Acanthosis nigricans
Treat underlying disease
Improve appearance with topical keratolytics, retinoids
316
Malignancy associated AN can be linked to
GI malignancy
Do a cancer workup
317
Hidradentis suppurativa
Apocrine duct obstruction in axilla or anogenital region
Dominant in females
Abscess formation
Will cause dermal contractures
318
There is an association with hidradentis suppurativa and
IBD
metabolic syndrome
Acne
319
Clinical features of Hidradentis suppurativa
Erythema, painful papules/nodules, abscess formation, discharge, scarring
Recurrence is a classic feature
320
Hurley staging system
Correlates mild, moderate, or severe HS
Stage 1 - Abscess, no sinus tracts
Stage 2 - Recurrent abscesses with sinus tracts/scar
Stage 3 - Diffuse involvement
321
Tx for HS
No cure!
Topical or oral ABx first line
IL steroids
Humira-TNF alpha inhibitor
322
Comorbidities for HS
Smoking
Overweight
323
Lipomas
A benign, slow-growing fatty tumor located between the skin and the muscle layer
More commonly seen in adults
324
Tx for lipomas
None needed
Surgical excision (purely cosmetic)
325
Epidermal inclusion cyst
Benign cyst developing from proliferation of epidermal cells within a circumscribed space in the dermis
326
Tx for epidermal inclusion cyst
Not necessary
Excision
327
The cyst lining of an epidermal inclusion cyst resembles the
Inner lining of an egg
328
Melasma
Hyperpigmentation triggered by hormonal changes, often during pregnancy or with birth control use
329
Tx for melasma
#1 sun avoidance
High SPF sunscreen
Hydroquinone- bleaching
Topical retinoids
330
Vitiligo
Autoimmune condition caused by the destruction of melanin that results in the appearance of white patches on the skin (commonly the face, hands, legs, and genital areas)
331
Woods lamp
illuminates skin conditions
Can Dx vitiligo
332
Consider ________________ evaluation in patients with vitiligo
Thyroid lab evaluation
333
Tx for vitiligo
High SPF sunscreen (45+ spf 100 is for them)
Phototherapy
Topical steroids, immunomodulators (calcineurin inhibitors)
Oral steroids
Surgical - skin grafting
Mental health referral
334
“Raised well circumscribed lesion of erythema and edema" (wheal)
Urticaria ~ hives
335
Dermographism
Development of urticaria with scratching
336
Angioedema
Localized areas of swelling beneath the skin, often around the eyes and lips, but it can also involve other body areas as well
Clinical feature of urticaria
337
Labs for chronic urticaria
CBC, TSH, ANA
338
Tx for urticaria
Front line: Antihistamines
Reserve systemic steroids for angioedema
Epipen Rx (go to ER after using)
339
Pressure ulcer
Any lesion caused by unrelieved pressure that results in damage to underlying tissue
340
Factors for pressure ulcers
Incontinence
Immobility (bed bound)
Malignancy
Nutritional status
341
Ulcer staging
1. Redness
2. Partial thickness loss of skin involving epidermis and maybe dermis
3. Subcutaneous damage that may go down to fascia
4. Through fascia
Unstageable - bad
342
Work up for pressure ulcer
Wound cultures, blood cultures (r/o sepsis)
CBC, UA, protein, albumin
X-ray,bone scan, MRI (r/o osteomyelitis)
343
Complications of pressure ulcers
Osteomyelitis
Pyarthrosis
Sepsis
Malignant transformation
344
How many deaths per year caused by pressure ulcer complications?
60,000
345
For patients with the same underlying illness,
patient with pressure ulcer has __________ higher risk of death
4.5
346
Pilonidal disease
Chronic infection in skin in the crease above the buttocks
More common in males (more hair)
347
Risk factors for pilonidal disease
Obesity
Sedentary lifestyle
Excess body hair
Poor hygiene
348
Tx for pilonidal disease
I&D
ABx in presence of cellulitis
Complete excision for recurrent lesion
349
What are the clinical manifestations of onychomycosis?
Usually asymptomatic at first
Can progress to pain, numbness
Sublingual hyperkeratosis
350
What is oncholysis?
Separation of the nail from the nail bed, usually with a white/yellow color
351
Onychomycosis DDx
Nail trauma
Nail psoriasis
Aging toenail
352
Main diagnostic tool in onychomycosis
KOH scrape (sublingual debris)
Nail clip for PAS stain
353
Treatment regimen for onychomycosis
Combo of topical and oral
354
Why are topical treatments typically ineffective with onychomycosis?
Unable to penetrate the thick nail plate
355
The first line TX for onychomycosis
Lamisil (terbinafine)
1x/day for 6 weeks in fingernails
1x/day for 3 months in toenails
356
What labs should we monitor with terbinafine (lamisil) and how often
LFT at baseline and 6 weeks at least
357
Paronychia
Soft tissue infection, usually of the lateral and proximal nail folds
358
Characteristics of acute paronychia?
Purulent and painful
Caused by staph infection
359
Characteristics of chronic paronychia?
Swelling
Non-purulent
Candida is often isolated, but not causative
360
Diagnostic evaluation for paronychia
Bacterial culture
KOH smear
361
What systemic problem should we consider with paronychia?
Osteomyelitis- imaging if needed
362
Primary treatment for acute paronychia includes
Soaks, I&D, Topical or oral ABx
363
Primary treatment for chronic paronychia includes
Topical or oral steroid and skin protection
364
Risk factors for paronychia
Nail biting
Educate - Trim hang nails and trim nails flush to tip
365
Alopecia areata presents with
Discrete patches of hair loss
366
Alopecia totalis presents with
Complete baldness of the scalp
367
Alopecia universalis presents with
Baldness of all hair-bearing areas
368
Exclamation hairs
Pathognomic hairs that can be located in or around affected areas of alopecia, shaped like an exclamation point, pull out easy in a pull test
369
What is important to note about the bald skin seen in Alopecia?
It is non-inflamed
370
Alopecia could have a possible association with
Thyroid diseases
Consider checking TSH
371
Tx of alopecia
Topical or IL steroids
Immunotherapy (second line)
Psychosocial support
372
Is androgenetic alopecia progressive?
Yes
373
What does male pattern baldness usually look like?
Thinning in the temporal area w/ gradual frontal recession
374
Female pattern baldness
Thinning at the crown
375
Hamilton-Norwood scale?
Used to classify severity of androgenetic alopecia
376
What labs should be performed in females with androgenetic alopecia?
DHEAS and testosterone
377
Medications we can use for androgenetic alopecia
Minoxidil (Rogaine) - Topical soln, both 2% and 5% strengths
Finasteride (propecia) - oral
Spironalactone in females
378
What is a risk associated with finasteride for androgenetic alopecia?
Teratogenic
379
Telogen effluvium
A prolonged resting phase of the hair cycle
(Non-scarring alopecia)
Self resolving but could take 6-12 months
380
Inciting factors for Telogen effluvium
General anesthesia
Pregnancy
Significant stress
Significant weight loss
Febrile illness
Dietary restrictions
381
Lab workup for Telogen effluvium
CBC, thyroid, iron
382
Topical therapy treatment for Atopic dermatitis
Topical steroids
Calcineurin inhibitors-immunomodulators (not for acute episodes- black box warning, not for under 2 year olds)
Eucrisa - non-steroidal topical
Phototherapy
383
Systemic treatment for atopic dermatitis
Steroids - acute episodes only
Antihistamines
ABx for infection
Dupixent - SQ injection for moderate to severe uncontrolled AD
JAK inhibitors- oral or topical, newer class
384
“White or yellow scale, flaky, background erythema, greasy appearance”
Hallmark of Seborrheic dermatitis
385
Systemic complications of brown recluse spider bite
Fevers, chills, weakness, HA, n/v, arthalgia, rash, leukocytosis
386
Testing for tinea includes
KOH, fungal culture, PAS stain on biopsy
387
Central Centrifugal Cicatrical Alopecia
Permanent hair loss starting at the crown and progressing outward
Almost exclusive to black women 30 yo+
Scarring alopecia
Skin is also affected
Clinical dx
Early intervention is vital - regrowth is possible
