Clin Med Derm Exam 1 Flashcards
Functions of the skin
Protects the underlying structures Barrier against microbes Prevents loss of fluids Regulates body temp Helps rid body of excess water and salt Sensation, temp, pain, touch
3 layers of skin
Epidermis
Dermis
Subcutaneous
Layers of epidermis
outer to inner
Stratum corneum
Squamous cells
Basal layer
(melanin is also present)
thin 0.2mm
Melanin
Protects the deeper layers of the skin against the sun
Located in the epidermis
Produced by melanocytes
Stratum corneum
Horny layer
outermost layer
made up of dead keratinocytes
main cell of the epidermis (continually shed)
Squamous cells
Living keratinocytes
below the stratum corneum
in epidermis
these cells form keratin (a protein)
Basal layer
is the lowest part of the epidermis
formed from basal cells
these cells continually divide and form new keratinocytes
Taking a history (lesions)
evolution of lesion
Site of onset
Manner in which it progressed or spread
duration
periods of resolution in chronic cases
Taking a history (lesions)
S/S
Itching, burning, pain, numbness
does anything relieve it
time of day when worst
Taking a history (lesions)
Taking meds
Sulfa - SJS
Staph - rash - scalded skin
Amox +mono - Rash
Taking a history (lesions)
Associated systemic S/S
Malaise
fever
arthralgias
etc
Taking a history (lesions)
Exposures
Plants metals detergents soaps etc
Taking a history (lesions)
Other….
Chronic or previous illnesses
History of allergies
Photosensitivity
Review of systems
Examination of skin
Inspection should be in well lit room
completely undressed patient
Exam is inspection heavy
Labs and biopsies can be used to confirm
Four basic features of cutaneous lesions
Type of primary lesions
Shape of individual lesions
Distribution of eruptions
Arrangement of eruptions
Characteristic’s of lesion
size shape color texture elevation exudates configuration location and distribution
Macule
Flat
less than 1 cm
change in normal skin color
freckles, flat moles, measles, petechiae
Patch
A large flat lesion
over 1 cm
vitiligo, port wine stains, Mongolian spots cafe au lait patches
Papule
Raised
superficial lesion
less than 1 cm
raised mole, white head, acne
Nodule
Raised
usually round
solid round ellipsoidal
over 1 cm
can be benign or malignant
(tumor over 2cm)
Tumor
Nodule over 2cm
Vesicle and bulla
Circumscribed elevated superficial cavity containing fluid less than 1 cm
Bulla is over 1cm
Cyst
soft raised encapsulated lesion
semisolid/liquid content
isnt transparent like bulla
(cant unroof, pop)
Pustule
Circumscribed superficial cavity
contains purulent exudate
can vary in size and shape
(does not signify the existence of infection
plaque
a plateau like elevation
over 1 cm in diameter
wider than it is high
psoriasis
Wheal
Rounded pale red papule or plaque
usually disappears within hours
various sizes and shapes
Crusts
Develop when serum, blood, exudate dry on skin surface
Impetigo
ecthyma
Impetigo
Crust (honey colored)
crust may be delicate thin and friable
Can happen in adults but usually kids
ABX
Ecthyma
Crust that involves the entire epidermis
crust may be adherent and thick
accompanied by necrosis of deeper tissues
Ecthyma involves dermis
Desquamation
Desquamation (scaling)
scales are flakes of the stratum corneum
psoriasis
actinic keratosis (solar)
Ulcer
Skin defect where there is a loss of epidermis and upper papillary dermis
may extend to the subcutis
(an erosion is a defect only involving the epidermis and heals without a scar)
Erosion
an erosion is a defect only involving the epidermis and heals without a scar
secondary lesions
Scale
Flaky accumulation of excess keratin
secondary lesions
excoriation
linear angular erosions caused by scratching
secondary lesions
atrophy
epidermal thinning of skin with loss of normal skin surface markings
dermal depression of skin surface due to loss of underlying collagen or dermal ground substance
secondary lesions
scar
collection of fibrous tissue replacing normal dermal constituents
secondary lesions
Maceration
Maceration occurs when skin is in contact with moisture for too long.
Macerated skin looks lighter in color and wrinkly
In addition to the pain and discomfort it causes, maceration can also slow wound healing and make skin more vulnerable to infection
secondary lesions
secondary lesions
lichenification
thickening of skin with accentuation of normal skin surface markings most commonly due to chronic rubbing
secondary lesions
Keloids
secondary lesion
some people are predisposed
very bad scarring
spider hemangioma
common in liver disease
central arteriole with radiating thin walled vessels
Blanches when compressed
telangiectasia
dilated superficial blood vessels
Blanches when compressed
can appear in older people
only cosmetic
Cherry hemangiomas
do not blanch
discrete papules
benign proliferation of endothelial cells
generally no tx
Dermatographism
A from of urticaria in which whealing occurs in the site and in the configuration of stroking of the skin
Lymphangitis
Red streak extends from the ankle to the groin
Follows lymph channels
IV ABX
Pedunculated
On a stalk
Squamous cell carcinoma
Verrucous
Wart like
Umbilicated
Containing a central depression
Basal Cell Carcinoma
Darier sign
Rubbing a lesion causes a urticarial flare
Auspitz sign
pin point bleeding after scale is removed
psoriasis
Nikolsky sign
Pushing a blister causes further separation of the dermis
TEN
Photopatch test
Documents photoallergy
Patch test
Demonstrates hypersensitivity reaction
koebner phenonmenon
Minor trauma leads to new lesions at the site of trauma
Psoriasis
Shagreen skin
An oval nevoid plaque
Skin is colored or pigmented on the trunk and back and is associated with tuberous sclerosis
Types of eczematous eruptions
Atopic Dermatitis Contact Dermatitis Perioral Dermatitis Seborrheic Dermatitis Stasis Dermatitis Nummular Dermatitis Dyshidrosis Lichen simplex chronicus
Atopic dermatitis
Strong correlation with asthma
poorly defined pruritic erythematous patches, papules and plaques
edema with widespread involvement
flexor surfaces, neck, eyelids, forehead, face, dorsum of hands and feet
often begins in childhood
Tx hydration, topical lotions, ointments, creams
topical steroids, antihistamines
Lichen simplex chronicus
lichenification
thickening of skin with accentuation of skin markings
well defined lichenified plaques and or papules occurring in areas of chronic scratching
Progression from atopic derm due to scratching
topical steroids or tar preparations
Contact dermatitis
Acute well defined areas of erythema and plaques
Can have vesicles, crusts and urticaria
Itching and burning
Exposure to metals, fake jewelry, nickel
solvents, oils, dust, enzymes etc
Patch testing
Avoid offending agent
treat itching
Steroids if severe
Nummular Dermatitis
Coin shaped lesion
plaque
small vesicles that have joined together
may have crust
Pruritic and inflammatory
occurs in winter
Emollients and topical steroids
Triamcinolone
Crude coal tar
Perioral Dermatitis
Papulopustules around mouth
May have satellite lesions
Rule out staph with culture
Tx: metronidazole or erythromycin
Avoid steroids (will worsen)
Seborrheic dermatitis
Yellowish red often greasy or white dry scaling
varying sizes
Very greased
Dandruff is this on scalp
Occurs where sebaceous glands are most active
scalp, face, ears, chest, groin
Tx: Topical steroids, ketoconazole, topical sulfa
Stasis Dermatitis
Inflammatory scales, papules, crusting
edema and varicosities
Ulcers in 30%
Seen in CHF
Swollen and weeping (dry is better)
Doppler / venography
biopsy
Tx compression stockings and topical steroids
Dyshidrosis
Dishwasher dermatitis
Small vesicles under the skin
Tapioca appearance
Can crack and become painful
Burrows cool dressing
Potent steroids used under occlusive dressing x 2 weeks
Oral steroids if severe
KOH Lab
To rule out fungus
Papulosquamous diseases
Acrochordons Drug eruptions Lichen planus Pityriasis Rosea Psoriasis
Acrochordons
Skin tags
In areas of friction
Obese and diabetic
No need to remove but can
Drug eruptions
itchy rash
symmetric measles like eruption
Can also be a fixed eruption violaceous pruritic sharply demarcated patch
Remove offending agent
Systemic prednisone
antihistamines
ie mono + amox = rash
AIDs + Sulfa = reaction
Drug induced photosensitivity
Rash limited to sun exposed areas
Carbamazepine, amiodarone, doxy, furosemide, phenothiazines, sulfonamides
Sun exposed Distribution porphyria cutanea tarda
Associated with hep C
Blisters and erosions
Lichen planus
Flat topped shiny violaceous papules with surface lines
Wickham striae
Flexor aspects of wrists lumbar area, eyelids, shins scalp
Can e on mucosa or glans penis (may ulcerate)
Biopsy and immunofluorescence
Tx: Topical steroids
Systemic steroids
Pityriasis Rosea
Herald patch (largest) (forms first)
Dull pink, fawn colored plaques
Round
Christmas tree pattern
most likely viral, will resolve in 3-8 weeks
treat itching
Pityriasis Alba
White scaly macular
Worsens with sun
indistinct borders
Tx low potent steroids topical
Psoriasis
Well marginated
erythematous plaques
Silvery white scales
Removal will result in blood droplet (auspitz)
common on Joints, may have arthritis
Pruritic
Scratching leads to more lesions
Koebners phenomenon
2% of population
Chronic, recurrent
Topical glucocorticoids Coal tar Phototherapy Methotrexate acitretin Biologics - enbrel, remicade, humira, stelara
Psoriasis Variant
Psoriatic erythroderma
Lesions involving entire skin and is an exfoliative and serious condition
Psoriasis Variant
Guttate
drop like
acute eruption disseminated pattern
typically appearing after strep pharyngitis
Pustular (von zumbuschs syndrome)
an abrupt life threatening condition
characterized by widespread pustules that join to form lakes of pus
Fever, malaise, leukocytosis
Psoriasis
Severity
Mild <2% BSA
Moderate 3-10%
Severe >10%
Most patient have mild
25% have mod/severe
Cream vs ointment
Cream no as effective as ointment
Good for dry rashes
ointments penetrate deeper
Desquamation
Staph TSS & SSS
Erythema Multiforme
SJS
TEN
Staph toxic shock syndrome
s. aureus is normal flora
Super antigens: cause an exaggerated dysregulated hyperimmune cytokine response
Macular erythroderma
Usually not purulent, but can desquamate
Multi systemic infection
CDC Definition Fever over 102 Rash - Diffuse macular erythroderma Hypotension SBP <90 or drop of 15 Desquamation 3-7 days after onset (palms/soles)
Check labs - CBC, CMP,CPK, LDH, cultures Tx: Consult ID ICU admit Shock management ABX - Vanc, zosyn, cef, meropenem Clind usually best if known
“Staph” Scalded Skin Syndrome
Under 5
Treat Staph with penicillinase-resistant penicillin
Treat skin like burn
usually to burn unit
Can be drug induced
Erythema multiforme
Target lesion eruptions
usually on hands and feet
fever malaise weakness
Drug reactions (pen, sulfons)
HSV
Mycoplasma
other drugs: phenytoin, barbs, allopurinol
avoid trigger
if hsv use antivirals
Antihistamines and nsaids
Systemic steroids if severe
SJS
Desquamation
Generalized macular eruption which rapidly become necrotic
Positive nikolsky sign
mouth, lips, genitalia = 90%
SJS = 10% BSA
SJS/TEN = 10-30%
TEN >30%
Drugs that can cause
Sulfonamides, quinolones, cephs, tetra, barbs, carbamazepine, phenytoin, valproic acid, allopurinol, steroids
Dx: clinical or biopsy
Tx Burn unit if necrotic
Pain control, fluids, electrolytes
Steroids and ABX are controversial
Vesicular bullae
Bullous Pemphigoid
Pemphigus Vulgaris
Bullous Pemphigoid
vesicles and bulla
Generalized or local
some may be hemorrhagic
severe pruritis progresses to tenderness
Axilla, thighs, groin, mucous membranes
autoimmune
patients over 60
Biopsy, immunofluorescence to confirm
High dose prednisone
Pemphigus Vulgaris
vesicles or bulla that rupture and leave a crust
oral lesions appear first
skin lesions 6-12 months later
Nikolskys sign
weakness, malaise, pain, burning sensation
No pruritus
Auto immune
Middle aged adults
Biopsy, immunofluorescence to confirm
Prednisone then add immunosuppressant azathioprine or methotrexate
Acneiform lesions
Acne vulgaris
Rosacea
Folliculitis
Acne vulgaris
Open and closed comedones, inflammatory papules and pustules, nodules and cysts.
common, genetic component
considered an inflammatory disease
Labs
Tx: cleaning, antibacterials, clinda
Systemic isotretinoin (accutane)
oral contraceptives
isotretinoin (accutane) monitoring
Triglycerides q 4-8 wks, stop if >800 CBC LFTs Cat X prescribe 2 types of contraception doesnt affect fetus with men taking it
Rosacea
chronic inflammatory disease
Scattered small inflammatory papulopustules
cheeks, chin, forehead, nose
enlarged nose
face appears flushed
telangiectasia
Triggers- heat, sun, alcohol, spicy food
metronidazole
oral abx tetra
Folliculitis
papules and pustules at hair follicles
clean
topical - clinda, erythromycin, mupirocin
oral ABX if severe
Staph or strep
Barbae is from shaving
Hairs curl in
Verrucous lesions
Seborrheic keratosis
Actinic keratosis
Seborrheic keratosis
Verrucated, velvety
stuck on beige, brown or black plaque
Benign
No tx
Can be linked to gastric cancer
Actinic keratosis
scaly erythematous
sun exposed skin
can be painful
fair skinned people
is precancer and will progress to squamous cell carcinoma
Tx: cryosurg fluorocil Aldara cream electrodessication peels
Neoplasms
Basal cell carcinoma
Squamous cell carcinoma
Kaposi Sarcoma
Melanoma
Basal cell carcinoma
Most common skin cancer
Doesn’t usually metastasize (just destroys surrounding tissue)
Donut sign
Pearly papule with telangiectasias
sun damaged skin
Commonly bleed
Surgery, Mohs, cryo, electro
Basal cell carcinoma Types
Noduloulcerative (most common)
Superficial (mimics eczema)
Pigmented (may be mistaken for melanoma)
Morpheaform (plaquelike lesion with telangiectasia)
Keratotic (basosquamous carcinoma)
Squamous cell carcinoma
indurated and keratotic papules or nodules
ulcerating and or crusting
Second most common type of skin cancer
Rarely metastasize but can in immunocompromised
Surgery, Mohs, cryo, electro
Kaposi sarcoma
Oval purple papule with faint yellow green halo
Aids/HIV
3rd world
violaceous papules and nodules with edema
Violaceous nodules on the upper gingiva, covering the teeth
Human Herpesvirus type 8
Biopsy, Labs for HIV, Hep
CXR, stool occult
Tx no cure, palliative excision,
Systemic treatment interferon
Classic Kaposi sarcoma
middle-aged men of Southern and Eastern European origin
violaceous, or bluish-black macules and patches
Abdomen, lymph nodes, usually starts on legs,
Kaposi sarcoma
subtypes
Subtypes
Classic KS African Cutaneous KS African Lymphadenopathic KS AIDS-Associated KS Immunosuppression-Associated KS
African cutaneous Karposi sarcoma
Nodular, infiltrating, vascular masses occur on the extremities, mostly men between the ages of 20-50
Endemic in tropical Africa
African Lymphadenopathic Karposi sarcoma
Lymph node involvement
with or without skin lesions
can happen in children under 10
aggressive and often fatal within 2 years
AIDS-Associated Karposi Sarcoma
Cutaneous lesions
Red to purple macules rapidly progress
head, neck, trunk, mucous membranes
systemic involvement
HIV
Immunosuppression-Associated Karposi sarcoma
similar to classic
renal transplants
cancer patients
chemo treatments
Melanoma
ABCD Black brown pink colored macule, papule, nodule >6mm in diameter Asymmetric irregular border color variation
25% arise from exisiting moles
75% from normal skin
Early detection is key
Tumor markers, Lactate dehydrogenase and S100B marker
US for lymph nodes
Tx: excision
Iplilmumab Metastatic stage 3 melanoma
Types of melanoma
- Superficial Spreading Melanoma
- Lentigo Maligna Melanoma
- Acral Lentiginous
- Nodular
Superficial Spreading Melanoma
Most common type of malignant melanoma
demonstrates color variegation (black, blue, brown, pink, and white) and irregular borders.
Lentigo Maligna Melanoma
Characterized by a single, flat, freckle-like macule with an irregular border, usually on the face.
Very long radial growth phase before invasion
Lentigo maligna(hutchinson’s melanotic freckle) is precursor lesion Most common in elderly and in sun-exposed areas(esp face)
Often confused with a solar lentigo or a seborrheic keratosis
Acral Lentiginous Melanoma
Occurs on palms and soles, mucosal surfaces, in nail beds and mucocutaneous junctions
Similar to lentigo maligna melanoma but with more aggressive biologic behavior
Metastasize easily, are often mistaken for plantar warts or subungual hematomas
Nodular melanoma
Starts as a papule which becomes an elevated nodule with irregular borders and variegation in color.
Generally poor prognosis because of invasive growth from onset
Must be differentiated from a hemangioma, angiokeratoma, or pigmented basal cell carcinoma.
Rapidly growing
Melanoma staging
Sentinel lymph no biopsy
best baseline
Stage 1 & 2 5-10 year survival
Stage 3 38-78% survival
Stage 4 metastasis 6-9 month survival without treatment
Insects and parasites
Lice
Bedbugs
Scabies
Spiders
Lice
scalp, body, pubic hair
Can see under microscope
nits on hairshaft
Permethrin, malathion, ivermectin
Special combs petroleum jelly suffocates lice
reapply in 7-10 days to kill newly hatched lice
Bed bugs
Bugs feed at night on blood
bites do not transmit disease or infection
can survive up to a year without a host
Scabies
burrows, pruritic vesicles
web spaces of hands and feet, genitalia, axillary
Mineral oil on burrow, scrape, look at under microscope
5% permethrin
Spider bites
Black widow causes pain prick at bite
Brown recluse does not cause pain prick at bite
Black widow
Black widow cause neurologic overstimulation
Myalgia, spasms, rigidity
Tx with valium & calcium gluconate
Brown recluse
Lesion is sinking macule
slightly eroded at center
Infarction of the skin
rapid coagulation within vessels
Avoid debridement until completely evolved
Analgesics, clean
Wound decreases in 5 - 10 days
Hair and nails
Alopecia areata Androgenic alopecia Onychomycosis Paronychia Nail conditions recognition
Alopecia areata
Circular patchy shape
can be seen with SLE
Unknown cause
totalis = complete scalp hair loss
Universalis Total body, scalp ahir loss
Tx: intralesion cortisone, topical
Androgenic alopecia
progressive balding
normal male pattern baldness with varying patterns
Tx minoxidil
finasteride (propecia)
Hair transplant
Finestaride is androgen inhibitor
Minoxidil is vasodialator
Hirsutism
male pattern hair in females
cultural and ethnic
genetic connection
Treat cause
Onycomycosis
Thick discolored nails
T. Rubrum = most common cause
Candida effects finger nails more than toe nails
Lab = KOH, PAS stain
Tx: topical antifungal
Terbinafine (not with liver issues)
Itraconazole
Can be from trauma (long nails), psoriasis, candida pseudomonas infection, hyperthyroid
Paronychia
erythema, swelling, pain, proximal nail fold
Acute I&D
Oral ABX if needed
Topical steroid if needed
Splinter hemorrhages
Seen in subacute bacterial endocarditis
Can also be seen in trauma, vasculitis, leukemia, lupus
Beaus lines
Transverse grooves in nails
Seen in infection poor nutrition chemotherapy alcoholism stress
Koilonychia
Spoon nail
Irion deficient anemia
Terrys nails
“White nails”
Seen in Cirrhosis Heart failure diabetes mellitus Hyperthyroid malnutrition
2/3’s of nailbed is white
Mees bands
White transverse line
seen in arsenic
thallium
chemotherapy
hodgkins lymphoma
Clubbing
Smoking
Bronchogenic carcinoma
Seen in bronchiectasis empyema pulmonary fibrosis Bronchogenic carcinoma Cystic fibrosis
Viral diseases
Condyloma Acuminatum Condyloma Lata Exanthems Herpes Simplex Herpetic Whitlow Molluscum Contagiosum Verrucae Varicella Zoster Echovirus 9
Condyloma Acuminatum
Soft skin colored fleshy warts
Ano-genital, oral mucosa
Biopsy with immunofluorescence
No cure for HPV
Trichloroacetic acid or topical podophyllin (hurts)
miquimod cream, podofilox
Cyrosurg, surg, electro, laser, cautery etc
Condylomata Lata
Verrucous intertriginous plaques seen in secondary syphillis
Exanthems
Rash
Generalized macular and or papular eruption associated with systemic infection
usually not itchy
Tx symptoms
Measles (Rubeola)
1st disease
Rash starts on face and spreads down the trunk
4D’S 3 C’s
4 days
cough, Coryza, conjunctivitis
Koplick spots (“O”)
Highly contagious
Dx: igm antibodies
Tx supportive
Scarlet fever
2nd disease
non itchy rash on trunk and extremities
Erythema marignatum
strawberry tongue
Cause= post strep pharyngitis
untreated can lead to rheumatic heart disease
Tx:ABX
German measles (Rubella)
3rd disease
milder than measles similar presentation
rash on face then to body
Supportive treatment
coryza type symptoms
supportive treatment
Erythema Infectiosum
5th disease
Slapped cheek
parvovirus B19
Rash AFTER low grade fever goes away
can cause hepatitis
self limiting
Papular purpuric glove and sock syndrome
Can come from a variety of viruses
coxsackie, parvo b19, CMV EBV, etc
looks like RMSF
can cause fetalis hydrops
Dx viral serology, IGM, IGG, PCR
Tx symptoms
Looks like hand foot mouth but with no mouth involvement
No wrist involvement (wrist involved with RMSF)
Exanthema Subitum (Roseola
6th disease
HHV6 and HHV7
<3yrs
Rash after super high fever 104
watch for seizures
Hand foot and mouth
Coxsackie virus
HSV 1
Oral
HSV 2
Genital
HSV
Labs direct microscopy Tzank smear (gold standard)
Culture must unroof lesion
PCR (not during active phase)
tx: Antivirals acyclovir
if eye keratitis - trifluiridine
Herpetic whitlow
Cluster of lesion on digits
Very painful and pruritic
dental workers
thumb sucking
Dx viral culture or PCR
tx: Antivirals acyclovir (must be oral)
I&D makes it worse
Molluscum contagiosum
Discrete flesh colored
waxy, pearly, dome shaped , umbilicated 2-6mm papules
pox virus
biopsy immunofluorescence
self limiting
Verrucae
Wart
flat with cauliflower surface
biopsy to rule out cancer
Tx salycylic acid is best
cryo, surg, elctro
