Derm 1 Flashcards
What is the epidermis?
stratum corneum is outermost layer
What is the dermis?
blood vessels, nerves, connective fibers
also has hair follicles, sebaceous glands, sweat glands and nails
What’s included in a skin exam?
all skin surfaces, mucosal membranes, hair, nails
What are some primary lesions?
macule, patch, papules, nodules, plaques, vesicles, bulla, pustules, wheals
Describe a macule
circumscribed area of change in skin color < 1cm without elevation or depression (flat)
Describe a patch
macule that’s larger than 1 cm
Describe a papule
circumscribed, solid superficial elevations <1 cm
Describe a nodules
papule > 1 cm, palpable, in dermis or subcutaneous tissue (may be above or below skin surface)
Describe a plaque
usually well-defined elevated confluence of papules >1 cm
Describe a vesicle
circumscribed epidermal elevations < 0.5 cm; contain serous fluid
Describe a bulla
large vesicle > 0.5 cm containing serous fluid
Describe a pustule
circumscribed, small elevations filled with purulent exudate, <1 cm
Describe a wheal
plateau-like edematous elevations, papules or plaques, pink or red; transient
Describe a scale
dry or greasy flakes of stratum corneum
Describe a crust
(scabs) – dried serum, blood, or pus with debris on skin surface
Describe excoriation
(scratch marks) – shallow, hemorrhagic linear excavations
Describe erosions
loss of all or portions of epidermis from physical abrasions, vesicles, or bullae
-think ulcer
Describe ulcer
rounded or irregular shaped excavations into the dermis or deeper
Describe fissure
(cracks)- linear deep skin split through epidermis or into dermis
Describe lichenification
thickened skin with accentuated skin markings
Describe atrophy
decresaed skin thickness
Dermatoses? Includes
inflammatory rash of the skin
Atopic dermatitis- type of exzema
Seborrheic Dermatitis
Dyshidrotic Eczema
Stasis Dermatitis
Lichen Simplex Chronicus
What is atopic dermatitis?
Chronic inflammatory skin disease characterized by pruritus; chronic exacerbations and remissions
Disruption of the skin surface (xerosis= dry skin);
The “itch that rashes”
What contributes to atopic dermatitis? What is the atopic triad?
genetics/family history;
“ATOPIC TRIAD”- eczema, asthma, allergic rhinitis
Atopic dermatitis is usually worse in the…
winter
“itch-scratch cycle”
Clinical findings in atopic dermatitis?
pruritis, chronic dry skin with scaly erythematous plaques and papules; sometimes vesicles, lichenification, crusting, weeping
Classic distributions of atopic dermatitis?
Infants/toddlers: cheeks, forehead, scalp, extensor surfaces
Older kids/adolescents: flexural surfaces; neck, elbows, wrists, ankles, behind knees
Adults: hands, wrists, ankles, feet, face; lichenification
Tx for atopic dermatitis?
avoid irritants
repair barrier of the skin- emollients “soak & seal”
corticosteroids- topical/oral
oral antihistamines
systemic abx
topical calcineurin inhibitors
What is seborrheic dermatitis?
aka dandruff
Chronic inflammatory dermatitis accompanied by overproduction of sebum and associated with yeast (Malassezia furfur, P. ovale); can be pruritic
Clinical findings of seborrheic dermatitis?
erythema with yellow-orange greasy scales of scalp, face (eyelids, eyebrows, nasolabial folds), ears, perineum
“Cradle Cap” in newborns
What can exacerbate seborrheic dermatitis?
winter/change in weather, stress
Tx for seborrheic dermatitis?
selenium sulfide shampoo
2% ketoconazole shampoo/cream
low potency topical steroids
What is dyshidrotic eczema?
Vesicular dermatitis on palms and soles
Sudden onset, usually pruritic, recurrent or chronic
Clinical findings of dyshidrotic eczema?
confluent, symmetric tapioca-like vesicles* on fingers, finger webs, palms, soles; secondary changes-crusts, scaling, fissures, lichenification
Treatment for dyshidrotic eczema?
r/o staph infx, dermatophytosis
- topical steroids
- emollient care, gen skin care
- oral abx for secondary infx
What is stasis dermatitis?
Chronic dermatitis from venous insufficiency
Clinical features of stasis dermatitis?
hyperpigmented plaques on lower legs and ankles; erythematous scales, edema; can see painful ulcers typically on medial ankles
Predisposing factors for stasis dermatitis?
varicose veins, thrombophlebitis, older age, prolonged standing, pregnancy, female
How is stasis dermatitis Dx? Tx?
clinical, US
- topical steroids
- abx for secondary infx
- Tx ulcerations
- reduce edema-compression wraps, tx veins
What is lichen simplex chronicus?
Localized, lichenification from repetitive rubbing/scratching
Epidemiology of lichen simplex chronicus?
women, >20 y/o, atopics
Clinical findings in lichen simplex chronicus?
well-defined plaques made by confluent papules, thickened skin, dull red and can progress to brown or black
can be right next to normal skin
Tx for lichen simplex chronicus?
Stopping scratching/rubbing is the key
Topical corticosteroids to stop itching +/- under occlusion at night
Describe immediate drug eruptions
Occur less than an hour after taking the drug
Urticaria, angioedema, anaphylaxis
Describe delayed drug reaction
Typically occur after 6 hours but sometimes weeks or months after taking the drug!
- Exanthematous eruptions – usually 7-10 days after drug
- Fixed drug eruption
- systemic rxn
- vasculitis
What is the MC type of drug eruption? Describe this
exanthematous
Symmetric erythematous macules and papules on trunk, then spreading to extremities in symmetric pattern
Morbilliform = measles-like
Common drugs that cause drug eruptions?
sulfonamides, ampicillin, amoxicillin, NSAIDS, barbituates, nitrofurantin, isoniazid, gold salts
Tx for drug eruptions?
stop offending agent
oral antihistamines
topical steroids +/- oral
What is Lichen Planus? What are the 4 Ps?
Chronic inflammatory disorder, middle aged adults
“Four P’s” – Pruritic, Purple (violaceous), Polygonal, Papules/plaques
volar wrists, shins/ankles, mm, genitalia, scalp/nails
Koebner’s phenomenon
Wickham’s striae
What is koebner’s phenomenon?
rubbing/scratching (physical trauma) stimulates proliferative process
Causes of lichen planus?
idiopathic, assoc. with Hep C, drugs
Treatment for lichen planus?
topical, intralesional or oral steroids
phototherapy
What is pityriasis rosea?
Acute exanthematous eruption characterized by a primary plaque usually on the trunk that develops into a secondary generalized scaling eruption 1-2 weeks later
Clinical findings of pityriasis rosea?
Herald patch – oval, slightly raised plaque 2-5 cm, salmon red with marginal collarette scale
Christmas tree distribution: fine scaled, pink, oval papules and plaques distributed in the lines of cleavage
Treatment for pityriasis rosea?
Symptomatic – oral antihistamines, +/- topical glucocorticosteroids for pruritis
Check RPR to r/o syphillis (inflammatory PR)
What is psoriasis vulgaris?
Common (1.5-2% population), chronic, recurrent, inflammatory disease
Hereditary component- HLA B13, B17, B27; peaks of onset: 20-30, and 50-60 years of age
Clinical presentation of psoriasis vulgaris?
varies from localized to generalized, pustular, erythrodermic
Well-demarcated erythematous plaques with silvery scale typically on extensor surfaces, scalp, sacrum
Auspitz’s sign
Koebner’s phenomenon
What is Auspit’z sign?
removal of scale results in blood droplets
What can trigger psoriasis?
physical trauma
infections (streptococcal –guttate)
drugs (b-blockers, lithium)
stress
smoking
alcohol
What can be assoc. with psoriasis?
nail changes: nail pits, onycholysis
psoriatic arthritis (PSA)
Treatment for psoriasis vulgaris?
depends on severity
mild-mod: topical steroids, emollients, Vit D analogues, coal tar, UA therapy, retinoids
mod-severe: systemic therapy
- Methotrexate, cyclosporin, oral retinoids
- biologics (i.e. infliximab)
What is erythema multiforme?
bullous disease
Reactive, inflammatory skin lesions in a symmetric distribution, predominantly on extremities caused by drugs (sulfa, phenytoin, PCN), viral syndromes (HSV), or idiopathic (50%)
Can be recurrent
Clinical findings of erythema multiforme?
Target or iris lesions: dull red macules and papules evolve over several days, can become confluent, vesicles/bullae may develop in center of lesion; pruritic or painful
Severe EM- constitutional symptoms such as fever, weakness, malaise
Treatment for erythema multiforme?
tx cause, discontinue drug
sxs: oral antihistamine, topical steroids
recurrent: oral antiviral in suppressive doses
Spectrum for erythema multiforme…
erythema multiforme >
SJS > TEN
What is stevens-johnson syndrome?
Severe mucocutaneous reaction often triggered by a medication but can be idiopathic
Extensive necrosis and sloughing of epidermis (<10%) *sheet like sloughing
Tenderness and erythema of skin and mucosa
potentially life threatening
Prodrome for stevens-johnson syndrome?
fever, flu-like symptoms, conjunctival itching
Common causes of SJS?
NSAIDS, sulfonamides, anticonvulsants
Clinical course in SJS?
generalized lesions initially with target-like appearance > confluent bright red > rapid progression into painful bullae and erosions
When might you see hemorrhagic crusts on lips?
SJS
Treatment for SJS?
discontinue offending agent
-supportive care: IV fluids, electrolytes, pain control
systemic steroids
+/-admit/burn unit
consult ophthalmology
What is Toxic Epidermal Necrolysis?
severe form of SJS
> 30% epidermal loss
morality rate 30%
comps of TEN?
fluid and electrolyte loss, septicemia, acute renal failure
Clinical presentation for TEN?
same as SJS; high fever, prodrome, conjunctivitis, stomatitis
Nikolsky’s sign – pressure near bullae causes more sloughing
Treatment for TEN?
burn center admission – fluid and electrolyte replacement, skin grafting
What is urticaria?
bullous disease
Superficial, well-defined pruritic wheals with central pallor; confluent, transient, common
Acute or chronic
Angioedema – involves dermis and SQ tissue
Causes for urticaria?
allergic, infectious, autoimmune, physical (pressure, heat/cold, vibration)
Tx for urticaria?
Allergen avoidance
Antihistamines
Systemic steroids
Epinephrine for angioedema/anaphylaxis
What is bullous pemphigoid?
bullous disease
Chronic, autoimmune bullous disorder, >60 year old
Subepithelial blisters and immunoglobulin deposits
Clinical findings of bullous pemphigoid?
erythematous, papular, or urticarial lesions -> tense, large, oval-round bullae that contain serous or hemorrhagic fluid
Lower legs, axillae, groin, thighs, abdomen, forearms, mouth
Pruritis, no constitutional symptoms
How can we diagnosis bullous pemphigoid?
punch biopsy with immunofluorescence
-shows immunoglobulin deposits
Tx for bullous pemphigoid?
topical, systemic steroids
Describe a 1st degree burn. Tx?
(sunburn)
Red, dry, painful; often sloughs next day
Treatment: symptom control (acetaminophen, cool compresses, emollients)
Describe 2nd deg burn. Tx?
Superficial: red, wet, painful
Deep: pale, anesthetic; scarring
Treatment: Burn center +/- based on criteria
prevent secondary infx
pain control
What is the burn center admission criteria?
> 10% TBSA younger than 10, older than 50 yo
20% TBSA in any other age group
Face, genitalia, perineum, hands, feet, major joints
Chemical burns, inhalation injury, electrical burns, pre-existing medical conditions
Describe 3rd deg burn. Tx?
Loss of tissue, full thickness of skin, some of SQ tissue; scarring
Treatment: Skin grafting
+/- burn center
Describe 4th deg burn. Tx?
Destruction of the entire thickness of skin and subcutaneous fat with any underlying tendons
Treatment: Burn unit admission, skin grafting
Epidemiology of acne vulgaris?
common
affects 90% of teens
What is acne vulgaris?
Chronic inflammatory disease of pilo-sebaceous follicles; keratin plug, increased sebum production, inflammation, bacterial colonization
What contributes to acne?
stress, hormone changes, occlusion of skin, drugs (lithium, steroids, OCPs)
Clinical findings of acne vulgaris?
comedones, papules, pustules, nodules and cysts on face, chest, back, scalp
Tx of acne vulgaris?
varies
Topical retinoids (tretinoin)
Benzoyl Peroxide (anti-bacterial)
Topical abx (clinda)
Oral abx (minocycline, doxy)
Isotretinoin (Accutane), OCPs,
What is rosacea?
Chronic erythema of centrofacial areas characterized by telangiectasias, flushing, erythematous papules and pustules
Common, affects fair skinned adults
Rhinophyma (enlarged bulbous nose) – men; ocular rosacea
What can trigger rosacea?
stress, alcohol, heat (vasodilators)
Treatment for rosacea?
avoid triggers, sun protection
Metronidazole gel, azelaic acid, sodium sulfacetamide/sulfur
Oral abx (doxy, tetracycline)
Intense pulsed light/broad band light
Laser surgery for telangiectasias/rhinophyma
What mite is assoc. with rosacea?
demodex, lives in hair follicles
What is hidradenitis suppurative?
Chronic inflammatory disease of the apocrine glands characterized by recurrent abscess formation, rupture, suppuration; leads to sinus tract formation and scarring
Presents after puberty
Clinical features of hidranitis suppurativa?
Very tender, erythematous, inflammatory nodule/abscess; may drain purulent material; double comedones*
Distribution: Females – axillae, breasts; Men- anogenital, groin
predisposing factors for hidradenitis suppurativa?
obesity, diabetes, genetic predisposition to acne
Tx for hidraenitis suppurativa?
difficult
- abx (tetracycline, minocycline)
- intralesional steroids
- isotretinoin
- surgical
