DERM 1 Step 2 Flashcards by Stephanie Escobar

3 topical treatment options for Tinea (Pitiryasis) Versicolor

a superficial nondermatophyte fungal skin infection caused by Malassezia species and characterized by salmon-colored, hyper- or hypopigmented macules.
Diagnosis is confirmed with potassium hydroxide preparation of skin scrapings

Topical Anti-Fungals:
⬩ketoconazole
⬩selenium sulfide
⬩terbinafine

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Typically occurs in infants and young children.
A prodrome of fever, irritability, and skin tenderness is followed by an acute generalized erythema, superficial flaccid blisters (+ Nikolsky sign), and skin shedding with light pressure.

Staphylococcal scalded skin syndrome

(s/t exfoliative toxin–producing strains of Staph A)

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Staphylococcal scalded skin syndrome Treatment options (2)

Nafcillin
Vancomycin

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Treatment for Tinea Corporis (Ringworm)
1st line & 2nd line

First-line/localized clotrimazole, terbinafine
(topical antifungals)

Second-line/extensive terbinafine, griseofulvin
(oral antifungals)

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Causes an intensely pruritic rash (Worse at Night) that classically affects the hands (palms, web spaces) and flexor surfaces of the wrist.
Patients develop small, crusted, erythematous papules with excoriations, vesicles, pustules, or wheals, & linear burrows are pathognomonic if visible.
It is highly contagious and a close contact with a similar rash (person-to-person transmission) supports the diagnosis.

Scabies

(within days to weeks)

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Scabies Treatment includes (3)

Topical 5% permethrin OR oral ivermectin
Treat household members & close personal contacts
Environmental measures (launder clothes/sheets)

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Tinea Pedis Treatment

Topical antifungal therapy Miconazole or Terbinafine, Tolnaftate cream
(nystatin is not effective)
Keep feet dry & dispose of old footwear

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Topical ___ are first-line treatment for noninflammatory comedonal acne .

They inhibit comedogenesis by normalizing keratinization, decreasing epithelial cohesiveness, and increasing epithelial turnover.

Retinoids

(if inflammatory add benzoyl peroxide)

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Treatment for Tinea Cruris (Jock Itch)

Spares the scrotum but affects inguinal region. Tineas can be subacute or chronic in presentation.

Topical antifungals clotrimazole, tolnaftate

If severe oral antifungals (fluconazole) can be used

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Recurrent tinea cruris is common and suggests reexposure to an external source or ____ from a concurrent dermatophyte infection elsewhere on the body (eg, tinea pedis, tinea corporis, onychomycosis).

auto-infection

Give pts thorough skin inspection & treatment to prevent re-infection.

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Usually occur in the setting of chronic lower-extremity edema and stasis dermatitis.

Venous stasis ulcers

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These ulcers are most common at the pretibial area or above the medial malleolus .

Venous stasis ulcers

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What is the first-line treatment of Vitiligo when desired?

Topical corticosteroids

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Infection with ___ causes leprosy, characterized by areas of hypopigmentation with anesthesia.

Mycobacterium leprae

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characterized by photosensitivity causing painless blisters that heal with scarring, skin fragility on the dorsal surfaces of the hands, facial hypertrichosis (excessive hair growth), and/or hyperpigmentation.

Porphyria cutanea tarda

TX: Phlebotomy, Hydroxychloroquine, treatment of HCV (if present)

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Porphyria cutanea tarda can be triggered by what 4-5 factors?

Estrogen Use
Alcohol/Smoking Use
Hep C infection
HIV

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What are 3 treatment options for Vitiligo unresponsive to 1st line treatment?

oral corticosteroids
topical calcineurin inhibitors (Tacrolimus ointment)
PUVA (Psoralen + Ultraviolet A light)

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Inflammatory acne is treated with topical retinoids + ____.

If inadequate, the addition of what medication is recommended?

benzoyl peroxide

Topical antibiotic, clindamycin/ erythromycin or
Oral antibiotics, doxycycline (if spread to back)

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Nodular cystic acne if moderate is treated with
topical retinoids + benzoyl peroxide + Topical → Oral antibiotic

However, if severe and persistent despite escalation treat with what medication?

Oral retinoid, Isotretinoin

(If Female, use 2 form contraceptives before starting)

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Diabetic ulcers that are either one:
⬩Deep
⬩long-standing (> 1 week)
⬩large (≥2 cm)
or
associated with adjacent soft tissue infection
require ____ to assess for underlying osteomyelitis, even when no signs or symptoms of soft tissue infection are present.

foot imaging (x-ray, MRI)

Diabetic ulcers with elevated ESR or CRP also require imaging.
(presents within days to weeks)

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Most common diaper rash in infants?

Irritant contact diaper dermatitis

(2nd is Candida diaper dermatitis)

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Which Diaper Rash presents with Beefy-red, confluent plaques, Involves skinfolds & has Satellite lesions?

Candida Diaper Dermatitis

Tx: Antifungal Cream, nystatin

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Which Diaper Rash presents with Erythematous papules, plaques
spares skinfolds?

Irritant contact diaper dermatitis

Tx: Topical barrier creams (petrolatum, zinc oxide)

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Which Diaper Rash presents with Bright, sharply demarcated erythema of strictly the perianal/perineal area in infants and school children ?

Perianal streptococcal dermatitis

Tx: Oral Beta-Lactam antibiotics (amoxicillin, Penicillin)

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Treatment for Perianal streptococcal dermatitis?

Oral Beta-Lactam antibiotics **Amoxicillin, Penicillin**

Treatment for **Irritant Contact** diaper dermatitis?

Topical **barrier** creams **petrolatum, zinc oxide**

Treatment for **Candida** diaper Dermatitis?

Antifungal Cream **Nystatin**

A skin infection of the **deep dermis** and subcutaneous fat with a slowly spreading rash that is tender, warm, and erythematous with **flat, indistinct** borders.

Cellulitis Streptococcus Pyogenes → nonpurulent Staphylococcus Aureus (MRSA/MSSA) → purulent

An **acute** skin infection limited to the **epidermis** and **superficial dermis** which results in a characteristic rapidly spreading rash that is intensely erythematous with a **raised** and **sharply demarcated** border. It has a rapid onset, spread and fever early in its course.

Erysipelas

Topical ___ can treat herpes simplex virus, which causes grouped, erythematous vesicles that evolve into painful ulcerations.

acyclovir

Molluscum contagiosum is a **subacute** benign Pox Virus condition characterized by small papules with central umbilication. First-line therapy in adults includes what?

cryotherapy with liquid nitrogen ⎯ topical cantharidin curretage

Herpes zoster (shingles) is an **acute** painful reactivation of VZV that causes a vesicular rash in a dermatomal distribution. Risk factors include elderly age & immunocompromise (s/t disease or medication). What medication may be used to decrease the duration of disease and the incidence of post-herpetic neuralgia?

Acyclovir (famciclovir, valacyclovir)

Topical ____ is used to treat skin conditions caused by rapid cell division, such as **actinic keratoses** and **superficial basal cell carcinomas**.

5-fluorouracil

Guttate psoriasis presents with widely scattered, erythematous, scaly papules and plaques. Presents **after a streptococcal infection** or in pts with **rheumatoid arthritis** especially if on **TNF-α inhibitors**. Treatment options include what? (low yield)

topical glucocorticoids (Betamethasone, Clobetasol) vitamin D analogs (calcipotriene) ultraviolet phototherapy

What is a topical antibiotic used to treat superficial skin infections such as impetigo, which presents with small vesicles with a yellow exudate and honey-colored crust?

Mupirocin

Presents with numerous red, annular plaques, predominantly in sun-exposed areas of the upper body. Itching is uncommon.

Subacute cutaneous lupus erythematosus

Presents **acutely** in a child a couple of days after a wound/burn/eczema with enlarging, yellow fluid-filled, flaccid bullae that leave a collarette of scale after rupture.

Bullous Impetigo ⎯ Bullous impetigo is **only** caused by Staph aureus vs Non-Bullous impetigo can be caused by staph **or** strept.

Presents with scaly plaques typically symmetrical on the extensor surfaces (**elbows and knees**) ± Itching More common at age >30

Psoriasis

Punched-out ulcer with well-defined borders Usually involves the foot, particularly pressure points like **lateral** malleolus & tips of the toes. s/t insufficient blood supply that leads to tissue necrosis.

Arterial Ulcer Tx: treat underlying cause (Atherosclerosis, smoking)

Possible presentations of this ulcer include: ⬩Shallow ulcer with irregular borders ⬩Edema, Pruritus, varicose veins ⬩Yellow-brown or red-brown skin pigmentation of the medial ankle or lower extremity ⬩Atrophie blanche: white, coin- to palm-sized atrophic plaques

Venous Ulcer Tx: compression stockings

__ ulcer → Shallow ulcer with irregular borders __ ulcer → Punched-out ulcer with well-defined borders

Venous (irregular) Arterial (defined)

__ ulcer → Lateral malleolus __ ulcer → Medial malleolus

Arterial (Lateral) Venous (Medial)

Diabetic foot ulcers result from chronic unnoticed trauma due to **peripheral neuropathy** and **poor wound healing** due to what?

microvascular insufficiency (low blood flow)

Begins with small papule or pustule at site of injury (if any) then rapidly progresses to a painful ulcer with purulent base & violaceous border Association with inflammatory bowel disease, rheumatoid (inflammatory) arthritis. Commonly seen in middle aged, women.

Pyoderma gangrenosum

Pyoderma gangrenosum (commonly seen in patients with IBD or inflammatory disorders) requires exclusion of infection and biopsy for diagnosis. What is the treatment?

**Glucocorticoids** (Local or systemic)

which skin tumor presents with: ⬩Skin-colored, pearly nodule ± rolled borders ⬩Telangiectatic vessels ⬩± Central ulceration, local invasion

Basal Cell Carcinoma

Suspected BCC is confirmed with what procedure?

Shave, punch, or excisional biopsy

1st line treatments for Basal Cell Carcinoma include: ⬩Surgical excision with __-mm margins For **face** or **high-risk tumors** ⬩____ surgery

4mm margins Mohs micrographic surgery (Face or High Risk Tumor)

2nd line treatment for Basal Cell Carcinoma includes

Topical **fluorouracil** topical **imiquimod** curettage & electrodessication (low-risk tumors only)

How is suspected Melanoma confirmed?

**Full-thickness excisional** biopsy (1-3-mm margins of normal tissue) Partial excision (deep shave biopsy, central or peripheral punch biopsy) only considered for a very large lesions or lesions in locations where complete excision may be problematic (**ear, face**)

List the Clinical features of melanoma (ABCDE) How many criteria need to be met to warrant an excisional biopsy?

1+ = Biopsy ⬩Asymmetry: the 2 halves are not identical ⬩Borders: irregularities, uneven edges ⬩Color: pigment fades off, variegated mixes of brown, black & red ⬩Diameter: ≥6 mm ⬩Evolving: lesion changing in size, shape, or color; new lesion

a slow-growing, ulcerated, pearly nodule with a rolled border on sun-exposed skin, typical features of what?

basal cell carcinoma (BCC)

Alternate presentations of BCC include: Chronic ulcer that ___, ___, or ___. An irritated area with a red, ___ ___ (superficial BCC). Pearly or translucent nodule that is pink, red, white, or skin toned (nodular BCC). Pale, scarlike area with ____ borders

Bleeds, Crusts, Oozes Red, Flat patch poorly defined borders

Is characterized by chronic, scaly papules or plaques with **sandpaper-like, rough** texture on sun-exposed areas (face, scalp). Lesions are a **precursors to squamous cell carcinoma**

Actinic keratosis

Elderly pt presents with chronic erythematous, scaly papules; rough plaques >1cm on the face and scalp. What is the Diagnosis and NBSIM?

Actinic keratosis **Biopsy** is indicated to rule out SCC if high-risk features: ⬩>1 cm (big) ⬩induration/ulceration (bleeding) ⬩rapidly growing ⬩therapeutic failure

Treatment of actinic keratosis (2)

Isolated lesions **cryotherapy** ⎯ Diffuse lesions Topical **fluorouracil** Topical imiquimod

SCC lesions often become **keratinized** (with a thickened, rough surface) or **ulcerate** with crusting and bleeding. SCC can cause regional neurologic symptoms like (3)

numbness, paresthesias, burning pain

A benign epidermal tumor that presents in middle-aged or elderly individuals as a tan or brown, round lesion with a well-demarcated border and "stuck-on" appearance.

Seborrheic keratosis (treatment is usually not required)

Strawberry (infantile) hemangiomas are benign capillary tumors of childhood. They occur during the first weeks of life, initially grow rapidly, and regress spontaneously. They look like bright red (or purple), sharply demarcated, blanching nodule or plaque. Complicated lesions may require treatment with what?

Propanolol (Beta Blocker Vasoconstrictor) complicated → disfiguring, ulcerating, disabling (strabismus from eyelid hemangioma), or life-threatening (tracheal lesions).

A young patient with multiple sexual partners has mild systemic symptoms and a painful, focal area of grouped vesicles on an erythematous base in their hand rash suggests what diagnosis? .

herpetic whitlow (In adults, infections typically occur after hand contact with an active genital herpes lesion, HSV-2)

β-hemolytic streptococci and Staphylococcus aureus are common causes of what two skin infections?

erysipelas cellulitis

Pseudomonas may cause ____ after hot tub exposure or ____ after a nail puncture.

folliculitis cellulitis

What is a tick-borne rickettsial illness that usually manifests with nonspecific signs (fever, headache, malaise, myalgias) and a diffuse maculopapular rash that begins on the wrists and ankles → spreads to the trunk, palms, and soles → that then turns petechial?

Rocky Mountain spotted fever (RMSF) Cx: Rapid clinical deterioration with shock and multiorgan dysfunction (DIC) Tx: Doxycycline *Chloramphenicol (if, ≤26 weeks gestation)

what causes a diffuse, **symmetric** macular/papular rash that includes the **palms and soles** ?

Secondary syphilis

Trichophyton rubrum is a dermatophyte that causes what?

Tineas (ringworm, tinea pedis, tinea manuum)

patient has an asymptomatic, scaly, well-demarcated, erythematous plaque that is slowly enlarging. The lesion is concerning for what diagnosis?

squamous cell carcinoma (SCC) in situ (Bowen disease) *Unlike plaque psoriasis & chronic atopic dermatitis, which look like SCC. SCC is typically asymptomatic, not pruritic.

Timely diagnosis of SCC in situ with ____ is important because it can become invasive and metastasize.

a biopsy (shave, punch, excisional)

Treatment of Invasive SCC (2)?

Excision with 4- to 6-mm margins Mohs micrographic surgery

Treatment of SCC in Situ (Bowen's)? (4)

Excision with 4- to 6-mm margins Topical 5-FU, imiquimod Cryotherapy Curettage & electrodesiccation

Typically presents as a pruritic, annular plaque with central clearing.

tinea corporis

What are used to treat severe, chronic atopic dermatitis, which typically manifests as pruritic, lichenified plaques?

Topical high-potency corticosteroids

Topical vitamin D analogues (calcipotriene) are used to treat ____, which presents with pruritic, erythematous plaques with silvery scales.

plaque psoriasis

A nonhealing ulcer arising from the site of a **chronic wound, scar, or skin graft** is concerning for what diagnosis? NBSIM?

Squamous cell carcinoma Biopsy

A nonhealing ulcer arising from the site of a **chronic wound, scar, or skin graft** is concerning for what diagnosis? NBSIM?

Squamous cell carcinoma Biopsy

what is the most common malignancy of the **lower lip** & can affect any cutaneous surface?

Cutaneous squamous cell carcinoma (cSCC) Well-differentiated cSCC→ firm, **scaly** papules, plaques, or nodules ± ulcerations. Poorly differentiated cSCC→ **beefy red** papules or nodules ± bleeding/ulceration.

Secondary _____ is a malignant endothelial tumor that develops **years after breast cancer therapy** Lesions are red, bruise-like plaques with purple papules and nodules. NBSIM?

**Angiosarcoma** (Get Biopsy) Risk factors: radiation & chronic lymphedema

Presents as a rapidly growing nodule with ulceration and a **central keratin plug**. Looks like a volcano with a hard keratinized top. Diagnosis and NBSIM?

keratoacanthoma Biopsy (potential precursor of SCC)

Topical **clotrimazole** used to treat what?

Tinea Corporis (ringworm) Tunea Cruris (jock itch)

Topical **clobetasol** (high-potency topical corticosteroid) Is used to treat what (3-4)?

Bullous Pemphigoid Psoriasis eczema Lichen Planus (Betamethasone, too)

Typically presents with thickened plaques with a prominent white or silver scale. It occurs predominantly in areas exposed to pressure or friction (eg, knees, elbows).

Psoriasis

Causes an erythematous, vesiculopapular rash in warm, moist areas (skinfolds, buttocks). It rarely affects the scalp.

Cutaneous candidiasis

Due to repeated plucking of hair, leading to an irregular pattern of broken **hair strands of varying length** .

Trichotillomania

**Erythema toxicum neonatorum** is a benign neonatal rash that presents within the first ___ of life as erythematous macules, papules, or pustules on the trunk and proximal extremities, **sparing the palms and soles** Patients are otherwise asymptomatic. Treatment?

3 days No treatment is required (self-resolves within a week)

Small, pruritic, erythematous papules with a central **hemorrhagic punctum**, in a linear pattern on **exposed** areas (neck, arms) are suggestive of what?

bedbug bites (Scabies causes intensely pruritic, erythematous papules, which may have nearby burrows (fine, serpiginous lines) Affected areas are typically intertriginous ( **finger webs, wrist, axillae, buttocks** )

Burn patient develops fever, reduced urine output, confusion and progressively worsening in thickness. A **change in burn wound appearance** (progressively worsening , purulence, etc) or the **loss of skin graft** is often the first sign of what?

burn wound infection Severe burns cx: wound infections & sepsis. Gram + in first 3 days. Gram – & Fungi 5 days out. Risks: large burns (>20% BSA)

A rash usually associated with fever and other symptoms (eg, cough, diarrhea) of a viral illness. It presents with nonpruritic, erythematous macules and papules that last for days.

Viral exanthem

Acute ___ presents with intensely pruritic, well-circumscribed erythematous soft plaques (wheals). Individual lesions resolve within 24 hours, but additional lesions may occur episodically. Angioedema sometimes accompanies this rash.

urticaria

Drug induced ACNE can be caused by Anti- Convulsants Anti- Psychotics and what other 3 drugs?

Prednisone (Glucocorticoids) Isoniazid (Tuberculosis) Immuno-modulators (auto-immune, inflammatory)

**Acanthosis nigricans** is characterized by symmetrical, hyperpigmented, velvety plaques in the axilla, groin, and neck. It is associated with **insulin resistance** states (T2DM, PCOS) in younger patients and ____ in older individuals.

gastrointestinal malignancy

**Drug-induced** type 1 hypersensitivity reactions have immediate onset & mediated by IgE and mast cells/basophils. Drug allergy manifestations that are **mild** (urticaria & pruritus) without evidence of anaphylaxis are usually treated with what?

antihistamine (discontinue the offending drug)