DERM Flashcards
MOLLUSCUM CONTAGIOUSUM
• Treat with _____ or other treatment modalities (see for skin warts)
liquid nitrogen
IMPETIGO
• Treatment is with topical antibiotics (_____, mupirocin)
• Systemic antibiotics are generally only required in widespread disease, in immunocompromised
o _____ 250 mg PO QID
• Patients should wash their hands frequently, not touch the lesions, and avoid sharing towels etc to help prevent spread!
bacitracin
Cephalexin
PSORIASIS
• Drugs that flare psoriasis: B-blockers, anti-malarials, statins, lithium
• Never use systemic steroids to treat flares
• Limited Dz TMT
o High potency to ultra-high potency (_____ or Ultravate)
o 2-3 weeks bid, then pulse then 3-4 Xs on weekends
o Also, calcipotriene ointment 0.005% (_____ analog) bid until lesion clears, then qd long term
Not on groin or face
• ADJUNCTS:
o Tar preps and _____
o Can use occlusion alone (clears lesions in 30-40% of pts)
o Can use occlusive hydrocolloid dressings: thin DuoDerm: leave on undisturbed for 7 days, then replace (do for several weeks)
o Tazarotene gel (topical retinoid) 0.1% qd
o Can use _____ in areas where you cannot apply steroids (face and groin)
• ADJUNCT THERAPY:
o On scalp: tar shampoo qd
o Thick scales: salicylic acid gel or other preps under a shower cap at night; shampoo in am
o Face, penile , groin psoriasis: Tacrolimus ointment 0.1% (no steroids)
• GENERALIZED DISEASE
o If psoriasis involvement is > 30% of body: topicals are not practical
o Tmt: outpt _____ exposure X 3 weekly
o Clearing in ~7 weeks; need maintenance
o Can try PUVA (increased risk of skin CA)
o Rapid aging of skin
o Can use it with acitretin (synthetic retinoid) with phototherapy; not for women contemplating pregnancy: must wait 3 years
• PSORIASIS
o _____: up to 25mg q week (effective; 50-60% achieving satisfaction)
o Monitor LFTs, consider referral to hepatology
o Use folic acid 1-2 mg qd to eliminate nausea
• Severe cases: can also use cyclosporine
• RAPID REBOUND WHEN DRUG IS STOPPED, so another agent must be started
• _____ etanercept (Enbrel) 50 mg X2 weekly (3 mos), then 25 X2 weekly and infliximab (Remicade) (for flares) have good activity against psoriasis
• Combo therapy most effective: entanercept or infliximab with MTX
Bethamethasone Vitamin D shampoos tacrolimus UVB light Methotrexate TNF IBHIBITOR
ROSACEA
• Avoidance of triggering factors
• Wear appropriate sun screen
• Topicals:
o Topical _____ cream 1-2 times daily
o Second line, topical clindamycin once daily
• Oral therapy with Minocycline or _____ 50-100 mg 1-2 xs daily
• Surgical debulking of rhinophyma
metronidazole
Doxyclicline
LICHEN PLANUS
• Topicals:
o Ultra high topical _____ bid in nonflexural areas; can use high potency under occlusion
o Topical _____ effective in oral and vaginal erosive lichen planus
o Long term tmt to prevent relapse
• Systemic Tmt:
o _____ in severe cases
o Relapse when steroids are tapered
o Not good for chronic cases
o Isotretinoin and acitretin by mouth sometimes effective in oral and cutaneous lichen planus
o UV phototherapy may help
steroids
tacrolimus
Corticosteroids
SEBORRHEIC DERMATITIS
• SCALP
o Shampoos with _____ or selenium (Selsun Blue) used daily
o Alternate with _____ shampoo (1 or 2%) X 2 weekly
o Use topical steroids as necessary bid
• FACIAL o Mild steroid \_\_\_\_\_ 1% o Use intermittently o Avoid eyes o Don’t use high potencies o Can add Nizoral (ketoconazole) bid o Topical Protopic or Elidel: steroid sparing alternatives (don’t use for long periods of time:black box warning re: immunosuppression)
zinc pyrithione
ketoconazole
Hydrocortisone
ATOPIC DERMATITIS
• These pts have skin that is hyperirritable!
• Anything that dries or irritates skin can cause an outbreak
• Avoid irritants (contact irritants, excessive heat, rough fibers, tight clothing, cool dry air)
• Use synthetic fibers or cotton in clothing (no wool or acrylic)
• Soap ONLY on pits, groin, scalp, feet
• Soaps: Dove, Eucerin, Aveeno, etc.
• Rinse, pat skin dry, cover with moisturizer:
o Eucerin, Vaseline
• TOPICALS
o Steroids sparingly bid
o Potency appropriate to severity of dermatitis
o Start _____ 0.1% (or a stronger corticosteroid)
o Then taper to _____
o Then taper to moisturizer when dermatitis clears
o Don’t stop steroids abruptly: rebound flare
• OINTMENTS – IMMUNOMODULATING AGENTS
o _____ ointment (Protopic) bid application: suppresses the immune system and the inflammation by inhibiting an enzyme (calcineurin) crucial for the multiplication of T-cells
o Pimecrolimus cream (Elidel): also a topical calcineurin inhibitor that decreases inflammation.
o Both have a Black Box warning: potential cancer risk (lymphoma)
• TREATING ECZEMA based on the lesion type…
o Acute weeping lesions-
Soaks in water, colloidal oatmeal, or Burrow’s solution
Use high-potency _____ after soaking (not on face or folds)
May need systemic steroids if lesions widespread
Investigate for possible superinfection
o Subacute or scaly lesions-
Mid to high potency steroids in ointment form
Taper to moisturizers as tolerated
Can substitute _____ or pimecrolimus
o Chronic lichenified lesions
Need high to ultra-high potency steroids, may need _____ dressing
• SYSTEMIC THERAPY
o Systemic corticosteroids are only employed for SEVERE acute exacerbations
o Long-term steroid use NOT recommended
o Bedtime doses of _____ may help with pruritis
o There are immunomodulating medications for severe, recalcitrant cases
triamcinolone hydrocortisone Tacrolimus steroids tacrolimus occlusive antihistamines
LICHEN SIMPLEX CHRONICUS
• Use high potency _____ (with or without _____) in nongenital areas
steroids
OCCLUSION
CONTACT DERMATITIS
• Acute weeping dermatitis:
o Compresses
o _____ lotion between wet dressings
o Wet dressings for 30-60 minutes several times daily
o Potent topical _____ (gel or cream) suppress dermatitis and relieve itching; then taper
o Fluocinonide gel 0.05% bid-tid with compresses
• Chronic:
o High to highest potency steroids in ointment form (not on face or skin folds)
• Systemic:
o Acute severe cases: _____ orally for 12-21 days
o Give 78 5mg tabs:
12 first day
11 second day
10 third day…..etc.
Don’t use prepackaged Medrol Dose pak: not enough steroid for long enough.
Takes 2-3 weeks to fully heal.
Calamine
steroids
prednisone
TINEA CORPORIS: RINGWORM
• TOPICALS: o \_\_\_\_\_ 2% cream o Clotrimazole 1% solution, cream, lotion o Betenafine, terbinafine o All over the counter o Treat for 1-2 weeks past clearing
• SYSTEMICS:
o Generally not needed unless disease is widespread or patient has immunocompromise
o _____ (ultramicrosize) 250-500 mg bid, 4-6 weeks of tmt
o Or.. _____ 200mg qd X 1 week
o Either topicals or systemics work in about 4 weeks
Miconazole
Griseofulvin
Itraconazole
TINEA CRURIS
- Drying powders (Zeasorb-AF)
- _____ cream qd X 7 days: curative
- Can use _____, clotrimazole, butenafine also
- Severe cases: systemic _____ 250-500mg bid X 1-2 weeks
- Itraconazole 200mg qd X1 week
Terbinafine
miconazole
griseofulvin
TINEA MANUUM/ TINEA PEDIS
- If toes are macerated:
- _____ soaks for 20min bid
- Topical _____ daily
- If that fails: allylamine (terbinafine or butenafine) will work
- Dry and scaly stage: use antifungals as listed for corporis
- On soles, you can add urea 10% lotion
- Severe: griseofulvin, itraconazole 200mg qd X 2 wks
Aluminum subacetate
imidazole
TINEA VERSICOLOR
• Topicals
o _____ lotion : neck to waist for 5-15 min. X 7 d; then weekly X 1 mo., then monthly.
o ______ shampoo lathered on back/chest for 5 min. weekly also works for maintenance
o Sulfur-salicylic acid soap or shampoo or zinc shampoos on continuing basis
o Pigmentation may take months to fill in; relapses also common
• Orals
o _____ 200mg qd X1week or 1 400mg single dose short term cure
o (Don’t shower for 12 hours after taking it; delivered in sweat to skin)
o Then need maintenance or they will relapse
Selenium sulfide
Ketoconazole
Ketoconazole
CANDIDA
• Tx: keep dry and exposed to air, discontinue systemic abx
o Nails: _____ 1%
o Skin: _____ ointment w/ hydrocortisone cream
o Vulva/anus: single dose fluconazole
o Intravaginal clotrimazole, miconazole, terconazole, or nystatin
clotrimazole
nystatin
INTERTRIGO
• _____ cream 1% plus _____ or nystatin cream
Hydrocortisone
imidazole
HERPES ZOSTER
GENERAL TMT
• Oral _____ 800 mg X 5 daily, or famciclovir 500 mg tid, or valacyclovir 1g tid (all 7 days)
• Keep hydrated
• Adjust for renal function
• Initial severe pain: nerve blocks can be used
• Systemic _____: reduces acute pain: tapering 3 week course prednisone: 60 mg/d
acyclovir
corticosteroids
BASAL CELL CARCINOMA
• _____ (usually with electrodesiccation)
o A looped blade (curette) is used to vigorously scrape tumor away from adjacent normal skin
o One may start with a larger curette to debulk the tumor and then follow with a smaller curette to better remove smaller fragments of tumor from surrounding stroma
o Curetting is most often followed by electrodesiccation, and the entire process may be repeated 1-2 more times
• _____ surgery
o Mohs surgery involves removal of the clinically apparent tumor and a thin rim of normal-appearing skin around the defect created
o This saucer-shaped tissue specimen represents tissue adjacent to the tumor or the margin surrounding the tumor
o This margin specimen is sectioned and marked so that the entirety of the undersurface and outer edges of the tumor are examined microscopically to minimize sampling error
o Use of the frozen-section technique allows for an examination of tissue while the patient is in the office
o Tissue is mapped microscopically so if any foci of tumor persist, further excision can be directed to only those areas to spare the normal tissue
o Mohs micrographic surgical excision has the best long-term cure rates of any treatment modality for BCC
o Cure rates for primary BCC are 98-99% with Mohs excision and 94-96% for recurrent BCC.
Curettage
Mohs micrographic
SQUAMOUS CELL CARCINOMA
• _____
• _____ surgery
o Especially for high-risk lesions
o Also, recurrent tumors
• Follow-up every 3 months
• Carefully examine lymph nodes
• Palpation of lips is essential to detect hard or indurated areas that represent early squamous cell carcinoma
• All such cases must be biopsied
• Very common to have multiple squamous cell cancers on sun-exposed skin of organ transplant pts
• Immunosuppressed pts: cancers begin about 5 years after immunosuppression
• They need regular derm evals
Excision
MOHS
MALIGNANT MELANOMA
- Skin surveillance exams, monitor any suspicious lesions for change
- _____: “when in doubt, cut it out” . General practitioners can attempt a _____ biopsy or refer to specialized surgical center.
- Outpt surgical centers: Send to histology, check the margins
- Go back in and re-excise ;leave clear margins: 1-3 cm (ouch)
- Sentinel lymph node biopsy: for staging (lesions > 1 mm thick)
- Refer to skin cancer center
Excision
punch
ACTINIC KERATOSIS
- Considered a premalignant lesion, so generally removed
- Application of liquid _____, lesions crust and flake off
- Can also use topical _____ (fluorouracil, imiquimod)
nitrogen
keratolytics
SEBORRHEIC KERATOSIS
- Common in elderly
- ___ treatment needed – removal done for cosmetic reasons
No
FOLLICULITIS
• General Folliculitis - often caused by staph infection, more common in the diabetic.
o Keep area clean and dry. If mild (only a few pustules) will resolve on its own. Can try topical _____ (mupirocin or clindamycin). Oral antibiotics in diffuse involvement (anti-staph) Cephalexin, Dicloxacillin. If MRSA suspected use _____ or Clinda.
• Sycosis - chronic and deep on neck, resistant to treatment
o Will need oral antibiotics, extended course
• Gram negative folliculitis - during antibiotic tmt of acne: flare of acne pustules and nodules
o Treat with topical _____
• Hot tub folliculitis: caused Pseudomonas aeruginosa
o Itchy, tender follicles 1-4 days after hot tub use
• Nonbacterial - oils that irritate hair follicle: machinists, hair preparations. Also from occlusion, perspiration, rubbing (tight jeans)
o Avoid irritants
• Malassezia folliculitis – occurs on the back. May present like acne that is resistant to treatment.
o Topical _____ lotion, antifungals (itraconazole, fluconazole)
• Eosinophilic Folliculitis – common in patients with AIDS. May occur with initiation of HART
o Treat with oral _____, topical corticosteroids
antibiotics BACTRIM isotretinoin sulfacetamide antihistamines
PSEUDOFOLLICULITIS
• Treat: grow a _____; use chemical depilatories, shave with a foil guard razor, _____ removal
beard
laser hair
WARTS
NON-GENITAL
• First line generally involves liquid _____ or _____ agents
o Often require multiple treatments
• Second line is some type of operative removal
o Blunt dissection
o Laser therapy
• Third line is some type of intralesional injection
o Immunotherapy with squaric acid
o Bleomycin
GENITAL
• Liquid _____ is an improved first line therapy, but should be used with caution due to risk of scarring and depigmentation
• Podophyllum resin cream applied BID, three times weekly. Must be used for 4-6 weeks. Often multiple courses needed.
• Imiquoid cream – not as effective in men! Recurrences common. More costly than podophyllum cream.
• Operative removal used for large, pedunculated lesions
• Laser surgery used for refractory warts
nitrogen
keratolytic
nitrogen
