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
SCABIES
• Kill the scabies mites
• Control dermatitis (can last for months after mites gone)
• Bedding/clothing laundered or cleaned or closed up in plastic bags for 14 days
• If there is secondary pyoderma: systemic antibiotics
• All people in family must be treated
• _____ 5% cream: very effective and safe
o One application for 8-12 hours
o Repeat in 1 week if necessary
• Treat pregnant women only if they definitely have scabies
• Patients will continue to itch for a few weeks post treatment
• _____ 0.1% cream: resolves the dermatitis
• Newer medication Ivermectin, oral therapy give single dose of 200 mcg/kg and then repeat one week later
Permethrin
Triamcinolone
PEDICULOSIS
body lice: _____ improvement
head lice: _____ topical
pubic lice: _____ or pyrethrins
hygiene
permethrin
permethrin
ACNE VULGARIS
• Educate your patient!!
• 4-6 weeks needed to see improvement
• Tell patient to leave face alone!
• Avoid (topical) oils,cocoa butter and greases
• Although specific foods (chocolate, grease etc) do not cause acne, some studies show a LOW glycemic diet may improve acne in some patients
• COMEDONAL ACNE
1. Use mild soap
2. Topical retinoids
3. Benzoyl peroxide
4. Antibiotics
5. Comedo extraction
• TOPICAL RETINOIDS:
• _____ (Retin-A, Atralin, Renova, Avita, Altinac): effective, but irritating
• Start with 0.025% cream X 2 weekly @hs
• Start with cream, then can use gel
• Work up to nightly as needed
• Use a pea sized amount to cover entire face:
Common to use too much, patient’s face gets irritated, and patient quits treatment
• It modulates gene expression
• Irritates skin, causes cells to die which speeds skin cell turnover
• New cells are formed
• Rapid turnover prevents new pimples from forming
• Also fades dark spots and removes wrinkles!!
• Wait 20 minutes after face washing to apply (lowers irritation)
• If they cannot tolerate Retin A, can use reformulated tretinoin (Renova, Retin A Micro, Avita). These are supposedly less irritating.
• Do NOT use during pregnancy
• Photosensitivity
• Might flare in first 4 weeks of use
• _____:
• In concentrations of 2.5%, 4%, 5%, 8% and 10%
• 2.5% works just as well, less irritating
• Flushes out and dries the contents of acne blemishes:
Oil, bacteria and dead skin cells
• Acts as an antiseptic
• Bacteria p. acnes lives on and in skin, and benzoyl peroxide reduces amount of bacteria, and acts as an anti-inflammatory agent
• It can enter pores and deliver O2
• Acne bacteria cannot live in the presence of oxygen, and benzoyl peroxide kills 99.9% of them almost instantly
• Usually need 2.5%
• ANTIBIOTICS:
• Topicals help comedonal acne
Combos of _____ or clindamycin with _____ topical gel (prescription only) (Benzamycin or BenzaClin)
_____ (Cleocin T) lotion, gel or solution X2 daily
Benzoyl peroxide qd in am
• COMEDO EXTRACTION:
• Open and closed comedones may be removed with comedo extractor
Tretinoin BENZOYL PEROXIDE erythromycin BENZOYL PEROXIDE Clindamycin
PAPULAR INFLAMMATORY ACNE
• _____: mainstay of treatment
• Either topicals or orals
• Generally start with topicals (if patient not having a lot of scarring lesions). Use in combo with benzoyl peroxide
• ORALS:
o _____ 100 mg BID
o Minocycline 50-100 mg 1-2 times daily
o Use orals with benzoyl peroxide
o Once patient’s skin is clear, begin slow taper or oral abx
o Then case use topical antibiotics or topical retinoids for maintenance
MILD PAPULAR INFLAMMATORY ACNE
• Topical: Combo _____ or clindamycin (Cleocin T bid) with _____ (qd) topical gel
MODERATE PAPULAR INFLAMMATORY ACNE
• Start with orals, then taper as able (see previous slide)
• Contraceptives may fail when prescribing antibiotics
• Discuss with pt use of barrier method
• Women whose acne resistant to antibiotics: oral contraceptives or spironolactone as antiandrogens can be added
SEVERE ACNE
• _____ (Accutane)
• Intralesional injection
• Laser, dermabrasion
ANTIBIOTICS Doxycycline erythromycin benzoyl peroxide Isotretinoin
CELLULITIS
- IV antibiotics for first 24-72 hours (Nafcillin, _____, _____)
- Then, dicloxacillin (Dynapen) or _____ (Keflex)X 5-10 days
- Bacterial strains are usually susceptible to clindamycin, gentamicin, rifampin, trimethoprim/sulfamethoxazole, and vancomycin. (IV)
Cefazolin
Clindamycin
cephalexin
ERYSIPELAS
• Treat with _____ to cover Strep (and Staph)
antibiotics
CHRONIC CUTANEOUS LUPUS
• Protect from sunlight (> 30 SPF)
• Try high-potency _____ creams each night (cover with saran wrap)
• Then _____ acetonide suspension 2.5-10 mg/mL injected into lesion once per month
• Then you may go onto systemic tmt
• SYSTEMIC:
o Antimalarials: (need ophthalmologic eval q 6 m)
_____ sulfate
Chloroquine sulfate
Quinacrine (Atabrine); safest; no eye damage
o Isotretinoin
Relapse when therapy discontinued
Not for women of childbearing age
o Thalidomide
Potent teratogen
Monitor for neuropathy
steroid
triamcinolone
Hydroxychloroquine
ERYTHEMA MULTIFORME
• Stevens-Johnson syndrome/TEN
o Denuded skin, treat in a burn unit
o Discontinue offending _____ before blistering happens
o Severe cases: _____ 100-250 mg
o IV Immunoglobulin (IGIV) for 4 days
o Ophthalmologic consult if ocular involvement, because vision loss can occur
• Erythema multiforme minor
o Oral _____ prophylaxis of herpes infection
drug
PREDNISONE
acyclovir
URTICARIA AND ANDIOEDEMA
• Search by hx for a cause of acute urticaria • Tailor tmt toward precipitating cause • Chief causes: drugs o Aspirin, NSAIDs, morphine codeine • Physical factors o Heat, cold, sunlight, pressure • Arthropod bites o Insects and bee stings • Neurogenic factors o Cholinergic urticaria from exercise, hot showers, excitement, etc. • SYSTEMIC TMT: o H1 antihistamines \_\_\_\_\_, 10 mg bid to 25 mg tid o Non-sedating antihistamines \_\_\_\_\_ (Zyrtec) 10 mg qd o Chronic: doxepine (TCA) 25-75 mg at hs o Systemic corticosteroids: 40 mg qd will suppress both acute and chronic urticaria urticaria will return
Hydroxyzine
Cetirizine
PITYRIASIS ROSEA
- Generally requires NO treatment; self-limiting
- Mild-mod cases: topical steroid, _____ 0.1%
- In Asians, Hispanics and Blacks, long lasting hyperpigmentation may be a problem: daily UVB tmts or prednisone
triamcinolone
VITILIGO
Cosmetics such as Covermark and Dermablend are highly effective for concealing disfiguring patches.
• Therapy of vitiligo is long and tedious, and the patient must be strongly motivated.
• If less than 20% of the skin is involved (most cases), topical _____ 0.1% twice daily is the first-line therapy.
• A superpotent _____ may also be used, but local skin atrophy from prolonged use may ensue.
• With 20–25% involvement, narrowband ___ or oral PUVA is the best option.
o Severe phototoxic response (sunburn) may occur with PUVA. The face and upper chest respond best, and the fingertips and the genital areas do not respond as well to treatment.
• Years of treatment may be required. There is evidence that topical or systemic JAK inhibitors (tofactinib, ruxolitinib) may be effective in some patients with recalcitrant vitiligo, although response to therapy is not the rule.
tacrolimus
corticosteroid
UVB
