DERM Flashcards
(159 cards)
1
Q
A lice egg is called a nit.
True or false.
A
False!
Trick question.
The eggs are small, about 1/3 the size of a sesame seed. Nits are the empty case left after the eggs hatch and are easier to see, and found further down the hair shaft.
2
Q
How many days does it take for lice eggs to hatch?
A
9 -10 days
3
Q
How are head lice transmitted?
A
Head to head contact. They cannot jump or fly.
4
Q
What is the wet-combing method of head lice treatment?
A
Copious amounts of conditioner onto wet hair (stops the little bastards from moving), and combing through all the hair. Wipe the comb onto a paper towel between stroked.
Wet comb every 4 days for at least 2 weeks. If still lice, continue combing every 4 days until no more lices. Louses? Lice.
Note: RXFiles reports low success rates with this method.
5
Q
When would you recommend someone repeat a chemical treatment for head lice?
A
In 7-10 days.
6
Q
If one of the four 1st-line head lice treatments are not effective, what is the 2nd-line recommendation?
A
Try again with another 1st line tx.
As per RxFiles.
7
Q
Name 2 of the 4 recommended medication used as 1st line tx for pediculosis capitis. (as per RxFiles)
A
Permethrin (NIX)
Pyrethrins/Piperonyl Butoxide (R&C)
Isopropyl Myristate (Resultz)
Dimethicone (NYDA)
8
Q
What are some common presentations of pediculosis corporis (body lice)?
A
Rash may be limited to linear excoriations on the trunk and neck along with postinflammatory hyperpigmentation, sometimes with thickening or lichenification.
Occasional presence of hemorrhagic puncta or wheals from fresh bites. Rashes primarily located around the waist and in the axillary folds.
9
Q
What is the recommended tx for body lice? (as per Marcela’s slide)
A
P. Corporis: Thorough bath. Infested clothing and bed linen-heat washed (149°F or hotter), dry cleaned, or discarded. Ironing clothing with particular attention to the seams will also kill lice on fabrics. If nits are persistent, prescribe a single 8 to 10-hour application of permethrin 5% cream to the entire body.
10
Q
What is the recommended tx for pubic lice? (as per Marcela’s slide)
A
P. Pubis: First line is topical permethrin 1% or a product containing pyrethrins with piperonyl butoxide. Treatment should be repeated after 9 to 10 days if lice remain. Advisable to screen for STIs. Sexual partners of individuals with pediculosis pubis should be treated simultaneously. Bedding and clothing should be laundered in hot water.
11
Q
Name some risk factors/populations more likely to develop thrush (oropharyngeal candidiasis)?
A
-infants
-older adults who wear dentures
-smoking
-poor oral hygiene
-patients treated with antibiotics, chemotherapy, or radiation therapy to the head and neck
-those with cellular immune deficiency states, such as AIDS
-patients with xerostomia and those treated with inhaled glucocorticoids for asthma or rhinitis are also at risk
12
Q
Although many people with thrush do not present with any symptoms, some complaints may be:
A
-a cottony feeling in the mouth
-loss of taste
-sometimes pain on eating and swallowing
-patients with dentures often have pain when they try to wear their dentures
13
Q
Is nystatin safe in pregnancy and lactation?
A
Yes as per RxFiles
14
Q
What is the tx for oral thrush?
A
Nystatin liquid 5 ml QID for 7 days or until 2 days after improvement.
Infants: 1-2 ml QID. May swab 0.5 ml onto tongue
15
Q
What is this:
Common in moist skin folds.
Results in tender, burning, pruritic areas (may develop satellite lesions)
A
Candidal Intertrigo
16
Q
What is the common tx recommended for candidal intertrigo?
A
Nystatin topical cream
17
Q
Is it safe to swallow nystatin liquid?
A
Totes. Tell your patients to swish and swallow.
18
Q
What does ‘atopic’ refer to?
What conditions does this include in kids?
A
refers to having a sensitivity to allergens such as environmental (extreme weather changes, dust, pollen etc), animals (dogs, cats), food (dairy, wheat, nuts, fish), irritants (detergents, soaps, creams etc), and stress
Atopic conditions commonly seen in children and adolescents: asthma, allergic conjunctivitis, allergic rhinitis, and atopic dermatitis (eczema)
19
Q
What is the difference between atopic and contact dermatitis? They are both kinds of _______.
A
- Both fall under the umbrella of eczema and present with similar symptoms
- they have different causes. Typically, a person inherits atopic dermatitis, while contact dermatitis occurs following exposure to an external factor that triggers a reaction
20
Q
Atopic dermatitis aka _____
A
Atopic eczema
**The most common inflammatory skin disease worldwide
21
Q
Who typically gets atopic dermatitis?
A
Those with other atopic conditions (asthma, hay fever, food allergies)
22
Q
When does atopic dermatitis usually present?
A
** most common in children
-usually starts in infancy, affecting up to 20% of children. Approximately 80% of children affected develop it before the age of 6 years.
Although it can settle in late childhood and adolescence, the prevalence in young adults up to 26 years of age is still 5–15%.
23
Q
What causes atopic dermatitis?
A
Results from a complex interplay between environmental and genetic factors
Triggers (according to Toronto Notes) include:
* Irritants (detergents, solvents,
clothing, water hardness)
* Contact allergens
* Environmental aeroallergens (e.g.
dust mites)
* Inappropriate bathing habits (e.g. long
hot showers)
* Sweating
*Changes to weather
* Microbes (e.g. S. aureus)
* Stress
24
Q
Clinical manifestations of atopic dermatitis
A
red, weeping/crusted (exudative) and may have blisters (vesicles or bullae)
Over time the dermatitis becomes chronic and the skin becomes less red but thickened (lichenified) and scaly. Cracking of the skin (fissures) can occur.
- possibly secondary bacterial infections
- itchy itchy itchy
25
Time course of atopic dermatitis
The clinical phenotype of atopic dermatitis can vary greatly, but is characterized by remission and relapse with acute flares on a background of chronic dermatitis.
26
How does infantile atopic dermatitis present?
* Most often on face & scalp, extensor surface
* Erythematous, pruritic, sale, crusted lesions (without or without vesicles and serous exudate)
Extra notes from DermNet:
- At or shortly after birth, atopic dermatitis may initially present as infantile seborrhoeic dermatitis involving the scalp, and the armpit and groin creases.
- The skin often feels dry and rough. With time the face, especially the cheeks, and flexures become involved.
27
How does atopic dermatitis distribution change as children enter toddlerhood and early childhood?
2-16 years old
*most often affects flexor surfaces and extremities (creases of inner aspect of elbows, wrists, ankles, neck)
From DermNet:
- With crawling, the extensor aspects of the elbows and wrists, knees and ankles are affected.
- The distribution becomes flexural with walking, particularly involving the antecubital and popliteal fossae (elbow and knee creases).
- Dribble and food can cause dermatitis around the mouth and chin. Scratching and chronic rubbing can cause the skin to become lichenified (thickened and dry), and around the eyes can lead to eye damage
28
The Dennie Morgan fold is a clue to dermatitis in kids. What is it?
A Dennie-Morgan fold is a fold of skin under the lower eyelids
- due to chronic eyelid dermatitis
29
What is the patho of atopic dermatitis?
IgE mediated immune response (Type 1 hypersensitivity reaction)
Basically the immune system is attacking the skin
30
T/F Atopic dermatitis is itchy
True! Itchy, dry skin.
31
What are the psychologic effects of atopic dermatitis?
Very common to cause depression and anxiety - screen for these!
32
Treatments for atopic dermatitis
ID and avoid any triggers
- avoid overheating
- dress in soft fabrics
- manage stress
- Frequent moisturizing to manage dry skin (particularly after luke warm bath): use ointments and creams with lower water content
- Keep short fingernails to avoid complications from scratching (especially in young children)
- Steroids, calcineurin inhibitors
- Antihistamines for itching
- Abx for secondary infections
33
What is the typical distribution of atopic dermatitis in adults?
* Localized lichenified plaques
* Flexural surface involvement
* uncommonly affects face, neck, hands
34
What is contact dermatitis?
- Inflammation of the skin after contact exposure to allergens/irritants (irritation can be mechanical, chemical, physical)
- Localized
- Exposure to foreign substances trigger immune response
- Most common form = irritant contact dermatitis
35
Common causes of contact dermatitis?
- Detergents, surfactants, extreme pH, organic solvents
- Plants with spines/irritant hairs
- Allergic contact dermatitis from: poison ivy or poison oak, nickel, fragrances, dyes
36
S&S of contact dermatitis
- Erythematous rash (can develop <72 hours after exposure)
- Vesicles/bullae/wheals occur at exposure site
- Glaze/parched/scaled presentation
- Scaling, hyperkeratosis, fissuring
- Itching favours allergic etiology, burning favours irritant etiology
37
What did Brenda really stress regarding the difference between atopic and contact dermatitis with regard to distribution?
Contact dermatitis will be localized to area of exposure (such as circumferential rash around wrist if caused by watch)
38
Treatment of contact dermatitis
- Pruritis: calamine lotion
- Mild topical corticosteroids (hydrocortisone)
- Oral antihistamine
- Allergic contact dermatitis: high potency topical steroid, oral corticosteroids, typical calcineurin inhibitors (tacrolimus/pimecrolimus), other forms of systemic immunosuppression
- Remove/avoid trigger
- Treat blistering: cold compress
- Avoid scratching
- Retain moisture/protect skin (such as zinc barrier cream)
- Possible phototherapy for allergic contact dermatitis
39
Urticaria aka ____
Caused by?
Hives/welts/wheals
40
What is tinea capitus?
A ringworm (dermatophyte) infection on one's head.
41
How is hives described in proper derm terms?
What is it and how is it different from angioedema?
intensely pruritic, erythematous plaque
- Have pale, papular centers
- not painful unless scratched
clinical rash produced by capillary leak vasodilation and edema of the skin
Angioedema: extension of urticarial process deeper into the dermis, producing swelling
42
What is tinea corporis?
A ringworm infection on one's body.
43
T/F Hives can persist for weeks or months without a known trigger
True! Can become chronic (defined as >6 weeks)
** individual lesions persist less than 24 hours...but new ones pop up or reocurr in same spot
44
What is tinea versicolor?
More accurately called pitryasis versicolor. Caused by the fungus Malassezia furfur, it is a common skin condition characterized by superficial scaly papules and circular plaques of varying colour (white, pink, brown) on the chest, back and shoulders.
45
What is the patho of urticaria?
-A reaction to epidermal mast cell release of histamine, prostaglandins, leukotrienes
-Occurs in sensitized patients on re-exposure to antigens in food, medications, supplements and insect venom
-Mast cells can also be activated independent of IgE mechanisms:
- Viral, bacterial, parasitic and fungal infections
- Collagen vascular disease
- Malignancy
- Endocrine disease
- Physical factors: heat, cold, pressure, sun, vibration
46
What is onychomycosis?
Tinea of the nails, caused by yeast or dermatophyte infection of the nail or nail bed.
47
T/F a urticarial rash is non-blanchable
F - they are blanchable
48
What is the recommended tx for diaper rash?
Apply antifungal underneath barrier cream until rash is resolved.
-Topical nystatin, clotrimazole, miconazole, or ketocanzole if rash is candidial or >3 days.
49
In taking a history for a patient with hives, what should we ask about?
History focus on exposure to
-drugs
-dietary changes
-new soaps/detergents
-environmental agents
-recent viral illnesses
50
What is the recommended tx for tinea capitis (scalp)?
What are some side effects to counsel about?
As per RXFiles, the drug of choice is oral terbinafine (Lamisil) x 4-8 weeks. May also prescribe selenium sulfide/ketoconazole shampoo 2-3x/week to decrease spread.
Common S/E of Lamisil: headache, GI upset, rash. Rare: alopecia
Very rare chance of liver injury but if you're concerned: baseline LFTs and at 4-6 weeks.
51
Treatment of urticaria-
Identify and eliminate causative agent
-Avoid causes, or treat underlying cause if more serious etiology
-H1 and H2 receptor agonists
-Corticosteroids in severe/persistent cases
-Role for tricyclic antidepressants due to potent antihistamine effects
52
S&S of angioedema in contrast to hives?
No distinct rash, not pruritic
Tissue swelling, sense of tightness, sometimes pain
53
Risk factors for scabies?
Crowded conditions
Poor hygiene
Poverty
Malnutrition
Homelessness
Immunodeficiency.
- common in pediatric population
54
Scabies is caused by an infestation of what?
Sarcoptes Scabiei
(a mite)
55
Which bacteria are responsible for impetigo?
Staphyl aureus (approx 80% of cases)
Group A strep (approx 20% of cases)
Or a combination of the 2.
Note: Group B strep may cause impetigo in a newborn.
56
Scabies typically affects what areas of the body?
Webbing of fingers and toes, skin folds/creases (intertriginous areas) such as intragluteal fold, wasite, soles of feed, axillae, genitals
*not typically above neck except infants, elderly, and immunocompromised
57
How is scabies transmitted?
Direct contact
spread amongst sexual partners is common
**A brief handshake or hug does not usually allow for transmission unless the patient has crusted scabies
**Spread via fomites (clothing, towels, etc.) is very uncommon as the mite perishes within hours of leaving the host
58
What is the most common part of the body that you will find impetigo?
The face.
59
Patho of scabies
When is the itch worst with scabies?
Adult female burrows under the skin and lays 60-90 eggs. The eggs become adults after 2 weeks
Up to 2-6 weeks after infestation, immune response becomes sensitized to mite or scybala (mite feces), causing systemic pruritis and rash
In most individuals the rash is an allergic phenomenon, each eruptive papule may not actually contain mites
**Generalized itch
**itch worst at night
**Itch occurs within hours of subsequent re-infection
60
How long is a typical scabies burrow?
What is crusted scabies?
Characteristic burrrow is 3-10 mm long greyish/white line and can be difficult to see
Crusted scabies – extensive mite infestation resulting in thick, greasy yellowish scale and crusts over extremeties and trunk
61
What are some differentials to consider if your working diagnosis is impetigo?
Perioral dermatitis
Allergic contact dermatitis
Herpes simplex and herpes zoster
Pemphigus foliaceus and pemphigus vulgaris
Tinea infection
62
Treatment of scabies
Preferred product: permethrin cream – approved for infants 2 months and older
- Apply head to toe in infants and neck to toe in small children/adults
- Leave on for 8-12 hours, then rinse off
- Repeat after 1 week
Oral invermectin is also successful. Given as a 200mcg/kg dose, then repeated in 1 week
All affected household members should be treated simultaneously and bed linens/clothing washed in hot water
Seal items in plastic bag for 48-72 hours if can't wash
63
What is the recommended tx for impetigo?
Topical therapy in less severe/localized cases: mupirocin 2% cream apply sparingly TID
Significant soft tissue infection or community outbreaks:
Cephalexin 50-100 mg/kg/day divided QID
Duration of therapy is usually 5-7 days.
64
What symptom in scabies may persist for weeks? How to treat?
Pruritis takes several weeks to subside and can be treated with steroids/antihistamines
65
Pathognomonic feature with scabies?
BURROWS
Curvilinear or serpiginous thread-like tracks -- these can be subtle
Typically identified in the web spaces, palms, soles, fingers, toes, inner wrists, elbows, umbilicus, and beltline.
**May see blood spots on sheets in the morning according to Brenda
66
What is an exanthem and what causes it?
Exanthem = widespread rash that is usually accompanied by systemic symptoms such as fever, malaise and headache, lymphadenopathy, GI symptoms, etc
A rash resulting from underlying disease
It is usually caused by an infectious condition such as a virus, and represents either a reaction to a toxin produced by the organism, damage to the skin by the organism, or an immune response
67
What is a morbilliform rash?
adjective is used to describe similar-appearing eruptions of macules and papules (a measles-like rash)
In pediatric populations, infectious eruptions are most commonly morbilliform, but can present as vesicular, bullous, petechial, or purpuric eruptions
68
Examples of viral exanthemas of childhood?
Varicella
HFMD
Measles
Rubella
Erythema infectiosum (fifth disease)
Roseola infantum
HSV 1 & 2
69
Classic general presentation/progression of viral childhood exanthems?
Morbilliform eruptions may involve the face, trunk, or extremities.
Usually erythematous
Lesions flat or slightly raised
Mouth lesions sometimes (called enanthema)
Most children febrile
Progress “Caudally” = “toward the tail”
70
What is pathognomonic for measles?
Koplik spots: (an enanthema)
lesions on buccal mucosa; well circumscribed white-gray papules; appear during prodrome and resolve at 3-4 days
Rare but pathognomonic for measles
71
What are the 3 C's of measles? Do they show before or after the exanthem?
Cough, Coryza, and Conjunctivitis
(in addition to fever)
last for several days before the eruption of the exanthem
72
Where does the measles rash usually begin and how does it progress?
measles rash itself usually begins on the head (esp behind the ears and around the margin of the scalp) and then spreads cephalocaudally (aka head to toe)
After 2 to 3 days, the eruption becomes confluent and copper-colored, fades in the order it appeared, and then may desquamate
Also have Koplik spots
73
Are the symptoms of Rubella similar to measles?
Yes - Can be a prodrome of fever, headache, conjunctivitis, and upper respiratory symptoms
Eruption of exanthem consists of fine erythematous macules and papules that become near confluent (merge), starting on the face and progressing caudally to the trunk, resolving after 3 days
74
Which viral exanthem of childhood are TORCH infections?
-Varicella zoster (can be fatal or cause congenital varicella syndrome)
- Parovirus B19
- Rubella (congenital rubella syndrome causes multisystem anomalies)
- Herpes
75
Is Rubella generally a serious illness in children?
No, generally minor in children.
- Up to 50% asymptomatic in kids
- Adults can develop painful arthritis
76
Erythema infectiosum aka?
What is it caused by?
Fifth disease
Parovirus B19
77
S&S of fifth disease
Characterized by “slapped cheek” appearance of rash: consists of erythematous patches on the cheeks with sparing of the nasal bridge and periorbital areas
Prodrome low-grade fever, headache, myalgia, malaise
Rash erupts 7-10 days after prodrome
Facial rash is 1st stageo of illness
2nd stage: extremities may develop lacy reticulated rash of papules and macules, may be pruritic; 1-4 days after facial rash; lasts 1wk but may recur in 3rd stage if triggered by activity, sunlight, stress, hot baths
Palm & sole involvement rare
78
Are kids with fifth disease typically seriously ill?
No Usually mildly ill and can attend school
** If underlying hematologic condition, may have asplastic crisis
- Immunocompromised may develop chronic anemia
79
What is the most common vesicular exanthem seen in childhood?
Chicken pox (varicella zoster)
80
What condition is caused by coxackie virus (an enterovirus)?
Hand foot and mouth disease (HFMD)
81
How is HFMD transmitted?
Direct and indirect contact with infected bodily fluids, fecal oral
Can also be transmitted by respiratory secretions and vesicle fluids
82
During what time of the year is HFMD most common?
Summer & early fall
83
Risk factors for HFMD?
day care, schools, summer camps, hospital wards, military installations
84
Does a child with HFMD need to stay home from school?
According to DermNet:
In the vast majority of cases, HFMD is a mild illness and there is no need to keep children from school once they are well enough to attend.
The blisters remain infective until they have dried, which is usually within a few days. However, the virus sheds through faecal stools and these remain infective for up to a month after the illness. Therefore, it is impractical to keep children who are well away from school.
**Instead focus on hand hygiene and not sharing items
85
S&S of HFMD
Prodrome: brief, mild: fever, malaise, mouth pain
-Exanthem: erythematous macules and papules with a central gray vesicle; vesicles and pustules on an erythematous base
Volar (palms, soles) surface of hands, feet, and buttocks, mouth
may extend up extremity
Enanthema on tongue, buccal mucosa, palate, uvula, anterior tonsils
-May have vesicles in posterior oral cavity
86
HFMD tx
-Mostly self limited and no treatment required except for parent/ guardian reassurance and education on adequate hydration
- Resolves in 1 week
- Watch for dehydration
-
87
T/F Vaccination for varicella guarantees a child will never get chicken pox
False - Breakthrough varicella in 1-3% vaccinated children
88
How is varicella spread?
Airborne spread of aerosolized viral particles from vesicles of infected person, respiratory secretions, and infected mother to fetus
Extremely infectious (transmission to susceptible household contacts is >90%)
89
At what point in the chickenpox lesion lifecycle is a person contagious?
Contagious from 1-2 days before onset of cutaneous lesions until they are crusted over (~5-7 days)
90
Describe the lesions in chicken pox.
Other S&S?
- Raised, fluid filled vesicles on skin (hundreds, in various stages of resolution)
- Progress from erythematous macules and papules to vesicles and eventually to pustules that crush and heal
- Dewdrop on rose petal
-Lesions may be pruritic
-Possible prodromal/ associated fever (mild), URTI symptoms, myalgia
-Lesions on mucous membranes
91
How does the S&S of chickenpox in a vaccinated individual differ from unvaccinated?
usually milder, with less than 50 lesions, low or no fever, and shorter duration than rash.
92
Tx for chicken pox?
Mostly self limited and no treatment required except for parent/ guardian reassurance and education on adequate hydration
Non pharm
- Teaching re contagiousness
- Calamine lotion, oat baths if intense pruritus or multiple lesions
- Keep fingernails short to prevent superinfection of lesions from scratching
- Drink plenty of fluids
Pharm
- Acetaminophen for fever (no ASA- Reyes)
- Oral antihistamines
- Oral antivirals not recommended routinely for tx (used in high risk only)
93
What condition is the leading cause of acquired heart disesase in children in the US (also fits under exanthems in childhood)?
Kawasaki Disease
94
What is Kawasaki disease?
What causes it?
What age is most affected?
Is acute, self-limited vasculitis
Affects multiple organ systems
Etiology uncertain but think it’s infectious because occurs in winter/spring
Affects mostly 6mo to 5 years
95
S&S of Kawasaki disease?
What is the key complication we are concerned about here?
Rash highly variable: may be morbilliform, urticarial, or scarlatiniform or resemble erythema multiforme
During first week, may have desquamation of perineum
Dx requires: fever (generally >39 lasting 5 days) and 4 of following:
1) bilateral non-purulent conjunctivitis
2) changes in the oropharyngeal mucosa including fissured lips, oral erythema, and strawberry tongue
3) changes in the extremities such as erythema/edema or desquamation
4) cervical lymphadenopathy with 1 node measuring at least 1.5 cm (0.2 in) in diameter
5) Exanthem described previously
Can have partial Kawasaki with 2 of these criteria met
May have irritability, arthralgia, abdo pain, diarrhea
Main complication = coronary artery abnormalities (esp males & <1 yr old)
WARMCREAM
- fever
- conjunctivities
- rash
- edema
- adenopathy
- mucosal involvement
96
Scarlet fever is a reaction to what pathogen?
Group A strep
(a toxin-medicated rash)
97
Who gets scarlet fever?
Usually seen in 1 – 10yr olds with pharyngitis
98
S&S of scarlet fever
Onset = sudden high fever, headache, vomiting, malaise, and sore throat
Within 12 to 48 hours, erythema develops on the neck, chest, and axillae. The rash quickly becomes generalized to a sandpaper-like rash of fine red papules on an erythematous background
Linear accentuation in the axillary, antecubital, and inguinal folds is known as Pastia lines
The face is flushed, except around the mouth (circumoral pallor)
Pharyngeal injection with exudate developing after a few days.
Tongue is initially white with prominent red papillae (strawberry tongue)
As the scarlet fever rash resolves, desquamation begins in 7 to 10 days, lasting up to 6 weeks.
99
Treatment of scarlet fever...what are we trying to prevent?
goal is prevent acute rhematic fever by giving abx within 9 days of onset of symptoms
Penicillin is 1st line, can use erythromycin if allergic
100
What causes rocky mountain spotted fever?
How is it transmitted?
Caused by Rickettsia rickettsii, intracellular bacteria
Transmission via Ixodes ticks
Children of any age at risk
101
Describe the rash of Rocky Mountain Spotted Fever?
Rash begins as blanchable pink macules or papules that evolve into petechial or purpuric non-blanching lesions.
Begin on the wrists and spread centripetally.
The palms and soles are almost always involved.
Prodrome: fever, headache, and malaise. Rash 2-3 days later.
GI symptoms may be present
102
What are bullae?
Bullae: elevated fluid filled lesions >1cm
103
Vesicular lesions on the lips and gums makes you think of what infection?
HSV 1 mostly
Non-herpetic blisters such as HFMD usually spare the lips and gums and more commonly affect back of throat, roof of mouth, around mouth on outside (although a lot of photos also seem to show blisters on the lips in HFMD)
104
How long is a child with HFMD contagious?
children remain infectious until the blisters have ruptured and healed (usually 7–10 days).
105
What is the most common skin condition seen by HCPs in Canada?
Acne
106
Name the risk factors for acne vulgaris
Genetic predisposition, Caucasian, excessive face washing, local skin occlusion, conditions with hormonal imbalance, medications (lithium, phenytoin, steroids, androgens, etc.), oily cosmetics, ointment, emotional stress
107
Briefly describe the patho of acne vulgaris.
1) Hyperkeratinization leads to pilosebaceous follicle plugging and microcomedone formation
2) Hormones induce sebum overproduction and lead to over proliferation of C. acnes
3) C. acnes leads to inflammation, innate immune response
4) Ongoing innate immune response attracts inflammatory cells and damages the dermal matrix
108
When does acne vulgaris often resolve by?
Uncomplicated cases of acne (~90%) resolve by 3rd decade after birth
109
What is the clinical presentation of acne/
Open and closed comedones, papules, pustules
Primarily affecting the face (central facial areas, T zone of forehead, nose, and chin), and other areas of body dense in sebaceous glands
110
T/F the dark central material of open comedones is dirt
False- open comedones (aka black heads) have are small, dome shaped, and have an open orifice with dark central material, which is oxidized fatty acids, not dirt
111
What do closed comedones look like?
"White heads" - small, flesh colored, no surrounding erythema (plugged sebaceous follicle)
112
T/F inflammatory acne includes pustules, papules, and nodules/ cyst
true
113
T/F there is a standardized grading level for acne
False
Berkowitz, TN, and Rx Files all have different ways of rating acne severity. Yay for exam purposes.
Basically, the fewer lesions/ comedonal lesions are mild
Increasing to moderate/ severe as you develop inflammatory lesions (papules, pustules > nodules, cysts)
Most severe= inflammatory acne with cysts, nodules, scarring
114
You assess a patient with multiple (10-20) comedones and 1-2 papulopustular lesions on their face. Is their acne mild, moderate, moderate severe, or severe?
Mild
115
You assess a patient with at least 50 papules and pustules. Is their acne mild, moderate, or severe?
Moderate
116
You assess a patient with multiple nodular lesions. Is their acne mild, moderate, or severe?
Severe
117
How is acne diagnosed?
Clinically
118
Are labs needed for acne?
No, unless concern for hormonal abnormality (hirsutism, male pattern baldness, obesity, acanthosis nigricans) or plans to treat with oral isotretinoin.
If F and has above signs of androgen excess, check testosterone, androgens, FSH, LH, PRL, estradiol, sex hormone binding globulin.
If concern for excess cortisol (central obesity, moon face, stretch marks, buffalo hump), screen for cushings (corticotropin and early am cortisol)
119
What labs are needed if you are starting a patient on isotretinoin?
CBC
LFTS
Fasting lipids
2 negative preg tests 1 mo apart and within 2 weeks of starting
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Ddx for acne?
Rosecea, folliculitis, keratosis pilaris, perioral dermatitis
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What are the goals of acne therapy?
-Reduce obstruction of pilosebaceous glands
-Control inflammatory process
-Reduce incidence of scarring
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General management recommendations for acne?
-Avoid excess skin care, wash skin with mild soap free cleanser no more than BID
-Use oil free/ non comedogenic make up
-Dont pick/ touch/ squeeze lesions
-Avoid sunlight, use non comodegenic sunscreen and moisturizers
-Diet- high fat/ sugar/ dairy MAY worse, but evidence limited and effect likely small
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Describe the pharmacological management options for acne/ how therapy is stepped up
1) General measures outlined above
2) Topical benzoyl peroxide (BPO), if comedonal start topical retinoids (can used with BPO)
3) If papulopustular (inflammatory) add topical abx with BPO +/- topical retinoid.
4) Women can consider combined oral contraceptive (Yaz, Diane 35)
5) Systemic antibiotics (+/- topical therapies), max 3 months then reassess/ step down
6) Isotretinon (avoid concurrent topical retinoid/ BPO as very drying
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You assess a 13 yo F patient with 10-20 comedones and 5 papules/ pustules. How to proceed?
1) Lifestyle/ skin care
2) BPO +/- topical retinoid
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You assess a 15 yo males with papulopustular acne (50-75 lesions). What treatment will you initiate? How will you step it up if not responding?
1) Lifestyle, skin care
2) BPO, +/- topical retinoid
3) Add topical abx- presence of papules and pustules= inflammatory acne. If excess dryness, lower BPO strength.
4) If ongoing/ severe, consider systemic abx
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What systemic antibiotics are commonly used for acne?
Tetracyclines, doxycycline, minocycline
NOTE: CI in pregnancy!
(Rx Files)
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How do topical retinoids work?
Vit A derivative
Comedolytic (tx existing lesions) and prevent formation of new microcomedones)
Normalize follicular keratinization, decrease adhesion of horny cells, reduce inflammation
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Can you apply BPO and retinoid at the same time?
No, BPO inactivates retinoid
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AE associated with topical retinoids?
* AE: redness, dryness, peeling, stinging, burning, skin irritation
* Use lowest concentration possible, use with moisturizer.
* Use with sunscreen!!!
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How does BPO work for acne?
* Comedolytic and anti-inflammatory
* Antibacterial properties against C acnes
* Use as part of antibiotic regime to prevent resistance.
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Topical abx used in acne?
Clindamycin, erythromycin
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You start 15 year old Alison on Alesse for moderate papulopustular acne. She wonders when she will see an effect on her skin. What do you tell her?
COCP must be taken for 3-4 mo to see improvement
Max effects at 6mo
Sadly sx with relapse if d/c
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Cara, 17, is seeing you for moderate papulopustular acne. You discuss oral contraceptives as an option for treatment. She is wondering about instead having an IUD put in, because she does not want to take a daily pill. Thoughts?
IUD great LARC but unfortunately not great for skin
We used combined OCPs for the estrogen and progestin
IUDs only have progestin
Unopposed progestin can provoke acne (and hirsutism)
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You are treating Jack, an adolescent with moderate to severe papulopustular acne. You notice his skin looks so angry and red and inflamed! Should you try a topical steroid to help with this?
Nope
Never use topical steroids in acne- can cause c. acnes to proliferate
Can consider oral in severe inflammatory nodulocystic acne
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Considerations for isotretinoin use?
-Influences all aspects of acne formation
-Strongest and most effective acne tx, can provide long term remission
-First line for severe nodulocystic acne
-Many AE (skin dryness, GU upset, myalgia and joint pain, fatigue, HA, hemturia, hematologic abnormalities, elevated trigylcerides)
-VERY TERATOGENIC needs 2 negative preg tests sep by 1 mo, 2 forms of active birth control.
-Unsafe in lactation
-Labs required- baseline CBC, LFTS, lipid panel ongoing and monitoring
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What is folliculitis?
What are the 3 most common types?
Folliculitis is an inflammation of the hair follicle.
Mechanical - persistent trauma, tight clothing etc
Bacterial
Fungal - less common, can result from untreated tinea in areas that grow hair
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What is a possible derm complication for a patient being treated with long term abx, most often for acne?
Gram-negative folliculitis. Superficial gram-negative bacterial overgrowth can cause an acneiform eruption to suddenly worsen and become pustular.
Oral abx may need to be d/c'd.
-skin disease text
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The most common organism responsible for bacterial folliculitis is?
Staph aureus.
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Edna, a 12 year old cis female, presents to your clinic with dome-shaped, brown, hyperkeratotic rough papules with black dots on the surface. These are on her left hand. Edna is active in team sports at school.
What is your diagnosis and plan?
Viral warts. Incidence in children and young adults is 10% with the peak age 12-16.
Warts can regress without tx over about 2 years.
OTC topical salicylic acid OD are safe and effective.
Liquid nitrogen therapy.
Podofilm is most recommended for plantar warts but has been used on common warts - must be applied by HCP.
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What are some recommendations for wart treatment and to reduce transmission?
Wear footwear in pool/gym.
Use condoms.
Soak warts before topical therapy to increase penetration of med.
Silver duct tape may speed healing.
Treat early.
HPV vaccine.
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What are filliform warts?
Warts with finger-like projections, most often found on the face.
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Why is it best to treat a few warts at a time rather than all, in a case where there are multiple?
To stimulate an immune response to promote regression.
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What organism causes molluscum contagiosum infections?
How is it spread?
Poxvirus.
Skin to skin contact, including autoinoculation.
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In which age groups does molluscum infection peak?
3-9 years old
16-24 years old
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Your pediatric patient has scattered papules over their torso. The papules are 2 - 5 mm in diameter, round, shiny with umbilication.
What is your diagnosis?
What are some differentials?
Molluscum contagiosum.
Warts, chicken pox, basal cell carcinoma
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What do you counsel someone about a molluscum diagnosis?
Most cases resolve on their own in 6 - 9 months.
Avoid skin-to-skin contact.
Keep lesions covered by clothing if able, avoid picking at them.
Curettage to remove the infectious central core of the lesion is possible and is best offered in an outpatient surgical environment - comes with a risk of scarring and is not the recommended course.
Erythema and scaling around lesions often indicate an immune response prior to spontaneous clearing.
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What are some pharmacological treatment options for treating molluscum contagiosum?
In pediatric populations:
cautiously applied cantharidin, imiquimod, or low-strength tretinoin.
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T/F Healthy individual exposed to chicken pox or shingles should get vaccine within 3-5 days
True (I assume just if they are unvaccinated and haven't had it already)
- MUMs says within 72 hours
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Who is at highest risk of complications from chickenpox?
adolescents, adults, pregnant women, and immunocompromised hosts.
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T/F Due to their higher risk for complications (including fatal complications), you need to consider antiviral treatment for a teen with chickenpox
T
From UTD:
Antivirals used for high risk individuals (unvaccinated, adolescent, adults, pregnant women, immunocompromised)
MUMs says:
Oral acyclovir cannot be recommended routinely for the treatment of uncomplicated chickenpox in otherwise healthy children (Klassen 2005).
In children at increased risk of severe chickenpox due to concurrent cutaneous or pulmonary disorders, in an immunocompromised state (on high dose steroids or taking salicylates chronically) or if >13 years of age, antiviral treatment should be considered if it can be initiated within 72 hours of rash onset
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Supportive management of chickenpox
Clip fingernails - reducing scarring & risk of secondary infection
Antihistamines for itching
Tylenol for fever
Calamine & oatmeal baths
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Which antivirals might you be prescribing for a varicella zoster infection?
How fast do they need to be initiated?
Acyclovir first line
(acyclovir 10-20 mg/kg/dose QID for 5 to 7 days)
Valcyclovir 2nd line
**Ideallystart within 24 hours of onset of rash
(I think max is up to 72 hours)
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Potential complications of chickenpox?
●Skin infections
●Pneumonia
●Encephalitis
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Is chicken pox dangerous in pregnancy? What can happen?
can lead to complications, such as pneumonia in the mother, or in rare cases, birth defects in the baby.
Chickenpox is also very dangerous for newborn babies, so pregnant women who are not immune should contact their healthcare provider right away if they develop any signs of chickenpox or if they are exposed to someone with chickenpox or shingles.
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What antibiotics will we use to treat scarlet fever?
Penicillin primarily
Macrolides
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Acronym used for symptoms of Kawasaki disease?
CRASH & BURN
C - Conjunctival injection (bilateral)
R - rash (polymorphous, d/t sensitivity to light)
A - cervical lymphAdenopathy
S - strawberry tongue
H - hand and feet edema (along with other peripheral extremity changes)
BURN = fever > 5 days
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Key diagnostic for Kawasaki disease (to check for complications)
Echo
- looking for coronary artery aneurysms
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Treatment of kawasaki?
IVIG, aspirin
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First line treatment for HSV in kids?
Acyclovir
