Derm Flashcards
Burns: 1st, 2nd, 3rd and 4th degree
*Thermal: scalding, contact w/ hot surface, fires ▪︎Complications: bacterial superinfection, sepsis, respiratory damage, multiorgan failure
*Non-Thermal: radiation, chemical burns, electrical burns
Superficial (1st degree)
▪︎epidermis ▪︎“sunburn” ⇢ dry, red
▪︎painful
▪︎3-6d ▪︎ no blisters ▪︎ no scarring
Superficial partial thickness (second degree)
▪︎epidermis + superficial (papillary) dermis
▪︎Moist, red, weeping
⊕ w/ pressure
▪︎painful to temp.,
▪︎7-21d ▪︎⊕blisters air, & touch
▪︎⊖scarring, +/- pigment Δ
Deep partial thickness (2nd degree)
▪︎epidermis + deeper (reticular) dermis
▪︎mottled, cheesy white to red
⊖ or sluggish
▪︎painful to pressure
▪︎2-9wks w/o grafting
▪︎damage hair follicles & glandular tissue
▪︎wet or waxy dry only ▪︎⊕hypertrophic scarring ▪︎⊕blisters (easily unroof)
Full thickness (3rd degree)
▪︎epidermis + dermis + SQ tissue ▪︎waxy white to leather gray ▪︎deep pressure only
▪︎healing w/o surgery not
(3rd degree) to charred & black possible ▪︎dry & inelastic, ⊘blisters ▪︎⊕severe scarring, contractures
Deeper injury (4th degree) ▪︎epidermis + dermis + SQ + deep ▪︎black, charred, dry, dull ▪︎minimal perception
▪︎life & limb threatening
structures (muscles, fat, fascia, bones)
▪︎⊘blisters of deep pressure
Criteria for Minor Burns
Criteria for Minor Burns: *pts meeting ALL criteria may be treated outpatient Burn Center Referral Criteria:
▪︎partial-thickness burns <10% TBSA in patients 10-50yo ▪︎partial-thickness burns >10% TBSA
▪︎partial-thickness burns <5% TBSA in patients <10yo or >50yo ▪︎third-degree burns in any age group
▪︎full-thickness burns <2% TBSA in any patient w/o other injury ▪︎burns of face, hands, feet, genitalia, perineum, or major joint
▪︎isolated injury (i.e., no suspicion of inhalation or high-voltage injury) ▪︎electrical burns (including lightning)
▪︎does not involve face, hands, feet, or perineum ▪︎chemical burns
▪︎does not cross major joints ▪︎inhalation injury
▪︎is not circumferential ▪︎burns in pts w/ medical conditions that could complicate
management, prolong recovery, or affect mortality
Rule of 9s
Estimating %TBSA (adults):
Rule of 9s ⇢ superficial (1st degree) NOT included Palmar Method ⇢ uses PATIENT’S palm
▪︎entire head/neck = 9% ▪︎entire palm including fingers = 1%
▪︎each arm = 9%, each leg = 18% ▪︎entire palm excluding fingers = 0.5%
▪︎anterior trunk = 18%, posterior trunk = 18%
▪︎genitalia = 1%
Burns parkland formula and fluids
Initial fluid resuscitation:
*indicated for any patient w/ >15% TBSA
*fluid requirement during initial 24h
Parkland formula ⇢ 4mL x %TBSA x weight(kg)
▪︎first half in first 8h, second half in remaining 16h
▪︎Lactated Ringer’s typically
*modify fluids to maintain urine output 0.5mL/kg/h
Burns tx
Immediate measures ⇢ ABC’s
*airway: intubation indicated for known/suspected
inhalation injury or >30-40% TBSA, DO NOT DELAY!!
*obtain vascular access
Immediate burn care:
*remove any burnt clothing/jewelry/obvious debris
*cool burns w/ cool water or saline-soaked gauze
*NEVER ICE
*maintain body temperate ≥95°F (35°C)
Pain management: IV morphine
LABS: CBC, electrolytes, BUN & creatinine, glucose, VBG, carboxyhemoglobin
Prophylaxis: tetanus update if indicated, topical antibiotics to all nonsuperficial burns
▪︎silver sulfadiazine (SSD), mafenide acetate
Superficial & superficial partial-thickness:
*irrigation, topical moisturizers
▪︎calamine lotion, aloe vera gel
*topical antibiotics
▪︎triple ointment ⇢ bacitracin, neomycin, polymyxin B
*daily cleansing & debridement
Deep partial-thickness, 3rd/4th degree:
*early debridement of burnt, necrotic tissue
*escharotomy &/or fasciotomy if indicated
▪︎impending vascular or respiratory compromise
*skin grafts, topical antibiotics
Cellulitis causes, sx, dx, tx
Acute spreading infection of the deeper dermis & subcutaneous tissues
Bacteria entry usually occurs after a break in the skin, such as underlying skin problems, trauma, surgical wounds
Etiologies:
*MC caused by group A strep
*staph aureus
sx
Localized macular erythema (flat margins not sharply demarcated), swelling, warmth, tenderness
Systemic sxs not common
Lymphangitis (streaking)
dx: clinical
tx
Oral abx: cephalexin, dicloxacillin
IV abx: cefazolin
Cat bite: Augmentin
Dog or human bite: Augmentin
MRSA:
PO: clindamycin, doxycycline, TMP-SMX
IV: vancomycin
Erysipelas definition, sx, dx, tx
Variant of cellulitis involving the upper dermis & cutaneous lymphatics
Etiologies: group A strep MC
sx
Intensely erythematous, raised area w/ sharply demarcated borders, tenderness, warm
MC involves LE, face, or skin w/ impaired lymphatic drainage
*Milian sign: ear involvement
Often associated w/ systemic sxs: fever, chills, leukocytosis
dx: clinical
tx
PO: penicillin, amoxicillin, cephalexin
IV: cefazolin, ceftriaxone
MRSA: vancomycin
Impetigo bullous vs non-bulbous: definition, sx, dx, tx
Highly contagious superficial vesicopustular skin infection
MC bacterial skin infection in children (highest incidence 2-6yrs)
Non-bullous (MC): vesicles, pustules; weeping, “honey-colored crust”
*occurs at sites of superficial skin trauma (insect bites)
*around nose/mouth, associated w/ regional LAD
*MCC: S. aureus, GABHS
Bullous: vesicles, then bullae, varnish-like crust
*fever, diarrhea
*MCC: S. aureus
*rare (seen in newborns or younger children)
Ecthyma: ulcerative pyoderma caused by group A strep (heals w/ scarring); not common
dx
clinical or gram stain/would culture
tx
Mild: topical mupirocin TID x10d
- bacitracin
- retapamulin
- wash area w/ soap/water
- good skin hygiene
Extensive disease or systemic sxs: systemic abx
- cephalexin or erythromycin x1wk
- dicloxacillin
- macrolides
MRSA: doxycycline; Sick + MRSA: vancomycin
Bullous Pemphigoid definition, sx, dx, tx
Autoimmune disorder leading to blister formation & severe pruritis – primarily seen in the elderly
Type II hypersensitivity reaction – IgG autoantibodies against hemidesmosomes & basement membrane zone causing subepidermal blistering; drug-induced (loop diuretics, metformin)
sx
Prodrome: pruritis w/ eczematous or urticarial plaques
Tense large bullae that don’t rupture as easily MC involving the groin, axilla, trunk, & flexural surfaces
*blister roof contains epidermis
PE: (-) Nikolsky sign (no epidermal detachment)
dx
Skin bx w/ direct immunofluorescence gold standard: linear C3 & IgG along the dermal-epidermal junction, subepidermal blisters, eosinophilia
ELISA: autoantibodies against BP antigen 230 & 180
tx
Topical steroids first line for mild disease or applied to early lesions to prevent blisters
- antihistamines for pruritis
Erythema Multiforme defintion, sx, dx, tx
Type IV hypersensitivity reaction of the skin often following infections or medication exposure – MC in young adults 20-40yrs
CLASSIC target lesions: THREE zones, well defined borders
sx
Target lesions – MC on extremities (hands/feet)
*dusky, violaceous macule or blister
*intermediate surrounding ring of pallor
*peripheral erythematous ring
NON-PRURITIC, blanches
NEGATIVE Nikolsky sign (no epidermal detachment)
Mucositis: typically mild & limited to one mucous membrane (usually oral); conjunctival/urogenital involvement rare
Minor: EM w/o or w/ only mild mucosal dz; NO systemic sxs
Major: EM w/ severe mucosal involvement + systemic sxs (fever, arthralgias)
dx: clinical
tx: self limited
SJS & TEN definition, sx, dx, tx
Rare hypersensitivity reactions affecting the skin & mucosal membranes
Etiology: predominantly drug-related (penicillin, sulfonamides, allopurinol, NSAIDs, anticonvulsants)
*other: infections (M. pneumoniae, influenza)
SJS: <10% BSA
SJS/TEN Overlap: 10-30% BSA
TEN: >30% BSA
sx
Prodrome: fever, malaise, pharyngitis, eye pain
Cutaneous: typically begin on torso & face; rapidly generalizes
SJS: atypical targetoid lesions, often violaceous &/or blistered; lesions may coalesce, particularly on face & torso
TEN: tender, erythematous patches & plaques that develop large bullae that coalesce & rapidly slough, leaving large, denuded areas of skin
(+) Nikolsky sign: applied lateral pressure to blister causes extension of separation from dermis
dx: clinical
tx
PROMP DC OF ALL POSSIBLE INCITING MEDS!!!
*if underlying infectious etiology 🡪 treat
Supportive: pain management, nutritional support, maintain normal body temperature, maintain hydration & electrolyte balance
*hypo-Na/K/phos common
Wound care: leave bullae intact, avoid aggressive debridement, petroleum gauze, topical antibiotics, minimize pressure, frequent application of bland emollients/lubricating ointments to involved mucosa, +/- PO disinfectant rinse (chlorhexidine)
Lyme Disease defintion, sx, dx, tx
Borrelia burgdoferi
Transmission: Ixodes scapularis (deer tick)
MC in northeast states
sx
Early localized (3-32d after bite): erythema migrans (red annular lesion w/ central clearing), fever, malaise, HA, myalgias, arthralgias
Early disseminated (3-10wks after bite): multiple erythema migrans lesions, CN palsies (esp. 7, lasts 2-8wks then resolves), fatigue, myalgia, HA, occasionally meningitis (stiff neck) or carditis (AV block)
Late disseminated (months-yrs after bite): monoarticular arthritis of large joint (knee in >90%), CNS involvement including chronic demyelinating encephalitis, polyneuritis, memory problems (rare in children)
dx
EIA, if ⊕ ⇢ western blot to confirm
⊕ = 2/3 IgM bands, 5/10 IgG bands
*IgM peaks @3-6wks, IgG weeks-months later
LP (meningitis): 10-150 WBC/mm3, <10% segmented neutrophils, ⇡ protein, normal glucose
EKG: heart block (pts w/ disseminated)
Joint aspiration: WBC 25,000-80,000/mm3 & ⊕ Lyme PCR of joint fluid
tx
Early localized: doxycycline x14-21d
Early disseminated: doxycycline x21d
Jarisch-Herxheimer Reaction: transient fever, HA, myalgias after therapy is started
Rocky Mountain Spotted Fever definition, sx, dx, tx
Rickettsia rickettsia
Transmission: dog tick (Dermacentor variabilis), wood tick (Dermacentor andersonii), Lone star tick (A. americanum)
sx
Early: high fever, myalgia, HA (w/ photophobia), V/D, abdominal pain
RASH (2-6d after fever onset): begins on ankles/wrists 🡪 trunk (within hours) & palms/soles
*initially blanching, erythematous, macular
*becomes petechial then hemorrhagic
Other organ systems: vascular leak causing edema, hypovolemia, & hypotension; conjunctivitis, splenomegaly, pneumonitis, meningitis, confusion
dx
Clinical: fever + rash + hx of tick exposure
Labs (vasculitis): thrombocytopenia, ⇣ Na, mild leukopenia, proteinuria, mildly abnormal LFTs, hypoalbuminemia, hematuria
Serology: indirect fluorescent or latex agglutination antibody (not ⊕ until 7-10d after onset); PCR from whole blood/skin biopsies (⊕ 1st week of illness)
tx
SUPPORTIVE; anticipate complications (hypotension, thrombocytopenia, DIC, hypoalbuminemia, hyponatremia)
DOXYCYCLINE x7-10d; alt – chloramphenicol
*continue until pt is afebrile x3d
Perioral Dermatitis MC, sx, dx, tx
MC seen in young adult women (20-45)
Erythematous grouped papulopustules, which may become confluent into plaques w/ scales; may have satellite lesions
*classically spares the vermilion border
dx: clinical
tx
Elimination of topical steroids & irritants
Topical:
- pimecrolimus
- metronidazole
- erythromycin
PO doxycycline if extensive
Contact Dermatitis irritant vs allergic: defintion, sx, dx, tx
Inflammation of the dermis & epidermis from direct contact between a substance & the surface of the skin
Irritant (MC): non-immunologic rxn (immediate)
- chemicals, alcohols, creams
Allergic: type IV hypersensitivity rxn (delayed)
- nickel MC, poison ivy
sx
Acute: erythematous papules or vesicles (may be linear or geometric)
*localized pruritis, stinging, or burning
Chronic: lichenification, fissuring, & scales
*well-demarcated border
dx: clinical and patch testing for allergy testing
tx
Identification & avoidance of irritants
Topical steroids first line (triamcinolone)
PO steroids in severe or extensive reactions
- alt: topical tacrolimus or pimecrolimus
Atopic Dermatitis (Eczema) definition, sx, tx, tx, atopic triad
Rash due to defective skin barrier susceptible to drying, leading to pruritis & inflammation
Atopic Triad:
*eczema + allergic rhinitis + asthma
Triggers: heat, sweat, allergens, contact irritants
sx
*dry (xerosis), PRURITIC skin
*acute changes: erythema, vesicles, crusting
*chronic changes: lichenification, scaling, hyper/hypopigmentation
*infantile: erythematous, scaly lesions on cheeks, scalp, extensor surfaces; diaper area usually spared
*childhood: lichenified plaques in flexural areas
*adolescence: more localized & lichenified skin changes; may be predominantly on hands/feet
Nummular/Discoid Eczema: sharply defined coin-shaped lesions; dorsum of hands/feet, extensor surfaces
dx: clinical
tx
Topical steroids first line q1-2x/d x7d for flares
*triamcinolone
Antihistamines for itching
Abx if secondary infection develops
Topical calcineurin inhibitors: second-line
*tacrolimus, pimecrolimus
Seborrheic Dermatitis defintion, sx, dx, tx
sx
Erythematous plaques w/ fine white scales & greasy appearance
Common in areas w/ high sebaceous gland secretion – scalp (dandruff), eyelids, beard, mustache, nasolabial folds, chest, groin
dx: clinical
tx
Mild: topical first line
- selenium sulfide
- sodium sulfacetamide
- zinc pyrithione
- ketoconazole (shampoo or cream)
- low potency steroids
Pressure Injury (Decubitus Ulcer) definition
Ulcers resulting from vertical pressure commonly seen on bony prominences (sacrum, calcaneus, ischium)
Pressure Injury (Decubitus Ulcer) stages 1-4
Stage I Superficial, nonblanchable redness that does not dissipate after pressure is relieved
Stage II Epidermal damage extending into the dermis; resembles a blister or abrasion
Stage III Full thickness of the skin & may extend into the subcutaneous layer
Stage IV Deepest; extends beyond the fascia, extending into the muscle, tendon, or bone
If slough or eschar obscures the extend of tissue loss, this is an unstageable ulcer
Pressure Ulcer tx
Wound care w/ moist wound environment; pain control (opioids if severe)
Debridement of necrotic tissue is present; negative pressure wound therapy
Optimize nutrition (protein & caloric intake, esp. stages 3/4)
Pressure redistribution: position & re-position & using support surfaces (air-fluidized beds, powered mattresses)
Stage 1: transparent film for protection
Stage 2: dressing that maintain a moist wound environment – transparent films or occlusive dressings (hydrocolloids or hydrogels) if there is no infection present
Stage 3/4: debridement of necrotic tissue (mechanical, surgical, enzymatic); surgical debridement for thick eschars or extensive tissue necrosis
Scabies definition, sx, dx, tx
A highly contagious skin infection due to the mite Sarcoptes scabiei
PATHO: female mites burrow into the skin to lay eggs, feed, & defecate (scybala are the fecal particles that precipitate a hypersensitivity reaction in the skin)
sx
Intense pruritis, esp. at night
Infected pts may remain w/o sxs for up to 4-6wks
PE:
*multiple, small erythematous papules, excoriations
*linear burrows – commonly found in the intertriginous zones, including the scalp & web spaces between the fingers & toes; usually spares neck & face
*red itchy pruritic papules or nodules on the scrotum, glans, penile shaft, or body folds
dx: Clinical
Skin scrapings: mites, eggs, feces seen w/ magnification
tx
Topical permethrin DOC
Lindane
- do NOT use after showers (causes seizures d/t increased absorption through open pores)
- CI: teratogenic, not usually used in breastfeeding & children <2yrs
Ivermectin if extensive
All clothing, bedding, etc. should be placed in a plastic bag at least 72hrs then washed & dried using heat
Pediculosis Pubis “pubic lice” transmission, sx, dx, tx
Transmission: usually sexually transmitted (esp. in teenagers & young adults)
sx
Pruritis of the involved area
Nits may be seen
dx
Clinical (visual of lice or nits)
Microscopic exam of hair shaft
tx
Topical permethrin or pyrethrins first line
Pediculosis Capitis “head lice” definition, sx, dx, tx
Transmission: person to person; fomites (hats, headsets, clothing, bedding)
Girls > boys; less common in AA
Outbreaks commonly affect children 3-12yrs, warmer & humid weather
sx
Intense itching (esp. occipital area); papular urticaria near lice bites
PE:
*visualization of crawling nymphs or adult lice; presence of nits alone does NOT confirm infection
*nits: white, oval-shaped egg capsules at the base of the hair shafts
dx: Clinical (visual of lice or nits)
Microscopic exam of hair shaft
tx
Topical permethrin – fine tooth comb to remove nits
- alt: malathion
- benzyl alcohol, Spinosad, topical ivermectin
Lindane
- ADRs: neurotoxic (HA, seizures)
Oral ivermectin in refractory cases
Pediculosis Corporis “body lice” defintion, sx, dx, tx
Transmission: usually sexually transmitted; strongly related to poor body hygiene (homeless, prisons, crowded, etc.)
sx
Pruritis & excoriations
dx: clinical
tx
Hygiene improvement first line
Permethrin 5% cream
Exanthematous Drug Eruption definition, sx, dx, tx
Morbilliform or maculopapular drug eruption characterized by macules or small papules after the initiation of drug treatment
MC occurs 5-14d after the initiation of the offending med or within 1-2d in previously sensitized individuals
sx
Latency (not previously sensitized): cutaneous eruption typically occurs within 7-10d after starting tx; for short courses of tx (e.g., antibiotics), the eruption may appear 2-4d AFTER stopping tx
Cutaneous features: erythematous macules &/or papules; morbilliform (measles like), rubelliform (rubella like); predominantly involves trunk/proximal extremities
*mild – acral sites often spared
*severe – can involve face, palms/soles
Systemic sxs (mild): pruritis, low-grade fever
dx: clinical
Labs: slightly elevated acute phase reactants, mild eosinophilia
tx
Prompt withdrawal of the offending med
Symptomatic: oral antihistamines (H1 blockers)
- second gen: cetirizine, loratadine, fexofenadine
- first gen: diphenhydramine, hydroxyzine, chlorpheniramine
Severe: short course of PO steroids
Angioedema definition, sx, dx, tx
Self-limited, localized subcutaneous (or submucosal) swelling resulting from extravasation of fluid into the interstitium
Affects the mucosal tissues of the face, lips, tongue, larynx, hands, feet, & genitalia
sx
Mast-cell (histamine) mediated (e.g., allergic rxns)
*angioedema that may be accompanied w/ other allergic rxn sxs (urticaria, flushing, pruritis, bronchospasm, stridor, throat tightness, hypotension)
dx
If there is no information to suggest an external cause & the patient has isolated angioedema then C4 levels & a C1 inhibitor antigenic level should be obtained
tx
Immediate: immediate assessment & ongoing airway protection; epi if severe
Mast-cell mediated: epi (if severe), steroids, antihistamines
Bradykinin-mediated: C1 inhibitor concentrate, ecallantide, icatibant
Angioedema Urticaria (Hives) definition, sx, dx, tx
Edema of the superficial layers of the skin due histamine-related increased vascular permeability
Type I (IgE) immediate hypersensitivity reaction
sx
Triggers: foods, meds, heat or cold, stress, insect bites, environmental, & infection
- chronic (>6wks)
Sudden onset of circumscribed hives or wheals (blanchable, raised, erythematous areas on the skin or mucous membranes) that may coalesce
*intense pruritis
*usually transient (often disappearing within 24hrs)
dx: clinical
tx
Antihistamines (H1 blockers) initial
- second gen: cetirizine, loratadine, fexofenadine
- first gen: diphenhydramine, hydroxyzine, chlorpheniramine
H2 blockers (ranitidine) may be added if no response to H1 blockers
Severe, recurrent, persistent: steroids
Drug Reaction w/ Eosinophilia & Systemic Symptoms (DRESS)/Drug-Induced Hypersensitivity Syndrome (DIHS) definition, sx, dx, tx
Definition: distinct & potentially life-threatening severe ADR characterized by a morbilliform cutaneous eruption w/ fever, LAD, hematologic abnormalities, & multiorgan manifestations
sx
Prodrome: fever, pharyngitis, malaise 2-3d before rash onset
Skin: morbilliform exanthem w/ accentuation on face, upper trunk, proximal extremities; may progress to erythroderma; pruritis common
*desquamation develops days-weeks after initial eruption; can last several weeks
Other manifestations: facial edema (esp. periorbital), LAD, mucosal involvement (cheilitis, pharyngeal erythema)
Organ system involvement: hepatitis, tubulointerstitial nephritis, pulmonary sxs (SOB, tachypnea, cough)
*rash/other abnormalities resolve 1-2mo after med DC
Autoimmune complications: Graves, DM1, AIHA
DX Criteria: acute onset exanthema w/ fever, suspicion of drug reaction, hospitalization, LAD, involvement of ≥1 internal organ, & hematologic abnormalities (lymphopenia, lymphocytosis, atypical lymphocytosis, eosinophilia >10%, thrombocytopenia)
CBC: can show lymphocytosis, atypical lymphocytosis, eosinophilia, thrombocytopenia
LFTs: ↑ ALT, alk phos; CMP: ↑ creatinine; ↑ LDH
UA: proteinuria, eosinophilic sediment
Blood PCR: HHV-6, HHV-7, EBV, CMV
Hepatitis panel: HAV IgM Ab, HBsAg, HBcAb (IgM), HCV viral RNA
TFTs: @baseline, again @6wks
tx
DERM CONSULT!
*identify & DC causative medication
*fluid replacement, electrolyte correction
Mild, predominantly cutaneous: topical corticosteroids; antihistamines for pruritis
Significant systemic involvement:
*systemic steroids; prednisone, methylprednisolone
*IVIG for no response to steroids; plasmapheresis, immunosuppressive drugs are other options
Rubeola (Measles) sx, dx, tx
sx
Prodrome: high fever + 3Cs (cough, coryza, conjunctivitis); usually lasts 3d
Koplik spots: small red spots w/ white centers on oral mucosa
*rash follows by 1-2d
Rash: maculopapular rash; cephalocaudal progression (head downwards)
*spares palms/soles; fades ~4d; left w/ persistent cough for 10-14d
dx
Clinical
Measle-specific IgM antibodies, PCR
Vaccine: MMR @12-15mo, 2nd dose @4-6y
tx
Supportive: acetaminophen, ibuprofen, oral hydration
*vitamin A for young/severely malnourished children; boosts immune response; ↓ risk of complications & death
Scarlet Fever sx, dx, tx
Etiology: group A strep
sx
Prodrome: fever, chills, pharyngitis
Rash: diffuse erythema that blanches w/ pressure + multiple small papular elevations w/ sandpaper texture
*axillae/groin 🡪 trunk/extremities (spares palms/soles)
Flushed face w/ circumoral pallor & strawberry tongue
Pastia’s Lines: linear petechial lesions seen at pressure points, axillary, antecubital, abdominal, or inguinal areas
dx: clincial
tx
Penicillin G or VK first line
- amoxicillin
- macrolides if PCN allergy
- clindamycin, cephalosporins
Rubella sx, dx, tx
sx
Prodrome: flu-like sxs (mild fever), arthralgias, postauricular LAD
Rash: erythematous, maculopapular rash; cephalocaudal spread (face downwards)
*spares palms/soles; disappears within 3d aka “3d measles”
*spreads much more rapidly than measles, does not darken/coalesce
Forchheimer spots: pinpoint red macules & petechiae on soft palate & uvula
dx: Clinical
Rubella-specific IgM Ab via EIA
tx
Supportive: acetaminophen, ibuprofen, oral hydration
*immunoglobulin in exposed individuals
Vaccine: MMR @12-15mo, 2nd dose @4-6y
Complications: teratogenic in 1st TM
*deafness, cataracts, congenital heart defects (PDA)
Erythema Infectiosum – 5th Disease MC, sx, dx, tx
Etiology: parvovirus B19 – infects & destroys reticulocytes, leading to a ↓ or transient halt in erythropoiesis
sx
Prodrome: flu-like sxs (mild fever, HA, malaise); *rash follows by a few days
Rash: “slapped cheek” rash; lacy reticular rash on extremities; spares palms/soles; resolves in 2-3wks
*arthritis or arthralgias in older children/adults
dx: Clinical
Serologies: parvovirus B19-specific IgM antibodies
tx
Supportive: acetaminophen, NSAIDs
Complications: hydrops fetalis in pregnancy, aplastic crisis in pts w/ sickle cell
Roseola Infantum MC, sx, dx, tx
Etiology: MC caused by HHV-6; less commonly HHV-7
sx
Prodrome: 3d of high fever – child appears well during febrile phase; can reach >104F
Rash: pink maculopapular blanchable rash
*starts on trunk 🡪 face (only viral exanthem that starts on the trunk)
dx: Clinical
Viral culture/PCR for confirmation
IgG antibodies against HHV-6/7
tx
Supportive: rest, fluids, antipyretics (acetaminophen)
Immunocompromised: antivirals (ganciclovir)
Complications: febrile seizures
Hand, Foot, & Mouth Disease MC, sx, dx, tx
Etiology: coxsackie virus A
Transmission: person-person, respiratory droplets, feces, direct contact w/ contaminated surface
MC in children <5yrs; MC in summer/early fall
sx
Prodrome: flu-like sxs, oral pain *rash follows within few days
Rash: painful vesicles & ulcers in mouth 🡪 vesicles on palms/soles
*usually clears within 10d
dx
Clinical – viral culture/PCR of throat swab or stool sample
Coxsackie-specific immunoglobulin A
tx
Supportive: acetaminophen, ibuprofen, hydration, topical lidocaine; usually resolves in 1wk
Complications: aseptic meningitis, Guillain-Barre syndrome
Herpangina MC, sx, dx, tx
Etiology: coxsackie virus (esp. type A)
MC in children 3-10yrs; MC in summer/early fall
sx
Sudden onset high fever
Stomatitis: small yellow white papulovesicular lesions on posterior pharynx (soft palate, uvula, tonsils) that ulcerate before healing
*anorexia due to pain common
*pharyngitis, odynophagia
*NO SORES ON HANDS/FEET
In older children: +/- malaise, HA, N/V, neck stiffness, back stiffness
dx: Clinical
Coxsackie-specific immunoglobulin A; viral culture
tx
Supportive: acetaminophen, ibuprofen, hydration
Mumps MC, sx, dx, tx
Etiology: paramyxovirus
sx
Prodrome: low-grade fever, fatigue, myalgia, malaise, HA, earache
Parotitis: parotid gland pain & swelling; usually bilateral
PE: parotid gland swelling & tenderness
dx
Clinical, serologies
↑ amylase, leukopenia w/ a relative lymphocytosis
tx
upportive: acetaminophen, ibuprofen, analgesics
Complications: epididymo-orchitis MC
Varicella Zoster Virus shingles vs chicken pox definition
VZV causes 2 clinically distinct diseases:
*Primary: varicella (chickenpox)
*Reactivation: herpes zoster (shingles)
Transmission: aerosolized droplets, direct contact w/ vesicular fluid
Incubation: 14-21d; asymptomatic
Travels retrograde to trigeminal ganglion & dorsal root ganglia where it can remain dormant in a latent state for many years; later, if immune system weakens (aging, stress, immunosuppressive therapy), virus can be reactivated & travel anterograde through sensory nerve to skin (herpes zoster/shingles)
Varicella Zoster Virus shingles vs chicken pox sx
Varicella (chickenpox): “dew drops on a rose petal”
Prodrome: fever, malaise, anorexia, pharyngitis; rash appears 24h later
Rash: *appears in successive crops over several days
*starts as macules, rapidly become papules, then vesicles; can develop pustular component followed by formation of crusted papules; crusts fall off within 1-2wks; leave temporary area of hypopigmentation
*lesions in different stages of development, PRURITIC!!!
Herpes zoster (shingles):
Prodrome: pain, itching, or tingling in area where rash will develop
Rash: single stripe of vesicles (single dermatome); don’t cross midline
*usually resolves within 1mo, but pain can last >90d 🡪 postherpetic neuralgia
Zoster Ophthalmicus: involves ophthalmic division of trigeminal nerve; 5
*eye pain, redness, swelling + fever + painful vesicular rash
Zoster Oticus (Ramsay-Hunt Syndrome): involves facial nerve (8)
*otalgia; lesions on ear, auditory canal, & TM; facial palsy, hearing loss
Varicella Zoster Virus shingles vs chicken pox dx
Clinical
PCR: viral DNA; confirmatory
Blood tests: IgM antibodies
Tzanck smear:
*multinucleated giant cells
Zoster Ophthalmicus:
*dendritic lesions on slit lamp if keratoconjunctivitis is present
Varicella Zoster Virus shingles vs chicken pox tx
Varicella (chickenpox): resolves in 1wk; develop immunity
*healthy children <12yo: supportive (ASPIRIN 🡪 REYE)
*≥13y & unvaccinated, immunocompromised: antivirals
PO acyclovir, valacyclovir, famciclovir
*varicella-zoster immune globulin (VZIG)
Herpes zoster (shingles): rash usually resolves in 1mo
*acyclovir, valacyclovir, famciclovir within 72h to prevent postherpetic neuralgia
Zoster Ophthalmicus: PO antivirals, can add acyclovir ophthalmic
Ramsay-Hunt: PO acyclovir, corticosteroids
Postherpetic Neuralgia: gabapentin, TCAs, topical lidocaine gel, capsaicin
Vaccines: varicella @12-15mo, second dose 4-6y; recombinant zoster vaccine (RZV) in pts >50y, 2 doses 2-6mo apart
Herpes Simplex Virus 1 vs 2 definition
HSV 1 – cold sores
Transmission: direct contact w/ contaminated saliva or other infected bodily secretions
HSV 2 – genital herpes
Transmission: sexually transmitted
Herpes Simplex Virus 1 vs 2 dx
HSV 1:
Primary lesions:
*most are asxs but may cause tonsillopharyngitis in adults & gingivostomatitis in children
*Herpetic Whitlow: herpes of the finger
Secondary lesions:
*Herpes Labialis (cold sore): prodromal sxs (pruritis, burning, tingling, pain) followed by grouped vesicles on an erythematous base; crust over before healing
HSV 2 (genital herpes):
Prodrome: burning, paresthesias, numbness; dysuria, fever
Rash: multiple, shallow, tender ulcers; grouped vesicles on an erythematous base; inguinal LAD
Herpes Simplex Virus 1 vs 2 dx and tx
dx
PCR
Tzanck smear: multinucleated giant cells
tx
HSV 1:
Orolabial: PO valacyclovir (2g BID x1d)
HSV 2:
Acyclovir, valacyclovir, famciclovir
Brown Recluse Spider Bite MC, sx, tx
MC in southwestern/midwestern US
Spider: violin pattern
sx
Local effects: local burning/erythema for 3-4hrs 🡪 blanching of affected area (due to vasoconstriction) 🡪 erythematous margin around the ischemic center “red halo” for 24-72hrs 🡪 hemorrhagic bulla that undergoes eschar formation
10% may develop skin necrosis
Systemic effects: fever, chills, N/V, morbilliform rash
tx
Local wound care + pain control
- local wound care: clean w/ soap & water, cold packs, elevation (most heal spontaneously within days to weeks)
- pain control: NSAIDs (opioids if severe); tetanus prophylaxis if needed
Black Widow Spider Bite sx and tx
Spider: red hourglass shape
PATHO: produces a neurotoxin
sx
Local sxs: pain at bite site
Systemic & neurologic sxs: onset within 30min-2hrs – muscle pain (most prominent feature), spasms, rigidity
Usually self-limited w/ resolution within 1-3d
PE: blanched circular patch w/ a surrounding red perimeter & central punctum (target lesion)
tx
Mild: wound care + pain control – soap/water, NSAIDs, opioids
Moderate to severe: muscle relaxants (BDZs, methocarbamol)
Antivenom reserved for pts not responsive to above
Pilonidal Disease definition, sx and tx
Results from an abscess, or sinus tract, in the upper part of the natal (gluteal) cleft
Pilonidal means “nest of hair” – a hair in the natal cleft allows hair to be drawn into the deeper tissues via negative pressure caused by movement of the buttocks, follicular occlusion from stretching, & blocking of pores w/ debris
MC seen in pts in late teens/early 20s; male predominance
Less frequently seen in children & >45yrs
sx
3 distinct clinical presentations:
*Asymptomatic: painless cyst or sinus at the top of the gluteal cleft
*Acute Abscess: severe pain, swelling, discharge from the top of the gluteal cleft that may or may not have drained spontaneously
*Chronic Abscess: persistent drainage from a sinus tract at the top of the gluteal cleft
dx: clinical
tx
Acute: prompt I&D
*abx only needed if cellulitis suspected (cefazolin + metronidazole or Augmentin)
Chronic: surgical excision
