Derm 2 Flashcards
What are the verrucous lesions?
Actinic keratosis
Seborrheic keratosis
What is actinic keratosis?
Most common pre-cancerous skin lesion resulting from chronic, cumulative sun exposure in susceptible individuals
Squamous cell carcinoma can arise from pre-existing AK
Presentation of actinic keratosis? dx?
single or multiple, discreet, 3mm-1cm erythematous or brown rough, scaly papules and plaques found on sun exposed skin; scale is coarse, sandpaper-like
Diagnosis: clinical, biopsy
Tx for actinic keratosis?
Cryotherapy – most common treatment Topical fluorouracil (Efudex) Topical imiquimod (Aldara)
prevention: good sun protection
What is seborrheic keratosis?
Common benign growths
onset 40-50 y/o
Oval, slightly raised, tan/light brown to black well-demarcated papules or plaques <3cm in size, “stuck-on” waxy greasy verrucous appearance on trunk, scalp, face, neck, extremities; usually multiples
Tx for seborrheic keratosis?
none necessary
Cryotherapy or curettage if irritating or bleeding
Biopsy to r/o malignant lesion if suspicious
What is the MC skin malignancy?
basal cell carcinoma
Epidemiology of basal cell carcinoma?
Occurs mostly in fair-skinned ind. 20-40 y/o
Heavy, cumulative sun exposure is a predisposing factor
Limited potential for metastasis
Clinical findings of basal cell carcinoma?
translucent, telangiectatic pearly papule/nodule with rolled border and sometimes ulcerated center; 85% on head and neck
“sock donut” with necrotic center
Tx for basal cell carcinoma?
bx for dx
Surgical – excision, curettage, MOHS surgery
Epidemiology of squamous cell carcinoma?
2nd MC skin CA
usually in pts >55
usually arises from AKs
Risk factors for squamous cell carcinoma?
Long-term sun exposure is major risk factor; exposure to industrial carcinogens, HPV, immunosuppression are predisposing factors
Clinical findings in squamous cell carcinoma?
solitary, slowly evolving keratotic or eroded erythematous, yellowish, or skin-colored papule or plaque found on sun exposed areas
Tx for squamous cell carcinoma?
biopsy for dx –>
excision, MOHS surgery
Any isolated keratotic or eroded papule or plaque present >1 month should be considered a…… until proven otherwise by biopsy
SCC
Epidemiology of malignant melanoma? Etiology?
MC CA among women aged 25-29
cumulative UV exposure
Risk factors for malignant melanoma?
age, fair skin, blue eyes, red or blonde hair, freckles, multiple nevi, atypical nevi, FHx, blistering sunburns before puberty, tanning bed use
What are the 5 types of malignant melanoma?
Superficial spreading- MC (men-back, women-back and legs)
Nodular – grows fast, more aggressive, grows vertically
-Breslow’s depth
Lentigo maligna
Acral lentiginous – MC in darker skin
Subungual
Presentation for malignant melanoma?
usually no symptoms, typically a pigmented papule, plaque, or nodule
What to look for with malignant melanoma?
Asymmetry Border- irregular/jagged Color-multi-colored Diameter >6mm (pencil eraser) Evolving
What type of melanoma can be seen freq. on the hands and feet and is more common in darker skin individuals?
Acral lentiginous
Dx for malignant melanoma?
need to do an excisional biopsy!!
Management for malignant melanoma?
high cure rate if dx early
thickness of lesion most important px factor
lymph node involvement has worse px
skin exam Q6 months x 2yrs
What is kaposi sarcoma? Presentation?
Vascular neoplastic condition linked to HHV-8
red, brown, or purple macules, plaques and nodules on trunk, extremities, face
Dx of kaposi sarcoma?
biopsy
Test for HIV if status unknown
AIDS associated type is more aggressive
Tx for kaposi sarcoma?
AIDS associated – treat with HAART, refer to oncologist/HIV specialist
Non-AIDS associated – cryotherapy, radiation, chemotherapy
What are dematophytoses?
Group of fungal infections affecting keratinized cutaneous structures; transmitted by humans, animals, soil
- Epidermal i.e. tinea pedia, (tinea corporis)
- Trichomycosis-dermatophytosis of hair and hair and hair follicles (tinea capitus)
- Onychomycosis-nail apparatus
Dx and tx for tinea pedis, tinea corporis, or tinea cruris?
KOH-hyphae
Clotrimazole, miconazole, terbinafine cream 4-6 wks
Dx and tx for tinea capitis?
Fungal culture-hair w/ whole follicle
Griseofulvin x 8 weeks or terbinafine 4-8 weeks (oral therapy!)
Dx and tx for onychomycosis?
Fungal culture, KOH of subungual debris
Oral terbenafine x 12 weeks, cure in 50%
What is tinea versicolor?
actually a yeast, not a dermatophyte
SF yeast infection caused by Malessezia furfur
colonization in humid environment, recurs in summer
Clinical findings in tinea versicolor?
hypo- or hyperpigmented coalescing scaly macules of varying color on trunk, upper extremities (tan, salmon)
Post-inflammatory hypomelanosis- after resolution, pigmentation doesn’t go away
How do we dx tinea versicolor?
scrap scales, KOH- spaghetti and meatballs
wood’s lamp exam: blue/green fluorescence
Tx for tinea versicolor?
Shampoo- selenium sulfide, ketoconazole- let it sit on skin x 10 min
Creams: ketoconazole, clotrimazole
Oral: Fluconazole, Itraconazole
ADEs of antifungals?
Hepatotoxicity, GI side effects, drug interactions, monitor LFTs
What is candidiasis? Predisposing factors?
(Candidia albicans)
Inflammation of skin folds = intertrigo
Predisposing factors: moisture, warmth, breaks in skin barrier, antibiotics, glucocorticoids
Clinical findings in candidiasis?
papules and pustules on erythematous base -> confluence and erosion ->beefy red patches with satellite lesions; burning>pruritis
How do we dx candidiasis?
KOH – pseudohyphae, spores; fungal culture may be more sensitive
How do we tx candidiasis?
Keep area dry, clean, cool
Loose clothing
Topical antifungals – miconazole, clotrimazole; nystatin
Topical steroids – helps burning; use low potency (1% hydrocortisone ointment)
What is condyloma acuminata?
A viral disease
genital warts
Etiology of condyloma acuminata? assoc. with?
caused by HPV 6, 11, 16, 18, 31 ++
Associated with neoplasia (16 & 18 cause most cervical CA)
Clinical findings in condyloma acuminata?
fleshy, broad-based papules
Tx for condyloma acuminata?
surg removal
electrocautery
laser
Imiquimod (cream also used for AK)
Prevention: HPV vaccine
What is verruca vulgaris?
viral: common wart
caused by HPV (types 2, 4)
clinical findings in verruca vulgaris?
Hyperkeratotic, exophytic papules on fingers, hands, knees (can occur anywhere)
Punctate black dots – thrombosed capillaries
Koebner rxn -spreads with skin trauma
Epidemiology of verruca vulgaris?
common in all age groups, skin to skin contact, contaminated objects
What are verruca plana?
viral: flat warts
caused by HPV (type 3, 10)
Clinical findings of verruca plana?
Skin colored or pink smooth slightly elevated flat-topped papules on dorsal hands, arms, face
What are palmoplantar warts?
viral: caused by HPV
Thick, endophytic papules on palms or soles of feet
Can form a callus
Pain with walking
What is a variated of palmoplantar warts?
mosaic warts (smaller warts coalesce into a large wart plaque)
Tx for palmoplantar warts?
Can spontaneously resolve
Acids, cryotherapy, retinoid cream, surgical removal, duct tape, laser – all irritating or destructive
Imiquimod, Candida antigen - Immune-stimulating
What is herpes zoster?
Reactivation of varicella-zoster virus latent in the nerve ganglia (same virus that causes chicken pox)
75% occur in patients >50 y old
Clinical findings of herpes zoster?
Prodrome of stinging/pain
Clinical findings: grouped vesicles on erythematous base, unilateral, in dermatomal distribution
Tx for herpes virus?
to prevent post-herpetic neuralgia
Valacyclovir or famciclovir PO within 48-72 hrs of eruption
Pain control
What will you see if you have ocular involvement in herpes zoster? What should you include in tx plan?
Hutchinson’s sign: vesicles on the side and tip of nose- nasociliary branch of trigeminal nerve affected
ophthalmology consult ASAP
What is molluscum contagiosum?
viral disease
Well demarcated small 2-6mm smooth, firm, shiny dome-shaped flesh-colored papules with central
UMBILICATION caused by DNA poxvirus
What two skin abnormalities can you seen umbilical lesions in?
molluscan contagiosum
basal cell carcinoma
How is molluscum contagiosum transmitted?
spread by skin to skin contact
genitalia in adults - considered STI
Tx for molluscum contagiosum?
spontaneous resolution
cryotherapy, curettage, acids, cantharidin
topical therapy- retinoids
What is impetigo?
Superficial infection of the epidermis by S. aureus and GAS (S. pyogenes) arising from superficial breaks in the skin or as a secondary infection of pre-existing dermatoses.
Clinical findings of impetigo?
small vesicles or pustules rupture ->erosions with yellow honey colored crusts usually peri-nasal or intertriginous sites (bullous form)
How can we dx impetigo?
gram stain or culture
but usually clinical dx
Tx for impetigo?
topical mupirocin (Bactroban) or retapamulin
How can we prevent impetigo?
proper hygiene, very contagious
daily bath with antibacterial soap, frequent hand washing;
check for other family or household members
What is erysipelas?
Upper dermis infection, more superficial than cellulitis
Group A strep
Clinical findings of erysipelas?
Raised, well demarcated
Enlarges rapidly
Face, arms, fingers, legs, toes
Tx for erysipelas?
IV antibiotics if systemic symptoms, otherwise oral PCN or amoxicillin
What is cellulitis?
Erythema, edema, warmth of skin
Infection in deep dermis and subcutaneous fat
Disruption of skin barrier predisposes to this
GAS and Strep pyogenes most common pathogens
Tx for cellulitis?
abx covering beta hemolytic strep and MRSA
-Cefazolin IV or cephalexin oral
What is scabies?
Infestation of the mite Sarcoptes scabiei spread by skin-skin contact; intensely pruritic especially worse at night
Clinical findings of scabies?
papules with excoriations and gray or skin-colored burrows in s-shape diagnostic especially in finger webs, wrists, ankles, feet, genitalia
Tx for scabies?
permethrin 5% topical lotion/cream
or Lindane or oral ivermectin
tx all household contacts
antipruritics (can be itchy for 6 wks after tx)
What is pediculosis?
lice
Capitis (head lice) and pubis (pubic lice) are most common
Pruritus in the affected area, nits (oval grayish-white egg capsules) may be visible
Tx for pediculosis?
permethrin 1% OTC or 5% overnight for resistance
- Malathion (ovide)
- 5% benzyl alcohol (Ulesfia)
- Treat all contacts
- Heat sensitive
What is the MC presentation from non-poisonous spider bites?
papular urticaria
Presentation for brown recluse spider?
venom is necrotizing
Mild urticaria to full-thickness necrosis
Spider has yellow-brown body with violin-shaped dark brown mark on abdomen
Tx for brown recluse spider bit?
ice/elevated?
abx: erythromycin, cephalosporins
update tetanus
Presentation for black widow spider?
venom is neurotoxic
Bite is non-painful; within minutes or hours, severe muscle cramping leg, back, generalized abdominal pain
Spider has red hourglass abdominal markings
Tx for black widow spider bit?
antivenom
muscle relaxants
supportive care
What is alopecia aerta?
Focalized hair loss
Autoimmune attack on hair follicles on head, beard, any hair-bearing body location
Can have associated autoimmune disorders
Clinical findings in alopecia aerata?
discrete, smooth round or oval areas of hair loss without visible inflammation of scalp, face, body
May have nail pits
Exclamation point hairs
Tx for alopecia aerata?
reassurance-spontaneous resolution in 6 months
Topical steroid – potent
Topical minoxidil
Intralesional steroids
Refer to dermatology - especially if larger areas of hair loss
What is paronychia?
Acute infection of lateral or proximal nail fold usually caused by S. aureus occuring from a break in the epidermal skin
Pt will c/o throbbing pain
Clinical findings in paronychia?
tenderness, erythema, swelling, +/- abscess formation and purulent drainage
Tx for paronychia?
warm compresses- sufficient in mild cases
I&D-Bacterial culture
Oral antibiotics based on organism sensitivity (cephalexin, dicloxacillin)
What is vitiligo?
Autoimmune process of melanocyte destruction leading to depigmentation; cause unknown
What are the predisposing factors to vitiligo?
genetic factors, stress, illness, trauma, severe sunburn
clinical findings in vitiligo?
bilateral, symmetric sharply defined depigmented “chalky”-white macules on hands, face, elbows, knees, skin folds, genitals
Tx for vitiligo?
sunscreens, cosmetic cover-up
Repigmentation – topical glucocorticoids and tacrolimus, PUVA, grafting
What does vitiligo look like on wood’s lamp?
chalky white- full depigmentation
What is melasma?
Common disorder; melanocytes produce a large amount of pigment when stimulated by UV light or increase in hormone levels (pregnancy, OCP’s), “mask of pregnancy”
unknown pathogenesis
Epidemiology of melasma?
darker skinned ind/ susceptible, women > men
Clinical findings of melasma?
sharply demarcated brown patches on the forehead and malar prominences
Tx for melasma?
sunscreen
Hydroquinone, tretinoin
Chemical peels, laser treatments
What is acanthosis nigricans?
Localized skin disorder manifested by hyperpigmented, symmetrical velvety plaques that are grayish, black, or brown commonly found on the neck, skinfolds
Can occur in obese persons with or without endocrine disorders
What are some conditions assoc. with acanthosis nigricans?
obesity, diabetes, PCOS
atypical presentations and acute onset - malignancy
acanthosis nigricans MCly affects…
Native American, African American, and Hispanic populations
Tx for acanthosis nigricans?
treat underlying condition
Fasting plasma insulin and glucose, weight loss counseling
Topical therapy for cosmetic purposes: lactic acid 12% cream, urea cream, retinoids, salicylic acid 6%
What are pressure ulcers? (Decubitus ulcers)
Bedsores; produced anywhere on the body by prolonged pressure especially bony sites- below the waist (95%)
Clinical findings of pressure ulcers?
“punched-out” ulcer -> necrosis with grayish pseudomembrane
Tx for pressure ulcers?
prevention – minimize pressure, change positions q 2 hours, foam products
Ulcer care- debridement, cleansing, wet-dry dressings, occlusive dressings
Bacterial culture if secondary infection is suspected
