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Derm 2.0 Flashcards

1
Q

What are the two functions of the epidermis?

Where is the epidermis thinnest and thickest?

What are the 5 layers from superficial to deep

A

Pathogen barrier, Water regulation

0.3mm- eyelid
3mm- back

Corenum- dead cells, primary barrier
Lucidum- lucent, only in thickest skin
Granulosum- keratinocytes lose nuclei/flatten
Spinosum- desmosome connection, Langherhan location
Basal- dividing keratinocytes, melanocyte/Merkel location

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2
Q

What are the 9 examples of primary lesions

A

MP3 NPV BW
Macule- flat discoloration
Patch- macule >1cm wide
Papule- elevated, < than .5cm wide
Plaque- elevated lesion >0.5cm, made of papules
Nodule- elevated, round lesion >0.5cm (large= tumor)
Pustule- collected leukocyte fluid (pus)
Vesicle- collection of free fluid 0.5cm or <
Bulla- collected fluid >0.5cm
Wheal- edematous plaque from dermis infiltration by fluid

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3
Q

Define Secondary Lesions and what their presence infers

A

Primary lesion modification (scratching, infection)
Infers primary Dz process

Fissure- loss of epi/dermis w/ defined walls
Atrophy- skin depression from thinning of epi/dermis
Crust- dried serum/cellular debris (scab)
Erosion- loss of epidermis, not below DE junction= no scar
Scale- excess cells from abnormal keratinization/shedding
Ulcer- loss of epidermis and dermis; heal w/ scar
Scar- abnormal CT formation, implies dermal damage

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4
Q

Define Special Skin Lesion

A

Lesion not characterized by primary or secondary definitions EMC BLT PCP:

Excoriation: linear erosion from scratching
Milia: superficial keratin cyst w/out opening
Comedone: plug in follicle (dilated- black, narrow- white)
Burrow: channel from parasite
Lichenification: thickened epidermis from scratching
Telangiectasia: dilated superficial blood vessel
Petechia: blood deposit <0.5cm wide
Cyst- lesion w/ wall and lumen
Purpura: blood deposit >0.5cm wide

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5
Q

What type of skin test is done for herpes

What is patch testing done for

What are the four main Tx categories of derm

A

Tzanck prep

Allergies

Topical Systemic Photo-therapy Surgical

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6
Q

What is the purpose of Topical Therapy

Dry skin/cutaneous lesions are corrected by replacing moisture w/ ? two ways

Xerosis Cutis:
Sxs
MC location/worse during ? time
Tx

A

Restore skin function after removal of water/lipid/protein from epidermis

Emollient cream, Lotion

Rough skin w/ white scale, progress to thick/tan patches
MC: hands/lower legs, worse during dry/winter months
Tx: emollients- 12% lactate lotion (Lac-Hydrin, AmLactin)

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7
Q

Emollient w/ ? two added ingredients have special lube power

? is thicker and more lubricating than lotion

What two ingredients can be added to topical therapies to decrease pruritus

A 
Urea (Carmol, Vanamide)
Lactic Acid (Lac-Hydrin, AmLactin)

Creams

Menthol, Phenol

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8
Q

What are 4 solutions used for Topical Therapy: Wet Dressings and indications for use

What is the technique for using Wet Dressings

A

Silver Nitrate 0.5%- aqueous solution, can stain skin; bactericidal, infected lesions (stasis ulcers/dermatitis)

Water- no need to be sterilized; Sunburn Ivy Non-infected

Acetic acid 1-2.5%- diluted vinegar; Pseudomonas

Burrows (Aluminum Acetate)- 1-3 packets in 16oz water, mild antiseptic; Athlete foot, Bite, Ivy acute inflammation

4-8 layers of material
Wring until sopping wet
Place on area and leave x 30-60min x 2-4/day
Stop when skin becomes dry

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9
Q

Define Vehicle and what does the vehicle determine

What are the 6 types of Vehicles

A

Base substance that disperses active ingredient
Rate of absorption

Ointment: primarily grease w/out preservatives
Most Moisturizing Occlusive Lipophilic
Not for: acute eczematous inflammation/intertriginous

Cream: organic chemical, water, preservative.
Most useful: intertriginous
Adverse: Sting Allergy Irritate Dryness

Foam: useful for Scalp dermatosis Ivy Plaque psoriasis
Don’t use <12y/o or >2wks

Lotion/Solution: water, ETOH and chemical mixture; LEAST lipophilic/MOST useful on scalp
Adverse: intertriginous use= sting/dryness

Gel: propylene glycol and water/alcohol; Greaseless
Useful: Ivy, Scalp

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10
Q

Waterproofing occlusion can enhance a steroids potency by ? much

Application to ? areas have natural occlusion and need caution

What effect does Hydration have on Topical Steroid Therapy

? regions of the body will have in/decreased topical steroid absorbing abilities

A

100x

Obese Axilla Inguinal Diaper

Stretches cellular connections- inc absorption 4-5x

Inc: eye lid/face d/t thin corneum w/ inc blood flow
Dec: sole/palm d/t thick stratum corneum

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11
Q

What are the local adverse effects of using Topical Steroid Therapy

A

WAR BIRD BASHH
Worsening infection
Atrophy
Rebound phenomenom

Burning
Itching
Rosacea
Dry skin d/t cream/lotion

Bruising
Acne/folliculitis
Striae
Hypertrichosis (face)
Hypopigmentation
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12
Q

How does local allergic reaction to topical steroid therapy present

Occasionally this allergic reaction will develop ? three signs?

If an allergic reaction is suspected, what is the next step

A

Chronic dermatitis that isn’t worse/better w/ CCS

Exanthem Purpura Urticaria

Patch testing

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13
Q

What are the adverse systemic effects of Topical Steroid Therapy

What are two benefits of IM steroid therapy and what is the risk of use

A 
FTT
Adrenal axis suppression (<2y/o, puberty)
Glaucoma
Stunted growth
Cushing Syndrome
Cataracts

Longer lasting, Easier
Local atrophy, especially if needle too short

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14
Q

What are the 5 MC mistakes of Topical Steroid Therapy

What is the unit of measurement for Topical Steroid application and what does this unit of measurement equate to in weight

Define the “Rule of Hand” for Topical Steroid Therapy usage

How much does one hand area equate to

How many hand areas are needed for one gram of medication

A

Failure to f/u
Too weak
Not enough given
Too strong face/kid

Finger Tip Unit- 5mm diameter
1FTU- 0.5gm

0.5FTU= one hand area/0.25gm

1% TBSA

4 hand areas= 1gm

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15
Q

Face/neck= ? FTU

Trunk= ? FTU

Arm= ? FTU

Hand= ? FTU

Leg= ? FTU

Foot= ? FTU

Child FTU Chart

A

F/n= 2.5FTU

Front/back trunk= 7FTU

Arm= 3 FTU

Hand= 1FTU

Leg= 6FTU

Foot= 2FTU

Deck 2, Slide 45

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16
Q

Topical Steroid Therapy dosing in general should not exceed ? much Group 1 agent

How often should certain steroid Groups be applied

Define Pulse Therapy and why would it be done w/ Group 1 agents

A

45-60gm/wk

1: QD-BID
2-6: BID x 2-6wks

2wks on, 1wk off
Avoids tachyphylaxis

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17
Q

? is the MC inflammatory skin Dz

This MC is often referred to as ?

What are the four characteristics of this MC

A

Eczema

Dermatitis- inflammation of the skin

Pruritus Erythema Vesicles Scale

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18
Q

What are the characteristic PE findings of the 3 stages of Eczema that can occur in any order, etiology and Txs

A

Acute: Vesicle Itch Bullae Erythema
D/t: Nummular Pompholyx Contact Stasis
Tx: ABX Steroid Antihistamine Cold compress

Subacute: Fissure Erythema Parched Scale
D/t: Atopic Contact Irritant Asteatotic
Tx: Antihistamine Steroids Emollients ABX

Chronic: Lichenification Excoriation Accentuation Fissure
D/t: LSC Atopic Habitual scratching
Tx: Antihistamine Steroid w/ occlusion Emollient ABX

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19
Q

How does Dyshidrotic Eczema present

What c/c may precede any PE finding

This is d/t irritants and is related to ?

How is Dyshidrotic Eczema managed and what is used as last resort when others fail

A

Symmetric ‘tapioca lesions; on palm/lateral finger/foot

Mod/Sev itching that turns into pain

Atopic dermatitis

PUVA- Psoralen+UV radiation
Antihistamine
Cool wet compress
Steroids w/ occlusion
Last Resort: Low dose Methotrexate
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20
Q

Define Asteatotic Eczema/Craquele

Where does this primarily develop although can be anywhere

What does this look like on PE

How is Asteatotic Eczema/Craquele managed

A

AKA Winter itch- itch>rash in atopic Pts during winter months/after long hot showers

Anterolateral legs

Cracked porcelain- accentuated dry, scaly skin lines

Group 3-4 steroids then emollient
Emollient after bath
Dec shower frequency/temp
OIC= wet compress w/ ABX

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21
Q

Who/How does Nummular Eczema present

What does this Latin term indicate for it’s appearance on PE

Where is Nummular Eczema likely to develop on the body

How is Nummular Eczema managed

A

> 50y/o w/ reoccurring spot each year as intense itching leading to lichenification

Coin shaped pruritic plaques w/ sparse/thin flakes

Dorsal hands
Upper extremities
Lower legs

Humidifiers
Antipruritics PRN
Group 1-3 steroids x 4-6wks
Emolients

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22
Q

Lichen Simplex Chronicus (LSC) is AKA and d/t ?

LSC can be precipitated by ? Dxs?

How does LSC appear on PE and what are the nodules called

How is LCS managed

A

Neurodermatitis- scratching causes eczematous eruption

Contact dermatitis
Atopic dermatitis
Nummular eczema
Seborrheic dermatitis
Nerve entrapment

Red papules w/ thick plaques that accentuate skin lines
Nodules= Prurigo nodularis

Biofeedback/behavior modification
Unconscious scratching- 1st gen antihistamine
Group 1 steroid, wean w/ improvement
Nodules= Intralesional Kenalog

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23
Q

Stasis Dermatitis is an inflammatory result d/t ? physiological process

How does Stasis Dermatitis appear on PE

How is this condition Tx

A

Decreased circulation distends vessels
Dec membrane permeability= fluid/proteins into tissue
Extravasation- stasis purpura/hemosiderin deposits

Hyperpigmentation Itch Scaling
Prolonged= Ulcers

Topical steroids Emollients Elevation Compression

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24
Q

Define Atopic Dermatitis

What will almost always be in their Med/FamHx

When do these Pts tend to experience flare ups

A

Chronic pruritic eczematous Dz that almost always begins in childhood but improves w/ age

Atopy Allergies Asthma Sinusitis Hayfever

Cold/Hot weather
Humidity
Illness/Irritants
Pollen
Stress
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25
Q

Atopic Dermatitis is AKA ?

What is the morphology of this condition

What secondary issues can develop

How does the distribution of Atopic Dermatitis change w/ age

A

Itch that rashes: Dry= Crack= Itch= Rash

Papules/plaques
Lichenification
Dermographism

Autoinnoculated Staph infections

0-2: red scale on cheeks
2-12: flexural area, face, scalp
>12: bilateral flexors; spares the face, except eyelids

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26
Q

How is Atopic Dermatitis Tx in adults, kids, steroid failure and recalcitrant/topical failures?

What two meds can be used to break the scratch cycles

What medication is used second line for Atopic Dermatitis Tx if Pt is intolerant/resistant to other therapies but can’t be used in ? two populations

A

Adult inflammation: Triamcinolone Fluocinonide
Children, inflammation: Desonide Hydrocortisone
Steroid failure= Crisaborole BID
Mod-Sev/Recalcitrant/topical failure= Dupiliumab (IL-4 inhibitor)

Hydroxyzine, Diphenhydramine

Topical Calcineurin Inhibitors: Pime/Ta-crolimus
ImmComp; <2y/o

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27
Q

What is the name of the Atopic Dermatitis variant that presents during childhood

How is this variant Tx

A

Keratosis Pilaris- ASx spiny papules on extensor surfaces of arms/legs

Lotion w/ urea or lactic acid
Short course w/ mild steroid

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28
Q

Define Contact Dermatitis

What are the two types of Contact Dermatitis

How is the Dx made/confirmed

A

Eczematous dermatitis from exposures

Irritant (Occupation/Diaper): corneum barrier damaged; non-immunologic
Allergic: Ag absorbed, subsequent eruption

Patch testing

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29
Q

How do the 3 different phases of Irritant Dermatitis present

What part of the body is MC affected by this form oc contact dermatitis

How is this condition managed

A

Acute: Vesicle Exudate
Subacute: Cracked Inflamed Fissured
Chronic: Lichenification w/ less erythema

Hands, but can be anywhere

Avoidance
Cool compress
Emollient= protective barrier
Steroid, topical

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30
Q

? is the #1 and #2 MC cause of Allergic Contact Dermatitis and how does this eruption appear on PE

How is Dx of Allergic Contact Dermatitis made/confirmed

How is Allergic Contact Dermatitis managed

A 
#1: Nickel
#2: Poison ivy (Uroshiol)
Pruritic Erythematous Crusty Swollen

Patch testing

Mild-Mod: topical steroid x 2wks
Sev: PO steroid x 2wks w/ taper
Antihistamine
Cool, wet compress

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31
Q

Define Urticaria

What causes Urticaria at the pathophysiological level and causes skin to take on ? appearance

Define Physical urticaria and what are the 6 types

A

Recurrent wheals (pruritic swelling of dermis that fade <24hrs)

Mast cell degranulation, histamine mediated response
Orange peel- dermis edema causes follicular accentuation

Dermographism
Pressure
Aquagenic
Cholinergic
Temp
Solar
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32
Q

Timelines for acute/chronic urticaria

Which one can lead to anaphylaxis

What labs may be ordered during Dx phase prior to being referred to ?

A

Acute: 6wks or less w/ acutely reproducible effects
Chronic: >6wks, smaller and less severe, Dx of exclusion

Acute; Tx: IV/IM Benadryl, CCS, Epi

CBC LFT UA ESR
Allergy

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33
Q

How is Acute Urticaria Tx

How is Chronic Urticaria Tx

How is Physical Urticaria Tx

A

H1 antihistamine
Avoidance
Prep for anaphylaxis: Benadryl Epi CCS

2nd Gen antihistamine
H2 blocker
PO steroid
Elimination diet

Pre-Tx w/ H1 blocker

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34
Q

Angioedema MC affects ? areas of the body

How is this condition Tx

STOPPED

A

Lips Eye Tongue Trunk Genitals Hands

IM/PO Antihistamine
PO steroid, if ossible

Slide 14, Deck 5

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35
Q

? PE finding is indicator of Measles

How does the Measles rash appear

How does the Measles rash spread

How is Measles Tx/Protected

A

Koplik spots: white spots on buccal mucosa

Blanching maculopapular, erythematous rash

Face, centrifugally: head to feet
As it clears, leaves brown discoloration/scale

Fluids Antipyretic Respiratory isolation w/ humidifier
Notify health department

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36
Q

How does HFM Dz present

How is HFM Dz Tx

A

First: 2-10 painful oral papules to vesicles
Typically: dorsal finger/toes

Support
Anti-histamine/pyretic
Diet adjustment if painful PO lesions

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37
Q

? Dz is AKA 5th Dz

How does this rash appear

When is Erythema Infectiosum contagious

How is it Tx

A

Erythema Infectiosum- Slapped Cheek

Macular erythematous and lacy, worsened by exercise

Prodrome, not during rash

Support

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38
Q

Kawasaki’s Dz is AKA ?

How does it tend to present to clinic and what are two key identifiers?

What are the 3 phases of this Dz

A

Mucocutaneous Lymph Node Syndrome

7wks-12y/o w/ fever 101-104 and cervical adenopathy
Strawberry tongue
Tender edema to palms/soles

Acute: 7-14 days; Strawberry Edema Rash Fever
Subacute: No fever-25days; Thrombocytosis Arthralgia Desquamation
Convalescent: no clinical signs - norm ESR (6-8wks total)

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39
Q

? is the MC adverse effect of drugs

What are the four types of reactions

How does the MC type of reaction present

What are possible culprits for this occurence

A

Cutaneous eruption

Fixed eruption
Urticarial
Maculopapular
Exanthematous- MC

Maculoapular/Morbilliform- Mucus Palm Soles
Spares face

TMP/SMX Acetaminophen Barbituates Antimalarials NSAIDs

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40
Q

How does a Fixed Drug Eruption present

Since these tend to occur at the same time, every time, where can they develop

How are Cutaneous Drug Reactions Tx

What are the two types of Cutaneous Drug reactions that tend to have more serious complications

A

Single/few red plaques that blister soon after first exposure to medication

MC- glans penis
Lips Hands Face Feet- involves face

Steroids, PO/Topical Group 3-5
Antihistamines
D/c medication

Urticarial, Exanthematous

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41
Q

Define Erythema Multiforme

What are the two types

What are the two etiologies

A

Immune mediated condition causing target/iris lesions

Major: major mucosal involvement
Minor: mild/no mucosal involvement

HSV- MC
Mycoplasma pneumonia

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42
Q

Where does Erythema Multiforme affect the body

What can be expected from this condition’s duration

How is this Tx

A

Palm Extensor surfaces Dorsal hands Soles
70%- mucosal involvement, eye= stat referral

Develop x 3-5d, Last x 14d
Resolves w/ hyperpigmentation of skin

V/A-cyclovir
Steroids, topical
Orajel
Antihistamine
Prednisone if widespread
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43
Q

Define SJS

What c/c may precede this condition’s mucocutaneous Sxs

Commonly, these SJS/TEN PTs are on ? meds?

Where/How does SJS cutaneous Sxs present

A

Vesiculobullous dz of Genital Eye Mouth Skin

URI w/ fever 102* or >
Stinging eyes, painful swallowing
Bullous lesions 1-14d after prodrome on palm/soles

Seizure ABX Gout:
Lamotrigine Mycoplasma -oxicams Allopurinol
TMP/SMX

Flat target/purpuric macules- FIRST on trunk then neck, face and upper extremities

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44
Q

TEN is initially seen mimicking ? but is d/t ?

What is the MC cause of TEN and why does this condition have a high mortality rate

How does this present/develop

A

SJS mucous membrane Dz;
Epidermis toxicity, causes full thickness necrosis

MC cause: medication toxicity (same as SJS)
Mortality d/t sepsis

Conjunctivitis
Ulcerative vaginitis
Painful red, sunburned skin
Stomatitis

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45
Q

What PE sign is seen in TEN to aid w/ Dx

How is the necrotic epidermis described in this condition

? part of the body is spared and ? part is constantly involved

A

Nikolsky: slight pressure peels epidermis from dermis

Wet cigarette paper that shows raw, scalded looking dermis

Spares: Scalp, GI tract
Constant: Ocular

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46
Q

How is TEN Tx

What is not used

Traditionally, SJS/TEN were considered more severe forms of ? and graded/classified depending on ? criteria

A

Plasma exchange IVIG Cyclosporine A Cyclophosphamide

CCS

Erythema Multiforme:
SJS: mucosal erosion, <10% skin detached
Overlap: 10-30% detached
TEN: >30% detached

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47
Q

Erythema Nodosum is usually limited to ? parts of the body

? type of reaction is this one

How is this condition’s presentation different than the other 3 hypersensitivity reactions

A

Extensor aspects of extremities

Hypersensitivity

More common in females
Erythematous eruptions on extensor surfaces
Sarcoidosis association

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48
Q

What is the presentation for Erythema Nodosum

How are the characteristic lesions described and located

How is this Tx

A

Low fever Arthralgia Malaise Arthritis

Red node swelling over shins
Week 1: tense, hard, painful
Week 2: fluctuant

Self limited, NSAIDs

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49
Q

Define Pyoderma Gangrenosum

This commonly occurs in ? population

Where do lesions begin

A

Non-infectious neutrophilic ulcerating skin Dz

IBDz

Tender, red lesion w/ pustule/vesicle
Necrotizing inflammation moves peripherally, leaves necrotic ulcer w/ purulent base, lasts months-years

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50
Q

Acne Vulgaris is a multifactorial Dz involving ? unit

What are the 3 components of this pathogenesis

Why is puberty such a triggering time frame for Acne Vulgaris?

A

Pilosebaceous

Secretions Obstruction Bacterial colonization by P. Acnes: breaks down sebum into free fatty acids, causes irritation/inflammation

T converted to Dihydrotestosterone= inc sebum= acne

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51
Q

How is Acne Classified

What is the rule about these two classifications

A

Non-Inflammatory: Open/Closed comedome
Inflammatory: Papule Pustule Nodule/Cyst

Inflammatory can have comedones
Non-inflammatory will not have inflammatory lesions

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52
Q

Criteria for Mild Non-Inflammatory Acne and how is it Tx

Criteria for Mild Inflammatory Acne and how is it Tx

Criteria for Moderate Inflammatory Acne and how is it Tx

Criteria for Severe Inflammatory Acne and how is it Tx

A

+Comedone/Papule/Pustule, - nodules
Retinoid (Tretinoin/Adapalene)
F/u 4-8wks
BPeroxide and/or Topical ABX (Benzaclin- combo)

+Papule/Pustule, - nodule
Retinoid and/or BPeroxide or Topical ABX
+ pustules at f/u= PO Doxy/Mino/Tetra-cycline x 3mon

+ Papule/Pustule and Nodule
Topical Retinoid and BPeroxide and PO D/M/T-cycline
Nodules= Triamcinolone injection 2.5-5mg

++Papule/Pustule and Nodule
Minimal scarring= Sulfacetamide or Topical ABX w/ BPeroxide
Scars/Long TxHx/Depressed/RxFailure= Accutane

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53
Q

What is the next step if Pt fails Mild Inflammatory Acne Tx

What is the next step if Pt fails Moderate Inflammatory Acne retinoid Tx

What is the next step if they fail the above step

A

Female/RxFailure/Not Accutane candidate= OCP/Spironolactone

Accutane

Relapse after 2nd course= OCP/Spironolactone

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54
Q

What are the alternative/2nd and 3rd line Tx options for Acne Vulgaris Txs

Severe Nodulocystic Acne usually presents in ? populations

How is this form Tx

A 
Tazarotene (retinoid)
Azelac acid (topical ABX)

Male w/ + FamHx

Isotretinoin- impacts/alters P Acnes, Inflammation, Comedogenesis and Sebum produciton

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55
Q

What are the two approved indications for Isotretinoin useage

How are Pts screened for eligibility for use and pledge

What FamHx needs to be asked for d/t loose association w/ this medication use and what odd PT education piece is needed

A

Nodular/Recalcitrant acne

6mon follow time
D/c Tetracyclines/Topical retinoids/Vitamins, esp Vit A
CBC HCG UA LFT Lipids before Rx, repeat each f/u
Female- hCG Qmon during, 1mon after w/ 2 BCs

IBDz
Can’t donate blood during Tx

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56
Q

What are the indication to d/c Isotretinoin usage

How does Adult Female Acne present

How is Adult Female Acne Tx primarily (w/ MOAs), second and last line

A 
Pregnancy
Mood swings (SI/HI)
S/Sx ICH: HA w/ vision change, unrelieved w/ OTC meds

Tender comedones on jaw/chin, worse during menses

Primary:
OCP- dec excess ovarian androgen suppression
Spironolactone- androgen receptor blockade
2nd: Tretinoin .025% cream
Last: Erythromycin 250mg

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57
Q

Who has Perioral Dermatitis and what PE finding is highly characteristic

What self-aid Hx is usually present in these PTs and w/ ? result

How is this condition managed systemically and locally

A

MC young females w/ pustules adjacent to nasolabial folds but clear border around vermillion border

Tried Bperoxide/Topical steroids w/ worsening Sxs

Systemic: Doxy and short use of HC cream
Local: Topical Erythromycin/Metronidazole

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58
Q

What is the suspected etiology behind Acne Rosacea

What is the morphology of this condition on PE

What will usually be in the Pts Hx

Since this can look similar to acne, what is missing on PE to differentiate the two Dxs

How is this condition Tx

A

Demodex Folliculorum

Rhinophyma
Swollen forehead/cheeks
Telangectasia

Long history of facial flushing leading to telangiectasia

Absence of comedones

Sunscreen/Avoidance
Metronidazole, topical (first line)
Azelaic acid
Tetracylcine- severe/resistant
Isotretinoin- refractory
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59
Q

Define Pomade Acne/Cosmetica

This usually involves forehead, temples and sides of the face, what areas can be spared?

How is this condition managed

A

Non-inflamed comedones in areas of product application

Sebaceous areas

Benzoyl Peroxide 10%
ABX for inflamed lesions
Tretinoin at bedtime
Stop all product use x 1mon

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60
Q

What 3 locations are MC affected by steroid acne

What is unique about this conditions morphology

How is Steroid Acne Tx

A

Chest Neck Back

Uniform size w/ symmetric distribution <4wks after PO CCS usage
No scarring, not c/i for further usage

D/c PO CCS
Benzoyl Peroxide and/or, Sulfacetamide lotion

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61
Q

Define Milia

Where do these MC appear

How are these managed

A

Epidermal cysts w/out openings d/t sun damage/physical trauma

Face, around eyelids

Few: Incision and excise, cannot express
Multiple: tretinoin until resolution

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62
Q

Define Miliaria

This can develop anywhere but especially ?

What structure is obstructed and causes the sweat retention etiology of this condition

How is it managed

A

Prickly eat rash; scattered skin-colored vesicles
Red= miliaria rubra

Forehead Trunk Cheeks

Eccrine gland occlusion

Anti-histamine, Cool compress

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63
Q

Define Hidradenitis Suppurativa

What is the etiology behind this condition

Where does this tend to occur

How is this condition staged for Tx

A

Painful, scarring of skin/SQ tissue ALWAYS presenting after puberty d/t invovlement of apocrine glands and folliculopilosebaceuous units

FamHx of scarring acne/hyperkeratosis over apocrine glands w/ secondary bacterial infections

Axilla Groin Infa-mammary

Hurley:

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64
Q

What morphology can Hidradenitis Suppurativa take on

What is a major trigger for this condition that is a part of Tx

What is the mainstay and other steps of Tx mild cases

How are extensive cases Tx

A

Double Comedone- black head w/ two or more communicating holes, healing makes band of scar tissue

D/c smoking

Tetracycline (DMET)= mainstay
(Rosh says Topical Clinda)
Hot compress
InD- large cysts
Steroid injections- smaller cysts

Surgical excision/grafts
Isotretinoin x 20wks

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65
Q

Define Staph Folliculitis

What is an uncommon Sx seen w/ this condition

This can develop as a complication of ? Tx

A

Painful pustules anywhere hair follicles are present w/ Staph A/E infection

Low fever

Occlusive topical steroids

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66
Q

What does it suggest if Pt has persistent/recurrent Staph Folliculitis

How is this Tx depending on the severity of outbreak?

How is this Tx if condition is persistent/recurrent

A

Nasal carrier

Isolated: topical Mupirocin/Clindamycin
Extensive: PO Dicloxacillin/Cephalexin

Hibiclens: hands, affected area
Mupirocin- nares
Clindamycin

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67
Q

What type of issue leads to PFB developing

How is PFB Tx

If on profile, Pts need to keep hairs how long?

Define Acne Keloidalis Nuchae

A

Foreign body reaction to hair= inflammation reaction from keratin and follicle distortion

BPeroxide wash
Glycolic/Aveeno shaving cream
Group 6-7 steroid on beard area after shaving
Group 2-3- steroid larger lesions
No resolution: add topical retinoid

<1/4”

Chronic scarring folliculitis w/out known etiology but coexists w/ PFB

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68
Q

If Acne Keloidalis Nuchae presents as pustular/exudative, how is it Tx?

What is the 3 step plan for controlling this condition?

A

Culture, Tetracycline x 3-6mon

Fluocinonide x3-6mon
Tretinoin x12mon
Clindamycin x12mon
PO steroids
Intrelesional injeciton
Laser therapy
Excisional surgery
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69
Q

Define EIC

These are more common in ? populations

How are these managed

A

Upper follicle occluded and dysfunctional, fills w/ sebum and swells

Oily sebaceous skin
FamHx cysts
Prone to acne

ASx/non-cosmetic: none
Non-inflammed: excision
Inflamed: Triamcinolone injection then excision
Ruptured: InD then excise

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70
Q

Pilar Cysts are AKA ?

How are these different than EICs

Nearly all will develop where and are Tx w/ ?

A

Wen

SubQ cyst w/ homogenous material that can calcify

Scalp, excision

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71
Q

What are the 5 topics of Papulosquamous D/os

What is the definition of the first type

What are the clinical presentations of the first types

A

Psoriasis Seborrheic Pityriasis Lichen Planus/Sclerosis

Immune mediated skin inflammation causing hyperkeratosis (7x faster; 4 vs 30 days)

Chronic Guttate Pustular Inverse

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72
Q

What do Chronic Psoriasis plaques look like

What ‘sign’ is seen if these plaques are picked off

Where is this disease distributed through the body

A

Flat, red papules w/ silvery scale

Auspitz- pin-point bleeding

Symmetric and Bilaterally:
Knee/Elbow extensor surfaces
Oil spot nails

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73
Q

What 3 medications can make Chronic Psoriasis worse

Sickness d/t ? type of microbe can cause this to worsen

How is Mild-Mod Psoriasis w/ <5% BSA Tx

Why is an analog used during Tx

A

BBs Lithium Systemic steroids

Strep

Salicylic acid then;
Analog Vit D3
Clobetasol/Fluocinonide to Triamcinolone w/ holiday
Calcipotriene- Vit D+Steroid combo
UVB light therapy
Tazarotene- topical retinoid (gel/cream)

Inhibit proliferation/neutrophils
Induces normal differentiation

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74
Q

How are Chronic Psoriasis- scalp lesions Tx

? Tx is best for moderate plaque psoriasis

What meds are used for facial/intertriginous psoriasis

What is the risk of using Tazarotene topical?

When is tar therapy most effective?

What therapy is ideal for chronic scalp/body plaques that are few/small in number

A

Traimcinolone spray/Fluocinolone solution
Diffuse/thick scale= Calcipotriene (Taclonex lotion)

Calcipotirol

Ta/Pimecrolimus w/ occlusion- doesn’t cause atrophy

Preg category x- excreted in milk

Combo w/ UVB therapy

Intralesion steroids

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75
Q

How is Chronic Psoriasis w/ >5% BSA Tx

Which ones are a-TNF, IL-17, IL-23 and p20 specific

Which ones are human Ab, fusion, human-ized Ab and chimeric Abs?

Which one is the only one w/out FDA and EMA approval

A

Biologics: Methotrexate Cyclosporine Aci/Iso-tretin UVA

a-TNF: Etanercept I/A-umab

17: SIB-umab
23: G-umab
p40: U-umab

Human: BAGUS-umab
Fusion: Etanercept
-ized: Ixek-umab
Chimeric: Inflix

Guse-umab

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76
Q

Define Guttate Psoriasis

What prodrome can precede ? presentation

What can cause Pts w/ Chronic Psoriasis to have a Guttate flare

What is first line Tx and later Txs?

A

Pts <20y/o, possible first indication of psoriasis

Strep pharyngitis/Viral URI- scaling pustules on trunk/extremities, spares palm/sole

Strep/Viral infection

First: UVB x 6-8ks
Analog Vit D Topical steroids Emollients

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77
Q

Where/how does Pustular Psoriasis present

What does this distribution develop as

How is it managed

What Tx needs to be avoided

A

Deep, creamy pustules on palm/sole that harden, fall off

Erythema forms on flexur areas, migrates to palm/sole
Pustules behind erythema

Cyclosporine Clobetasol Methotrexate Acitretin PUVA

PO steroids (induces severe Sxs)  
Smoking
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78
Q

What is the generalized variant of Pustular Psoriasis called

How do Pts present w/ this rare variant

Many Pts have ? Hx

A

von Zumbusch

Painful pustules Leukocytosis Febrile Toxic

Smoking

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79
Q

Define Psoriasis Inversus

What type of nail abnormality to these Pts have

Define Seborrheic Dermatitis

A

Flexur/Intertriginous scale that is macerated

Onycholysis
Subungual debris
Oil spots- localized separation of nail plate

Chronic inflammatory skin dz localized to areas w/ high sebum production

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80
Q

When does Seborrheic Dermatitis tend to peak in life

When do these Pts tend to have flares

What Pt populations tend to have more severe cases

This is one of the MC cutaneous manifestations of ? Dx

A

Teens Infancy Maternity (high hormonal periods)

Dryness Stress Hygiene changes

Elderly w/ neuro problems

AIDS

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81
Q

What is the etiology behind why Seborrheic Dermatitis exists

What morphology does this take on for PE

If this condition is long standing/chronic, what other issue is probably present

A

Over produced sebum
Over grown yeast (Malassezia furfur)

Greasy white/yellow flakes w/ pruritic/inflamed base

Staph infxn

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82
Q

How does the distribution of Seborrheic Dermatitis differ in infants and adolescent/adults?

What areas are less common to develop this condition

How is this Tx w/ shampoo, topical antigunal, topical steroid, secondary infections or mod/sev cases?

A 
Infant- scalp vertex; Cradle Cap
Adolescent/Adult- 
Posterior auricular fold
External ear canal
Nasolabial fold
Eyebrow/eyelash base
Scalp and margins

Presternal Umbilicus Groin Axilla

Shampoo/Topical: Ketoconazole
Steroid: Hczn/desonide (face) Fluocinolone (diffuse scalp)
Secondary infection: Diclox/Cephalexin
Mod-sev: PO Itraconazole

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83
Q

Pityriasis Rosea is d/t ? etiology and more common during ? times and in ? populations

How does this condition foreshadow and present

Where does the uncommon Reverse Pityriasis affect

A

HHV6/7 in 10-35y/o during colder months

Preceding URI, sudden Herald patch development- salmon pink in Christmas tree

Herald patch: trunk/prox extremities
Eruptive lesion: lower abdomen

Neck Face Palm/Sole

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84
Q

How is Pityriasis Rosea Tx

How are severe cases Tx

What odd DDx needs to be considered

A

Group 5 topical steroid
Antihistamine
Sunlight

Prednisone or,
UVB x 2wks or,
PO Acyclovir

Secondary syphillis

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85
Q

What type of reaction is Lichen Planus

This condition has an association w/ ? Dz

Define the Koebnerize phenomenon that occurs w/ this d/o

A

Inflamed skin/mucous membrane reaction

Hep C

Lesions form at site of skin trauma

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86
Q

What are the 5 P’s of Lichen Planus and what is the new, 6th P

What does the primary lesion look like

What type of striae may develop and how can they be seen

A 
Pruritic
Planar (flat topped)
Polygonal
Purple
Papule/Plaque
6th: Persistent

Flat papule w/ polygonal border

Wickman’s- white, lacy pattern of criss-crossed lines; easier to see w/ immersion oil

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87
Q

How do Lichen Planus papules progress through different colors

What type of distribution does this condition present w/

Although the true etiology is unknown, what are the 3 proposed etiologies

A

Pink/white to purple w/ waxy appearance

Scalp: scarring hair loss
Oral lesion- white, lacy
Nail: splitting/dystrophy 
Genitals
Acral: Hand Feet Ankle Wrist

Hep C Immune Drugs

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88
Q

How is a Lichen Planus Dx confirmed and why is this method needed

How is this managed if lesion is local, oral/resistant, generalized or itching

A

Biopsy to r/o SCC

Local: Group 1-2 w/ occlusion/injection q3wk
Oral: Clobetasol Fluocinonide Traimcinolone Azathioprine (resistant)
General: Prednisone
Itch: Hydroxyzine

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89
Q

Define Lichen Sclerosis

Where does this MC occur on the body

How do these manifestation appear early/later on

How is Lichen Sclerosis Tx

A

Inflammatory dz of superficial dermis/submucosa leading to ivory-white, scarring atrophy

Vulva Perianal Groin

Early: white-brown, horny follicular plugs
Later: porcelain/ivory w/ wrinkled atrophic surface

Topical Clobetasol: BID x 1mon, daily x 1mon
PUVA

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90
Q

What is the progressive morphology of Necrobiosis Lipoidica

What is the etiology of this condition

Nearly all lesions will occur ? on the body and if chronic, can develop into ?

How is it Tx

A

Purple ovals w/ red borders
Ulcerates, leaves woody induration

DM- diabetic microangiopathy

Anterior tib/fib;
SCC

Topical/Intralesion steroids: inflammation
PO steroids: stop Dz
Pentoxifylline

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91
Q

Who/where is Granuloma Annulare more likely to present

What do these lesions look like

The generalized form of this condition is associated w/ ? two systemic conditions

How are these Tx for cosmetic, disseminated, or generalized

A

Young/child w/ diabetic female on dorsal hand/feet (MC)

ASx flesh colored papule, Central involution, Inc diameter x months

DM or HIV

  • Cosmetic: topical w/ occlusio/papular ring injection
  • Disseminated- PUVA
  • Generalized: HydroxyChlqn Isotretinoin Dapsone
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92
Q

What unique texture does Acanthosis Nigricans have

Where is this MC to be seen

Condition can be d/t malignancy, MC ? type

How can the lesions be Tx although they are ASx

A

Velvety, symmetrical thickening and hyperpigmentation of skin

Axilla

Gastric

Ammonium lactate- softens lesions
Tretinoin- thins skin

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93
Q

Define Xanthomas

What are the 5 types

A

Lipid deposits in skin/tendons from hyperlipidemia

Xanthelasma- MC type; yellow plaques near canthus; half have normal lipids

Eruptive- sudden yellow plaque on extensor surface/pressure point w/ red halo; sign of hypertriglyceride; rapidly resolve w/ drop of lipids

Tuberous- slow papule on extensor surfaces/palm; sign of hypertriglyceride or biliary cirrhosis; persist post-tx

Tendinous: MC on Achilles; sign of hyperlipidemia or biliary cirrhosis; persist post-tx

Tx: Trichloroacetic acid, risk altered pigment

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94
Q

Define Kaposi Sarcoma

What are the different types and characteristics of each

A

Vascular neoplasms usually on older male legs

Classic- slowly progressing on male hand/feet, move upward.
AIDS Pt- rapid development anywhere, MC head, face, neck

AIDS: slightly raised ovals w/ rapid progression to purple nodules
Dec in size w/ pressure, return w/ relief (differentiator from LP)

ImmSupp: d/t HHV-8

African Cutaneous/Lymphoadenopathic

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95
Q

What is the Classic Kaposi Sarcoma is the MC tumor in ? Pts

How is a Dx confirmed

How are these Tx

A

AIDS

Biopsy- proliferation of vessels w/ neoplastic endothelial cells

LN2
Vinblastine- intralesional chemo, better for lesion >1cm
Excision- single
Radiotherapy- larger masses

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96
Q

What are two types of finger nail issues seen in Hyperthyroidism

What type of lower extremity issue do they have

This can develop in Hypo/Hyper/Eu-thyroid but is mostly associated w/ ? thyroid condition

A

Thyroid Acropachy- digital clubbing w/ periosteal changes

Plummer’s nails- onycholysis w/ concave appearance

Dermopathy- AKA Pretibial Myxedema
Early: asymmetric, non-pitting
Late: symmetrical, orange peel appearance

Graves- hyperthyroidism

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97
Q

Vesicular and Bullous Dzs are autoimmune blistering Dzs w/ ? two characteristics

How are these Dzs characterized

These are classifed by ?

A

Impaired epidermis to basement adhesion
ABs against adhesion proteins

Substantial morbidity/mortality

Histology- level of skin separation

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98
Q

Define Pemphigus

What is the pathophysiological reason this occurs

When does this tend to occur and in ? population

A

Greek- blister, bubble;
Intraepidermal blister d/t loss of keratinocyte adhesion

IgG against Desmoglein 1 and 3: cell-cell adhesion in desmosomes

50-60y/o w/ Myasthenia Gravis w/ near universal involvement of oral mucosa

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99
Q

What do Pemphigus Vulgaris primary blisters look like

Why are these bad once they pop

How are they Dx

How is it Tx

A

Non-pruritic, thin walled w/ +Nikolsky
Rupture, painful erosion that ooze/bleed

Little/no healing occurs

Derm consult THEN
Skin biopsy for light microscopy

PRICC MAP:
Prednisone Rituximab IVIG Cyclosporine Cyclophosphamide Mycophenolate Azathioprine Plasmapheresis

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100
Q

? is the MC auto-immune sub-epidermal blistering Dz

Four differentiators about this MC

How are these Dx

How is this Tx

A

Bullous Pemphigoid

TENSE vesicles (PV- flaccid bullae)
Onsets >60y/o (pemphigus was 50-60y/o)
Pruritic bullous eruptions
Serous/hemorrhagic fluid

Derm consult THEN
Biopsy for light microscopy

Mild-Local: Group 1 topical steroid w/ PO CCS
Mod-Sev: same as PV (PRICC MAP)

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101
Q

Define Dermatitis Herpetiformis

What systemic dz is this associated w/

What population is this MC in

A

Intense burn/itch vesicular skin dz

Celiac dz

Northern European males

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102
Q

What is the classic distribution pattern for Dermatitis Herpetiformis

How is this Dx

How is this Tx short and long term

A

Symmetric, bilateral extensor surfaces
Scalp
Buttocks

Punch biopsy
Serological test- Celiac Dz

Short term: Dapsone
Long: gluten free diet

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103
Q

UV light is the MC cause of ?

What are the 3 types of UV light

A

Photobiologic skin reactions/Dzs

UVA: 320-400nm
Long waves, most constant year round
Penetrate deep, release free radical, alters DNA/Ca
Chronic exposure= CT degeneration/Photo-aging/allergy

UVB: 290-320nm
Greatest during summer, MOST harmful of waves
High amounts of energy to corneum/superficial layers
Pigmentation Inflammation Erythema Sun burn/tan

UVC: 100-290nm
Shortest wave, absorbed by the ozone layer
Transmitted only by artificial sources: germicidal lamp

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104
Q

What are the 6 Fitzpatrick phenotypes

What is the inverse relationship w/ these 6 classes

A

AES MDN
1: Always burns, never tans; blue eyes, red hair

2: Easily burns, barely tans; blond hair
3: Some burn, gradually tans; Mediterranean/Hispanic
4: Minimal burn, always tans well; darker hispanic/asians
5: Deep tan, rarely burns; Mid-east, Asian, some blacks
6: Never burns d/t deep pigmentation; blacks

Higher class= dec Ca risk

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105
Q

What environmental factors can affect amount of UV light exposure

Define SPF

A

Ozone: absorbs UVC
Clouds: 90% of UV light penetrates through
Sun elevation: peaks at 10am-3pm
Snow/Ice: reflects UVB

Sun Protection Factor: ratio of least amount of UVB required for minimal erythemal reaction through sunscreen compared to amount needed for same reaction w/out sunscreen
SPF 30- 30x longer exposure before burn

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106
Q

What are the 5 ways to optimize protection from UV damage

What are the body’s two natural sun protectors

What is the best protection method

A 
Wear loos, dry clothes w/ wide hat
Reapply q2hrs/after water exposure
Avoid peak sun time 10A-3P
Prior to outdoors, apply 15-30m
SPF 15-30 daily

Statum corneum
Melanin

Clothing

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107
Q

What are the 3 MOAs of sunscreen

Define Photoaging

What four types of damage can the sun induce

A

Physical: titanium dioxide/zinc oxide- scatter/reflect light
Chemical: absorbs radiation
Water: proof x 80min/resistant x 40min

Skin changes superimposed on intrinsic aging from chronic exposures

Pigment Papular Texture Vascular

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108
Q

What are the 3 types of texture changes exposure can cause

What are the 4 types of vascular changes exposure can cause

What are the 3 types of pigmentation changes exposure can cause

What are the 4 types of papular changes exposure can cause

A

Atrophy- think skin, bruises easily
Rhomboidalis nuchae- deep wrinkles on neck that don’t disappear w/ stretching
Elastosis- thick skin w/ yellow hue

Venous lakes
Erythema/Ecchymosis
Stellate pseudoscars
Telangiectasis

Lentigo- large brown macules
Poikiloderma of Civatte: brown reticulated pigment w/ Telangiectasis, Atrophy, and Prominent follicles
Ephelides- freckles

Favre Racouchot- comedone/EIC around eye
Elastosis- thickened yellow skin
Nevi
SK

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109
Q

What is key for treating photoaging

What topicals are used for Tx

A

Prevention

Retinoids: Tretinoin/Tazarotene w/ sunscreen
Txs: Fine wrinkles Roughness Pigment
Won’t Tx: Coarse wrinkles, Telangiectasias

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110
Q

Define Polymorphous Light Eruption

What is the pathogenesis for this condition

When does this tend to present and w/ ? relationship to geography

What does the morphology look like

A

MC light induced skin Dz from UVB>UVA

Delayed hypersensitivity to endogenous photoinduced Ags

First 3 decades of life w/ inverse relation to latitude

Polymorphous and varies, but:
DPP- pin-head size groups in exposed areas

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111
Q

What phenomenon does Polymorphous Light Eruption cause

What are the 6 classical types of skin morphologies this condition causes

What is the clinical presentation of Polymorphous Light Eruptions

A

Hardening- Incremental doses of UV radiation based on tolerance/resolution

Papular- MC
Plaque- 2nd MC
Papulovesicular
Eczematous
Erythema multiforme
Hemorrhagic

Malaise Chills HA Nausea x1-2hrs before rash, which heals w/out scars

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112
Q

How is PLME differentiated from Lupus

What type has mandatory Dx tests in order to r/o SLE

A

Delayed onset
Characteristic morphology
Histopahtlogical changes
Quick resolution

Plaque type: must get biopsy and Immunofluorescence

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113
Q

How is a Dx of Polymorphous Light Eruption confirmed

How is this condition Tx

What is used as last line Tx resort

A

Phototesting w/ UVA/UVB light

CCS: topical 4-5 for pruritus/PO wide spread
Sun protection/limited exposure
Desensitization w/ phototherapy
PUVA

Hydroxychloroquine

114
Q

What is the name of the hereditary form of Polymorphic Light Eruption and what population is this more common in

What morphology does this form have and where does it MC appear

This condition may only be evident w/ ? feature

A

Actinic Prurigo
Inuit/Native American (North Central South)

MC face w/ intensely itching papules, possible hemorrhagic crust

Actinic cheilitis

115
Q

Define Phototoxicity

What is the name for this condition if d/t plant etiology

What morphology can be seen on presentation

A

Non-allergic skin response d/t topical/systemic agent reaction w/ UVA

Phytophotodermatitis

Minimal: erythema then hyperpigmentation

Max- tingling erythema then burning, then vesicles then bullae w/ linear streaking then desquamation

116
Q

What plants can cause phototoxic reactions

What medications can cause these reactions

How are cases of Phototoxicity managed

A

Celery Parsnip Limes Carrot Fig Hogweed Grass

Ibuprofen/Naproxen
FQ
Diltiazem
Isotretinoin
Sulfonamides 
TCNs
Amiodarone
Furosemide
5-FU

Topical steroids for Sx relief
ID and avoid
PUVA if persistant x mon/yrs
Sunscreen

117
Q

Define Vitiligo

Half of these cases will present prior to ?

What is the MC type of Vitiligo

What is the other type classified as

A

Acquired loss of pigmentation d/t Abs against melanocytes

20y/o (Type B-segmental presents early)

Type A: symmetric white macules (halo nevi) w/ Koebner phenomenon

Type B: asymmetric pattern w/out crossing midline and depigmentation of follicles

118
Q

What are 3 risks Pts w/ Vitiligo have depending on location affected

What comorbidities put Pts at risk for developing Vitiligo

How is this condition Dx’d

A

Depigmented retina= Uveitis
Depigmented labyrinth= hearing loss
Leptomeningeal malnocyte destruction= aseptic meningitis

Alopecia areata
Hypothyroid
Graves
Addison
Pernicious anemia
DM1
Melanoma

Clinical presentation
Woods lamp accentuates involved areas

119
Q

What are the goals of Vitiligo Tx at Pts request

What areas of the body will not respond to Txs

What is used for Tx

A

Stabilize depigmentation
Repigment w/ melanocyte stimulation w/in hair follicles

Little/No/White hair

First line- topical CCS
Calcitriol
Ta/Pime-crolimus
NB-UVB phototherapy
Excimer laser
Dihydroacetone tanner
Monobenzone/Hydroquinone- depigment remaining skin in Pts w/ > BSA involvement
120
Q

Define Idiopathic Guttate Hypomelanosis

What other Dxs are present in same areas

What would be seen on histology results of biopsy

How is this Tx

A

ASx white spots on sun exposed arm/legs in mid age/older adults

SK, Lentingines, Xerosis

Dec melanocytes

LN2
Abrasions
Tretinoin cream
Steroid, low potency

121
Q

Define Solar Lentigo

What other term are these known as

How is Solar Lentigo differentiated from Ephelides

How is this condition managed

A

Solar Lentigines; tan/brown macules d/t melanocyte proliferation d/t chronic sun

Liver spots

Freckles darken after sun exposure, SL does not

Topical retinoids
Laser removal
Cryotherapy
Combo: hydroquinone/retinoid

122
Q

Define Melasma

What are the etiologies of this condition

What are the 3 clinical patterns of this condition

A

Mask of pregnancy; symmetric brown pigmentation of face/neck

Pregnancy
OCPs
Thyroid dysfunction
Phenytoin- Phototoxic/Anti-seizure meds

Centrofacial: Forehead Upper lip Cheek Chin
Malar: cheek and nose
Mandibular

123
Q

How is Melasma Tx

? is the MC benign cutaneous neoplasm

What is the etiology behind this MC

A 
Tri-Luma: combo Hqn Tretinoin Fluocinolone
Hydroquinone
Acelaic acid
Tretinoin
Sun protection- most important

SKs- proliferation of immature, pigmented keratinocytes on any hair growing area

124
Q

SKs have ? possible etiology relation

How do the begin and what can they progress to

What terms are used to describe their morphology

A

Sun exposure

Macule to papule/verrucous

Greasy, stuck on appearance

125
Q

How are SKs Tx

What type of presentation needs to have malignancy r/o

Define Stucco Keratosis

What population is this more common in

A

LN2 Curettage Excision

Leser-Trelat sign: sudden appearance of multiple SKs; r/o malignant melanoma

Vascular insufficiency causing benign proliferation of keratinocytes

Elderly LPPts and peripheral edema

126
Q

Where are Stucco Keratosis more and less likely to develop

What is the Tx and prognosis for these

Define Dermatosis Papulosa Nigra

A

Ankle, Dorsal foot
Less commonly: forearm, hands

Curettage/Cryo- completely benign

Small, darker SKs more common in females
(Morgan Freeman face) on cheeks and bilateral eyes in photo distribution pattern

127
Q

What are skin tags called

What populations are these MC and common in

What education goes w/ freeze/excision Tx

A

Acrochordon

MC: Obese
1/4: all people after 25y/o

Won’t regrow but new lesions can occur

128
Q

Define Dermatofibromas

How does these present

What PE test/finding can help w/ Dx

A

Reactive fibrous collection of fibroblasts, endothelial cells and histocytes from trauma

Pruritic/tender but become ASx

Dimpling- retract downward w/ squeezing

129
Q

Where is Dermatofibroma most likely to develop

How are these Tx and what needs to be r/o if these develop darkly

What is used to differentiate hypertrophic scar from keloid?

Why/how do keloids return after Tx

A

Anterior lower legs
Anywhere extremity/trunk

Punch biopsy- r/o MM
Excise

HS: scar confined to site, regresses w/ time
K: past borders, starts later, rarely subsides and MC on shoulder/chest

Continued collagen production

130
Q

How are HS/Keloids Tx

Define Keratoacanthoma

What characteristic finding indicates this Dx on PE

A 
SLICC:
Silicone gel sheeting
Lasers
Intralesional 5-FU
Cryo
Combo surgery w/ steroids

Benign epithelial tumor from sun exposure to arms/hands

Solitary dome w/ rapid expansion and central hyperkeratotic core

131
Q

Why are Keratocanthomas biopsied when they’ll naturally self resolve

What is the appearance and concern for Dx of Cutaneous Horn

What type of Tx is needed

A

Indistinguishable from SCC
Excision
Recurrent/Multiple: 5-FU/Methotrexate

Cone in elderly LPPts d/t sun exposure
1/5 arise in situ/invasive SCC

LN2/excise

132
Q

Define Sebaceous Hyperplasia

How is this Tx if there are many lesions present

What PE finding needs to have BCC r/o and how is this done

A

Tumors of enlarged sebaceous glands on face that become dome/umbilicated

Isotretinoin; recurrence common but benign

Telangiectasia:
SH= vessels only in valleys w/ yellow lobule
BCC: haphazard vessels on surface

133
Q

Define Syringoma

What Pt population are these usually in

What is the prognosis for this

If requested Tx for cosmetics, how is this Tx

A

Sweat duct tumor; common under eye lid
Can be on: Forehead Abdomen Trunk Vulva

Females 20-30y/o

Once appeared: stable in number

Shave w/ 11-blade
Elevate and excise
Electrodissection/curettage

134
Q

Define Neurofibroma

If two or more are found on PE, what needs to be done for these Pts

A

Nerve sheath tumor w/ pedunculation and button-hole sign: invaginate skin w/ pressure

Axillary freckles/Cafe au lait spots (Von Recklinhausen, NF-1)- can become Ca

135
Q

Define Cherry Angioma

Where/how do these develop

How are these Tx

A

MC vascular malformation; nearly always in Pts >30y/o

Smooth, firm, deep red papules on trunk/prox extremeties

Excision/Electro-ablation

136
Q

Define Telangiectasia

What are the different types and Tx for each

A

Permanantly dilated vessels, max diameter of 1mm

Arterioles: Spider bodies- surface of skin
Radiate capillaries Spider legs
Electrodissection/Ablation

137
Q

Define Pyogenic Granuloma

What two populations can this develop in

What PE finding can help clue in to Dx

A

Benign, acquired vascular lesions of skin/mucus membranes

Pregnant: gingival lesion
Isotretinoin Pts: in cysts of acne

Friable- slight trauma causes bleeding that is difficult to control

138
Q

What doe Pyogenic Granulomas look like

How are these Tx

Why is careful Tx so essential

A

Rapidly growing domes that are yellow/bright red and glistening top

Curettage through base
Electrodissection to control bleeds

Recurrence if any tissue remains

139
Q

? is the MC benign soft tissue tumor

What morphology does this have

Where can these grow

A

Lipoma

Soft, mobile SQ lesions

Trunk, Extremeties MC in mid-20s

140
Q

? is the MC skin cancer and MC malignant neoplasm in humans

What causes this MC to be the highest risk

What is the most important RF

A

BCC- malignant proliferation of the basal layer of the epidermis

Intense, intermittent sun exposure

Inability to tan

141
Q

What is the MC form of BCC

What is the MC presenting c/c of BCC

Where are the two types of BCC MC to occur on the body

A

Nodular- ASx slowly growing dome, evolves into ‘rodent ulcer’ of telangiectasis and ulcerates

Bleeding/scabbing sore that heals and recurs

Nodular: Nose
Superficial: trunk

142
Q

Why does BCC have malignant potential

What is the ‘good news’ of this Dx

What is the f/u frequency for these Pts

A

Older nodes evade by direct extension, invade/replace structures

Almost never metastasizes

Annual TBSE, d/c after 3yrs of tumor free

143
Q

Define Actinic Keratosis

What etiology causes these to develop

How doe these appear on PE

A

Premalignant SCC confined to epidermis

Chronic UVB exposure

Rough feeling hyperkeratotic lesion, erythema w/ yellow scale

144
Q

What are AKs renamed to if they develop on lower lip

How is this renamed if it develops on superior pinna w/ tenderness

How is this form Tx

A

Actinic cheilitis

Chondrodermatitis Nodularis Helicis: degeneration of collagen

Excise, special pillow

145
Q

How are AKs Tx if there are few, many or thick/indurated lesions

When are AKs reclassified from pre-malignant into malignant

SCC In Situ is AKA ? and Dx by ? method

A

Few: LN2
Many: 5FU, Imiquimod-alternative
Thick/Indurated: shave excision

Invades dermis= SCC

Bowen Dz: keratinocytic dysplasia of epidermis w/out atypical penetrating dermis
Histological Dx

146
Q

How does SCC In Situ appear on PE

Where are these more likely to develop in wo/men?

How do these differ from AKs?

A

Well defined, elevated, red, scaly plaques w/ very slow lateral growth

Female: lower extremities
Male: scalp/ear

Epidermis only

147
Q

How is Bowen’s Dx Tx by size of lesion

How often do these Pts need to f/u and why

Define Erythroplasia of Queyrat

A

Small: LN2 Excise EDandC
Large: 5FU Imiquimod Ecision

q6mon to prevent progression to invasive SCC, recurrence common

Bowen Dz: SCC in situ of mucous membrane

148
Q

What populations are more likely to develop Erythroplasia of Queyrat

What microbe is responsible for this

How is it Tx

A

Uncircumcised males

HPV-8

5FU Imiquimod Laser

149
Q

? is the 2nd MC skin Ca

Why is this MC scarier

What causes this type

What is this type’s precursor

A

SCC

High metastasis risk

UVA/B exposure

AKs

150
Q

What are the RFs for SCC

A 
HPV infection
Burns (radiation, thermal)
Inflammation
Bowens
Arsenic
Sun exposure
ImmSupp
Chronic irritation
151
Q

Where can SCC develop on the body

How are these Tx if they arise from AKs

How are they Tx if lesion is larger/on lip

A

Scalp
Dorsal hands
Superior pinna
Bowens: anywhere

EDnC

Excise w/ margins

152
Q

What needs to be assessed on PE for PTs w/ SCC

How often do they need f/u

SCC in ? location has the highest risk for mets

A

Lymph nodes

q12mon for life

Lips

153
Q

Define Nevus

These may be AKA ?

How are Nevus cells different from melanocytes

A

Benign growth of cells derived from melanocytes

Moles

Larger
Abundant cytoplasm
No dendrites
Coarse granules

154
Q

How are Nevus’ examined on PE

What are the four types of Common Nevi?

? AKA Moles become larger ? and when does their incidence peak

A

ABCDEs:
Asymmetry Border irregularity Color variation
Diameter Evolution

Melanocytic Junctional Compound Dermal

Melanocytic: Pregnancy/Puberty; 4-5th decade

155
Q

Where do Malanocytic Nevus develop

What would histology results show from biopsy

F/u is needed if there are more than ? and how often?

A

Anywhere: include palm, sole, mucosa
Sun exposed areas

Nest of nevus cells

> 100, q6-12mon

156
Q

What are the 3 subtypes of common/acquired Melanocytic Nevi based on location

What affects these subtypes

A

Junction: flat, uniform color at epi/dermal junction

Compound: elevated dome, halo nevus, cells in dermo-epidermal and upper dermis junction

Dermal: pedunculated dome, pink-brown w/ hair, nevus cells in dermis/adipose tissue

Sun exposure
Hormones

157
Q

Junctional Nevus are more common during ?

What are Congenital Melanocyctic Nevi AKA?

These carry a greater risk if they’re ? size

A

Childhood

Birthmark

5% TBSA or more or,
>20cm

158
Q

How are Congenital Melanocytic Nevi managed based on size

Why is surgical removal recommended for some so early?

Speckled Lentiginou Nevus is AKA and MC during ?

A

Small/Med: observe
Large/Giant: prophylactic removal

Half develop malignancy by 5y/o

Nevus Spilus; birth/early infancy/adolescence

159
Q

Nevus Spilus lack ? association to development

How are these Tx

Define Becker’s Nevus

A

Not associated to sun exposure

None; rare malignancy potential

Not ‘true’ nevus; lacks nevus cells

160
Q

When is the occurrence of Becker’s Nevus higher

Where do these MC develop

What is the good news about these types

How are these Tx

A

Adolescent males as brown macule and/or patch of hair

Unilateral upper back
Shoulder
Upper arm
Sub-mammary

Never reported malignancy potential

Laser depigmentation/hair removal

161
Q

Define Halo Nevus

When do these tend to develop

What does their presence indicate

A

Compound/Dermal nevus w/ white border

15y/o

Onset of vitiligo

162
Q

What causes Halo Nevus to have a halo

Where do these MC develop

What is their natural progression

What is done on PE that is different from other nevus’

A

No melanocytes in halo

Trunk
Never palm/soles

Nevus regresses w/ pigmentation returning over decades

Woods lamp: highlights areas of depigmentation

163
Q

What are Spitz Nevus AKA

Why is this AKA term given

When/Where do these MC develop

How are these Tx

A

Benign Juvenile Melanoma: sudden development of hairless red/brown dome

Histologically similarity to melanoma

Children on head, neck, lower extremities

Removed for pathological eval

164
Q

Define Blue Nevus

These typically remain under ? size

Where do these MC develop

A

Elevated, round and regular nevus

<5mm

Extremities, hand dorsum

165
Q

How are Blue Nevus’ differentiated from Malignant Melanomas

Where do these MC develop

How are these Tx

A

Hx: develop in childhood, remain unchanged

Extremities, dorsal hands

Cosmetic removal at Pts request

166
Q

Define Mongolian Spot

Where are Mongolian Spots MC develop

A

Flat blue/black lesion of melanocytes
Appear dark d/t Tyndall effect: melanin in deeper skin

Scalp, Pre-sacral
Asian/AfAm

167
Q

Define Nevus of Ota

Because of their location, ? structures are affected

What population do these occur in MC?

How are they Tx

A

Dark pigmentation on 1st-2nd branch of CN5

Sclera Conjunctiva Periorbital skin

Female Asians

Laser- lighten lesions
F/u for glaucoma monitoring

168
Q

Define Labial Melanotic Macule

Who do these occur in more commonly

How are these differentiated from freckles

How are they Tx

A

Dark macule on lower lip

Young women

No change w/ sun exposure

Cryo/Laser if desired

169
Q

Define Nevus Flammeus

Where do these develop

When do Dysplastic/Atypical Nevus develop

A

Port Wine Stain; congenital vascular malformation, not a nevus

Face/Neck

Caucasian onset of puberty - 4th decade of life

170
Q

What appearance do Dysplastic/Atypical Nevus have on PE and where are they seen

What is needed for Dx

A

‘Fried Egg’- >5mm w/ raised center, sun protected area

At least 3:
>5mm diameter
Ill define border
Irregular margin
Varying pigment
Papular+Macular components
171
Q

How are Dysplastic/Atypical Nevi Tx

How often do Pts need f/u

What referral should be considered for these Pts

A

Excision biopsy w/ margins
Family screening

TBSE q6-12mon

Ophtho

172
Q

How common is Malignant Melanoma

What is the median age for Dx and death

What are the 6 groups, in descending order, that are at greatly increased relative risk for MM

A

5th MC: men- back (LPP>DPP)
6th MC: women- arms/legs

57y/o at Dx
67y/o at death

Greatly:
\+atypical mole & FamHx Melanoma &>75moles: 35
\+non-melanoma skin Ca: 17
Giant/>20cm nevus: 15
Hx melanoma: 9
FamHx w/ Melanoma: 8
ImmSupp: 8
Moderate:
2-9 atypical nevi: 7
51-100 nevi: 5
26-50 nevi: 4
Chronic tanning/>250 PUVA Txs: 5
Modest:
3 blistering sunburn: 3
2 blistering sunburn: 2
Freckling: 3
Unable to tan: 2.6
Read/blonde hair: 2.2
1 atypical nevus: 2.3
173
Q

What population is more likely to develop Noncutaneous Malignant Melanoma and where does this develop

What labs are ordered for MM workup to search for ?

What needs to be avoided in a MM workup and how often do Pts need f/u

What are the 4 clinical histological types of MM in order of frequency

A

Non-white:
Mouth Nose Eyes Penis Vagina Anus

CBC CMP UA
Signs of Leukocytosis/Mets

Shave biopsy- inadequate Breslow depth measurement
q3-4mon x 1yr then, q6mon

Superficial spreading
Nodule
Lentigo
Acral-lentiginous

174
Q

What is the most important histological part of a MM prognosis

What is the most important prognostic variable:

A 
Breslow Microstage by mm- Clark level
1-Epidermis 
2-Papillary dermis 
3-Fills pappillary dermis 
4-Reticular dermis 
5-Enters SQ
Breslow thickness:
In situ: 95-100%
<1mm: 95-100%
1-2mm: 80-96%
2.1-4mm: 60-75%
>4mm: 50%
175
Q

? is the MC type of melanoma

Where on the body does this MC develop in wo/men

What is the hallmark PE finding

What progression finding helps w/ Dx

A

Superficial Spreading in 30-40y/o

Back- both sexes
Legs- women

Many colors haphazazrdly combo’d

Nodules appear when >2.5cm

176
Q

What are the ABCDEs of Superficial Spreading Melanoma

A 
Asymmetric
Irregular
Brown/Black 
>5mm, radial growth first
Black/Blue/White/Red then vertical growth
177
Q

Define Nodular Melanoma

What color will this have

What are the ABCDEs of Nodular Melanoma

How can this be differentiated from a hemangioma

A

Completely vertical growth phase

Red and black/brown or Dark brown

Dome, Polypoid, Pedunculated
Irregular, surrounded by primary lesion
Brown/black papule/nodule
Rapid growth
Ulcerates and bleeds

Press x 30sec, near total involution= hemangioma

178
Q

Define Lentigo Maligna Melansom

Where is LMM MC seen on the body

? type of melanomsa is MC in darker pigmented Pts

What PE finding indicates this Dx and a poor prognosis

A

Raised brown/black macule in 60-70y/o

MC on Face from sun damage w/ slow growth (5-20yrs)

Acral Lentiginous- palm, sole, terminal phalange, mucous membranes

Hutchinson- sudden pigmented band on prox nailfold

179
Q

MM stats between Light/Dark pigment Pts

A

LPP:
90% on sun exposed site
2% on foot

DPP:
67% not on sun exposed
40% on foot
Subungual Mucosa Plantar Palmar MC in DPP

180
Q

TBSE on Pt w/ MM needs to focus on ? areas

What is the modified ABCDEs for MM in DPP

A

Palm Finger Sole Toe Subungual Mucosal surfaces

Age 5-6th decade
Brown/black band
Change
Digit MC involved
Extended brown pigment onto cuticle
FamHx/personal Hx of unusual moles/MM
181
Q

What phase of MM has a better prognosis

What risk develops once a change occurs

Breslow is most important histological prognosis, ? is the most important prognostic factor in lesion >1mm thick

80% of MMs will develop in ? regions of the body

A

Horizontal/radial

Mets inc once vertical growth begins

Sentinel node status

Covered by clothes

182
Q

Majority of skin/soft tissue infections are due to ? microbes

What can each microbe cause

A

Staph A/GABHS- gram pos cocci

Staph A: Cellulitis Impetigo Folliculitis Furuncles
Staph toxins- bullous imptetigo, SSSS

GABHS: Lymphangitis Impetigo Cellulitis Erysipelas

183
Q

Define Non-Bullous Impetigo

What population/climate makes these more common

These are commonly infected w/ ? and need ? step done on PE

How is it Tx

Why are ABX needed

What can be done to reduce contagiousness

A

GABHS starting as corneum vesicle that ruptures to leave red, moist base; progresses to ‘honey crusted’ weeping lesion

2-5y/o kids in warm/moist climates and poor hygiene

Staph, regional adenopathy

Soaks- remove crus
ABX:
Limited- Mupirocin
Widespread: Doclox/Cephalexn

Prevent PSGN

Dressings

184
Q

Only times Methotrexate comes up in Tx plans

Only time Metronidazole comes up in Tx plans

A

Keratoacanthoma
Psoriasis- pustular/>5% BSA
Pompholyx

Perioral dermatitis
Acne Rosacea

185
Q

Define Cellulitis

What is the MC microbe

What are two possible microbes

What is the probable microbe if PT is diabetic

A

Skin infection w/ SQ involvement causing Pain Erythema Edema

GABHS

Staph, H Influenza

Pseudomonas

186
Q

What is the common portal of entry leading to Cellulitis

What will Pts present w/?

How is this Tx out-Pt

How is this Tx in-Pt

How is this Tx if Pt is diabetic

Hos is this Tx if caused by H Influenza

A

Areas affected by stasis/lymphedema

F/C/Leukocytosis
Warm tender area w/ poorly defined borders

Cold compress w/ elevation
Cephalexin Diclox Clindamycin TMP-SMX

IV Nafcillin
PCN allegy= Vanc

Aminoglycosides

Cephalosporins

187
Q

Erysipelas is AKA ? and defined as ?

What microbe causes this and what will Pt present w/

How is this Tx PO/IV

How is Erysipeals differentiated from Cellulitis on PE

A

St Anthony’s Fire: superficial cellulitis of lymphatics

Strep pyogenes: Pain Erythema Edema (Face Ears Legs)
Fever Adenopathy Malaise

PO: Amoxicillin Cephalexin Dicloxacillin
IV: Cephazolin Ceftriaxone

Ery: raised plaque w/ sharp demarcation borders

188
Q

Blistering Distal Dactylitis is defined as ? and more common in ? ages

How does this present on PE

How is this Tx

A

Blistering infection of superficial finger fat pad in 2-16y/o

Vessicle w/ exfoliation and clear/purulent fluid

InD
PO anti-strep ABX x 10 days (Amox Cephalex Diclox)

189
Q

Define Folliculitis

What is the MC form and what is it d/t?

What is a variant of folliculitis

How is this worked up for specific microbe Dx

How is this Tx

A

Inflammed follicle d/t infection/chemical/injury

Staph folliculitis from occlusion of follicle

Superfiical folliculitis: perifollicular pustule w/ undamaged hair in center

Culture whole pustule w/ 15 blade

PO ABX x 7-10 days
BPeroxide w/ Emycin/Clinda/Diclox/Cephalexin

190
Q

Define Syncosis Barbe

What is this Dx AKA as?

How is this Tx

What is done if Pt is severe/ABX Tx failure

A

Inflammation of entire follicle

Staph impetigo of beard d/t razor spreading infection

PO ABX x 2wks

Eval for dermatophyte infection, culture by hair removal

191
Q

Furuncle/Carbuncles are both defined as ?

Define Furuncle

Define Carbuncle

Where are Furuncle/Carbuncles likely to develop

How are they Tx

A

Painful perifollicular deep infections of follicles

Boil/Abscess- walled off pus collection

Multi-headed boil, associated w/ cellulitis

Friction prone areas

InD w/ moist heat
Systemic ABX if cellulitis present

192
Q

What Pt populations are more likely to develop MRSA

How is this Tx w/ ABX

What Tx plan is an alternative

A

Recurrent furunclosis

Mupirocin TMP/SMX Clindamycin

Chlorhexidine or bleach bath

193
Q

Define SSSS

This is primarily a Dz of ? is is d/t ? physiological defect

What can this condition start as

A

Blistering dz from Staph A toxins

Infant/younger kids w/ dec renal toxin clearance, causes hematogenous spread

Bullous Impetigo

194
Q

What type of prodrome may precede a SSS Dx

What PE finding is indicative

How is this Tx

A

Malaise Fever Irritable Tender skin
+Nikolsky sign 1-2 days later

Sandpaper skin, especially flexors/perioralfacial skin w/out mucus membrane involvement

Mild: PO Diclox/Cephalexin
Mod/Sev: admit for IV ABX

195
Q

What does Hot Tub Folliculitis present as

Pt may present w/ fever/malaise but is at low risk for ?

How is this Tx

A

Pseudomonas infx causing round, pruritic plaques w/ center papule

Sepsis

Vinegar soak
Antihistamin PRN
Sev= Cipro

196
Q

What Pt population is more at risk for Pseudomonas Cellulitis

What does the microbe gain entry to body

A soldier may get this infection if operating in ? environment

What ENT issue can cause this Dx to develop

How is this Tx

A

Debilitated, diabetic Pt

Toe web/groin
Ulcers
Bed sores

Swamps

External Otitis

Monitor diabetic glucose
Acetic Acid/Domeboro soaks- dry area
PO Cipro

197
Q

Pseudomonas Toe Web infections

What does this look like on PE

How is it Tx

What is used if Pt is topical failure

A

Secondary infection from Tinea, MC between 4-5th toe

White, macerated skin w/ green hue on Woods Lamp

Candida

Acetic Acid/Drysol
Once dry- Gentamycin cream

PO Cipro

198
Q

Define Trichomycosis Axillaris

How is this Tx

A

Corynebacterium infection causing axilla hairs to be white and severe malodorous

Shave area
Topical Naftifine/Erythromycin/Clindamycin
Antipersperant/Drysol

199
Q

Define Erythrasma

What does this look like on PE

What predisposing factors can put PTs at risk

Where is this MC seen on the body

A

Over proliferating skin infection of Corynebacterium Minutissimum

Macular brown scale w/ itch/burn and no inflammation

Humidity Hyperhidrosis Hygeiene
DM Obese Age ImmSupp

4th interdigit space

200
Q

How can Erythrasma be differentiated from T Cruris on exam

How is this Dx

How is this Tx

A

Does NOT spare scrotum/labia
T. Cruris- spares scrotum/labia and is coral-pink color

KOH
Coral red on woods lamp

Erythro/Clindamycin
Sev/Recalcitrant: Erythromycin/Clarithromycin

201
Q

What causes Pitted Keratolysis and where is it seen on the body

What cause that distinctive malodorous/slimy skin

What is the MC associated Sx for these PTs

A

Kytococcus Sedentarius- weight bearing parts of feet

K Sedentarius releases enzymes that digest keratin

Hyperhidrosis

202
Q

How is Pitted Keratolysis Tx

What is added if condition is recalcitrant/topical failure

What are the 5 viral infections

A

Topical Erythromycin/Clindamycin/Mupirocin w/ Drysol

PO Erythromycin

Wars Bowenoid Molluscum HSV HZ

203
Q

Define Wart

How does a viral infection cause these to develop

How are these transmitted and what are they AKA if they are

A

Neoplasm confined to epidermis (no scarring)

HPV infects keratinocytes, causes hyper-plasia/keratosis

Touch, touching toes= kissing lesions

204
Q

What is the visual diagnostic sign of warts

Why do they have black dots on them

What is the name for the ‘common’ wart and where do these MC develop

A

Mosaic pattern- cylindrical projections

Thrombosed vessels trapped at surface

Veruca Vulgaris- hyperkeratotic dome papule w/ black dot
MC on hands

205
Q

How are Verruca Vulgaris Tx

What Tx can be applied by clinician for Tx

Define Filiform Warts

A

LN2 q2-4wks
Topical salicylic acid/Imiquimod

Cantharidin

Superficial flesh colored finger-like projections
MC on face, easiest to Tx (curettage/cry/electrocautery)

206
Q

Define Verruca Plana

Where are these seen on the body

How are these types Tx

A

Flat warts- groups of flat tan/yellow/pink papules

Forehead Perioral Dorsal hands
Shaved areas- beard, legs

5-FU Tretinoin Imiquimod Cryo

207
Q

Where do Plantar Warts develop

What common DDx is this confused with and how are they differentiated

How are these Tx

What are possible alternative Txs

A

Points of max pressure (soles) w/ association w/ calluses

Corns- will have skin lines
PW- no skin lines and +black dots

Soak/Pare, then:
Salicylic acid
Imiquinod
LN2
Cantharidin

Laser
Intralesion bleomycin sulfate
Chemo: bichloracetic acid
Electodissection and curettage

208
Q

How are Sub/Peri-ungual warts spread

Since these types can be more resistant to Tx, what options are used for Tx

A

Cuticle biting

Cryo
Cantharidin
Salicylic acid
Duct tape occlusion x 6d w/ 12hr break x 2mon

209
Q

What are genital warts called

What types of HPV infections can cause these

What types of HPVs are highly/low risk for cervical CA

A

Condyoma Acuminata/Venireal

6 11 16 18 52 56

High- 16/18, esp 16
Low- 6/11

210
Q

What do genital warts look like on pE

Why do these have this appearance

How does the appearance change in ImmSupp Pts

How are these more easily transmitted

A

Pale lesion w/ narrow-broad projection on broad base that is smooth/velvet

Lacks hyperkeratosis feature of other warts

Cauliflower grouping

Spread fast on moist surfaces

211
Q

How are Genital Warts Tx by PT

How are these Tx by providers

A

Podofilox gel- 3d on, 4d off x 6wks
Imiquimod- every other day at bedtime x 16wks
5-FU- last line

Podophylin resin
Cryo
Scissor/Curettage/Electrosurgery
CO2 laser
Trichloroacetic acid
212
Q

What are possible DDxs for Genital Warts

A

Pearly Penile Papules- angiofibroma on corona; normal variant

Bowenoid Papules- grouped papules like flat/genital warts on penis/vulva/anus d/t sexually transmitted HPV
Quasi-premalignant but spontaneously self-resolve

213
Q

What causes Molluscum Conagiosum

What does this look like on exam

What areas is this expected/concerned in kids

How are these best Tx if only few lesions are present

How are these best Tx if many lesions are present

A

DNA poxvirus

Pruritic dome-shaped papule that is flesh colored w/ central unbilication and produces caseous material w/ expression

Expected: arms/face
Abuse concern: genitals

Few: curette
Many: trichloroacetic acid peel

214
Q

What are the two types of HSV and their more likely location

What is the primary mode of transmission

What will the first eruption look like after exposure

A

HSV-1: PO/genital
HSV-2: genital

ASx viral shedding across moist surfaces

Vessicles 6d after exposure, lasts 14d
Viral shedding lasts 15d

215
Q

How long after presentation of subsequent genital HSV flares can cultures be attempted

What phrase describes their appearance on PE

What are 3 cutaneous HSV infections

A

x5d

Grouped vessicles on an erythematous base

Gladiatroum- contact sport athletes
Ocular- dendritic fluorescein pattern; corneal blindness
Whitlow- distal phalanx

216
Q

What is the best method for Dx genital HSV infections

What is the window to perform a viral culture

What result is sought out if doing a Tzanck prep

A

PCR- gold standard; same day HSV 1 vs 2 differentiator

4d window of vesicular lesions

Multi-nucleated giant cells

217
Q

What are the two Tx methods for HSV

A

Episodic: FAV-cyclovir administered at first prodrome sign:
F: 125mg BID x 5d or 1g BID x 1d
A: 800mg TID
V: 500mg BID x 3d or 1g daily x 5d

Suppressive Tx: FAV-cyclovir
F: 250mg BID
A: 400mg BID
V: 500mg BID or 1g daily

218
Q

What causes Shingles

What presentation is a referral emergency

Why are antivirals needed w/in first 72hrs

What antivirals are used and for how long

When can Pts get ? vaccines for prevention?

A

Reactivated Varicella virus from dorsal ganglion

CN5, ophth branch

Prevent postherpetic neuralgia

FAV-cyclovir x 7-10 days

Pts 50y/o and older:
Zostavax: live vaccine
Shingrix: recombinant vaccine

219
Q

Define Dermatophytes

What are the 3 generas of Tineas

What are the 4 modes of transmission to humans

A

Fungi that infect corneum (keratin layer) but can’t survive on mucosal surfaces

Microsporum Epidermophyton Trichophyton- MC

Human Animal Soil Fomites

220
Q

What morphology do tinea lesions have

How are these infections Dx

What test is needed for Dx if hair/nail infection is suspected

A

Annular w/ raised scaly border and clear expanding center

KOH prep by scraping border w/ 15 blade

Dermatophyte Test Medium- turns red 7-14d later

221
Q

How are T. Corporis superficial lesions Tx

What Pt education is needed during Tx

What PO meds are used for extensive/deep infection

A

MCK-azole BID x 2-4wks

Continue applying 7d after erythema resolves

Fluconazole Itraconazole Terbinafine
Griseofulvin- kids

222
Q

How is T. Pedis Tx if located interdigitally

How is the infection Tx if it’s ‘moccasin’ type of infection

Define T. Manuum and how is it Tx

A

Topical Terbinafine/Clotrimazole

PO Fluconazole/Itraconazole/Terbinafine

M>F infection of hands
Interdigit: Topical Terbinafine/Clotrimazole
Moccasin: PO Fluconazole/Itraconazole/Terbinafine

223
Q

T. Barbae can only be Tx w/ ? agents

T. Faciei is Tx w/ ? unless it’s located ?

How is T. Cruris differentiated from Erythrasma on PE

How is this type of infection Tx

A

PO agents

Topical, near eyes

T Cruris spares scrotum/labia
Erythrasma will be coral-pink w/ Woods Lamp and does not spare scrotum/labia

MCK-azole BID x 2wks w/ 2cm beyond border
Extensive/refractory: PO Terbinafine/Itra/Flu-conazole
Griseofulvin- kids

224
Q

T Capitis is more common in ? populations

What is the MC type of infection pattern

How is this infection Dx

How is it Tx

A

Children

Black dot- broken hair follicles at orifice

Gauze/Toothbrush rub to innoculate medium

Must be PO systemic meds:
Adult: Griseofulvin Itrazonazole Terbinafine
Kids: Griseofulvin

225
Q

Define Kerion

What S/Sxs are possibly seen with this

Why can Dx be difficult

How is this Tx

A

Inflammatory T. Capitis w/ painful, boggy nodules that drain

Fever Adenopathy Alopecia

KOH may be negative d/t destruction of fungal structures

PO antifungal (Greseofulvin or Terbinafine)
PO steroid
226
Q

Define T Incognito

What will be seen in PE

Where on the body are these more commonly seen

A

Fungal infection that is Tx w/ steroids causing characteristic changes to fungus structures

No border/margin scales
Diffuse erythemia

Face Groin Dorsal hands

227
Q

Define Caidiasis infection

What predisposing factors can cause this to become pathogenic

A

C. Albican, normal flora, becomes pathogenic and opportunistic infection when corneum is damaged in warm, moist and dark areas

OCP
Pregnant
Topical steroids
ImmSupp
Macerated skin
ABX
DM
228
Q

What are the 4 possible manifestations of Candidiasis infections

How are Candidiasis infections Dx

A

Thrush: white adherent tongue plaques
Angular cheilitis
Vulvovaginitis- thick d/c w/ external satellite lesions
Intertriginous: Blastomycetica-toe web; Balanitis: uncircumcised males

KOH prep- pseudohyphae w/ budding spores

229
Q

How is Candidal Vulvovaginitis Tx

How is Oropharyngeal Cadidiasis Tx

How is Angular Cheilitis Tx

A

PO Fluconazole 150mg x 1 dose (not if pregnant)
Topical Clotrimazole and Miconazole- most wide usage; safe for pregnancy (topical -azoles or nystatins)

PO Fluconazole
Infant/Kid- Nystatin oral suspension
Clotrimazole troche (lozenge) (greek- little wheel)

Topical antifungal and Group 5 steroid
D/c steroid once inflammation is gone

230
Q

How are Intertrigo/Diaper/Balanitis Candidiasis Tx

What causes Pityriasis Versicolor

What parts of the body is this dysfunction common in

A

Topical MCK-azole BID
Intertrigo: Wet dressing until dry

Overgrowth of P. orbiculare/ovale (AKA Malassezia Furfur)

Corneum/follicles in highly sebaceous areas;
MC on mid chest/upper back
Facial eruptions more common in kids

231
Q

How is Pityriasis Versicolor Dx

What is done for Tx

What can be done for prevention

A

Woods lamp- accentuates areas
KOH- spagehetti and meatballs: short, broad hyphae w/ clusters of budding cells

Limited: Topical Ketoconazole/Selenium Sulfide
Extensive: PO FIK-azole

Ketoconazole shampoo x 10min weekly

232
Q

Define Sporotrichosis

What Pt education can go w/ this Dx

Where/what populations is this Dx common in

A

SQ infection of Sporothrix (saprophytic fungus)

MC and least serious of deep fungal infections

MC finger of Florist/Farmer/Hunter w/ trauma induced inoculation

233
Q

How does Sporotrichosis progress

How is this Dx

What DDx is considered

How is it Tx

A

Painless lesion that increases in number over weeks w/ lymphatic pattern

Punch/excision biopsy

Cat Scratch Fever from M marinum
Primary lesion: TB Tularemia Syphillis

PO Itraconazole QD for up to 6mon

234
Q

What are the 3 types of hair

What are the 3 phases of hair growth/loss

A

Terminal: thick pigmented hair that requires androgens for growth regulation (scalp beard axilla pubis)

Velus: fine, thin hairs that are independent of androgens

Lanugo: fine hairs on fetus

Anagen: grow phase; 95% of hairs, 100 follicles enter/day
Catagen: transitional phase
Telogen: rest phase; 100 lost/day

235
Q

How many hairs does the average scalp have

How long is a growth phase

How much growth occurs each day

A

100K

1000 days

.3-.4mm/day= 6”/year

236
Q

Define Pull Test

How is this done and what do results mean

What Pt education is needed for this test

A

Easy technique to assess for hair loss

Grasp 60 hairs and pull
6 or <= neg
7 or >= pos

No shampooing hair 24hrs prior

237
Q

Define Telogen Effluvium

What population is this more common in

What can cause this to start

A

Loss of resting hair 2-4mon after insult that inc daily and lasts 4wks, leaves healthy scalp

Adult females

Birth
Crash diet/weight loss
D/c OCP
High fevers
Surgery
238
Q

What labs are needed for a Telogen Effluvium work up

What DDx is considered but different

What is this Tx

A

CBC CMP Serum ferritin Thyroid panel

Anagen effluvium- loss of growing hair d/t Chemo/Rad poison

Reassure and cosmetic advice

239
Q

Define Androgenic Allopecia

What are the two types of hair follicles affected

How is this Tx

A

Male Pattern Baldness d/t shortening anagen cycles

Top/vertex- androgen sensitive
Side- androgen independent

Minoxidil: ideally male Pt <30y/o w/ hair loss <5yrs; inc anagen duration and causes follicles at rest to grow/enlarge

Finasteride: inhibits 5a-red and follicle miniaturization; also Tx BPH; treatment is indefinite

Dutasteride: inhibits Type i and II 5a-red, 3x more than finasteride

240
Q

Define Androgenic Allopecia; Female pattern

What part of the scalp is affected

What labs should be ordered

Hos is this form Tx

A

MC in post-menopausal women d/t dec of estrogen/inc of androgens

Lost vertex follicles

DHEA-s T Prolactin SHBG

Minoxidil 2 or 5%

241
Q

What are the 3 types of alopecia

A

Areata: partial loss of hair
Totalis: all of scalp hair is lost
Universalis: all scalp and body hair is lost

242
Q

What type of visual appearance do hairs have in Alopecia Areats

What ‘pattern’ is seen in these Pts

How is this Tx if Pt is <10y/o

How is this Tx if Pt is >10y/o but <50% of scalp

How is this Tx if Pt is >10y/o and >50% of scalp

A

Exclamation- peripheral hair have normal shaft and narrow base

Ophiasis: band like hair loss in parietal/temporal/occipital area

Topical steroid and 5% Minoxidil

Triancinolone injection and Minoxidil

Minodil and Steroid
Anthralin

243
Q

What Pts have the best prognosis for Alopecia Areata

What types have poorer prognosis

How long before any regrowth can be seen

A

Adult w/ small area involved and Tx during first attack

Ophiasis Univeralis Totalis

1-3mon w/ finer/whiter hair

244
Q

Define Trichorrhexis Nodosa

Why is the hair loss potentially permanent

How is this Tx

A

Over working hair causes hair to be brittle d/t weak points at the hair shaft node

Scarring

Stop all hair Txs
Screen for hypothyroid

245
Q

Define Traction Alopecia

How is this Tx

A

Tight hair styles causes hair shaft Fx and follicle damage and progresses to receding hair line

Change hair style

246
Q

Define Folliculitis Decalvans

What are two possible etiologies

How is this Tx

A

Chronic pustular eruptions on the scalp that scar and cause permanent alopecia patches

Chronic Staph A folliculitis
Altered immune responses

Clindamycin 300mg BID x 10wks

247
Q

Although rare, what population is dissecting cellulitis more common in

What does this look like on PE

How is this Tx

A

AfAm men

Inflammatory nodules coalesce into linear ridges w/ foul smelling d/c

Isotretinoin

248
Q

Define Hirsutism

What are two possible etiologies

What RFs put Pts at risk for developing this condition

A

Females w/ terminal hair in male-pattern (chest face areola)

High androgen level
Inc follicle sensitivity to normal androgen levels

PCOS
Cushing synd.
Androgen tumor
CCS use
Obesity
249
Q

How is Hirustism managed

Define Hypertrichosis

What are 3 suspected etiologies of this condition

A

Spironolactone
OCP
Low dose CCS
Efloronithine- hair removal cream

Excessive hair length and density that are non-androgen sensitive and spares palm/sole

Rx: Minoxidil Phenytoin Cyclosporine CCS
Internal malignancy
Genetic d/o

250
Q

Define Nail Plate

Define Nailfold

Define Matrix

Define Lunula

A

Hard, translucent dead keratin; the nail

Proximal nailfold overlying the matrix

Epithelium that synthesizes the plate

White half moon, distal aspect of matrix and continuous w/ nail bed

251
Q

Define Nail Bed

Define Hyponychium

Define Eponychium

A

Parallel longitudinal ridges w/ small vessels in base

Short skin segment w/out nail cover

Cuticle

252
Q

What are two nail d/os associated w/ psoriasis

What are the MC nail findings of Lichen Planus

Define Pterygium Unguis

A

Oil spots
Onycholysis

Longitudinal grooves/ridges

Inflammation of matrix causing adhesion of proximal nailfold to matrix

253
Q

What class of ABXs can cause nail changes

Define Onychomycosis

How is a Dx confirmed and why is confirmation needed

A

Tetracyclines

Tinea unguium

KOH and culture prior to PO antifungals

254
Q

What are the 3 infection patterns of Onychomycosis

How is Onychomycosis Tx

A

Distal
White, superficial
Proximal

PO:
Terbinafine/Itraconazole
Topical:
Ciclopirox- daily application, weekly removal
Efinaconazole- Txs distal lateral onychomycosis

255
Q

Define Chronic Exposure nails

What is used for Tx

What can be used for preventing ingrown toenails

A

Repeat water immersion/nail polish removal causes nails to be brittle

B7- biotin, inc thickness

MC great toe; phenol

256
Q

Subungual hematoma is d/t trauma to ? structure

If severe, how are these Tx

A

Nail plate

Trephination

257
Q

Define Habit-Tic deformity

What does this look like on PE

How is this Tx

A

OCD Pt biting/picking proximal nail fold on thumb

Longitudinal band w/ horizontal, yellow grooves

Stop

258
Q

Define Pincer Nails

What causes this

Hos is this Tx

A

Later edge of toe nail grow inward

Shoe compression

Nail removal
Wider shoes

259
Q

Define Paronychia

How is this Tx

What does a pseudomonas infected nail look like

How is this Tx

A

Ascess induced pain/swelling of lateral/proximal nail fold

Ind and anti-staph ABX

Green/black

Chlorine-bleach mixture or,
Vinegar
Sev/Tx failure= Cipro

260
Q

Define Beaus Lines

How are these Tx

A

Transverse depression at base of lunula wks after stressful event

None needed

261
Q

What is Yellow Nail Syndrome associated w/

What population is this seen in

What does it look like on PE

How is it Tx

A

Respiratory Dzs
Lymphedema Dzs

AIDS Pts

Usually all nail plates curve and yellow

Vit E, PO or Topical

262
Q

What is the name of the angle used to quantify finger clubbing

Normally this angle is ?

Define Koilonychia and it’s association

How is it Tx

A

Lovibond angle (>180*- clubbed)

160*

Spoon nails; Fe deficient anemia

Tx anemia

263
Q

Define Mee’s Lines

What are these associated w/

How are they Tx

A

Transverse white line through nail plate

Sepsis
LF/RF
Arsenic poison
CHF
Chemo

Self resolves w/ nail growth, Tx underlying issue

264
Q

Define Terry’s Nails

What are these associated w/

A

White/pink nails w/ retained pink distal band

Cirrhosis
CHF
AODM
Age

265
Q

What c/c can indicate Pt has scabies

What part of the body is affected in adults

What parts are affected in infants

How is scabies Dx

A

Itch that worsens at night

Webs Wrist Groin Butt

Palms/Soles

Felt tip marker
15 blade scrape w/ immersion oil

266
Q

What is used for scabies Tx

How is the Tx plan changed if Pt is institutionalized, nursing home resident of topical failure

What is a toxic Tx option

A

Permethrin 5% at bedtime on dry skin/hair line
Retreat in 7 days

Ivermectin on day 1 and 8; expect worsening Sxs on day 2-3, does not indicate Tx failure

Lindane- chemical pesticide used after steroid Tx

267
Q

Define Norwegian Scabies

What differentiator can be used for this Dx

What are the three types of Pediculosis infections

A

Scabies variant of HIV Pts involving hands and face

Thousands of mites, very little itch

Capitits: nits in hair, red papules on neck
Corporis: red papules and excoriation on wrist/ankle, eye lash infestation only seen in children
Pubis: red papules w/ excoriation on abdomen/groin

268
Q

How can lice be ID’d on PE

What is the danger associated w/ body lice

How are these different types Tx

A

Live in seams of clothes;
Woods lamp shows yellow/blue-green colors

Carry Typhus/Trench Fever

Head: Permethrin 1% x 10min, rpt 7days
Lashes: Vaseline and baby shampoo
Body: Permethrin 5% x 10min, rpt 7-10days

269
Q

How would fleas present

How are these Pts managed

Define Cimex lectularis

How is this Tx

A

Red, pruritic bite marks on lower legs/ankles

Antihistamine
Topical ABX/steroids

Bed bugs: rows (3-5) of pruritic, erythematous papules on exposed skin
Numerous bits can lead to adenopathy/fever

Anit-histamine
Topical steroids

270
Q

Define Chigger

Where do they affect the body

What family do Fire Ants belong to

What ware the three groups of this family

A

Mites living in tall grass and attach to human

Leg/belt line

Hymenoptera

Apoidea: bees
Vespoidea: wasp, hornet, yellow jacket
Formicidae: ants

271
Q

What is used for Tx of Fire Ant stings

What is the Loxosceles

What type of venom do they have

What Pt presentation indicates this bite

A

Steroids Antihistamine Cool compress Sarna lotion

Brown spiders (recluse)

Cytolytic venom: causes skin necrosis

Painless bite causing mildly erythematous lesion

272
Q

Rarely, ? type of severe adverse reaction can occur form a Loxosceles bite

What ‘sign’ is this called

What population is more likely to have ? systemic Sxs

A

Hrs- pain
24hrs: blue hermorrhagic blister
3-4d: ecchymotic center, blanced periphery
7d: necrotic ulcer that heals w/ defect

Red White Blue: erythema blanch ecchymosis

Peds- F/C/N/V arthralgias

273
Q

How are Loxosceles bites Tx

What other spider is similar in appearance and bite to Loxosceles

What family do Black Widows belong to

A

Hyperbaric Dapsone Analgesic Tetanus ABX

Hobo: Tegenaria agrestis, Pacific NW of USA

Latrodectus- neurotoxic venom causing massive release of Ach/NorEpi

274
Q

How do Black Widow bites present

What other c/c is commonly present w/ bite

What trifecta is used for Dx

How are Black Widow bites Tx

A

Immediate pin-prick pain
Erythematous papule <60min, becomes target lesion (blanched center, peripheral erythema)

Latrodectism- abdominal cramping

Pain Target lesion Spasms

Tetanus Benzox Opioids
Antivenom- severe/hospitalized cases

275
Q

What is a rare complication that can arise from Rosacea

What systemic S/Sxs can this present w/

What Rx is used for first line therapy

What other Rxs can be used

A

Rosacea Fulminans- nodules and abscess w/ sinus tracts

Low fever
Inc ESR
Leukocytosis

Metronidazole

Clinda/Erythromycin

276
Q

Only two times Mycoplasma Pneumonia appear

The ABCDE of MM, ‘D’ concern starts at ? size

A

Erythema multiform
SJS

> 5mm

277
Q

Pos Nikolsky Signs

5-FU Txs

Punch Biopsy for Dx

A

Pemphigus Vulgaris w/ non-pruritic lesion
SSSS
TEN

Bowenoid Dz/papules
AKs
Hypertrophic Scar/Keloid
Keratoacanthoma

Dermatitis Herpetiformis
Sporotrichosis
Dermatofibroma

278
Q

Referral

Apocrine vs Eccrine

A 
Pemphigus Vulgaris
Acne Vulgaris for Accutane
MM
Multiple Sevbaceous Hyperplasis lesion for Isotreinoin
Urticaria to allergist
Dysplastic Nevus to Ophthalmology

Eccrine gland occlusion= miliaria
Apocrine occlusion/infection= HS

279
Q

HIV

AIDS

HHV

A

Granuloma annulare
Kaposi Sarcoma on face/trunk
Ivermectin for Pts w/ Scabies Dx and HIV
Norwegian crusted scabies

Yellow nail syndrome
Seborrheic Dermatitis
Kaposi Sarcoma

HHV-8: Kaposi sarcoma in ImmSupp Pts
HHV-6/7: Pityriasis Rosea

280
Q

Microscopic Hyphae

A

Dermatophyte: branching hyphae w/ uniform width

Candidiasis: pseudohyphae w/ budding spores

Pityriasis Versicolor: short, broad hyphae w/ clusters of budding cells; Spaghetti and Meatballs

IPAP (212 decks)

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