Derm 2.0 Flashcards
What are the two functions of the epidermis?
Where is the epidermis thinnest and thickest?
What are the 5 layers from superficial to deep
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
What are the 9 examples of primary lesions
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
Define Secondary Lesions and what their presence infers
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
Define Special Skin Lesion
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
What type of skin test is done for herpes
What is patch testing done for
What are the four main Tx categories of derm
Tzanck prep
Allergies
Topical Systemic Photo-therapy Surgical
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
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)
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
Urea (Carmol, Vanamide) Lactic Acid (Lac-Hydrin, AmLactin)
Creams
Menthol, Phenol
What are 4 solutions used for Topical Therapy: Wet Dressings and indications for use
What is the technique for using Wet Dressings
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
Define Vehicle and what does the vehicle determine
What are the 6 types of Vehicles
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
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
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
What are the local adverse effects of using Topical Steroid Therapy
WAR BIRD BASHH
Worsening infection
Atrophy
Rebound phenomenom
Burning
Itching
Rosacea
Dry skin d/t cream/lotion
Bruising Acne/folliculitis Striae Hypertrichosis (face) Hypopigmentation
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
Chronic dermatitis that isn’t worse/better w/ CCS
Exanthem Purpura Urticaria
Patch testing
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
FTT Adrenal axis suppression (<2y/o, puberty) Glaucoma Stunted growth Cushing Syndrome Cataracts
Longer lasting, Easier
Local atrophy, especially if needle too short
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
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
Face/neck= ? FTU
Trunk= ? FTU
Arm= ? FTU
Hand= ? FTU
Leg= ? FTU
Foot= ? FTU
Child FTU Chart
F/n= 2.5FTU
Front/back trunk= 7FTU
Arm= 3 FTU
Hand= 1FTU
Leg= 6FTU
Foot= 2FTU
Deck 2, Slide 45
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
45-60gm/wk
1: QD-BID
2-6: BID x 2-6wks
2wks on, 1wk off
Avoids tachyphylaxis
? is the MC inflammatory skin Dz
This MC is often referred to as ?
What are the four characteristics of this MC
Eczema
Dermatitis- inflammation of the skin
Pruritus Erythema Vesicles Scale
What are the characteristic PE findings of the 3 stages of Eczema that can occur in any order, etiology and Txs
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
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
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
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
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
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
> 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
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
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
Stasis Dermatitis is an inflammatory result d/t ? physiological process
How does Stasis Dermatitis appear on PE
How is this condition Tx
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
Define Atopic Dermatitis
What will almost always be in their Med/FamHx
When do these Pts tend to experience flare ups
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
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
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
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
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
What is the name of the Atopic Dermatitis variant that presents during childhood
How is this variant Tx
Keratosis Pilaris- ASx spiny papules on extensor surfaces of arms/legs
Lotion w/ urea or lactic acid
Short course w/ mild steroid
Define Contact Dermatitis
What are the two types of Contact Dermatitis
How is the Dx made/confirmed
Eczematous dermatitis from exposures
Irritant (Occupation/Diaper): corneum barrier damaged; non-immunologic
Allergic: Ag absorbed, subsequent eruption
Patch testing
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
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
? 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
#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
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
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
Timelines for acute/chronic urticaria
Which one can lead to anaphylaxis
What labs may be ordered during Dx phase prior to being referred to ?
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
How is Acute Urticaria Tx
How is Chronic Urticaria Tx
How is Physical Urticaria Tx
H1 antihistamine
Avoidance
Prep for anaphylaxis: Benadryl Epi CCS
2nd Gen antihistamine
H2 blocker
PO steroid
Elimination diet
Pre-Tx w/ H1 blocker
Angioedema MC affects ? areas of the body
How is this condition Tx
STOPPED
Lips Eye Tongue Trunk Genitals Hands
IM/PO Antihistamine
PO steroid, if ossible
Slide 14, Deck 5
? PE finding is indicator of Measles
How does the Measles rash appear
How does the Measles rash spread
How is Measles Tx/Protected
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
How does HFM Dz present
How is HFM Dz Tx
First: 2-10 painful oral papules to vesicles
Typically: dorsal finger/toes
Support
Anti-histamine/pyretic
Diet adjustment if painful PO lesions
? Dz is AKA 5th Dz
How does this rash appear
When is Erythema Infectiosum contagious
How is it Tx
Erythema Infectiosum- Slapped Cheek
Macular erythematous and lacy, worsened by exercise
Prodrome, not during rash
Support
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
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)
? 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
Cutaneous eruption
Fixed eruption
Urticarial
Maculopapular
Exanthematous- MC
Maculoapular/Morbilliform- Mucus Palm Soles
Spares face
TMP/SMX Acetaminophen Barbituates Antimalarials NSAIDs
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
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
Define Erythema Multiforme
What are the two types
What are the two etiologies
Immune mediated condition causing target/iris lesions
Major: major mucosal involvement
Minor: mild/no mucosal involvement
HSV- MC
Mycoplasma pneumonia
Where does Erythema Multiforme affect the body
What can be expected from this condition’s duration
How is this Tx
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
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
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
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
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
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
Nikolsky: slight pressure peels epidermis from dermis
Wet cigarette paper that shows raw, scalded looking dermis
Spares: Scalp, GI tract
Constant: Ocular
How is TEN Tx
What is not used
Traditionally, SJS/TEN were considered more severe forms of ? and graded/classified depending on ? criteria
Plasma exchange IVIG Cyclosporine A Cyclophosphamide
CCS
Erythema Multiforme:
SJS: mucosal erosion, <10% skin detached
Overlap: 10-30% detached
TEN: >30% detached
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
Extensor aspects of extremities
Hypersensitivity
More common in females
Erythematous eruptions on extensor surfaces
Sarcoidosis association
What is the presentation for Erythema Nodosum
How are the characteristic lesions described and located
How is this Tx
Low fever Arthralgia Malaise Arthritis
Red node swelling over shins
Week 1: tense, hard, painful
Week 2: fluctuant
Self limited, NSAIDs
Define Pyoderma Gangrenosum
This commonly occurs in ? population
Where do lesions begin
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
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?
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
How is Acne Classified
What is the rule about these two classifications
Non-Inflammatory: Open/Closed comedome
Inflammatory: Papule Pustule Nodule/Cyst
Inflammatory can have comedones
Non-inflammatory will not have inflammatory lesions
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
+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
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
Female/RxFailure/Not Accutane candidate= OCP/Spironolactone
Accutane
Relapse after 2nd course= OCP/Spironolactone
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
Tazarotene (retinoid) Azelac acid (topical ABX)
Male w/ + FamHx
Isotretinoin- impacts/alters P Acnes, Inflammation, Comedogenesis and Sebum produciton
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
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
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
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
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
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
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
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
Define Pomade Acne/Cosmetica
This usually involves forehead, temples and sides of the face, what areas can be spared?
How is this condition managed
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
What 3 locations are MC affected by steroid acne
What is unique about this conditions morphology
How is Steroid Acne Tx
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
Define Milia
Where do these MC appear
How are these managed
Epidermal cysts w/out openings d/t sun damage/physical trauma
Face, around eyelids
Few: Incision and excise, cannot express
Multiple: tretinoin until resolution
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
Prickly eat rash; scattered skin-colored vesicles
Red= miliaria rubra
Forehead Trunk Cheeks
Eccrine gland occlusion
Anti-histamine, Cool compress
Define Hidradenitis Suppurativa
What is the etiology behind this condition
Where does this tend to occur
How is this condition staged for Tx
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:
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
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
Define Staph Folliculitis
What is an uncommon Sx seen w/ this condition
This can develop as a complication of ? Tx
Painful pustules anywhere hair follicles are present w/ Staph A/E infection
Low fever
Occlusive topical steroids
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
Nasal carrier
Isolated: topical Mupirocin/Clindamycin
Extensive: PO Dicloxacillin/Cephalexin
Hibiclens: hands, affected area
Mupirocin- nares
Clindamycin
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
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
If Acne Keloidalis Nuchae presents as pustular/exudative, how is it Tx?
What is the 3 step plan for controlling this condition?
Culture, Tetracycline x 3-6mon
Fluocinonide x3-6mon Tretinoin x12mon Clindamycin x12mon PO steroids Intrelesional injeciton Laser therapy Excisional surgery
Define EIC
These are more common in ? populations
How are these managed
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
Pilar Cysts are AKA ?
How are these different than EICs
Nearly all will develop where and are Tx w/ ?
Wen
SubQ cyst w/ homogenous material that can calcify
Scalp, excision
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
Psoriasis Seborrheic Pityriasis Lichen Planus/Sclerosis
Immune mediated skin inflammation causing hyperkeratosis (7x faster; 4 vs 30 days)
Chronic Guttate Pustular Inverse
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
Flat, red papules w/ silvery scale
Auspitz- pin-point bleeding
Symmetric and Bilaterally:
Knee/Elbow extensor surfaces
Oil spot nails
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
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
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
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
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
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
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?
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
Where/how does Pustular Psoriasis present
What does this distribution develop as
How is it managed
What Tx needs to be avoided
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
What is the generalized variant of Pustular Psoriasis called
How do Pts present w/ this rare variant
Many Pts have ? Hx
von Zumbusch
Painful pustules Leukocytosis Febrile Toxic
Smoking
Define Psoriasis Inversus
What type of nail abnormality to these Pts have
Define Seborrheic Dermatitis
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
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
Teens Infancy Maternity (high hormonal periods)
Dryness Stress Hygiene changes
Elderly w/ neuro problems
AIDS
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
Over produced sebum
Over grown yeast (Malassezia furfur)
Greasy white/yellow flakes w/ pruritic/inflamed base
Staph infxn
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?
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
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
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
How is Pityriasis Rosea Tx
How are severe cases Tx
What odd DDx needs to be considered
Group 5 topical steroid
Antihistamine
Sunlight
Prednisone or,
UVB x 2wks or,
PO Acyclovir
Secondary syphillis
What type of reaction is Lichen Planus
This condition has an association w/ ? Dz
Define the Koebnerize phenomenon that occurs w/ this d/o
Inflamed skin/mucous membrane reaction
Hep C
Lesions form at site of skin trauma
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
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
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
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
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
Biopsy to r/o SCC
Local: Group 1-2 w/ occlusion/injection q3wk
Oral: Clobetasol Fluocinonide Traimcinolone Azathioprine (resistant)
General: Prednisone
Itch: Hydroxyzine
Define Lichen Sclerosis
Where does this MC occur on the body
How do these manifestation appear early/later on
How is Lichen Sclerosis Tx
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
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
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
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
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
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
Velvety, symmetrical thickening and hyperpigmentation of skin
Axilla
Gastric
Ammonium lactate- softens lesions
Tretinoin- thins skin
Define Xanthomas
What are the 5 types
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
Define Kaposi Sarcoma
What are the different types and characteristics of each
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
What is the Classic Kaposi Sarcoma is the MC tumor in ? Pts
How is a Dx confirmed
How are these Tx
AIDS
Biopsy- proliferation of vessels w/ neoplastic endothelial cells
LN2
Vinblastine- intralesional chemo, better for lesion >1cm
Excision- single
Radiotherapy- larger masses
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
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
Vesicular and Bullous Dzs are autoimmune blistering Dzs w/ ? two characteristics
How are these Dzs characterized
These are classifed by ?
Impaired epidermis to basement adhesion
ABs against adhesion proteins
Substantial morbidity/mortality
Histology- level of skin separation
Define Pemphigus
What is the pathophysiological reason this occurs
When does this tend to occur and in ? population
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
What do Pemphigus Vulgaris primary blisters look like
Why are these bad once they pop
How are they Dx
How is it Tx
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
? is the MC auto-immune sub-epidermal blistering Dz
Four differentiators about this MC
How are these Dx
How is this Tx
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)
Define Dermatitis Herpetiformis
What systemic dz is this associated w/
What population is this MC in
Intense burn/itch vesicular skin dz
Celiac dz
Northern European males
What is the classic distribution pattern for Dermatitis Herpetiformis
How is this Dx
How is this Tx short and long term
Symmetric, bilateral extensor surfaces
Scalp
Buttocks
Punch biopsy
Serological test- Celiac Dz
Short term: Dapsone
Long: gluten free diet
UV light is the MC cause of ?
What are the 3 types of UV light
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
What are the 6 Fitzpatrick phenotypes
What is the inverse relationship w/ these 6 classes
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
What environmental factors can affect amount of UV light exposure
Define SPF
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
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
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
What are the 3 MOAs of sunscreen
Define Photoaging
What four types of damage can the sun induce
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
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
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
What is key for treating photoaging
What topicals are used for Tx
Prevention
Retinoids: Tretinoin/Tazarotene w/ sunscreen
Txs: Fine wrinkles Roughness Pigment
Won’t Tx: Coarse wrinkles, Telangiectasias
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
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
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
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
How is PLME differentiated from Lupus
What type has mandatory Dx tests in order to r/o SLE
Delayed onset
Characteristic morphology
Histopahtlogical changes
Quick resolution
Plaque type: must get biopsy and Immunofluorescence
How is a Dx of Polymorphous Light Eruption confirmed
How is this condition Tx
What is used as last line Tx resort
Phototesting w/ UVA/UVB light
CCS: topical 4-5 for pruritus/PO wide spread
Sun protection/limited exposure
Desensitization w/ phototherapy
PUVA
Hydroxychloroquine
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
Actinic Prurigo
Inuit/Native American (North Central South)
MC face w/ intensely itching papules, possible hemorrhagic crust
Actinic cheilitis
Define Phototoxicity
What is the name for this condition if d/t plant etiology
What morphology can be seen on presentation
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
What plants can cause phototoxic reactions
What medications can cause these reactions
How are cases of Phototoxicity managed
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
Define Vitiligo
Half of these cases will present prior to ?
What is the MC type of Vitiligo
What is the other type classified as
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
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
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
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
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
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
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
Define Solar Lentigo
What other term are these known as
How is Solar Lentigo differentiated from Ephelides
How is this condition managed
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
Define Melasma
What are the etiologies of this condition
What are the 3 clinical patterns of this condition
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
How is Melasma Tx
? is the MC benign cutaneous neoplasm
What is the etiology behind this MC
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
SKs have ? possible etiology relation
How do the begin and what can they progress to
What terms are used to describe their morphology
Sun exposure
Macule to papule/verrucous
Greasy, stuck on appearance
How are SKs Tx
What type of presentation needs to have malignancy r/o
Define Stucco Keratosis
What population is this more common in
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
Where are Stucco Keratosis more and less likely to develop
What is the Tx and prognosis for these
Define Dermatosis Papulosa Nigra
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
What are skin tags called
What populations are these MC and common in
What education goes w/ freeze/excision Tx
Acrochordon
MC: Obese
1/4: all people after 25y/o
Won’t regrow but new lesions can occur
Define Dermatofibromas
How does these present
What PE test/finding can help w/ Dx
Reactive fibrous collection of fibroblasts, endothelial cells and histocytes from trauma
Pruritic/tender but become ASx
Dimpling- retract downward w/ squeezing
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
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
How are HS/Keloids Tx
Define Keratoacanthoma
What characteristic finding indicates this Dx on PE
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
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
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
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
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
Define Syringoma
What Pt population are these usually in
What is the prognosis for this
If requested Tx for cosmetics, how is this Tx
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
Define Neurofibroma
If two or more are found on PE, what needs to be done for these Pts
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
Define Cherry Angioma
Where/how do these develop
How are these Tx
MC vascular malformation; nearly always in Pts >30y/o
Smooth, firm, deep red papules on trunk/prox extremeties
Excision/Electro-ablation
Define Telangiectasia
What are the different types and Tx for each
Permanantly dilated vessels, max diameter of 1mm
Arterioles: Spider bodies- surface of skin
Radiate capillaries Spider legs
Electrodissection/Ablation
Define Pyogenic Granuloma
What two populations can this develop in
What PE finding can help clue in to Dx
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
What doe Pyogenic Granulomas look like
How are these Tx
Why is careful Tx so essential
Rapidly growing domes that are yellow/bright red and glistening top
Curettage through base
Electrodissection to control bleeds
Recurrence if any tissue remains
? is the MC benign soft tissue tumor
What morphology does this have
Where can these grow
Lipoma
Soft, mobile SQ lesions
Trunk, Extremeties MC in mid-20s
? 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
BCC- malignant proliferation of the basal layer of the epidermis
Intense, intermittent sun exposure
Inability to tan
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
Nodular- ASx slowly growing dome, evolves into ‘rodent ulcer’ of telangiectasis and ulcerates
Bleeding/scabbing sore that heals and recurs
Nodular: Nose
Superficial: trunk
Why does BCC have malignant potential
What is the ‘good news’ of this Dx
What is the f/u frequency for these Pts
Older nodes evade by direct extension, invade/replace structures
Almost never metastasizes
Annual TBSE, d/c after 3yrs of tumor free
Define Actinic Keratosis
What etiology causes these to develop
How doe these appear on PE
Premalignant SCC confined to epidermis
Chronic UVB exposure
Rough feeling hyperkeratotic lesion, erythema w/ yellow scale
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
Actinic cheilitis
Chondrodermatitis Nodularis Helicis: degeneration of collagen
Excise, special pillow
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
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
How does SCC In Situ appear on PE
Where are these more likely to develop in wo/men?
How do these differ from AKs?
Well defined, elevated, red, scaly plaques w/ very slow lateral growth
Female: lower extremities
Male: scalp/ear
Epidermis only
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
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
What populations are more likely to develop Erythroplasia of Queyrat
What microbe is responsible for this
How is it Tx
Uncircumcised males
HPV-8
5FU Imiquimod Laser
? is the 2nd MC skin Ca
Why is this MC scarier
What causes this type
What is this type’s precursor
SCC
High metastasis risk
UVA/B exposure
AKs
What are the RFs for SCC
HPV infection Burns (radiation, thermal) Inflammation Bowens Arsenic Sun exposure ImmSupp Chronic irritation
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
Scalp
Dorsal hands
Superior pinna
Bowens: anywhere
EDnC
Excise w/ margins
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
Lymph nodes
q12mon for life
Lips
Define Nevus
These may be AKA ?
How are Nevus cells different from melanocytes
Benign growth of cells derived from melanocytes
Moles
Larger
Abundant cytoplasm
No dendrites
Coarse granules
How are Nevus’ examined on PE
What are the four types of Common Nevi?
? AKA Moles become larger ? and when does their incidence peak
ABCDEs:
Asymmetry Border irregularity Color variation
Diameter Evolution
Melanocytic Junctional Compound Dermal
Melanocytic: Pregnancy/Puberty; 4-5th decade
Where do Malanocytic Nevus develop
What would histology results show from biopsy
F/u is needed if there are more than ? and how often?
Anywhere: include palm, sole, mucosa
Sun exposed areas
Nest of nevus cells
> 100, q6-12mon
What are the 3 subtypes of common/acquired Melanocytic Nevi based on location
What affects these subtypes
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
Junctional Nevus are more common during ?
What are Congenital Melanocyctic Nevi AKA?
These carry a greater risk if they’re ? size
Childhood
Birthmark
5% TBSA or more or,
>20cm
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 ?
Small/Med: observe
Large/Giant: prophylactic removal
Half develop malignancy by 5y/o
Nevus Spilus; birth/early infancy/adolescence
Nevus Spilus lack ? association to development
How are these Tx
Define Becker’s Nevus
Not associated to sun exposure
None; rare malignancy potential
Not ‘true’ nevus; lacks nevus cells
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
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
Define Halo Nevus
When do these tend to develop
What does their presence indicate
Compound/Dermal nevus w/ white border
15y/o
Onset of vitiligo
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’
No melanocytes in halo
Trunk
Never palm/soles
Nevus regresses w/ pigmentation returning over decades
Woods lamp: highlights areas of depigmentation
What are Spitz Nevus AKA
Why is this AKA term given
When/Where do these MC develop
How are these Tx
Benign Juvenile Melanoma: sudden development of hairless red/brown dome
Histologically similarity to melanoma
Children on head, neck, lower extremities
Removed for pathological eval
Define Blue Nevus
These typically remain under ? size
Where do these MC develop
Elevated, round and regular nevus
<5mm
Extremities, hand dorsum
How are Blue Nevus’ differentiated from Malignant Melanomas
Where do these MC develop
How are these Tx
Hx: develop in childhood, remain unchanged
Extremities, dorsal hands
Cosmetic removal at Pts request
Define Mongolian Spot
Where are Mongolian Spots MC develop
Flat blue/black lesion of melanocytes
Appear dark d/t Tyndall effect: melanin in deeper skin
Scalp, Pre-sacral
Asian/AfAm
Define Nevus of Ota
Because of their location, ? structures are affected
What population do these occur in MC?
How are they Tx
Dark pigmentation on 1st-2nd branch of CN5
Sclera Conjunctiva Periorbital skin
Female Asians
Laser- lighten lesions
F/u for glaucoma monitoring
Define Labial Melanotic Macule
Who do these occur in more commonly
How are these differentiated from freckles
How are they Tx
Dark macule on lower lip
Young women
No change w/ sun exposure
Cryo/Laser if desired
Define Nevus Flammeus
Where do these develop
When do Dysplastic/Atypical Nevus develop
Port Wine Stain; congenital vascular malformation, not a nevus
Face/Neck
Caucasian onset of puberty - 4th decade of life
What appearance do Dysplastic/Atypical Nevus have on PE and where are they seen
What is needed for Dx
‘Fried Egg’- >5mm w/ raised center, sun protected area
At least 3: >5mm diameter Ill define border Irregular margin Varying pigment Papular+Macular components
How are Dysplastic/Atypical Nevi Tx
How often do Pts need f/u
What referral should be considered for these Pts
Excision biopsy w/ margins
Family screening
TBSE q6-12mon
Ophtho
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
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
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
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
What is the most important histological part of a MM prognosis
What is the most important prognostic variable:
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%
? 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
Superficial Spreading in 30-40y/o
Back- both sexes
Legs- women
Many colors haphazazrdly combo’d
Nodules appear when >2.5cm
What are the ABCDEs of Superficial Spreading Melanoma
Asymmetric Irregular Brown/Black >5mm, radial growth first Black/Blue/White/Red then vertical growth
Define Nodular Melanoma
What color will this have
What are the ABCDEs of Nodular Melanoma
How can this be differentiated from a hemangioma
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
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
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
MM stats between Light/Dark pigment Pts
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
TBSE on Pt w/ MM needs to focus on ? areas
What is the modified ABCDEs for MM in DPP
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
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
Horizontal/radial
Mets inc once vertical growth begins
Sentinel node status
Covered by clothes
Majority of skin/soft tissue infections are due to ? microbes
What can each microbe cause
Staph A/GABHS- gram pos cocci
Staph A: Cellulitis Impetigo Folliculitis Furuncles
Staph toxins- bullous imptetigo, SSSS
GABHS: Lymphangitis Impetigo Cellulitis Erysipelas
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
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
Only times Methotrexate comes up in Tx plans
Only time Metronidazole comes up in Tx plans
Keratoacanthoma
Psoriasis- pustular/>5% BSA
Pompholyx
Perioral dermatitis
Acne Rosacea
Define Cellulitis
What is the MC microbe
What are two possible microbes
What is the probable microbe if PT is diabetic
Skin infection w/ SQ involvement causing Pain Erythema Edema
GABHS
Staph, H Influenza
Pseudomonas
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
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
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
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
Blistering Distal Dactylitis is defined as ? and more common in ? ages
How does this present on PE
How is this Tx
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)
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
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
Define Syncosis Barbe
What is this Dx AKA as?
How is this Tx
What is done if Pt is severe/ABX Tx failure
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
Furuncle/Carbuncles are both defined as ?
Define Furuncle
Define Carbuncle
Where are Furuncle/Carbuncles likely to develop
How are they Tx
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
What Pt populations are more likely to develop MRSA
How is this Tx w/ ABX
What Tx plan is an alternative
Recurrent furunclosis
Mupirocin TMP/SMX Clindamycin
Chlorhexidine or bleach bath
Define SSSS
This is primarily a Dz of ? is is d/t ? physiological defect
What can this condition start as
Blistering dz from Staph A toxins
Infant/younger kids w/ dec renal toxin clearance, causes hematogenous spread
Bullous Impetigo
What type of prodrome may precede a SSS Dx
What PE finding is indicative
How is this Tx
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
What does Hot Tub Folliculitis present as
Pt may present w/ fever/malaise but is at low risk for ?
How is this Tx
Pseudomonas infx causing round, pruritic plaques w/ center papule
Sepsis
Vinegar soak
Antihistamin PRN
Sev= Cipro
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
Debilitated, diabetic Pt
Toe web/groin
Ulcers
Bed sores
Swamps
External Otitis
Monitor diabetic glucose
Acetic Acid/Domeboro soaks- dry area
PO Cipro
Pseudomonas Toe Web infections
What does this look like on PE
How is it Tx
What is used if Pt is topical failure
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
Define Trichomycosis Axillaris
How is this Tx
Corynebacterium infection causing axilla hairs to be white and severe malodorous
Shave area
Topical Naftifine/Erythromycin/Clindamycin
Antipersperant/Drysol
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
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
How can Erythrasma be differentiated from T Cruris on exam
How is this Dx
How is this Tx
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
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
Kytococcus Sedentarius- weight bearing parts of feet
K Sedentarius releases enzymes that digest keratin
Hyperhidrosis
How is Pitted Keratolysis Tx
What is added if condition is recalcitrant/topical failure
What are the 5 viral infections
Topical Erythromycin/Clindamycin/Mupirocin w/ Drysol
PO Erythromycin
Wars Bowenoid Molluscum HSV HZ
Define Wart
How does a viral infection cause these to develop
How are these transmitted and what are they AKA if they are
Neoplasm confined to epidermis (no scarring)
HPV infects keratinocytes, causes hyper-plasia/keratosis
Touch, touching toes= kissing lesions
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
Mosaic pattern- cylindrical projections
Thrombosed vessels trapped at surface
Veruca Vulgaris- hyperkeratotic dome papule w/ black dot
MC on hands
How are Verruca Vulgaris Tx
What Tx can be applied by clinician for Tx
Define Filiform Warts
LN2 q2-4wks
Topical salicylic acid/Imiquimod
Cantharidin
Superficial flesh colored finger-like projections
MC on face, easiest to Tx (curettage/cry/electrocautery)
Define Verruca Plana
Where are these seen on the body
How are these types Tx
Flat warts- groups of flat tan/yellow/pink papules
Forehead Perioral Dorsal hands
Shaved areas- beard, legs
5-FU Tretinoin Imiquimod Cryo
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
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
How are Sub/Peri-ungual warts spread
Since these types can be more resistant to Tx, what options are used for Tx
Cuticle biting
Cryo
Cantharidin
Salicylic acid
Duct tape occlusion x 6d w/ 12hr break x 2mon
What are genital warts called
What types of HPV infections can cause these
What types of HPVs are highly/low risk for cervical CA
Condyoma Acuminata/Venireal
6 11 16 18 52 56
High- 16/18, esp 16
Low- 6/11
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
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
How are Genital Warts Tx by PT
How are these Tx by providers
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
What are possible DDxs for Genital Warts
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
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
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
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
HSV-1: PO/genital
HSV-2: genital
ASx viral shedding across moist surfaces
Vessicles 6d after exposure, lasts 14d
Viral shedding lasts 15d
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
x5d
Grouped vessicles on an erythematous base
Gladiatroum- contact sport athletes
Ocular- dendritic fluorescein pattern; corneal blindness
Whitlow- distal phalanx
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
PCR- gold standard; same day HSV 1 vs 2 differentiator
4d window of vesicular lesions
Multi-nucleated giant cells
What are the two Tx methods for HSV
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
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?
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
Define Dermatophytes
What are the 3 generas of Tineas
What are the 4 modes of transmission to humans
Fungi that infect corneum (keratin layer) but can’t survive on mucosal surfaces
Microsporum Epidermophyton Trichophyton- MC
Human Animal Soil Fomites
What morphology do tinea lesions have
How are these infections Dx
What test is needed for Dx if hair/nail infection is suspected
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
How are T. Corporis superficial lesions Tx
What Pt education is needed during Tx
What PO meds are used for extensive/deep infection
MCK-azole BID x 2-4wks
Continue applying 7d after erythema resolves
Fluconazole Itraconazole Terbinafine
Griseofulvin- kids
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
Topical Terbinafine/Clotrimazole
PO Fluconazole/Itraconazole/Terbinafine
M>F infection of hands
Interdigit: Topical Terbinafine/Clotrimazole
Moccasin: PO Fluconazole/Itraconazole/Terbinafine
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
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
T Capitis is more common in ? populations
What is the MC type of infection pattern
How is this infection Dx
How is it Tx
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
Define Kerion
What S/Sxs are possibly seen with this
Why can Dx be difficult
How is this Tx
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
Define T Incognito
What will be seen in PE
Where on the body are these more commonly seen
Fungal infection that is Tx w/ steroids causing characteristic changes to fungus structures
No border/margin scales
Diffuse erythemia
Face Groin Dorsal hands
Define Caidiasis infection
What predisposing factors can cause this to become pathogenic
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
What are the 4 possible manifestations of Candidiasis infections
How are Candidiasis infections Dx
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
How is Candidal Vulvovaginitis Tx
How is Oropharyngeal Cadidiasis Tx
How is Angular Cheilitis Tx
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
How are Intertrigo/Diaper/Balanitis Candidiasis Tx
What causes Pityriasis Versicolor
What parts of the body is this dysfunction common in
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
How is Pityriasis Versicolor Dx
What is done for Tx
What can be done for prevention
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
Define Sporotrichosis
What Pt education can go w/ this Dx
Where/what populations is this Dx common in
SQ infection of Sporothrix (saprophytic fungus)
MC and least serious of deep fungal infections
MC finger of Florist/Farmer/Hunter w/ trauma induced inoculation
How does Sporotrichosis progress
How is this Dx
What DDx is considered
How is it Tx
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
What are the 3 types of hair
What are the 3 phases of hair growth/loss
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
How many hairs does the average scalp have
How long is a growth phase
How much growth occurs each day
100K
1000 days
.3-.4mm/day= 6”/year
Define Pull Test
How is this done and what do results mean
What Pt education is needed for this test
Easy technique to assess for hair loss
Grasp 60 hairs and pull
6 or <= neg
7 or >= pos
No shampooing hair 24hrs prior
Define Telogen Effluvium
What population is this more common in
What can cause this to start
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
What labs are needed for a Telogen Effluvium work up
What DDx is considered but different
What is this Tx
CBC CMP Serum ferritin Thyroid panel
Anagen effluvium- loss of growing hair d/t Chemo/Rad poison
Reassure and cosmetic advice
Define Androgenic Allopecia
What are the two types of hair follicles affected
How is this Tx
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
Define Androgenic Allopecia; Female pattern
What part of the scalp is affected
What labs should be ordered
Hos is this form Tx
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%
What are the 3 types of alopecia
Areata: partial loss of hair
Totalis: all of scalp hair is lost
Universalis: all scalp and body hair is lost
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
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
What Pts have the best prognosis for Alopecia Areata
What types have poorer prognosis
How long before any regrowth can be seen
Adult w/ small area involved and Tx during first attack
Ophiasis Univeralis Totalis
1-3mon w/ finer/whiter hair
Define Trichorrhexis Nodosa
Why is the hair loss potentially permanent
How is this Tx
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
Define Traction Alopecia
How is this Tx
Tight hair styles causes hair shaft Fx and follicle damage and progresses to receding hair line
Change hair style
Define Folliculitis Decalvans
What are two possible etiologies
How is this Tx
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
Although rare, what population is dissecting cellulitis more common in
What does this look like on PE
How is this Tx
AfAm men
Inflammatory nodules coalesce into linear ridges w/ foul smelling d/c
Isotretinoin
Define Hirsutism
What are two possible etiologies
What RFs put Pts at risk for developing this condition
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
How is Hirustism managed
Define Hypertrichosis
What are 3 suspected etiologies of this condition
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
Define Nail Plate
Define Nailfold
Define Matrix
Define Lunula
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
Define Nail Bed
Define Hyponychium
Define Eponychium
Parallel longitudinal ridges w/ small vessels in base
Short skin segment w/out nail cover
Cuticle
What are two nail d/os associated w/ psoriasis
What are the MC nail findings of Lichen Planus
Define Pterygium Unguis
Oil spots
Onycholysis
Longitudinal grooves/ridges
Inflammation of matrix causing adhesion of proximal nailfold to matrix
What class of ABXs can cause nail changes
Define Onychomycosis
How is a Dx confirmed and why is confirmation needed
Tetracyclines
Tinea unguium
KOH and culture prior to PO antifungals
What are the 3 infection patterns of Onychomycosis
How is Onychomycosis Tx
Distal
White, superficial
Proximal
PO:
Terbinafine/Itraconazole
Topical:
Ciclopirox- daily application, weekly removal
Efinaconazole- Txs distal lateral onychomycosis
Define Chronic Exposure nails
What is used for Tx
What can be used for preventing ingrown toenails
Repeat water immersion/nail polish removal causes nails to be brittle
B7- biotin, inc thickness
MC great toe; phenol
Subungual hematoma is d/t trauma to ? structure
If severe, how are these Tx
Nail plate
Trephination
Define Habit-Tic deformity
What does this look like on PE
How is this Tx
OCD Pt biting/picking proximal nail fold on thumb
Longitudinal band w/ horizontal, yellow grooves
Stop
Define Pincer Nails
What causes this
Hos is this Tx
Later edge of toe nail grow inward
Shoe compression
Nail removal
Wider shoes
Define Paronychia
How is this Tx
What does a pseudomonas infected nail look like
How is this Tx
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
Define Beaus Lines
How are these Tx
Transverse depression at base of lunula wks after stressful event
None needed
What is Yellow Nail Syndrome associated w/
What population is this seen in
What does it look like on PE
How is it Tx
Respiratory Dzs
Lymphedema Dzs
AIDS Pts
Usually all nail plates curve and yellow
Vit E, PO or Topical
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
Lovibond angle (>180*- clubbed)
160*
Spoon nails; Fe deficient anemia
Tx anemia
Define Mee’s Lines
What are these associated w/
How are they Tx
Transverse white line through nail plate
Sepsis LF/RF Arsenic poison CHF Chemo
Self resolves w/ nail growth, Tx underlying issue
Define Terry’s Nails
What are these associated w/
White/pink nails w/ retained pink distal band
Cirrhosis
CHF
AODM
Age
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
Itch that worsens at night
Webs Wrist Groin Butt
Palms/Soles
Felt tip marker
15 blade scrape w/ immersion oil
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
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
Define Norwegian Scabies
What differentiator can be used for this Dx
What are the three types of Pediculosis infections
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
How can lice be ID’d on PE
What is the danger associated w/ body lice
How are these different types Tx
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
How would fleas present
How are these Pts managed
Define Cimex lectularis
How is this Tx
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
Define Chigger
Where do they affect the body
What family do Fire Ants belong to
What ware the three groups of this family
Mites living in tall grass and attach to human
Leg/belt line
Hymenoptera
Apoidea: bees
Vespoidea: wasp, hornet, yellow jacket
Formicidae: ants
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
Steroids Antihistamine Cool compress Sarna lotion
Brown spiders (recluse)
Cytolytic venom: causes skin necrosis
Painless bite causing mildly erythematous lesion
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
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
How are Loxosceles bites Tx
What other spider is similar in appearance and bite to Loxosceles
What family do Black Widows belong to
Hyperbaric Dapsone Analgesic Tetanus ABX
Hobo: Tegenaria agrestis, Pacific NW of USA
Latrodectus- neurotoxic venom causing massive release of Ach/NorEpi
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
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
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
Rosacea Fulminans- nodules and abscess w/ sinus tracts
Low fever
Inc ESR
Leukocytosis
Metronidazole
Clinda/Erythromycin
Only two times Mycoplasma Pneumonia appear
The ABCDE of MM, ‘D’ concern starts at ? size
Erythema multiform
SJS
> 5mm
Pos Nikolsky Signs
5-FU Txs
Punch Biopsy for Dx
Pemphigus Vulgaris w/ non-pruritic lesion
SSSS
TEN
Bowenoid Dz/papules
AKs
Hypertrophic Scar/Keloid
Keratoacanthoma
Dermatitis Herpetiformis
Sporotrichosis
Dermatofibroma
Referral
Apocrine vs Eccrine
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
HIV
AIDS
HHV
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
Microscopic Hyphae
Dermatophyte: branching hyphae w/ uniform width
Candidiasis: pseudohyphae w/ budding spores
Pityriasis Versicolor: short, broad hyphae w/ clusters of budding cells; Spaghetti and Meatballs
