CPD > Derm > Flashcards
Derm Flashcards
Papule
elevated, palpable; less than 10 mm
Macule
flat, usu less than 10 mm, variable shape, nonpalpable color change
Plaque
elevated plateau-like lesion greater than 10 mm; superficial;
Nodule
firm papule, palpable, extends into dermis or subQ tissue
Tumor
large nodule more than 10 mm
Vesicle
fluid-filled blister less than 10 mm
Bullae
vesicles larger than 10 mm
Pustule
elevated lesion containing pus
Urticaria
(wheals or hives) - transient elevated lesion due to localized edema
Scale
accumulation of epithelium; dry, whitish
Crust
dried pus, blood or serous exudate on the surface usually due to broken pustules or vesicles
Erosion
loss of epidermis.
Excoriation
linear erosion, usu caused by scratching
Ulcer
deeper erosions involving the dermis; bleed and scar
Petechiae
small non-blanchable punctuate foci of hemorrhage
Purpura
Larger area or hemorrhage, mb palpable
Large areas are bruises or ecchymosis
Atrophy
paper thin wrinkled and dry-appearing skin
Scar
fibrous tissue replacement after injury
Telangiectasia
dilated superficial blood vessels
Secondary morphology - Linear
in a line
Secondary morphology - Annular
rings with central clearing
Secondary morphology - nummular
Circular
Secondary morphology - target
rings around central duskiness
Secondary morphology - serpiginous
serpent like - fungal/parasitic infections
Secondary morphology - reticulated
lacy pattern
Texture types?
Verrucous – irregular surface (cauliflowery)
Lichenification: epidermal thickening with accentuation of skin lines due to chronic irritation
Induration: dermal thickening; skin feels hard and rough
Umbilicated: with a central indentation
Location/Distribution notes?
Single versus multiple lesions Presence on particular body parts may be significant Random versus patterned distribution Symmetric or asymmetric distribution Sun-exposed areas versus not Crosses midline?
Color of lesions?
Red (Erythematous); increased blood flow to the skin
Orange: hypercarotenemia
Yellow: jaundice, heavy metal poisoning, myxedema, uremia
Green: in fingernails, suggests pseudomonas
Violet: darkening cutaneous hemorrhage, vasculitis
Gray/blue skin: cyanosis, metal deposits
Black: melanocytic lesions, infection, arterial insufficiency
White: tinea, Pityriasis alba, vitiligo
Dermatographism
Urticaria after stroking the skin
Diascopy
pressure to indicate blanching (hemorrhagic lesions dunt blanch, but inflammatory lesions do)
Darier’s sign
stroking lesion causes intense and sudden erythema and wheal formation
Nikolsky’s sign
bullae formation and erosion following gentle traction pressure
Auspitz sign
pinpoint bleeding after removal of plaque (psoriasis)
Koebner’s phenomenon
Lesions within areas of trauma
Pruritis
Itching is stimulated by chemical and physical stimulation of cutaneous nerve endings. Stimulus may be external or internal. Several mediators of itching exist: histamine, kallekrein, and various peptidases.
Etiology: Dry skin most common cause
History: must include drug and occupational/hobby exposures
Testing: biopsy, CBC, liver, kidney, thyroid function, evaluation for underlying malignancy, immunoglobulins
Itching may occur with or without an associated skin eruption, which may help determine the cause.
Urticaria
Acute vs Chronic: >6 weeks duration?
Migratory, erythematous pruritic plaques. Mostly involves release of histamine.
Etiology: viral/bacterial infection, IgE allergy, medications esp NSAIDS. Rare- autoimmune dz, malignancy
History: duration, triggers, frequency, concomitant sxs (GI). Always ask about resp system. Also – use of drugs, travel and family history
PE: Complete examination of skin, sign of infections or systemic disease.
Testing: CBC, Immunoglobulins to foods, ANA or thyroid studies may be appropriate. Biopsy if uncertain.
Acne vulgaris
Obstruction of the pilosebaceous unit presenting with comedones (whiteheads = closed; blackheads = open), papules, pustules, inflamed nodules, superficial pus filled cysts and sometimes deep purulent sacs. Common on face, back, chest, and upper arms from puberty - ~35yrs, M>F.
Etiology: androgen stimulus, sebum, bacteria interaction, drug induction, diet (milk, sugar, bromine)
S/Sxs: comedones, papules, pustules, nodules, cysts (actually very rare).
Dx: H & P, comedones and often several stages of lesions. Grade by severity (mild = 5 cysts or >125 lesions)
Labs - Serum total/free testosterone w/DHT, FSH, LH, DHEA-S. Bacterial and fungal cultures can be done to r/o infectious folliculitis
DDX: rosacea (no comedones), perioral dermatitis, drug eruptions, folliculitis (yeast or bacterial, keratosis pilaris, Pseudofolliculitis barbae and acne keloidalis nuchae (in African Americans)
Rosacea
chronic inflammatory disorder characterized by facial flushing, telangiectasias, erythema, papules, pustules, and possibly rhinophyma.
Ages 30-60, fair complexions, and blushers.
Distribution: Most on the central area of the face and scalp
Hx: Pts have increased susceptibility to recurrent flushing reactions that may be provoked by a variety of stimuli including hot or spicy foods, drinking alcohol, temperature extremes, and emotional reactions. Pt’s may have eye involvement such as include foreign body sensation and burning, telangiectasia and irregularity of lid margins, meibomian gland dysfunction (posterior blepharitis), keratitis, conjunctivitis, and episcleritis
Etiology: “Idiopathic” although pts have a higher infection rates of H. Pylori and small intestinal bacterial overgrowth (SIBO)
S/Sxs: Stages:
- “Pre-rosacea”
- Vascular phase
- Inflammatory phase-papules, pustules, nodules and cysts present
- Late-stage/rhinophyma
Dx: one or more of the following primary features: flushing (transient erythema), Nontransient erythem, Papules and pustules, Telangiectasia and one or more of the following secondary features: Burning or stinging, Plaque, Dry appearance, Edema, Ocular manifestation, Peripheral location, Phymatous changes
DDX: SLE, discoid lupus, acne vulgaris, drug eruptions, granulomas, perioral derm, infectious folliculitis, seborrheic dermatitis, carcinoid, chronic topical glucocorticoids
Bullous pemphigoid
Chronic pruritic bullous eruptions. Uncommon.
Distribution: trunk, lower legs, extremity flexures, and axillary and inguinal folds
Age >60
Etiology: Autoimmune, drug induced from furosemide, captopril and NSAIDS
S/Sxs: prodromal phase maybe with pruritic eczematous, papular, or urticaria-like skin lesions that become tense bullae
Negative Nikolsky’s sign
May see urticaria early that turns dusky annular lesions
Bullae form on top of erythematous plaques and rupture in about 1 week leaving an eroded base
Pruritis common.
Associated with dementia, Parkinson’s disease, and unipolar or bipolar
Dx: H & P, skin biopsy (from edge of intact blister) shows subepidermal bulla with infiltrate of eosinophils- direct immunofluorescence (Gold Standard) of skin shows IgG and/or C3 in a linear band in basement membrane, serum antibody titers- Anti-BP180 antibodies. Biopsy must be done to dx
DDX: pemphigus vulgaris, dermatitis herpetiformis, erythema multiforme, drug eruptions
Dermatitis herpetiformis
Autoimmune, chronic, recurring, intensely itchy, with symmetrical groups of inflamed vesicles, papules and hives.
Distribution: Symmetrical extensor aspects, sacrum, base of head or generalized.
Age 20-50
Gender male:female 2:1
Etiology: Autoimmune, celiac dz (asx), also associated with thyroid disorders
S/Sxs: Burning, severe stinging and itching, and last for weeks to years.
DX: H & P, skin biopsy of lesion and adjacent normal skin, shows subepidermal clefting and papillary dermal tips w/neutrophils and eosinophils. Direct immunofluorenscence is gold stand for dx. IgA deposition. Labs- TTG, anti-endomysial Ab, jejunal bx for celiac dx
DDX: pemphigus, bullous pemphigoid, dermatitis, herpes, insect bites, scabies
Pemphigus vulgaris
potentially fatal blistering disease. Rare
Distribution: Oral lesions often precede skin lesions in 50-70%, then found on groin, scalp, abd, back, upper legs, axilla and umbilicus.
Age >60, F>M
Incidence highest in Ashkenazi Jews
Etiology: Autoimmune
S/Sxs: Flaccid bullae, various sizes, on the skin and mucus membranes. Skin shears off easily, leaving painful erosions. Positive Nikolsky’s sign.
Dx: H & P and biopsy. Biopsy shows intraepidermal bulla or speration of epidermal cells, eosinophil infiltrate, IgG, complement C3. Immunofluorescence from edge of fresh lesion and adjacent normal area. Serum anti-Dsg 3 and anti-Dsg 1 Ab- titers relate to dz activity. Nikolsky’s sign present.
Hospitalization almost universally required. 15% mortality rate
DDX: Herpes simplex and zoster, bullous pemphigoid, canker sores, paraneoplastic pemphigus (must do bx to exclude)
Calluses and Corns
epidermal thickening from pressure or friction; feet and toes
Calluses: usu asymptomatic, intact skin lines
Corns: mb painful with pressure, yellowish core when pared, interrupts skin lines
Ichthyosis
Scaling and flaking of skin, a range of types
Age- improves and can resolve with age
Distribution: shins, outer arms most common.
Inherited ichthyoses: Autosomal Dominant and X-linked. excessive accumulation of scales on skin. Resembles cracked pavement. Accentuated palmar creases
DX: H&P - No biopsy needed
DDx- dry skin, acquired ichthyosis (related to infection or systemic disease, sudden onset
Keratosis pilaris
keratinization disorder where horny plugs fill the openings of the hair follicles
Age usually worse in children and resolved or improves with adulthood
More common in atopy
Etiology: Nutritional deficiency, genetic
S/Sxs: keratotic follicular papules on lateral aspects of the upper arms, thighs and buttocks. On the face in children (can be confused with acne). Skin feels rough like sandpaper.
Atopic dermatitis (AD)
Immune-mediated skin inflammation, with typically a genetic component
Age: begins very young- distribution changes
Infantile phase (2months-2year) cheeks, perioral, scalp, extensor tops of feet and elbows with exudates
Childhood phase (2-12) flexural surfaces, lichenification
Adult phase (12-adult) flexural, hands, upper eyelids or patchy and diffuse over whole body
Etiology: genetic component (Atopy), food and environmental allergies; Aggravated by dry skin, wool, sweating, allergens, tight clothing, emotional stress, nutritional deficiency, SIBO
S/Sxs: red, weeping, crusted lesions on face, spread to neck, extremities, abdomen, flexor surfaces of elbow and knee, buttocks, neck, hands. Pruritic (intense), lichenification. May have palmar hyperlinearity, keratosis pilaris, hand/foot involvement, cheilitis, increased susceptibility to cutaneous infections
Dx: H & P. culture and sensitivity if infection is suspected. Eosinohila can occur. Food allergy/sensitivity testing- especially in children, vitamin D, GI assessment (dysbiosis, 3hr lactulose breath test for methane, hydrogen)
DDX: seborrheic derm, contact derm, nummular derm, Candida, scabies, tinea
Contact dermatitis
Acute inflammation of skin caused by irritants or allergens
Etiology: exposure
Irritant contact derm: Chemicals, soap, acids, alkaline chemicals, oils, water, woods dust, fiberglass or body fluids.
Allergic contact derm: Hypersensitivity reaction with an initial sensitization, then reaction on re-exposure. Drugs (this is big! Neomycin, bacitracin, hydrocortisone), latex, metals, cosmetics, lotion, sunscreen, nail polish, or fragrances. Also poison ivy, oak, sumac are types.
S/Sxs:
ICD - hands often effected, both the dorsal and palmar surfaces. Around mouth of chronic lip lickers. Erythema, dryness, painful cracking or fissuring. Acute may have papules with weeping and edema, chronic may have lichenification, excoriations and scaling.
ACD - intensely pruritic. Mild erythema to hemorrhage, vesiculization and ulceration.
Dx: H & P (including occupation, hobbies, household duties, travel, topical exposures). Patch testing when ACD doesn’t respond to treatment
DDX: seborrheic derm, atopic derm, nummular derm, tinea
Lichen simplex chronicus (neurodermatitis)
chronic pruritis that causes an extreme scratch-itch-scratch cycle without demonstrable cause.
S/Sxs: pruritis, dry scaling skin, hyperpigmentation, erythematous, violaceous, lichenified plaques in irregular shapes. Most common areas are back of neck, wrists, ankles and public region, usually not present on back, abd, face or upper leges
Dx: H & P, KOH wet mount (to differentiate from tinea), biopsy, patch testing to identify role of allergens
DDX: tinea, lichen planus, psoriasis
Nummular Dermatitis
Inflammation of the skin in a coin-shaped pattern.
Mostly mid-aged pts with dry skin. Idiopathic, often with no hx of eczema gradual onset. M>W
S/Sxs: exceedingly pruritic, inflamed coin shaped lesions, vesicular, crusting and scaling, as well as pruritic. Extensor surfaces, buttocks and trunk. Often begins on the legs. 1-50 lesions can be present
Dx: H & P, patch testing can be positive, culture can reveal Staph aureus, biopsy, KOH wet mount
DDX: Psoriasis, Tinea corporis, cutanous T Cell lymphoma scabies, seborrheic dermatitis, fungus, Paget’s disease when on the breast.
Seborrheic dermatitis
Inflammation of skin in high-density areas of sebaceous glands (scalp, eyebrows, eyelids, face)
Biphasic incidence 2-12 months then during adolescence and adulthood, that peaks between 30-50. M>W.
Etiology- speculated that Malazzezia fungi may play a role, nutritional deficiency
Increases susceptibility in HIV+(may be presenting sign), Parkinson’s and the use of neuroleptic medications
S/Sxs: gradual onset, well demarcated erythematous plaques with greasy-looking, yellowish scales distributed on areas rich in sebaceous glands such as the scalp, the external ear, the center of the face, eyebrows, axillae, nasolabial folds, the upper part of the trunk, and the intertriginous areas. May see papules. No hair loss. Cradle cap in newborns.
Dx: H & P, KOH and fungal culture may be indicated
DDX: atopic dermatitis, contact dermatitis, psoriasis (may overlap), tinea, cutaneous lupus, rosacea
Stasis dermatitis
Persistent dermatitis of the lower legs, especially the ankle, secondary to chronic venous insufficiency
S/Sxs: Brown pigmentation over time, bronze. Often edema and petechiae. Then erythema, fissured, dry or weeping, crusting. Pruritic. May see varicosities, and cellulitis. Often develop stasis ulcers that do not heal, and may penetrate to the bone. Pt complains of heaviness/aching in leg that is agg by walking/standing. Legs are often swollen at the end of the day. Secondary infxn with Staph aureus is common.
Hx may include DVT, surgery, trauma or ulceration
Dx: H & P. veinous studies, ankle brachial index, if DVT hx should check protein S, C, factor V Leiden, fibrinogen, and homocystiene levels
DDX: cellulitis, contact dermatitis, tinea
Polymorphous Light Eruption
An idiopathic, recurrent photodermatitis that occurs after sun exposure
Age: all ages, all races, all genders although most common in young W
S/Sx-lesions appear 2hrs-5days after sun exposure. Burning, itching, erythema to exposed skin. 3 types: papular, plaque or papulovesicular. Lesions persist 7-10 days
Dx: H &P. ANA, anti-SSA, anti-SSB to distinguish from SLE
DDX: SLE, photodrug rxn, porphyria tarda, solar urticaria
Actinic keratosis
precancerous neoplasm due to UV exposure
Distribution: face, lips, backs of hand, shoulders, legs (think sun)
Age: increases with age, usu in blondes or red-heads with light skin (skin type I and II)
S/Sx: Rough scaling macule, papule or plaque; 1-10 mm; reddish/pink, ill-marginated with rough scale, with time develop a thin, adherent transparent scale- this becomes thicker and more yellow over time and forms horns
Dx: biopsy to distinguish from squamous cell carcinoma
DDX: seborrheic keratoses, squamous cell carcinoma
Psoriasis
chronic recurring inflammation of epidermis and dermis with increased epidermal proliferation resulting in scaling. Immune mediated.
Distribution: Scalp, extensor surfaces, buttocks, and back but may also be seen in the nails, eyebrows, axilla, umbilicus and anogenital region.
Age: Biphasic 20 -30 and 50-60. M=W
Etiology: genetics, environmental triggers, infection, physical or psychological stress, and medications. Smoking, obesity and HIV predispose
S/Sxs: dry, sharply demarcated, erythematous papules and plaques topped with silvery scales. May itch but usually asx. Limited or systemic. Better in the summer.
7 different types
- Plaque psoriasis (classic)
- Guttate psoriasis (sudden appearance of many papules on the trunk ass w/Strep A or steroid withdrawl)
- Pustular psoriasis(small pustules on palms and soles)
- Inverse psoriasis (found on flexor surfaces and intertriginous areas)
- Nail psoriasis
- Generalized Pustular (generalized pustules w/fever-emergency)
- Erythrodermic psoriasis (total body redness with chills and skin pain-emergency)
May see systemic signs of arthritis, fever, chills, and deformed nails(pitting). Comes and goes.
Dx: H & P, Auspitz sign. Biopsy rarely necessary but will thickening of epidermis.
DDX: seborrheic dermatitis, eczema, pityriasis rosea, tinea capitus, squamous cell carcinoma, dermatophytoses, cutaneous lupus, dermatitis, lichen simplex chronicus
Pityriasis rosea
acute, self limited, mild inflammatory, scaling skin disease.
Age: young adults
Distribution: trunk
Etiology: possibly reactivation of HHV-7, or primary infxn with HHV-6, -8 or H1N1 flu
S/Sxs: Prodrome of headache, malaise, and pharyngitis may occur in some cases, but except for itching, usually asx. Oval, minimally elevated scaling papules and plaques. “Herald” patch. “Christmas tree” distribution. Can persist for months.
Dx: by examination.
DDX: tinea corporis, tinea versicolor, drug eruptions, psoriasis, syphilis
Lichen planus
Recurrent itching, inflammation with small, discrete angular papules that can coalesce. Uncommon
Age: >5. W>M
Distribution: ankles, wrists, pubic region, lips, mouth. Uncommon on trunk, upper legs, face and head
Etiology: unknown, Hep C may play a role
S/Sxs: Papules are 2-4 mm, with angular borders, and a violaceous color. Oral lesions. May see severe itching. Abrupt or gradual onset, with symmetrical distribution on flexor surfaces, trunk, genitals, Koebner phenomenon. “purple, polygonal pruritic papules”. New lesions are pink/white but change to the PPPP, surface shows lacy reticulated pattern of whitish lines. Lesions that persist become thicker and dark red.
Dx: by examination, biopsy- accumulation of PMN’s and T-cell mediated cytotoxic rxn against basal cell keratinocytes. Antibodies to Hepatitis C are detected in 16% of cutaneous LP and 30% with mucosal involvement.
DDX: leukoplakia, candidiasis, herpes stomatitis, carcinoma, aphthous ulcers, erythema multiforme, psoriasis, discoid lupus, drug eruptions
Drug eruptions
a common condition that that immune mediated
Causes: most common drugs are penicillin, sulfonamides, quinidine but almost any drug can induce
S/Sx: depends on type
- Exanthems. Most common. Antibiotics cause. Mildly pruritis measles-like (morbilliform) rash, macules or papules. Symmetric distribution almost always on trunk and extremities. Can occur on palms/soles/mucus membranes. Age- not common in infants- all other ages equal. Hx should include EBV, CMV for amoxicillin.
- Urticaria: common and IgE-mediated. Antibiotics often cause. Also non IgE mediated- NSAIDS often cause. Pruritis, burning of palm/soles. May also have systemic sx such as flushing, fatigue, numbness of tongue, bronchospasm, N/V, palpitations, hypotension.
- Pustular: ‘acne’ on arms and legs.
- Fixed drug eruptions: circular and recurring at same site. Can also be generalized. Erythematous patch, plaque, bulla or erosion. Occurs within hours of ingestion. Many classes of drugs implicated.
- Pigmentations: gray, brown, black, orange, blue. Many drugs and they are all different as to which color change they can induce.
Dx: H&P. CBC-eosinophils
DDx: too many to list.
Erythema multiforme
inflammatory reaction characterized by “target” lesions
Distribution: dorsal/palmar hands, soles, forearms, feet, face, elbows, knees, penis and vulva, mucus membranes.
Age: 50% F
Etiology: drugs(many), infections (HSV or mycoplasma), immunization, autoimmune dz, malignancy or unknown
- Major: w/ mucosal involvement (ano genital, oral, ocular)
- Minor w/out mucosal involvement.
S/Sxs: onset 3-5 days, often resolved in 2 weeks. Can recur. erythema, edema, bullous lesions, of sudden onset mainly on face and extremities. Symmetrical annular lesions, bulls-eye, target, or iris forms. Pruritic, painful and sometimes see systemic symptoms like fever, weakness, malaise. Can be mild to very severe
Dx: Hx &P. biopsy is non-specific but will show PMN infiltrate, edema. HSV serology/PCR, M. pneumonia serology/PCR
DDX: urticaria, drug eruptions, bullous pemphigoid, pemphigus, dermatitis herpetiformis, aphthous stomatitis, herpes stomatitis
Erythema nodosum
inflammation of the skin and subQ tissue (panniculitis) characterized by tender, red nodules on the shins
Age: peaks at 20-30 but can occur at any age. F>M (6x)
Etiology: infections, drugs, malignancy, inflammatory/granulomatous dx (sarcoidosis)
S/Sxs: indurated nodules that look like bruises, gradually changing color, with successive crops of nodules. Nodules are very painful. Mostly pretibial. Systemic symptoms such as fever, malaise, joint pain. spontaneous resolution in about 6 weeks.
Dx: By H & P, but must look for underlying disorder. Biopsy, ESR, CRP ANA, CBC, chest x-ray (sarcoid), ASO-titer or pharyngeal culture (for group A beta-hemolytic strep).
DDx: vasculitis, pretibial myxedema, lymphoma
