Derm Flashcards
Basic things to consider for skin
Appearance: texture, hydration, sun exposure
Temperature: cold vs hot, sweating, clammy, doughy
Rash/lesions: redness, excoriations, borders, changes
Color: natural pigment- can influence tx choice
Hx of eczema
Hx of allergies
Recurring rash, worse in winter mos, exacerbation by heat
“The itch that rashes”
Usually flexor/extensor surfaces, faces, hands
-Dry, erythematous, scaly patches or plaques
Lab and work up for eczema
Could do KOH prep to r/o tinea
DDx of eczema
Tinea
Contact dermatitis
Lichen simplex chronicus
Seborrheic dermatitis
Health maintenance of eczema
Avoid hot water bathing
Use detergent/soap without fragrances/dyes
Keep skin lubricated
Tx/medications of eczema
Antihistamines for itching
Topical steroids
-Not curable, only treatable
-Choose appropriate steroid class for location
-Do not use for longer than 2 wks at a time- can cause striae
–Peds: one wk
-Occlusive dressings if needed
F/u in eczema
As needed
Refer to derm if no relief
-Can cause significant skin disfigurement that can be embarrassing, esp in peds
Clinical pearls of eczema
Extra virgin olive oil is a great moisturizer and can be used to maintain between flare ups; apply to damp skin after bathing; add to bath water
Typical sites of eczema
Face Neck Elbows Wrist Groin Knees Ankles
Hx taking/PE findings of drug reactions
Recent medication changes -Think beyond new medication (pharmacy change, etc) Symmetric cutaneous reaction -Purpura, erythema, blisters R/o other causes
Lab and workup for drug reactions
Usually based on HPI/PE Bx if needed -Cannot tell you if it is a drug reaction only Based on severity of reaction -CBC, CMP, cultures
DDx of drug reactions
Contact dermatitis Erythema multiforme Lichen planus Pityriasis Urticaria Vasculitis SJS
Health maintenance of drug reactions
Avoid causative agent
Label medical record
Tx/medications of drug reactions
Antihistamine
Topical steroid
Systemic steroids
IVIG
Hx/PE of pityriasis rosea
Usually acute onset, spreading over last several weeks
+/- itching
Herald patch, Christmas tree distribution
-Salmon colored, usually on trunk
Lab and work up for pityriasis rosea
KOH prep to r/o tinea
DDx of pityriasis rosea
Contact dermatitis
Tinea
Drug reaction
Health maintenance of pityriasis rosea
No known cause
Tx/meds for pityriasis rosea
Usually resolves spontaneously in 6-8 wks
Sometimes topical/PO steroids
F/u for pityriasis rosea
As needed
Bx if not resolving
Hx/PE of psoriasis
Usually hx of similar
Worse with stress
+/- joint pain
Silver “fish scale” plaques usually on knees and elbows
Variant-punctate psoriasis, gutate psoriasis
Lab and work up of psoriasis
Bx to confirm
ANA usually positive
DDx of psoriasis
Eczema
Lichen sclerosis chronicus
Health maintenance of psoriasis
None
Avoid triggers
Tx/meds of psoriasis
Topical steroids
Kenalog intralesional injections
UV light therapy
Biologic agents- Humira, Remicade, Embrel
Hx/PE of herpes simplex
Recurrent skin lesions, usually oral or genital
Prodrome pain, itching, burning before lesion arises
Erythematous viesicles that spread
Herpetic whitlow: nail bed
Ocular: refer to ophthalmology
Lab and work up of herpes simplex
Culture HSV 1 and 2
Tzanck smear
DDx of herpes simplex
Herpes zoster
Hand/foot/mouth
Chancroid (genital)
Health maintenance of herpes simplex
DO NOT SHARE razors
Avoid contact during outbreak
Tx/meds for herpes simplex
Zovirax cream/ointment
Acyclovir, Famvir, valacyclovir
Vaccine?
F/u for herpes simplex
As needed for recurrent breakouts
Maintenance therapy
Hx/PE of molluscum contagiosum
Flesh colored papules with central umbilication that spread
Can be sexually transmitted
-R/o sexual abuse in peds
Lab and work up of molluscum contagiosum
Bx
DDx of molluscum contagiosum
Verruca
Chicken pox
Health maintenance of molluscum contagiosum
Hand washing-contagious through contact
Tx/meds of molluscum contagiosum
Self-limited
Retin-A: apply daily
LN2 tx
Podophylin: wash off in 1-2 hrs, repeat q2 wks prn
Hx/PE of impetigo
Highly contagious Gram + bacteria
Honey crusted lesion
Lab and diagnostic workup of impetigo
Culture
DDx of impetigo
Erysipelas
Herpes
Folliculitis/acne
Health maintenance of impetigo
Avoid contact during outbreak
Good hygiene
Tx/meds for impetigo
Mupirocin
Keflex PO
Altabax
F/u of impetigo
Within 1 wk to ensure clearing
Hx/PE of erythema multiforme
Type IV hypersensitivity
Minor, major, SJS
Hx recent URI
Target lesions, mucous involvement, +/- palms/soles
Lab and work up of erythema multiforme
CBC, CMP
Bx
Etiology of erythema multiforme
EM and SJS are both caused by drugs, but infectious agents are considered to be the major cause of EM
Hx of HSV infections 1-3 wks before onset of EM
EM minor: triggered by HSV in nearly 100% of cases
EM major: herpetic etiology also accounts for 55% of cases, other infections, Mycoplasma
SJS and EM major: Drugs are found to be major cause, antibacterial sulfonamides, anticonvulsants, NSAIDs, allopurinol
DDx of erythema multiforme
Granuloma annulare
Erythema migrans
Drug eruption
Viral exanthem
Health maintenance for erythema multiforme
Symptomatic tx
Self-limited
Avoid causative agent
Risk of recurrence
Tx/meds for erythema multiforme
Topical corticosteroids
Antivirals
Supportive measures
F/u for erythema multiforme
Prophylaxis for recurrence
Hx/PE of acne
Current skin cleansing regimen Can often be due to irritation Recurrent breakouts on face, chest, back Consider other underlying causes- Cushings, thyroid, etc Comedones, pustules, cysts
Lab and work up of acne
R/o underlying cause
DDx of acne
MRSA
Hidradentitis supporitiva
Cushings
Health maintenance of acne
Avoid skin irritants
Sometimes d/t pH imbalance- avoid acidic/alkali foods
Tx/meds for acne
Depends on severity Topical abx/bacteriocidals PO abx OCP for females Accutane- only qualified providers, +/- teratogenic, monitor lipids
Acne f/u
Monthly
Maintain tx for several mos (>6 mos)
Clinical pearls of acne
Always ask about it, pts don’t talk about it but it bothers them
If not resolving, think MRSA, culture
Hx/PE of actinic keratosis
Non healing scaly erythematous based plaque
Sometimes heal but comes back
Face, scalp, arms
Lab and work up of actinic keratosis
Bx to r/o SCC
DDx of actinic keratosis
SCC/BCC
Dyshidrosis
Dermatitis
Health maintenance of actinic keratosis
Sunscreen at young ages
Avoid smoking
Tx/meds for actinic keratosis
Topical fluorouracil
-Apply sparingly, basically burns top layer of skin so causes redness; use in winter mos
Liquid nitro
TCA peel
F/u of actinic keratosis
2 wks after start tx
Monthly/q3-6 mos
Hx/PE of seborrheic keratosis
“Stuck on” hyperpigmented macules
Spreading, growing
Face, back, abdomen
Lab and work up of seborrheic keratosis
Bx to r/o DN versus AK
DDx of seborrheic keratosis
DN/melanoma
Actinic keratosis
Neurofibroma
Health maintenance for seborrheic keratosis
Usually genetic
Tx/meds for seborrheic keratosis
Lachydrinf or mild lesions
Liquid nitrogen
F/u of seborrheic keratosis
As needed
Hx/PE of cellulitis
Localized erythema and edema +/- tenderness
Usually underlying infection
Can be non-necrotizing which only requires local tx vs. necrotizing which requires systemic tx and close monitoring bc life-threatening
Lab and workup of cellulitis
CBC, CMP
Culture
DDx of cellulitis
Erysipelas (GAS)- superficial, shiny, defined borders
Necrotizing fasciitis
-Can be streptococcal or non streptococcal, determines tx
-Must suspect if rapidly progressing (24 hrs) eschar/necrosis and/or signs of sepsis (increased HR, oliguria, mental status changes)
-Life threatening
MRSA
DVT
Health maintenance of cellulitis
Hygiene
Prevention
Tx/meds for cellulitis
IV vs PO abx
- In mild cases of cellulitis treated on an outpt basis: Dicloxacillin, amoxicillin, or cephalexin
- In pts who are allergic to pcn: clindamycin or a macrolide (clarithromycin or azithromycin)
- An initial dose of parenteral antibiotic with a long half-life (e.g., ceftriaxone) followed by an oral agent
