Derm Flashcards
Natural course of infantile hemangiomas
- Generally appear in first 2 weeks of life
- Reach maximum size by 3-6 months
- Spontaneously involution at 10% per year (50% by 5 years, 90% by 10 years)
- 50% of kids with untreated hemangiomas have residual scarring or discoloration
Anatomic locations you have to worry about infantile hemangiomas
- Eyes (strabismus, amblyopia)
- Nares (airway compromise)
- Auditory canals (deafness)
- Pharynx/larynx (airway compromise)
- Liver (congestive heart failure)
- Segmental lumbosacral (tethered cord, GU anomalies)
Treatment of hemangiomas
- Pulsed dye laser
- Beta blockers (oral propranolol or topical timolol
Erythematous plaques with thick scales and areas of hemorrhage where scales have been removed (Auspitz sign)
Psoriasis
5 types of psoriasis
- Plaque psoriasis - extensor surfaces most commonly but can be anywhere, often in areas of trauma (the Koebner phenomenon)
- Scalp psoriasis
- Nail psoriasis - have pitting of nails
- Guttate psoriasis - precipitated by strep pyogenes
- Diaper area psoriasis
Psoriasis cause and treatment
- Genetic predisposition and environmental trigger
- 30-50% onset before age 20
- Topical steroid (low potency for face or groin) is first line
- Other agents: topical calcipotriene, calcineurin inhibitors, retinoids, phototherapy, systemic agents
Infantile hemangioma normal time course
- First 5 months: proliferation (most in months 1-2)
- 6-12 months: growth lows and lesions begin to involute
- Most kids have persistent telangiectasisa, redundant skin, fibrofatty tissue, or scars
Infantile hemangiomas requirement treatment
- Tx: oral propranolol
- Periocular (vision issues), nasal tip (can damage cartilage), lip (feeding troubles), beard area (may be associated with hemangiomas involving the airway), midline lumbosacral (can be associated with spinal issues)
Pruritic, scaly eruption that involves the interdigital spaces with scaling and fissuring
Tinea pedis
Tx: clotrimazole
Superficial erosions on plantar surface of foot, excessive foot moisture, foot order
- Pitted keratolysis
- Infection with organisms that produce proteases and degrade keratin
- Tx: topical aluminum chloride and topical antibiotic
Clustered or group vesicles on an erythematous base in a neonate
- Neonatal herpes
- Most common on buttocks or scalp
- Look for lesions not present at birth, could have mention of scalp probe
- Dx with PCR swab of lesions
- Tx with IV acyclovir
Neonate with vesicles in a linear pattern without an erythematous base
Incontinentia pigmenti
Neonate with multiple pustules, brown macules, vesicles, and pustules on a non-erythematous base
Transient neonatel pustular melanosis
- Present at birth
- More common in African Americans
- Gram stain will show neutrophils without organisms
Neonate with yellow pustules on an erythematous base or generalized erythematous macules with solitary papules or vesicles in the center
Erythema toxicum neonatorum
- Appears within a few days of birth (not present at birth)
- Wright stain with eosinophils
Diaper dermatitis vs candidasis
- Contact dermatitis willl often spare the creases
- Candidasis will have satellite lesions and be worse in the creases
Workup for infantile acne
- Usually starts around 2-4 months of age and resolves at 6-12 months of age but if severe deserves workup for excess androgen cause
- Check 17-hydroxyprogesterone levels
Location of fixed drug eruption
Hand, trunk, genital, perioral areas
Neonate with clustered or grouped vesicles on an erythematous base on teh buttocks or scalp
Neonatal herpes - watch for lesions not present at birth, also think about this if scalp pH monitor
Diagnosis/treatment of neonatal herpes
- Wright stain with multinucleated giant cells and eosinophilic intranuclear inclusions
- Can do surface culture or PCR
- Tx with IV acyclovir
Neonate with vesicles in a linear pattern without an erythematous base
Incontinentia pigmenti
Multiple pustules, brown macules, vesciles, pustules on a non-erythematous base that is present at birth
Transient neonatal pustular melanosis
- More common in African Americans
- No treatment needed
- Gram stain will show PMNs with no organisms
Neonate with yellow pustules on an erythematous base, not present at birth but presents within a few days
Erythema toxicum neonatorum
- Can also have occasional vesicles
- Wright stain will show eosinophils
Diffuse scaling and erythematous papules/pustules
Cutaneous candidiasis
Lichenification with scratching, commonly behind the knees and in antecubital areas
Atopic dermatitis
- Family hx asthma and allergic rhinitis are common triggers
- Also have high blood level IgE
- Food infections are a trigger in up to 30% of cases but need allergy testing before you would eliminate foods
Tinea pedis rash location
NOT on the dorsal aspect
- Will be pruritic with scaling and peeling on the plantar aspect and lateral aspect of the foot
Inflamed eczema not responding to steroids and antibiotics
Eczema herpeticum
- Vesicles, punched out lesions, crusted erosions
- Tx with acyclovir
Greasy yellow patches on the scalp, face, behind the ears, in skin folds in first few months of life
Seborrheic dermatitis
- Tx with antifungal washes and topical steroids
- If also have profuse ear discharge or urine output think of Langerhans cell histiocytosis
Delayed hypersensitivity reaction after multiple exposures causing red, vesicular, crusting rash
Allergic contact dermatitis
- Jewelry and poison ivy are typical examples
- Primary irritant contact dermatitis occurs with the first time (soap/detergents)
Rash on pre-pubertal child on the feet with minimal scaling, thickening of the skin, hyper-linearity of distal soles with normal interdigital skin
Juvenile plantar dermatosis
- Tx with triamcinolone
Linear vesicles and papules
Poison ivy
- Type 4 reaction
- Rash is not contagious, fluid from the vesicles will not spread the rash
Silvery lesions on the elbows or knees, Auspitz sign (bleeding spots if plaques come off), erythematous plaques surrounded by thicken adherent scales, pinpoint areas of hemorrhage, thick scales on the scalp
Psoriasis
Small oval scaling patches on trunk and back
Pityriasis Rosea
- Herald patch in christmas tree pattern
- Long axis of lesions parallel to the lines of skin stresss
Rash with elevated border with central clearing on trunk
Tinea corporis
Dry skin with thin scales that have a pasted on appearance in preschool years
Ichthyosis vulgaris
- Tx with keratolytic agents like ammonium creams or urea containing emollients
Non scaling annular lesions without epidermal involvement
Granuloma annularea
- Remember non-scaling, skin will be intact
MCC impetigo
Staph aureus but can also be strep
- Tx with mupirocin
Staph scalded skin syndrome
Diffusely erythematous rash that is tender and red and spreads to a sheet like loss of skin
- Due to toxin from staph aureus
- Need antibiotics
Rash triggered by infection like herpes simplex or medication
Erythema multiforme
- Starts on extremities and then spreads to teh trunk
Bullous/target lesions that spread rapidly to involve mucosal membranes
Stevens Johnson
- Rash is preceded by fever, muscle aches, and joint aches
- Lesions involving mucosa frequently become encrusted
- Tx is preventing dehydration and superinfection
Common triggers for Stevens Johnson
Sulfa drugs, anticonvulsants, NSAIDs
Sunburn like erythema and sheet like separation of skin with widespread bullae and denuded necrotic skin
Toxic epidermal necrolysis
- Need biopsy to distinguish from staph scalded skin syndrome (TEN involves the dermis, SSSS does not)
- TEN often is in older children, SSSS in younger children
- TEN is a hypersensitivity reaction, not due to toxins
Painful bluish lesions on the shin
Erythema nodosum
- Associated with TB, birth control pills, inflammatory bowel disease, fungal infections
Erythematous macule on the trunk with central clearing
Erythema marginatum
- Rheumatic fever
Intensely pruritic linear lesions that are papular or pustular with burrows and involvement between the digits
Scabies
- Extremely contagious, often involves family members
- Treat with permethrin cream including all household members
- In infants can be on scalp, palms, or soles
Intense scalp itching with excoriation on neck or behind ears in family members
Head lice
- Nits are white dots that can’t be removed on teh hair shaft
- Tx is permethin cream rinse that is repeated in a week and need to treat all household contacts
- If itching after treatment may need to use steroid creams
Random facts about lice
- Can last 36 hours without a blood meal
- Fresh eggs on hair shafts can hatch 10 days later
Signs of public lice
- Blue/gray macules on abdomen or inner thigh
- Suggestive of sexual abuse, not common in children
- Tx is permethrin
Pearly papules with central dimpling/umbilication
Molluscum contagiosum
- Will clear in months to years
- Wright staining has viral inclusion bodies
Pink and excoriated pruritic erythematous papules with central punctum on extensor surfaces of arms/legs
Papular urticaria
- Often are recurrent at night and may last up to 10 days
- Due to delayed hypersensitvity reaction to an insect bite
- No one else in the family is affected
Cause of acne
- Sebum made by sebaceous glands in reponse to androgen production
- Propionibacterium acnes is the bacteria –> WBC –> pustules/inflammation
Two types of non-inflammatory acne
- Closed comedones - whiteheads - covered with epithelium
- Open comedones - blackheads - no covering (black covering is due to oxidation of melanin)
Description of inflammatory acne
Erythematous papules, pustules, and nodules
Small papules that are firm and may be pink, red, or brown
Adenoma sebaceum or angiofibromas
Medication causes of acne
Systemic steroids, anticonvulsants (phenobarbital, phenytoin)
Treatment options of acne
- Salicylic acid reduces formation of obstructive lesions and is good for comedonal acne, good for large areas (chest/back)
- Benzoyl peroxide is bactericidal so is good for inflammatory acne but can’t use with tretinoin
- Topical antibiotics for inflammatory acne
- Tretinoin is best for comedonal acne
- Oral antibiotics for moderate to severe inflammatory acne (need to use backup contraception if on OCPs)
- OCPs due to anti-androgeric effects
- Isotretinoin: antibacterial, reduces sebum production, anti-inflammatory, destroys comedones
Black dots or broken hairs on scalp with tender boggy areas of induration
Tinea capitis
- Fungal culture is gold standard
- Tx with oral griseofulvin
Association with alopecia areata
Nail pitting
- There is no inflammation with alopecia
Sudden loss of large amounts of hair during stressful events
Telogen effluvium
- Round patches, well defined, complete areas of hair loss
Irregular patches of hair loss, incomplete patches of hair loss, hair shafts of different length
Trichotillomania or traction alopecia
Pigmented lesions that flush or turn into hives and develop blisters with rubbing or scratching
Urticaria pigmentosa
- Common in first 6 months of life
- Pathognomic for presence of mast cells within the lesion
- Infant should avoid narcotic pain relievers, radiocontrast material, NSAIDs but there is otherwise no treatment
Persistent scalp or diaper sebborheic rash, chronic ear drainage, lytic lesions in skull or vertebrae, excessive urination
Langerhans cell histiocytosis
- Dx with skin biopsy and electron microscopy
Hypopigmented patches that get worse with exposure to sun
Pityriasis veriscolor
- Caused by a fungus, can see on KOH prep
- Tx with astringents or topical antifungals
- Could also use oral azoles if needed or topical selenium
Lesions in 4 stages:
- Erythematous papules/vesicles along lines of Blaschko for 1-2 weeks
- Swirls of warty growths
- Streaks of hyperpigmentation
- Hypopigmentation
Incontinentia pigmenti
- X linked dominant, generally lethal in males
Cause/treatment of vitiligo
- Autoimmune destruction of melanocytes leading to depigmentation
- Tx topical steroids and tacrolimus
Hypopigmentation following inflammation in atopic skin
Pityriasis alba
5 main characteristics of Sturge Weber
- Port wine stain in a trigeminal distribution (nevus flammeus) –> can be associated with venous leptomeningeal angiomatosis on MRI
- Developmental delay
- Seizures (usually focal)
- Hemiplegia
- Vision problems/calcification/glaucoma (on same side as port wine stain)
Seven diagnostic criteria for neurofibromatosis type 1 (Von Recklinghausen disease) - need 2/7
- 6 or more cafe au lait spots (must be > 5 mm in kids or > 15mm post pubertal)
- 2 or more lisch nodules (iris hamartomas seen on slit lamp exam)
- Neurofibromas (usually not until after puberty)
- Optic nerve glioma
- Inguinal and axillary freckling
- Tibial pseudoarthrosis
- First degree relative with NF1
Genetics of NF1
- Autosomal dominant on chromosome 17 - 50% are due to spontaneous mutations
Complications of NF1
- Renal artery stenosis
- Pheochromocyotoma
- Hypertension
Characteristics of NF2
- Acoustic neuroma (schwannoma)
- Chromosome 22
- Hearing loss or tinnitus, cataracts or hamartomas of retina
- Diagnosis made by bilateral cranial nerve VIII masses on CT or MRI
Diagnostic criteria for tuberous sclerosis (need 2)
- More than 3 ash leaf spots (hypomelanotic macules)
- Periventricular/cortical tubers (seizures)
- Sebaceous gland hyperplasia (common on the face)
- Shagreen patch (cobblestone appearing skin)
- sub/periungual fibroma
- cardiac rhabdomyoma
- retinal nodular hamartomas
- renal angiomyolipoma
Developmental abnormalities of skin, teeth, nails, hair, sweat glands
Etodermal dysplasia
Recurrent blistering of skin and mucosa after minor trauma as well as nail changes
Epidermolysis bullosa
Infantile hemangioma life cycle
Located in upper dermis
- Present at birth or shortly after, get larger until maximum at 6-9 months of age and then slowly involute over the years
- Tx only required when hemangioma interferes with vision, breathing, eating, hearing, or other normal functions
Blue hemangiomas in lower dermis, fat, muscle treatment
Cavernous hemangiomas
- Tx with steroids, laser, or propranolol
Hemangioma that enlarged rapidly and low platelets
Kasabach-Merritt syndrome
