Derm Flashcards
Onset of rash with RMSF
2-5 days after fever
RMSF rash
- petechiae erupting on both wrists, forearms, and ankles
- rapidly progress towards trunk and becomes generalized
- 10% do not develop rash
First line treatment for RMSF
Doxycycline
Erythema migrans
-bulls eye rash
When does erythema migrans rash occur
-7-14 days after deer tick bite
Measles rash description
-Koplick spots: small, white, round spots on red base of buccal mucosa
Scabies rash description
- pruritic especially at night
- serpiginous rash on interdigital webs, waist, axilla, penis
Scarlet fever rash description
-sandpaper rash with sore throat
Meningococcemia rash
purple-colored to dark-red painful skin lesions all over body
Meningococcemia (meningitis) presentation
- sore throat
- cough
- fever
- Headache
- stiff neck
- photophobia
- change in LOC
People at highest risk for meningitis
- first year college students in dorms
- asplenia
- defective spleen (sickle cell)
- HIV
- complement immune system deficiencies
What level of precaution is needed for meningitis
droplet
What CN does herpes zoster ophthalmicus affect
-CNV
Most common type of melanoma in AA and Asians
- Acral Lentiginous melanoma
- palms, under nails, soles of feet
Acral lentiginous melanoma presentation
- dark brown to black lesions on nail beds, palmar, and plantar surfaces
- subungal melanoma: longitudinal brown to black bands on nail bed
BCC presentation
- pearly or waxy skin lesion with atrophic or ulcerated center that does not heal
- bleeds easily with trauma
Actinic keratosis
- precursor to SCC
- dry, round, red colored lesions with rough texture
- does not heal
> ___% hematoma of nail matrix has high risk of permanent ischemic damage to nail bed if not drained.
25
SJS and TENs
- multiple lesions ranging from hives to necrosis
- TEN more severe than SJS
HIV patients taking which medication is at higher risk for SJS
Bactrim
3 layers of skin
epidermis
dermis
subcutaneous
Common skin conditions of AA
- keloids
- hyperpigmentation
- traction alopecia
T/F People with darker skin need more sun exposure to synthesize vitamin D
true
Vitamin D deficiency in pregnancy
infantile rickets
Which cancer is most common
BCC
Macule
flat
-<1 cm
papule
palpable solid
<0.5 cm
Plaque
flattened elevated with variable shape
>1 cm
Bullae
fluid filled
>1 cm
Vesicle
filled with serous fluid
<1 cm
Pustule
elevated lesion <1 cm filled with purulent fluid
Lichenification
-thickening of epidermis due to chronic itching
Acral
-distal portions of the limbs like hands and feet
Annular
ring shaped
exanthem
cutaneous rash
Flexural
skin flexure are body folds
Morbilliform
rash that resembles measles
Nummular
coin-shaped
round
Serpiginous
shaped like a snake
Verrucous
wart-like
Xanthelasma
raised and yellow-colored soft plaques
-if <40, r/o HLD
Melasma
- mask of pregnancy
- upper cheeks, malar area, forehead, chin
- can be permanent, may lighten over time
Vitiligo is more common in patients with
autoimmune disease
Vitiligo treatment
refer to derm
Cherry angioma treatment
none needed
Xerosis
-inherited skin disorder that is extremely dry skin
Acanthosis nigricans can indicate what
-diabetes
-metabolic syndrome
-obesity
Cancer of GI tract
Acrochordon
skin tags
-more common in diabetics and obese
Steroid class range
1 (superpotent) to 7 (least potent)
Topical steroids on children and face
- use class 7: 0.5%-1% hydrocortisone
- Class 6: fluocinolone
How long do topical steroids need to be used for HPA axis suppression to occur
> 2 weeks
Psoriasis patho
- inherited
- squamous epithelial undergo rapid mitotic division and abnormal maturation
Koebner phenomenon
new psoriatic plaques form over areas of skin trauma
Auspitz sign
pinpoint areas of bleeding in skin when scales from a psoriatic plaque are removed
Fingernail presentation with psoriasis
pitting
Psoriasis medications
- topical steroids
- topical retinoids
- tar preparations
- severe disease: MTX, cyclosporine, biologics
Topical tacrolimus BBW
- rare malignancy
- use sunblock
Goeckerman regimen
-UVB light and tar-derived topical may induce remission in severe psoriasis
Guttate sporiasis
- drop-shaped lesions
- severe psoriasis from GABHS
Actinic keratoses treatment
-refer to derm for biopsy
Tinea versicolor treatment
- selenium sulfide and topical azole antifungals (ketoconazole, terbinafine)
- will take several months for pigment to fill in
Mild eczema treatment
- hydrocortisone 2.5%
- low-potency, group 5
Moderate eczema treatment
- Triamcinolone acetonide
- medium potency, group 4
Halcinonide (Halog)
high potency topical steroid
group 2
Contact dermatitis treatment
- stop exposure
- topical steroids once to twice a week 1-2 weeks
- calamine lotion
- oatmeal baths
- consider referral to allergist
superficial candidiasis presentation
- bright red shiny lesions
- itch or burn
- intertriginous areas
thrush presentation
- severe sore throat
- white adherent patches
- hard to dislodge
Superficial candidiasis treatment
- Nystatin powder and/or cream in skin folds
- OTC antifungals: miconazole, clotrimazole
- Prescription: terconazole, ciclopirox
- keep dry and aerated
Thrush treatment
- Nystatin oral suspension (swish and swallow)
- Magic mouthwash: lidocaine, diphydramine, Maalox for severe sore throat
HIV positive patients with thrush treatment
-oral fluconazole
Leading cause of shellfish associated death in US
V. vulnificus
People with liver disease or IC or pregnant should avoid eating raw or undercooked oysters or clams due to
- Vibrio vulnificus infection
- 50% mortality
Clenched fist injuries treatment
-ED
Necrotizing Fasciitis infected area may appear like what
-woody induration
Folliculitis treatment
Muporicin
usually self limiting
Furuncle treatment
- warm compress
- if >2 cm, I&D
- if over joint, refer to ED for xray to rule out osteomyelitis
What is a furuncle
infected hair follicle
What is a carbuncle
-several boils that coalesce to form a large boil or abscess
Carbuncle treamtent
- mild cases
- nonpurulent: dicloxacillin PO, cephalexin, clindamycin
- PCN allergy: azithromycin
- suspected MRSA: Bactrim DS or doxycycline
- severe cases: ED referral
Erysipelas is what
- subtype of cellulitis involving upper dermis and superficial lymphatics
- usually Strep
Erysipelas can present where
- lower legs
- cheeks
Human and dog bite treatment
- Augmentin 875mg/125mg PO BID x 10 days
- PCN allergy: Doxycyline BID, Bactrim + metronidazole or clindamycin
- irrigate
- no suture
- if cartilage involvement refer to plastics
- tetanus booster
- f/u 24-48 hours
Hidradenitis Suppurativa patho
- chronic and recurrent inflammatory disorder of apocrine glands
- painful nodules, abscess, pustules in axilla, mammary area, perianal, groin
- risk: smoking and obesity
- no cure
Hidradenitis suppurativa treatment
- mild: CHX (Hibiclens) wipes
- topical clindamycin
- warm compress
- avoid high glycemic foods, dairy
- smoking cessation, weight loss
- oral abx: tetracycline, doxycycline, minocycline
- refer to derm
Two types of impetigo
- bullous
- nonbullous; more common
Treatment for severe impetigo
-Keflex, dicloxacillin x10 days
Mild impetigo treatment
-Clean lesions and apply muporicin
Impetigo and school
-no school until 48-72 hours of treatment
Prophylaxis for close contacts with meningitis
-Rifampin PO every 12 hours x 2 days
close contact description
-<3 feet of persons infected for >8 hours or directly exposed to patients oral secretions, going back to 7 days before onset of patients symptoms and until 24 hours after initiating abx
Lyme disease organism
-Borrelia burgdorferi
Early lyme labs
- enzyme immunoassay (EIA): if negative, no further
- if positive, IFA or western blot
- if both EIA and IFA are (+)= Lymes
- antibody testing may have false negative in first 4-6 weeks
Early Lyme treatment
-Doxycycline BID x 10 days
RMSF labs
- Antibody titers to R.rickettssi by indirect fluorescent abs
- biopsy of skin lesion
- CBC, LFTs, CSF, etc
how to remove tick
- tweezers grasp part closest to tick
- pull upward
- do not twist or jerk
How long is chickenpox contagious
-1-2 days before onset of rash and until all lesions have crusted over
How long is shingles contagious
-onset of rash until lesions have crusted over
Gold standard diagnosis for varicella zoster virus
-viral culture, PCR
When are antivirals most effective for varicella zoster
-within 48-72 hours after appearance of rash
Postherpetic neuralgia treatment
- tricyclic antidepressants (low-dose amitriptyline)
- anticonvulsants
- gabapentin
- lidocaine 5% patch
Ramsay Hunt syndrome
- ipsilateral facial paralysis
- ear pain
- vesicles in ear canal and auricle
- refer to neurologist
Herpetic whitlow cause by
herpes simplex 1 or 2
Herpetic whitlow presentation
- acute onset extremely painful red bumps
- small blisters on sides of skin
- ask about oral or genital herpes
Herpetic whitlow treatment
- mild: analgesics
- severe: acyclovir
Herpetic whitlow patient education
-cover with bandage until lesions healed
Paronychia treatment
- soak in warm water for 20 minutes three times a day
- apply triple abx or muporicin after soaking
- Abscess: I&D, gently separate the cuticle margin from nail bed to drain
Herald patch
- first lesion to appear
- largest
- appears 2 weeks before full breakout
How long does pityriasis rosea last
6-8 weeks
self-limiting
Scabies presentation
-serpiginous or linear burrow rash
Scabies labs
- skin scraping wet mount
- observe for mites or eggs
Scabies treatment
- Pemethrin 5%
- apply from neck to feet
- wash off after 8-14 hours
- repeat in 7 days
- treat everyone in household
- wash all things
- pruritus improves in 48 hours but can last up to 2-4 weeks
- treat with Benadryl and topical steroids
Tinea capitis treatment
- Baseline LFT and repeat 2 weeks after starting systemic antifungal treatment –> not needed unless treatment extends beyond 8 weeks
- Gold standard: griseofulvin daily to BID x 6-12 weeks
Kerion
complication of tinea capitis
- inflammatory and indurated lesions that permanently damage hair follicles causing patchy alopecia
- permanent
Tinea corporis treatment
- Topical treatment 1-2x per week for 3 weeks (ketoconazole, clotrimazole)
- oral antifungals (terbinafine, itraconazole, fluconazole)
Tinea manuum is usually caused by
-scratching foot that is infected with tinea
What medication should be avoided with suspected dermatophyte infection
topical steroids
Treatment of mild onychomycosis
Penlac “nail polish” (cyclopirox)
Onychomycosis treatment
- oral terbinafine or itraconazole 1 week per month for 3 months (pulse therapy)
- not all need treatment
Mild acne treatment
- Rx: Tretinoin topical (Retin-A)
- benzoyl peroxide gel with erythromycin (Benzamycin) or with clindamycin (Cleocin)
- start with lowest dose: Retin-A 0.25%
- alt: azelaic acid or salicylic acid (OTC)
Patient education with retinoids
- skin can become red and irritated
- may worsen at first, will improve in 4-6 weeks
- if no improvement in 8-12 weeks, consider increasing dose or adding BP with erythromycin
Mild acne criteria
- open and closed comedones
- with or without small papules
Moderate acne criteria
-papules and pustules with comedones
Moderate acne treatment
- Retin-A, Benzamycin, or Cleocin
- Oral abx: Tetracycline, minocycline, doxycycline, erythromycin, or clindamycin
- Tetracyclines not for <13 years old!
- can consider OCP
Severe cystic acne criteria
-mild and mod acne with painful indurated nodules, cysts, abscesses, and pustules over face, shoulders and chest
Severe cystic acne treatment
- Isotretinoin (Accutane) category X
- prescribed by prescribers in iPLEDGE program
- 2 forms of contraception
- monthly pregnancy test shown to pharmacist
Rosacea patho
-chronic relapse inflammatory skin disorder
Rosacea presentation
- Celtic background
- chronic and small acne-like papules and pustules around nose, mouth, chin
- telangiectasias present on nasal area and cheeks
- blushes easily
- blonde or red-haired with light eyes
- may have red eyes, dry eyes, or chronic blepharitis
Rosacea treatment
- Metronidazole (Metrogel) topical gel
- Azelaic acid (Azelex) topical gel
Complications of rosacea
- rhinophyma
- ocular rosacea
How long does molluscum take to resolve
6-12 months
When is molluscum considered an STD
-if lesions are located on genitals in sexually active adolescents and adults
First degree burn
- superficial
- erythema only, painful
- clean with soap and water
- cold packs for 24-48 hours
- benzocaine or aloe vera
Second degree burn
- partial thickness
- red colored with superficial blisters
- painful
- water and mild soap
- do not rupture blisters
- treat with silver sulfadiazine (Silvadene) or triple antibiotic (Polysporin)
- honey or aloe vera
Third degree burn
- full thickness burn
- rule out airway and breathing compromise
- smoke inhalation injury –> emergency
- painless
- REFER
Body surface for child each arm
9%
Body surface for child each leg
14%
Body surface child front trunk and back
18% each
Body surface adult each arm and head
9%
Body surface adult each leg, anterior trunk, posterior trunk
18%
Criteria for burn referral
- burns involving face, hands, feet, genitals, major joints
- electrical burns, lightening burns
- partial thickness >10% TBSA
- Third-degree burn in any age group
Anthrax is caused by
Bacillus anthracis
G-
Cutaneous anthrax presentation
- papule that enlarges in 24-48 hours
- eschar and ulceration
Pulmonary anthrax presentation
- recent work with animals, wools, hair
- bioterrorism
- flu-like
- cough, hemoptysis, dyspnea, hypoxia, shock
Cutaneous anthrax treatment
-doxycycline, cipro, levo
Smallpox treatment
- symptomatic
- 20-50% mortality rate
Smallpox vaccine is given when
3-4 days postexposure
With suspected MRSA infection, which antibiotic to give if patient has PCN allergy
- doxycycline
- minocycline
- clindamycin
Treatment duration for suspected bioterrorism with anthrax
60 days
Trephination
straighten one end of a large paper clip or 18 gauge needle and heat it with a flame
gently drill down nail until blood seeps out
Primary healing
- primary closure
- wound closed within 24 hours by suturing, glue, strips
- least amount of scarring
Secondary intention wound healing
- left open with formation of granulation tissue and scarring
- heals from bottom of wound up
- wound edges not well approximated
- more scarring
Tertiary intention
- delayed primary closure
- wounds with heavy contamination left open to heal by secondary intention (granulation) and contarction
- wound edges approximated in 3-4 days
- produces most scarring
Phases of wound healing
- hemostasis
- inflammation
- Proliferation
- Remodeling
HIPR (HYPER)
Hemostasis
constriction of blood vessels, platelet aggregation, fibrin formation
Inflammation
- macrophages and lymphocytes proliferate
- inflammatory mediators
Proliferation
basal and epithelial cells proliferate
-angiogenesis
Remodeling
-remodeling of collagen and scar formation
Areas with high risk of ischemia
-tip of nose
-ears
fingertips
toes
penis
Local anesthesia medication used
lidocaine 1%
What wounds are not to be sutured
-puncture wounds or human or animal bites
-heavily contaminated wounds
lacerations >12 hours old
wounds open for more than 24 hours
When are sutures to be removed
within 7-10 days
Why is ecthyma treated with an oral medication
because of dermis involvement
Which tinea infections require oral treatment
- captitis
- unguium (onychomycosis)
- barbae
Lupus presentation
- butterfly rash
- child-bearing aged female
- arthritis
- arthralgias
Lupus labs
- presence of ANA antibodies
- refer to rheumatology
Weakest vehicle strength for topical steroids
lotions
Most potent vehicle strength for topical steroids
ointments
Pinworm diagnosis
- visual inspection of anus, may have mobile worms
- looks like cotton threads
- tape on asshole early in the morning
Pinworm treatment
-Albendazole
PO
Alt medication for child presenting with Lyme-like symptoms
- Amoxicillin
- doxycycline should not be used in children <13
First line treatment for genital warts
cyrotherapy
Erythema multiforme description
target rash
Days to quarantine suspected rabies positive animal
10 days
Candida intertrigo
- candida in body areas where skin rubs together
- breasts, groin
