Derm - Acne, Roscae, Insects - Exam 1 Flashcards
What are the four factors that drive Acne vulgaris?
- Follicular hyperkeratinization
- Increased sebum production
- Cutibacterium acnes within the follicle
- Inflammation
What is considered the precursor for the clinical lesions of acne vulgaris?
Microcomedone
What converts a microcomedone into a closed comedone or whitehead?
Accumulation of sebum and keratinous material.
What contributes to the development of inflammatory lesions in acne vulgaris?
Follicular rupture and presence of bacteria.
What areas of the body does acne affect?
Areas that have the largest, hormonally-responsive sebaceous glands such as the face, neck, chest, upper back, and upper arms.
When would you prescribe oral antibiotics for acne?
Severe inflammatory acne
What is the role of benzoyl peroxide with acne?
Decreases the emergence of antibiotic resistant bacteria.
What is the most effective treatment method for comedonal (noninflammatory) acne?
Topical retinoid (tretinoin)
What is the most effective treatment method for mild papulopustular and mixed acne?
Benzoyl peroxide +/- topical antibiotic (erythromycin, clindamycin) and topical retinoid.
What is the most effective treatment method for moderate papulopustular and mixed acne?
Benzoyl peroxide + topical retinoid + oral antibiotic (tetracycline class)
What is the most effective treatment method for severe acne?
- Retinoid + oral antibiotic (tetracycline class) + benzoyl peroxide
OR
- Oral isotretinoin monotherapy (Accutane)
Which acne medications are teratogenic and contraindicated in pregnancy?
Retinoids
What is a safe acne regimen for pregnancy?
Oral erythromycin, topical clindamycin, topical azelaic acid
What population is Acne Rosacea most prevalent in?
Fair-skinned females
At what age does Acne Rosacea typically emerge?
In the 30’s
What areas of the body are commonly affected in acne rosacea?
Nose, cheeks, chin, and forehead
What are the four subtypes of acne rosacea?
- Erythematotelangiectatic
- Papulopustular
- Phymatous
- Ocular
What are clinical signs typically associated with Erythematotelangiectatic rosacea?
- Chronic redness of central face
- Flushing (wet or dry)
- Skin sensitivity
- Dry appearance
- Telangiectasias (vascular markings)
What are clinical signs typically associated with Papulopustular rosacea?
- Papules and pustules of central face
- Inflammation can be confluent
- No comedones
What are clinical signs typically associated with Phymatous rosacea?
- Tissue hypertrophy causing irregular contours
- Mostly nose, but can involve cheeks, forehead, and chin
- Most affects men (exception to the general rule)
What are clinical signs typically associated with Occular rosacea?
- Greater than 50% of those have other types of rosacea
- Seen in children and adults
- May precede, coincide, or follow other acne rosacea types
- Dry eyes, pain, itching, blurred vision
- Photosensitivity
- Blepharitis
- Keratitis
- Conjunctivitis
- Stye
What is the first line of treatment for erythematotelangiectatic rosacea?
Behavior modification
- Avoid triggers
- Sun protection
- Gentle skin care
What is the second line of treatment for erythematotelangiectatic rosacea?
- Laser and pulsed light therapies
- Topical Brimonodine (vasoconstrictor)
What is the first line of treatment for mild to moderate papulopustular rosacea?
- Metronidazole
- Azelaic acid
What are the second line topicals used in mild to moderate papulopustular rosacea?
- Ivermectin
- Sulfacetamide-sulfur
What is the treatment method for moderate to severe disease or failed topical treatment for papulopustular rosacea?
- Oral Tetracyclines
- Oral Macrolides
What is the treatment method for early phymatous rosacea?
Isotretinoin (topical retinoid)
What is the treatment method for advanced phymatous rosacea?
- Surgical debulking
- Laser ablation
What is the treatment method for ocular rosacea?
- Refer to ophthalmologist
- Topical/oral antibiotics and cyclosporin
What can the venom in scorpion stings cause?
Hyperexcitability and excessive neuro/muscular activity
What are clinical findings associated with a grade 1 envenomation from a scorpion?
Local pain and paresthesias at the sting
What are clinical findings associated with a grade 2 envenomation from a scorpion?
Local symptoms as well as remote pain and paresthesias
What are clinical findings associated with a grade 3 envenomation from a scorpion?
Either cranial nerve or somatic skeletal neuromuscular dysfunction.
What are clinical findings associated with a grade 4 envenomation from a scorpion?
Both cranial nerve and somatic skeletal neuromuscular dysfunction.
What are some clinical signs of cranial nerve dysfunction associated with a scorpion sting?
- Hypersalivation
- Abnormal eye movements
- Blurred vision
- Slurred speech
- Tongue fasciculations
What are some clinical signs of somatic skeletal neuromuscular dysfunction associated with a scorpion sting?
- Fasciculations
- Shaking and jerking of extremities
- Opisthotonos (arching of back)
- Emprosthotonos (tetanic forward flexion of the body)
- Fever up to 104 F from excess motor activity
What is the typical treatment for mild envenomations by a scorpion?
- Pain management with oral medications
- Cleansing of the sting site
- Tetanus prophylaxis
- Observe for four hours
What should you monitor for in cases of severe envenomation by a scorpion?
- Respiratory compromise
- Myocardial infarction
- Hyperthermia
- Rhabdomyolysis
- Multiple organ failure
What does the treatment for severe envenomations by a scorpion include?
- IV fentanyl for pain
- IV benzodiazepines UNLESS you give Antivenom as the combination could cause respiratory depression
What is the most common reaction from a bee sting?
What is it treated with?
Localized swelling and erythema that lasts for a few hours to 1-2 days
Treat with cold compress
What does a bee sting cause about 10% of the time?
What are the symptoms associated with it?
What is it treated with?
Large Local Reaction (LLR)
- Exaggerated erythema and swelling
- Gradually enlarges over 1-2 days
- Resolves in 5-10 days
Treated with cold compress, prednisone, antihisatmines, NSAIDS
How do you treat an anaphylactic reaction to a bee sting?
IM epinephrine
What is the leading cause of fatal anaphylaxis?
Insect stings
What does the release of catecholamine from a Black Widow’s venom cause?
- Intermittent radiating pain
- Abdominal/chest/back pain and muscle spasm
- Local/regional diaphoresis
- Headache
- Nausea/vomiting
Do Black Widow bites typically cause many symptoms? Why or why not?
Often cause few symptoms because no venom is typically injected
What are clinical signs of a Black Widow bite?
Blanched circular patch, surrounding red perimeter and central punctum
What is the treatment management for Black Widow bites?
- Local wound care
- Antiemetics
- Narcotic analgesics
- Tetanus immunization
- Muscle relaxers
- Antivenom (caution)
Brown Recluse bites are often painless initially, but what are some possible effects after the initial bite?
When do the symptoms typically resolve?
- Progress to severe pain in 2-8 hours
- Usually a red plaque or papule with central pallor
- May see two small puncture marks within the erythema
- Vesiculation can occur
Typically resolves in a week.
What signs/symptoms are associated with rare, severe ulcerative necrosis from a Brown Recluse bite?
- Dark, depressed center develops at wound site after 1-2 days
- Nausea/vomiting
- Headache
- Fever/chills
- Rarely have renal failure, hemolytic anemia, hypotension, DIC, rhabdomyolysis
How do necrotic lesions from Brown Recluse bites typically heal?
By secondary intention without scarring
What is the treatment management for necrotic lesions from Brown Recluse bites?
- Cleansing
- Cold compresses
- Analgesics
- Antibiotics
- Surgical excision and reconstruction may be necessary, but is avoided until wound has stabilized
What is Vitiligo?
An acquired skin depigmentation via an autoimmume process directed against melanocytes.
What are clinical indications of Vitiligo?
- Milk-white macules with homogenous depigmentation and well-defined borders
- Slow progression
Where does Hidradenitis Suppurativa “acne inversa” occur?
Occurs in the axillary, inguinal, and anogenital regions
What does Hidradenitis Suppurativa result from?
What are some other factors that may contribute to Hidradenitis Suppurativa?
- Results from the cycle of follicular occlusion, rupture, and the associated immune response
- Other factors include genetics, mechanical stress, obesity, smoking, and diet
How does Hidradenitis Suppurativa begin?
How does it progress?
- Begins with a single, deep-seated inflammatory nodule.
- More nodules form as disease progresses
- May form an abscess that opens to the skin
- Purulent drainage occurs if ruptured
What are some other skin changes that occur as Hidradenitis Suppurativa progresses?
- Sinus tract
- Comedones
- Scarring
What are medical treatment options for Hidradenitis Suppurativa that are used in combination with lifestyle strategies?
- Local treatment with topical clindamycin or intralesional corticosteroids
- Systemic antibiotics such as doxycycline or minocycline
- Anti-androgenic agents
- Surgery such as punch debridement of nodules or wide excision
- TNF inhibitors and oral retinoids for severe cases
What are complications associated with Hidradenitis Suppurativa?
- Fistulaes
- Strictures and contractures
- Lymphatic obstruction
- Infectious complications
- Squamous cell cancer
- Malaise
- Depression
- Suicide
What should you consider doing when patient is diagnosed with Vitiligo or you are considering Vitiligo as a diagnosis?
- Consider screening for other autoimmune diseases
- Skin biopsy will show epidermis devoid of melanocytes
What contributes to the first stage of acne, microcomedone?
Increased serum production and follicular hyperkeratinization
How is an open comedone or blackhead formed?
Follicular orifice is opened with continued distention
What factors contribute to the process of developing inflammatory lesions in acne vulgaris?
- Androgens stimulate the growth and secretory function of sebaceous glands
- Mechanical trauma can rupture comedones, causing inflammatory lesions
- Stress has effect on severity
What are important considerations when diagnosing acne vulgaris?
- Work up for hyperandrogenism is indicated for females patients with acne and additional signs of androgen excess
- Rapid appearance of acne in conjunction with virilization suggests an underlying adrenal or ovarian tumor
- A medication history should also be reviewed for acne-inducing drugs
What are clinical signs of a secondary bacterial infection caused by a hymenoptera sting?
How is it treated?
- Worsening of symptoms 3-5 days after sting
- Fever
- Sting is from fire ants or yellow jacket
Treated with antibiotics
What are treatment methods for vitiligo?
- Topical and systemic corticosteroids (first line)
- Calcineurin inhibitors
- Narrowband ultraviolet B phototherapy (for extensive disease)
- Skin grafts
What helps you distinguish between acne vulgaris and papulopustular rosacea?
Papulopustular rosacea does not have comedones
