DERM BLOCK II Flashcards
3 groups of Light
UVA (320-400nm)
UVB (290-320nm)
UVC (100-290nm)
UVA light
Constant throughout the day/year
Long waves penetrate deeply - dermis, subcutaneous fat
Chronic exposure = connective tissue degeneration
PhotoAging & photoAllergic
UVB light
Greatest during the summer - most harmful of waves
High amt of energy to corneum/superficial layers
SunBurn/tan, erythema, pigmentation and inflammation
UVC light
Absorbed by ozone layer
Transmitted only by artificial sources – germicidal lamps
SLide 6 chart of skin photo types
Lecture 10
What does the SPF mean
The least amount of UVB energy req’d to produce a min. erythema reaction
(minimum erythema dose, MED) through sunscreen, compared to
-The amt of energy req’d to produce the same erythema w/out any sunscreen application
SPF 30 = 30x longer exposure before sunburn
Beyond SPF 30 – marginally better
Texture change that Develops in chronically sun-exposed areas and presents as thickened skin with a yellow hue.
Solar elastosis
Texture change that is Thinned skin, prominent blood vessels, easy bruising, etc.
Atrophy
What is sun-induced wrinkling on back of neck that forms a rhomboidal pattern
Cutis Rhomboidalis Nuchae
Lentigo is
Large brown macules from the sun
What is. Red-brown reticulated pigmentation with telangiectasias, atrophy, prominent hair follicles on the
Chest and neck
Poikiloderma of Civatte
Open and closed comedones and epidermal inclusion cysts around the eyes 2/2 sun damage/ photoaging
Favre Racouchot
Retinoids for photoaging need what approach
Maintenance requires continued use
Increased photosensitivity during txt = need daily sunscreen use
What is the most common light induced skin dz
Polymorphous light eruption
Delayed-type hypersensitivity response endogenous cutaneous photoinduced antigens
What is the phenomenon known as “hardening” in pts wtih polymorphous light erutopon
Sun exposure leads to incremental doses of UV radiation based on tolerance & resolution
What are the two types of polymorphous light eruption
Papular and Plaque type
A pt presents in the spring/early summer with Malaise, chills, HA, nausea x 1-2 hrs preceding rash
With Mildly to markedly pruritic, grouped, erythematous or skin-colored papules of varying sizes
Most common to sun exposed areas
Think
Polymorphous light eruption
R/o lupus with Hx, Bx and Immunofluorescense
Tx: corticosteroids and limit sun exposure (group II-V)
Short course oral steroids if wide spread
SUN PROTECTION AND LIMIT EXPOSURE
A Native American female presents with early onset of intensely itchy papules, plaques, and nodules MC to the face
With a hemorrhagic crust with lichenification
Think
Actinic Prurigo
Corticosteroids
(Group II-V)
Short course Oral steroids with widespread
SUN PROTECTION and LIMIT exposure
PUVA
Last line tx: is hydroxychlorquine
A pt presents with non allergic skin response from a topical or systemic agent
Then Skin is exposed to certain wavelengths of light (UVA) inducing the reaction.
Think
Phototoxicity
Most severe resopnse: Tingling, erythema shortly after exposure -> burning edema & vesicles within hours ->bullae, linear streaking -> desquamation
Residual hyperpigmentation lasts up to 1 yr
MC Rx RXN: TCNS (Doxy)
Tx: Dc causative agent
Generous use of sunscreen
Topical steroids for S/s relief
Don’t do PUVA
A pt presents with symmetric pattern of white macules on the dorasal Hands, face, body folds, genitalia, or body openings
+Koebner phenomenon on the elbows or sunburned areas
+Halo Nevi
Think
Vitiligo type A
Dx with a woods lamp
Tx only if pt desires
With Topical corticosteroids (typically 1st line)
Vitamin D3 analogues (calcitriol)
Topical calcineurin inhibitors (tacrolimus/pimecrolimus)
Phototherapy with NB-UVB
Excimer laser
Camouflage
A pt presents with skin whitening that is in a asymmetric pattern and early early onset
Think
Type B segmental vitiligo
A pt presents with 2-5 mm white spots with sharply demarcated borders Located on exposed areas of hands, forearms, and lower legs of middle aged and older people
Think
Idiopathic Guttate Hypomelanosis
Prevent with Sun/UV light avoidance
SPF therapy
Tx: is elective Tretinoin cream Low potency steroids Liquid nitrogen (LN2) Hypopigmentation risk Dermabrasion Cosmetics/Make-up cover up
A pt presents with Tan to brown macules due to localized proliferation of melanocytes from acute or chronic exposure to sunlight
Aka liver spots
Multiple lesions usually arise in sun-exposed sites
Lesions may be round, oval, with slightly irregular, ill defined border
Scattered, discrete lesions, stellate, sharply defined, and roughly the same size
Think
Solar Lentigo
MC to the sun exposed areas
Chronic sun exposure ->hyperplasia of melanocytes ->increased pigmentation
What does ABCDE mean
Asymmetry Border Irregularity Color Diameter Evolving
A pregnant pt presents with symmetric brown hyperpigmentation of the face and neck without signs of inflammation
Think
Melasma
(Can be 2/2 preg. Or OCP)
Rx cause: phenytoin
Prevent with sun Protection
Tx: Hydroquinone (Most effective) Azalaic acid or tretinoin To Triluma cream (Hydro, tretinoin, flucinoloine) x 8 weeks QD (EVEN MORE EFFECTIVE)
What is the most common Benign cutaneous neoplasm
Seborrheic Keratosis
-Proliferation of immature keratinocytes
Usually pigmented as melanin transfers into keratinocytes
Possible relation to sun exposure
Typically evolve from a macule and may progress to become papular or verrucous
A pt presetns with a “stuck on” “greasy” macule of brown or black verrucous
Think
Seborrheic Keratosis
Cut it out even though its not malignant (dont take the chance of miss dx)
What separates SK from Melanoma
Melanomas have a smooth surface that varies in elevation and in color, density, and shade.
SKs preserve a uniform appearance over their entire surface
When in doubt Bx
“Leser-Trelat” Sign – sudden appearance of multiple SKs:
Rare sign of internal malignancy
What is Lesner-Trelat sign
In SKs R/O malignant melanoma in dark lesions
“Leser-Trelat” Sign – sudden appearance of multiple SKs:
—Rare sign of internal malignancy
A pt presents with 1 - 10 mm, round, dry White or skin colored Hyperkeratotic papules, warty lesions
“Stuck on” appearance
MC on the Ankles, or dorsal feet
Think
Stucco Keratosis
2/2 Vascular insufficiency, xerosis,
Benign proliferation of keratinocytes
Completely benign
A pt presents with small SKs that are darker on dark skin tones
2-3mm dome shaped papules
Brown to black
Hyperkeratotic, pedunculated or verrucous papules
Female predominance
MC in Cheeks and around eyes bilaterally
Think
Dermatosis papulosa Nigra
Common in African Americans
Completely Benign
Tx directed at cosemtics
- freezing (can cause hypopigmentation)
- scissor snip, or removal
A pt presents Skin colored to brown
Soft Pedunculated 1mm - 1cm raised lesions
Located in areas with lots of rubbing
Think
Skin Tags, Aka Acrochordon
MC in obese pts
Smaller lesions may not require anesthesia
- Scissor excision
- Electrodessication
- Cryosurgery
Larger lesions
Anesthetize and excise
A pt presents with 3-10mm, slightly raised, pink-brown, sometimes scaly, hard growths, 1-10 lesions
That Retract beneath skin surface w/ compression -“ dimpling”
MC to the extremities and trunk
Think
Dermatofibromas
- Fibrous reactive process to trauma
- Bug bite, viral infection lesion, shaving, etc.
Dimpling is the clinical presentation
Tx: Removal with punch Bx or regular excision
- Biopsy dark lesions - r/o MM
- Conservative cryosurgery to decrease color
Completely benign
A pt presents with raised, red or hyper pigmented, firm or shiny, smooth surface,-a hypertrophic scar
Think
Keloid
Tx options:
- Intralesional steroids – effective, but painful
- Atrophic effect on scar tissue
- Combo surgery and intralesional steroids
- Cryotherapy
- Silicone gel sheeting
- Intralesional 5-FU
- Lasers
A pt presents with a solitary, discrete, smooth, dome shaped, red papule/ tumor
With a distinctive central hyperkeratotic core
MC to the limbs/ Sun exposed surfaces
Think
Keratoacanthoma
Will resolve on its own but dont wait!
Often indistinguishable from squamous cell carcinoma – clinically and histologically
MGMT: excision, do not just Debride!
If recurrent use Intralesion 5-FU or Methotrexate
A pt presents with a white to yellow, hard, keratosis conical lesion
On sun exposed sites
MC in men and elderly
Think
Cutaneous Horn
up to 20% of cutaneous horns arise in an in situ or invasive SCC
Treatment:
- Excision
- May shave or use LN2 if small, narrow base
A por presents with small tumors of enlarges sebaceous glands
That begin as small yellow papules, that become dome chapped with a central puncture
With a sebaceous gland like appearance
Mc location is the face And in pts over 30
Think
Sebaceous Hyperplasia
No Txt required
-Curette, shave bx, electrosurgery
Take care to prevent scarring
Lesion can extend into dermis
If many lesions, may refer for isotretinoin (very low dose)
Rule of BCC
What is the DDX of BCC and Sebnaceous Hyperpplasia
BCC – haphazard arrangement of vessels on surface
SH – vessels occur only within the valleys bordered with small yellow lobules
What is the differnce between hypertrophic scars and keloids
HS usually regress over time
And Keloids do not
A pt presents with a “sweat duct tumor” that is 1-3 mm, small, firm flesh colored dermal papules
Lasted under the eyes/ lower lid
Common in young women
Think
Syringoma
MGMT:
None, risk of scaring young skin
Cosmetically: can remove shave with an 11 blade
Completely benign
A pt presents with a segmented, firm, waxy Nevus that appears after adolescence,
Think
Neurofibroma
Nerve sheath tumor, with a button hole sign
“Invaginated through skin with digital pressure”
MGMT: if 2 or more suspect Von Recklinghousen (NF1) – can become cancerous
Followed by Neuro
What is the most common vascular malformation
Cherry Angioma
A pt presents with 0.5- to 5-mm, smooth, firm, deep red papules
MC to the trunk or proximal extremities
Think
Cherry Angioma
no tx necessary
May shave or exisce as desired
A pt presents with permanently dilated small blood vessels
That are less than 1mm, that appear as single strands, in groups as small as macules
Think
Telangiectasia
Treatment with electrodessication or laser ablation
A pt presents with small, rapidly growing, yellow to bright red dome shapes glistening lesions
MC to the Head and Neck, fingers or Gingivia
Extremely friable
Pyogenic Granuloma
Treatment:
- Thorough curettage of the base and border
- Electrodessication often necessary to eradicate the lesions completely and to control bleeding
- Recurs if the smallest piece of abnormal tissue remains
What is the most benign soft tissue tumor
Lipoma
A pt presents with soft pillowy, mobile, lesion
On the truck or extremities
Think
Lipoma,
Management
Excision or no Txt
Prognosis
Once removed normally don’t recur
If fast growing consider malignant transformation
What is the most common skin cancer and most common malignant neoplasm in humans
Basal Cell Carcinoma
What is the highest risk fx for BCC
Highest risk: Intense, intermittent exposure vs. equal dose of continuous exposure
And the inability to tan
(light light skin)
Define: Malignant proliferation in basal layer of epidermis
BCC
What is the standard appearance for BCC
There isnt one
it varies
Think about this if there is a weird lesion on skin exposed areas
Most common form of BCC
Nodular
Pink/skin colored, “pearly” !!(opalescence)
Firm, dome shaped papule
Evolves - ulcerates and has elevated, rolled borders and telangiectasias
—“rodent ulcer”
A pt presents with a bleeding/scab/sore that heals and recurs
“A zit that wont go away”
Think
Classical presentation for a BCC
What is the most common location for a BCC
NOSE (nodular)
Trunk (superficial)
What is the approach to BCC
Deferral to derm
With an annual TBSE (total body examination)
May stop if tumor free x 3 years
Define SCC (Squamous Cell Carcinoma) confined to the epidermis -Premalignant
Actinic Keratosis
A pt presents with persistent localized rough feeling to the skin, erythema with a scale
-hyperkeratotic lesion on the ears or hand , with sharp adherent yellow scale
Think
Actinic Keratosis
On any sun exposed area,
If on lower lip - actinic cheilitis
If on ear- Chondrodermatitis Nodularis Helicis
Tx: Excise or remove it
(LN2/ cryotherapy)
(5-FU-standard)
TBSE
What is the difference between actinic keratosis and SCC
SCC invades the invades the dermis
What are the standard and alternate treatment for Actinic Keratosis
5-fluoruracil (5-FU, Efudex cream) - standard
Imiquimod (Aldara cream) – alternative
What is Bowen Dz
Squamous Cell Carcinoma In Situ
Slightly elevated, red, scaly plaques
Extends DOWNWARD into the follicle
Low grade for malignancy, can progeress to SCC
F/u q 6 months!! Required!!
What is Bowens Disease of the Mucosa called
Erythroplasia of Queyrat – SCC in situ of mucous membranes
Assoc with HPV-8
Uncircumcised, elderly males, vulva of elderly females and/or oral mucosa
Presents with moist, red, smooth, slightly raised plaque
Treat with 5-FU or Imiquimod or Laser
A pt presents with a red, scaly, persistent, deep, hypertrophic lesion with ulcer/ induration
Most commonly to sun exposed areas
Think
Bowens dz -> SCC
High risk of Metz
From UVA/UVB exposure
Preceded by Actinic Keratosis
Associated with HPV infections
Treat with excision + lymph nodes
F/u q 12 months indefinitely
SCC on what location has the greatest chance to Metz
on the lips
So excision + margins
What is the approach to Nevus evaluation
ABCDE!
Asymmetry Borders Color Diameter (>5mm) Evolution (changes)
Any lesion that changes in appearance should get what
Bx!
What is the F.u for a pt with more than 100 Nevi
If >100 nevi, follow at 6-12 month intervals
What are the three types of Melanocytic Nevi
-Junction nevi
(flat, brown, common in childhood)
-Compound nevi
(slightly elevated, smooth or warty, +halo Nevus)
-Dermal nevi
(Dome snapped, verrucous, pedunculated, sessile, arising from the dermis)
Dermal Nervus
Dome shaped most common
What is a “birth mark”
Congenital Melanocytic Nevi
Grows proportionally with child growth
Prophylactic removal only if LARGE
-malignancy risk
What is Nevus Spilus
Speckled Lentiginous Nevus
Rare malignancy risk
Hairless, oval or irregularly shaped brown macule
Dotted w/ darker brown to black papular spots
Beckers Nevus
Common in adolescent men,
MC tot he upper back, shoulder, upper arm
No cancer risk
Tx; Usually too large to remove with excision
- Hair may be shaved or permanently removed
- Laser tx for removal of hair and pigmentation
Halo Nevus
Compound or dermal nevus that develops a white border
Typically occurs around age 15
May herald onset of vitiligo
NOT MALIGNANT
MC to trunk
Tx- none needed, Bx if suspicious
Eval with Woods lamp for vitiligo
A pt presents with a Hairless, red or reddish-brown, dome shaped papules/nodules
Think
Spitz Nevus
MC to head, neck, or LE
Occurs most in children
And appears suddenly
Tx: remove and send to path
A pt presents with a slightly elevated, round, regular Nevus, MC to the extremities and dorsum of the hand
Think
Blue Nevus
Often confused with malignant melanoma
- Develops in childhood
- Remains unchanged
- History is discriminator
Tx: none
A pt presents with Blue-black lesions dermal melanocytes (more flattened) mc to the presacral area
Mongolian Spot
No treatment necessary
Caused by Appear blue-black due to “Tyndall effect” of melanin deeper in skin
A pt presents wtih Blue-black pigmentation in 1st - 2nd branch of trigeminal nerve
Affects the sclera, conjunctiva and skin around eye
Nevus of Ota
Get a Visual acuity and document baseline
Treatment
- Laser to lighten lesions
- Monitor patient for glaucoma
A pt presents with Brown-black macules on lower lip
Common in young adult women
Resemble freckles, but no change w/ sun exposure
Labial melanotic Macule
Treat with Cryotherapy if desired
A pt presents with Brown-black macules on lower lip
Common in young adult women
Resemble freckles, but no change w/ sun exposure
Labial melanotic Macule
Treat with Cryotherapy if desired
How does polymorphic light eruption appear in dark skinned individuals
most common morphology is grouped, pinhead-sized papules in sun-exposed areas
What are the coomorbidites assoc with Vitiligo
Alopecia areata
hypothyroidism
Graves dz
Addison disease
pernicious anemia
DM1
melanoma
How is a Nevus different than a melanocyte
Larger, lacks dendrites, has more abundant cytoplasm, and contains coarse granules
