Derm MDT Flashcards
The following describes what:
Inflammation of a hair follicle that can occur anywhere on the body where hair is found
Folliculitis
What are bacterial causes of folliculitis
- S. aureus(+/- MRSA)
- Pseudomonas (H20 contamination)
What are fungal causes of folliculitis
- Dermatophytic (tinea capitis, tinea corporis, tinea pedis)
- Pityrosporum (affecting teenagers and men) on upper chest and back)
- Candida albicans
What are viral causes of folliculitis
- Herpes Simplex Virus (HSV)
- Molluscum contagiosum
What are parasitic causes of folliculitis
- Demodexspp. Mites
- Schistosomes (swimmer’s Itch)
What are non infectious causes of folliculitis
Pseudo-folliculitis barbae (PFB)
Mechanical Folliculitis (Skinny Jeans Syndrome)
The following are risk factors for what:
- Hair removal (shaving, plucking, waxing, epilating agents)
- Other pruritic skin conditions: eczema, scabies
- Occlusive dressing or clothing
- Personal carrier or contact with MRSA-infected persons
- Diabetes mellitus
- Immunosuppression
- Use of hot tubs or saunas
- Chronic antibiotic use (gram-negative folliculitis)
- Tattoo recipient
- Poor Hygiene
Folliculitis
Pt presents with:
- Abrupt onset of follicular erythematous papules or pustules, with pruritus & pain in hairy areas
- Rash occurs on hair-bearing skin, especially the face (beard), proximal limbs, scalp, and pubis
- Pseudomonal folliculitis appears as a widespread rash, mainly on the trunk and limbs.
- The clinical hallmark is hair emanating from the center of the pustule
Folliculitis
Conservative Treatment of Folliculitis
- Antiseptic and supportive care is usually enough.
- Systemic antibiotics may be used with questionable efficacy.
- Good hygiene practices
- Wash hands frequently
- Wash towels, clothes, and linens frequently with hot water to avoid reinfection
- Good hair removal practices
- Use witch hazel, alcohol, or Tend Skin afterward
Medications for Staphylococcal Folliculitis
- Mupirocin ointment applied TID for 10 days
- Cephalexin: 250-500 mg PO QID (7-10 days)
- Dicloxacillin: 250-500 mg PO QID (7-10 days)
Medications for MRSA Folliculitis
- Bactrim DS: 1-2 tablets BID PO (5-10 days)
- Clindamycin: 300 mg PO TID (10 to 14 days)
- Doxycycline: 50-100 mg PO BID (5-10 days)
Medications for Pseudomonas folliculitis
- Ciprofloxacin: 500 to 750 mg PO BID for 7 to 14 days if lesions are persistent
- High-potency topical corticosteroids for inflammation
- Antihistamines (Hydroxyzine, Cetirizine) to control itching
Medications for fungal folliculitis
- Topical antifungals: ketoconazole 2% cream or shampoo or selenium sulfide shampoo daily
- Systemic antifungals for relapses fluconazole (100 to 200 mg/day for 3 weeks) or Itraconazole (200 mg/day for 1 week) or Griseofulvin (500 mg/day for 2 to 4 weeks)
What is the order of likelihood of causes for folliculitis
- Staph
- Strep
- Pseudomonas
The following describes what:
- Condition caused by ingrowing hairs, mostly in the beard area (neck area is typically most severe)
- Affects people with curly hair or those with hair follicles oriented at an oblique angle to the skin surface.
- A sharp, shaved, tapered hair re-enters the skin as it grows from below the skin surface and induces a foreign body reaction, producing a micro-abscess.
- Significant problem in predisposed individuals who are required to shave closely.
Pseudo folliculitis barbae
Pt presents with:
- Red papules or pustules appear in the affected skin - - Lesions can be both painful and/or pruritic.
- Occurs in any area where the hair is shaved (scalp, posterior neck, groin, legs).
- Scarring and hyperpigmentation may result from this condition.
- Keloid formation is often a problem in affected skin, especially in African- American people.
- Condition if found in 50% - 75% of blacks and 3% - 5% of whites who shave.
- Found in both men and women.
Pseudo folliculitis barbae
What is the PFB instruction
BUPERSINST 1000.22C
Tx Approach 1 – Mild to Moderate PFB
- Application of medicated creams to soften hairs, shaving with gentle equipment and shaving techniques to minimize irritation hair re-entry into the skin
- Either a topical retinoid or eflornithine 13.9% (if available) and temporary shave chit for up to 60 days
- Medications should be used for full 60 days before shaving is attempted & used continuously after successful shaving is resumed
- After 60 days using these products, shaving can be attempted with a PFB razor with foil guard, a multi-blade razor with lubricating strips or with an electric razor
Tx Approach 2 – Moderate to Severe PFB
- Laser Hair Reduction with grooming modifications
- The most reliable approach allowing a return to grooming standards
- Appropriate treatment for moderate to severe cases of PFB or any case desiring permanent hair reduction
- At least three treatments is usually needed, with 30-45 days between treatments
- This procedure is usually available at MTF facilities with a dermatology department
- Complete relief of symptoms is rare; goal is to improve symptoms enough to allow comfortable shaving
The following describes what:
- A contagious, superficial, intraepidermal infection occurring prominently on exposed areas of the face and extremities
Impetigo
Which impetigo is the following:
- Invasion of previously normal skin
- Most common form of impetigo.
- Formation of vesiculopustules that rupture, leading to crusting with a characteristic golden appearance; local lymphadenopathy may occur
Primary impetigo (pyoderma), non bullous impetigo
Which impetigo is the following:
- Invasion at sites of minor trauma (abrasions, insect bites, underlying eczema)
- Can be considered to beS. aureusimpetigo of hair folliclesstaphylococcal impetigo that progresses from small to large flaccid bullae (newborns/young children) caused by epidermolytic toxin release; ruptured bullae leaving brown crust; less lymphadenopathy; trunk more often affected; <30% of patients
Secondary impetigo (impetiginization) (bullous impetigo)
The following are risk factors for:
- Warm, humid environment
- Tropical or subtropical climate
- Summer or fall season
- Minor trauma, insect bites, breaches in skin
- Poor hygiene, poverty, crowding, epidemics, wartime
- Familial spread
- Complication of pediculosis, scabies, chickenpox, eczema/atopic dermatitis
- Contact dermatitis
- Burns
- Contact sports
- Children in daycare
- Carriage of group A Streptococcus and Staphylococcus aureus
Impetigo
The following describes what:
- characterized by thickly crusted erosions or ulcerations.
- a consequence of neglected impetigo and classically evolves in impetigo occluded by footwear and clothing
Ecthyma
Conservative treatment t of Impetigo
- Avoidance of infection spread is the key; hand washing is vital, especially for reducing spread in children
- Prevent with mupirocin ointment TID to sites of minor skin trauma
- Remove crusts; clean with gentle washing 2 to 3 times daily; and clean with antibacterial soap, chlorhexidine, or Betadine
- Washing of entire body may prevent recurrence at distant sites
Medications for Staph impetigo
- Nonbullous (minor spread, treat 7 days; widespread, treat 10 days); bullous (treat 10 days)
- Mupirocin (Bactroban) 2% topical ointment applied TID for 5 to 7 days (nonbullous only)
- Dicloxacillin: adult 250 mg PO QID
Medications for MRSA impetigo
- Clindamycin, tetracyclines, or trimethoprim-sulfamethoxazole. Oral doses given for 7 days are usually sufficient
- Clindamycin 300 mg q6-8h
- Severe bullous disease may require IV therapy such as nafcillin or cefazolin
The following describes what:
- An acute bacterial infection of the dermis and subcutaneous (SC) tissue
- Typically caused by bacterial penetration through a break in the skin
- Microbiology: -β-Hemolytic streptococci, Staphylococcus aureus, including MRSA, and gram-negative aerobic bacilli are most common
- Presents with the (4) classic signs of inflammation:
Erythema, edema, tenderness to palpation, elevated skin temperature surrounding area of infection
- Unilateral lower-extremity involvement is typical and systemic symptoms are usually absent
Cellulitis
The following describes what condition:
- Most common portal of entry is toe web due to tinea pedis
- Typically occurs near surgical wounds and trauma sites
- Pre-existing lesions such an ulcer or erosion may act as portal of entry
- However, it may develop in apparently normal skin or at site of dermatoses
Cellulitis
Pt PE:
- Localized pain and tenderness with erythema, induration, swelling, and warmth
- Regional lymphadenopathy
- Purulent drainage (from abscesses)
Cellulitis
Why should US be done for cellulitis of lower leg?
R/o DVT
Conservative treatment of Cellulitis
- Demarcate area w/a sharpie to measure progress once you start treatment
- Immobilize and elevate involved limb to reduce swelling
- Sterile saline dressings or cool aluminum acetate compresses for pain relief
- Compression stocking for edema
- Acetaminophen +/- NSAIDs for pain relief
- Tetanus immunization if needed, particularly if there is an open (traumatic) wound
Medications for Non-purulent cellulitis
(target treatment toward β-hemolytic streptococci and MSSA)
Cephalexin 500 mg PO q6h
Dicloxacillin 500 mg PO q6h
Medications for Purulent cellulitis
(probable CA-MRSA)
Clindamycin 450mg PO
Trimethoprim-sulfamethoxazole (TMP-SMX) 1 DS tab PO BID
Doxycycline 100 mg PO BID
Medications for Human/animal Bites
Amoxicillin + clavulanic acid (Augmentin)
If the following occurs while treating cellulitis, what should occur?
- Elevated white blood cell count with marked left shift
- Failure to respond to oral antibiotics
- Severe infection, suspicion of deeper or rapidly spreading infection, tissue necrosis, or severe pain
- Worsening symptoms that do not resolve/improve after 24 to 48 hours of therapy
- Cellulitis of the hand and face may require hospitalization
MED ADVICE
The following describes what:
- rare and rapidly progressing infections involving any layer of soft tissue including skin, subcutaneous fat, fascia, and/or muscle
- associated with extensive tissue destruction, systemic toxicity, limb loss and are potentially fatal
- medical emergency. Early diagnosis, prompt surgical consultation, and initiation of broad-spectrum antibiotics are essential in improving outcomes
Necrotizing Fasciitis
The following are risk factors for:
- can occur among healthy individuals with no past medical history or clear portal of entry in any age group
- Major penetrating trauma
- Minor laceration or blunt trauma (muscle strain, sprain, or contusion)
- Skin breach (varicella lesion, insect bite, injection drug use)
- Recent surgery
- Mucosal breach (hemorrhoids, rectal fissures, episiotomy)
- Immunosuppression
- Malignancy
- Obesity
- Alcoholism
Necrotizing Fasciitis
Pt presents with:
- Most frequently occurs in the extremities (Predilection for the lower leg) and may mimic DVT
Initially there is pain, erythema, edema, cellulitis and high fever
- The pain is progressive, relentless, and severe and is often out of proportion to the severity of the physical findings
- Skin exam may be unrevealing early on, or may be confused with cellulitis or abscess; may see blistering, crepitus, soft tissue edema, erythema, discoloration, necrosis, bullae, vesicles, or ulceration
Necrotizing Fasciitis
What condition do these results confirm:
- MRI: May show edema along the fascial plane
X-ray, CT or US are useful in demonstrating the air bubble in the soft tissues
- Cultures: Group A Strep and mixed aerobic and anaerobic bacteria
- Direct inspection at surgery shows the fascia is swollen and dull gray with areas of necrotic tissue
Necrotizing Fasciitis
treatment of Necrotizing Fasciitis
- Immediate medevac is required for this patient
- Prompt and wide surgical debridement is the cornerstone of treatment
- Broad-spectrum antibiotics should be administered once diagnosis of NSTI is suspected
The following describes what:
- well-circumscribed, painful, inflammatory nodule at any site that contains hair follicles. May extend into the dermis and subcutaneous tissues
Furuncle (AKA boil)
The following describes what:
A collection of pus within the dermis and deeper skin tissues. Manifests as painful, tender, fluctuant, and erythematous nodules
- Typically do not present with systemic symptoms
Skin abscess
The following describes what:
- A coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles
- Typically presents with systemic symptoms and fever
Carbuncle
The following describes what:
- Infection spreads away from hair follicle into surrounding dermis
- Pathogenic strain of S. aureus or CA-MRSA
Abscess/ Carbuncle/Furuncle
The following are risk factors for what conditions:
- Carriage of pathogenic Staphylococcus sp. in nares, skin, axilla, and perineum
- Diabetes mellitus, malnutrition, alcoholism, obesity, atopic dermatitis
Abscess/ Carbuncle/Furuncle
Pt presents with:
- Deep subcutaneous erythematous papules enlarge to deep-seated nodules that can be stable or become fluctuant within several days
- Most commonly occurs on the back of the neck, upper back and the lateral thighs
- Tender, perifollicular swelling, terminating in discharge of pus & necrotic plug
- malaise, chills and fever may precede or occur during the height of inflammation
Carbuncle
treatment for an abscess, furuncle, and carbuncle
- Incision & Drainage
- Carbuncles should be handled by dermatology or general surgery in all situations unless patient is unable to be transferred
Antibiotics for MSSA Abscess
Dicloxacillin 250-500 mg QID for 10 days
Cephalexin 250-500 mg QID for 10 days
Amoxicillin and Clavulanate (Augmentin) 875 mg BID for 10 days
Antibiotics for MRSA Abscess
Doxycycline 100 mg BID
Trimethoprim-Sulfamethoxazole DS BID
Clindamycin 150-300 mg BID for 10 days
The following describes what:
- most common benign cutaneous cysts
- Can occur anywhere on the body and the size ranges from a few millimeters to several centimeters in diameter
- consists of normal stratified squamous epithelium derived from the follicular infundibulum
- may arise from the implantation of the follicular epithelium in the dermis as a result of trauma or from a comedone
- Lesions may remain stable or progressively enlarge
- Spontaneous inflammation and rupture can occur, with significant involvement of surrounding tissue
Epidermal Cysts
The following describes what:
- Usually a firm or fluctuant flesh-to-yellow-colored solitary nodule (0.5 to 5 cm) which often connects with the surface by keratin-filled pores
- Cyst grow slowly over time and may remain stable for months or years
- Commonly located on face, neck, upper back, chest; if due to trauma, on buttocks, palms, or plantar side of feet
Stable Epidermal Cysts
The following describes what:
- warm, red and boggy and tender on palpation
- Sterile, purulent material and keratin debris often point towards and drain to the surface
- These lesions mimic and present very similarly to abscesses
- There is no way to predict which lesions will remain quiescent and which will become larger or inflamed
Inflamed/Ruptured Epidermal Cyst
treatment of Stable Epidermal Cyst
- Asymptomatic epidermal cysts do not require treatment
- Cosmetic outcome must be weighed against scarring. Consider Gen Surg or Derm for elective excision
Indications for removal of Stable Epidermal Cyst
- Inflamed/ruptured or infected epidermal cyst
- Produces functional deficit
- Cosmetic removal (Dermatology/Gen Surg)
- Pain 2/2 location & duties
treatment of Inflamed/Ruptured Epidermal Cyst
- Infected, ruptured, or inflamed cysts will require incision and drainage. They’re treated like an abscess with an extra step:
- The cyst always contains a capsule that must be removed to prevent further infection
- Very large cyst cavities may then be packed with wick to aid further drainage
- Epidermal cysts that have not previously ruptured can be excised easily and completely under local anesthesia
The following describes what:
- most common benign mesenchymal neoplasm in adults and are composed of mature white adipocytes
- can occur on any part of the body and usually develop superficially in the subcutaneous tissue
- often occur on the neck, trunk, and on the extremities, but can occur anywhere on the body
- Rarely symptomatic and generally painless
- A patient may have one or many
Lipoma
Pt presents with:
- as soft, painless subcutaneous nodules ranging in size from 1 to >10 cm
- Occur most frequently on the trunk and upper extremities and can be round, oval, or multilobulated
- patients may have more than one
- Malignant transformation is rare
Lipoma
What lab should be done for a lipoma
Biopsy
treatment of Lipoma
- Treatment is not usually required. Lipomas may be excised by Dermatology for:
- Cosmetic concerns; pain; Impedance of duties
The following describes what:
- an acute inflammatory process, with or without abscess formation, that involves the proximal and lateral nail folds and that has been present for less than six weeks
- Most commonly caused by Staphylococcus aureus,Streptococcus pyogenes infection in the periungual tissues by minor mechanical or chemical traumas that disrupt the nail fold barrier
- Common favoring factors include manicuring, nail biting, thumb sucking, and picking at a hangnail
- occurs in most cases in association with ingrown toenails
- most common infection of the hand, representing 35% of all hand infections in the United States
Paronychia
The following are risk factors for:
- presents with localized pain and tenderness. The nail fold appears erythematous and inflamed, and a collection of pus usually develops
- Early in the course, cellulitis alone may be present. An abscess can form if the infection does not resolve quickly
- Develops along the nail margin (proximal and lateral nail folds), manifesting over hours to days with pain, warmth, redness and swelling
- Pus accumulates behind the cuticle, sometimes spreading beneath the nail or deeper into the lateral nail folds
Paronychia
treatment of Paronychia
- Early treatment with warm compresses or soaks
- Antibiotic therapy if warranted that includes coverage for Staph and strep
Bactrim/Septra DS in areas where MRSA is common and based on results of sensitivity testing - Fluctuant or visible pus should be drained using scalpel blade inserted between the nail and nail fold
- Skin incision is unnecessary
What describes the following:
- abscess of the distal phalanx fat pad. S. aureus is the most common pathogen. The patient usually presents with a painful and swollen distal pulp space
- The digital pulp, the fleshy mass at the finger tips, is divided into multiple compartments by fibrous septae that provide structural support
- A pyogenic infection of the distal digital pulp space, with pus collecting in the spaces formed by the vertical septa anchoring the pad to the distal phalanx
- Nearly always follows minor finger injury (i.e. splinter or needle prick)
Felon
Pt presents:
- Condition is characterized by severe pain, exquisite tenderness, and tense swelling of the distal digit with erythema. There may be a visible collection of pus or palpable fluctuance
- Septa between the pulp spaces limits the spread of infection, resulting in an abscess, creating pressure and necrosis of adjacent tissues
- Underlying bone, joint or flexor tendons may become infected
Felon
Treatment of Felon
- Rest and immobilization
- Elevation
- Wet Normal saline dressings 3-4 times daily when ulcerating
- Pain management: NSAIDS, Narcs may be required
- Prompt incision, with division of the fibrous septa to ensure adequate drainage performed by Dermatologist
IDC should treat with antibiotics - MSSA- Systemic antibiotics - Dicloxacillin or Keflex are indicated
- MRSA suspected, trimethoprim/sulfamethoxazole, clindamycin, or doxycycline, should be used
What describes the following:
- UV light will appear purple/violet without fluorescence
- Spectrum of cutaneous infections caused by yeast
- Frequent commensal organisms on human hosts & found throughout the environment
- Yeasts grow best in warm, moist environments, so infection is often confined to mucous membranes and intertriginous areas
- acts as an opportunistic pathogen when allowed to overgrow and predisposing conditions permit
- Yeast infects only the outer layers of the epithelium of the mucous membrane and skin (stratum corneum)
Candidiasis
The following are risk factors for what condition:
Hormonal alterations of the skin microbiome:
- Pregnancy
- Oral contraceptive use
- Diabetes
Elimination of competing microorganisms
- Systemic antibiotic therapy
Physical environment changes:
- Skin maceration
- Increased humidity/temperature
Direct/Indirect Immunosuppression
- Topical/systemic corticosteroid therapy
- Immunosuppression
Candidiasis
Pt presents:
- Occurs most commonly in intertriginous areas such as the axillae, groin, digital web spaces, glans penis, and beneath the breasts.
- Intertriginous infections manifest as pruritic, well-demarcated, erythematous patches of varying size and shape; erythema may be difficult to detect in darker-skinned patients
- Primary patches may have adjacent satellite papules and pustules; the contents of which dissect horizontally under the stratum corneum and then peel it away
- Hormonal alterations of the skin microbiome:
Results in a red, denuded, glistening surface with a long, cigarette paper-like, scaling and advancing border
- Oral candidiasis in adults (can be) first sign of HIV
Candidiasis
Treatment of Candidiasis
- Affected skin should be kept dry and exposed to air as much as possible
- Miconazole, Clotrimazole, Ketoconazole
- Terbinafine
- Relief is almost immediate, but treatment should be continued for 10 days
Treatment of Vaginal Candidiasis
- Patient should be advised to avoid sexual contact until the infection resolves
First Line (Topical) - Clotrimazole Vaginal Cream (Gyne-Lotrimin), - Miconazole Nitrate Vaginal Cream (Monistat)
Second Line (Oral) - Fluconazole (Diflucan)
What describes the following:
- Superficial fungal infections of the skin/scalp; names relate to the particular area affected
- Dermatophytes can subsist on protein, namely keratin and can cause disease in keratin-rich structures such as skin, nails, and hair
- Infections result from contact with infected persons/animals
Tinea
Where are the following tinea found:
- Tinea Cruris
- Tinea Corpori
- Tinea Capitis
- Tinea Cruris: Infection of crural fold and gluteal cleft
- Tinea Corporis: infection involving the face, trunk, and/or extremities; often presents with ring-shaped lesions, hence the misnomer ringworm
- Tinea Capitis: infection of the scalp and hair; not covered here - exclusively occurs in children
What describes the following:
- Pink-to-red annular patches and plaques with raised scaly borders that expand peripherally and tend to clear centrally
- Characterized by a sharply defined annular pattern with peripheral activity and central clearing (ring-shaped lesions)
- Papules and occasionally pustules/vesicles present at border and, less commonly, in center
- Pruritus may or may not be present
Tinea Corporis (Ring Worm)
Topical treatment of Tinea Corporis
- Clotrimazole, Miconazole or Terbinafine applied BID for a minimum of 2 weeks
- Continue treatment for at least 1 week after resolution of the infection
- Extensive lesions or those with red papules may require oral therapy
Oral treatment of Tinea Corporis
- Griseofulvin (ultra-microsize) 250 po mg QD x 2 weeks or Fluconazole 150 mg once a week for 3-4 weeks
- Secondary bacterial infections are treated with oral antibiotics
- A short course of prednisone may be considered for highly inflamed lesions to minimize scarring
What describes the following:
- Pruritic, ringed lesion extending from the crural fold over the adjacent upper inner thigh
- Lesion is erythematous, half-moon-shaped; advancing border is well defined, often with fine scaling and sometimes vesicular eruptions
- Lesions are usually bilateral and do not include scrotum/penis (unlike withCandidainfections).
- May migrate to perineum, perianal area, and gluteal cleft and onto the buttocks in chronic/progressive cases
Tinea Cruris (Jock Itch)
First-Line treatment of Tinea Cruris
- Topical antifungal cream (Terbinafine, Miconazole, Clotrimazole, Ketoconazole) applied 2 times a day for 10 to 14 days
- Absorbent powders (+/- antifungals) help to control moisture and prevent re-infection
Refractory, inflammatory or widespread infection treatment of tinea cruris
- terbinafine 250 mg orally once a day for 3 to 6 weeks may be needed in patients who have
- Resume topical antifungal cream once symptoms are controlled
What describes the following:
- Superficial infection in the interdigital web and soles of the feet caused by dermatophytes
- Most common dermatophyte infection encountered in clinical practice; contagious amongst personnel sharing berthing & hygiene facilities
- Often accompanied by tinea manuum, tinea unguium, and tinea cruris
- Common in males, uncommon in females
- Common co-factor in lower leg cellulitis
Tinea Pedis
Pt presents:
- Symptoms include itching, burning, and stinging of interdigital webs and plantar surfaces. Pain may indicate secondary infection
- Most often presenting with asymptomatic scaling
-May present with the classic “ringworm” pattern, but most infections are found in toe webs or on the soles
- May progress to fissuring or maceration in toe web spaces
- Wood lamp exam will not fluoresce unless complicated by another fungus, which is uncommon
Tinea Pedis
Conservative treatment of Tinea pedis
- Open-toed sandals when possible
- Wear shower shoes in showers
- Dry between toes after showering and frequent sock changing
- Absorbent, non-synthetic socks preferred (Cotton)
- Antifungal powders
- Recurrence is prevented by wearing wider shoes and expanding the web space
- Powders are used to absorb excess moisture
Topical and oral medication for tinea pedis
- Topical medications applied BID for 2-4 weeks. (Clotrimazole, Miconazole, Terbinafine)
- Lamisil, Sporanox, Fluconazole
What describes the following:
- AKA Pityriasis Versicolor
- Caused by Pityrosporum orbiculare, which is part of the normal skin flora
- Organism is nourished by sebum; converts from yeast form to mycelial form and causes the disorder
- Excess heat and humidity predispose to infection
Very common especially in tropical or semi- tropical regions. Prevalence can reach 50%
- male = female
- Not linked to poor hygiene
Tinea Versicolor
Pt presents:
- Velvety tan, pink or white macules that do not tan
- Color is uniform in each person but may vary between people
- Fine scales that are not visible but are seen by scraping the lesion
- Central upper back, chest, and proximal arms (same areas as the highest concentration of sebum)
- Typically asymptomatic, but a few patients note itching when overheated
- Appearance is often the patient’s major concern
Tinea Versicolor
Wood’s lamp will show faint yellow-green fluorescence
Tinea Versicolor
Topical treatment of Tinea Versicolor
- Topical treatment is indicated for limited disease
- Selenium Sulfide 2.5% applied from neck to waist wash off after 5-15 minutes, repeat daily x 7 days. Repeat weekly x 1 month, then monthly for maintenance
-Ketoconazole 2% shampoo chest and back, wash off after 5 minutes. Repeat weekly
Oral treatment of tinea versicolor
- Ketoconazole 400 mg in a single dose with exercise to point of sweating after ingestion. Single dose is not always effective
- Fluconazole 300 mg (2 capsules weekly x 2 weeks) has similar efficacy
- Oral Terbinafine is not effective for this condition
What describes the following:
- Acquired through direct contact of the nail with dermatophytes, yeast, or non-dermatophyte molds in the environment or through spread of fungal infection from affected skin
- Most often occurs in adults & the elderly; not common in younger patients
Onychomycosis
The following are predisposing factors for what condition:
- Tinea pedis, psoriasis, hyperhidrosis, obesity, advancing age, contact with infected household members
- Trauma, poor nail grooming, sports & fitness activities, occlusive shoes
Onychomycosis
Pt presents:
- Begins with white/yellow/brown discoloration of distal corner of nail that gradually spreads to the entire nail width, moving proximally
- Nail discoloration, subungual hyperkeratosis, onycholysis, splitting of the nail plate, and nail plate destruction
- Potential complications include pain, transmission of fungal infection to other body sites, concurrent tinea pedis
- Most patient concerns are based on cosmetic appearance and not functional deficit
Onychomycosis
What must be done prior to Onychomycosis treatment
- Confirmation of infection is required prior to treatment due to potential for liver toxicity of treatment with oral antifungals
- Potassium hydroxide (KOH) preparation (confirms presence of infection) and fungal culture (determines the type/species of the actual infecting organism)
- Treatment is not done on deployment due to inability to perform LFT testing
Treatment of Onychomycosis
- Oral antifungal therapy is considered the gold standard for onychomycosis; higher complete cure rates & shorter course of treatment compared with topical therapy
- Topical antifungal agents are poorly effective for onychomycosis because of poor penetration of the nail plate
What describes the following:
- A contagious parasitic infection of the skin caused by the miteSarcoptes scabiei, var.hominis
- An obligate human parasite
- Whitish-brown, eight-legged mite
- After mating, female mites burrow into the epidermis, a process facilitated by secretion of proteolytic enzymes that cause keratinocyte damage
- Female mites continue to extend the burrow and lay two to three eggs per day before dying after four to six weeks
- Larvae hatch in three to four days and molt three times within the burrow to reach adulthood
- Primarily transmitted by prolonged human-to-human direct skin contact
Scabies
Pt presents:
- Scabies rash appears 2-6 weeks after exposure
- Intense pruritus that worsens at night is a cardinal feature
- A burrow is the classic lesion; a linear, curved or S-shaped slightly elevated vesicle or papule up to 1-2 mm wide
- Finger webs, wrists, sides of the hands and feet, the penis, buttocks and scrotum
- Burrows may obscured by scratching and secondary lesions
- Partners will also be symptomatic
- Persistent itching after adequate treatment is due to prolonged allergic response
- Eczema and Impetigo may appear as secondary lesions
Scabies
What is the ink test for scabies
Rub a black felt-tip marker across an affected area. Remove excess ink is wiped away with an alcohol pad, burrow appears darker than the surrounding skin because of ink accumulation in the burrow
Treatment of Scabies
- Permethrin 5% or Lindane 1%
After 12 hours patient will bathe
Treatment regimen should be repeated in 1 week - No need for fumigation or extermination of the house or berthing area because mites do not live long off of the human body
- All clothes and bedding must be washed in hot water or put in a hot dryer at the time of application
- Can also be set aside wrapped in plastic bags for 14 days
What describes the following:
Obligate human parasites (cannot survive on other animals or furniture)
- Direct contact is source of transmission
- Lice feed or suck blood 3-6 hours (blood meal)
- They live for about 1 month, female can lay 7-10 eggs per day
- Eggs (or nits) are firm casts cemented to the hair shaft; hatch every 8-10 days
- Highly contagious
- Transmission via, hats, brushes or ear phones is common
Pediculosis
Pt presents:
- Head lice are 3-4 mm in length. They can be seen on the hair shafts and scalp with careful observation
- Nits are sometimes easier to see than the lice and are fluorescent
Dx not typically difficult but may require repeated examinations
- Pruritus with excoriation
- Occasionally, sky-blue macules (maculae ceruleae) on the inner thighs or lower abdomen in pubic louse infestation
- Eyelash infestation may induce blepharitis, with lid pruritus, scaling, crusting and purulent discharge
Pediculosis
Treatment of Pediculosis
- Permethrin rinse 1% (Nix); Permethrin 5% (Elimite); Lindane % (Kwell)
- Removing nits is essential (Nit combs)
If you kill the lice but leave the nits, they come back in 8-10 days - Hair saturated with a solution of 50% vinegar and 50% water, applied and removed in 15 minutes may help to “unglue” nits
What describes the following:
- Common, acute, self-limited papulosquamous skin rash that most commonly seen in individuals 10-35 years old
- Etiology isn’t completely understood; viral etiology hypothesized based upon the following observations:
- sometimes preceded by a prodrome
- It occasionally occurs in small case clusters
- It has not been shown to be associated with bacterial or fungal organisms
Pityriasis Rosea
Pt presents:
- Malaise, mild fever, headache, sore throat, cough, or mild URI or GI symptoms
- begins with a solitary herald patch that appears on the trunk or proximal limbs that precedes secondary eruption by 7-14 days
- Herald patch: a 2-5 cm round or oval, sharply delimited, pink or salmon-colored lesion on the chest, neck, or back
- Within 7-14 days, oval lesions similar in appearance to the herald patch, but smaller, appear in crops on the trunk and proximal areas of the extremities
- Lesions range from 0.5 to 2 cm oval papules and plaques, and have a scaly, slightly raised border (collarette) and resemble ringworm (tinea corporis)
Lesions are distributed with long axes along cleavage (Langer’s) lines:
“Christmas tree pattern” on back
V-shaped pattern on upper chest
- Mild to moderate pruritus is a common complaint. - - However, in rare cases patients may experience severe pruritus on lesions
- The rose or fawn color is not as evident in patients with darker skin
Pityriasis Rosea
Treatment of Pityriasis
No treatment or symptomatic treatment is indicated for most patients
If you’re not actively treating the patient, you’re on the hook for educating the patient why
Symptomatic treatment of pruritus:
Non-sedating oral antihistamines (centrizine, loratidine, fexofenadine)
Sedating antihistamines if sleep interrupted (benedryl/atarax)
Topical corticosteroids commonly used, however, drains AMAL meds due to size or eruption (logistically dumb)
What describes the following:
- Primary outbreaks manifest as herpetic gingivostomatitis, while recurrent episodes usually affect the vermillion border of lips or the mucosa of the hard palate
- can be transmitted via mucous membranes/secretions and open or abraded skin by kissing and by sharing utensils or towels
- Symptoms will resolve but the infection cannot be cured due to the lifelong latency of the virus
HSV
What describes the following:
- Primary infection usually occurs in childhood (via nonsexual contact) and ~ 33% infected by age 6
- Primary infection may also occur in previously non-exposed young adults via intimate physical or sexual contact
HSV 1
Pt presents:
- Recurrent episodes occur in older children and adults, frequently with a prodrome of perioral tingling, itching, numbness, pain, or burning followed by papulovesicular lesions (“cold sores”) on the lip or vermilion border
- Laboratory testing not typically performed unless:
atypical presentation
- immunosuppressed patients
HSV
Treatment of HSV 1
Pt education:
- Handwashing, avoidance of kissing during episodes, avoidance of shared utensils, contagious nature of virus and modes of transmission, potential reactivation triggers, appropriate use of sunscreen
- Symptomatic treatment includes analgesics and adequate hydration
- Antiviral treatment is typically not required by many patients due to self-limited nature of disease
What complication of herpes describes the following:
- Diffuse pox-like eruption complicating atopic dermatitis; sudden appearance of lesions in typical atopic areas (upper trunk, neck, head); high fever, localized edema, adenopathy Full duty
Eczema herpeticum
What complication of herpe describes the following:
- Localized infection of affected finger with intense itching and pain, followed by vesicles that may coalesce with swelling and erythema
- Mimics pyogenic paronychia; heals in 2 to 3 weeks
Herpetic whitlow
What describes the following:
- May occur at any age in persons previously infected with varicella zoster virus (chickenpox)
- ≥ 95% of adults in United States are seropositive for varicella (indicating latent viral infection or prior vaccination)
- Herpes zoster most common in adults > 60 years old with age-related immune decline
- Approximately one-third of people will contract in their lifetime
- Estimated 1 million cases each year in the United States
Herpes zoster (Shingles)
Pt presents:
- Typically unilateral dermatomal rash without midline crossing that favors the thoracic, cranial (particularly trigeminal), lumbar, and cervical dermatomes
- Overlap to adjacent dermatomes reported in 20% of patients; involvement of noncontiguous dermatomes almost never occurs
- Begins with red macules & papules that progress to clear vesicles within 1-2 days, with new vesicles forming over 3-5 days
- Vesicles evolve into pustules within 7 days; ulcerating & crusting of pustules by day 14
- Lesions usually heal within 2-4 weeks
Herpes zoster (Shingles)
Treatment of Shingles ≤72 hours after onset
Antiviral therapy should be initiated to maximize benefits of treatment
- Valacyclovir: 1000 mg three times daily for seven days
- Acyclovir: 800 mg five times daily for seven days
Topical treatment with antiviral agents is not effective
Treatment of Shingles >72 hours after onset
- Antiviral therapy initiated if new lesions are appearing at time of presentation (indicates ongoing viral replication)
- Minimal benefit of antivirals in the patient whose lesions that have encrusted
Pain management of shingles
- NSAIDS and acetaminophen are useful for mild pain, either alone, or in combination with a weak opioid analgesic (e.g., codeine or tramadol)
- For moderate to severe pain that disturbs sleep, stronger opioid analgesics (e.g., oxycodone or morphine) may be necessary
What describes the following:
- Occurrence of pain for months or years in the same dermatomal distribution as was affected by the herpes zoster
Postherpetic neuralgia (PHN)
What describes the following:
- involves the ophthalmic division of the trigeminal nerve
- Presents with malaise, fever, headache, and periorbital burning/itching
- Approximately 50 percent of patients with experience direct ocular involvement if antiviral therapy is not used
- Hutchinson’s Sign: Vesicles on the tip/side of the nose precedes the development
- The nasociliary branch of the trigeminal nerve innervates both the cornea and the lateral dorsum of the nose as well as the tip of the nose
Herpes Zoster Opthalmicus
What describes the following:
- Caused by Human papillomavirus (HPV)
- HPV is a group viruses belonging to the family Papillomaviridae
- Over 200 types have been identified and 150 can infect humans
- Infection occurs by direct skin contact, with maceration or sites of trauma predisposing patients to inoculation
- Reservoir is humans with clinical/subclinical infection
Warts
What is the incubation period of warts
2-6months
Cutaneous warts manifest as:
- Common warts (verruca vulgaris)
- Plantar warts (verruca plantaris)
- Flat (plane) warts (verruca plana)
- Genital Warts (covered in Infectious Disease Block)
What describes the following:
- typically few in number
- Common sites are the hands, periungual skin, elbows, knees and plantar surfaces
- The black dots are thrombosed capillaries
- may occur singly, in groups, or as coalescing warts forming plaques
Verrucae Vulgaris
What describes the following:
- Slightly elevated and flat-topped
- Vary in size from 0.1-0.3 cm
- May be a few or numerous and often occur grouped or in a line as a result of spread from scratching
- Typical sites are forehead, back of the hands, the chin, neck and legs
- Typically asymptomatic, however, cosmetically distressing
Verrucae Planta
What describes the following:
- Caused by HPV infection on the plantar foot
- Frequently occurs at points of maximal pressure, such as over the heads of the metatarsal bones
- A cluster of many warts is called a “mosaic wart”
- Black dots help discriminate from callus or corn
- Corns have a hard, painful translucent central core
Verrucae Plantaris
Treatment of warts
- Salicylic acid
- Cryotherapy
- Duct Tape Application
What describes the following:
- Non-immunologic reaction to substance or action producing direct damage to skin by chemical abrasion or physical irritation. Causes include chemical agents, alcohol, creams, powders, moisture, friction, and temperature extremes
- Most causes are from irritants encountered in the workplace
Irritant contact dermatitis
What describes the following:
- Due to a delayed immunologic response (type IV hypersensitivity) to a cutaneous or systemic exposure to an allergen to which the patient has been previously sensitized
- There is a latency period of 12-48 hours between exposure to allergen and clinical dermatitis in sensitized patients
- Poison ivy, poison sumac, and poison oak (Toxicodendron genus) are the most common causes of allergic (cell-mediated) contact dermatitis in the United States
- Nickel is the most common cause of metal dermatitis
Allergic contact dermatitis
Pt presents:
- The hands are most often affected. Both dorsal and palmar surfaces can be affected
- Erythema, dryness, painful cracking or fissuring and scaling are typical. Vesicles may be present
- Tenderness and burning are common and predominate the itching
- May show juicy papules and/or vesicles on an erythematous patchy background with weeping and edema
- Persistent, chronic irritant dermatitis is characterized by Lichenification, patches of erythema, fissures, excoriations and scaling
- Open skin may burn on contact with topical products
Irritant contact dermatitis
Prevention of Irritant contact dermatitis
- Avoidance of or decreased exposure to cutaneous irritants is critical for recovery of an effective skin barrier
- PPE (i.e., goggles, shields, and gloves, etc.)
- Occupational ICD persisting with PPE may require a change of job
Treatment of Irritant contact dermatitis
- Medium or high-potency topical steroid ointment applied BID for several weeks
- Frequent application of a bland emollient to affected skin is essential
- Antihistamines (except for their sedative effect) are ineffective in contact dermatitis
What describes the following:
- Characterized by vesicles, edema, redness and extreme pruritus. Strong allergens such as poison ivy produce bullae
- Distribution first confined to the area of direct exposure. May spread beyond areas of direct contact if exposure is chronic
- Itch and swelling are key components of the history. Itch predominates the burning sensation
- The hands, forearms and face are the most common sites. May also affect limited skin sites such as the eyelids, dorsal aspect of the hands, lips, tops of the feet and genitalia
- Careful history should include date of onset, possible relationship to work, type and specifics of contact to work exposures and type of skin care products used
Allergic contact dermatitis
Allergic contact dermatitis Prevention
- Identification and avoidance of the allergenic substance is essential to recovery
- Topical treatment using topical corticosteroid. Discontinue all moisturizers, lotions and topical products
Treatment of Allergic contact dermatitis
- Identify and remove the etiologic agent
- Topical class I–II glucocorticoid preparations. In severe cases, systemic glucocorticoids may be indicated
- Educate patient, detailing potential sources of exposure
What describes the following:
- Chronic, superficial, recurrent inflammatory rash affecting sebum-rich, hairy regions of the body, especially the scalp, eyebrows, and face
- Predominance: adolescence, and adulthood, male > female
- Skin surface yeasts Malassezia may be a contributing factor
- Flares are common with stress/illness
- Parallels increased sebaceous gland activity
- Positive family history; no genetic marker is identified to date
Seborrheic dermatitis
Pt presents:
- Intermittent active phases with burning, scaling, and itching, alternating with inactive periods; activity is increased in winter and early spring, with remissions commonly occurring in summer
- Red, greasy, scaling rash in most locations consisting of patches and plaques with indistinct margins
- Red, smooth, glazed appearance in skin folds
- Minimal pruritus
- Chronic waxing and waning course
- Bilateral and symmetric
- Most commonly located in hairy skin areas: scalp and scalp margins, eyebrows and eyelid margins, nasolabial folds, ears and retroauricular folds
Seborrheic dermatitis (Dandruff)
Treatment of Seborrheic dermatitis (Dandruff)
- Can be treated with shampoos containing:
Zinc pyrithione (Head & Shoulders)
Selenium Sulfide (Selsun Blue)
Ketoconazole (Nizoral)
Salicylic Acid (T/Sal)
Coal tar (T/Gel) - Daily facial washing with antidandruff shampoo or soaps diluted with water is also effective
What describes the following:
- A chronic, inflammatory disorder most commonly characterized by cutaneous erythematous plaques with silvery scale
- It is a complex immune-mediated disorder associated with flares related to systemic, psychological, infectious, and environmental factors
- Plaque (vulgaris): most common variant (~80% of cases)
- Genetic predisposition (polygenic); 40% have a first-degree relative
Psoriasis
Pt presents with:
- Well-demarcated salmon pink-to-red erythematous papules and plaques; silvery scale
- Distribution favors scalp, auricular conchal bowls, and postauricular area; extensor surface of extremities, especially knees and elbows; umbilicus, lower back, intergluteal cleft, and nails
- Nail findings: pitting, oil spots, onycholysis
- Auspitz sign: pinpoint bleeding with removal of scale
- Koebner phenomenon: new psoriatic lesions arising at sites of skin injury/trauma
- Genitals affected in up to 40% of patients
Plaque Psoriasis
Topical Treatment of psoriasis
-Topical retinoids
IDCs do not typically have the specific formulations & strengths required to initiate effective topical therapy
Who manages systemic therapy of psoriasis
Patients with Psoriasis involving more than 20% of the body surface or who are very uncomfortable should consider systemic therapy. Therapy is complicated and best managed by a Dermatologist
What describes the following:
- disorder of the pilosebaceous units
- Notable for open/closed comedones, papules, pustules, nodules
- Predominant age: early to late puberty, may persist in 20-40% of affected individuals into 4th decade
- Male >female (adolescence)
- Female > male (adult)
- 80-95% of adolescents affected. A smaller percentage will seek medical advice
- 8% of adults aged 25 to 34 years; 3% at 35 to 44 years
- African Americans 37%, Caucasians 24%
Acne
The following predisposes someone to what condition:
- Increased endogenous androgenic effect
- Oily cosmetics, cocoa butter
- Rubbing or occluding skin surface (e.g., sports equipment such as helmets and shoulder pads), telephone, or hands against the skin
- Numerous drugs, including androgenic steroids (e.g., steroid abuse, some birth control pills), lithium, phenytoin
- Endocrine disorders: polycystic ovarian syndrome
Stress
- High-glycemic load and possibly high-dairy diets may exacerbate acne
- Severe acne may worsen with smoking
Acne
Pt presents with:
- Non-inflammatory lesions consist of:
Open comedones (blackheads)
Closed comedones (whiteheads)
- Inflammatory lesions presence of papules, pustules and nodules/cysts:
Papules with visible central core of purulent material
Nodules may become suppurative (cysts) or hemorrhagic
Recurring rupture & re-epithelialization of cysts leads to epithelial-lined sinus tracks potential scarring
Acne
Comedonal (noninflammatory) acne treatment
Topical retinoid
Mild comedonal + papulopustular acne treatment
- Topical antimicrobial (BP alone or BP +/- topical antibiotic)
- Topical retinoid OR
- Topical antimicrobial (BP)
- Topical antibiotic (for patients who cannot tolerate retinoids)
Moderate papulopustular and mixed acne treatment
- Topical retinoid
- Oral antibiotic
- Topical benzoyl peroxide
Severe acne (nodulocystic acne) treatment
Oral isotretinoin monotherapy
How long does benzoyl peroxide take to improve acne?
- 8-12 weeks
What are the most common topical antibiotics used for the treatment of acne
Erythromycin and clindamycin
What strain of bacteria causes acne?
C. acnes
What medication should be used in conjunction with topical antibiotics
Benzoyl peroxide
When is oral acne treatment indicated?
Moderate to severe inflammatory acne
How long should oral antibiotics be given to treat acne
3-4 months
Which oral antibiotics are most frequently given for moderate to severe inflammatory acne
Doxycycline and minocycline
What medication is given for Severe recalcitrant nodular acne who are unresponsive to conventional therapy, including systemic antibiotics
Oral isotretinoin (Accutane)
How long is accutane given for
20-week course
Risks of Oral isotretinoin (Accutane)
- Isotretinoin is a teratogen with a very high risk for severe birth defects if taken during pregnancy in any amount, even for a short period of time
- Isotretinoin can only be prescribed by clinicians who participate in a special restricted distribution program (iPLEDGE)
What describes the following:
- An abscess, or sinus tract, in the upper part of the natal (gluteal) cleft
- “nest of hair”
- Often asymptomatic until an abscess forms, causing pain, swelling, and erythema
- Predominant sex: male >female (3 to 4:1)
- Predominant age: 2nd to 3rd decade, rare > 45 years
- Ethnic consideration: whites > blacks > Asians
- Synonyms: Pilonidal cyst, pilonidal sinus, pilonidal disease, “jeep disease”
Pilonidal Abscess
Pt presents with:
- cleft creates a suction that draws hair into the midline pits when a patient sits.
- physical examination reveals one or more primary pores (pits) in the midline of the natal cleft and/or a painless sinus opening
- no acute inflammation or infection
- may not even be aware of the sinus tract formation
Asymptomatic Pilonidal Disease
Pt presents wtih:
- Sudden onset of mild-to-severe pain in the intergluteal region while sitting or stretching the skin overlying the natal cleft +/- swelling with mucoid, purulent, and/or bloody drainage in the area
- The ingrown hairs may become infected and present acutely as an abscess in the sacrococcygeal region
- Typical are normal skin flora, withStaphylococcusspecies being the most common. Contamination with peritoneal and fecal organisms is also possible
- Clinical hallmark is a tender, swollen, and fluctuant nodule located along the superior gluteal fold
Actual Pilonidal Abscess
Treatment of asymptomatic Pilonidal Abscess
Surgical excision is not typically performed for patients without an acute flare of a pilonidal sinus. Surgery should be discouraged in the asymptomatic patient
Treatment of acute pilonidal abscess
- incision and drainage at the time of presentation
- Incise over the area of maximal fluctuance, and remove/debride all inflammatory debris & visible hair within the abscess cavity should be debrided. Wounds are packed with gauze, and healing occurs by secondary intention in the acute setting
- Antibiotic use should be reserved for those with cellulitis in the absence of abscess, or in those with an abscess and significant cellulitis after surgical drainage
Alopecia occurs everywhere except?
soles, palms, the mouth, some external genital areas, navel, and scar tissue
Alopecias are divided into what 2 forms
scarring & nonscarring forms
How do you determine scarring & nonscarring forms of alopecia
- Present follicular markings suggest a non-scarring alopecia; raises suspicion for a hormonal or autoimmune etiology
- Absent follicular markings suggest a scarring alopecia; raises suspicion of some form of acute or chronic trauma
What describes the following:
- Believed to be an immunologic process. Patches that are perfectly smooth and without scarring
- Involvement may extend to all of the scalp hair (alopecia totalis) or to all scalp and body hair (alopecia universalis)
Alopecia areata
What describes the following:
- Temporary hair loss that usually happens after stress, a shock, or a traumatic event. It usually occurs on the top of the scalp
Telogen effluvium
The following describes:
- Most common form of male hair loss affecting 30-50% of men by age 50
- Occurs in highly reproducible pattern, preferentially affecting the temples, vertex and mid frontal scalp
- alteration in hair cycle development
- Familial tendency & racial variation and heredity account for 80% of predisposition; genes inherited from both mother & father
- predominately psychological along with higher risk for melanoma and non-melanoma skin cancer of scalp
Male Androgenic Alopecia
The following describes:
- may occur following any type of trauma or inflammation that may scar hair follicles
- Chemical or physical trauma, bacterial or fungal infections, severe herpes zoster, and excessive ionizing radiation
- Specific cause is often suggested by the history, the distribution of hair loss, and the appearance of the skin
- Scarring alopecias are irreversible and permanent. It is important to diagnose and treat the scarring process as early in its course as possible
Cicatricial Alopecia
Treatment of alopecia
- most areas hair re-grows and no treatment is needed
- Oral corticosteroid therapy does not prevent the spread or relapse of severe alopecia
- Consider treatment/counsel on how to deal with emotional stress
- Consider consult to dermatology to more intense treatment
What describes the following:
- Acute, delayed, and transient inflammatory response of the skin secondary to excessive exposure to ultraviolet radiation (UVR)
- Depending on frequency and exposure time damage can be cause to Melanocytes and Keratinocytes
- Susceptibility to sunburn = susceptibility to skin cancer; associated with an increased risk of melanoma at all ages
- Occurs more frequently in adolescents & young adults.
Sunburn
The following are risk factors for what condition:
- Increased near the equator and with altitude
- More likely to occur at noon than earlier or later in the day
- Cloud cover offers some protection, but significant quantities of ultraviolet radiation (UVR) still reach the earth’s surface
- Reflection from snow (90%), sand (15-30%), water (5-20%)
- Phenotypic characteristics that confer high susceptibility to sunburn include fair skin, blue eyes, and red or blond hair
Sunburn
Pt presents with:
- Clinical manifestations range from mild erythema to highly painful erythema with edema, vesiculation, and blistering
- Erythema is usually first noted 3 to 5 hours following sunlight exposure, peaks at 12 to 24 hours, and in most cases subsides at 72 hours
- Increased skin sensitivity to heat and mechanical pressure are characteristic and present even in mild cases
- The erythema typically resolves in three to seven days. Blisters heal without scarring in 7 to 10 days. Scaling, desquamation, and tanning are noted four to seven days after exposure
Sunburn
Sunburn prevention
Sun avoidance; protective clothing (SPF 50+); broad spectrum sunscreens (UVA & UVB with SPF 30+)
Treatment of sunburn
- Self-limiting condition that usually resolves in a few days
- There are no specific therapies to reverse the skin damage and hasten the healing time
- Management involves the symptomatic treatment of skin inflammation and control of pain
- Cool compresses or soaks, Calamine lotion, Aloe Vera based topical products; NSAIDs/APAP initiated when symptoms present & continued for 24 to 48 hours
- Topical corticosteroids contraindicated for the treatment of sunburn
The following describes:
- a common disorder, 20% prevalence in the general population and occurs at all ages
- typical lesion is an intensely pruritic, erythematous plaque
- mediated by cutaneous mast cells in the superficial dermis. Mast cells release multiple mediators upon activation including histamine (which causes itching) and vasodilatory mediators (cause localized swelling in the uppermost layers of the skin)
Urticaria
Pt presents with:
- Transient, edematous, red plaques vary in size and shape; typically round or oval. May become confluent and polycyclic
- Lesions may be uniformly red, pink or flesh- colored or surrounded by a white or red halo
- Dynamic: Plaques change in size and shape by peripheral extension, migrate and regress
Individual lesions last less than 24 hours
Acute Urticaria
What describes the following:
- Defined as urticarial or whealing of the skin for more than 6 weeks
- In the majority of patients, an underlying disease will not be found
- Affects all ages, but highest incidence is in young adults
- Easily diagnosed, but presents a major problem in treatment and management
Chronic Urticaria
Treatment of urticaria
All suspected triggers should be discontinued
- Antihistamines:
Hydroxyzine 10-25 mg q 4-6 hours
- Non-sedating H1 blockers do not work as well, but are useful for daytime hours:
Loratidine (Claritin) 10 mg, Cetirizine (Zyrtec) 5-10 mg and Fexofenadine (Allegra) 60-180 mg
-Prednisone can be given periodically and may work in people whose condition is difficult to treat with antihistamines alone
- Epinephrine is administered for extensive, severe cases with intolerable itching
- Topical steroids are generally not effective
What should be ruled out while dx urticaria?
- Internal Diseases - chronic infections, thyroid disease, lupus erythematosus
- Ingestants (common)
- Inhalants
- Injectants
- Infections
What describes the following:
- Caused by lateral pressure of poorly fitting shoes, by improper or excessive trimming of the lateral nail plate or by trauma
- Pain, redness and swelling cause by the nail penetrating the surrounding nail tissue
- The nail enters the lateral or medial nail fold and enters the dermis, where it acts as a foreign body
- The area of penetration becomes purulent and edematous as granulation tissue grows alongside the penetrating nail
- Great toe is virtually the only toe involved, with either the medial or lateral border of the nail may be affected
Ingrown Nail
Treatment of ingrown toe nail
Removing penetrated nail & curetting granulation tissue
Small areas of granulation tissue can be simply treated with silver nitrate
What describes the following:
- Most common of all injuries to the upper extremities; typically results from a direct blow to the fingernail or a squeezing-type injury to the distal finger
- Injury causes bleeding into the space between the nail bed and fingernail itself
- Intense pain caused by pressure generated by the hematoma
- The bleeding may cause separation of the nail (onycholysis)
Subungual Hematoma
Treatment of Subungual Hematoma
Drainage Methods:
Heated paperclip
Cautery Pen
Drill method
Needle Method
What describes the following:
- Most common acquired benign epithelial tumor of the skin
- Typically develop after the age of 50, but they can also appear in young adulthood
- There is a genetic predisposition t
- The pathogenesis is incompletely understood (we don’t completely know why people get them)
- They are generally asymptomatic, but chronic irritation due to friction trauma may occasionally cause pruritus, pain, or bleeding
seborrheic keratosis
Pt presents with:
- Usually multiple lesions, which can arise anywhere except the lips, palms and soles
- begin as circumscribed tan brown patches or thin plaques
- Over time, they may become more papular or verrucous with a greasy scale and a stuck-on appearance
- Unless disturbed, tend to persist and grow slowly
Some lesions may be removed by trauma. Develop over hair bearing areas
- Surface tends to crumble when picked at
seborrheic keratosis
Treatment of seborrheic keratosis
- treatment is generally not required
- Cryotherapy
- Curettage/shave excision
- Electrodessication
What describes the following:
- Patients frequently point out these areas to their physician
- Initially present as a poorly defined area of redness or telangiectasia
- Lesion becomes more defined and develops a thin/adherent, yellowish or transparent scale
- As lesion progresses, scale becomes thicker and more yellow in color
- represent early lesions on a continuum with squamous cell carcinoma (SCC) and occasionally progress to SCC
- Frequently occur in sun-exposed areas
Actinic keratosis (AKA solar keratosis)
The following are risk factors for:
- Extensive sun exposure, hx of sunburns, sunscreen usage
- Fair skin (FS I-II), male, >40 years old, geography (hot places)
Actinic keratosis (AKA solar keratosis)
The following are risk factors for:
- Extensive sun exposure, hx of sunburns, sunscreen usage
- Fair skin (FS I-II), male, >40 years old, geography (hot places)
Actinic keratosis (AKA solar keratosis)
Treatment of Actinic keratosis (AKA solar keratosis)
- Topical 5-fluorouracil 5% cream (Efudex)
- Imiquimod 5% cream
- Electrodessication & curettage
- Application of liquid nitrogen (cryotherapy)
What describes the following:
- Malignant tumor arising from melanocytic cells and hence can occur anywhere where these cells are found (anywhere on the body)
- the most fatal form of skin cancer, is increasing faster than any other potentially preventable cancer in the United States
Melanoma
The following are risk factors for:
- 10% of melanomas are familial
- ~ 10-20% arise in association with atypical nevi
- >5 clinically atypical nevi = higher risk
- > 25 or more nevi = higher risk
- Light skin pigmentation, red or blond hair color, high-density freckling, and light eye color [green, hazel, blue]).
- Extensive or repeated intense exposure to sunlight or other UV sources (tanning beds)
- Strongest association = intermittent exposure and sunburn that occurred in adolescence or childhood
- Nearly 50 percent of melanoma deaths in the U.S. occur in white men > age 50
Melanoma
Pt presents with:
- Lesion will be the “Ugly Duckling”, and different than the other nevi
- A) Asymmetrical
- B) Irregular borders
- C) Color changes
- D) Diameter > 6mm
- E) Evolving
- 30% develop within a pre-existing nevus; 70% develop de novo
- Pigmented lesions may change slowly over months to years or abruptly change
- Pruritus is common early, but most are asymptomatic
- Later symptoms include tenderness, bleeding and ulceration
Melanoma
What lab should be done for melanoma
biopsy
Treatment for melanoma
- No treatment in the scope of care for IDC’s
- Biopsy technique
- Allows for accurate measurement of Breslow depth
- Follow-up examination should be performed at regular intervals with Dermatologist
What wounds can be easily repaired with sutures, wound closure tapes, stapes or tissue adhesive?
Lacerations and incisions
What are the goals of wound repair for lacerations and incisions?
- Achieve hemostasis
- Prevent infection
- Preserve function
- Restore appearance
- Minimize patient discomfort
What is phase I of wound closure?
Initial lag phase
Days 0-5: No gain in wound strength
What is phase II of wound closure
Fibroplasia phase
Days 5-14: Rapid increase in wound strength occurs. At week 2, the wound has achieved only 7% of its final strength
What is phase III of wound closure
Final Maturation phase
Day 14 until healing is complete: further connective tissue remodeling. Up to 80% of normal skin strength achieved
What material is used to give the wound strength during the first 2 phases
Non-absorbable skin sutures or staples
What material plays an important role in the final phase of wound healing?
wound closure tapes or previously placed deep absorbable sutures
What are indications for wound closure
- Lacerations open < 12 hrs. on body or < 24 hrs. on the face
- Repair of sites where a lesion has been surgically removed
What are contraindications of wound closure
- Open > 12 hrs old or > 24 hrs old on the face
- Animal & human bite wounds
- Puncture wounds
- Sites of incision & drainage
What are the steps for wound closure
Prep Site
Assess neurovascular integrity
Anesthesia Administration
Tissue Examination & Irrigation
What are wound closure principles
Control all bleeding before closure
Eliminate “dead space”
Accurately approximate tissue layers
Approximate the wound with minimal skin tension
Which suture describes the following:
- ideal in the scalp or any other location with minimal tension
- Stitch should be as wide as it is deep
- Should be equal distance from the wound margin and of equal depth
-Sutures need be no closer than 2 mm in a fine plastic closure
- Avoid tying the knot too tight. Knots should be lined up on one side of the wound
- On completion, the skin margins should be slightly everted
Simple Interrupted Suture
Which suture describes the following:
- Advantageous in sterile wounds under little or no tension
- Quick suture that distributes tension evenly and provides excellent cosmetic results
- Less desirable in traumatic lacerations because of the increased risk for contamination
Simple Running Stitch
Which suture describes the following:
- Promotes eversion of the skin edges
- Useful in loose skin to prevent inversion of the wound margins
- Also appropriate when the skin is very thin and interrupted sutures have a tendency to pull through
- Suture distributes tension along larger area and minimizes chance of pull through
Vertical Mattress Sutures
Which suture describes the following:
- Good in wounds under a moderate amount of tension and promotes wound edge eversion
- Especially useful for:
- Palms of hands or soles of the feet
- Patients who are poor candidates for deep sutures because of susceptibility to wound infections
Horizontal Mattress Sutures
What closure is indicated for the following:
- Wounds with easily approximated edges not under undue tension
- Long, linear wounds of the scalp
- Proximal extremities or the torso where cosmesis is not a concern
Skin Staples
Contraindications for skin staples
- Facial or neck tissue; areas without adequate subcutaneous base
- Over small mobile joints or any other location where the staples may interfere with normal function
- Wounds that are macerated/infected or over areas of large tissue loss
