Derm Tx Flashcards
Atopic Dermatitis Tx
- Education: to avoid exacerbating factors and hydrate the skin
- vasline is best or other ltion -BID and after bathing - Topical Corticosteroid
-mild: low potency 1-2x per day x2-4 wks
-moderate: med-high pot
-acute: med-very high pot for up to 2wks then replaced with lower potency. - Topical Calcinereurin Inhibitors -
Pimecrolimus(Elidel) cream and Tacrolimus(protopic)
-steroid sparing and antiinflammatory because they imped production of proinflammatory cytokines.
-.1% for adults
-.03% for 2-15
-BID for mild eczema on face, eyelids, skin folds
-2-3x per week for maintanance
may have bruning or itching during the first week of use - Oral antihistamines prn pruitis, antibiotics for 2nd infection, oral steroids for severe or wide spread cases.
Topical Corticosteroid warning
Face, groin, and skin folds have higher absoprtion so use caution when applying to those locations
-skin atropy, rosacea, striae, bruisng, telangiectasis, hypertrichosis
Lichen Simplex Chronicus Tx
Want patient to stop the rubbing!
1. High Potency topical steroid
then:
2. Moisturizers
3. Antidepressants: Paroxetine(paxil) or Sertraline(zoloft)
4. for nocturnal pruritis: 1st gen antihistamine, hydroxyzine(Visatril) or Tricyclic antidepressent
Dyshidrotic Eczema Tx
Primary:
1. Reassurance -usually resolve in 2-3wks
2. Topical Steroids (maybe at night with occlusion)
Secon:
3. Wet dressings (burow’s soaks)
Keratosis Pilaris Tx
No really good treatment
pt. may try: exfoliating scrubs, topical retnoid, salicylic acid, alpha-hydroxy acids
Contact Dermatitis Tx
Discontinue exposure or decrease hand washing
and wear protective clothing
- use a bland emollient like vasaline or aquaphor
*Topical corticosteroid 1-2 days x 7-14days
or oral corticosteroid if on face or more than 20% of the body
Tx for common cutaneous drug reactions
Discontinue drug!!!
-sytemic corticosteroids to come the immune system
-topical steroids or antihistamines prn for pruitis
-cousel to avoid crossreactive drugs in the future
Typically resolved in 5-14 days
may be left with post inflammatory hyper-pigmentation
SJS and TEN Tx:
Discontinue Medication!!!! Hospital admission if severe usually to ICU or Burn Unite Supportive care: -nutritional and fluid replacement( B/C mouth sores) -Temperature maintance -Pain relief -Occular managment -Wound care and sterile handling
Tinea Capitis at risk populations
Children, african americans, homeless, poor hygeine, low SES, and overcrowding
Tinea Capitus Cause/Presentation
Fingual infection (Trichophyton/Microsprorin)
From direct contact
-Scaly patches with alopecia
-black dots with alopecia
-widespread scaling with subtle hair loss
- Kerion
-Favus (multiple cup shaped yellow crusts): usually with immunocomp pt.
Tinea Capitus Associated Signs
Cervical adenopathy, Dermatophydid reaction ( eczema like,in response to treatment), and rerely erythema nodosum (tender nodules)
Tin Cap Dx
KOH prep, physical exam, culture, dermascope,woods lamp
Tin Cap Tx
Systematic antifungal therapy
- Griseofulvin x 6-12wks for microsporin or empiric tx
- Terbinafine x2-4wks if tricophyton
Tine Corporis Risk factors
Cargivers of children c tinea cap
athletes with skin contact (tinea corporis gladiatroum)
immunocomp
Tinea Corporis Presentation
Pruritic, annular, erythematous plaque
with a central clearing , raised advancing border
Tinea corp,cruris,pedis Dx
Physical exam. KOH prep, and culture
Tinea Corp,Cruris,Pedis Pharm Tx
Topical antifungus
-Cotrimazole at least 2 wks (4wks if pedis)
Systemic only in special circum
-Intraconazole
Improper treatment of Tinea infections can lead to what?
Usually if you accidentally use steroids
- Tinea Ingognito
- Mojpcchi’s granuloma
Tinea Cruris Risk factors
Male, sweaty/humid, obese/skinfolds, athletes foot, and occulusive clothing
Tinea Cruris Presentation
Begins at the inguina folds
well marginated, scaly, annular, with raised border
scrotum is typically spared
-Pruritis, pain
Tinea Cruris tx non Pharm
Drying powder, avoid tight clothing, weightloss
Tinea Pedis Risk Factors
occlusive footwear, communal baths or showers
Acute Tinea Pedis presentation
self limited, intermittnet, recurrent infection
- itchy/pain vessicles following sweating
- secondary staph infections may occur*
Chronic Tinea Pedis Presentation
slowly progressive that may persist indefinatly
- erosions between the toes (oft bw 3-4)
- interdigital fissures
- May progress to Mocassin Ringworm (along the whole bttom of the foot, with shapr demarcations of accumulated scale
- Tinea Manuum ( two feet one hand)
Tinea Pedis non pharm Tx
Burrows wet dressing 20min BID-TID
Treat secondary infections
Food powers, proper footwear
Onycomycosis Etiology
Nail infection caused by fungus, yeast, or non-dermatophyte molds
- typically yeast(candida albicans) with fingernails
Onycomycosis Risk factors
Old Age, Tinea Pedis, Genetics, Immunodeficiency, Household infection
Onycomycosis Presentation
Typically Cosmetic but may be painful
- brown/yellowing of the nail and nail thickening
1. Dista Sugungual: most common and starts from distal corner and moves proximal. Distal nail bed may break exposing nail bed
2. Proximal Subungual: near cutical and extends up usualy seen in immunocomprimised patients
3. White superficial: begins with dull white spots that will extend out. These spots are soft
Onycomycosis Dx
KOH prep, culutre, histopathology
Onycomycosis Tx
Not neccessary but considered if Hx of cellulitis, diabetic, desires cosmetic improv, or discomfort
- topical meds inefffective and high rate of failure
1. Dermatophye:Oral Terbinafine (6wks fingernails, 12wks toenails
2. Non-Dermatophyte: oral intraconazole (same duration as above)
What drugs treat both Onycomychosis and Tinea infections
Terbinafine- tinea capitus
Intraconazole - other tinea inf
Candidial Interrigo etilogy and Risk Factors
infectious or noninfection skin condition of two closely opposed skin surfaces
-moisture, skin friction, immunocompromised
Candidal Interrigo Presentation
typically affects the groin,mammary/ab folds, web spaces, and axilla
- erythemous, maccerated(soggy) palques or errosions
- sattelite papules/pustules
- fine peripheral scaling
Candidal Intertrigo Dx
-Physical Exam, KOH prep, culutre
Candidal Intertrigo Tx
Prevent:
-drying agents, weight loss, address underlying med cond.
Pharm:
Topical x2-4 wks: Nystatin (for yeast)
Syestemic for resistant/severe: Fluconazole 2-5wks
Tinea Versicolor Cause/ Risk Factors
Caused by malassezia- normal skin flora of the skin that becomes pathologic
Seen in tropical climates, adolecents/ young adults, hyperhidrosis, genetics, immunosupression
NOT contageous
Tinea Versicolor Presentation
Macules, patches/plaques of the trunk and UE, can coalesce, often have fine scale, maybe erythemous
- often asymptomatic but may be mildly itchy
- often hypopigemented on dark skin and hyperpigmented on lighter skin
Tinea Versicolor Dx
Physical, KOH prep, Woods lamp (sometimes yellow/green flourescense)
Tinea Versicolor Tx
Topical
- Clotrimazole (2wk), Selenium sulfide( lotion, foam, shampoo x1wk), or Zinc Pyrinthione shampoos x2wk
Systemic
-oral intraconazole 5-7days
- only insevere cases and failed topical, not used in children
*note pigmentation can persist for months which makes it hard to nknow if the treatment has worked
Scabes etilogy/ risk factors
Parasitic infection- sarcoptes scabiei mite
- female mites and their eggs
- eggs hatch in 10 days
All groups affectes and it is transfered through direct contact
Scabes Presntation
Intial lesion and burrow (pathonomonic)
- locations: groin, rists, waist
severe pruritis which is often morse at night
In immunocomprimised people: Norwgian or crusted scabies
-will have severe fissures and requires oral medication
Scabies Dx
-Visualization of the burrow , microscopic identifcation of the mite, eggs, or fecal pellates with dermatoscope
Scabies Tx
Permethrin 5%- first treatment and then 2nd dose 10-14 days later
Oral Ivermectin- single dose repeated 2 weeks later
Edu: treat house and close contacts simulaneously, itching may persist for 2 wks( can treat with antihistamines and emoilliants), wash linens under high heat
Pubic Lice etilogy/ presentation
Parasites that are larger than Scabies
- crab louse (phthirus pubis)
- transmitted through sexual contact
- presents as itching in the groin or axilla
Pubic Lice Dx/Tx
Visualize the lice or nits with a microscope
Tx: Permithrin 1% cream and repeat in 10 days
and treat sexual partners
* often have another type of STI*
Important things to note when diagnosing acne vulgaris
- possible workup for hyperandrogenism for female patients with other sx
- rapid acne with other signs of virilication may be becuase of ovarian or adrenal tumor
- medication history may reveal acnes causing medications
Comedonal (non-inf) acne Tx
Topical retnoid
Mild papulopustuar and mixed acne Tx
Moderate
Sever
BP +/- topical antibiotic and topical retnoid
BP + topical retnoid+ oral abx (tetracycline class)
BP+ top ret+Oabx
OR oral isotrtinoin monotherapy
What acne meds are teratogenic ? What are okay?
Topical retnoid and not okay during pregnancy and BP is not really known
- oral erythromycin, topical clindamycin, and topical azelaic acid
Solar Lentigo
Age spot or freckles
- local proliferation of melanocytes and from UV damage
- well circumscribed
- brown macules
- often found in group
- no treatment required
Seborrheic Keratosis (SK)
-benign epidermal lesion proliferation of immature keratinocytes
- usually after age 50
warty, waxy, stuck on apperance
-well circumscribed
-back,head, neck
Irritated SK
caused by rubbing of friction of the SK
- may have pruitis, pain, or bleeding
Leser-Trelat sign
sudden onset of multiple SK +skin tahs + acanthosis nigrican
- possible associated with GI and Lung cancer
SK eval and managment
Dx- clinical presentation and biopsy if necessry
Tx: reassurance and possible removal for some ISKs. Shave off or use cryotherapy.
Keratoacanthoma Presetation
rapid growth- 6-8wks
- round, flesh colored nodule with central keratin plug
- same risk factors as skin cancer
- benign but some say it pseudo-malignancy
Karatonacanthoma Managment
Majority will resolve on their own in 6-9mo
Difficult Dx: requires biopsy and treatment
- typically excisional biopsy is typically preferred
Actinic Keratosis etiology andRisk Factors
AK
“pre cancer” may progress to SCC
M>F
light skin, history of UV exp, immonsuppression, ^age
AK presentation
- Erthematous, scaly/gritty macule or papule
- may be tender
- often felt easier than seen
AK dx
clinical
dermatoscope
Shave or punch biopsy if unable to differentiate from SCC (>1cm, rapid growth, ulcer)
*if >6mm then we just consider it SCC in situ
AK tx
may spont resolve but usually treat anyway
- Cryotherapy or surgical intervention
Field Treatment: if you have multiple lesions
-topical flourouracil cream (preferred)
-Photodynamic therapy (PDT)
-Imiquimod (Aldara)
Basal Cell Carcinoma Etiology
Most common type of skin cancer
- arised from the basal layer of the epidermis
BCC presentation
nodular
- flesh colored
- pearly* papule
- has telangiectasia*
- may have central ulcer with *rolled boreder
- most common on the head and neck
- may be pink patch to AK or SCC in situ.
BCC tx
Surgical is preffered -currettage or desiccation -excision within 4mm margins -Mohs for high risk or cosmetic Nonsurgical -radiation if poor surgical canidate -Imiquimod cream -5% fluoroiracil cream -Photdynamic therapy
Squamous cell carcinoma etilogy
2nd most common
-originated from keeratinocytes and AK
M>F
- can arise from previous area of skin injuries like scars
SCC presentation
papule, plaque, nodule
- not as sandpapery as a AK
pink, red, skin colored
- get a scaly appearance, friable, indurated
-not as nice of a border
-often asymptomatic but van be very irritable
SCC tx
Surgical - wide excision or mohs Non surgical - Radiationfor poor surgical canidate or residual tumor -Curettahe and Desiccation or cryotherapy ( good for SCC in situ which is low risk) -5-fluorouracil therapy -Imiquimod -PDT
Malignant Melanoma Etiology + Risk
high morbidity and Mortality
>5 atypical nevi or >25 nevi in gen
Risks: fair skin, blue eyes, red/blonde hair, freckling, immunosupression, family history
Melanoma presentaion
-usually asymptomatic and arise usually de novo but some can arise from pre-existing nevus
- pigmented papule, plaque, or nodule
ABCDE
Superfiial spreading melanoma
- most common
- confined to epidermis
- often in younger pop
- radial spread> verticle spread
Nodular Melanoma
Rapid verticle growth and minimal radial growth
- very agressive
- nodule is inflammed and friable
Lentigo Maligna
Elderly pt with chronic sun exposure
- slightly less common
- slowl progression and usually spead radially and remains superficial
Acrak Lentiginous
More in darker skin and AA pop
- M>F
- spreads superficial more than verticle
Breslow depth and Melanoma
How deep the lesion is related to the prognosis of the skin cancer
Melanoma Tx
Wide surgical clearing -2cm margins - typically dont use Mohs -regional lymph node dissection If really large or advanced: radiation, chemo, immuno 3mo follow up
Erthymatotelangiectatic rosacea
Chronic redness of central face, flushing (wet or dry), skin sensitivity, dry appearance, telangiectasias
Papulopustular rosacea
papules and pustules
inflammation can be confluent
but there are no comedones
Phymatous rosacea
only rosacea that is more common in men than women
- tissue hypertrophy causing irregular contours
- mostly on nose and can involve cheeks, forehead, and chin
Occular rosacea
in addition to one of the other 3 types
- may preceded, coincide, or follow
- dry eyes, pain, itching, blurry vision, photosensitivity
Erythematotelangiectatic rosacea Tx
- Modify behavior to avoid triggers, gentle skin care, and avoid sun exposure
- Laser pulse light therapy or topical brimonodine (vasoconstrictor)
Papulopustular rosacea Tx
Mild:
- metronidazole
- Azelaic acid
- then: ivermiectin or sulfacetamide-sulfur
Phymatous rosacea Tx
Early- Isotretinoin( retinoid)
Advnced- surgical debulking or laser ablation
Scorpion sting Grades 1-4
1: local pain c paresthesiaa at sting site
2. local symp + remot pain and parasthersias
3. Either cranial nerve or somatic skeletal neuromuscular disfunction
4. Both cranial and somatic skeletal dysfunction
Scorpion Sting Dx
-clinical
Tap Sign: local pain made worse by tapping near the stinging sight
cranial nerve disfunction: hypersalivation, abnormal eye move, blurred vision, slurred speech, tongue fascicilations
Skeletal dis: fasiculations, shaking or jerking, emprosthotonos (tetanic forward flx), fever
Scorpion tx
Pain managment cleansing of sting site tetanus prophylaxis observe for 4hrs Severe cases: -treat for respiratory comprimise, MI, Hyperthermia, Rhabdomyolysis, multiple organ failure -fentanyl for pain -IV benzodiazepines -Antivenom** cannot use with the benzos
Bee sting LLR
Rare
- exagerated erythema and swelling
-gradually elnarges over 5-10days
Tx; cold compress and prednisone, antihist, NSAID
Bee sting complications
- Secondary bacterial infection- worsening after 3-5 days of it getting better
- Anaphylaxis
- treat with epinephrine and refer to speciallist
Widow bites
-found near human habitats
- small local reaction (often no venom inj)
-blanched circular round patch with central punctum
- venom causes catacholamine relase> intermitant radiating pain, ab/chest/back spasm, sweating, HA/N/V
Tx: local wound care, antiemetics, narcotic analgesics, tentanus, muscle relaxers, maybe antivenom
Recluse spider bite
usually happen indoors
-painless initially> red plaque/papule c central pallor> possible vessiculation
- necrosis can occur +N/V/Ha» rareley renal failur, rhabdo, anemia, hypotension
Tx: cleansing, cold compress, analgesics, antibiotics, surgical excision for necrosis only fter the wound has stabilized
Tx of vitiligo
- screen for other autoimmune disorders
Tx: topical and systemic corticosteroids, calcineurin inhibitors, narrow band UV B phototherapy, skin grafts - edu on sunscreen
Hidradenitis Supprativa etiology/ risk factors
chronic inflammatory skin dis of the hair follicle
female>males usually around 23
genetics, mechanical stress, smoking obesity
from a cycle of occlusion and rupture
Hidradenitis Supprativa presentation
Nodules in the axilla and groin more form as the disease progresses may form abscess(collection of pus) -sinus tracts can form -comedomes -scaring
Hidradenitis Supporativa Dx
Clinical based off lesion, location and history of relapse
hidradenitis supprativa Tx
- Lifestyle Mod: avoid skin trauma, hygeine, no smoking, weight managment, diet
- Pharm:
- Topical clindamycin
-intralesional corticosteroids
-anti-androgenic agents
-Surgery ( punch debredment or wide exicion)
Super sever> TNF inhibitors, oral retnoids
Complications asso. c Hidradenitis supprative
fistulae, contractures(melted skin appearance), Lymphatic obstruction, infection, SCC, depression
Measles Etiology
Rubeola
-Virus Paramyxovirus
highly contageous- maintain in an area for 2hrs
spread via cough sneezes, close breathing
Measles Clinical Stages
- Incubation: 2-3 wks - typ asymptomatic
- Promodone: anorexia, malaisw, fever 105+
followed by 3C’s cough, coryza, conjunctivitis - Enanthem: *Koplik spots
- Exanthem: blanching and maculopapular
- starts on face head to toe and spares the hands and the feet
Measles Dx
Reportable disease!
- serum and throat swab for histologic analysis
- serology: measles specific IgM
Measles complications
Common:
-diarrhea > ottis media
Severe and less common:
-Pneumonia ( common in children), Encephalitis, subacute sclerosing panencephalitis (1-2 yrs later)
High risk: preg, immunocomp, young or old
Measles Tx
Symptomatic treatment nly - vitamin A may lessen severity Patient education - avoid contact with pregnant women *vaccination!!!!
Erythema Infectiosum Etiology
Fifths disease- parovirus B-19
- transmitted by respiratory secretions
- common in children
Erythema Infectiosum Presentation
can last from weeks to years
- Incubation : 7-14 day
- prodorome: no specific flu sx
- low grade fver, coryza, HA, Nauseae, diahreeha, malaise, sorethroat - Facial Rash- Slapped Cheek
- Body Rash: 2-3 days later
- lacey rash- paink macular rash on extensor surfces
- may get polyarthropath (pain in joins)
Erthyema indectiosum Dx/ complications
- based on clinical presentation
Compl:
- transient aplastic crisis
- in preg: *hydrops fetalis
Erthyema Indectiosum managmentn
reassurance and tell them to avoid pregnant women
- will go away on its own
- a lot of people have already had it
Rubella
German Measles
Rubella virus
- large particles in the air
Rubella presentation
- Incubation 12-23 days
- Prodorone 1-5 days
- may have rash during
- low fever, *lymphadenopathy, cold symptoms - Rash appears
- erythemous papules and purpura- pin point pink
- can be contageous for 7 days
* * head to toe progresson**
Rubella Dx
clinical presentations - often resolve on its own
- may do serology if you cant tell
Rubella Complications
Congenital rubella syndrome- in pregnant women and is lethal to bany
blue berry muffin rash
Rubella Managment
treat symptoms and avoid pregnant women
- rubella titer is drawn at first prenatal visit!
- prevention via immunization
Roseola Infantum etiology
Herpes virus 6 is most common
- infants and younger children
- transmission is not understood
Roseola Infantum present
- high fever that comes and then resolves abruptily
- then a rash comes out of nowhere
- this story is very classic
1incubation: 9-10 days
2. Prodrome: febrile maybe higher than >105 with abrupt end
3. Rash: neck to trunk and then it will go toface - blanching, pink, maculopapular rash
- not itchy usually
Roseola Infantum Dx/ tx
Clinical presentation
- serology is the pt is immunocomprimised
Tx: suppotive treatment -antipyretucs
Hand, Foot, and Mouth Disease Etiology
Cozsackie A16 virus
- mostly children 1-5
- fecal oral or oral respiratory secretions
HFM disease presentation
- incubation: 3-5 days
- Prodorome 12-24 hrs
- no symptoms, fever, fussiness, abdominal pain, diarrhea - Oral enanthem/exanthem- oral more
- sore throat and vessicles on buccal mucose and toungue
- vessicles on hands* feet* and buttocks
HFM dx/Tx
Dx: clinical presentation
- usually by based on location
Tx: symptomatic maybe litocaine gel and prevent with good hygeine
Molluscum Contagiosum etiology/risk factors
Poxvirus
common in children/ immunocomp
-direct physical contact with fomites (towel, lines etc.) or skin
- can also autoinoculation via scratching or clothing or shaving
Molluscum Contagiosum Presentation
Lesions: flesh colored and umbilicated
located anywhere except palms and soles!
- usually no associated symptoms
- self limiting but super duper contagious
Molluscum Contagiosum Dx/Tx
Clinical presentation
Tx: you dont really need treatment
- home: podophyllotoxin cream ( not in preg)
-office: quick cyotherapy, currettage, canatharidin
HPV types
- mucosal: condyloma acuminata
2. Cutaneous: common, plantar, and flat wart
HPV condyloma accuminata etiology/pres/Dx/tx
genital warts
- most commonanorectal infection in MSM
transmission- sexual contact
Present: cauliflower like lesions, perianal growth, mild pruritis
Dx; clinical presentation may need to evaluate for internal lesions (anoscopy or proctosigmoidoscopy)
Tx: Topical posophyllin, electrocautery, laser, cryother. excision
HPV verruca Vulgaris etiology
more common in kids and younger adults Common Warts -transmission skin to skin contact - spont resolution 1-2 yrs - reoccurance is common Present: raised rough surfaced lesions wih tiny pigmented **thrombosed cappillaries** "seeds". Common on hands and feet.
HPV verruca vulgaris dx/tx
Dx: clinical presentation- may scrape of with 15 blade to visualize the thrombosed cappilaries
Tx: may spont resolve, salicylic acid, cryotherapy, electrodessication,
Varicella etiology/transmission
Chicken pox
Varicella Zoster virus- a herpes vaccine
- through aerosolized droplets and is highly contagious
- reoccurance can occur
Varicella Presentations/Dx
- incubations 10-21 days
- Prodorome 2-5
-fever, malaise, paryngitis, anorexia - Rash vesicular rash
-pruritic
rash occurs in stages paipule> blister> ulcer Dx: clinical typically but a Tzanck smear will show mononucleated giant cells
Varicella complications
- group A strep
- Encephalitis and reye syndrome (uncommon)
- most complications occur in immunocomp pt.
Varicella tx:
sypotomatic treatment
- contagious until all lesion have crusted over
- avoid pregnant females!!
- acyclovir in imminosup pts.
- vaccines
Herpes Zoster presentation
- Prodrome:
- acute neuritic pain precedes eruption 3-5 days
- throbbing stabbing burning senstions
- itching fever, headade, allodynia - Rash Active
- development of grouped vessicles on a erythematous base
- follows dermatome and unilateral most often
- thoracis distribution most common
Herpes Zosters chronic complications
- . post herpetic nerualgia: lanciating pain that lasts months after resoltution of lesions
- Herpes Zosters Qphthlmicus- sight threatening linked to trigemial ganglion
- begins with sign on nose (hutchinsons sign) - Other retinal problems or nerve palsies
Herpes Zosters Tx
treat early -72hrs ( lower pain/severity)
Antiviral: Famciclovir 500mg TID 7days
Valacyclovir 1g TID x 7days
- hydration, keep skin clear, pain managment
- NSAIDs, narchotic, topical anesthetics for acute
- Chronic; tricyclic antidepressets, gabapentin, pregablin
* if ocular involvment send right away to an eye doctor (emergency)
Herpes Zosters Infectious precautions
- can transmit virus to give someone chickenpox but can not give shingles
- avoid pregnent women, infants, and immunocomp
- infectious until crusts have healed
Prevention: Zostavax or Shingrix** vaccines - approved >50 yo and recommended for >60
Herpes Symplex Virus -1
-location and transmis.
Most common oral- cold sores and transmitted by direct contact during viral shedding
- can have a very severe primary presentation ( Pharygitis, mouth pain, fever )
Herpes symplex Virus II
-location and trans.
Most often genital
- sexually transmitted
- pt may be asymptomatic and still spread the disease
- genital herpes can also comes from HSV-1
HSV presentation
Prodrome: burining, tingling, or pruritis
Lesions appear: grouped vesicles on an erythematous base> may crust later
- can have lymphadenopathy
HSV dx
- clinical presentation
- Can do viral culture
- Direct microscopy via Tzanck smear use wright stain> see giant mononucleated cells ( just pos for herpes)
HSV tx
Start early!!- 72 hours
Valcyclovir, Famciclovir, or Acyclovir
- can treat before outbreak or chronic suppression which decreases recurrences and asymptomatic sheading
Epidermal Inclusion Cyst Presentation/ Tx
epidermpid cyst - soft, mobile, often central punctum - if infected> erythema and pain Tx: - may spontaneously go away but recur often -kenalog injection, I&D, excision - if infected then I&D, oral abx
Lipomas
Composed of adipose tissue and most common soft tissue tumor
Present: soft, mobile, non tender
Tx: surgical removal
- there is a concern of maligncancy with deeper tumors
Sarcoma
Rare malignant tumor -usually of soft tissue
Presentation: enlarging, painless mass of extremities or trunk
Managment: imaging of primary lesion MRI, core needle biopsy, surgical resection, chest CT to rule out metastasis
Seborreheic Dermatitis risk factors
infants and then again as teenagers
M>F
in 3rd 4th decade
- cause is unknown but possibly a fungus malessezia furfur
Seborrehic Dermatitis presentation
Infants
Dandruff
common, chronic, relapsing dandruff or inflammation
- gets worse with stress and when it is cold and dry
Infants: yellow greecy scale “cradal cap” and you will see it in the diaper region and axilla
Adults: erythematous coalescing macules, patches or plaques areas where there is hair, scalp, eybrows
^ with HIV and parkinsons
Seborrheic Blepharitis
dandruff around the eyelid
- have yellow crust with a greasy appearing flakes and edges are pink
Tx: warm compress and eyelid scrubs
Sebhorrheic Dermatitis Dx Tx
Clinical diagnosis
Tx: warm compress for cradal cap and baby shampoo. Can use olive oil to losen up
Scalp: antifungal shampoo and topical steroid
Ketoconazole (shampoo or cream)
Senlenium Sulfide or antidandruff shampoo
Face: low pot top steroid, topical antifungal, or combination
Pityriasis Rosea Etiology
Benign viral exanthems
- common in teens and young adults in the spring or fall
Pityriasis Rosea Present
Possible prodroms- fver or malaise
Herald patch (2-5cm) as primary lesion which is larger than the other ones on the trunk and secodnary lesion 1-2 wks later
-pink or slamon, fine scale (collarette scale), oval papulaes and plaques
-Christmas tree pattern
- usually asymptomatic possible itching
Pityriasis Rosea Dx/ Tx
Tx: self limiting and will go away on its own
- antihistamine for itching and possibly topical steroid ( just for itching)
- sun helps it go away faster
- can do a KOH prep to make sure its not funcgal
Lichen Planus presentation
Prurutuc, purple, polygonal, papulaes (4 Ps)
-papulosquamous eruption
- skin (itchy) genitals nails, scalp, most common- wrist, ankles, shins back and MOUTH (painful)
Wickhams striae- tiny white lines running through papules
Lichen Planus cause
idiopathic: dont know why
- 30-60yr olds
- immune mediated response
- drugs can cause
association with hep C
Koebner phenomenon- development of lesions in site of trauma
Lichen Planus Dx/Tx
Dx: punch or shave biopsy
Tx: self limiting disorder and resolved 1-2 yrs
- topical steroids (high pot)
- injection intralesional triamcinolone
then: oral steroids, phottherapy, oral retinoids
Psorisis Etiology/ Risks/
hyperproliferation inflammatory skin disorder
-overactive T cells to cause inflamation which shortens skin cell cycle so skin pile up.
M=F
20-30 and 50-60 yo
genetic- usually have 1st degree relative
Risks: genes, infections (strep), medications, stress/skin inj, weather(cold and dry), tobacco or heavy alch
Psorisis presentation
erythematous with silvery white scale
- itchy or burning
- can be local or generalized
may also have nail pitting and psoriatic arthritis
Psorisis Vulgaris
most common form
- plaques with scale and defined margins
- the plaques are symetrical on the body and smaller ones can clump together
Koebner phenomenon and auspitz sign
Guttate Psorisis
Strep infection often preceded this onset
- will often resolve on its own but you may get plaque psorisis
- little droplets
Pustular psorisis and palmplantar psorisis
Pustular- such wide spread inflamation may have fever> treated in hospital
Palm- debilitating becuase fissures will form so hard to walk and use hands and usually require more exstensive treatment
Psorisis Tx
sunshine, warm baths, emollients (reduce pruritus), occlusive dressing, rest,
* do NOT use oral steroids*
Topical:
1.Group 1 or II corticosteroids (high pot) 2-3wks [ good if small TBSA and not in genitals, hand, face]
2.steroid sparing agents [can be used in combination therapy]
- synthetic vIt D
- coal tar
- topical retinoids- tazarotene
-totcal caliceurin inhibitors (tacrolimus and pimecrolimus)
> use topicals after soaking
3. Phototherapy
Moderate to sever: >5% TBSA requires care by derm and wil need photo therp or systemic
Psoriatic Arthritis Etiology/ present
inflamatory arthritis
- 1/3 of pt with psorisis will have this
- pain and stiffness usually worse in the morning
- usually asymetric
- typically of the smaller joints (hands fingers) but also spine
- enthesitis and dactylitis (sausage digets)
Psoriatic arthritis Dx
lab findings non-specific - will have elavated sedimentation rate and leukocytosis - usually negative for RF factor lab tests are just to rule out other Dx ***usually just a history and physical - possbile additional immaging
Inverse psorisis
Will often appear in the axilla, genitals
- often not as scaly as other types
Folliculitis Cause/ presentation
itchy Inflammation of the hair follicle with pustules and papules
Infectious:
-s. aureus (most common)
-“hot tub folliculitis) - gram neg Pseudomonas
possibly from a drug interaction
If folliculitis gets worse what can happen?
can turn in a furnucle and then possibly a carbuncle abscess
Folliculitis Tx
- saphylococcal
- gram neg
Usually no tx (self limiting) Staphylococcal folliculitls - topical: mupirocin - oral abx: cephalexin If MRSA: clindamycin or doxycyclin Gram Negative folliculitis - Ciprofloxacin
Impetigo eitology and risks
Contagious superficial bacterial infection
Kids>adults
1.S. aureus- bullous and non bulllous
1. Ecthyma is usually strep
Impetigo types
Honey colored crusting- typically on face neck and extremities
- Nonbullous: most common
papules. vessicles> pustules> hone colored ccrusting - Bullous- vesicles enlarged and forms bulla
- Ecthyma- punched out ulcers with overlying crusts
- like cigarrette burns
Impetigo Dx/Tx
typically clinical possible culture TX: 1. non bullous and bullous: - - mild abs : mupirocin - mod/sever: dicloxicillin cephalexin 2. Ecthema is always oral therapy (ones above)
Cellulitis etiology and risks
Risks: skin trauma, lymphedema, venous indufficency, obesity, immunosup
- pus- strep
- no pus- s. aureus
- caused by beta-hemolytic strep, staph
Types of cellulitis
Expanding redness and not really well demarcated. Pain and swelling
1. Nonpurulent (non pus)- cellulitis or erysipelas
- erythema edema warmth
2. Purulent: absess or purulent cellulitis
painful fluctuant and erythematous nodule
Erysipelas
Type of non-purulent cellulitis -streptocci bacteria Well demarcated and perfect border of erythema -usually on cheeks and lower extremities - warm. with fever and chills usually in the elderly
Abscess etiology
Type of purluent cellulitis
enclosed collection of pus
-painful fluctuant erythematoud nodule
abscess Dx/ Tx
clinical diagnosis- maybe U/S
Tx: I and D - sometimes we test with culture and may need additional abs ( IC, very red
Cellulitis tx
Erysipelas
purulent
Cellulitis: oral cephalexin or IV cefazolin
Erysipelas: beta-hemolytic strep therapy
-cefazolin, ceftiaxone
Purulent infection:
1. abscess- I&D +/- abx
- trimethoprim-sulfamethoxazole, doxycycline, clindamycin
2. Purulent cellulitis- sim abx to above
MRSA prevention and control
Hand hyfeine, enviornmental cleaning, contact precautions
- decolonization with chlorohexidine wash and mupirocin ointment intranasally
MRSA risk factor
Abx, invasive device, chronic wound, hospitalization, group settings, colonization of MRSA,
MRSA tx
Oral abx: trimethoprim-sulfamethoxazole, doxycycline, clindamycin
- tailored to culture results
IV abx may be necessary (vancomycin):
-if extensive involvement, toxicity, rapid progression, failure PO tx, immunocomp
Systemic Lupus Cutanious manifestations
- Discoid lupus: scaly plaques, annular on sun exposed areas
- Malar/butterfly rash
- erythema on cheeks and bridge of the nose
- nasolabial folds are spared !
Lupus Rash DX/Tx
Dx: autoimmune connective tissue disease workup
sun protection and smoking cessation
- topical or intralesional steroids
- Hydroxychloroquine
* some people are on medications that cause a lupus rash*
Erythema Multiforme
acute, immune mediated conditions distinct target like lesions
can be associated with viral, bacterial or functions
- herpes is most common
- can be associated with NSaIDS or abx
Erythema Multiforme Dx/Tx
Dx: clinical dx
may have labs will be non specific inflammatory markers, leukocytosis
Tx: symptomatic tratment
- usually self limiting
-topical steroids, oral antihistamines, anestetic mouthwash
- antiviral meds are not indicated
Dermatitis Herpetiformis etilogy
autoimmune skin condition associated with gluten sensitivity (possibly celiac disease)
Sx: pruruitic papules and vesicles
herpeticform pattern- forearm, knees, scalp, butt
Dx: markers for seriological, biopsies of the lesions (looking through direct immunoflourescence)***
Tx: gluten elimination and dapsone
Pemphigus Etioogy
life thretening blistering disorder on epidermis
- autoimmmune:antibodies can cause acantholysis
- genetic, idopathic, drug induced
Pemphigus presentation
Accantholysis: separation of the epidermis
Mucosal involvment
- flaccid bullae
Nikolsky sign: gentle pressure causes superficial layer to slough off
Pemphigous Dx/Tx
Physical: acantholysis and Nikolsky sign
-biopsy and perilesional skin biopsy
later can do IIF and ELISA
Tx: always indicated
systemic corticosteroids and immunosupressive agents
Pemphigoid etilogy
Chronic autoimmune subepithelial blistering condition
Pemphigoid Presentation
- begin with prurirtis eczematous or uticarial lesions
Classic: *tense bullae**urticarial erythematous plaque. on trunk and extremities
+/- mucosal involvment
Pemphigoid Dx/Tx
Dx: biospy *perilesional direct immunoflourensense**
Tx: topical and/or systemic corticosteroids
- immunosupressive agents
Melasma/Cholasma
aquired hyperpigmentation of the skin.
- often with hormones like the pill of pregnancy
- regresses within a year
Tx: skin lightener and sun protection
Acanthosis Nigricans
hyperpigmentation velvety plaques
- associated with insulin resistance
Hirsutism
male pattern hair growth in women
- caused by a variety of things
Adrenal excess on skin
Cushing syndrome
- increase sebum, acne, androgenic alopecia, hirsutism, striae
Adrenal insufficency of skin
Addisons disease
- hyperpigmentation of the gums, buccal mucosa, elbows, knees, palms, genitalia
Thyroid effects on skin
Hyperthyroidism: warm moist skin
-pretibial myxedema
- non pitting, scaly, orange peel skin
Hypothyroidism: dry cool skin
Porphyria Cutanea Tarda cause /Sx/ risks
deficiency of uroporphyrinogen decrarboxylase- suppose to break down porphyrins
Sx: painless sub-epidermal blistering on sun exposed areas
Risk: genetic, tobacco, etoh, estorgens, liver disease
Porphyria Cutanea Tarda Dx/TX
Dx; ^ serum/ urinar porphyrins, ^ liver tests irons stores
Tx: discontinue potential cause
phlebotomy for the the ^iron
wear sun protective clothing
Pressure injury stages
1: intact skin with localized erythema
2. partial thickness loss with exposed dermis
- no adipose visible and no eschar
3. full thickness
- adipose is visible with rolled edges but no facia or muscle visible
4. Full thickness skin and tissue loss with esposed muscle, tendon or bone
- eschar with rolled edges
Pressure injury tx:
- redistiribute pressure
- local wound care
1. transparent film for protection
2. dressings that maintain moisture
3. debridement of necrotic tissue with appropriate dressing +/-abx
Tick removal
- grasp tick as close to skin surface
- wash area
>36hrs ^ risk for lymes
RMSF can be after only 6 hrs
Erythema Migrans
Etiology: borrelia Burgdorferi
Pres: bulls eye rash
- fatigue, HA, arthralgia,fever
- later: cardiac, arthritis, beuro, bells palsy
Tx: doxycycline or amoxicillin
- can do 200mg dose of doxycycline for prophylaxis is >36hrs
Rocky Mountain Spotted Fever
Etiology: rickettsia rickettsia
1. non specific symptoms: Fever, HA, arthralgias, nausea 2-14 after tick bite
* do not wait for the rash becuase some people dont get it
Rash: petechial lesion on ankles wrists then trunk
Rocky Mountain spotted fever Dx and Tx
Dx: clinical because the serology is retrospective
Tx: doxycycline
