derm wk 5 Flashcards
erythematous brown hyperpigmented plaque
w fine fissuring and scale located above the medial malleolus
Stasis dermatitis
Stasis Dermatitis
Presents with redness, scale, itchy, erosions, exudate, and crust
Stasis Dermatitis
Common on lower 1/3 of legs
Lichenification may develop
Pitting edema
Scaly and erythema
Stasis Dermatitis
What is causing Stasis Dermatitis?
Venous insufficiency
What is causing Venous insuff
When the valves in the deep or perforating veins are not working, so there is BLOOD REFLUX/ backup into the superficial system
“Venous hypertension”
Risk factors for venous insuff
Genes Older Female Pregnant Obese Prolonged standing Prior injury or surgery Prior DDVT Sedentary life
What is Lipodermatosclerosis?
Stasis dermatitis can –> lead to this
fat necrosis looking like “inverted champagne bottle”
can have acute inflammatory episodes with pain and redness
Lipodermatosclersosi
Chronic inflammation and Fat necrosis
Complication of venous insuff
Recurrent ulcer
Cellulitis
Contact dermatitis
Venous clot
Tx of Stasis Dermatitis
Super high and High potency STEROIDS
Elevate
Compression
Change wraps at least weekly
Ulcers from venous insuff generally look like
Tender, shallow, irregular ulcer with fibrinous base
always below the knee
What to do if you diagnose a Venous insuff ulcer?
Measure the blood pressure in the Left arm and Left ankle
to make sure there is not also arterial disease goin’ on
Compression therapy is CONTRA if
ABI is <0.5
OR
Absolute ankle pressure is <60 mmHg
Normal ABI
> 0.8
What should you perform with all pts with Venous insuff?
Pulse exam
Venous duplex US
ABI
Should you use Abx on Venous ulcers?
NO
can lead to contact dermatitis
arterial ulcers
“punched out”
well-demarcated
pale base
Arterial ischemia
loss of hair
Shiny atrophic skin
Arterial insuff
leg elevation does not help!
Pain and claud at rest
Arterial insuff
PG is often mistaken for a spider bite
If you think someone has spider bite, consider PG or MRSA
PG= pyoderma gangrenosum
PG= Pyoderma Gangrenosum
Auto-inflammatory process
Ulcerative
Starts small pustule, breaks down and rapidly expands forming an ulcer with an UNDERMINED (can probe underneath) violaceous border
Pyoderma Gangrenosum
Rapid progression
Usually happens on lower legs
Can be V painful
What do patients experiencing PG (pyoderma gangrenosum) often have also?
ARTHRITIS!!
or IBD, RA, Hematologic pathy, or CA
Pyoderma Gangrenosum is triggered by
TRAUMA
i.e. insect bite, surgical debridement, grafting
Pyoderma Gangrenosum
DERM EMERGENCY
Tx:
Topical therapy- superpotent Steroid, Tacrolimus
Systemic- Steroid, Cyclosporine, Tacrolimus, Cellcept, Thalidomide, TNF- inhibitor
Dermatitis in general
ACUTE vs
CHRONIC
Acute: red, vesicles, itching
Chronic: dry, scaly, lichenification, fissure, itching (still)
Two types of Contact Dermatitis
Irritant
Allergic
How does Allergic Contact Derm work?
Sensitization process: 10-14 days
Upon re-exposure: 12-48 hours
Most common type of Allergic Contact Derm
Rhus dermatitis
- poison ivy
- poison oak
- poison sumac
How long does poison ivy last?
10-21 days
about 1-3 weeks
How long is the first episode of poison ivy?
Up to 6 weeks
the first one is the longest
What can you use to treat poison ivy if Clobetasol ointment doesn’t work?
2 week taper of Oral prednisone
What to consider when treating poison ivy with oral steroids
If given for a short amt of time, pt may relapse. avoid short bursts of steroids
GIVE LONGER DURATION
Tx of Allergic Contact Derm
like poison ivy
Mild- mod: topical steroids, maybe systemic steroids short course
Oatmeal bath, soothing lotion
If extensive oozing: wet dressing
Chronic case or if Allergic Contact derm is taking up >10% BSA
Refer to Derm
Scaling and redness b/w the toes with associated maceration
Tinea Pedis- Interdigital type
Tinea Pedis- Moccasin type
aka
Hyperkeratotic type
Sharply marginated scale
Lateral borders of feet, heels, and soles
Often a/w fungal infection of nails
Moccasin Type/ Hyperkeratotic often presents with
ONE HAND involvement
“One hand, two feet” syndrome
Tinea pedis- Vesicular type
Grouped vesicles or bullae, often on medial foot
Itchy or painful
Tinea pedis- Ulcerative
Worsening of interdigital
Ulcer and erosion in web space
Tinea pedis- ulcerative
Seen in:
Immunocompromised
Diabetic
Best diagnostic exam w fungal infections
KOH
dissolves keratinocytes making it easier to see Fungal hyphae
Tinea Versicolor
“Spaghetti and Meatballs”
Tinea capitis
Spores
can be inside or outside hair shaft
KOH exam prep
Clean skin w alc Collect sample Put on glass slide Add 1-2 drops KOH Let sit for 10 min Examine at low power, then --> 10X to study Hyphae
Moccasin foot Tx
Terbinifine cream BID for 2 weeks
1st line Tx for Tinea Pedis
Terbinafine
Naftifine
Butenafine
cream or gel BID for 1-2 wks
All are Allylamines
2nd line tx for Tinea Pedis
Clortimazole
Miconazole
BID for 4-6 wks
How many grams to Rx for Tinea Pedis tx?
30-45 g to cover both soles BID for 1 month
1st line tx for Tinea Pedis
Terbinafine BID for 1-2 wks
Sharply marginated, Erythematous annular plaque w central clearing and scaling at edges
Ringworm
tinea corporis
Tinea corporis
Annular lesion with central clearing
Tinea Corporis tx duration
4-6 wks total
Until resolution, then 2 more weeks after that
Tinea corporis “ringworm” 1st line tx
Terbinafine
Butenafine
Naftifene
(more expensive)
Tinea corporis
“ringworm” 1nd line (less expensive)
Clotrimazole
Miconazole
(Imidazoles)
When to use ORAL tx for ringworm?
Poor response to topical
Animal is source
Large surface area
ORAL tx for “ringworm”
Terbinafine daily 7-14 days
Oral Terbinafine SE
Taste loss or disturbance in 3% people taking this
How to describe toe fungus
Nail thickening and Subungual debris
Most common type of Onychomycosis
Distal subungual onychomycosis
thickened nail bed
subungual debris
separation from nail plate
1st line tx for Onychomycosis
Terbinafine 250 mg daily for 90 days
Risk of Onychomycosis oral tx
Liver toxic
Taste disturbance (reversible)
Drug intxns
Skin rxn
Failure to cure. only 50%.
To help this, also add Topical Antifungal therapy
Tinea corporis “ringworm” 1st line tx
Terbinafine
Butenafine
Naftifene
(more expensive)
Tinea corporis
“ringworm” 1nd line (less expensive)
Clotrimazole
Miconazole
(Imidazoles)
When to use ORAL tx for ringworm?
Poor response to topical
Animal is source
Large surface area
2nd line tx for Onychomycosis
Fluconazole
Itraconazole
(IF)
Oral Terbinafine SE
Taste loss or disturbance in 3% people taking this
Tinea Versicolor is different from other tinea, how?
NOT caused by dermatophyte, but rather my a YEAST
Malassezia furfur
Most common type of Onychomycosis
Distal subungual onychomycosis
thickened nail bed
subungual debris
separation from nail plate
1st line tx for Onychomycosis
Terbinafine 250 mg daily for 90 days
Option for pts concerned about long term liver issues
PULSE THERAPY
short bursts of oral tx given (either until nail is healthy or for a total of 3 bursts)
1st line for mostly all fungal infections: Tinea and Onychomycocis
Terbinafine
onychomycosis is Oral
Maintenance therapy for tinea versicolor
Topical shampoo 1-2x per week
Selenium sulfide
Ketoconazole
Zinc
leave on 10 min b4 rinsing off
2nd line tx for Onychomycosis
Fluconazole
Itraconazole
(IF)
How to describe Tinea Versicolor
Well-demarcated, hyperpigmented macules and patches across the back
More about Malassezia (Tinea versicolor)
Lipophilic yeast that’s actually a normal resident in the keratin of skin and hair follicles of those at puberty and beyond
Diagnostic feature of Tinea Versicolor
Visible scale not present until rubbed with finger or scalpel
Evoked scale dissappears after tx
Tx for Tinea Versicolor
topical is 1st line
SHAMPOOS-
Selenium sulfide
Ketoconazole
Zinc pyrithione
IMIDAZOLE cream-
Ketoconazole
Clotrimazole
(for limited areas, more $)
Two tx classes for Intertrigo
Imidazoles-
Clotrimazole, Miconazole, Econazole
(more effective but may burn)
OR
Polyene-
Nystatin (not as affective but benefit is can be powder and ointment)
What can you apply to Candidal Intertrigo to improve the burning and itching?
Low strength steroid
Desonide or Hydrocortisone
ointment, BID x 1-2 wks
Intertrigo
inflammation of large skin folds
Classic signs of Intertrigo complicated by Candida yeast
Burns
Satellite macules, papules, pustules around the redness in the fold
Satellite papules
Candidal intertrigo
Best tx for Intertrigo
Clotrimazole cream
Prevention of Intertrigo
Dry area after bathing
Weight loss
Loose clothing made of cotton
Tx options for Seborrheic derm
Topical Ketoconazole
Low potency steroid (Desonide, Hydrocort)
Antidandruff shampoo
Chronic conditions req maintenance tx
Tinea versicolor
Seborrheic derm
Seborrheic dermatitis
Common, inflammatory rxn to Malassezia yeast that thrives on Seborrheic oil producing skin
Seborrheic derm
Inflammatory rxn to normal flora
chronic condition, can be controlled (but not cured)
Red scaling patches on scalp, hairline, eyebrow, eyelids, central face, nasolabial folds, central chest
Seborrheic derm
worse in HIV pts
Central chest
Red and scaly
Seborrheic derm
Tx for Seborrheic derm
Desonide cream
Chronic conditions req maintenance tx
Tinea versicolor
Seborrheic derm
Tx for Candidal Intertrigo
Clotrimazole cream (preferred) Nystatin powder (may be easier tolerated)
Is Intertrigo usually caused by fungus?
No, usually just from irritation to skin by warmth, moisture, etc
Tx for PVD - veins
Exercise, Leg elevation
Compression stockings
Tx for PAD - arteries
Fixed distance walking/ exercise
Stop smoking
Cilostazol (pharm)
Angioplasty Revascularization (surgery)
PAD tx
exercise
meds- cilostazol
surgery- revascularization
