DERM1-Table 1 Flashcards
What happens to the epidermis with age?
–Skin more fragile; prolonged turnover rate & ↓ DNA repair
–↓7-dehydrocholesterol + less outdoor activity = insufficient sun exposure = ↓ Vitamin D production
What happens to the dermis with age?
–Loss thickness
–↓ Mast cells & histamine; ↓ vascular supply; ↓ collagen synthesis
What happens to the SQ fat with age?
↓ volume (face & hands) & ↑ volume (abdomen & thighs)
this can lead to pressure ulcers
What does the change in hair with age potentially lead to?
Thinning of hair can lead to baldness/alopecia
What does the decrease in melanin production potentially lead to?
Graying of hair
What does the flattening of the dermo-epidermal jxn lead to?
Skin fragility and propensity to injury
What does capillary fragility lead to?
Actinic purpura
What can atrophy of sweat glands lead to?
Difficult with temp regulation with advanced age
A pt presents with rash…. What are the classification basics?
–Onset: acute vs. chronic –Distribution & pattern –Type of primary lesion & topography –Secondary features –Consistency w/palpation
What are secondary features? What classifies them?
–Crusts: serous, hemorrhagic, purulent
–Scales: hyperkeratosis, accumulated stratum corneum
–Fissure: linear cleft in skin d/t marked dryness, thickening & loss elasticity
–Erosion: loss of epidermis, moist & oozing or crusted
–Ulceration: loss of epidermis & partial superficial dermis: note size, shape & depth along w/traits border, base & surrounding skin
–Excoriation: exogenous, all or part epidermis
-atrophy: epidermal thinning leads to shiny wrinkled appearance, dermal leads too depression
-lichenification” thickening and accentuation of natural skin lines
What are 3 ROS you must ask if a pt presents with a rash?
Fever, pruritus, dysesthesia
Acute fever+ rash = what?
Infectious
Inflammatory
Other
What are the infectious causes of acute fever+ rash?
Bacterial: TSS, scarlet fever, meningococcal
Viral: exanthems, dissem zoster, immunocompromised
Fungal/ protazoal
What are the inflammatory causes of acute fever+ rash?
SJS/TENS/erythema multiforme, pustular psoriasis, rheumatologic (SLE, vasculitis), drug rxn (serum sickness rxn), graft vs. host rxn
What are the other causes of acute fever + rash?
Neoplastic- lymphoma
What are the types of pruritus? What is the ddx for each?
- Primary (aka idiopathic)
- Secondary: derm disorder, allergy, systemic dz, malignancy, toxin d/t renal/hepatic failure, meds, neuro dz, behavioral dz
What are the types of dysesthesia?
Neuropathic and psychocutaneous
What is the DDX for neuropathic dysesthesia?
–Radiculopathy; small fiber polyneuropathies
–Orodynia (burning mouth syndrome); burning scalp syndrome
What is the DDX for psychocutaneous dysesthesia?
Neurotic (psychogenic) excoriation: associated w/OCD, stress, anxiety, depression & bipolar disorder
What can you use KOH prep on?
Scales, hair shafts, subungual and or nail plate
What is dermoscopy?
noninvasive method: allow in vivo evaluation of colors & microstructures in epidermis, dermoepidermal junction & papillary dermis not visible to naked eye
What is dermscopy used to ID?
specific diagnostic patterns related to distribution of colors & dermoscopy structures can better suggest a malignant or benign pigmented skin lesion
When is biopsy indicated?
- Rash or vessels involving dermis: r/o drug rxn, deep tissue infection, vasculitis, E. multiforme
- Atypical moles – malignant suspicion (FHx/PMH – risk factor evaluation, advanced age, fair skin, multiple pigmented nevi)
What are some criteria for atypical moles?
–ABCDE criteria
–Glasgow 7-point checklist: major vs minor features
–“Ugly duckling” sign
What are the types of biopsy?
Shave or punch and excisional
What is a saucerization?
Spoon shaped biopsy
What is an elliptical?
Excision where the entire lesion is removed
What is primary intention?
Wound healing where wound edges heal directly touching each other
–Results in linear scar tissue = goal whenever a wound is sutured closed
What is secondary intention?
wound is left open & filled with granulation tissue which subsequently turns into scar tissue
When is shave biopsy indicated?
predominantly epidermal lesions w/out dermal extension - warts, papillomas, skin tags, superficial BCC & SCC, seborrheic & actinic keratoses
When is shave biopsy not indicated?
When there is a suspicious pigmented lesion
How is a shave biopsy performed?
–Inject anesthetic & create wheal to elevate lesion
–45 angle to shave (#15 scalpel blade, dermablade, double edge razor blade, scissors)
•Remove thin disk of tissue:
What is the healing for a shave biopsy?
Can use silver nitrate or aluminm chloride for hemostasis, keep area clean and covered for one week
A punch biopsy can be both ???? OR ???
Excisional or incisional
When is punch biopsy indicated?
lesion requires dermal or subcutis (bullous lesion, dysplastic or complex nevi, scalp or hair follicle)
What is the limitation of punch biopsy?
narrow deep specimen – may not be wide enough sample because select thickest area of lesion
How is punch biopsy performed?
Punch perpendicular to surface of lesion & rotate through skin until no tension on tissue = full thickness sample; remove tissue w/forceps or needle to minimize crushing
What is the post procedure tx of punch biopsy?
Can do electrocautery or use an agent for hemostasis
Close small site with 2nd intention and large site with steri-strip adhesives or suture
When is a saucerization biopsy indicated?
for pigmented or suspect skin lesions
lesions difficult to remove elliptically d/t cosmesis or anatomic location, vesicobullous disorders, seborrheic keratosis
How is a saucerization biopsy performed?
–45 angle to remove disk of tissue: 1- 4 mm deep combined epidermis & dermis + subcutis
•Nidus of pigment noted s/p biopsy - perform punch or elliptical biopsy
How do you tx a saucer biopsy?
Same as punch but keep area clean and dressed for healing by secondary intention
What is a wedge biopsy?
Incisional, for large lesions - need length, width & depth; stab incision (V or triangular shape) = remove a cone of tissue
What does an excisional biopsy do?
remove entire lesion down to the subcutis
When is an excisional biopsy indicated?
Neoplasms
How is an excisional biopsy tx?
–Hemostasis: electrocautery or agent
–Close site w/sutures
When are powders used topically?
mix w/active agent & use for lesions in moist or intertriginous areas
When can foams be used?
alcohol or emollient based, aerosolized, hairy areas
When are solutions used?
mixed w/solvent, intertriginous & hairy areas
When are lotions used?
water based emulsion, cool & dry inflammatory/exudative lesions
When are creams used?
exudative conditions
When are ointments used?
allow drug penetration, less stinging w/ulcerations, lichenified lesions
What are non-occlusive dressings and how are they used?
- Gauze: allow air to reach wound
* Soak w/saline solution: cleanse & debride crusted lesions when dressing has dried
What are the occlusive dressings and how are they used?
•Transparent films, hydrocolloid, zinc oxide gelatin
•Apply over steroids to increase absorption
Protect/heal burn wounds or pressure ulcers
What are the antipruritics and when are they used?
- Doxepin: atopy, lichen simplex chronicus, nummular dermatitis
- Diphenhydramine: can be sensitizing in topical preps
- Camphor: 0.5-3%; Menthol: 0.1-2%; Pramoxine HCl (Caladryl)- stains
What are the non steroid anti-inflammatory?what are the ADRS?
Tar preparations:
ADR = photosensitization, stain clothes, irritation, folliculitis
What are antistringents?
Drying agents… these are used for exudative lesions, weeping pressure ulcers
What are the antistringents?
cornstarch, aluminum chloride, aluminum acetate (Burrow’s)- good on feet and btwn fingers and toes, aluminum sulfate & calcium acetate (Domeboro), witch hazel
What are the keratolytics?
Salicylic acid and retinoids
What does salicylic acid do?
dissolves intercellular cement substance, & produces desquamation of horny layer w/out affecting structure of viable epidermis
What do retinoids do?
Inhibits microcomedo formation & eliminates lesions, makes keratinocytes in sebaceous follicles less adherent & easier to remove
What are 1st line anti-inflammatory agents?
Steroids
Where are low potency steroids used? High potency?
–Low potency: thin lesions, body folds, face
–High potency: lichenified plaques, hand, feet
What are the ADRs after 1 mo use of steroids?
localized skin atrophy, striae, fungal growth, contact dermatitis d/t additives/solvents
What topical abx are used for what skin conditions?
Clindamycin or erythromycin: acne vulgaris
Metronidazole: rosacea
Bacitracin/polymyxin: post op, superficial cuts/abrasions
What is the ADR of neomycin?
Contact dermatitis
What is the 1st line tx for scabies?
permethrin 5% cream leave on 8-14 H then wash off, can repeat in 1 wk if needed
What is 1st line tx for lice- capitis?
1st line: wet combing & permethrin; can repeat in 7-9 days if live nits observed
»Apply permethrin to wet hair, behind ears & nape, wash off in 10 minutes
What is 1st line for lice- corporis?
1st line: linen & clothes hygiene (149F), treat pruritus & 2ndary infection
What is 1st line for lice- pubic?
–1st line: wet combing & permethrin 1% cream; can repeat in 7-9 days if live nits observed
»Apply permethrin to wet hair, wash off in 10 minutes
What is the tx for lice in the eyebrows?
–Petrolatum TID-QID x 8-10 days
–Fluorescein drops 10-20%: apply to eyelids = immediate pediculicidal effect
Remove physically
What are the topial antifungals categories?
–Allylamines
–Benzylamine
–Imidazoles
–Miscellaneous
What are the allylamines and their indications?
Amorolfine 5% solution – T. unguium
•Naftifine 1% cream or gel – dermatophytoses, candidiasis
•Terbinafine 1% cream or solution, 250 mg tablet – dermatophytoses
What are the Benzylamine and their indications?
Butenafine 1% cream - dermatophytoses
What are the Imidazoles and their indications?
- Butoconazole 2% cream – vulvovaginal candida
- Clotrimazole 1% cream/lotion/solution, 10 mg lozenges – dermatophytoses, oropharyngeal candida
- Econazole 1% cream – dermatophytoses, T. versicolor
- Itraconazole 100 mg tabs, 10mg/ml solution – T. unguium, onychomycoses
- Oxiconazole 1% cream/lotion or sulconazole 1% cream/solution – T. versicolor, dermatophytoses
What are the miscellaneous antifungals and their indications?
- Carbolfuchsin solution – chronic dermatophytoses
- Ciclopirox 0 .77% gel, 8% lacquer solution – dermatophytoses, onychomycosis, T. versicolor
- Gentian violet 1-2% solution – T. pedis
- Tolnaftate 1% liquid, powder, aerosol, cream – T. versicolor, dermatophytoses
- Zinc 25% solution, 10% tincture – superficial dermatophytoses, T. pedis
What are the 2nd line anti-inflammatory agents?
topical immunomodulators
How do immunomodulators work?
Suppress immune system & inflammation by inhibition of enzyme (calcineurin) crucial for multiplication of T-cells required for activation of immune system (cytokines)
Can the immunomodulators be applied to delicate areas such as the face and eyelids?
Yes, they are not significantly absorbed into bloodstream & less likely than steroids to cause systemic side-effects
–Don’t affect collagen in skin as topical steroids can so don’t cause localized skin thinning
Why might systemic immunosuppressants be given to a pt?
Gives a break from high potency topicals, breaks the itch-scratch cycle & allow skin to heal w/out immune system input
Which immunosuppressant is usually given?
Cyclosporine
use
What are the ADRs with using systemic immunosuppressants?
–↑ risk bacterial (including TB) & viral (shingles) infection
–GI upset & vomiting
–↑ risk skin/internal CA
–↑ BP (cyclosporine), kidney damage (cyclosporine & methotrexate), liver damage (methotrexate)
what is Fitzpatrick classification referring to?
–amount of melanin pigment in skin
•Constitutional color (white, brown or black) + result of exposure to ultraviolet radiation (tanning)
What are the skin phototypes?
–I: pale white skin, blue/green eyes, blond/red hair – always burns, does not tan
–II: fair skin, blue eyes – burns easily, tans poorly
–III: darker white skin – tans after initial burn
–IV: light brown skin – burns minimally, tans easily
–V: brown skin – rarely burns, tans darkly easily
–VI : dark brown or black skin – never burns, always tans darkly
What is MED?
•minimal erythema dose
–Lowest dose of UVR capable of inducing erythema in a person
What are the acute cutaneous effects of UVR?
sunburn (inflammation + erythema) & tanning (immediate vs. delayed)
What are chronuc effects of UVR?
»Photoaging: ephelides, dyspigmentation
»Photocarcinogenesis
What are the categories of photodermatoses?
1) Polymorphic light eruption (PMLE)
2) Photoaggravated dermatoses
3) Drug induced photosensitivity & Phototoxicity
What is PMLE most likely caused by?
Idiopathic and autoimmune
What is the onset and duration of PMLE?
–1-3 H s/p sun exposure; usually spring/summer
–Duration: lesions last days
What is the clinical presentation on PMLE typically?
extensor forearms, dorsa/hands, face & neck; pruritic, symmetric, flesh colored or red papules &/or papulovesicles that coalesce into plaques
How is PMLE tx?
Photoprotection: avoid sun, clothing/hat, zinc or titanium sunscreen & topical CS
What are examples of photoaggravated dermatoses?
atopic derm, seborrheic derm, SLE, rosacea
What is the onset and duration of photoaggravated dermatoses?
–Onset: w/in hours of exposure
–Duration: days to months
What is the clinical picture for photoaggravated dermatoses?
exacerbation of underlying skin condition in sun-exposed & non-sun exposed areas
How are photoaggravated dermatoses tx?
Photoprotection
Manage underlying condition
What is the onset and duration of drug induced photosensitivity/toxicity?
hours s/p exposure
What is the clinical presentation for drug induced photosensitivity/toxicity?
“exaggerated sunburn” reaction – burning/stinging, vesicles or bulla followed by desquamation & hyperpigmentation
What is the etiology of drug induced photosensitivity/toxicity?
photo-onycholysis (tetracyclines, psoralens), thiazides, slate gray hyperpigmentation (amiodarone, diltiazem, tricyclics)
How is drug induced photosensitivity/toxicity tx?
DC causative agent
What is photoallergy?
photoallergic contact dermatitis to topical med’n or chemical & UVR exposure
What is the onset of a photoallergy?
1st exposure – 7-10 days; recurrent – minutes to hours
What is the clinical presentation of photodermatoses?
Pruritic, eczematous eruption with/without vesicles/bulla
How is photoallergy tx?
discontinue agent, photoprotection, topical or oral CS
What is phytophotodermatitis?
phototoxic rxn to plant exposure
What is the distribution with phytophotodermatitis?
sites exposed to plant toxin + sun exposure
What is the clinical presentation of phytophotodermatitis?
–Inflammatory rxn: w/in 1 day, erythematous streaks, vesicles/bulla, non-pruritic but painful
–Delayed hyperpigmentation – lasts months to years
How is phytophotodermatitis tx?
Wash off the plant pollen/juice, supportive care, photoprotection, topical or oral CS, pt education
