DERM2-Table 1 Flashcards
What is psoriasis?
chronic disorder w/polygenic predisposition & trigger factors (strep pharyngitis, HIV, interferon, beta blockers, lithium, steroid tapering), characterized by flares & remission
What is the clinical skin finding of psoriasis?
Plaque: most common, well demarcated brick red plaques w/adherent silvery scales; scalp, trunk, limbs (extensor surfaces); B/L symmetrical – elbows & knees*,
What are the clinical variants of psoriasis other than the classic plaque finding?
1)Guttate: usually presents
What are PE findings with psoriasis?
Well-defined red papules coalesce into plaques, sharply demarcated silver scales that adhere to plaque and inflammatory autoimmune associations (RA, spondylitis)
What are the nail PE findings in psoriasis?
Pitting, salmon patch (oil spot), onycholysis w/red rim, splinter hemorrhages, subungual debris
What are 2 signs specific to psoriasis?
1) Auspitz sign: pinpoint bleeding following scraping or pulling scale
2)Koebner phenomenon = response to trauma
How is psoriasis diagnosed?
Order RF & HLA-B27 w/arthropathy
Consider CBC, CMP, hepatitis panel, HIV, etc
Annual CVD assessment
What is first line tx for psoriasis?
- Emollients- maintenance
- Topical steroids: moderate to high potency- 1st line
- Vitamin D analogues: calcipotriene, topical retinoids: tazarotene
- Ultraviolet phototherapy or laser: significant body surface area involvement or non-response to topical
What is 2nd line tx for psoriasis?
methotrexate, targeted immunomodulators, biologics, cyclosporine/immunosuppressants
What are the mild psoriasis topical agents that can be used?
corticosteroids, Vit D analogue (calcipotriene), moisturizers
Reserve topical calcineurin inhibitors (TCI)
What are the tx combos for mod-severe psoriasis?
: combo phototherapy & systemic (MTX, cyclosporine/calcineurin inhibitor, acitretin/retinoid), biologics d/t TNF-α inhibition (etanercept, adalimumab, infliximab, ustekinumab) or d/t PDE4 inhibition (apremilast)
When should you refer psoriasis?
moderate-severe psoriasis, recalcitrant psoriasis
What is pityriasis rosea?
self-limiting skin eruption w/multiple papulosquamous lesions; ↑ spring & autumn incidence
What is the suspected etiology of pit rosea?
HHV 6&7
What might be a common hx a pt presents with when suspected pit rosea?
›5% w/ HA, arthralgia, low grade fever, malaise prior to Herald patch, + pruritus
›Over few weeks lesions increase in # & distribution then spontaneously resolve
What is the most common initial sign for pit rosea?
salmon-colored oval lesion aka “herald patch” ( trunk & enlarges over days to 3-10 cm) w/widespread rash following after 7–14 days
What is the average duration of pit rosea?
6-8 weeks
What is the PE findng for the rash following the herald patch?
›Pink to salmon color round/oval plaques w/fine scales centrally & collarets of loose scales; follows Langer’s lines
with a secondary eruption in the “Christmas tree” pattern
How is pit rosea dx?
›Clinical features
›KOH prep to r/o tinea; r/o syphilis, WBC – normal
›Punch biopsy
What is the tx for pit rosea?
›Self-limiting – give reassurance ›Pruritus: topical steroids (class 3 or 4 – triamcinolone cream) ›Severe case: UVB phototherapy or natural sunlight
What is lichen planus?
idiopathic, cutaneous, inflammatory disorder of skin, hair, nails & mucous membranes
cell mediated immune response
What is lichen planus associated with?
Hep C
What will be pt hx with lichen planus?
Pruritus, white(lacy) area on oral mucosa
When does lichen planus typically resolve?
In 2 years
What are PE findings for lichen planus?
1-10 mm flat-topped (planar), red to violaceous, shiny papules occur in crops
Violaceous w/fine, white lacy pattern (Wickham striae) on surface of papules & plaques
What is pathogomonic for lichen planus?
Wickham striae
What is a phenomenon associated with lichen planus?
Koebner phenomenon: new lesions may be noted at sites of minor injuries such as scratches or burns
How is lichen planus dx?
Biopsy if indicated
What is tx for lichen planus?
›Topical or intralesional steroids; TCI, phototherapy
›Systemic steroids if no response
What is atopic dermatitis?
Common inflammatory condition - pruritic, chronic, relapsing
What is atopic dermatitis associated with?
Asthma and allergies
What is the age dependent sequence of atopic dermatitis?
atopic march (epidermal defect atopy asthma allergic rhinitis
What is the hallmark saying of atopic dermatitis?
An itch that rashes
Where is the rash presentation in kids? Adults?
›Infant/child/adolescent: Face & neck, extensor surfaces
›Adult: flexor surfaces
What are PE findings for atopic dermatitis?
Lesions: erythematous, macular or papular, + crusts &/or oozing; can develop lichenification w/chronic scratching
Associated: xerosis, excoriations, keratosis pilaris (red bumps on back of arm), periorbital darkening (allergic shiners), Dennie-Morgan folds (lower lid pleats), post-inflammatory hypopigmentation/lesion sites
How is atopic dermatitis dx?
no single test, IgE can be elevated, + eosinophilia
What is the tx for atopic dermatitis?
›Low level maintenance/all pt
Everyone at all times
›Daily emollient cream or ointment & trigger avoidance- could be cream during day ointment at night, avoid temp changes, pollens, etc whatever triggers pts specific
›High level maintenance/ pt w/“hot spot”
›Intermittent topical CS (2 days/week)
›Want to prevent steroid atrophy
What do you do in an active flare of atopic derm for tx?
Daily use of topical steroids until all lesions clear, then low level maintenance
Why might you give a pt with atopic derm abx?
if there are lots of opening from itching
What kind of steroids do you want to use to tx atopic derm in kiddos? Adults?
›Infants/kiddos: low potency (hydrocortisone) BID to TID
›Adults: higher potency (triamcinolone or betamethasone) BID to TID
What is dyshidrotic eczema?
chronic, relapsing, pruritic eruption w/ vesicles; associated w/hyperhidrosis & atopic dermatitis
What will be a pt hx that may lead you to think dyshidrotic eczema?
›Episodic dysesthesia (burns, stings) & pruritus w/symptom-free intervals
›PMH: atopy
What should you evaluate your pt for if you suspect dyshidrotic eczema?
Evaluate for stress
What are PE findings for dyshydrotic eczema?
›Sites: palms > soles, interdigital areas; typically B/L & symmetric
›Early: clear vesicles, non-erythematous
later: vesicles become unroofed & inflamed w/desquamation & peeling
How is dyshydrotic eczema dx?
›biopsy if uncertain
›Exclude allergic or irritant contact dermatitis
How is dyshydrotic eczema tx?
›Mild: low potency topical steroids; moderate to severe: high potency steroids w/occlusive dressing
›Emollients, lukewarm (aka tepid) bathing
›Antihistamines
What is nummular eczema?
common pruritic, chronic, relapsing inflammatory condition
What is the pt hx for nummular eczema?
no prior atopic dz
What is the PE for nummular eczema?
well-demarcated lesions (coin shaped, 2-3 cm diameter - legs/men & arms/women)
How is nummular eczema dx?
No specific way
How is nummular eczema tx?
topical steroids, TCI, phototherapy
What is lichen simplex chronicus?
chronic dermatitis d/t habitual rubbing or scratching; often superimposed over atopic dermatitis
What is the typical hx of lichen simplex chronicus?
gradual onset pruritus out of proportion to appearance of lesion
What do you need to evaluate your pt for if dx with lichen simplex chronicus?
psychosocial issues (stress, depression, anxiety)
What are PE findings of lichen Simplex Chroniucs?
Lichenification & excoriated areas: flesh tone to pink or hyperpigmented plaques w/exaggerated skin lines; non-erythematous, non-vesicular in easily reached areas
How is lichen dx?
biopsy if no response to treatment
What is the tx for lichen?
›Topical anti-pruritic agents (doxepin, menthol preps) or oral antihistamines; topical anesthetic
›High potency topical steroids w/transition to lower potency topical steroids as resolution allows, + occlusive dressing
What is seborrheic dermatitis?
chronic, relapsing disorder of burning, scaling & itching w/symptom-free intervals
what are PE findings of seborrheic dermatitis?
symmetric distribution; pink-yellow to red-brown greasy, scaly lesions scalp, ears, medial eyebrows, upper lids, nasolabial folds, central chest, body folds
How is seborrheic derm dx?
biopsy w/treatment failure or if think its CA
How is seborrheic derm tx?
›Topical steroids (short course)
›Mild strength – face & body folds
›Moderate strength – scalp, ears
›Daily shampoo: alternate gentle shampoo w/selenium sulfide or zinc shampoo – every other week
What is stasis dermatitis?
chronic, pruritic, eczematous, erythematous, scale-crust dermatitis; non-inflammatory edema of LE
What is stasis derm often seen?
Chronic venous insufficiency: typically = cycle of scratching, excoriations, weeping & crusting d/t inflammation; starts UL goes BL
What is the typical pt hx with stasis derm?
›Usually > 50 y/o; usually insidious onset w/erythema & edema initially with PMH of vascular dx DVT, cellulitis
What should you evaluate your pt for if suspected stasis derm?
hypercoag status also get ABI
What are PE findings of stasis derm?
Scaly, eczematous patches w/violaceous or brown lesions, medial malleolus
Varicosities, petechiae superimposed on discoloration
Secondary ulcers occur as a result of weakened skin around the ankles
What is 1st line tx for stasis derm?
›Antibiotics w/indication 2ndary infection
›Burrow’s (wet dressing, soak) or cooling paste if ulcerated
›Apply x 15-30 min & reapply PRN or soak area x 15-30 min q8hr
›Topical steroid, leg elevation, debride PRN
What are PE findings of diaper dermatitis?
›Mild: shiny erythema + scaling; Moderate: papules, vesicles, erosions
›Prominent lesions on buttocks, thighs, mons pubis or scrotum
What pathogen should you suspect if your pt has satellite lesions from diaper derm?
CANDIDA
How is diaper derm tx?
Purely contact dermatitis: low potency topical steroid
Candida suspected: antifungal
Barrier ointment
NAKED BABIES YAY SO CUTE
What is the hx for contact derm?
›Pruritus 2ndary to direct toxic effect (topical or systemic exposure)
exposures and allergies… meds can also cause this
What are the types of contact derm?
irritant contact dermatitis vs. allergic contact dermatitis
What is irritant contact derm?
localized, non-immunologically mediated cutaneous inflammatory rxn
What is allergic contact derm?
delayed-type hypersensitivity rxn d/t prior exposure & sensitization
What does contact derm look like?
erythema, edema, vesiculation w/subsequent erosions & scaling
Where is the contact derm rash located?
›Sites/irritant: usually hands, feet, lips
›Sites/allergic: well demarcated & localized to contact area or diffuse, patchy distribution (body shampoo); extension beyond site w/autosensitization
How is contact derm dx?
patch test
What is the tx for contact derm?
›Avoid irritant or allergen
›Antipruritic
What are some short term tx options for contact derm?
topical steroids: higher potency (fluocinonide TID) w/transition to low or medium potency (triamcinolone)or systemic (severity dependent)
What does poison ivy look like?
streaky erythema & papules @ site of contact w/vesicular development hours later
-w/in 48 hours
How is poison ivy tx?
›Ultrapotent topical steroids or oral w/severe/widespread
›Antipruritic
›Education: “leaves of 3, leave them be”
What are the comedones in acne vulgaris?
›Closed comedones = “whitehead; open comedones (dilated follicular opening w/keratin plug (oxidized lipids & melanin)= “blackhead”
What are the subtypes of acne vulgaris and who is affected by them?
›Acne excoriee (habitual picking) – girls & young women
Acne fulminans - boys 13-16 y/o w/inflamed nodular lesions face, trunk & UE – systemic symptoms too!
What are the degrees of involvement for acne?
Mild: few papules/pustules; no nodules
Moderate: some papules/pustules; few nodules Severe: numerous papules/pustules; many nodules
What should you r/o with acne vulgaris?
r/o androgen excess
How is acne vulgaris tx?
1st line: topical retinoids & benzyl peroxide or retinoids & topical antibiotic
When should you refer acne?
nodulocystic acne, moderate-severe acne, recalcitrant acne
What is rosacea?
chronic condition characterized by recurrent flushing/blushing & telangiectasia (erythematotelangiectatic)
or pink to red papules & pustules (papulopustular )
or hypertrophy & irregular thickening of the nose/forehead/cheeks/chin (phymatous)
What is the typical presentation?
episodic erythema, “flushing & blushing”
What are the subtypes of rosacea?
›Subtype: transient papulopustular of central face
›Subtype: phymatous = persistent deep erythema, irregular surface nodules, thickened skin
How is rosacea tx?
›Oral/low-dose tetracyclines
›Topical: metronidazole(really good 1st line), antibiotics, sulfur-containing compounds
Should you use steroid in rosacea?
NO DO NOT- one of the only non steroids
What is perioral dermatitis?
chronic papulopustular facial dermatitis
What often precedes perioral derm?
long-term use topical steroids on face
What are aggravating factors for perioral derm?
anti-aging creams, skin care w/petrolatum or paraffin base, whitening toothpaste
What are PE findings for perioral derm?
pinpoint erythematous papulovesicles & papulopustules w/ scaling around eyes, chin, lips & nasolabial folds
what is the tx for perioal derm?
›Pt education, reassurance, discontinue anti-aging (retinol) creams, whitening toothpaste & all steroids
›Oral tetracycline antibiotic 4-8 week course; topical metronidazole gel….
Typical first-line therapy: Doxycycline 100mg BID x 3-4 weeks
What is lice?
contagious, parasitic infestation spread by direct contact w/fomites, bedding/linens or infected individuals
What is first line tx for capitis?
wet combing & permethrin; can repeat in 7-9 days if live nits observed
What is 1st line tx for corporis?
linen & clothes hygiene (149F), treat pruritus & 2ndary infection
What is 1st line tx for pubic?
wet combing & permethrin 1% cream; can repeat in 7-9 days if live nits observed
What is scabies?
contagious, parasitic infestation spread by direct contact w/fomites, bedding/linens or infected individuals
How long might it take for symptoms of scabies to appear?
3-6 weeks
What are common PE findings for scabies?
›Erythematous papules w/scale-crust, excoriations
›Most common: finger webs, flexor surfaces of wrists, elbows, axillae, buttocks, genitalia, ankles & feet
What is pathognomonic of scabies?
Burrows (threadlike, gray-white, wavy lines)
How is scabies tx?
1st line: permethrin 5% cream leave on 8-14 H then wash off, can repeat in 1 wk if needed
Who else should be tx if your pt has scabies?
ALL CLOSE CONTACTS
what are local symptoms of black widow spider bite?
sharp or burning pain within minutes of bite but typically resolves within minutes to hours
What are systemic symptoms of black widow bite?
›onset within 20 – 30 minutes
›Hyperesthesia, perspiration, N/V, tachycardia, restlessness, agitation or sense of impending death
›Painful cramps or spasms: arm bite may lead to chest tightness or dyspnea; leg bite may lead to abdominal pain or leg spasms
What should you look for on the skin with black widow spider bite?
often nothing seen or palpated but look for be two pinpricks size openings, tender target lesion, urticaria, piloerection, edema, localized perspiration
What are findings of neuro for black widow bites?
tetanic contractions of limbs, spasms, rigidity
What is tx for a black widow spider bite?
Supportive care, tetanus immunization prn & ED for severe rxn
What are local symptoms of brown recluse bite?
often asymptomatic or stinging/burning pain w/onset 1 – 24 hours s/p bite
What are systemic signs of brown recluse bites?
F/C/N/V, malaise
What are skin findings for brown recluse?
usually no visible injury the first 1 – 3 days, possible pinprick lesions
What should you get in brown recluse spider bites?
UA to check for systemic hemolysis
What is tx for brown recluse?
Supportive care, tetanus immunization prn & ED for severe rxn, hemolysis or shock
What is the incubation period for RMSF?
2-14 days post bite
What days does the fever happen?
3-5 days PRE-rash myalgias and HA
What does the rash look like in RMSF?
Pink to erythematous macular-popular rash on wrists/ankles, widespread central petechiae
What is the 1st line tx for RMSF?
empiric doxycycline or TCN
When do symptoms appear in lyme dz?
3-30 days post-bite
What are s/s of lyme?
›F/C, HA, fatigue, myalgia, arthralgia, LAD
›Erythema migrans rash (average about 7 days)
What are s/s that can present days- months post bite in lyme?
Severe HA, neck stiffness, arthritis (knees & large joints), Bell’s palsy, palpitations or an irregular heart beat (aka Lyme carditis), episodic dizziness or SOB, shooting pain, numbness or tingling/hands or feet, problems w/short-term memory
How is lyme dx?
2 step process for antibodies
›EIA followed by Western blot
›Both need to be positive
How is lyme dx tx?
›oral doxycycline, amoxicillin, or cefuroxime axetil
›CNS or cardiac forms of illness – IV ceftriaxone or penicillin
What is myiasis?
Cutaneous furuncular myiasis, caused by the human botfly
What is the clinical presentation for myiasis?
locally painful, firm furuncular lesion w/centrally located pore
What are common pathogens in cat/dog bites?
Strep, staph, Pasteurella multocida, anerobes
How should cat/dog bites be tx?
›Clean wound
›Broad-spectrum antibiotics
›Tetanus booster
›+ rabies vaccine/immunoglobulin
What is marine envenomation?
Dermatitis d/t contact w/sea anemone, coral, sponges
What is the acute rxn caused by marine envenomation?
›urticarial, erythematous or hemorrhagic = seabather’s eruption
›Localized bathing suit area & intertriginous sites – edematous pink papules
(Jellyfish or sea anemone )
How is marine envenomation tx?
Denature venom, remove foreign body, or topical steroids
What is seborrheic ketatosis?
common condition > 40 y/o;
greasy appearance, warty texture; appears “stuck on; sites: face, neck, scalp, back, upper chest & less frequently on arms, legs & lower trunk
How is seborrheic ketatosis dx?
dermoscopy
How is seborrheic ketatosis tx?
liquid nitrogen, surgical excision
What is actinic keratosis?
typically multiple pre-malignant lesions on sun-exposed areas d/t cumulative solar damage
What are PE findings typical of actinic keratosis?
small (
What should you do if you have a pt present with actinic keratosis?
biopsy - r/o SCC & BCC
How is actinic keratosis tx?
liquid nitrogen cryo or topical 5-fluorouracil, imiquimod or diclofenac
What is a classic pt hx when present with high suspicion of BCC?
present w/pimple that won’t heal or recurrent scab
What are risk factors for BCC?
Sun exposure, pale. Light eye/hair, male, tendency to sunburn, hx of skin CA, FITZ skin types I/II
Where are the majority of BCC found?
Face, then neck
What is the most common presentation of BCC?
Nodular: most common, pink, pearly papule, or nodule often w/central telangiectasia or umbilication, ulceration & rolled periphery
What are 2 other presentations? What can they be mistaken for?
Pigmented: papule w/glassy transparency, can be speckled
Can be mistaken for melanoma
Superficial: erythematous patch/plaque w/atrophic center ringed by translucent micropapules, usually on trunk or extremities
Morpheaform: firm, flesh-colored or yellowish & waxy w/pink tinge, scar like papule or plaque w/ill-defined borders
How is BCC dx?
Dermoscopy/ biopsy
How is BCC tx?
Topical imiquimod
Surgical excision
What is SCC?
malignant epithelial tumor arising from keratinocytes of epidermis; 2nd most common skin cancer
What is the typical presentation of SCC?
Ca in sun-exposed sites of elderly & fair-skinned individuals
What does SCC typically grow from?
arise from actinic keratoses but some arise de novo, old scar, sites previously exposed to radiation or HPV
Where is the most common site of mets and where does SCC most commonly met to?
Ears or vermilion border and mets to the LUNGS
What are PE findings in SCC?
Erythematous, keratotic papule or nodule on sun damaged skin; varying degrees of ulceration, erosion, crust or scale & color red to brown, tan or pearly;
How is SCC dx?
biopsy, CT
How is SCC tx?
total excision: electrocautery or Mohs
What is tx for melanoma?
surgical w/staging & sentinel LN biopsy
Mohs microsurgery
What sunblock ingredients cover which wavelengths?
UVA coverage: benzophenones, oxybenzone, methyl anthranilate, avobenzone
UVB coverage: PABA, cinnamates
All wavelength: titanium dioxide, zinc oxide
