Dermatologic Flashcards
Atopic dermatitis
Epi
- h/o atopy
- infants: face, scalp, ext surfaces
- children: flexures
- adults: hands, eyelids, nipples, flexures
- d/t irritants, allergens, psych, envr, microbial
Sxs
- chronic, itchy skin; rough red patch; scaling
- acute flare - may have weeping area
Mgmt
- topical steroids
- PO anti-histamine (sedative)
- secondary infection: abx
Contact dermatitis
Epi
- common allergens: plants, nickel, neomycin, terpentine, procaine
Allergic:
- acute onset, pruritic, vesicles, weeping, crusts, erythema
- sensitization after first contact; future contact results in allergic response
Irritant:
- first exposure
- chronic in nature; erythema w/scale and excoriations; burning/stinging
Mgmt:
- avoid irritants, wear gloves, barrier creams, topical steroids
Nummular eczematous dermatitis
- groups of coin shaped plaques of papules and vesicles
- plaques may be dry and scaly or exudative and crusty
- lower legs of older men
- consider ring worm but nummular is solidly scaly throughout
- winter flares
Mgmt: topical steroids (can use higher potency on older men on lower legs)
Perioral dermatitis
- often in adults who say they have never had acne before
- superficial inflammatory papules in clusters on patches of erythema
- itchy or asx
Mgmt:
- PO abx + topical metronidazole or azelaic acid gel BID
- abx: doxy, mino, erythro, ttc
come back in 6wk, if better, can reduce to daily
Seborrheic dermatitis
- D/t: sebum production, overgrowth of Malassezia and immunologic abnormalities
Sx:
- scalp, eyebrows, nasolabial fold, groin, chest
- skin inflamed w/yellow or white greasy scale; mildly pruritic
- worse in winter
adults: dandruff
peds: cradle cap
Mgmt:
- scalp: anti-seb shampoo* (zinc, selenium); ketoconazole shampoo twice weekly; tar shampoo mild case; topical corticosteroid solution
- skin: low potency corticosteroid*
Stasis dermatitis
- d/t chronic venous insufficiency
Sx:
- itchy, eczematous, scaly rash on lower legs
- fissures, ulcers
- hyperpigmentation (hemosiderin) - “brawny”
Mgmt:
- topical steroids
- lubrication
- elevation, compression stockings
Dyshidrotic eczema
Epi: atopy; outbreaks during hot, humid weather
Sx
- pruritic, clear “tapioca-like” vesicles that progress to papules, scaling, lichenification
- fingers, palms, soles
Mgmt: topical steroid
If concern for athletes foot, treat w/antifungal first and then switch to steroid for eczema
Lichen simplex chronicus
D/t habitual scratching –> leathery and lichenification [neck, wrists, extensor surfaces of forearms, legs, scrotum, vulva]
Sx
- well circumscribed plaque of Lichenification arising from confluence of small papules*
- pruritic
Mgmt: stop itch-scratch cycle
- mid/high potency topical steroid x 3wk to thick lesion (less potency for thinner skin)
- PO antianxiety/sedating meds may be beneficial to stop scratch at night
Drug eruptions
Type I: classic immediate hypersensitivity [urticaria, angioedema, anaphylaxis]
Type II: cytotoxic [hemolysis, purpura]
Type III: immune complex [vasculitis, serum sickness, urticaria, angioedema]
Type IV: delayed hypersensitivity [contact dermatitis, exanthematous rxn, photoallergic rxn]
Morbilliform eruptions
MC cutaneous drug reaction (Type IV) - 7-10d after starting drug
Sx: maculopapular eruption, itching, polycyclic erythema; symmetrical on trunk, extremities
Common drugs: PCN, NSAIDs, TMP-SMX, thiazides
Mgmt: D/c drug; antihistamine
Urticarial drug reactions
Onset depends on governing mechanism
Sx: hives/wheals; angioedema; anaphylaxis; pruritus; burning of palms/soles
Common drugs: ASA, PCN, blood products, radiographic dye, morphine
Mgmt: d/c drug, antihistamine, +/- systemic steroid
Fixed drug eruption
Presents soon after drug exposure (30min to 8hr); reappears same site each time drug is taken
Sx: dusky red, round, plaques/bullae
MC: glans of penis (location)
Common drugs: ASA, NSAIDs, sulfonamides, TTC, TMP-SMX
Mgmt: d/c drug, topical steroid
- eroded lesion: use bactroban (abx ointment)
Lichenoid drug reaction
Onset 3wk - 3yr from drug exposure
Sx: multiple purple, flat topped, itchy papules
- heal w/brown post-inflammatory hyperpigmentation
- oral mucosa can be affected
Common drugs: gold salts, antimalarials, TTC, ketoconazole, sulfonylureas, NSAIDs, BB, ACE, CCB, furosemide, thiazide
Mgmt: d/c drug +/- steroid; antihistamine
Drug hypersensitivity syndrome
W/in first 2mo of drug exposure
Dx criteria: hematologic abnormality, cutaneous eruption, systemic involvement
Sx: fever, facial edema; exfoliative dermatitis; erythematous papules; LAD; eosinophilia, leukocytosis, atypical lymphocytes
Common drugs: sulfonamides, AEDs, allopurinol, minocycline, CCBs, ranitidine
Mgmt: d/c drug, prednisone, topical steroids, PO antihistamine
Acute Generalized Exanthematous Pustulosis (AGEP)
5d after drug ingested
Sx: superficial inflammatory pustules all over; fever, chills, ill; leukocytosis
Common drugs: macrolides, PCN, diltiazem
Mgmt: d/c drug; refer to derm
Stevens-Johnson Syndrome
MC: AEDs, sulfa, PCN, cold/cough OTC, NSAIDs, analgesics
Sx: erythematous macules w/darker purpuric centers (2 zones of color)
- extensive mucous membrane involvement
- fever, malaise, myalgias
Mgmt:
- ICU/burn unit
- tx infection
- d/c drug
- +/- steroids
- supportive treatment
Toxic epidermal necrolysis
Sx:
- prodrome: flu-like sxs, fever, prior to mucus membrane lesions
- mild/mod tenderness of skin to pain, burning, paresthesias
- skin peels off, glistening
- mouth lesions, conjunctival burning
Nikolsky sign: push on skin and it peels away
Mgmt: d/c drug
- supportive, pain relief
- IVIG
- tx infection
Lichen planus
Epi: MC in women
Sx: 1-10mm flat-topped pink-purple pruritic, polygonal, papules (4Ps)
Wickman’s Striae: fine white lines
Dx confirmed w/bx
Mgmt:
- steroids, retinoids, immunosuppressive agents
Pityriasis rosea
Et: viral
- older children, young adults
- spring, fall
Herald patch: single 2-5cm Oval lesion, red with collarette of scale
Progress to exanthem (smaller, salmon patch)
“Christmas tree” distribution
Initially look like ring worm but widespread distribution w/in a few days
Mgmt: spontaneous resolution 6-12wk
Psoriasis
MC elbows, knees, scalp
Sx: silvery, dry scales on bright red well-demarcated plaques
- mild pruritus
- nail pitting or onycholysis
- Koebner phenomenon: lesions at trauma site
- Auspitz sign: pinpoint bleeding after removal of scale
- Woronoff ring: blanching around healing plaque
Mgmt:
- > 5% BSA = derm referral
- do NOT use PO steroid
- topical steroid: high/ultra high x 2-3wk then pulse
- Pluse: calcipoteriene, retinoids, coal tar, salicylic acid
Types of Psoriasis
Plaque: localized area w/thick scale (MC on extensor surfaces)
Guttate: small red papules w/scale
Inverse: shiny red areas in flexures
Pustular: pustules on palms and soles
Erythrodermic: generalized redness, may require admit
Psoriatic arthritis: hand joints MC, nail involvement, requires systemic therapy
Erythema multiforme
Et: HSV (MC)
Sx: targetoid pink, dark red, purple macules
- papules/plaques +/- vesicles and bullae on palms, soles, forearms, legs
- 3 zones of color**
Mgmt:
- d/c drug
- tx infection; control HSV w/acyclovir
- topical abx for eroded vesicles
- prednisone taper
Acne vulgaris
Bacteria: propionibacterium acnes
Sx: inflammatory papules/pustules, cysts/nodules
- open: blackheads
- closed: whiteheads
- ice pick/pock mark scars, keloids
Mgmt:
- inflammatory: benzoyl peroxide cream +/- topical Abx
- comedome: topical retinoid [tretinoin, adapalene, tazarotene]
can add: PO abx (doxy or other ttc)
wear sunscreen!
refer to derm
Rosacea
Erythematous telangiectasia - fixed erythema w telangiectasia, intermittent flushing
Tx: metronidazole gel*
Papulopustular type
Tx: topical metronidazole gel + oral abx (doxy or mino)
Actinic keratosis
Premalignant - BCC or SCC* dt sun exposure
Fair skin, older than 40
Sx: red brown scaly Papule without underlying induration, 1-6mm, usually asx
Skin checks q 6mo
Sun protection
Mgmt
Derm referral
Cryotherapy <15 lesions
Tx: topical 5fu, imiquimod, aminolevulinic acid pulse light therapy*
Seborrheic keratosis
Mc after age 30
Sx: warty stuck on appearance anywhere except lips, palms, soles
Any color and variable size
Mgmt
Don’t have to treat unless cosmetics
Cryo, E&D
Seborrheic keratosis subtypes
Dermatosis papulosa nigra- African descent smaller darker papules on cheek
Stucco keratosis: white papules on legs
Sign of leser trelat: can indicate internal malignancy
Lice
Children
Hair shaft
Nits behind ears or near neck
Itching
OTC: permethrin 1% repeat in 9d
Rx: benzyl alcohol lotion 5% ivermectin and malathion lotion
Nit comb
Scabies
Infants, I/c head and neck
Extremely pruritic papules and burrows seen abdomen hands feet axilla and genitals
Scabies prep: scrape lesion w 15 blade
Mgmt 5% permetherin cream repeat in 1 wk, ivermectin (not under 5y or pregnant females); tx family and close contacts
Alopecia areata
Immunologic phenomenon - emotional physical mental stress
Sx: sudden hair loss, skin is NORMAL (no scarring erythema or scale)
Can regrow but lose hair in another area
Indicator: missing medial brows and eyelashes
Labs: thyroid, cbc, ana, cmp
Mgmt
Steroids w immunomodulator, control autoimmune condition
Androgenic alopecia
Mc type of hair loss in men
Progressive loss of terminal hairs on scalp - anterior scalp, mid scalp, temporal and vertex
Mgmt: minoxidil, po finasteride
Onychomychosis
Fungal infection of the nail, increased with age and immunosuppression
Paronychia
Bacterial infection of lateral nail fold
Skin red, inflamed, warm, tender +/- pus
Mgmt
I&D
Bacterial infection: pcn or cph
Antifungal cream bid
Condyloma accuminatum
Anogenital warts
Soft, single or multiple, flat, dome shaped, cauliflower, filiform, fungating, pedunculated, smooth, verruceous w variable color
Typically asx but sometimes pruritic
Mgmt
Pt applied: topical imiquimod, podophyllotoxin, sinecatechins
Clinician applied: cryo, trichloroacetic acid, surgery
Measles (rubeola)
Prodrome: coryza, cough, Koplik spots (1-3mm grayish elevations w erythematous base, typically buccal mucosa)
Brick red erythematous maculopapular blanching rash beginning on face spreading down body
Supportive care
Rubella (German measles)
Pink pinpoint maculopapules appearing on face and spreading cephalocaudal; generalized in 24hr
Anterior, posterior, and occipital LAD
SUPPORTIVE CARE
Roseola infantum
Kids <2y
High fever for several days, followed by blanching maculopapular rash
Neck and trunk then spreads to face and extremities
Supportive care
Erythema infectiosum
Parvovirus b19*
Slapped cheek rash
Followed by “lace-like” rash (reticulated blanching erythema) on trunk and extremities
Supportive care
Scarlet fever
GAS (pyogenes)
Pastia lines - confluent petechiae in antecubital fossa
Diffuse erythematous sandpaper rash
Occurs w or preceded by pharyngitis
Mgmt
Resolute followed by desquamation or frank peeling
Tx strep
HSV 1 Primary
Asx
Primary gingivostomatitis - lips oral mucosa involved, swollen bleeding gums
Vesicles become erosion
HSV 1 recurrent
Trigger - uv exposure, abrasions, chapping, stress, hormones, illness
Prodrome- tingling, burning, itching
Eruption of tender vesicles on erythematous base (dew drop on rose petal)
A/w Bell’s palsy
HSV 1 dx tx
Clinical dx
Viral culture or pcr
Thank smear
Mgmt
Mild - topical penciclovir or doconosol
Extensive, frequent - po antivirals
HSV 2
Genitalia herpes
Tx po antiviral on hand
VZV
Reactivation of varicella virus most over 60
Prodrome: burning, tingling, itching
Red patch - vesicles - rupture - crust
Dermatomal dist
Herpes zoster ophthalmicus- Hutchinson sign (tip of nose) risk for corneal involvement
Postherpetic neuralgia
Dx- tzanck and culture
Tx - po abx
Zostavax vaccine >50; one dose live vaccine
Verrucae (warts) info and tx
Hpv infecting epidermis and mucous membranes
Direct contact and auto inoculation *
Rf- young age, sexual activity, I/c
Most resolve on their own Exfoliative - salicylic acid; retinoid Ablative - cryo, cantharidin, laser Cytotoxic - bleomycin, 5fu, interferon Immunomod - imiquinod, candida antigen Other - duct tape, pads, apple cider vinegar
Types of warts
1. Common 1-10mm hyperkeratotic outgrowth Disruption of palmar crease Red brown dot might bleed w scraping Filiform - small base w elongated cap and digital projections
- Plantar
Small shiny sharp marginated papule then plaque w rough hyperkeratotic surface studded w brown black dots
Disrupt skin lines - Flat
1-5mm sharp defined flat papule
Skin colored to light brown on dorsal hand face or shin
Linear distribution - Corn (not wart)
Friction pressure - progress to tenderness w pressure
Skin lines travel through lesion
Shaved = glassy core w no cap bleed points
Molluscum contagiosum
Child and sexually active adult
Smooth, pearly, dome shaped, umbilicated papule* often multiple lesions
Resolve on own, may use cryo, curettage, cantharidin, imiquimod
Candidiasis
Sweaty area, skin fold
Red moist glistening papule with “satellite lesions”*
Dx KOH and culture
Manage - dry w powder, topical nystatin and azole
Tinea versicolor
Superficial skin infection of trunk, neck, and upper arm
Velvety tan, pink, or white macules that may coalesce
Asx or mild itch
Likely to recur
Manage:
Topical - selenium sulfide or ketoconazole shampoo, antifungal azole cream
PO - itraconazole or fluconazole
Tinea corporis/pedis
Pedis - athletes foot: erythema, scaling, maceration, itch
Capitis- head: black dot, scaling and broken hairs (require PO therapy)
Sx- ring shaped lesion w advanced scaly border and central clearing, mild pruritus
Dx - skin scraping for KOH
Mgmt
Local - topical therapy
Extensive or follicular - Po therapy
Acanthosis nigricans
DM, hypothyroid, obesity, drug, malignancy
Velvety thickening and hyperpigmentation of skin may have skin tags super imposed on top
Axilla, posterior neck
Dx - FBG, TSH, imaging if suspicious for malignancy
Tx- underlying; DM; sxs
Hiradenitis suppurativa
Apocrine gland, more common w F
Inflammatory papules/pustules, cysts, comedones, sinus tracts
Mgmt Acne meds - Po abx, topical or Po retinoids Steroid injections I&d Adalimumab
Lipoma
SQ tissue neoplasm
Soft mobile, solitary or multiple round, lobulated, yellow masses
Well circumscribed, no overlying skin changes
Mgmt
Excision
Epithelial inclusion cysts
Epidermis/epithelium of hair follicle
Soft, mobile nodule (may have overlying puncta)
Mgmt
Excision - white and shiny after extraction
I&d not effective
Melasma
Harmless pigmentary seen on malar region of darker skin women commonly during pregnancy
Brown tan patches Mc on face
Irregular patches w well demarcated borders
Dx — HCG; TSH, cortisol (addisons), woods lamp Mgmt Gone after pregnancy Hydroquinone Limit sunlight exposure Topical retinoid
