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Emergency Medicine > Dermatologic Conditions > Flashcards

Dermatologic Conditions Flashcards

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Royal College: Emergency Medicine flashcards
1
Q

Approach to ED Dermatologic Conditions

A
  • CC
  • brief history- duration, rate of progression, location
  • derm exam
  • age-appropriate differential diagnosis
  • additional concerns- associated complaints, meds, exposures, pertinent +/-
  • evaluate systemic involvement
  • dermatologic consultation if necessary
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2
Q

Dermatologic Exam

A
  • type of lesion
  • secondary changes to surface
  • color
  • shape
  • arrangement
  • distribution
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3
Q

DDx - Plantar surfaces

A

atopic dermatitis, candidiasis, eczema, ichthyosis

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4
Q

DDx - Sun exposure

A

sunburn, photosensitive drug eruption, photosensitive dermatitis,

SLE, viral exanthem, porphyria

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5
Q

DDx - Distal extremeties

A

viral exanthem, atopic/contact dermatitis, eczema, Rocky Mtn SF, gonococcemia

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6
Q

DDx - Front/Back of chest

A

pityriasis rosea, secondary syphilis, drug eruption, atopic/contact dermatitis, psoriasis

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7
Q

DDx - Clothing covered

(thorax and distal lower extremeties)

A

contact dermatitis, psoriasis, folliculitis

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8
Q

DDx - Acneform

(face and upper thorax)

A

acne, drug-induced acne, irritant dermatitis

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9
Q

<0.5cm, flat, level w/ skin

A

macule

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10
Q

Macule Conditions

A
  • syphilis (secondary)
  • miningococcemia (early)
  • viral exanthema
  • drug eruption
  • vitiligo
  • tinea versicolor - hyper (sun) / hypo (tan)
  • nevus
  • tattoo (ink)
  • rheumatic fever
  • toxic/infectious erythemas
  • ecchymosis (external trauma)
  • cellulitis (early)
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11
Q

<0.5cm, solid, elevated

A

papule

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12
Q

Papule Conditions

A
  • molluscum
  • dermatitis
  • dermatitis
  • erythema multiform
  • acne
  • basal cell carcinoma
  • melanoma
  • nevus
  • warts
  • skin tags
  • atopic dermatitis
  • urticaria
  • eczema
  • folliculitis
  • insect bites
  • vasculitis
  • psoriasis
  • scabies
  • toxicodendron dermatitis- poison ivy, oak, sumac
  • varicella (early)
  • gonococcemia
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13
Q

papule >0.5cm, solid, elevated

A

plaque

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14
Q

Plaque Conditions

A
  • pityriasis rosea
  • syphilis (secondary)
  • eczema
  • tinea corporis and versicolor
  • psoriasis
  • seborrheic dermatitsi
  • urticaria
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15
Q

>0.5cm dermal or SQ solid, elevated

A

nodule

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16
Q

Nodule Conditions

A
  • erythema nodosum
  • furuncle (carbuncle larger)
  • lipoma
  • warts
  • basal cell, squamous cell, metastatic carcinoma
  • melanoma
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17
Q

any size, white to pink, edematous papule or plaque lasting <24h

A

wheal

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18
Q

Wheal Conditions

A
  • PPD test
  • angioedema
  • urticaria
  • insect bites
  • erythema multiforme
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19
Q

<0.5cm cavity filled w/ pus (purulent) or sterile

A

pustule

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20
Q

Pustule Conditions

A
  • gonococcemia
  • herpetic infection
  • impetigo
  • rosacea
  • pyoderma gangrenosum (assoc. w/ UC and Crohn’s)
  • acne
  • folliculitis
  • hidradenitis suppurativa
  • psoriasis
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21
Q

<0.5cm blister containing clear fluid or blood

A

vesicle

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22
Q

Vesicle Conditions

A
  • pemphigus vulgaris
  • herpetic infection (herpes simplex, herpes zoster, varicella)
  • impetigo
  • Toxicodendron dermtitis- poison ivy, oak, sumac
  • thermal burn (2nd degree)
  • friction blister
  • toxic epidermal necrolysis
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23
Q

>0.5cm blister containing fluid or blood

A

bulla

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24
Q

Bulla Conditions

A
  • bullous impetigo
  • bullous pemphigoid
  • pemphigus vulgaris
  • Toxicodendron dermatitis
  • thermal burn
  • friction blister
  • toxic epidermal necrolysis
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25
Q

skin defect that extends into dermis or deeper

A

ulcer

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26
Q

Ulcer Conditions

A
  • apthous lesions- tx w/ Kenalog or orabase dental cream
  • chancre (primary syphilis, non-painful)
  • stasis ulcer
  • chancroid (painful)
  • decubitus ulcer
  • thermal or friction injury
  • subacute or chronic ischemia
  • malignancy
  • primary blistering disorders- bullous pemphigoid/vulgaris
  • brown recluse spider envenomation
  • pyoderma gangrenosum
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27
Q

skin defect only in the dermis

A

erosion

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28
Q

Erosion Conditions

A
  • candidiasis
  • dermatophytic infection (tinea)
  • eczema
  • toxic epidermal necrolysis
  • toxic-infectious erythemas
  • erythema multiforme
  • primary blistering disorders
  • bullous pemphigoid
  • pemphigus vulgaris
  • brown recluse spider envenomation
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29
Q

dried blood/exudate on skin surface

A

crust

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30
Q

Crust Conditions

A
  • eczema
  • dermatophytic infection (tinea)
  • impetigo
  • contact dermatitis
  • insect bite
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31
Q

flakes of stratum corneum

A

scales

32
Q

Scale Conditions

A
  • psoriasis
  • xerosis (dry skin)
  • pityriasis rosea
  • toxic and infectious erythemas
  • syphilis (secondary)
  • dermatophytic infection (tinea)
  • tinea versicolor
  • thermal burn (first degree)
33
Q

least potent, mild, upper mid-strength corticosteroids

A
  • least: hydrocortisone
  • mild: Triamcinolone (Kenalog) 0.025%
  • mid-strength: Triamcinolone (Kenalog) 0.1%
34
Q

Uses

  1. Superpotent
  • Clobetasol (Temovate, Clobex) 0.05% cream or ointment
  • Halobetasol (Halonate, Ultravate)
  • Betamethasone (Diprolene)
  1. Potent
  • Fluocinonide (Lidex, Vanos) 0.05% ointment
  • Halcinonide (Halog) 0.1% cream
  • Mometasone (Elocon) 0.1% ointment
A
  • psoriasis
  • eczema of hand (severe)
  • poison ivy (severe)
  • atopic dermatitis (severe)
35
Q

Uses

  1. Upper mid-strength
  • Betamethasone (Diprolene) 0.05% lotion
  • Fluticasone (Cutivate) 0.005% ointment
  • Triamcinolone (Kenalog) 0.1% ointment
  1. Mid-strength
    * Mometasone (Elocon) 0.1%cream, lotion
  2. Lower mid-strength
  • Betamethasone (Diprolene) 0.1% cream
  • Fluocinolone (Synalar) 0.025% cream
  • Fluticasone (Cutivate) 0.05% cream
A
  • atopic dematitis
  • stasis dermatitis
  • seborrheic dermatitis
  • tinea
  • scabies
  • nonspecific dermatitis of face (severe)
36
Q

Uses

  1. Mild
  • Alclometasone (Alclovate) 0.05% cream or ointment
  • Desonide (Desonate, Desocort) 0.05% cream
  • Triamcinolone (Kenalog) 0.025% cream
  1. Least Potent
    * Hydrocortisone 1% or 2.5% cream, lotion or ointment
A
  • nonspecific dermatitis of face, eyelids, perineum
37
Q

Evaluation of Wounds & Lacerations:

Symptoms

A
  • pain
  • swelling
  • paresthesias
  • muscle weakness (distal too)
38
Q

Evaluation of Wounds & Lacerations:

Type of Force

A
  • crush (blunt)
  • shear (shart)
  • bite
  • puncture
39
Q

Evaluation of Wounds & Lacerations:

Elements of Contamination

A
  • time from injury to initial cleansing
  • time from injury to presentation
  • wound care prior to ED
  • object causing injury
  • cleanliness of body and environment at injury and afterward
40
Q

Evaluation of Wounds & Lacerations:

Factors Resulting in Injury

A
  • intentional vs. unintentional
  • occupational vs. non-occupational
  • assault or self-inflicted (for reporting)
41
Q

Evaluation of Wounds & Lacerations:

Foreign Body Potential

A
  • did the object break or shatter
  • is there foreign body sensation
  • was a portion of the object removed
42
Q

Evaluation of Wounds & Lacerations:

Function

A

occupation and handedness (R/L)

43
Q

Evaluation of Wounds & Lacerations:

Allergies

A
  • anesthetics
  • analgesics
  • antibiotics
  • latex
44
Q

Evaluation of Wounds & Lacerations:

Medications

A

status of prior tetanus immunization

45
Q

Evaluation of Wounds & Lacerations:

Chronic Medical Conditions

A
  • increased risk of infection
  • increased likelihood of poor wound healing
    • DM
    • clotting/bleeding disorders
46
Q

Evaluation of Wounds & Lacerations:

Previous Scar Formation

A

hypertrophic scars or keloids

47
Q

3 items of concern for wound care in ED

A
  1. cosmesis
    • glue or steristrips in non-tension areas
  2. pain
  3. infection
48
Q

Suture Types and Sizes

A
  • Type
    • dissovable: vicryl or catgut only for SQ
  • Sizes
    • 3.0-4.0
      • thick skin, palm/soles, high tension
    • 4.0-5.0
      • most common, not for face
    • 6.0
      • nylon or prolene
      • best for face
      • MC simple interruupted
    • 7.0
      • difficult to see - eyelid only
49
Q

Suture Removal Times

  • face
  • neck
  • upper extremety
  • hand
  • chest
  • back
  • legs
  • foot
  • overlying joints
  • tongue
A
  • face: 3-4 (child), 3-5 (adult)
  • neck: 2-3 (child), 3-4 (adult)
  • upper extremity: 7-10
  • hand: 10-14
  • chest: 7-10
  • back: 10-14
  • legs: 8-10
  • foot: 10-14
  • joints: 10-14
  • tongue: absorbable
50
Q

Puncture Wound Care & Tx

A

uncomplicated, clean presenting <6 h

  • superficial wound cleansing
  • tetanus prophylaxis as indicated

high-risk pts. w/ plantar puncture

  • Cephalosporing 1st gen -or-
  • anti-staphylococcal Penicillin

through athletic shoes

  • Ciprofloxacin PO
51
Q

Tx of Bite Wounds

A
  • dog: Augmentin 875mg BID x7d

(Clindamycin+Cipro if PCN allergy)

  • cat: Augmentin
  • human: Augmentin
  • monkey: Acyclovir
  • fish: Fouroquinolone
  • wild/unknown: Rabies immunoglobulin + vac.
52
Q

Reduction of Bacterial Isolates in Wound

(cleansing)

A
  • hair removal (vaseline, shaving, clipping)
  • irrigation: isotonic or tap water, 7-11 lbs psi
    • 35mL syringe w/ 18ga angiocath
    • zero wet on 65cc syringe
    • Canyons wound irrigation system
  • scrubbing (brush or sponge)
53
Q

Cleanser Options

A
  • normal saline (best)
  • for skin around wound:
    • hydrogen peroxide 1/2 strength
    • pHisoHex detergent
    • disinfectants
      • providone-iodine
      • shure-clens
      • hibiclens
  • debridement if all else fails

(when in doubt, wash or pick it out)

54
Q

Indications for Tetanus Prophylaxis

A
  • 3+ doses
    • 5-10 years since last dose
      • booster if not clean, minor wound
    • >10 years since last dose
      • booster for ALL wounds
  • < 3 doses or uncertain
    • clean, minor wound- booster
    • all other- booster and immunoglobulin
55
Q

Care of Traumatic Wounds

A

compulsive cleansing!

  • remove dressing after 24h and cleanse, inspect (unless 4-5d or physician re-eval)
  • daily cleansing and inspection (red, warm, swelling, drainage)
  • adhesives- can shower but not bathe/swim
  • antibiotics if
    • human, cat, deep dog bite
    • bite to hand
    • open fractures
    • exposed joints or tendons
56
Q

Black Widow S/s and Tx

A
  • S/s
    • erythema and swelling in 20-60 min
    • pain and cramps 20-40 min later
      • rigid abdomen
      • HTN, shock, coma, m. paralysis
    • sx resolve in 2-3 days
  • Tx
    • Antivenin (Lyovac), benzos, opiates
    • no allergy to horse serum
57
Q

Brown Recluse S/s and Tx

A
  • S/s
    • “bullseye” pattern
    • pain, myalgias, arthralgias, vomiting, seizures, hemolysis, renal failure
  • Dapsone
    • leukocyte inhibitor
    • prevents progression of tissue necrosis
    • must monitor pt for hemolysis and agranulocytosis
58
Q

swelling of deeper dermal and SQ tissues

worse if mouth, tongue, lips, lower airway

A

Angioedema

(hereditary- <16 y/o vs. acquired- ACEI, NSAIDs)

EMERGENCY INERVENTION

  • emergency airway protection
  • fluids for shock
  • O2 to keep pulse ox > 90%
  • Epinephrine 0.1-0.5mg IM or SQ (.3 is good)
  • H1 antihistamine- Benadryl 25mg IV/50mg IM
  • Solumedrol 125mg IV q6h (or IM)
  • consider: H2 blocker- Pepcid 20mg IV
  • admit to ICU or monitor for sx return
59
Q
  • allergic- mast cell mediated
  • 50% associated w/ angioedema
  • transient edematous papule/plaque w/ peripheral erythema

Treatment

A

Urticaria (hives)

  • identify and remove allergen
  • antihistamine tx
    • OTC
      • Zyrtec 10mg qd, Allegra 180mg qd, Xyzal 5mg qd
    • OTC
      • Zantac 150mg bid, Pepcid 20mg bid
    • Rx
      • Vistaril (Atarax) 25mg q6h (6x more potent than Benedryl)
  • Short course corticosteroids
  • Prednisone 20mg bid w/ food 5-7d and 9d taper
60
Q
  • papules, vesicles, bullae on erythematous base
  • streaky, linear, intensely pruritic

Treatment

A

Contact Dermatitis

  • good hx to ID irritant or allergen
  • avoidance
  • OCT- topical baths
  • antihistamine- Zyrtec 10mg qd
  • topical steroid cream
    • Triamcinolone .05% bid x7d
  • systemic steroids for poison ivy
    • Prednisone 10mg #36 tabs, 80mg today then taper by 10mg until gone
    • SoluMedrol 125mg IM
  • Zanfel or Mean Green OTC soap
61
Q

Characteristic locations such as suprapatellar or olecranon, may have palpable fluid collection

A

bursitis

62
Q

Pruritus instead of pain, absence of fever, may have bulla, but patient is nontoxic in appearance.

A

contact dermatitis

63
Q

Abscess may appear similar to cellulitis initially; eventual fluctuanceand purulent drainage

A

cutaneous abscess

64
Q

Typically not associated with skin redness or fever

A

DVT

65
Q
A
66
Q

Temporal relation to new drug exposure, pruritus instead of pain, absence of fever

A

drug reaction

67
Q

Pronounced pain with involved joint movement

A

gouty arthritis

68
Q

Characteristic vesicles, dermatomal pattern

A

herpes zoster

69
Q

Pronounced pain most at onset

A

insect sting

70
Q

Rapid progression; triad of severe pain, swelling, and fever; pain out of proportion to exam; severe toxicity; hemorrhagic or bluish bullae; gas or crepitus; skin necrosis or extensive ecchymosis

A

necrotizing soft tissue infection

71
Q

Deeper involvement, prolonged course, comorbidities

A

osteomyelitis

72
Q

Typically not associated with fever, limited to venous path

A

superficial thrombophlebitis

73
Q

Hypotension, multiorganinvolvement, severe toxicity

A

TSS

74
Q

Tx of Abscess

A
  • I&D at bedside (iodoform gauze pack if deep)
  • antibiotics
    • healthy w/ no systemic signs - NONE
    • immuno. or mild systemic (cellulitis/fever)
      • Bactrim DS PO bid 10d
      • Doxycycline 100mg PO bid 10d (if sulfa allergy)
      • Clindamycin 300-400mg PO 4xd 10d (hard on GI)
  • deep wound culture to ID bacteria
  • circle redness and have pt return if larger after 2 doses Bactrim
75
Q

Tx of Abscess if

PO Abx Failure, severe dz, s/s of infection

A
  • admit to hospital
  • culture wound prior to starting abx
  • start IV Vancomycin or Clindamycin
  • suspect necrotizing fasciitis
76
Q

Cellulitis / Erysipelas Cause and Tx

(deep tissue / superficial dermis)

A

Group A Strep, Strep pyogenes, Staph aureus

  • mild (no systemic signs)
    • no labs, discharge w/ PO abx
    • Cephalexin 500mg qid 7d
    • Dicloxacillin 250mg qid
    • Clindamycin 450mg qid
    • Erythromycin if PCN allergy
    • Bactrim DS bid if MRSA
  • moderate (mild-mod systemic signs)
    • admit
    • IV Pen G, Nafcillin, Vanco for MRSA
  • severe (sepsis, deep, immuno)
    • admit
    • surgery consult for debridement
    • blood cultures
    • IV Vanco +
      • Piperacillin-tazobactam
      • Meropenem
      • Imipenem-cilastatin
77
Q

Celluliltis / Erysipelas ER Disposition

A
  • healthy w/out systemic toxicity
    • discharge w/ warnings for prompt return
    • follow-up in 2-3 days
    • mark skin for monitoring
  • systemic response, extensive infection, cannot tolerate PO, unreliable
    • inpatient therapy
  • deep soft tissue infection or osteomyelitis
    • admission
    • surgical intervention
    • IV abx

Emergency Medicine (2 decks)

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