Dermatological

Question 1

Questions to ask Dermatology patients

Answer 1

How long has the rash or lesion been present?

Has the rash or lesion changed?

Where do the rash or lesion first appear and where are they now?

Any associated symptoms? (Ex: Itching, pain, fever, body aches)

Anyone else affected with this dermatological complaint?

Has the patient ever experienced this before?

What does the patient think caused the rash or lesion?

Does anything make it better? Anything make it worse?

Any potential allergen exposure? (Ex: Medication, food, animals, personal care products)

What treatments have been attempted thus far?

Question 2

Macules

Answer 2

Non-palpable lesions

<1cm

Vary in pigment from surrounding skin

Question 3

Patches

Answer 3

Non-palpable lesions

> 1cm

Question 4

Papules

Answer 4

Palpable

<1cm

May be isolated or grouped

Question 5

Plaques

Answer 5

Elevated lesions

> 1cm

May for from clustering of papules

Question 6

Nodules

Answer 6

Palpable

Solid or cystic

Between 1 and 2 cm

Question 7

Tumors

Answer 7

Solid or cystic

> 2cm

Question 8

Telangiectasia

Answer 8

Dilated

Superficial blood vessels

Question 9

Purpura

Answer 9

Red-purple lesions that do not blanch

May be macular or raised

Question 10

Pustules

Answer 10

Small Circumscribed papules with Purulent fluid

Question 11

Vesicles

Answer 11

Circumscribed papules

<1cm

Filled with clear serous or hemorrhagic fluid

Question 12

Bullae

Answer 12

> 1cm vesicles

Question 13

Wheals

Answer 13

Irregularly shaped elevated edematous skin

May be pale or erythematous

Borders are well demarcated however can move

Question 14

Scale

Answer 14

Flakes on the skin surface

Question 15

Seborrheic Dermatitis

Answer 15

Chronic, relapsing, typically mild form of dermatitis

Presentation:
- Erythematous, scaly patches on the scalp, face and upper trunk
- Mildest and most common form is “dandruff”

Treatment:
- Topical antifungals (Ketoconazole), topical corticosteroids (short term only), Selenium sulfide (Available OTC, heavy metal salt with antifungal properties), oral antifungals (when multiple areas are involved)

Question 16

Atopic Dermatitis (eczema)

Answer 16

• Chronic, pruritic, inflammatory skin disease
• Can affect all ages however more common in children

Presentation:
- Pruritus, typical presentation of eczema (facial, neck and extensor involvement in infants and children, current or previous flexural lesions in any age group, sparing of the groin and axillary region), chronic or relapsing history.

Treatment:
- Initially treated with topical corticosteroids and emollients, topical tacrolimus for high risk areas.

Question 17

Allergic Contact dermatitis

Answer 17

Delayed hypersensitivity skin reaction after a topical exposure to an allergen (for example: nickel in jewelry, topical antibiotics or urushiol in poison ivy)

Presentation:
- Eczematous dermatitis that can be mild to severe pruritus, burning, pain

Treatment:
- Initially treated with topical corticosteroids and emollients, topical tacrolimus for high risk areas

Question 18

Irritant contact dermatitis

Answer 18

Most common contact dermatitis that occurs from exposure to substances that cause physical, mechanical or chemical irritation of the skin

Presentation:
- Presents with erythema, dryness and/or fissuring

Treatment:
- Emollients and moisturizers plus topical corticosteroids

Question 19

Poison Ivy, Oak Sumac

Answer 19

Causes an allergic contact dermatitis, from the highly allergenic plant oil, urushiol

Presentation:
- Acute, intensely pruritic, erythematous vesicles, that typically presents in areas that made contact with the plant’s oil

Treatment:
- Soothing: Oatmeal baths, calamine lotion, cool/damp cloths
- Mild to moderate dermatitis, localized and does not involve areas at increased risk for atrophy: Clobetasol propionate 0.05% cream, BID until reaction improves
- Severe, extensive dermatitis; or if face or genital region involved: Systemic corticosteroids
- Typical taper pack: Prednisone for 15 days: 50 mg for the first 5 days, then 20mg for 5 days, finally 10mg for 5 days.

Education:
- If exposed, wash clothes right away, wash body in warm to hot water with mild soap or dish soap right away
- Never burn poison ivy plants
- Bathe pets if exposed because they can spread the urushiol

Question 20

Pityriasis Rosea

Answer 20

Generally affects adolescents and young adults

Presentation:
- Most individuals will be asymptomatic, except for a pruritic rash
- Up to 90% of individuals will experience a “herald patch” a single, sharply demarcated pink/red lesion, about 2 to 5 cm on the trunk or neck before rash spreads

Treatment:
- Supportive treatment
- Topical corticosteroids for itching, if desired.

Question 21

Cellulitis

Answer 21

• Bacterial skin and soft tissue infection that may present with or without abscess
• Most common cause of cellulitis are streptococcus and less often
• Most commonly group A Streptococcus or Streptococcus pyogenes: S. Aureus (including methicillin-resistant strains) occur however less frequently.

Presentation:
- Skin erythema, swelling and warmth
- Fever and other systemic symptoms may also be present

Diagnosis:
- Made on clinical exam

Treatment:
- Immunocompetent, with non-Purulent cellulitis, without systemic toxicity and without risk factors for MRSA options:
- Dicloxacillin, cephalexin and Clindamycin if the patient has allergies.

 - Immunocompetent patient with Purulent, systemic symptoms or risk factors for MRSA options:
      - Trimethoprim-sulfamethoxazole, amoxicillin plus doxycycline, linezolid

Question 22

Erysipelas

Answer 22

• Form of cellulitis that involves the upper dermis and superficial lymphatics
• Lesions are raised above the level of surrounding skin with clear demarcation

Treatment:
- Penicillin V potassium, amoxicillin, cephalexin, cefadroxil

Question 23

Abscess

Answer 23

Most patients with a skin abscess should undergo incision and drainage
- Indications for surgical referral
- Perirectal abscess, anterior and lateral neck, hand, vital nerves or blood vessels, central triangle of the face and also breast

IF I&D is indicated:
- Properly anesthetize
- Lidocaine toxic dose: 4mg/kg
- Lidocaine with epinephrine toxic dose: 7mg/kg
- Use 11 inch blade to make a linear incision along the total length of the abscess and a hemostat to probe the cavity, breaking up pockets of pus
- Close with secondary intention
- All abscesses >5cm in diameter, also immunocompromised or diabetic patients should have their wounds packed
- Use sterile gauze or iodoform gauze and make sure to leave about a 1cm tail out of the wound
- With packing: re-evaluate every 24 to 48 hours, continuously replace packing until drainage stops
- Without packing: Soak the wound several times a day in warm, soapy water and return for a re-evaluation in 7 to 10 days.
- All open wounds should be covered with dry gauze until it is fully healed
- Patients who have I&D should receive antibiotics
- Choose agent that covers MRSA; for example Bactrim, Doxycycline, or Clindamycin if the patient has allergies.

Question 24

Paronychia

Answer 24

Inflammation, typically involving just 1 finger around the lateral and proximal nail folds

Risk factors:
- Nail biting, picking at a hang nail, overdoing it with a manicure, diabetes

Presentation:
- Acute pain, erythema, swelling, typically an abscess

Treatment:
- WITHOUT abscess
- Warm water or antiseptic soaks multiple times a day
- Followed by a topical antibiotics (Mupirocin or triple antibiotic ointment)

 - WITH abscess
      - I&D after anesthetizing 
      - Culture abscess
      - Followed by soaks multiple times a day and topical antibiotics
           - If infection persists >7 days after a topical antibiotic, start oral antibiotics based on culture results 
      - If patient is immunocompromised or if paronychia is severe, start oral antibiotics empirically while waiting for culture results 
           -Empiric antibiotics: Cephalexin, trimethoprim-sulfamethoxazole, doxycycline, clindamycin)

Question 25

Dog and Cat bites

Answer 25

Pasteurella species are found in about 50% of dog bite wounds and 75% of cat bite wounds Treatment: - Secondary intention closure - Primary closure is a reasonable alternative in the following: - Bites on the face (dog or cat) OR gaping dog bite on the trunk, arm or leg. If all of the following are met: - Clinically uninfected - <24 hours if it is a facial wound - <12 hours if wound anywhere other than face - Patient is immunocompetent - Not a crush injury or puncture wound - No history of cellulitis or venous compromise to the affected extremity. - Copious irrigation - Monitor daily for signs of infection - Tetanus vaccine - If the patient is fully vaccinated against tetanus, tetanus vaccine is only indicated if their last dose was given > 5 years ago - Rabies immune globulin and vaccine if indicated Antibiotic Prophylaxis treatment options: - First line is Amoxicillin-Clavulanate for 3 to 5 days. - Alternative: Cefuroxime, doxycycline, TMP-SMX, or Levofloxacin PLUS clindamycin or metronidazole Antibiotic for established infection: - Generally given 5 to 14 days - antibiotic therapy should be continued at least 1 to 2 days after symptoms have resolved.

Question 26

Tick Bites

Answer 26

Lyme disease is caused by species in the spirochete family, Borreliaceae - Phases of Lyme disease: early localized, early disseminated, and late disease Presentation: - Early localized disease - Erythema migrans: rash that appears at the site of the tick bite, between 3 to 30 days afterwards - Viral syndrome - Late disease: - Arthritis is the major manifestation. Indication for antibiotic prophylaxis - Non-pregnant adults and children, residing in a highly endemic area, who meet all of the following criteria: - Attached tick is identified as an adult of nymphal I. Scapularis tick (deer tick) - Tick is estimated to have been attached for >36 hours based on degree of engorgement or time of exposure - Prophylaxis is begun within 72 hours of tick removal Treatment options for prophylaxis and infection - Doxycycline - Single dose for prophylaxis - 10 days for Lyme disease - Alternative options for Lyme disease treatment: Amoxicillin or Cefuroxime for 14 days

Question 27

Impetigo

Answer 27

- Contagious bacterial skin infection - The most common pathogen is Staphylococcus Aureus Presentation: - Variants include nonbullous impetigo, bullous impetigo and ecthyma - Lesions often described as “honey colored crust” - Ecythema extends in to the dermis, described as “punched out” Diagnosis: - Clinical Exam - Gram Stain and culture Treatment: - If the impetigo is localized - Topical Mupirocin - If multiple lesions or erythema are present - Preferred oral antibiotics include Cephalexin or Dicloxacillin - If MRSA is suspected or confirmed: - Trimethoprim-Sulfamethoxazole, clindamycin or doxycycline

Question 28

Herpes Zoster

Answer 28

- Generally occurs > 50 years old - Lesions are not infectious after the lesions have crusted over Presentation: - The rash begins as erythematous papules, that generally follow a dermatome (typically on the thoracic or lower back area) - Acute Neuritis Treatment: - Antivirals (Acyclovir or Valacyclovir) and analgesics

Question 29

Herpes Zoster Opthalmic

Answer 29

An eye emergency! Presentation: - Begins with fever, headache, fatigue and pain in the affected eye - With the appearance of the rash, also occurs conjunctivitis, uveitis and keratitis Treatment: - Emergent referral to ophthalmology - Left untreated can lead to permanent vision loss or encephalitis

Question 30

Tinea Capitis

Answer 30

“Cap” for head Presentation: - Pruritic, single or multiple scaly patches with alopecia Treatment: - Oral Anti-fungals (Itraconazole, Fluconazole, Griseofulvin, Terbinafine— Systemic antifungals are associated with hepatic injury)

Question 31

Tinea Corporis

Answer 31

“Ring worm” Think “core” for trunk Presentation: - Pruritic ring shaped plaque Treatment: - Topical antifungal (Ketoconazole, Clotrimazole)

Question 32

Tinea Cruris

Answer 32

“Jock Itch” Presentation: - More common in males, often begins with an erythematous patch on the proximal medial thighs and spreads, scrotum typically spared Treatment: - Topical antifungals (Ketoconazole, Clotrimazole)

Question 33

Tinea Pedis

Answer 33

“Athlete’s Foot” Think “pedal” for foot Presentation: - Pruritic erosions or scales between the toes that can lead to maceration Treatment: - Topical Antifungals (Ketoconazole, Clotrimazole)

Question 34

Onychomycosis

Answer 34

Think ONychomycosis ON NAIL Presentation: - Nail discoloration, subungual hyperkeratosis, splitting of the nail, nail plate destruction Treatment: - Oral Anti-fungals (Itraconazole, Fluconazole, Griseofulvin, Terbinafine— Systemic antifungals are associated with hepatic injury)

Question 35

Actinic Keratosis

Answer 35

- Pre-cancerous lesions that arise from atypical epidermal keratinocytes - Most squamous cell cancers arise from actinic lesions Presentation: - Lesion generally appears on the face and sun exposed areas - These lesions are typically reddened macules or papules or plaques with a scaly appearance Diagnosis: - Visual and tactile inspection - Dermascopic exam can support diagnosis - Biopsy if diagnosis is uncertain, or if the lesion(s) are treated than 1 cm in diameters, indicated, ulcerated, rapidly growing or for lesions that fail to respond to treatment. Treatment: - Fluorouracil (Antineoplastic agent) - Educate patient on what to expect (erythema, blistering, necrosis with erosion and finally re-epithelialization over a 4 to 6 week course) - Imiquimod (Topical immune response modifier) - Not as effective as fluorouracil

Question 36

Basal Cell Carcinoma

Answer 36

Common skin cancer arising from the basal layer of the epidermis Presentation: - Majority (70%) appear on the face - Described as “pearly, translucent” appearance - Telangiectasia is often present Cutaneous Squamous cell carcinoma - Malignant tumor arising from epidermal keratinocytes Presentation: - Fair skinned individuals usually present with SCC on areas of the body exposed to the sun, however individuals with a darker pigment may present with SCC on less exposed areas. - A variety of lesions, including papules, plaques and nodules that can be smooth in texture or hyperkeratotic - Generally, they are well demarcated and erythematous - May crust or bleed

Question 37

Melanoma

Answer 37

The most serious form of skin cancer Presentation: - Generally presents as a macular or thin plaque, with irregular borders and can be various colors including red, brown, black, blue, grey and white. Early signs of melanoma include (ABCDE Rule) — A: Asymmetry — B: Border irregularities — C: Color variation — D: Diameter >6mm — E: Evolves in characteristics (Size, color, shape, etc.)

Question 38

Acne Vulgaris

Answer 38

- Mild acne, exclusively comedonal, without papulopustular acne - Topical Retinoid - Examples: Tretinoin, adapalene, tazarotene and trifarotene - Mild inflammatory, papulopustular ace - Topical Retinoid AND topical antimicrobial - Benzoyl peroxide alone OR - Benzoyl peroxide plus topical clindamycin - Moderate to severe acne: - Systemic therapy required - Major treatments options include: Oral Isotretinoin (Accutane), oral antibiotics and oral hormonal therapies - Isotretinoin use as monotherapy and should not be combine with tetracyclines - Risk for idiopathic intracranial hypertension - Isotretinoin is teratigenic and thus contraindicated in pregnancy and breastfeeding - Must have negative pregnancy test and commit to two forms of birth control 1 month prior to starting isotretinoin and 1 month after completion of treatment - Tetracyclines preferred choice for antibiotic therapy - Limit to 3-4 months - Use adjunct benzoyl peroxide

Question 39

Psoriasis

Answer 39

A common inflammatory skin disease that most often presents on the scalp, knees and elbows Presentation: - Described as sharply demarcated erythematous plaques, that are covered in silvery scales - Auspitz sign: Bleeding occurs if a scale is peeled from the plaque Treatment: - Topical corticosteroids for mild and limited disease - The lowest strength that provides the patient relief - Alternative options: Vitamind D analogs, Calcinuerin inhibitors, phototherapy.