Dermatology 1 Flashcards

Question

EDC Process (3 steps)

Answer 1

1. Curette over lesion in all 4 directions 2. Cauterize skinwith safety margin 3. Repeat for total of 3 passes

Answer 2

Used for superficial skin lesions to confirm diagnosis Does not include the full thickness of the skin No stitches required – the wound forms a scab that should heal in one to three weeks

Answer 3

full thickness sample of the skin A disposable, round stainless steel blade is rotated through the skin Typically 3, 3.5, 4 mm punches are used Suture may be used to close a punch biopsy wound or control bleeding, but it’s not necessary with smaller biopsy diameters | 4 and larger typically need stitches

Answer 4

typically done by dermatologist/derm surgeon the complete removal of a skin lesion w a margin surounding tissue taken to minimize recurrence

Answer 5

Lower recurrence rate done by derm surgeon complete histologic analysis of the tumor margins while permitting the max conservation of tissue.

Answer 6

1. Location on face, nose, lips, ears, hands, scalp, groin 2. Aggressive malignancy subtypes: infiltrative, sclerosing, morpheaform, micronodular 3. large tumors or tumors with indistinct borders 4. recurrent tumors

Answer 7

used for contact sensitivity for allergens **testing Type IV Hypersensitivity rxn** requires large area of skin, takes 2-5 days

Answer 8

liquid nitrogen directly to the skin for short durations of time results in the cryo- destruction of the superficial layers of the skin. results in blister-like lesion initially that transform into an eschar that will be shed from the skin over a 2-4 week period.

Answer 9

Does not require local anesthetic, is generally well tolerated, and requires minimal wound care after the procedure.

Answer 10

A- Asymmetry B- Border C- Color D- Diameter E- Evolving

Answer 11

Melanomas are usually greater than 6 mm

Answer 12

Consider biopsy if there are pigmentary changes, changes in border or diameter, bleeding, itching, a new lesion in a patient over 50 years of age, the ugly duckling sign

Answer 13

take 2 one upclose and second at a distant for landmarks.

Answer 14

biopsy the entire lesion, unless very large in size

Answer 15

**a basic rule for non-dermatology providers to follow is never do a superficial shave biopsy that you are considering for a possible melanoma**

Answer 16

freckles, sun spots, age spots benign, brown macules and patches typically found in sun exposed areas result of UV damage no Tx, use sunscreen to minimize appearance.

Answer 17

Clinical manifestations: velvety, hyperpigmented plaques on intertriginous areas, especially the neck and axillary regions. Associated with insulin resistance – diabetes mellitus, metabolic syndrome, and polycystic ovarian syndrome.

Answer 18

Associated with insulin resistance – diabetes mellitus, metabolic syndrome, and polycystic ovarian syndrome.

Answer 19

Acanthosis nigricans

Answer 20

Characterized by patchy light to dark brown hyperpigmentation of the face Usually affects women and may run in families Hyperpigmentation will worsen with exposure to UV light

Answer 21

Associated with hormonal changes, but it may occur idiopathically, with use of birth control pills or hormone replacement therapy

Answer 22

strict sun avoidance, use of SPF 30 to 50 daily. Hydroquinone 4% cream qd-bid to affected area up to one month at a time, can be repeated for a second month. Use of hydroquinone should be reserved for fall/winter months. Advise patients that hyperpigmentation can recur if area is exposed to UV

Answer 23

for fall/winter months

Answer 24

Melasma / Chloasma

Answer 25

Seborrheic Keratosis (SK) (wisdom spots) | pigmented lesions

Answer 26

Most common benign epidermal skin growth Common in fair skin, elderly individuals, with a history of prolonged sun exposure. Clinical Manifestations: Well demarcated, round or oval, velvety, warty lesions with a greasy or “stuck“ appearance. Variety of colors from flesh colored to brown or black. May be scaly. Usually asymptomatic, but irritation due to friction may lead to pruritis, pain, or bleeding.

Answer 27

No treatment necessary Can be symptomatically treated with cryotherapy - can recur with time.

Answer 28

A common benign skin lesion due to localized proliferation of melanocytes Can be present at birth (congenital) or appear later in life (acquired) e.g. mole more common in fair-skinned pts variety of presentations, colors,shapes, flat/raised, pink to black

Answer 29

MELANOCYTIC Nevi

Answer 30

tend to be the most prominent and persist throughout life

Answer 31

follow sun exposure, may fade away

Answer 32

MELANOCYTIC nevi

Answer 33

Atypical or dysplastic Nevi

Answer 34

A melanocytic nevi with atypical features Clinical Manifestations Nevus with at least 3 of the following features Size >5mm Ill-defined or blurry borders Irregular margin —unusual shape Variety of colors within lesion Flat and bumpy components

Answer 35

shave biopsy to determine atypia then, Mild DN: monitor for recurrence Moderate, Severe DN - excision

Answer 36

Mild —> Moderate —> Severe —> melanoma in situ —> malignant melanoma

Answer 37

General Type of melanocytic nevus which are located deep within the dermis. Twice as common in women as in men More prevalent among Asian populations Can rarely form into melanoma Clinical Manifestations Solitary, bluish-grey, smooth-surfaced macule, papule, or plaque Treatment: observation

Answer 38

Lifetime risk of melanoma has increased Affects all ages The second most common cancer among young women ages 15-29

Answer 39

Blue Nevus

Answer 40

Etiology: Cumulative and prolonged UV exposure

Answer 41

Tanning bed use increased risk of melanoma by 75% Especially risky if used before age 35 and risk increase with each exposure

Answer 42

1.Increasing age 2.Fitzpatrick skin types 1&2 3.Greater than 25 acquired nevi 4.Atypical nevi 5.Immunosuppression 6.Personal or family history (1st degree relatives) of melanoma 7.UV exposure Severe blistering sunburns before puberty Indoor tanning

Answer 43

basal cell carcinoma

Answer 44

General: Most common skin cancer Arises from the basal layer of the epidermis Locally invasive, metastasis is rare Etiology: Exposure to UV radiation induced DNA damage - think patients with significant sunburn history, tanning bed use

Answer 45

Fitzpatrick skin types 1 & 2 Severe actinic damage Males > females Immunosuppression

Answer 46

Nodular BCC Superficial BCC

Answer 47

raised, dome-shaped, papules with “rolled” borders and central depression/ulceration with overlying telangectasias Pink, white or flesh-colored Translucent, waxy, or pearly quality

Answer 48

Slightly scaly, “eczematous-like” macules, patches, or thin plaques with characteristic raised, pearly white rolled border Pink to light red

Answer 49

Usually asymptomatic, pigmented papule, plaque, or nodule with any of the ABCDE features Can bleed, be eroded, or crusted History of changing appearance Most are de novo - arise from within an existing lesion Sun-exposed or non-sun-exposed areas

Answer 50

Course and Prognosis High cure rates if diagnosed and treated early Prognostic Factors: Thickness or depth of tumor invasion - Breslow’s depth Survival decreases with increasing Breslow’s depth Ulceration = worse prognosis Involvement of lymph nodes or distant metastases have worse prognosis **If you suspect melanoma, refer to dermatology for biopsy**

Answer 51

If you suspect melanoma, refer to dermatology for biopsy

Answer 52

Dependent on Stage - based on Breslow’s depth, ulceration, lymph node involvement Mainstay of treatment: Surgical excision with wide margins +/- lymph node biopsy

Answer 53

Seen by dermatology every 6 months for 10 years, then yearly for life Annual eye examination Annual complete physical examination

Answer 54

BCC, think malignant melanoma

Answer 55

BCC that can easily be mistaken for excema

Answer 56

Electrodessication and curettage Excision MOHS

Answer 57

reserved for superficial BCC or poor surgical candidate -Imiquimod 5% cream - weeknight application x 6 weeks to affected area -Fluorouracil 5% cream bid to affected area up to 12 weeks until response -Radiation

Answer 58

Etiology: cumulative and prolonged UV exposure resulting in genetic mutation of keratinocytes.

Answer 59

1. Increasing age 2.fair skin, light eyes/hair - think Fitzpatrick skin types 1 & 2 3.Immunosuppression 4.Prior radiation history 5.Albinism **AKs have the potential to transform into squamous cell carcinoma over time**

Answer 60

Erythematous to tan, flat papule or thin plaque with a characteristic rough, gritty scale. **Feels like sandpaper.** Can present as a hypertrophic papule Located in sun exposed areas, typically on sun damaged skin. **Maybe tender to touch**

Answer 61

actinic keratosis

Answer 62

There are several topical and procedural treatment options for AKs Localized therapy field therapy

Answer 63

Typically treated with cryotherapy

Answer 64

Typically treated with topical 5-fluorouracil or imiquimod 5%cream 5-FU: twice daily application to affected area, typically treated for 2 to 4 weeks depending on treatment area, until erythematous, hemorrhagic crust formation. Imiquimod 5% cream MWF at night, typically treated for four weeks until erythematous, hemorrhagic crust formation. * better compliance due to once daily application, more tolerable for patients than 5-FU

Answer 65

(progress from AK) well defined circumscribed pink to red patch or thin plaque with scaly/rough surface

Answer 66

Plan: Biopsy - pathology will indicate that atypia is confined to the epidermis. Treatment Options: Cryotherapy, typically followed with either 5-fluorouracil or Imiquimod Electrodesiccation and curettage

Answer 67

SCC in situ / bowen disease

Answer 68

Second most common dermatologic malignancy. Increased mortality compared to basal cell carcinoma, due to a higher rate of metastasis

Answer 69

Cell of origin: keratinocyte Cumulative UV exposure is a major risk factor as it results in genetic alterations

Answer 70

Most commonly occurs in fair skin individuals - think Fitzpatrick 1&2 Increase risk with tanning bed use Chemical carcinogen exposure - arsenic

Answer 71

Treatment: medical and surgical treatment options Standard of care: surgical excision or MOHS Poor surgical candidates: radiation therapy Non-surgical candidates: Fluorouracil, imiquimod, and others

Answer 72

Vascular reaction of the upper epidermis characterized by wheals surrounded by a erythematous halo The mast cell is the major player in urticaria - release histamine Type 1 hypersensitivity reaction Think hives | Reactive Erythemas

Answer 73

Idiopathic Infection Food reaction Drug reaction - penicillins, aspirin, NSAIDs (PAN) IV administration of blood products or contrast dye Physical causes: pressure cold/heat, water, sunlight, exercise, emotion Autoimmune

Answer 74

Trademark: ITCH! Lesions appears over the course of minutes, enlarge, and then disappear within hours (rarely longer than 12 hours) Blanch with pressure

Answer 75

First-line: 1st generation antihistamines (Benadryl, hydroxyzine) 1st generation antihistamines cause more sedation, require dose adjustment in children, elderly, renal or hepatic impairment, respiratory disease, BPH, glaucoma. Real-life: 2nd generation antihistamines are used more commonly

Answer 76

angioedema

Answer 77

Can be caused by the same mechanisms as urticaria, but is located in the deep dermis and subcutaneous tissue Type 1 hypersensitivity reaction **Check for ACE - Inhibitor use!**

Answer 78

Trademark swelling - most commonly affects the face (lips, cheeks, periorbital areas) or portion of an extremity Concerning if the tongue, pharynx, larynx, and bowels are affected May be painful or burning - usually not pruritic May last several days

Answer 79

IV or oral glucocorticoids and 1st generation antihistamines Epinephrine if severe

Answer 80

Toxic Epidermal necrolysis

Answer 81

Acute, life-threatening mucocutaneous reactions Characterized by extensive necrosis and detachment of the epidermis and/or mucosal surfaces Similar processes but differ in severity based on total body’s surface area involved

Answer 82

Mortality rate varies from 5-12% for SJS and >20% for TEN Increasing age, comorbidities, greater extent of skin involvement correlated with poor prognosis

Answer 83

Stevens-Johnson syndrome / Toxic Epidermal necrolysis

Answer 84

Associated with medications, especially Sulfa drugs, sulfasalazine Allopurinol Tetracyclines Anticonvulsants NSAIDS (SATAN) Typically begins within the first 8 weeks after drug initiation

Answer 85

Eruption is initially symmetric and distributed on the face, upper trunk, and proximal extremities Pain is a prominent symptom in skin lesions - signifies necrosis Lesions can rapidly extend to the rest of the body The epidermis, especially when necrotic, is easily detached at pressure points or by friction trauma revealing exposed, erythematous, sometimes oozing dermis.

Answer 86

Initial lesions are characterized by erythematous, irregularly-shaped, dusky red to pruritic macules, which progressively coalesce and evolve to flaccid blisters, which spread with pressure and break easily

Answer 87

Mucous membranes involvement begins with erythema, follow by painful erosions of mouth, eyes, and genitals - ocular involvement can result in permanent ocular damage or blindness

Answer 88

Stevens-Johnson Syndrome

Answer 89

SJS - less than10% SJS/TEN - 10-30% TEN - greater than 30%

Answer 90

hospital admission to burn unit Stop offending medication Will require multidisciplinary care during admission Therapies include IV corticosteroids, IVIG, cyclosporine, etanercept

Answer 91

Type 4 hypersensitivity reaction of the skin following infectious exposure or medication exposure Most commonly affects young adults (20-40 years old) | reactive erythema

Answer 92

Erythema Multiforme

Answer 93

Infections: HSV, mycoplasma, S. pneumoniae Medications: sulfa drugs, beta-lactams, phenytoin, phenobarbital, allopurinol (PHABS) Malignancy Autoimmune Idiopathic

Answer 94

Hallmark: **target lesion** 3 components: dusky, central area or bulla; dark red inflammatory zone surrounded by a pale ring of edema ; erythematous halo on periphery Negative nikolsky sign

Answer 95

Minor: target lesions distributed on extremities with *no mucosal membrane involvement* Major:target lesions on extremities with central progression *with mucosal membrane involvement. No epidermal detachment*

Answer 96

Remove offending drugs, topical steroids, antihistamines, analgesics. Systemic corticosteroids if severe. Antibiotics if mycoplasma is inciting cause

Answer 97

Most common in the midwestern and southwestern US The brown recluse spider has a violin pattern on it cephalothorax Venom is cytotoxic and hemolytic – local symptoms, can be necrotic, associated with a lack of severe systemic symptoms.

Answer 98

Burning sensation Typical progression: erythema at bite site for 3 to 4 hours, followed by *blanching* of the affected area, followed by a “red halo” (erythematous margin around the ischemic center) for 24 to 72 hours, followed by a hemorrhagic bulla that undergoes eschar formation May develop skin necrosis Systemic side effects: fever, chills, nausea, vomiting, or a morbilliform rash

Answer 99

Brown recluse spider bite

Answer 100

Local wound care and pain control Most wounds heal spontaneously with adequate cleansing Pain control: NSAIDs are mostly commonly used, opioids if severe, refractory pain Necrosis: debridement once the lesion is well demarcated Antibiotics only if secondary infection present Tetanus vaccination if needed

Answer 101

Black widow spider produces a neurotoxin Characteristic right hourglass shape on the underside of its belly.

Answer 102

Typical progression: localized pain at the bite site with the onset of systemic and neurologic symptoms within 30 minutes to 2 hours after bite Muscle pain is most common symptom, typically in the extremities, abdomen, or back Spasms and rigidity possible **Classic appearance**blanched circular patch with erythematous perimeter and central punctum

Answer 103

Usually self limited, tends to resolve within 1 to 3 days. Wound care and pain and spasm control Most wounds heal spontaneously with adequate cleansing Pain control: NSAIDs are mostly commonly used Muscle relaxants for spasm - benzodiazepines Antivenom - reserved for refractory symptoms. Tetanus vaccination if needed

Answer 104

black widow bite

Answer 105

cellulitis

Answer 106

Results from an infection of the dermis that often begins with loss of integrity of the skin 80% of cases are caused by Gram - Positive organisms (Group A Strep) Staphylococcus aureus - IV drug use MRSA - purulent drainage present Pasteurella multiocida - animal bites

Answer 107

Local trauma - insect/animal bite, laceration, abrasion, puncture wound Spread of a preceding or concurrent skin lesion - furuncle, ulcer Pre-existing skin infection due to compromised skin barrier Edema and impaired lymphatics in the affected area

Answer 108

Spreading erythematous, non-fluctuant, tender, poor-defined plaque Tends to occur on lower extremities

Answer 109

Non-purulent cellulitis: Cephalexin, amoxicillin, amoxicillin- clavulanate (animal bites), or clindamycin Purulent cellulitis: Clindamycin, TMP/SMX, doxycycline + amoxicillin General measures - elevation of extremity, cool compresses

Answer 110

Superficial cellulitis with marked dermal lymphatic involvement - causes edema Main pathogen: Group A Streptococcus Others: S. aureus, Haemophilus

Answer 111

Usually affects face, lower extremities Painful, bright red erythematous, plaque-like edema with sharp margin May develop bullae Can be associated with high WBC count (>20,000/mcl) Can have associated fever, chills, headache, vomiting, joint pain

Answer 112

Erysipelas | reactive erythema

Answer 113

Empiric antibiotic therapy - penicillin V, amoxicillin, clindamycin, azithromycin Elevation of involved area Monitor patients closely

Answer 114

Inflammation of lymphatic channels due to infectious or non infectious causes Pathogens include bacteria, viruses, fungi, and parasites - typically introduced through a skin wound or as a complication of a distal infection.

Answer 115

Red, tender streaks extending proximally from a site of cellulitis May have lymphadenopathy or systemic symptoms such as fever and chills

Answer 116

Lymphangitis

Answer 117

Oral: cephalexin, dicloxacillin. Erythromycin or Clindamycin if penicillin allergy IV: cefazolin, ampicillin-sulbactam, ceftriaxone + Clindamycin MRSA: Oral: TMP-SMZ+cephalexin IV: vancomycin