Dermatology Flashcards
First degree burn
dry, red, no blisters
-involves the epidermis only
Second degree burn
= partial thickness burn
moist, blisters, extends beyond the epidermis
Third degree burn
= full thickness burn
dry, leathery, black, pearly, waxy
extends from epidermis to dermis to underlying tissues, fat, muscle, and/or bone
Rule of 9s to measure the extent of burn body surface injury only applies after the age of
9
Primary management of burns
- Assess ABCs. Intubate if necessary.
- Drench the burn thoroughly with cool (not icey) water to prevent further damage and remove all burn clothing - this stops the burn.
- Do NOT cover with lotion, toothpaste, butter, etc.
- If the burn is limited, immerse the site in cold water for 30 minutes to reduce pain; then, apply a clean wrap.
- If the area of the burn is large, after it has been doused with cool water, apply clean wraps about the burned area to prevent systematic heat loss and hypothermia.
- Hypothermia is a particular risk in young children.
- The first 6 hours following the injury are critical - transport a patient with severe burns to the hospital ASAP.
Burn patients will require prophylactic intubation if
- singed nares or eyebrows
- evaluate nares/mouth for soot/mucous
Evaluation of skin disorders must identify what 3 things?
Morphology
Configuration
Distribution
Morphology
The character of the lesion itself
Macule
A flat discoloration
ex: ephelides (freckles), petechia, flat nevi (moles)
Patch
A flat discoloration that looks as thought it is a collection of multiple, tiny pigment changes
- may be some subtle surface change
ex: Mongolian spot, cafe au lait spot
Nodule
An elevated, firm lesion > 1 cm
ex: Xanthoma and fibroma
Tumor
A firm, elevated lump
ex: benign or malignant
Papule
A small < 1 cm, elevated, firm skin lesion
ex: ant bite, elevated nevus (mole), verruca (wart)
Plaque
A scaly, elevated lesion
ex: classic psoriasis lesion
Vesicle
A small < 1 cm lesion filled with serous fluid (clear liquid)
ex: herpes simplex, varicella (chicken pox), herpes zoster (shingles)
Bulla
Serous fluid-filled vesicle > 1 cm
- a big vesicle
ex: burns, superficial blister, contact dermatitis
Wheal
A lesion raises about the surface and extending a bit below the epidermis
- many times an allergic reaction/response (either contact or systemic
ex: PPD test and mosquito bites
Pustule
A small < 1 cm pus-filled lesion
ex: acne and impetigo
Abscess
A pus-filled lesion > 1 cm
*a great big pustule
Cyst
Large, raised lesions filled with serous fluid, blood, and pus
Primary lesion
First appearing
Secondary lesions
Follows primary lesions
Configuration
How the lesions present on the body
Solitary or discrete configuration
Individual or distinct lesions that remain separate
Grouped configuration
Linear cluster
Confluent configuration
Lesions that run together
Linear configuration
Scratch, streak, LINE, or stripe
Annular configuration
Circular, beginning in the center and spreading to the periphery
Polycyclic configuration
Annular lesions merge
Distribution
Where the lesions appear on the body
Ex: face, trunk, upper extremities, groin, dermatomal, feet, axilla
Acne
A polymorphic skin disorder characterized by comedones, papule, bustles, and cysts
- cause unknown by appears to be activated by androgens in genetically predisposed individuals
- can be exacerbated by steroids and anticonvulsants
- more common and severe in males
- *food has NOT been demonstrated to be a contributing factor
S/S of acne
- Comedones, papules, bustles, nodules, and/or cysts on the face and/or upper trunk
- Depressed or hypertrophic scars
- In women, may be exacerbated just prior to menses
Open comedones
Blackheads - opening in the skin capped with blackened mass of skin debris
Closed comedones
Whiteheads - obstructed opening which may rupture, causing a low-grade local inflammatory reaction
Labs/diagnostics for acne
NONE indicated, except to identify causative organism in atypical folliculitis
Non-pharmacologic management of acne
- avoidance of topical, oil-based products
- use of oil-free, mild soaps, cleansers, and moisturizers
Pharmacologic management of mild acne
- Topical treatment with Benzoyl peroxide (2.5-10%)
- - If not responsive, retinoic acid (0.025-0.1%) cream or gel (pregnancy category C)
- - Tretinoin is inactivated by UV light and oxidized by benzoyl peroxide; this agent should only be applied at night and not used concomitantly with benzoyl peroxide - Salicyclic acid preparations (Neutrogena 2% wash)
- Topical antibiotics: Erythromycin or clindamycin lotion or pads (d/t staph infections)
Pharmacologic management of moderate (or severe pustular) acne
Requires systematic antibiotics along with topical treatments
- use -cyclines first, followed by macrolides if needed
- Doxycycline: 100 mg BID
- Erythromycin: 1 g in 2-3 divided doses
- Minocycline: 50-100 mg BID
Fungal infections
- a variety of fungal infections disguised by the causal species of fungi and the location on the body
- Trichophyton (80%) and Microsporum causative agents in most fungal infections
- pharmacologic management centers on anti-fungal therapy and the prevention of transmission
Tinea capitis
Fungal infection on scalp
Tinea corporis
Body ringworm (fungal infection on body)
Tinea cruris
Jock itch (fungal infection)
Tinea magnum and tine pedis
Athlete’s foot (fungal)
Tinea versicolor
Hypo/hyperpigmentation macules on limbs
S/S of fungal infection
- *vary by location on body
1. May be asymptomatic (capitits)
2. Some forms presents with severe itching (cruris and pedis)
3. Erythematous rings (corporis)
4. Solitary areas of hypo pigmentation or hyperpigmentation (versicolor)
Labs/diagnostics for fungal infection
“Spaghetti and meatballs” hyphae microscopically when treated with potassium hydroxide (KOH)
Primary treatment for fungal infections
Griseofulvin 20mg/kg/day for 6 weeks
*big or severe lesions, skip topical and go right to systemic antifungals
Treatment for tinea capitis
Primary management is Griseofulvin 20mg/kg/day for 6 weeks
Treatment for tinea corporsis
Use of topical antifungals is usually adequate:
Miconazole 2%
Ketoconazole 2%
Treatment for tinea cruris
Topical antifungals (Miconazole 2%, Ketoconazole 2%)
Terbinafine cream curative in more than 80% of cases when used BID x 7 days
Griseofulvin 20mg/kg/day for 6 weeks for severe cases
Treatment for tinea mannum and pedis
In macerated stage, use aluminum sub acetate solution to soak for 20 minutes BID
Topical antifungals (Miconazole 2%, Ketoconazole 2%) in the dry, scaly stage
Oral Griseofulvin in severe cases
Treatment for tinea versicolor
Selenium sulfide shampoo for 5-15 minutes daily x 7 days OR 200 mg Itraconzole (Sporanox) every day by mouth
Varicella Zoster Virus
= chickenpox
- acute, contagious disease caused by herpes virus, transmitted by direct contact with lesions or airborne
- infected individuals are contagious for 48 hours before outbreak of any rash/bumps and until lesions have crusted over
- most common in ages 5-10
S/S Varicella zoster virus
- erythematous macules
- papule develop over macules
- vesicles erupt: usually distributes initially on the trunk, then scalp and face
- intense pruritus ***
- low grade fever
- generalized lymphadenopathy
Labs/diagnostics for varicella zoster
None - typically a clinical diagnosis
Management for varicella zoster
- Supportive treatment
- calamine/caladryl lotion
- antihistamine
- acetaminophen for fever - PO Acyclovir 20 mg/kg 5 times a day - given in the first 24 hours, this can reduce the magnitude and/or duration of symptoms
* IV Acyclovir used for immunocompromised
Molluscum Contagiosum
A common, benign viral skin infection
- lesions frequently disappear on their own in a few weeks to a few months and are NOT easily treated
- diagnostic criteria: pruritis and the presecnce of very small, firm, pink- to flesh-colored discrete papule, which become umbilicate papule with a cheesy core
- children who are sexually active or abused may have grouped lesions in the genital area
- children with eczema or immunosuppression may have severe infections
S/S Molluscum Contagiosum
- lesions most commonly present on face, axillae, antecubital fossa, trunk, crural fascia, and extremities
Labs/diagnostics for Molluscum Contagiosum
None - clinical diagnosis
*History of exposure to Molluscum Contagiosum
Management for Molluscum Contagiosum
***Resolves spontaneously if left alone! But it can take 6-9 months, or even up to a year, but educate that they are benign lesions (viral) and are not dangerous
- Mechanical removal of the central core prevents spread and autoinnoculation.
- Curettage, after anesthetizing the area with prilocaine 2.5% and lidocaine 2.5% cream (EMLA), is a useful treatment in a few lesions but should not be used on sensitive areas as it may scare.
- Pharmacological agents
- Prevent scratching and touching lesions to stop from spreading.
- Spontaneous resolution may occur after 6-9 months in immunocompetent patients.
- If patient has extensive lesions or the diagnosis is unclear, refer to a dermatologist.
Pharmacological agents for Molluscum Contagiosum
- Tretinion 0.025% gel or 0.1% cream at bedtime
- Salicyclic acid daily at bedtime
- Liquid nitrogen applied for 2-3 seconds
- Trichloracetic acid peel 25-50% applied by dropper to the center of lesion, followed by alcohol, repeated every 2 weeks
- Silver nitrate, iodine 7-9%, or phenol 1% applied for 2-3 seconds
- Cantharidin 0.7% applied to individual lesions and covered with clear tape; blistering within 24 hours and possible clearing without scarring; should be avoided on facial lesions
Atopic Dermatitis
= Eczema
Chronic skin condition characterized by intense itching along a typical pattern of distribution with periods of remission and exacerbation
- particularly sensitive to low humidity and often worsens in the winter when the air is dry
- a personal or family history of asthma, allergic rhinitis, atopic dermatitis, elevated serum IgE levels, and a tendency for skin infections is helpful to the diagnosis!!!
- any allergic reaction = eosinophils
S/S Atopic Dermatitis
- Intense pruritus along face, neck, trunk, wrists, hands, antecubital and popliteal folds
- Dry scaly skin
- acute flare-ups may show red, shiny, or thickened patches
- inflamed and/or scabbed lesions with diffuse erythema and scaling
- dry, leathery, and lichenified skin (secondary skin condition, trying to prevent this from occurring)
Labs/diagnostics for Atopic Dermatitis
- Radioallergosorbent test (RAST) or skin tests may suggest dust mite allergy.
- Serum IgE may be elevated.
- Eosinophilia may be present.
Management of Atopic Dermatitis
- HALLMARK treatment = dry skin management: moisturizing lotion immediately after bathing; must blot dry
- Topical steroids applied 2-4 times daily and rubbed in well
* *Start with hydrocortisone or other steroids (Fluocinonide cream 0.05%, Desonide, triamcinolone 0.1%)
* *Adverse effects of hydrocortisone: bladder dysfunction, hyperglycemia, etc - Systemic steroids only in extremely severe cases: Prednisone taper over 5-7 days
- In acute weeping: use saline or aluminum sub acetate solution and/or colloidal oatmeal baths (Aveeno)
Allergic Contact Dermatitis
An acute or chronic dermatitis that results from direct skin contact with chemicals or allergens
Ex: poison ivy
S/S Allergic Contact Dermatitis
- Redness, pruritus, scabbing
- Tiny vesicles and weepy, encrusted lesions in acute phases
- Scaling, erythema and thickened skin (lichenification) in chronic phase
- Location with suggest cause
- Affected areas hot and swollen
- History of exposure to the offending agent
Labs/diagnostics for Allergic Contact Dermatitis
None indicated
Management of Allergic Contact Dermatitis
- Eliminate allergic item
- Depends of severity - compresses locally, avoid scrubbing with soap and water
- High potency topical steroids locally
- If severe and systemic: Prednisone taper
Irritant (Diaper) Dermatitis
Common skin irritation of the genital-perianal region
- most common type of diaper rash, typically due to exposure to chemical irritants and prolonged contact with urine and/or feces
- occurs at some time in 95% of infants; peaks at 9-12 months
S/S Irritant (Diaper) Dermatitis
- Fiery red rash
- Papules, vesicles, crusts, ulcerations
- Infant may be irritable!!!
Labs/diagnostics for Irritant (Diaper) Dermatitis
None indicated
Management of Irritant (Diaper) Dermatitis
- In mild cases, barrier emollients
- When erythema/papules present, 1% hydrocortisone
- Use Burow’s (Domeboro) compresses for severe erythema and vesicles
- Secondary bacterial infection may beed topical antibiotics
- Secondary fungus may need topical antifungals
- Educate parents about preventative measures.
- Allow diaper area to air several times daily.
Psoriasis
A common benign hyper-proliferative inflammatory skin disorder (acute or chronic) based on genetic presidpostion (affecting ~ 3-5% of the population.
- The epidermal turnover time is reduced from 14 days to 2 days.
- Normal maturation of the skin cells cannot take place and keratinization is faulty.
- The epidermis is thickened, and immature nucleated cells are seen on the horny layer.
- May be immunologically mediated
S/S Psoriasis
- Often asymptomatic; itching may occur
- Lesions are red, sharply defined plaques with silvery scales ***
- Scalp, elbows, knees, palms, soles, and nails are common sites
- Fine pitting of the nails is strongly suggestive of psoriasis, as is separation of the nail plate from the bed
- Pink or red line in the intergluteal fold
- Auspitz sign: Droplets of blood when scales are removed ***
Labs/diagnostics for Psoriasis
None indicated
Management of Psoriasis
- Topical for the scalp:
a. Tar/salicylic acid shampoo
b. Medium potency topical steroid oil - Topical steriods for the skin:
a. Topical steroids BID for 2-3 weeks; resume with calcipotriene (Dovonex), a synthetic vitamin D3 derivative
b. Betamethason dipropionate 0.05% (Diprolene AF)
c. Triamcinolone acetonide 0.5% (Aristocort) - UVB light and coal tar exposure if more than 30% of the body surface is involved
- Moisturizers
Pityriasis Rosea
A mild, acute inflammatory disorder that is usually self-limiting, lasting 3-8 weeks
- If the cause is unknown, the current theory is that it is viral in origin.
- More common in the spring and fall seasons, and patients typically report a recent URI.
- More common in females than males
S/S Pityriasis Rosea
- May be asymptomatic
- Initial lesion (2-10 cm) known as “herald patch” - usually macular, oval, and fawn-colored with a crinkled appearance and collarette scale
- Pruritic rash in a CHRISTMAS TREE pattern (usually mild) may be found on the trunk and proximal extremities within 1-2 weeks
Labs/diagnostics for Pityriasis Rosea
Serologic test for syphilis should be performed if:
- the rash does not itch
- palmar surfaces, genitalia, or mucous membranes involved
- if a few typically perfect lesions are not present
Management for Pityriasis Rosea
- None usually required
- Control pruritus.
- Daily sunlight exposure will hasten healing; most effectively UVB daily x 1 week.
- Oral erythromycin (2 week course) is effective in most cases (when it is d/t staph)
Pruritus remedies for Pityriasis Rosea
- Atarax (hydroxyzine
- Oral antihistamines (loratadine, fexofendaine (allegra), cetirizine)
- Topical antipruritic (Sarna lotion, Prax lotion, Itch-X gel, Cetaphil with menthol 0.25% and phenol 0.25%)
- Cool compresses, baths (with or without colloidal oatmeal)
- Topical steroids (medium strength): Triamcinolone 0.1%
Scarlet Fever
Generally mild infection caused by group A beta-hemolytic streptococci (GAHGS)
- contracted through contact with infected respiratory droplets or skin exudate, as a complication of strep throat, or as a result of food borne bacteria
- most common in children 5-15 yo
Initial presentation of Scarlet Fever
Days 1-2:
- fever (101F or higher)
- exudate pharyngitis
- swollen tongue with white exudate and/or red papillae
- young children: abdominal upset, vomiting, seizure
Rash presentation of Scarlet Fever
Typically 12-48 hours after fever onset:
- confined, bright red, flat blotches that progress into widespread sandpaper-like papillae
- initially presents on neck, armpits, and groin before spreading across the trunk and extremities
- reddened cheeks with circumoral pallor
Diagnostics for Scarlet Fever
Primarily diagnosed through a physical exam
*Throat culture may be used to prove it was strep
Management of Scarlet Fever
10-14 day course of penicillin or amoxicillin – should see improvement in 24-48 hours
Emollients or oral antihistamines for desquamating rash
Impetigo
A bacterial infection of the skin typically caused by gram positive streptococcus or staphylococcus (S. aureus) organisms
- predominantly involved the face but can occur anywhere on the body
- occurs most often in the summer
- highly contagious and autoinoculable
S/S of Impetigo
- Signs of inflammation
- Pain, swelling, warmth
- Regional lymphadenopathy
- Classic honey-crusting lesions ***
Labs/diagnostics for Impetigo
- None indicated - clinical diagnosis
2. Culture wound to confirm causative organism if desired – only necessary in severe cases
Topical antimicrobials for minor Impetigo infections
Mupirocin
Fusidic acid
Retapamulin
+ apply Burrow’s (Domeboro) solution to clean lesions
Systemic treatment for Impetigo
Should be directed at offending organism; use PO beta lactamase resistant antibiotics when oral route is preferred:
Amoxicillin-clavulanate
Dicloxacillin
Cephalexin
Erythromycin (if PCN or cephalosporin allergy)
Clindamycin
Severe Impetigo management
IV antibiotics:
nafcillin
vancomycin
doxycycline
Isolation d/t Impetigo
Abstain from school and other community events until 48 hours of treatment
Scabies
Highly contagious skin infection caused by a parasitic mite that burrows into stratum corneum
- incubation of 4-6 weeks
- spread through the direct or indirect contact with personal items
S/S Scabies
- intense itching
- irritability in infants
- linear or curved burrows
- infants: red-brown vesiculopapular lesions on head, neck, palms, or soles
- older children: red papule on skin folds, umbilicus, or abdomen
- may see regional lymphadenopathy
- interdigital lesions (in between the fingers/toes) ***
“burrowing lesions”
“girate lesions”
“snake-like lesions”
Labs/diagnostics for Scabies
Skin scrapings shoe mites, ova, and/or feces
None typically necessary
Management for Scabies
- Medications
- Rash may persist for 1 week
- Wash all washable items
- Store non-washable items x 1 week.
- Antihistamines for pruritis
Medications for Scabies
Permethrin (Nix) 5% rinse (1st treatment, leave on for 8-14 hours) and repeat treatment in 1 week – need 2 treatments
OR
Ivermectin
- only need 1 treatment
- do not use if mother is pregnant, lactating, or for children under 15kg
Pinworms
Thin, white roundworms that live in the colon and rectum of humans
Occurs most commonly among school-age children and younger
Spread by fecal-oral route
S/S Pinworms
Itching in the perineal area
Labs/diagnostics for Pinworms
“Tape test” - press clear tape to the skin around anus, place on slide and look at under microscope
Management of Pinworms
- Symptomatic treatment
- Anthelmintics to eradicate infection:
Pyrantel (Pin-X) - OTC
Mebendazole or albendazole (Rid-X) - require Rx
Lyme Disease
A spirochete disease, and the most common vector-borne disease in the US
Most cases in the NE, upper Midwest, and Pacific Coast.
Mice and deer TICKS are the major animal reservoirs, but birds may also be a source.
Etiology of Lyme Disease
Borrelia burgdorferi (Spirochete)
Ticks must ffed more than 24-36 hours to transmit the infecting organism.
Congenital infection has been documented but is questionable.
Stage 1 of Lyme Disease
Erythema migrans: A flat or slightly raised red lesion that expands over several days but has central clearing; commonly appears in areas of tight clothing
–bulls-eye/target lesion
50% of patients have flu-like symptoms
Stage 2 of Lyme Disease
- Headache, stiff joints
- Migratory pains
- Some patients may have cardiac symptoms (dysrphtymias, heart block)
- Aspetic meningitis
- Bell’s palsy
- Peripheral neuropathy
Stage 3 of Lyme Disease
- Joint and periarticular pain
- Subacte encephaolopathy
- Acrodermatitis chronic atrophicans: Bluish red discoloration of the distal extremity with edema (localized DIC)
Labs/diagnostics for Lyme Disease
- Detection of antibody to B. burgdorferi via ELISA screening
- Western blot assay is CONFIRMATORY
- B. burgdorferi may be cultured from skin aspirate
- Elevated ESR
Diagnostic criteria for Lyme Disease
Exposure to tick habitat within the last 30 days with:
- erythema migrans or
- one late manifestation and
- laboratory confirmation
Management of Lyme Disease
If infection is confined to the skin:
Amoxicillin or Cefuroxime axetil: children under 7 yo
Doxycycline: children over 7
Referral to ID for stage 2 or 3 disease
Rubeola
= Ordinary measles; red measles
occurs at any age
causes by viral pathogen
S/S Rubeola
- fever
- runny nose
- cough
- red eyes
- Koplik’s spots ***appear a couple days before rash
- spreading skin rash
*Supportive treatment, vaccinate
Rubella
= 3-day measles
Contagious viral disease caused by RNA virus known for teratogenicity (BAD - birth defects & neurologic devastation)
occurs at any age
causes by viral pathogen
S/S Rubella
- erythematous maculopapular rash
- starts of face, spreads to extremities, trunk; gone in 72 hours ***
- malaise
- joint pain
- post auricular and subocciptal lymphadenopathy
Erythema infectiosum
= Fifth disease
“5 fingers slapped their face”
Typically occurs between 5-14 years old
Caused by Human parvovirus B19
S/S Erythema infectiosum
- “slapped cheek” appearance
- lacy reticular exanthema
- face then arms, legs, trunk and dorm of hands/feet
- rash can last up to 40 days! average = 1.5 week duration
- NOT contagious after fever breaks
Can cause fetal aplastic crisis
Roseola infantum
= Sixth disease
Typically occurs between 6 months - 2 years
*VERY rare after age 4
Caused by Herpesvirus 6
S/S Roseola infantum
- URI symptoms
- small pink, flat to raised bumps
- trunk then extremities
- high fever, abrupt end when rash develops
- high fever for up to 8 days with abrupt end when rash breaks out
Coxsackie Virus
= Hand-Foot-and-Mouth disease
A highly contagious viral illness resulting in ulceration and inflammation of the soft palate (herpangina) and papulovesicular exanthema on the hands and feet
- Affects children < 10yo
- Resolves spontaneously in less than a week
- Peeling/loss of nails is common
S/S Coxsackie Virus
- fever
- malaise
- vomiting
- drooling
- papulovesicular rash
Labs/diagnostics for Coxsackie Virus
None indicated
Management of Coxsackie Virus
- Acetaminophen
2. Topical applications for comfort
Mumps
A HIGHLY contagious viral infection primarily affecting the salivary glands
- resolves within 2 weeks
**MMR vaccine to prevent
S/S of Mumps
- Swollen salivary glands (ie parotitis) causing puffy cheeks and a tender, swollen jaw ***
- Fever
- HA
- Muscle aches
- Weakness and fatigue
- Loss of appetite
Labs/diagnositics for Mumps
Mumps IgM
Management of Mumps
- Rest and isolation
- NSAIDs
- Warm or cold compresses for swollen glands
