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Peds EOR > Dermatology (15%) > Flashcards

Dermatology (15%) Flashcards

1
Q

Acne Vulgaris

General info

and pathophys

A

inflammatory skin condition associated w/ papules & pustules involving the pilosebaceous units

4 main factors of pathophys
1) follicular hyperkeratinization
2) increased sebum production (hormonal / endocrine)
3) propionibacterium acne overgrowth
4) inflammatory reponse

increased sebum in everyone BUT esp in hormone / endocrine issues

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2
Q

Acne Vulgaris

Clinical manifestations

A
  • common areas = face, back, chest, upper arms (more sebaceous glands here
  • Comedones = noninflammatory, open (blackheads, incomplete) vs closed (whiteheads, complete)
  • Inflammatory = pimple with surrounding inflammation / redness
  • Nodular or cystic = inc. rates of scarring and hyperpigmentation
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3
Q

Acne Vulgaris

Diagnostics / Severity determination

A
  • Mild = < 20 comedones and < 15 inflammatory lesions, total < 30
  • Moderate = 20-100 comedones, 15-20 inflammatory, total 30-125
  • Severe = >100 comedones, >50 inflammatory, total >125

severity helps you choose treatment steps

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4
Q

Acne Vulgaris

Management Options

Mild, Moderate, and Severe

A

ALL PATIENTS START WITH SKINCARE REGIMEN
* Mild = topical retinoid (tretinoin / adapalene) PLUS topical abx (clindamycin)
* Moderate = PO abx AND topical BPO +/- topical retinoid
* Severe (refractory nodular) = PO Isotretinoin

PO Antibiotic options
< 8 y = erythromycin, bactrim, azithromycin
> 8 y = tetracycline, doxy, minocyline

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5
Q

Pharmacology

Isotretinoin

A
  • MOA = targets all four pathways in acne mechanism
  • Indications = severe or refractory acne
  • ADR = teratogenic (highly, bHCG monthly), elevates triglycerides, arthralgia, photosensitivity (vit A derivative), dry skin / lips

d/t severe teratogenesis, patients and providers must sign up for iPledge

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5
Q

Androgenic Alopecia

General Info

A
  • genetic progressive hair loss in characteristic pattern / distribution
  • MC type of hair loss in men (and women)
  • Mostly in men > 20 years
  • DHT angrogen pathophys = too much DHT activiation causes shortened hair growth pohase (anagen), causing hair loss

usually occurs AFTER puberty

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5
Q

Androgenic Alopecia

Diagnostics

A
  • Dermoscopy = miniaturized hair & brown perihilar casts
  • Biopsy = telogen & atrophic follicles
  • Hormones = testosterone, DHEA, prolactin,
  • Other labs = CBC, TIBC, Ferritin, TSH/Free T4, ANA

treatable: anemia, thyroid, autoimmune (ish)

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6
Q

Androgenic Alopecia

Clinical Manifestations

A
  • Males = bitemporal thinning of frontal scalp → vertex thinning
  • Females = thinning between frontal and vertex w/o frontal hairline involvement
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6
Q

Androgenic Alopecia

Management

A
  • first line = topical minoxidil qd (takes 4-6 months before improvement)
  • add on = PO Finasteride or Minoxidil (5aR type 2 inhibitor) OR PO Spironolactone (blocks DHT action)
  • Last line = hair transplant
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6
Q

Perioral Dermatitis

General info

A
  • most common in young adult women (20-45)
  • risk factors = recent topical steroid use, fluorinated toothpaste
  • spares vermillion border
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7
Q

Perioral Dermatitis

Clinical Manifestation

A
  • erythematous grouped papulopustules that confluence into plaques w/ scales +/- satellite lesions

spares vermillion border

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8
Q

Perioral Dermatitis

Diagnostics

A
  • clinical diagnosis typically BUT can consider allergen patch testing if recurrent / prolonged / resistant to treatment
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9
Q

Perioral Dermatitis

Management

A
  • elimination of topical steroids and irritants (fragrances, alcohols, etc)
  • Topical Pimecrolimus, Metronidazole, or Erythromycin
  • Consider PO Doxy if refractory or extensive
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10
Q

Contact Dermatitis

General Info

A
  • irritation of the dermis & epidermis from direct contact of irritant/allergen
  • Irritant is most common type = non-immunologic reaction, chemicals / alcohols / creams / fragrances
  • Allergic = type 4 hypersensitivity reaction (delayed), MC with nickel and poison ivy
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11
Q

Contact Dermatitis

Clinical Manifestation

A
  • Acute = erythematous papules or vesicles (linear or geometric) with localized pruritis, stinging, or burning
  • Chronic = lichenification, fissuring, and scaling of skin with well-demarcated border
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12
Q

Contact Dermatitis

Diagnostics

A
  • clinical diagnosis
  • consider patch testing for potential allergens
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13
Q

Contact Dermatitis

Management

A
  1. Identify and avoid irritants (perfume, lotions, makeup, etc)
  2. first line = topical steroids (triamcinolone or hydrocortisone)
  3. alternative topicals = tacrolimus

consider PO steroids in severe or extensive reactions

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14
Q

Diaper Dermatitis

General Info

A
  • Common rash seen in infants around the buttocks region
  • Causes = wet diapers/underwear, friction, prolonged contact with urine (basic) or feces, microorganism proliferation
  • Prone to secondary infections!

Secondary infections:
* satellite lesions → candidiasis
* impetigo → S. aureus
* HSV → consider child sexual abuse

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15
Q

Diaper Dermatitis

Clinical Manifestation

A
  • increased fussiness, crying w/ diaper changes, diarrhea
  • skin = shiny erythematous rash with dull margins
  • non-candidial SPARES skin folds
  • candidal INVOLVES skin folds
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16
Q

Diaper Dermatitis

Diagnostics

A
  • Candida rule-out = KOH prep + fungal culture
  • S. aureus / Group A strep rule-out = lesion swab culture
  • Scabies concern = viral culture + mineral oil slide
  • Otherwise, usually clinical diagnosis +/- KOH and bacterial culture
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17
Q

Diaper Dermatitis

Management

A
  • wound care = keep area clean and dry
  • barrier creams = zinc oxide and petroleum jelly
  • candidiasis = topical nystatin or clotrimazole x2 weeks

make sure to discuss proper diaper changing, use disposable diapers, avoid tight-fitting diapers and clothes

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18
Q

Atopic Dermatitis / Eczema

General Info

A
  • rash d/t defective** skin barrier being susceptible to drying** → itching and redness
  • ** atopic triad **= eczema + allergic rhinitis + asthma
  • Onset usually < 5 years
  • Typically resolves/improves in >75% of patients by adulthood
  • Triggers = heat, sweat, allergens, contact irritants, stress
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19
Q

Atopic Dermatitis / Eczema

Clinical Manifestation

A
  • dry (xerosis) pruritic rash
  • acute changes = erythema, vesicles, crusting
  • chronic changes = skin lichenification, scaling, hyper/hypopigmentation
  • Infantile = cheeks, scalp, extensor surfaces, none in diaper area
  • Child = flexural areas
  • Adolescence = localized, hands / feet more common

also, nummular/discoid eczema = sharply defined coin-shaped lesions commonly on dorsum of hands/feet and extensor surfaces

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20
Q

Atopic Dermatitis / Eczema

Diagnostics

A
  • typically clinical d/t characteristics features
  • serum IgE would be elevated (supports diagnosis)
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21
Q

Atopic Dermatitis / Eczema

Management

A
  • First line = topical steroids (triamcinolone or hydrocortisone) q1-2x daily for x7d during flares + PO antihistamines (itching)
  • Second line = topical calcineurin inhibitors (tacrolimus)
  • Adjunct / Third line = systemic therapy (UVA / UVB, PO cyclosporine, mycophenolate, methotrexate)
  • Lifestyle changes = avoid products with alcohol / fragrances / astringents, pat skin dry (do not rub) and frequently use bland lubricant after shower (aquaphor or vaseline)
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22
Q

Seborrheic Dermatitis

General Info

A
  • patho is not fully understood; ? increased sebaceous fland activity + hypersensitivity reaction to Malassezia furfur
  • most common in men
  • worse in patients with parkinson’s and HIV
  • worse during fall / winter and with stress
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23
Q

Seborrheic Dermatitis

Clinical Manifestation

A
  • erythematous plaques w/ fine white scales & greasy appearance
  • Common in areas w/ high sebaceous gland secretion; scalp, eyelids, beard, nasolabial folds, chest, groin
  • +/- burning and pruritis
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24
Q

Seborrheic Dermatitis

Diagnostics

A
  • clinical BUT can consider swab culture to r/o bacterial or candidal infection
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25
Q

Seborrheic Dermatitis

Management

A
  • Mild = topical selenium sulfate / zinc pyrithione / ketoconazole / low potency steroid / sodium sulfacetamide
  • Severe or resistant = PO antifungals (fluconazole, ketoconazole, terbinafine)
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26
Q

Burns

General Info

most seen causes by age group

A
  • Infants = bathing-related scalds, abuse
  • Toddlers = hot liquid spills
  • School-age = fire (playing with lighters/etc)
  • Adolescents = volatile agents, high-voltage electrical lines
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27
Q

Burns

Clinical Manifestations

1st degree, 2nd deg super partial / deep partial, 3rd deg, 4th deg

A
  • Superficial 1st = confined to epidermis, red and dry, tender to touch and blanches with pressure, heals in 3-6d without scarring
  • Superficial parcial 2nd = epidermis + papillary dermis, pink-red with weeping/moist and blistering, painful, blanches, heals in 7-21d no scarring +/- pigmentation changes
  • Deep partial 2nd = epidermis + reticular dermis, mottled color, wet / waxy with blistering, painful only to pressure, does NOT blanch, heals in 3-9 weeks WITH hypertrophic scarring
  • Full 3rd = epidermis + dermis (papillary / reticular) + subQ tissue, varies in color from waxy white to leathery gray or charred black, DRY and inelastic skin without blistering, minimal sensation or pain, does NOT blanch, requires surgical grafting
  • 4th degree = down to fascia / muscle / bone, black and charred dry skin without blistering, NO sensation or pain, does NOT blanch, required surgery
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28
Q

Burns

Diagnostics

A
  • Use BSA calculations for determine severity and full care needed
  • anterior / posterior head = 9% each = 18% total
  • anterior / posterior torso = 18% each = 36% total
  • anterior / posterior arm = 4.5% each = 9% total
  • anterior / posterior leg = 7% each = 14% total
  • genitalia / perineum = 1%
  • LABS = aBG, CBC, CK, CMP, UA, carboxyhemoglobin
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29
Q

Burns

Management

A
  • circumferential burns = fasciotomy for compartment syndrome prevention
  • Superficial and partial = wound care with topical abx (bacitracin) and wound dressing (xeroform), daily dressing changes w/ 2d follow-up
  • All other = admission, Fluid resuscitation (parkland formula) + mIVF (4/2/1 rule), wound cares + surgical grafting

Parkland = 3 mL x TBSA % x wt (kg) ; 50% of total given over 1st 8h, rest given over next 16hr
4/2/1 rule for calculating maintenance fluids = 4mL/hr for 1st 10kg + 2mL/hr 2nd 10 kg + 1mL/hr remaining kg = total rate for hour

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30
Q

Burns

Burn Center Admit Criteria

A
  • > 10 % BSA or ANY deep partial /** full-thickness**
  • burns to hand, face, feet, or genitalia / perineum
  • any electrical, chemical, or inhalation injury
  • circumferential burns, underlying chronic condition than can worsen outcome, abuse concerns

electrical = arrhthymia complication
chemical = toxicity compliction
inhalation = pulmonary / respiratory distress complication

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31
Q

Erythema Multiforme

General Info

A
  • type 4 hypersensitivity reaction of skin following infection or medication exposure
  • infections = HSV, M. pneumoniae, VZV, EBV, CMV, Coxsackie, Parvovirus B19
  • medications = NSAIDs, sulfonamides, anticonvulsants, antibiotics
  • CLASSIC TARGET LESIONS

target lesions with THREE zones (central, white ring, red ring)

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32
Q

Erythema Multiforme

Clinical Manifestations

A
  • target lesions typically on extremities = dusky violaceous macule or blisters with ring of pallor and peripheral red ring
  • non-pruritic and blanches
  • NEGATIVE Nikolsky sign = no epidermal detachment when touching
  • ? Mucositis = mild and limited to one mucous membrane (usually oral)
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33
Q

Erythema Multiforme

Diagnostics

A
  • clinical diagnosis
  • Minor = mild mucositis and no systemic symptoms
  • Major = severe mucositis + systemic symptoms (fever, arthralgia)
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34
Q

Erythema Multiforme

Management

A
  • self-limited, treat the symptoms
  • bland emollients or topical abx + PO antihistamines
  • HSV related = PO Acyclovir
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35
Q

SJS / TEN

General info

A
  • rare hypersensitivity reactions affecting the skin AND mucosal membranes
  • Etiology = predominantly drug-related; penicillin, sulfonamides, allopurinol, NSAIDS, anticonvulstants
  • SJS = < 10% of BSA
  • SJS / TEN overlap = 10-30% BSA
  • TEN = > 30% BSA
  • ATYPICAL target lesions

two ringed lesion

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36
Q

SJS / TEN

Clinical Manifestation

A
  • prodrome = fever, malaise, pharyngitis, eye pain
  • Cutaneous = begins on torso / face and rapidly generalizes
  • SJS = atypical targetoid lesions +/- blisters and coalescence (face and torso)
  • TEN = tender erythematous patches / plaques that develop into large bullae that coalesce and rapidly slough → large denuded areas of skin
  • POSITIVE Nikolsky sign
  • Ocular = conjunctivitis, eyelid edema, blepharitis, corneal erosions
  • Mucositis = OP, conjunctival, urethral, genital, perirectal

  • Nikolsky = skin seperates from dermis with lateral pressure
  • OP = oropharyngeal
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37
Q

SJS / TEN

Diagnostics

A
  • clinical
  • Biopsy = full thickness skin necrosis (derm consult)
  • Consider = bacterial cultures and M. pneumoniae PCR
  • SJS more in kids vs TEN more in elderly
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38
Q

SJS / TEN

Management

A
  • Prompt STOP of all possible inciting meds
  • Underly infectious etiology? treat
  • Supportive = pain analgesia (morphine, tylenol, no NSAIDS), mIVF if nutrition support, body temp regulation
  • consider adding K or Phos to fluids (hypoK / NA / P often)
  • Wound care = leave bullae intact, petroleum gauze, topical abx
  • IVIg may stop progression
  • Close monitor for sepsis

SIRS criteria: any 2+ of below
* fever ( > 100.4 / 38c) OR hypothermia ( < 96.8 / 36c)
* HR > 90 bpm
* RR > 20 or PaCO2 < 32 mmHg
* WBC > 12k or < 4k

Sepsis criteria = SIRS + source of infection (UTI, PNA, URI, cellulitis, pyelonephritis, appendicitis, etc)

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39
Q

Cutaneous Drug Eruption / Reaction

General Info

A
  • medication induced changes in the skin and mucous membranes (most are hypersensitivity reactions)
  • self-limiting and improve with drug removal
  • typically starts 1-2 days after drug exposure BUT can take up to 2-3 weeks
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40
Q

Cutaneous Drug Eruption / Reaction

Hypersensitivity Reaction Classifications

A
  • Type 1 = IgE mediated, urticaria, angioedema, immediate
  • Type 2 = cytotoxic, antibody mediated, cell lysis
  • Type 3 = immune antibody-antigen complex (drug-mediated vasculitis and drug serum sickness)
  • Type 4 = delayed (cell-mediated), morbilliform reaction (erythema multiforme)
  • Non-immunologic = cutaneous drug reactions d/t* genetic incapability* to detoxify certain meds (anticonvulsants, sulfonamides)
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41
Q

Exanthematous Drug Eruption

General Info

A
  • morbilliform or maculopapular drug eruption with macules or small papules s/p initiation of drug treatment
  • typically starts 5-14d after starting offending med
  • Type 4 delayed hypersensitivity reaction
  • MC drugs = aminopenicillins, sulfonamides, anticonvulsants (carbamazepine)
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42
Q

Exanthematous Drug Eruption

Clinical Manifestation

A
  • latency onset period
  • erythematous macules or papules that are morbilliform (measles like) +/- rubelliform (rubella like) and usually on trunk / proximal extremities
  • mild = spares acral sites
  • sevre - involves face, palms, soles
  • Systemic symptoms usually mild = pruritis and low-grade fever
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43
Q

Exanthematous Drug Eruption

Diagnostics

A
  • clinical diagnosis
  • Labs = CBC w/ diff +/- urine eosinophil smear (mild eosinophila)
  • CRP / ESR likely elevated

consider kidney function in sicker kiddos, risk of AIN / ATN

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44
Q

Exanthematous Drug Eruption

Management

A
  • stop offending med (recently started)
  • symptomatic = PO antihistamines (H1 blockers)
  • Severe = IV Methylprednisolone or Decadron (or PO steroids)

  • 2nd gen antihistamine choices = cetirizine, loratidine
  • 1st gen (more sleepy / ADR) = diphenhydramine, hydroxyzine (good if anxious)
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45
Q

Angioedema

General Info

A
  • self-limited localized subQ (or submucosal) tissue swelling d/t extravassation of fluid into interstitium
  • affects mucosal tissue of face, lips, tongue, larynx, hands, feet, genitalia
  • onset in min-hours w/ spontaneous resolution in hours-days
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46
Q

Angioedema

Clinical Manifestation

A
  • mast-cell (histamine) mediated (aka allergic reactions) = angioedema with urticaria, flushing, pruritis, bronchospasm +/- stridor, throat tightness, HOTN
  • bradykinin-mediated (aka ACEI-induced, hereditary) = angioedema w/o above symptoms

hereditary = C1 esterase inhibitor deficiency

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47
Q

Angioedema

Diagnostics

A
  • if cause is unknown and there is no history to suggest external cause, consider C4 levels + C1 inhibitor antigenic level
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48
Q

Angioedema

Management

A
  • Immediate = ABC’s → airway, breathing, cardiac + first epi dose (consider IM vs racemic epi)
  • Mast-cell mediated = epi + decadron / prednisolone (steroids) + antihistamines (benadryl)
  • Bradykinin-mediated = C1 inhibitor concentrate, Ecallantide, Icatibant
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49
Q

Urticaria (hives)

General Info

A
  • superficial skin edema d/t histamine-related increased vascular permeability
  • Type 1 (IgE) immediate hypersensitivity reaction
  • Patho = vasodilator release (histamine, bradykinin, PGs) form mast cells & basophils in the skin
  • Common triggers = food, meds, heat / cold, stress, insect bites, environmental allergens, infection
  • Chronic if > 6 weeks
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50
Q

Urticaria (hives)

Clinical Manifestation

A
  • sudden onset circumscribed hives / wheals that are blanchable, raised, erythematous +/- coalesce
  • intense pruritis
  • usually transient and dissapear within 24hrs
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51
Q

Urticaria (hives)

Management

A
  • initial = PO antihistamine (1st gen vs 2nd gen)
  • Add on = H2 blocker if no response to H1 blockers (ie add Ranitidine)

  • 2nd gen antihistamine choices = cetirizine, loratidine
  • 1st gen (more sleepy / ADR) = diphenhydramine, hydroxyzine (good if anxious)
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52
Q

DRESS / DIHS

General Info

  • DRESS = Drug Reaction with Eosinophila & Systemic Symptoms
  • DIHS = Drug-Induced Hypersensivity Syndrome
A
  • distinct and ?** life-threatening** severe ADR characterized by → morbilliform cutaneous eruption, fever, LAD, thrombophilia, heme abnormalities, multiorgan involvement (usually hepatic transaminitis, thyroiditis, and/or renal AIN / ATN)
  • Patho = CD4 / CD8 T cell activation
  • most common ~2-6 weeks s/p medication initiation
  • Common meds = anticonvulsants ( !! phenobarbital, carbmazepine, phenytoin, lamotrigine), minocycline, sulfa abx
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53
Q

DRESS / DIHS

Clinical Manifestation

A
  • Prodrome (2-3d before rash) = fever, pharyngitis, malaise
  • Skin = morbilliform exanthem w/ accentuation on face, upper trunk, and proximal extremities (may progress to erythroderma)
  • pruritis
  • facial edema (esp periorbital), LAD, mucosal involvement (cheilitis)
  • Organ involvement = heptitis, AIN, ATN, SOB, tachypnea, cough, thyroiditis, pancreatitis, etc
54
Q

DRESS / DIHS

Associated Autoimmune Complications

A
  • graves (thyroiditis)
  • DM1 (pancreatitis)
55
Q

DRESS / DIHS

Diagnostics

A
  • Dx criteria = acute onset exanthema w/ fever + drug reaction suspicion + hospitalization + LAD + involvement of 1+ organ, lymphopenia, lymphocytosis, eosinophilia > 10%, thrombocytopenia)
  • CBC = eosinophilia, thrombocytopenia, lymphocytosis, lymphopenia
  • LFTs = transaminitis (↑ ALT / AST / Alk phos)
  • CMP = ↑ Cr
  • ↑ LDH
  • UA = proteinuria, eosinophilic sediment +/- hematuria
  • Consider blood PCR = HHV6, HHV7, EBV, CMV
  • TFT at onset then again @ 6 weeks

  • Thrombocytopenia = ↓ platelets
  • Lymphocytosis = ↑ WBC
  • Lymphopenia = ↓ WBC
56
Q

DRESS / DIHS

Management

A
  • Derm consult!!!
  • Identify and STOP causative medication
  • IV fluid replacement + electrolyte correction
  • Mild (mostly cutaneous) = topical corticosteroids (triamcinolone, hydrocortisone) + antihistamines for itching (atarax, diphenhydramine, loratidine)
  • Systemic = IV methylprednisolone or PO prednisone +/- IVIg or plasmapharesis
57
Q

Rubeola (Measles) / 1st disease

General Info

A
  • measles virus (paramyxovirus family)
  • transmission via respiratory droplets or contact with contaminated surface
  • incubation 6-21 days
  • vaccination = MMR @ 12-15 months then again @ 4-6 years
58
Q

Rubeola (Measles) / 1st disease

Clinical Manifestation

A
  • Prodrome = high fever and 3 C’s (cough, coryza, conjunctivitis) for 2-3 days
  • Koplik spots = small red spots w/ white centers on oral mucosa (rash usually then starts 1-2d later)
  • Rash = morbilliform rash with cephalocaudal progression (head down) that SPAREs palms/soles
  • rash fades in ~4 days
  • persistent cough for 10-14 days
59
Q

Rubeola (Measles) / 1st disease

Diagnostics

A
  • clinical diagonsis PLUS
  • measle-specific IgM antibodies and PCR

pregnant women usually get serum titer during gestation as screening measure

60
Q

Rubeola (Measles) / 1st disease

Management

A
  • supportive = analgesia (tylenol / motrin), encourage PO hydration
  • kids can take** daily VitA** = can help boost immune response and decrease risk of complications
  • Complications = severe diarrhea most common, pneumonia, immune suppression for ~6 weeks (↑ AOM and bacterial PNA)
61
Q

Scarlet Fever / 2nd disease

General info

A
  • group A strep
  • type 4 (delayed) hypersensitivity reaction to pyrogenic GAS strain (erythrogenic toxin A, B, C)
62
Q

Scarlet Fever / 2nd disease

Clinical Manifestation

A
  • prodrome = fever, chills, pharyngitis
  • rash = diffuse blanchable erythema with small papular elevations w/ sandpaper texture (starts @ axillae and spreads to trunk and extremities, sparing palms/soles)
  • flushed face with circumoral pallor & strawberry tongue
  • Pastia’s lines = linea petechial lesions seen at pressure points, axillary, antecubital, abdominal, or inguinal areas
63
Q

Scarlet Fever / 2nd disease

Diagnostics

A
  • clinical diagnosis +/- GABHS swab
64
Q

Scarlet Fever / 2nd disease

Management

A
  • first line = penicillin G or amoxicillin
  • alternative = macrolides, clindamycin, cephalosporins
65
Q

Scarlet Fever / 2nd disease

Rapid Review

A
  • etiology = GABHS
  • patho = type 4 delayed hypersensitivity rxn
  • S/S = prodromal URI, sandpaper rash in axillae/groin spread to trunk/extremities (no palms or soles)
  • “flushed face, circumoral pallor, strawberry tongue, sandpaper”
  • first line tx = amoxicillin
66
Q

Rubella / 3rd Disease

General Info

also known as “german measles”

A
  • rubella virus (togavirus family)
  • transmission via respiratory droplets
  • incubation period 14 days
  • TORCH infection!

congenital defects = teratogenic miscarriage 1st TM, deafness, cataracts / blindness, congenital heart defects (PDA)

67
Q

Rubella / 3rd Disease

Clinical Manifestation

A
  • prodromal flu sx’s (mild fever), arthraligia, postauricular LAD
  • rash = erythematous maculopapular rash with cephalocaudal spread (face down), sparing palms and soles
  • rash spreads fast and resolves within 3 days
  • Forchheimer spots = pinpoint red petechiae on soft palate and uvula
68
Q

Rubella / 3rd Disease

Diagnostics

A
  • clinical diagnosis BUT = rubella-specific IgM Ab via EIA

moms are screened via serum IgM Ab titer during gestation

69
Q

Rubella / 3rd Disease

Management

A
  • Supportive cares = analgesia (tylenol / motrin), encourage PO hydration
  • exposure? IVIg
  • Vaccination!! MMR @ 12-15 months and 4-6 years
  • Complications mainly fetal = teratogenic, deagness, blindness, CHD (PDA)
70
Q

Rubella / 3rd Disease

Rapid Review

A
  • rubella virus (togavirus family)
  • prodromal flu sx’s with mild fever, arthralgia, LAD
  • maculopapular cephalocaudal spread rash with rapid resolution (3 days)
  • look in mouth = forchheimer spots
  • clinical diagnosis vs IgM Ab titer
  • supportive cares + vaccination
  • TORCH = deaf, blind, CHD
71
Q

Erythema Infectiousum / 5th Disease

General Info

A
  • parvovirus b19 = infects and destroys reticulocytes → slowed erythropoiesis
  • transmission via droplets
  • incubation period 4-14d
72
Q

Erythema Infectiousum / 5th Disease

Clinical Manifestation

A
  • prodromal flu sx’s (mild fever, HA, malaise) followed by rash within few days
  • rash = “slapped cheek” rash sparing palms and soles, spreads to lacy reticular pattern on limbs
  • arthritis / arthralgia common complaint!!
73
Q

Erythema Infectiousum / 5th Disease

Diagnostics

A
  • clinical BUT = parvovirus b19-specific IgM antibody titer
74
Q

Erythema Infectiousum / 5th Disease

Management

A
  • supportive = tylenol and motrin
  • complications = hydrops fetalis (if pregnant), aplastic sickle cell crisis
75
Q

Erythema Infectiousum / 5th Disease

Rapid Review

A
  • parvovirus b19
  • slapped cheek rash with lacy pattern on limbs
  • arthalgia / joint pain
  • supportive cares
  • aplastic sickle cell crisis d/t destruction of reticulocytes
76
Q

Roseola Infantum / 6th Disease

General Info

also called Exanthema Subitum

A
  • HHV6 (sometimes HHV7)
  • droplet tansmission, saliva
  • incubation period 10 days
  • MC in kiddos 6 month - 2 years
  • abrupt fever onset!
77
Q

Roseola Infantum / 6th Disease

Clinical Manifestation

A
  • prodromal 2-3d of high fever (kiddo may look good, fever can reach >104)
  • Rash = pink maculopapular blanchable rash starting on TRUNK then spreading to face
  • only viral exanthem with rash STARTING on trunk
78
Q

Roseola Infantum / 6th Disease

Diagnostics

A
  • Clinical diagnosis + viral culture/PCR confirmation
  • also serum IgG antibody titer against HHV 6/7
79
Q

Roseola Infantum / 6th Disease

Management

A
  • Supportive = rest, fluids, antipyretics for high fevers (tylenol q6h)
  • Immunocompromised = antivirals (ganciclovir)
  • Complications = febrile seizures!
80
Q

Roseola Infantum / 6th Disease

Rapid Review

A
  • HHV 6/7 in kids 6m-2y
  • high fevers then rash on trunk
  • viral PCR or serum IgG antibody titer
  • supportive care
  • febrile seizure caution
81
Q

Hand, Foot, Mouth

General Info

A
  • coxsackie virus A
  • transmission WIDE = person-person, droplet, feces, direct contact with contaminated surface
  • MC in kiddos < 5 years
  • MC in summer / early fall!

think through why this time period so common = kiddos play outside, less clothing, more contact with other kids / people, playing in parks / outdoors / on shared things

82
Q

Hand, Foot, Mouth

Clinical Manifestation

A
  • prodromal flu-like symptoms +/- oral pain followed by rash
  • rash = painful oral vesicles / uclers followed by vesicles on hands / feet
  • rash usually clears within 10 days
83
Q

Hand, Foot, Mouth

Diagnostics

A
  • clinical BUT = viral culture / PCR throat swab OR stool sample
  • Serum Coxsackie-specific IgA
84
Q

Hand, Foot, Mouth

Management

A
  • supportive = tylenol and motrin, hydration, topical lidocaine or lidocaine mouthwash
  • self-resolves in ~1-2 weeks
  • complications = aseptic meningitis, Guillain-barre syndrome

Guillain-Barre = rare neurological disorder in which a person’s immune system mistakenly attacks part of their peripheral nervous system following viral/bacterial infection, starts with paresthesias in hands/feet then spreads to entire limbs / paralysis

85
Q

Hand, Foot, Mouth

Rapid Review

A
  • coxsackie A virus that is HIGHLY contagious
  • kiddos < 5yr and summer / fall
  • prodrome flu sx’s with oral pain then vesicles in/on mouth, feet, hands resolving within 10d
  • Guillain-barre and aseptic meningitis risk
86
Q

Herpangina

General Info

A
  • coxsackie virus (esp. type A)
  • MC in kids 3-10 yrs
  • MC in summer / early fall
87
Q

Herpangina

Clinical Manifestation

A
  • sudden onset high fever
  • stomatitis = small yellow/white papulovesicular lesions on posterior pharynx that ULCERATE before healing
  • anorexia d/t oral pain
  • pharyngitis / odynophagia
  • no sores on hands or feet!!!
  • older kids = malaise, HA, N/V, neck stiffness, back stiffness
88
Q

Herpangina

Diagnostics

A
  • clinical +/- serum IgA titer +/- viral PCR
89
Q

Herpangina

Management

A
  • supportive = tylenol / motrin, PO hydration, rest
  • consider lidocaine gargle
  • complications = aseptic meningitis, Guillain-Barre syndrome
90
Q

Herpangina

Rapid Review

A
  • Coxsackie virus (usually A)
  • kids 3-10 years
  • HIGH fever with stomatitis and anorexia d/t oral pain
  • supportive cares
  • Guillain-Barre and Meningitis risk
91
Q

Mumps

General Info

A
  • paramyxovirus
  • transmission via droplets, saliva, & household fomites
  • incubation period 12-14 days
  • vaccination!! 12-15 months then 4-6 years
92
Q

Mumps

Clinical Manifestation

A
  • prodromal low-grade fever, fatigue, myalgia, malaisesa, HA, earache
  • parotitis = parotid gland swelling / pain (usually bilateral)
  • check for orchitis in males
  • PE = parotid gland swelling & tenderness
93
Q

Mumps

Diagnostics

A
  • clinical diagnosis
  • if really sick, consider = amylase and CBC w/ diff = ↑ amylase, leukopenia (low WBC) with ↑ lymphocytes
94
Q

Mumps

Management

A
  • supportive cares = tylenol, motrin, hydration
  • complications = epididymo-orchitis common
95
Q

Mumps

Rapid Review

A
  • paramyxovirus
  • 12-14d incubation
  • prodromal low-grade fever, malaise, HA, earache
  • bilateral parotitis +/- orchitis in males
  • clinical diagnosis
  • supportive cares
96
Q

Varicella-Zoster Virus (VZV / HHV3)

General Info

A
  • 2 distinct diseases = primary chickenpox / varicells & reactivated herpes zoster / shingles
  • transmission via aerosolized droplets, direct contact with vesicular fluid
  • incubation 14-21 days
  • stays dormant (latent stage) in trigeminal ganglion and dorsal root ganglia = virus reactivation years later (aging, stress, immune suppression)

  • VZV vaccination @ 12-15 months AND 4-6 years
  • Shingles / recombinant vaccine in pts > 50yrs (2 doses 6 months apart)
97
Q

Varicella-Zoster Virus (VZV / HHV3)

Clinical Manifestation

chicken pox only

A
  • “dew drops on a rose petal” = varying macules, papules, vesicles with pustular component followed by crusted papules and crusting
  • other prodromal sx’s = fever, malaise, anorexia, pharngitis = rash within 24 hrs
  • pruritic!!!
  • crusts fall off within 1-2 weeks leaving hypopigmentation
98
Q

Varicella-Zoster Virus (VZV / HHV3)

Clinical Manifestation

shingles

A
  • prodromal pain, itching, burning, tingling (this is where rash will develop)
  • rash = single stripe of vesicles (single dermatome) that DOES NOT cross midline
  • usually resolves within 1 month BUT pain can last > 90 days (post-herpetic neuralgia)
  • Zoster opthalmicus = involves ophthalmic dibision of trigeminal nerve (5) = eye pain, rednes, swelling + fever + painful vesicular ash
  • Zoster Oticus (Ramsay-Hunt Syndrome) = facial nerve (8) involvement = otalgia, lesions on ear / auditory canal / TM, facial palsy, hearing loss
99
Q

Varicella-Zoster Virus (VZV / HHV3)

Diagnostics

A
  • clinical diagnosis, BUT = PCR or viral DNA, confirmatory blood IgM antibody
  • Tzanck smear = “multinucleated giant cells”
  • Zoster ophthalmicus = dendritic lesions on slit lamp IF keratoconjunctivitis present
100
Q

Varicella-Zoster Virus (VZV / HHV3)

Chickenpox Management

A
  • self-limiting resolution within 1 week
  • ISOLATION d/t high contagiousness
  • healthy kids < 12 = supportive cares (No NSAIDS or ASA!!!)
  • kids > 13y & unvaccination / immune = PO antivirals (Acyclovir $ vs Valacyclovir $$$)
  • Consider VZV IgG (VZIG) therapy in sick / at risk kids

no NSAIDS/ASA d/t risk of Reye syndrome

101
Q

Varicella-Zoster Virus (VZV / HHV3)

Shingles Management

A
  • rash resolves within 1 month but pain can last > 90 days
  • PO Acyclovir within 72h onset (prevents postherpetic neuralgia)
  • Zoster ophthalmicus = PO antivirals +/- acyclovir eye drops
  • Ramsay-Hunt = PO acyclovir and corticosteroids
  • Postherptic neuralgia = PO gabapentin or Capsaicin
  • Vaccination!!! shingles in pts > 50yrs (2 doses 6 months apart)
102
Q

Impetigo

General Info

A
  • highly contagious superficial vesiculopustular skin infection = S. aureus or GABHS
  • single **MOST COMMON skin infection in kids **
  • highest incidence 2-6yrs
  • RF = poor hygiene, poverty, crowding, warm / humid weather (less clothes to cover skin), skin trauma
  • Complications = cellulitis (10%), acute glomerulonephritis
  • does NOT lead to rheumatic fever
103
Q

Impetigo

Clinical Manifestation

A

Non-bullous (MC type) = vesicles / pustules, weeping, “honey-colored crust”, occurs at site of skin trauma (insect bites MC)
* around mouth/nose, associated LAD

Bullous = vesicules then bullae, varnish-like crust, more rare
* fever, diarrhea, S. aureus only etiology

Ecthyma = ulcerative pyoderma caused by GABHS (not common), scarring

104
Q

Impetigo

Diagnostics

A
  • clinical diagnosis BUT = lesion swab culture with gram stain
105
Q

Impetigo

Management

A

Mild = topical Mupirocin TID x 10 days
* or; bacitracin or retapamulin
* keep area clean (mild soap/water)

Extensive = PO Cephalexin or Erythromycin x 1 week
* or; Macrolide abx

MRSA complication = PO Doxy OR IV Vanco if quite sick

106
Q

Impetigo

Rapid Review

A
  • S. aureus or GABHS
  • highly contagious common in kids 2-6 yrs (esp. in crowding, poverty, hot/humid weather)
  • Cellulitis common complication
  • S/S = weeping honey crusted lesions MC at sites of trauma (bug bites) and around mouth / nose with LAD
  • Diarrhea ? bullous, S. aureus
  • Can confirm with lesion culture / gram stain
  • Mild = topical mupirocin x 10 days
  • Extensive = PO Cephalexin
  • MRSA = Doxy or Vanco
107
Q

Scabies

General Info

A
  • highly contagious skininfection d/t mite Sarcoptes scabiei
  • patho = female mites burrow into skin to lay eggs, feed, and defecate

fecal particles (scybala) are what cause the hypersensitivity reaction and itching

108
Q

Scabies

Clinical Manifestations

A

Symptoms
* intense pruritis worse at night
* can be asymptomatic but infected for up to 4-6 weeks

Exam
* multiple small erythematous papules / excorations with linear burrows @ intertriginous zones (scalp, web spaces)
* red itchy pruritic papules or nodules on scrotum, glans, penile shaft, or body folds

109
Q

Scabies

Diagnostics

A
  • clinical +/- skin scrapings = mites, eggs, feces (on magnification)
110
Q

Scabies

Management

A
  • Topical Permethrin DOC (do not use after showers = seizures d/t increased absorption through pores)
  • Extensive = Ivermectin
  • All bedding, clothing, etc should be placed in plastic air tight bags for AT LEAST 72-92 hours then washed and dried with high heat
111
Q

Scabies

Rapid Review

A
  • Sarcoptes scabiei females leave poop under skin causing hypersentivity itching
  • pruritis worse at night
  • skin burrows found in intertriginous zones
  • skin scraping = mites, eggs, feces
  • Topical Permethrin (seizure risk) or Ivermectin (extensive)
112
Q

Pediculosis / Lice

Rapid Review

A
  • pubis = pubic / genitalia area, STI, pruritis, topical permethrin
  • capitis = head lice, person to person, girls more common, 3-12 years, intense occipital itching, topical permethrin or Lindane (neurotoxic)
  • corporis = body lice, STI, poor body hygiene, vector for human blood disease person to person, pruritis, first line hygiene then permethrin 5% cream
113
Q

Lichen Planus

General Info

A
  • acute or chronic inflammatory dermatitis
  • cell-mediated immune response
  • increased incidence in = hepatitis C
  • “purple polygonal planar pruritic papules or plaquestion”
114
Q

Lichen Planus

Clinical Manifestation

A
  • pruritic rash MC on extremities (esp volar surfaces of wrist / ankles)
  • can involve mouth, scalp, genitals, nails, mucous membranes

Exam
* 5 P’s = purple, polygonal, planar, pruritic, papules OR plaques
* fine scales with irregular borders +/- Wickham striae
* Koebner’s phenomenon!
* ? nail dystrophy +/- scarring alopecia

  • Wickham striae = fine white lines on skin lesions or oral mucosa
  • Koebner‘s = new lesions @ site of trauma (shins common)
115
Q

Lichen Planus

Diagnostics

A
  • clinical +/-** skin biopsy & immunofluorescence confirmatory** = saw-tooth lymphocyte infiltrate at dermal epidermal junction
116
Q

Lichen Planus

Management

A
  • First line = topical steroids w/ occlusive dressings
  • antihistamines for itching
  • Second line = PO or intralesional steroids +/- topical tretinoin +/- UV light therapy
  • resolves spontaneously within 8-12 months
117
Q

Lichen Planus

Rapid Review

A
  • cell-mediated immune response
  • pruritis
  • 5 P’s = polygonal, planar, purple, pruritic, papules OR plaques
  • Wickham striae +/- koebner’s
  • confirmatory biopsy and immunofluoresence (saw-tooth lymphocyte)
  • first line tx = topical steroids and PO antihistamines
  • resolves in 8-12 months
118
Q

Pityriasis Rosea

General Info

A
  • unclear etiology but ? HHV6/7
  • primarily in older kids / young adults
  • more common in spring / fall
119
Q

Pityriasis Rosea

Clinical Manifestation

A
  • herald patch = solitary salmon-colored macule on trunk (2-6mm)
  • 1-2 weeks later = general exanthem with smaller pruritic 1cm round/oval salmon-colored papules w/ white collarette scaling
  • christmas tree pattern!!
  • confined to trunk and proximal extremities
120
Q

Staphylococal Scaled Skin Syndrome (SSSS)

General Info

A
  • dissemination of S. aureus exfoliative toxins (esp strains 55 & 71)
  • Patho = toxins cleave desmoglein-1 = formation of flaccid fragile bullae
  • common in infants 3-7d OR children < 5 years
121
Q

Staphylococal Scaled Skin Syndrome (SSSS)

Clinical Manifestation

A

Erythema phase
* fever, irritability, skin tenderness, then;
* cutananeous blanching erythema (usually starts @ mouth); worse in flexor areas & around orifices

Bullae phase
* sterile flaccid blisters 1-2d after erythema (esp in areas of mechanical stress = flexural, buttocks, hands, feet)
* (+) Nikolsky sign!!

Desquamative phase
* skin that easily ruptures = denuded skin before healing
* +/- conjunctivitis

122
Q

Staphylococal Scaled Skin Syndrome (SSSS)

Diagnostics

A
  • clinical but = skin biopsy, NP cultures, lesion cultures
  • Skin biopsy = splitting of lower stratum granulosum layer
123
Q

Staphylococal Scaled Skin Syndrome (SSSS)

Management

A
  • Nafcillin or Oxacillin
  • MRSA concern = IV Vancomycin
  • Supportive cares = keep skin clear and moist, emollients for barrier protection, encourage hydration
  • NO STEROIDS (can make worse)
124
Q

Everything Tinea

Mass Rapid Review

A

Tinea capitis = “ring worm”
* scalp, trichophyton, patches of alopecia w/ black dots OR scaly patches with varying alopecia, diagnosed KOH prep and definitive culture
* tx via* PO Griseofulvin x6-12 weeks* (or PO Terbinafine)

Tinea pedis = “athlete’s foot”
* common in young men, dermatophyte infection, interdigital itching and erythema with erosions or scaling, diagnosed via KOH prep and culture
* tx via topical antifungal (butenafine or clotrimazole) x4 weeks
* PO terbinafine or fluconazole if refractory

Tinea cruris = “jock itch”
* trichophyton T. rubrum fungal infection of groin / inner thights, common in males w/ copious sweating or close contact sports (wrestlers)
* can spread from tinea pedis
* diagnosed via KOH prep and definitive fungal culture
* tx via topical clotrimazole and dessicant powders to area

Tinea corporis = “ringworm”
* trichophyton & microsporum genera (T. rubrum) fungal infection of body (trunk, legs, arms, neck, chest)
* direct contact, risk if stray animal exposure
* circular or oval plaques/patches with central clearing and well-defined raised borders
* tx via topical clotrimazole or ketoconazole x1-3 weeks

Tinea (Pityriasis) veriscolor
* Malsassezia furfur yeast / fungal infection MC in adolescents
* RF = hot humid weather
* hyper/hypopigmented well-demarcated round/oval patches with fine scaling MC on upper trunk / proximal extremities
* diagnosis via KOH prep (spaghetti and meatballs) and wood’s lamp (yellow-green fluorescence)
* tx via topical selenium sulfide or zinc pyrithion

125
Q

Psoriasis

General info

A
  • immune-mediated multisystemic disease
  • Patho = keratin hyperplasia and proliferation @ stratum basale / spinosum d/t T cell activation & cytokine release
  • plaque is MC type
  • associated with arthritis and increased risk for CVD (plaque formation)
126
Q

Psoriasis

Clinical Manifestation

A

Plaque
* well-demarcated pink-red plaques/papules w/ thick silvery-white scales
* extensor surfaes (elbows, knees, scalop, nape of neck)
* pruritic

Exam
* Auspitz sign = punctate bleeding w/ removal of plaque or scale
* Koebner’s = lesions at sign of trauma
* Nails = pitting, onycholysis

Other variants
* Guttate = small erythematous “tear drop” papules w/ fine scales, discrete lesions, and confluent plaques, often s/p strep pharyngitis
* Pustular = deep yellow pustules that coalesce to large areas of pus + fever, leukocytosis
* Erythroderma = generalized erythematous rash involving most of skin (worst type)

127
Q

Psoriais

Management

A
  • clinical diagnosis
  • first line = topical steroids and vitD analogs (calcipotriene)
  • moderate/severe = topical steroids PLUS UVA/B phototherapy PLUS PO Psoralen
  • severe = PO systemic (cyclosporine, acitretin, biologic agents adalimumab)

methotrexate usually last resort

128
Q

Erythema Toxicum Neonatormum

General Info

A
  • common in first 72hrs of life, can be present at birth
  • higher incidence in neonates with LGA or greater gestational age
  • basically skin reaction to new outside world
129
Q

Erythema Toxicum Neonatormum

Clinical Manifestation

A
  • multiple erythematous macules / papules that rapidly progress to pustules on erythematous base
  • MC on trunk and proximal extremities
  • SPARES palms/soles
130
Q

Erythema Toxicum Neonatormum

Diagnostics

A
  • clinical diagnosis usually without any testing
  • can consider Wright-stain smear if concerned = eosinophils
131
Q

Erythema Toxicum Neonatormum

Management

A
  • no treatment required
  • resolves spontaneously in 5-7d
132
Q

Transient Neonatal Pustular Melanosis

General Info

A
  • mostly affects full-term black infants
  • 3 types of lesions that present @ birth and resolve over several weeks to months

need to look up why more frequent in black infants?

133
Q

Transient Neonatal Pustular Melanosis

Clinical Manifestation

A
  • Small pustules on non-erythematous base @ birth
  • erythematous to hyperpigmented macules with surrounding collarette of scale +/- pustules (can persist for weeks to months)
  • hyperpigmented macules that gradually fade over months
134
Q

Transient Neonatal Pustular Melanosis

Diagnostics

A
  • clinical diagnosis so no testing necessary
  • can consider wright-stain smear = neutrophils
135
Q

Transient Neonatal Pustular Melanosis

Treatment

A

none needed :)

can discuss skin care with parents, bland emollients

136
Q
A

Peds EOR (2 decks)

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