Dermatology

Question 1

Treatment of Mild-Moderate Acne?

Answer 1

If mostly comedonal: retinoid
If mostly inflammatory: Benzoyl peroxide (reduces resistance; anti-inflammatory) OR Topical abx (tetracyclines x 3 months) AND Benzoyl peroxide (reduces resistance; anti-inflammatory)

Can use all three—retinoid, BP, topical antibiotic

Duration: Treat for 2-3 months then reassess

Question 2

Treatment of Severe Acne?

Answer 2

Isotrentinoin (Accutane)

Tests needed before treatment: LFTs, urinalysis, CBC, cholesterol, trigs

Question 3

Side effects of Accutane?

Answer 3

Cheilitis (lip inflammation)
Xerostomia (dry mouth)
Xerophthalmia (dry eyes)
Conjunctivitis
Myalgia
Headache
Hepatitis
Hypercholesterolemia
Hypertriglyceridemia
Pseudotumor cerebri
Teratogenic

Question 4

Alopecia Areata

Answer 4

• T cell driven autoimmune condition with hair loss
• Associated features: atopy, nail changes
• Associated conditions: autoimmune conditions, Down syndrome
• Treatment: spontaneous resolution in 6-12 mo, can use topical or injected steroids, should screen for other autoimmune conditions

Question 5

Psoriasis

Answer 5

Red scaly plaques (silver scales)
- Extensor surfaces
- Can see nail pitting

Associated with increased risk of: cardiovascular disease, metabolic syndrome, anterior uveitis, IBD, celiac

Exacerbated by: Sun, Strep, Smoking, Stress, B blockers and NSAIDs

Tx: If <20% BSA-> topical betamethasone 0.05-0.1%
If >20% BSA consider UV light, systemic tx (methotrexate or cyclosporine)

Question 6

Guttate patterned rash?

Answer 6

Guttate psoriasis
Rapid onset; many small papules (<1 cm)
Often there is a hx of preceding Strep A infection, consider treating with penicillin x 10 days
Spontaneous remission-weeks to months
Usually treated to shorten course

Question 7

Molluscum Contagiosum

Answer 7

Umbilicated, waxy, flesh-colored papules

Resolve within 2 years if immunocompetent

Question 8

Pityriasis Rosea

Answer 8

Viral rash that is acute, self-limiting eruption (up to 3 months)
- Oval papule with characteristic scale (ring of scale, thicker scale on the outside)
- Starts as single, large papule: Herald patch- annular plaque with scale with central clearing
- Other papules develop in days to weeks after
- Classic presentation “Christmas tree pattern”
- Can be itchy

Location: trunk (mainly) and extremities
- face, palms and soles are spared

Tx: self resolves 6wk-3mo, can use topical steroids or erythro if ++ itchy or bothersome

Question 9

Rhus Dermatitis

Answer 9

From poison ivy!

Linear streaks of vesicles

Tx: spontaneously resolves in 1-3 weeks

Question 10

Tinea Capitis

Answer 10

Ringworm of the scalp
- Most common in black and prepubertal kids
- ALWAYS SEND FUNGAL SCRAPING
- Looks like dry flaking on scalp with small black dots and some hair loss
- May get post-auricular lymphadenopathy

Treatment: Oral Terbinafine x 2-8 weeks

Question 11

Tinea Corporis

Answer 11

Ringworm of the body
- Scaly red plaques with central clearing
- Spares palms, soles, groin

Dx: send scale for KOH and cx

Treatment: topical antifungals (azoles) or terbinafine

Question 12

Treatment of oropharyngeal candidiasis

Answer 12

Oral nystatin after feeds

1st gen imidazoles (miconazole and clotrimazole = more effective)

PO fluconazole if moderate to severe or failed first line tx

Question 13

Candida Diaper Dermatitis

Answer 13

Found in the folds

Tx: topical antifungal ointments or powders (nystatin)

Question 14

Pityriasis Versicolor

Answer 14

scaly hypo- or hyperpigmented lesions (usually oval papules) on the trunk caused by fungal infection with Malassezia

Dx: clinical or woods lamp (yellow fluorescence)

Tx: topical ketoconazole, selenium sulfide and clotrimazole @ night x 1-2 weeks

Question 15

Tinea Pedis

Answer 15

Fungal infection of the foot

Tx: topical antifungal to nails, if refractory treat with terbinafiine PO x 6-12weeks for nail infections

Question 16

What to monitor when a pt is on Terbinafine?

Answer 16

LE (hepatotoxic)

Question 17

Eczema Herpeticum

Answer 17

Punched out erosions and vesicles, often on head and neck
Child often unwell with fever and adenopathy

Dx: Send swabs/PCR from lesion

Tx: If unwell, <1yr, poor fluid intake or severe-> admit and IV acyclovir
If well, localized, good fluid intake and reliable f/u-> oral acyclovir x 10d
If V1 involve-> optho consult
Add abx if suspect bacterial superinfection

Question 18

Staph Scalded Skin Syndrome

Answer 18

Bullous eruptions
+ Nikilosky sign (skin seperates with gentle force)
NON TOXIC CHILD (fever and systemic sx uncommon)
Circumoral erythema is prominent as is neck (while intraoral surfaces are spared), can see perioral and neck crusting/ crusting around the eyes

Dx: bullae are sterile (no point in swabbing), do swabs for staph (eyes, perirectal, nares, umbilicius)

Tx: IV clox + clinda, pain control

Question 19

Lice (Tx and Return to School)

Answer 19

Tx: Permethrins (1%) and pyethrins first line with repeat tx in 7-10d
Resistance: if 2 permethrin applications 7d apart do not eradicate or known resistance-> GET RESULTZ!! (isopropyl myristate and ST cyclomethicone) for kids >4 and do 2 applications 1 week apart or dimethicone (smother the lice)

Can go to school with lice

Question 20

Scabies

Answer 20

Transmission: skin to skin
High risk pop: Indigenous, immunocomprimised, devel delay, crowded living, malnutrition
Clinical: burrows and erythematous papules with itching that is worse at night
- burrows usually between fingers and in flextures

dx: clinical, skin scraping

Tx: 5% permethrin (5 fingers = 5 percent). Infants = full body, older = neck to toes overnight and repeat treatment in 1 week
- TREAT ALL HOUSEHOLD CONTACTS/CLOSE CONTACTS

Question 21

Drug Hypersensitivity Syndrome (criteria and mangagement)

Answer 21

Maculopapular drug eruption with one or more of…
- Fever
-Pharyngitis
- Elevated LE
- Lymphadenopathy, Eosinophilia

Management: stop drug, alternate class if meds needed, antihistamines

Question 22

Erythema Multiforme

Answer 22

HSV is most common trigger!!!
- IF target lesions and no mucositis-> HSV
- If target lesions and mucositis -> RIME (from mycoplasma)

Rash looks like targets and is usually asymptomatic

Tx: if suspected HSV-> may need acyclovir , overall is acute and self resolving within 2-3 weeks

Question 23

RIME/MIRM

Answer 23

Mycoplasma is trigger

Have hemorrhagic crusting or lips, erosions on tongue and buccal mucosa and purulent conjunctivitis

Dx criteria:
- Mucocutaneous eruption (<10% BSA)
- 2 mucosal sites involved
- scattered atypical targetoid lesions or vesiculobullous lesions
- Mycoplasma infection

Question 24

SJS/TENS

Answer 24

Erythematous macules with central necrosis forming vesicles and bullae
+ 2 or more mucosal surfaces (eyes, mouth, airway, GI tract, anogenital)
+systemic involvement

SJS = <10%, TENS = >30%

Triggers: sz meds, sulfonamides, penicillin, NSAIDS

Tx: Supportive and symptomatic (life threatening illness- must admit)
- IVIG 1g/kg/d x 3 d
- Needs optho consult for risk of corneal ulceration, anterior uveitis

Question 25

SJS vs Staph scalded skin

Answer 25

SSSS Mucosal involvement: No Nikolsky skin: Yes, everywhere Age: <5 yo Etiology: Recent staph infection SJS/TEN Mucosal involvement: yes Nikilsky sign: Yes but only in area of erythema Age: often older kids Etiology: drugs

Question 26

RF for Hemangiomas

Answer 26

Prematurity (more likely to have multiple) Low birth weight Multiple gestation Female White race

Question 27

Natural History of Hemangiomas

Answer 27

Usually not present at birth, usually begins at 4wk-3 months Precursor: color change at site before lesion Proliferative; first few weeks until 4-6 months -Rapid growth “out of proportion” to child’s growth -Rapid phase of usually complete by 5 months Plateau: ~from 4-6 months to ~12-18 months Regression: ~18 months until 9-10 years of age (50% by age 5y) Residual: lasting skin changes in 50%

Question 28

PHACES

Answer 28

P: posterior fossa tumor H: hemangioma large segmental face (>5cm) A: arterial anomalies C: cardiac anomalies (MC: coarctation) E: eye anomalies, endocrine anomalies (thyroid) (S): sternal cleft or supraumbilical raphe (pits, scars) Needs work up: derm referral, MRI/MRA head and neck, Echo, ECG and ophtho

Question 29

Over ___ (how many) hemangiomas requires workup for visceral involvement? What is the workup?

Answer 29

5 (increased risk of liver hemangiomas) - Need abdo US, CBC, FOBT

Question 30

Infantile Hemangioma Treatment (who to treat and with what)

Answer 30

Who requires treatment: - Vision or airway threatening -Risk of significant negative cosmetic outcome (large on the face) - High Risk Hemangiomas Requiring Treatment Consideration ---Ulceration/Areas at high risk of Ulceration (large size, segmental, mixed IH, neck, anogenital, axillae, lip) ---Disfigurement risk/Cosmetically sensitive areas (Tip of the nose, lips, face (may include - neck, breast, arms, and hands)) ---Impairment function/vital structures (Periocular, Intranasal, Lip, Large neck – torticollis) Tx: Propranolol = standard therapy Titrate up to 2mg/kg/day divided TID, 1-6 months Avoid in asthma, diabetes Monitor BP (hypotension), hypoglycemia

Question 31

Sturge Weber

Answer 31

- Capillary malformation of the forehead - Glaucoma - Leptomeningial capillary venous malformation Refer to Optho, derm, and do MRI head with contrast if hemangioma in V1 region

Question 32

Port wine stain (Nevus Flammeus) natural history

Answer 32

Persist life long and may darken

Question 33

Mastocytomas

Answer 33

Congenital or early infancy Become inflammed and hive life when scratched or touched Confirm Dx with Darier sign: urticaria when lesion scratched Tx: observe, if systemic symptoms given epipen

Question 34

Nevus Sebaceous

Answer 34

Waxy, hairless plaque present at birth typically on head, scalp and neck Permanent

Question 35

Pilomatricoma

Answer 35

Firm, irregular,lobulated blueish purple nodule than can be tender, tpically on the head and neck or upper extremeties Associated with Myotonic dystrophy, Gardner syndrome, Turner syndrome Tx: remove

Question 36

Atopic Dermatitis Dx and Clinical Picture

Answer 36

Evidence of 3 of the following: -Pruritus -Early age of onset -Typical morphology and distribution -Chronically relapsing course -Xerosis (dryness) -Personal or family history of atopy Sparing of groin and axillary regions in all ages in infants -> extensor predominant in older children-> flexor predominant antecubital, popliteal fossa in any age

Question 37

Atopic Dermatitis Treatment

Answer 37

Baths daily, short (5-10mins) and apply emollient right out of bath Topical steroids: - Low potency hydrocortisone for face/groin/folds (e.g. 1% hydrocortisone) - Moderate potency for limbs/trunk (e.g. 0.05% betamethasone valerate) - Severe ezcema on body: Clobetasol 0.05%

Question 38

Irritant Contact Diaper Dermatitis

Answer 38

- No satillites - Spares the creases Tx: zinc oxide

Question 39

Acrodermatitis Enteropathica

Answer 39

AR zinc deficiency Diarrhea, severe dermatitis around perioral, sacral and diaper region, irritability Tx: Zinc supplement

Question 40

Langerhans Cell Histiocytosis

Answer 40

-Affects scalp, groin, axilla and chest - Can see ottohrea - Often areas of petechia or purpura - Non pruritic - Can be associated with lymphadenopathy, HSM, lytic bone lesions and diabetes insipidus Work-up and follow by oncology Need CBC, LFT, BUN, Cr, lytes, UA Skeletal survey CXR Abdo US Skin biopsy

Question 41

Erythema Toxicum

Answer 41

Appear 24-48h of age Red macules, papules and pustules Palms and soles are not involved Lesions last 1-2 days, new crops q few days Common in term infants, rare in prems Dx: clinical diagnosis, smear of pustule would be sterile but show eosinophils Treatment: none

Question 42

Transient Neonatal Pustular Melanosis

Answer 42

3 lesion types -Pustules with no erythema -Ruptured pustules with peripheral scale -Hyperpigmented macules Unknown etiology More common in term infants and African-Americans Lesions always present at birth Dx: clinical; smear of pustule shows PMNS (neutrophils) Treatment: none

Question 43

Cephalic Pustulosis

Answer 43

"Neonatal Acne" Develops in first few weeks (3rd week) Resolves by around 3 months Caused by malassezia colonization Generally resolves without treatment, but ketoconazole may be helpful

Question 44

Neonatal Lupus

Answer 44

Discrete, round-oval scaly papules “Raccoon” pattern Appears up to 6 weeks, resolve by 6 months Maternal antibodies cross placenta—anti-Ro +/- anti-La Mother often asymptomatic Can have associated heart disease -Typically heart block (1st, 2nd, 3rd degree) -Cardiomyopathy

Question 45

Congenital Candidiasis

Answer 45

Onset from birth to first week Risk factors: -Prematurity -Maternal history of vaginal candidiasis Eruption: Generalized red papules with pustules and scale Often palms and soles involved Systemic: baby unwell, temp instability Dx: KOH for yeast cells and culture Treatment: systemic antifungals

Question 46

Subcutaneous Fat Necrosis

Answer 46

Skin-colored to purple nodules/plaques in the fat, it is a form of panniculitis Hard, indurated, not warm Occurs in the first few weeks after birth Usually self-limited, weeks to months Healthy term delivery with obstetrical trauma Meconium aspiration, asphyxia, hypothermia, hypoxemia, etc. Check for hypercalcemia until lesion gone

Question 47

Incontinentia Pigmenti (inheritance and clinical features)

Answer 47

Inheritance: X linked dominant Clinical Features: Skin: alopecia, nail ridging and pitting, linear vesicles on red base sparing the face Dental: late dentition, hypodontia, conical teeth, malocclusion, impaction CNS: seizures, intellectual disability, hemiplegia, hemiparesis, spasticity, microcephaly Ocular: micopthalmous, strabismus, optic nerve atrophy, cataracts

Question 48

Neurocutaneous melanocytosis

Answer 48

proliferation of melanocytes within the CNS Risk factors: multiple CMNs, large size, >20 satellite lesions, posterior axial location - Big = 12cm on head or 6-7cm on body Consider if signs of increased ICP <2yrs IF RF are present-> screening MRI at <4-6 months to look for melanocytosis of the leptomeninges

Question 49

NF-1 Dx Criteria

Answer 49

6 CALMs -> think Neurofibromatosis type 1 Need 2/7 criteria: > 5 CALMs (>5mm prepuberty; >15mm after) Family history Axillary or inguinal freckling Specific bony abnormalities 2 neurofibromas (or 1 plexiform neurofibroma) Optic glioma-> always send to optho to screen for this and look for lisch nodules Lisch nodules

Question 50

Tuberous Sclerosis Dx Criteria

Answer 50

ASHLEAF A- Angiomyolipomas S- Shagreen patch (orange peel consistency, usually in the lumbosacral region) H- Heart rhabdomyosarcoma L- Lymphangiomyomatosis / Lung Hamartomas E-Epilepsy from cortical tubers A-Ashleaf spots (hypopigmentation) F- Facial Angiofibromas (may be on the face and look like acne) Minor features: -Dental enamel pits (>3) -Intraoral fibromas (>2) -Retinal achromic patch -Confetti skin lesions -Non renal hamartomas -Multiple renal cysts

Question 51

Pityriasis Alba

Answer 51

Hypopigmented fine white scaley spots that are commonly on the face Tx: Hydrocort 1% (low potency steroid)

Question 52

Treatment for Impetigo

Answer 52

If localized: toipical with mupirocin or bactroban If more extensive: Keflex or septra x 7d PO if well If unwell: IV cephalospoirins or septra

Question 53

Blistering Dactyllitis

Answer 53

Etiology: GAS Dx: bacterial swab Tx: Keflex x 10d

Question 54

Lichen Sclerosis

Answer 54

primarily anogenital Females figure 8, red and eroded-> scloerotic and white putple/fissured with time Males phimosis or recurrent balanitis Extragenital= neck, shoulder, flexor wrist Treatment: topical corticosteroids bid for 1 week then daily x 1 month then 2-3x per month Can trial topical calcinueurin inhibitors or barrier creams

Question 55

Herpetic Whitlow

Answer 55

HSV infection of fingertip Grouped vesicles PO acyclovir can speed up healing