Dermatology Flashcards
Treatment of Mild-Moderate Acne?
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
Treatment of Severe Acne?
Isotrentinoin (Accutane)
Tests needed before treatment: LFTs, urinalysis, CBC, cholesterol, trigs
Side effects of Accutane?
Cheilitis (lip inflammation)
Xerostomia (dry mouth)
Xerophthalmia (dry eyes)
Conjunctivitis
Myalgia
Headache
Hepatitis
Hypercholesterolemia
Hypertriglyceridemia
Pseudotumor cerebri
Teratogenic
Alopecia Areata
- 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
Psoriasis
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)
Guttate patterned rash?
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
Molluscum Contagiosum
Umbilicated, waxy, flesh-colored papules
Resolve within 2 years if immunocompetent
Pityriasis Rosea
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
Rhus Dermatitis
From poison ivy!
Linear streaks of vesicles
Tx: spontaneously resolves in 1-3 weeks
Tinea Capitis
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
Tinea Corporis
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
Treatment of oropharyngeal candidiasis
Oral nystatin after feeds
1st gen imidazoles (miconazole and clotrimazole = more effective)
PO fluconazole if moderate to severe or failed first line tx
Candida Diaper Dermatitis
Found in the folds
Tx: topical antifungal ointments or powders (nystatin)
Pityriasis Versicolor
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
Tinea Pedis
Fungal infection of the foot
Tx: topical antifungal to nails, if refractory treat with terbinafiine PO x 6-12weeks for nail infections
What to monitor when a pt is on Terbinafine?
LE (hepatotoxic)
Eczema Herpeticum
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
Staph Scalded Skin Syndrome
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
Lice (Tx and Return to School)
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
Scabies
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
Drug Hypersensitivity Syndrome (criteria and mangagement)
Maculopapular drug eruption with one or more of…
- Fever
-Pharyngitis
- Elevated LE
- Lymphadenopathy, Eosinophilia
Management: stop drug, alternate class if meds needed, antihistamines
Erythema Multiforme
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
RIME/MIRM
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
SJS/TENS
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
SJS vs Staph scalded skin
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
RF for Hemangiomas
Prematurity (more likely to have multiple)
Low birth weight
Multiple gestation
Female
White race
Natural History of Hemangiomas
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%
PHACES
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
Over ___ (how many) hemangiomas requires workup for visceral involvement? What is the workup?
5 (increased risk of liver hemangiomas)
- Need abdo US, CBC, FOBT
Infantile Hemangioma Treatment (who to treat and with what)
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
Sturge Weber
- 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
Port wine stain (Nevus Flammeus) natural history
Persist life long and may darken
Mastocytomas
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
Nevus Sebaceous
Waxy, hairless plaque present at birth typically on head, scalp and neck
Permanent
Pilomatricoma
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
Atopic Dermatitis Dx and Clinical Picture
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
Atopic Dermatitis Treatment
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%
Irritant Contact Diaper Dermatitis
- No satillites
- Spares the creases
Tx: zinc oxide
Acrodermatitis Enteropathica
AR zinc deficiency
Diarrhea, severe dermatitis around perioral, sacral and diaper region, irritability
Tx: Zinc supplement
Langerhans Cell Histiocytosis
-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
Erythema Toxicum
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
Transient Neonatal Pustular Melanosis
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
Cephalic Pustulosis
“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
Neonatal Lupus
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
Congenital Candidiasis
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
Subcutaneous Fat Necrosis
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
Incontinentia Pigmenti (inheritance and clinical features)
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
Neurocutaneous melanocytosis
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
NF-1 Dx Criteria
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
Tuberous Sclerosis Dx Criteria
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
Pityriasis Alba
Hypopigmented fine white scaley spots that are commonly on the face
Tx: Hydrocort 1% (low potency steroid)
Treatment for Impetigo
If localized: toipical with mupirocin or bactroban
If more extensive: Keflex or septra x 7d PO if well
If unwell: IV cephalospoirins or septra
Blistering Dactyllitis
Etiology: GAS
Dx: bacterial swab
Tx: Keflex x 10d
Lichen Sclerosis
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
Herpetic Whitlow
HSV infection of fingertip
Grouped vesicles
PO acyclovir can speed up healing
