Dermatology - 2019 Updated! Flashcards
Photo of nail pitting. Diagnosis is (what condition is associated with nail pits?): a) psoriasis b) fungal infection c) traumatic d) chemical reaction/exposure e) ectodermal dysplasia
a) psoriasis Can also see nail pitting with dermatitis and alopecia areata
Two pictures of rash consistent with Incontinentia Pigmenti. Which of the following is not associated with this problem: a. alopecia b. seizures c. developmental delay d. malignant changes in the skin e. dental problems
d. malignant changes in the skin - nope, the skin lesions are benign Neurocutaneous disorder - skin, dental and ocular abnormalities - Random X inactivation - Skin manifestations (vesicles, verrucous, hyper pigmented, hypo pigmented) - Alopecia - Dental - Neuro (seizures, ID, hemiplegia, hemiparesis, spasticity, microcephaly, cerebellar ataxia) - Ocular abn - Skeletal defects, nail dystrophy
What are 4 non-derm findings associated with incontinentia pigment?
Alopecia areata seizures intellectual disability dental anomalies cataracts
Girl that gets vesicles with sun exposure and hypopigmented flat scars with mild trauma. What medication is she likely to be taking? What is this condition called? a. prednisone b. naproxen c. methotrexate d. linolid
b. naproxen Many drugs can cause photosensitivity reactions People on NSAIDs for long periods of time (e.g. rheumatologic diseases) can develop pseudoporphyria (small hypo pigmented scars with mild trauma) - need to stop NSAID ASAP as scarring can be permanent
A 9 year old boy has very swollen, dry, cracking lips and swollen tender gums. He is systemically well. Which of the following conditions is this associated with:*** a. Eosinophilic gastroenteropathy b. Contact dermatitis c. Chronic candidal infection d. Crohn’s disease
b. Contact dermatitis (lip licking - not clear on why the gums are swollen; could also be description of herpetic gingivostomatitis)
Advantage of benzoyl peroxide? a. Decrease P acnes resistance to antibiotic b. Decrease duration for oral antibiotic c. Inhibits androgen effect of sebum d. Decrease need for antibiotic
a. Decrease P acnes resistance to antibiotic advantage over topical antibiotics in that it does not enhance antimicrobial resistance.
How would you treat mild comedonal acne? How long do you need to treat to see effect? What are the anticipated side effects to counsel on?
Topical retinoid 6-8 weeks Causes irritation and dryness; start using every 3 days, then every 2 days, then daily to build tolerance
How would you treat mild-moderate papulopustular acne?
topical retinoid plus benzoyl peroxide OR topical retinoid plus topical abx (clinda or eryrthro) OR topical retinoid plus BPO plus oral antibiotic (tetracycline) *note benzoyl peroxide can bleach clothing Combined OCP for women
How would you treat severe papulopustular or nodular/cystic acne?
topical retinoid plus benzoyl peroxide AND oral antibiotics OR isotretinoin (accutane) - 1mg/kg/day
A 14 y/o has been treated with Accutane for severe cystic acne. There have been a few case reports in the literature as well as some media attention to which of the following severe side effects: a) Hallucinations b) Cerebral thrombosis c) Somnambulism d) Major depression with suicide risk e) Long term memory problems
d) Major depression with suicide risk SE: - Skin: chelitis, xerosis, dry skin, photosensitivity, epistaxis, pruritus - SJS - Teratogenic - ? Increased risk IBD - Idiopathic intracranial hypertension - hypertriglyceridemia
Girl with only blackheads. Best treatment? a. Topical tretinoin b. Topical benzoyl peroxide c. Oral antibiotic d. Accutane
a. Topical tretinoin Closed comedones : topical retinoid, benzoyl peroxide
Teenage female presents with blackheads only, mild acne, what do you recommend? a) Topical benzoyl peroxide gel b) Topical retinoic acid c) Accutane d) Topical clindamycin
b) Topical retinoic acid
What are some examples of topical retinoic acids?
tretinoin adapelene tazarotene
Kid with acne on a medication now develops headaches; description consistent with benign ICH. What is the most likely medication that she is on? (repeat from previous) a. Minocycline b. OCP c. topical retinoid d. erythromycin
a. Minocycline
Describe the process of comedogenesis (4 factors in development of acne)
- Abnormal keratinization of follicular epithelium (impaction of keratinized cells) - Increased sebum - Proliferation of Propionibacterium in follicles - Inflammation (free fatty acid formation by bacteria are inflammation causing)
Pustular acne in teenager. List 3 initial treatment options.
- topical retinoid
- Benzoyl peroxide
- Topical antibiotics (erythromycin, clindamycin)
- mild to moderate cleansing routine → not too aggressive
- discontinue greasy makeup or hair products which can plug follicles
- Oral antibiotic
- Oral retinoid (if severe/nodular)
- OCP for females
Child sucks on finger. Lesions on finger for 10 days. Finger hurts when mom touches it – picture of a finger with vesicles but also a central are of ulceration, some diffuse erythema of finger. We thought that this was herpetic whitlow, but not a very clear picture. What is your management? a) PO cephalexin b) I & D c) PO acyclovir d) flamazine dressing
c) PO acyclovir *best answer would be to do nothing Acyclovir if immunosuppressed or severely infected; herpetic whitlow expected to spontaneously resolve in 2-3 weeks
Which of the following is true of molluscum: a. it is pruritic b. high infectivity c. contagious for entire rash d. lesions scar when healing
c. contagious for entire rash Aggressively treating/picking at molluscum lesions can cause them to scar Molluscum -Pox virus - can last weeks/months, up to 2 years - self limited but Tx options; - cantharidin - curettage - liquid nitrogen - topical tretinoin
What are some treatment options for molluscum contagiosum?
- do nothing 2. curettage 3. cantharidin 4. cryotherapy
Photo of tinea capitus. a) shave the child’s hair and treat with selenium shampoo daily for 14 days b) treat the entire family with selenium shampoo daily for 14 days c) treat with oral griseofulvin for 4-6 weeks d) he should not attend school until treatment is complete e) refer to a psychiatrist
c) treat with oral griseofulvin for 4-6 weeks Tinea captious: - trichophytan tonsurans - microsporum canis Usually requires oral therapy - griseofulvin first line - terbinafine - itraconazole
Treatment of tinea capitis? a. Po lamisil b. Topical fluconazole c. Topical steroids
a. Po lamisil (terbinafine) - second line; griseofulvin is first line
What is the treatment for scabies?
5% permethrin applied to entire body from neck down. Leave cream on for 8-12 hours, then wash off. Repeat treatment in 7 days. Treat the entire family and any caregivers for the child
A child is fully treated for scabies but 3 weeks later still has significant itching and discomfort. What is the cause and how is it treated?
Mite antigen remains in the skin and can cause a hypersensitivity reaction causing pruritus for days to weeks. Can treat with topical steroid.
A young boy has three circular patches of complete hair loss on his head. It is slightly itchy. His finger nails are normal. His mother had a similar episode when she was younger. What is the diagnosis? a) Trichotillomania b) alopecia areata c) telogen effluvium d) tinea capitis
d) tinea capitis
Picture of diffuse erythematous rash, confluent in areas, sparing inguinal folds, mucous membrane involvement. An 18 month old child has been on amoxicillin for 1 week for viral URTI symptoms. This rash develops on day 7, there is a positive Nikolsky’s sign and a large obvious bullae on one leg. What diagnosis is this consistent with: a. Staphylococcal scalded skin syndrome b. Eczema herpeticum c. Toxic epidermal necrolysis
c. Toxic epidermal necrolysis Nikolay sign: with slight pressure, skin wrinkles, slides laterally and separate from dermis -SSSS, SJS and TEN would all have positive Nikolsky’s sign
Child comes in with acute onset over 24 hours of fever and diffuse erythroderma. In your ED is hypotensive and complaining of myalgia. There is renal and liver dysfunction on bloodwork. What diagnosis is this most consistent with: a. Stevens-Johnson syndrome b. Kawasaki’s disease c. Staphylococcal toxic shock
c. Staphylococcal toxic shock (need all major + 3 minor) Major Criteria - Acute fever - Hypotension - Rash Minor - Mucous membrane inflam - vomiting, diarrhea - Liver abn - Renal abn - Muscle abn - CNS - Thrombocytopenia
Describe bullous and non-bullous impetigo
Non-bullous: honey crusted lesion, on face and extremities, caused by staph, sometimes GAS, no pain or surrounding erythema Bullous: large, loose bullae, on face, extremities, butt, trunk and perineum, caused by toxin producing strain of staph,
Complications of bullous and non-bullous impetigo?
cellulitis, osteo, septic arthritis, pneumonia, sepsis
How is impetigo treated?
topical - mupirocin 2% TID x10-14 days systemic - keflex x7-10 days
Kid with non-bullous impetigo a week ago now has hematuria. What’s happening?
Post strep GN
What is Gianotti-Crosti? What is it’s natural course?
immune reaction occurring 1 week after viral infection or immunizations - main viruses: EBV, coxsackie, paraflu, Hep B - crops of firm red papillose (may look like vesicles but there is no fluid inside) - benign and self-resolves in 2 months
What are treatment options for genital warts?
25% podophyllin weekly 5% imiquimod 3x/week Sinecatechins
What are management options for common warts?
Do nothing - 65% spontaneously resolve in 2 years liquid nitrogen laser salicylic acid daily imiquimod
What is the natural course of molluscum contagiosum? What is some anticipatory guidance for families to prevent transmission to others?
- self-limited - average exacerbation lasts 6-9 months - lesions can persist for years (new lesions forming as old ones resolve) - avoid shared towels and baths while lesions present - if swimming, cover exposed lesions with bandage
14 yo boy with some itchy lesions on R foot. Oral antibiotics and topical steroid creams not helpful. Now the condition is worse. On exam there is interdigital fissuring and maceration with erythema of the skin with peeling. What is the likely diagnosis (1). List 3 other causes on your differential diagnosis
- Dx: tinea pedis
- Ddx:
- contact dermatitis
- atopic dermatitis
- juvenile plantar dermatitis
- palmoplantar psoriasis
- interdigital candida
- hyperhydrosis
An 8 month old child is brought in with several small brownish nodules on his back and extremities. The parents have observed that when they touch the nodule, wheals develop around it, it it transiently becomes erythematous and their child starts to scratch it. What is the diagnosis? a) mastocytosis b) neurofibromatosis c) benign congenital nevi
a) mastocytosis Gentle touch of the lesion triggers degranulation of mast cells and local histamine release causing a red wheal around the lesion (Darier sign)
What is the most common type of mastocytosis? When does it present? How is it managed?
urticaria pigmentosa - present at birth, and develop more lesions over first few months - spontaneously resolve, no need for treatment
Mean age of onset of neonatal acne? Treatment?
3 weeks, looks like teenage acne (closed comedones, papules and pustules on face and trunk) - no treatment - disappears within 6 months
Picture showing rash with ppearance of militia rubra, timing of presentation and management?
AKA prickly heat rash tiny red papules or papulovesicular lesions - appear in first week of life - found in intertriginous regions - treat with air conditiong, cool soaks
Scaley rash that has pinpoint dot of blood visible when you pick off the scales. What is it?
psoriasis Remember Koebner phenomenon - develop plaques at site of trauma
- List 3 treatment modalities for psoriasis.
- Topical steroids mid potency BID; (betamethasone 0.05-1%)
- Topical vitamin D analogues(calcipotriene)
- Calcineurin inhibitors (alterantive to steroids - “protopic”)
- UV light therapy
- Immunosuppressants (methotrexate first line, cyclosporine)
- Biologic response modifiers (TNF alpha inhibitors - infliximab/etanercept)
You are seeing a 13 year old boy in your Emergency department. About one week ago he noticed an erythematous lesion, approximately 5 cm in diameter, on his lower back, which has since resolved. He now presents with a diffuse erythematous rash over his torso, which follows the skin cleavage lines. a. What is the most likely diagnosis?
pityriasis rosea (description is of herald patch - 1-10cm) 5-10 days after herald patch, widespread rash over trunk and proximal limbs develops (oval/round, <1cm diameter, pink to brown, slightly raised)
In pityriasis rosea, how long will the rash last and how is it treated? Is it contagious?
Cause unknown - thought likely viral - rash lasts for 2-12 weeks - spontaneously resolves so treatment is symptomatic only (if scaling rash, use emollient, if pruritic use oral antihistamine, or may need topical steroids) - can have post inflammatory hypo/hyperpigmentation which resolves - not contagious
What is true of strawberry hemangiomas? a. involution occurs after the second decade of life b. they are usually not present at birth c. there is never an indication to treat
b. they are usually not present at birth
When do infantile hemagiomas (aka strawberry) classically appear? When do they disappear?
first 2 weeks of life - 60% gone by 5 years, 95% by 9 years
See a child with large segmental facial hemangioma. What are the components of PHACES syndrome?
Posterior fossa abnormalities Hemangioma (large, V1 distribution) Arterial abnormalities Cardiac defects (coarctation) Eye abnormalities (microphthalmia, glaucoma, optic nerve hypoplasia) Sternal abnormalities (atresia)
Three initial investigations if you suspect PHACES in a child?
MRI brain (orbits, posterior fossa, optic nerve) Echo Ophtho consult
What is piebaldism? What syndrome is it associated with?
- hypopigmentation of skin, can affect anterior scalp also causing white forelock - cutaneous sign of Waardenburg syndrome
List 5 features of Waardenburg syndrome
Hypo pigmentation of skin White forelock Heterochromia Deafness Limb anomalies
Hypopigmented area surrounding a hyperpigmented centre. What do you tell the parents? What is this? a. this will spread to all over her trunk b. spontaneous resolution c. 1% chance of progression to melanoma d. will become a neurofibroma
b. spontaneous resolution Halo nevus: melanocytic nevus with surrounding halo of hypo pigmentation; skin is normal after is regression and no concern in kids for malignant transformation
7 year old boy with query Neurofibromatosis type 1. (1) how many clinical criteria do you need for diagnosis (2) what are four clinical criteria for NF-1
- minumum 2/7 clinical criteria for diagnosis 2. 6+ CALMs (>5mm for prepubertal, >15mm for pubertal) - 2+ Lisch nodules (iris hamartomas) - optic nerve glioma - 2+ neurofibroma (nodules under skin) - axillary/inguinal freckling - boney lesions (sphenoid dysplasia or cortical thinning of long bones) - first degree relative with NF1
2 year old with diffuse atopic dermatitis. He is compliant with steroid treatment but is not improving. What topical agent could be the next line? a. Methotrexate b. Tar c. Tacrolimus topical d. Cyclosporine
c. Tacrolimus topical Topical calcineurin inhibitor (moderate to severe AD in kids >2 years not responding to steroids)
Baby with bright red peri-anal dermatitis a) Strep b) Contact c) Candida d) Sexual abuse
b) strep Peri-anal strep dermatitis Rash is superficial, erythematous, well marginated, nonindurated, and confluent from the anus outward; no constitutional symptoms Acutely (<6 weeks): rash tends to be bright, red, moist and tender to touch; white pseudomembrane may be present
Picture of infant who is 2 months old with a rash on cheeks – more irritable than usual, otherwise well. Rash on legs is crusting. Identify. 3 different classes of medications and routes .
Thinking atopic dermatitis: - topical steroids - topical calcineurin inhibitors - tar preparations - immunosuppressants (oral - cyclosporine, MTX)
Child with trisomy 21. 3 discrete round completely hairless areas on the scalp. No other findings. What is the most likely diagnosis? What will you tell mom is the natural history of this problem?
Alopecia areata (increased incidence in T21 - 5-10%) - spontaneous resolution is common, but relapses can occur
Picture of a child with a red erythematous nodule in neck at midline.(location difficult to see b/c poor picture). What is your initial treatment. *** 1. Abx 2. I & D 3. resection 4. U/S
Probably need more info, but U/S or Abx Thinking thyroglossal duct cyst that is infected so would need treatment with antibiotics. Once infection resolved should be resected. No I&D as can seed. U/S is best initial imaging modality
Pictures of a 4 week infant with a papular, pustular rash, on erythematous base on face and trunk. (upper chest) Well child. (first picture of face, second of the face and trunk –What is your diagnosis? How do you manage this problem?
Miliaria Rubra (Heat Rash) - occluded sweat glands from hot weather or fever
- Remove clothing
- Antipyretic if febrile
- Avoid topical agents
DDx:
- Erythema toxicum neonatorum - between 24-48h of age, lesions last 1-2 days but new crops show up every few days. Self limiting
- Neonatal acne - develops in first few weeks, resolves by 3 mos, no treatment needed
- Transient pustular melanosis : most common in term dark skinned babies, present at birth. Self limiting.
Picture of a 7 year old boy’s thigh, linear vesicles with some excoriation. He comes to your office, in July, with a rash on his left thigh, It is itchy and has seemed to spread where he scratches.
What is your diagnosis?
Treatment?
- Poison ivy (aka allergic contact dermatitis) - Type IV delayed hypersensitivity reaction - rash appears 48 hours after exposure in a sensitized individual
- Wash without scrubbing, remove affected clothing
Oatmeal bath, cool compresses
Topic lotions like calamine
Avoid topical antihistamines
Oral antihistamines are of minimal benefit (itching not due to histamine release)
Systemic steroids for several weeks but can cause rebound dermatitis
What is the treatment of poison ivy?
- wash skin and other items that may have been in contact with plant - systemic antihistamines for itch - mild-moderate strength topical steroids - topical pramocaine (topical anesthetic) for itch
A 3-month-old infant has a diffuse eczematous pruritic rash over his head, trunk, and extremities. The presence of nodules is noted. His brother recently had scabies. Proper treatment: a) 1% permethrin x 1 dose b) 5% permethrin x 1 dose c) 6% sulfur in petroleum x 3 doses d) 10% crotamiton e) Kwellada x 1 dose
c) 6% sulfur in petroleum x 3 doses – not commonly used b/c it is messy (and CPS says 8-10%) Scabies as per CPS 5% permethrin for >3 mos - repeat in 7 days (first line)
Child with 3 discrete round bald patches on his scalp that are occasionally mildly itchy. His fingernails are fine. Mother recalls having the same thing occur when she was young. a) alopecia areata b) tinea capitis c) telogen effluvium d) trichitollomania
b) tinea capitis Alopecia areata: - can get nail pitting - sudden onset discrete patches of non scarring hair loss Telogen effluvium: - diffuse thinning ~ 3 mos after stressful event
13 year old girl had scoliosis surgery 2 months ago. She now presents with significant amount of hair loss. On exam she has diffuse hair loss with no underlying inflammation. What is the likely cause? 1. Tricotillomania 2. Tinea capitis 3. Telogen effluviam 4. Alopeica areata
- Telogen effluviam
Teenage girl with severe acne thinking about starting systemic isotretinoin. What is the most important topic to discuss. 1. Need to monitor CBC and liver enzymes 2. Need to monitor triglycerides 3. Need for strict birth control
- Need for strict birth control
Picture of baby sucking on a pacifier and looking relatively content. Severe thrombocytopenia. Has a large lesion overlying his left forehead and eyelid (not a port-wine stain). What is the most likely finding on labs? a. normal INR and PTT b. Elevated fibrinogen c. schistocytes and RBC fragments on smear d. neutropenia and anemia
c. schistocytes and RBC fragments on smear I think they’re talking about Kassabach-Merritt: Disorder is suspected when children with large hemangiomas present with pallor, petechiae, ecchymoses, easy bruising, prolonged bleeding of superficial abrasions, or rapid changes in size or appearance of the hemangioma
Child with a large port wine stain in the distribution of the 1st trigeminal nerve. What do you work him up for? a. optic glioma b. cerebral arteriovenous malformation c. glaucoma d. liver disease
c. glaucoma Sturge Weber sydrome = Manifestations include port wine stain leptomeningeal vascular malformation seizure hemiparesis intellctual disability visual field defects glaucoma neuroendocrine abnormalities (thyroid, GH deficiency)
Down syndrome child with well demarcated patch of hair loss. What do tell the mom about chances of recovery a) Progressive hair loss b) will likely regrow in 1 yr
b) will likely regrow in 1 yr Alopecia Areata - increased incidence with T21 and other autoimmune conditions - often spontaneous resolution in 6-12 months -Tx: topical steroids, systemic steroids beneficial in most (but not great long term), can use long term immunosuppressants - consider MTX
Patient with hypopigmented macules with sun exposure. This is a side effect of what medication? a) MTX b) prednisone c) Lisinopril d) Indomethacin
d) indomethacin
Etiology:
a) Staph
b) Strep
c) Roseola
d) Rubeola
e) Rubella
b. Strep
The rash of scarlet fever is marked in the skin folds of the inguinal, axillary, antecubital, and abdominal areas and about pressure points. It often exhibits a linear petechial character in the antecubital fossae and axillary folds, known as Pastia’s lines.
A young child is followed by your colleague for recalcitrant eczema. His mother brings him to your attention in the local emergency department because the eczema on his face has changed drastically in the last few days and seems to be bothering him significantly. At this time, you will prescribe:
a. Amoxicillin
b. Cefazolin
c. Acyclovir
d. Fluconazole
c. Acyclovir
Patients with eczema herpeticum present with shallow, “punched-out” erosions in areas of skin affected with or prone to AD.
Eczema herpeticum can be potentially life threatening and requires systemic treatment with acyclovir. In addition, adequate analgesia, skin care, and topical antiinflammatory medications are used. Secondary bacterial infection often coexists with eczema herpeticum and should be treated appropriately as well. Herpetic keratitis is associated with periocular eczema herpeticum
What is the inheritance pattern
a) Aut Dominant
b) Spontaneus
c) Autosomal Recessive
d) X-Linked
a) Aut Dominant
(Tuberous Sclerosis)
Name some of the major criteria for tuberous sclerosis
Major Criteria
- => 3 HYPOpigmented patches (>5mm)
- Facial angiofibromas or forehead plaque (pathognmonic)
- Non-traumatic ungual or periungual fibromas
- Shagreen patch
- Subependymal nodule
- Subependymal giant cell astrocytoma
- Cardiac rhabdomyoma
- Lymphangiomyomatosis
- Renal angiomyolipomas
Minor Criteria
- Multiple randomly distributed pits in dental enamel
- Hamartomatous rectal polyps
- Bone cysts
- Cerebral white matter migration lines
- Gngival fibromas
- Non-renal hamartomas
- Retinal achromic patch
- Confetti skin lesions
Definite - 2 major, or 1 major and 2 minor
What is this condition associated with
a. Tinea Capitis
b. OCD
c. Autoimmune hypothyroidism
c. autoimmune hypothyroidism
A 1 month-old baby presents to your office with 24 hours of unilateral eye swelling and discharge. They appear like the following image. What is the diagnosis?
Dacryocystitis
Orbital Cellulitis
Bacterial conjunctivitis
Neuroblastoma
Dacrocystitis
(a blue nodule and racoon eyes would make you consider neuroblastoma)
What is this neonatal rash?
HSV
Neonatal erythema toxicum
Pustular melanosis
Miliaria
Transient Neonatal Pustular Melanosis - Mostly seen in full-term black neonates
Consists of 3 lesions
- Small pustules on nonerythematous base - usually present at birth
- Erythematous to hyperpigmented macules with surrounding collarette of scale - develop as pustules rupture and may persist weeks to months
- Hyperpigmented macules that gradually fade over several weeks to months
No Tx necessary
A girl comes in complaining of this itchy rash. What is the diagnosis?
Pityriasis rosea
Nummular eczema
Tinea
Pityriasis Rosea
3yo boy referred to you for language delay. On his exam you notice the following finding. What is the mode of inheritance of this condition?
Autosomal dominant
Autosomal recessive
X linked dominant
X linked recessive
Autosomal Dominant (NF1)
Name this rash (see photo). When you pick at it, there are little spots of blood underneath.
Psoriasis
Photo of rash: not responsive to antifungals and topical steroids, diabetes insipidous, red and brown papules.
What is the dx?
How do you confirm?
Langerhans cell histiocytosis
Biopsy
Child with painful erythematous swollen lesions on the legs.
What is the diagnosis ?
List some causes
Dx: Erythema Nodosum
Etiology:
- Infectious:
- EBV, HBV, Mumps
- Coccidiomycosis, histoplasmosis, blastomycosis
- GAS, TB, Yersinia, Psittacosis, brucellosis
- Sarcoid
- IBD
- SLE
- Behcets
- Lymphoma
- Pregnancy
- Drugs:
- OCP, sulfonamides
Girl comes in complaining of itchy rash.
What is the likely diagnosis?
List 3 other causes on your differential diagnosis?
- Pityriasis Rosacea
Differential:
- Guttate psoriasis
- Tinea corporis
- Nummular dermatitis
- Drug eruption
- Pityriasis lichenoides
- Viral exanthem
Trichotillomania
a) Associated with OCD in older kids
b) Usually self-limiting
c) Rare
a) Associated with OCD in older kids
Trichotillomania
Seen in OCD, and in adolescents with other psychiatric disorders
Diagnostic Criteria: hair loss due to pulling, mounting tension prior to hair pulling which is relieved by hair pulling
This causes areas of incomplete hair loss - often on the crown of the head, eyebrows, eyelashes
The remaining hairs are of variable length and the scalp usually appears normal
If trichotillomania occurs secondary to OCD - treat with fluoxetine and behavioural interventions
Mechanism of action of Retin-A
a) Comedolytic
b) Decrease P acnes
c) Decrease sebum production
d) Decrease proliferation of epithelial cells
a) Comedolytic
Retinoids inhibit formation and number of microcomedones, reduce number of mature comedones, reduce inflammatory lesions, and produce normal desquamation of the follicular epithelium
PO abx decrease P. acnes
Isotretinoin decreases size and secretion of sebaceous glands, normalzies keratinization, prevents new microcomedone formation, decreases the population of P.acnes and exerts an antiinflammatory effect
Picture of erythema multiforme. Teen has rash and oral ulcers. Most likely trigger
a. Mycoplasma
b. Varicella
c. NSAID
a. Mycoplasma
A variety of factors have been implicated in the pathogenesis of EM. The disorder is most commonly induced by infection, with herpes simplex virus being the most frequent precipitator.
Mycoplasma pneumoniae infection is another important cause of EM, particularly in children
It has been estimated that drugs induce EM in less than 10 percent of cases - The most common precipitators appear to be nonsteroidal anti-inflammatory drugs, sulfonamides, antiepileptics, and antibiotics
(UTD)
Girl with bilateral weeping, erythema after piecing ears what do you do?
a. 0.1% betamethasone
b. 1% hydrocortisone
a. 0.1% betamethasone ( mid potency)
1% hCT is low potentcy
- take piercing out, stop OTC disinfecting product
- treat perichondritis of pinna with topical +/- systemic ABx
- medium-low potentcy for contact dermatitis
Photo of female genitalia with labia adhesions: management
a) estrogen cream
b) CPS
c) Ultrasound of abdomen
d) Karyotype
a) estrogen cream
May be asymptomatic or have vulvitis, urinary dribbling, UTI, urethritis
Dx made by visual inspection of adherent labia with central semitranslucent line
Tx
- None if asymptomatic
If symptomatic
- Topical estrogen cream or betamethasone ointment (or combined) daily x6weeks
- Apply with cotton swab applying gentle traction
- Stop E if see breast budding
- Usually resolve in 6-12 weeks
- Risk reduction
- Good hygiene, petroleum jelly
Boy with cervical adenopathy and lesion on the finger…
a) Bartonella Hensela
b) mycoplasma
c) atypical myobacterium
d) toxoplasmosis
a) Bartonella Hensela
Cat Scratch Disease
- Inocculation period of 7-12 days, then one or more 3-5mm red papules develop at site of cutaneous inoculation (linear cat scratch)
- Lymphadenopathy within 1-4 weeks
Axillary > cervical > submandibular > preauricular
- 10-40% will drain, May persist for 1 year
- tx: ABx not always needed - if decide to Tx use Azithro, TMP-SMX or Rifampin
Child with abscess on buttock, brother had one too recently, looked well, no overlying skin edema, no fever, best management:
a) Incise and drain
b) Keflex alone
c) Keflex + I&D
d) IV antibiotics
a) incise and drain
Teenage boy with acne, currently on topical antibiotic and BP in the AM, and topical retinoids in the PM. No symptomatic improvement. What is your next step in management?
a) Minocyclin
b) Clindamycin
c) Isotretintoin
d) Cefazolin
a) Minocycline
Rx: initial control takes at least 6-8 weeks, depending on severity of acne; all patients should be on topical retinoid
- Comedonal acne: topical retinoid, or azelaic acid or salicylic acid
- Mild papulopustular acne: topical retinoid PLUS benzoyl peroxide or benzoyl peroxide/topical antibiotic or benzoyl peroxide/oral antibiotic
- Severe papulopustular or nodular acne: topical retinoid PLUS benzoyl peroxide and oral antibiotic or isotretinoin
Flat nevus- how to prevent malignant transformation (1), what to watch for (4)
- Suncreen, avoid sunburns
- Asymmetry, irregular borders, color heterogenous, diameter >6mm, elvolving (ABCDE)
Melanoma.
Give 2 recommendations for prevention
List 4 risk factors
- Sunscreen, no indoor tanning, protective clothing - long sleeved shirt, wide brimmed hat, pants
- High nevus count, light skin, red/blond hair, family history, high sun exposure, sunburns
Dermatomyositis - 4 confirmatory tests.
Treatment
Confirmatory Tests:
- Elevated muscle enzymes (CK, LDH, AST, aldolase)
- EMG changes
- Muscle Biopsy
- Proximal muscle weakness
- MRI (upcoming)
Treatment:
- Corticosteroids is mainstay treatment
- Methotrexate
- Physiotherapy
- Aoid sun exposure, use sunscreen
What should you do for this child?
Admit to hospital
Start IV acyclovir
Urgent optho consult
(Herpes Zoster Opthalmicus)
What are 3 indications to use oral propanolol for infantile hemangioma
Facial/oral lesions that impact feeding
Facial lesions that obstruct vision
Lesions causing respiratory compromise
Potential for poor cosmetic outcome (tip of nose)
A baby boy is treated for atopic dermatitis with various doses of steroids with no improvement. He also has failure to thrive.
Name 3 alternative diagnosis that could explain his skin findings other than eczema.
- Zinc deficiency
- SCID (leaky SCID = Omenn syndrome)
- Wiscott-Aldrich Syndrome
- Netherton Syndrome (AR disorder with ichythosis + hair abn, FTT, elevated IgE)
- Seborrheic dermatitis
- Psoriasis
Girl comes in with difficulty breathing and laryngeal edema after a minor scratch to the face. This has happened 3 times before. There is a family history of individuals with facial edema after minor trauma.
a) What is your immediate management?
b) What is your diagnosis
c) What is the long term treatment?
a) Monitor ABCs - intubate if any signs of stridor or respiratory failure, prepare for cricothyroidotomy
Administer C1INH (C1 Esterase inhibitor) concentrate
Trial of IM Epi (will not help if HAE)
b) Hereditary angioedema
c) Purified C1-INH prophylaxis, Patient education, Emergency plans for attacks
