Dermatology Flashcards
SCC
what causes tinea capitis and kerion?
Tricophyton (very little microsporum)
what is the tx for warts?
debride: make sure to scrape off keratinized skin layers first, may, may Spontaneously disolve, physical/chemical removal (salicyclic acid), immunotherapy, chemotherapy, insurance company probably won’t cover it–seen as cosmetic. Harder to tx if it has been there a while, occlusion (duct tape–will take about 3 months), if really stubborn–intralesional injection of candida to get body to realize it needs to fight it off
what microorganism causes pityriasis (tinea) versicolor?
Malassezzia (Furfur/Globosa) (P.ovale)
incubation about 2 wks, Varied stages, macule to crusts, start flat, turn vesicular, become teardrop vesicles surrounding erythrya, flu like prodrome 1-2 days, long incubation. Crust falls off in about a week, vesicles crust over in about 8-12 hours, then no longer contagious, dew drop on rose
chicken pox (varicella)
what’s the tx for pityriasis (tinea) versicolor?
Topical Anti-fungal i.e. selsun blue–just lather on body for10-15 minutes, Keep Dry, Medicated (selsum blue) shampoos, oral antifungal (keto-conazole),
o (Prodromal sxs, morphology, intensity varies)
o Prodrome: malaise, fever, itching, burning, cough
o Numerous lesions: target lesions, erythematous macules & papules, urticarial-like, vesicles, bullae
o Primary lesion: small dull red macule or urticarial papule with central papule/vesicle that may flatten and clear
o Hallmark=Targetoidlesion–spreadscentripetallyupto1-3cminsize
o Symmetricalonpalms,soles,hands,feet,extensorsurfacesofforearms and legs
erythema multiforme
what is a pre-malignant (SCC) but usually asymptomatic lesion that usually occurs in people over 50 in chronically sun exposed areas? the lesions are usually multiple or discreet, flat or elevated, red, pigmented or skin colored, may or may not have scales, is less than 6mm, and feels lrough like sandpaper?
actinic keratosis
a usually oval, flat or raised lesion, that is pigmented and looks warty in appearance and can somewhat be scratched off.
sebhorreic keratosis
scale
hypertrophic scars
raised in shape of wound
nevus simplex/salmon patch/angel kiss/stork bite
what causes scabies?
sarcoptes scabiei (burrowing mite)
kerion
cafe au lait spot
what causes tinea manus?
T rubrum
Feet, many variation, between digits, dorsal foot only, fissuring. Moccasin distribution. Toenails, may have scaling, may have annular lesions, white skin (never dries out), may have erythema, bullae
tinea pedis
Uncommon. Smooth, red and sharply defined plaques. Found in flexural or intertriginous areas (groin, axilla, under breasts)
inverse psoriasis
scc
what does a scc look like?
red base with hyperkeratotic white aherent scale; raised, larger, can become nodular and ulcerated, fast growing
a pt comes in with papules on the flexor surfaces of their wrists, its itchy, purple, polyangular, they are a photographer, have had hep c. they also have a reticular white lesion in mouth.
lichen planus
what’s the tx for thrush?
Topical Anti-fungal, tablets, troches, swish and spit, gentian violet (stain)
lichenification
thickening of epidermis resulting in accentuation of skin lines
what bacteria causes impetigo?
S. Aureus or S. Pyogenes
keratoacanthoma
•Thinning or depression of skin due to reduction of underlying tissue
atrophy
what txs are rec’d with bcc?
shave biopsy; then can be removed with electrodessication/curettage (scraping), elliptical excision, moh’s surgery, topical chemo
what are the tx for molluscum contagiosum?
Supportive, Topical treatment (tretinoin, aldara, cantharidin, salicylic acid) or removalin genital region vai curretage, ED&C, cryotherapy works well, just have to get them to sit still, self limited–but can take years. If they don’t bother a small child she would skip tx (the cryotherapy will hurt them) .
o raised, red, transitory, area of edema
o Various sizes and shapes- Papules, plaques, annular, arcuate, polycyclic
o Newest lesions=reddest
o No scale
o Pruritus–varies in severity
o Suddenonset;eachlesionlasts <24 hours
o Occuronanyskinsurface
urticaria
when can kids with impetigo return to school?
when crusts and bullae are gone
cherry angioma
what is the tx for impetigo?
local: vinegar/bleach wet dressings, topical cream/ointment (mupirocin), antibacterial soap. Widespread: PO AB.recurrent: swab/treat for colonization, nasal/fingernail ointment may be necessary, self limiting, can use mupirocin 2% ointment tidx7 days, wash bid with soap and h20, if spread or recalcitrant–oral dicloxicillin or keflex, if neonates have bullae–need iV because immune suppressed and bullae decreases temp reg and protection
tinea cruris
pt with negative rh factor, but has joint point, and some red scaly plaques on body
psoriatic arthritis
cyst
what is this condition: painful bumps in axilla groin, under breasts, they usually describe it as I get infections all the time and pop them, can become nodules, abscesses, surrounded by erthema, especialy in intrigrinous areas, may look very disfiguring
hidradenitis suppurativa
a blue/black spot, 2-8 cm in appearnce, on the sacrum, that usually goes away in childhood
mongolian spot
what are the clinical signs of meningococcemia?
fever, malaise, rapidly progressing to sepsis within 24 hrs, will feel fine in AM and by 5 pm they feel horrible, may have non blanching, petechial, or purpuric rash (80-90%) of people,
a patient present to you with erythamtous skin on their extensor surfaces, that is easily irritated, and feels “burning”, it has cracks
xerosis
Small sterile pustules on a red base on palms and soles
Generalized (von Zumbusch’s syndrome)
Widespread sterile pustules can coalesce into large areas of pus – life threatening
pustular psoriasis-medical emergency
hand, foot, and mouth
what skin condition is usually present at birth, is flat, and is uniformally colored a light tan? should they be monitored?
cafe au lait spot. just make sure they don’t change or get dark spots.
what is the rec’d F/U tx for skin cancer pts?
q 6 months x first year then annual
unilateral, warm, RAISED, sharp margins. Tender, warm, peau d’orange
ersypilas
Groin, itchy, plaques with scale, red or brown, bilateral, spares penis/scrotum. Post-pubertal
tinea cruris
T or F: yeast are fungi
true
what causes lyme disease?
ixodes scapularis (black legged, deer, bear tick) or borrelia burgdorferi
what primary lesion can a scc come form?
actinic keratosis
granuloma anulare
tender, pain, creamy cheesy white exudate, pinpoint papules, satellite lesions, red, skin can glistening, may have pustules that rupture, inability to retract foreskin (might be stuck), scaling, on glans penis
candida balantis
excoriation from itching
Red, scaly, round-to-oval plaques.
Symmetrical
Sharply marginated
Loosely adherent “silvery-white” scale
Extensor surfaces, predominantly elbows, knees and scalp
gluteal cleft, umbilicus, penis
Usually spares palms, soles and face
Exceptions: based on morphologic variations
The degree of pruritis varies per individual and type
chronic plaque psoriasis
erythema infectiosum
what is the tx for herpes zoster?
PO antiviral–valacyclovir 1000 mg PO q8h x7 days, try to get them on within first 24 hours,rest, topical analgesics,narcotics, steroids or sympathetic blocks if pain continues? REFER to opthalmo if anything on the face, could get near the eyes
what bacteria cause erysipelas?
Group A Strep (pyogenes), or staph. aureus
what causes scabies?
sarcoptes scabiei (burrowing mite)
Linear or serpiginous (wavy, serpent-like borders) tunnels within the epidermis
burrow
SCC
hands. Usually unilateral, scaling, itch, papules, vesicles, bullae (look different on dorsal and volar surface). Can porgress slowly. May itch. Back of hand May look like ringworm while palms resemble dry skin. Hyperkeratosis, palmar creases/fissures pronounced,
tinea manus
crust: secondary lesion from blood, purulent material (leukocytes) or serous fluid
SCC
what is the tx and pt ed for lice?
permethrin 1% cream, apply to scalp, leave on 10 minutes, may need to repeat I 1 week, must be head to head contact, lice can’t fly/jump just on hair shaft/follicle, louse cannot survive more than 24 hours off head, can bag stuff that can’t be washed in bags and put outside, clean brushes, bedding, put couch, can get infected if scratched too much, cushions outside for 24 hours
varicella
what are the clinical signs of folliculitis?
History, They can usually tell you what it was
Recently shaved
And then did something—go in a lake, hot tub
• Or recently shaved using an old razor
o Use of hot tub
Long-term abx use – acne
and physical exam
erythematous plaques around hair follicle, speckled around all the hair
what’s the tx for tinea corporis and other tineas?
Topical or oral Anti-fungal, if extensive may require oral, NO STEROIDS, be careful with oral, can effect liver–need to monitor, no drinking, or anything else that will effect liver
what is the tx for animal bites?
make sure no foreign body, thoroughly explore wound, irrigate wound, if <8 hrs, close wound, if >24 hours, secondary intent, consider referal
what two signs are prevalent with chronic plaque psorias?
koehbner phenomenon, auspitz sign (pinpoint bleeding when scale removed)
halo nevi
Scalp infection, fine scales (looks like dandruff), hair broken off, alopecia, .Skin, hair, nails. Resident flora, looks like patch with lack of hair growth with little black dots
tinea capitis
what are some risk factors of melanoma?
§ Fair skin
§ > 50-100 nevi
§ h/o atypical nevi
§ PMH of melanoma
§ FH of melanoma / atypical nevi
§ h/o 1 blistering sunburn or 5+ sunburns
§ Large congenital nevi
§ Immunosuppression
Tanning bed
epidermal inclusion cyst
what causes tinea pedis?
dermatophytes
, burning, diminished taste, stuck on creamy exudate/plauques, white won’t scrape off, may have surrounding erythema. Asymptomatic, irritability in infants, otherwise asymptomatic
oral candidiasis/thrush
Vesicle
- Small, superficial, circumscribed elevations
- Size: < 0.5 cm
- Contains serous fluid
vesicle
what differentiates a tumor from a nodule?
a nodule is 1-2 cm; a tumor is >2 cm
for which conditions is moh’s surgery preferable/
bcc, scc, large, high risk locations, aggressive tumors, incompletely excised
what do you do to tx a cutaneous horn?
excisional bx–must get base in order to determine underlying dx, then tx underlying lesion
what is the tx for tinea versicolor?
Topical Anti-fungal i.e. selsun blue–just lather on body for10-15 minutes, Keep Dry, Medicated (selsum blue) shampoos, oral antifungal (keto-conazole),
infantile hemangiomas
poikelmoderma
•The combination of cutaneous pigmentation (hyper- & hypo-), atrophy, and telangiectasia
–Produces a “mottled” appearance to skin (ex: DM)
what are some tx for cherry angiomas?
Reassurance,Cosmetic removal, Electrocautery, Vascular laser (PDL, KTP)
what kind of distribution is this?
discrete
keloid
Inflammation corners of mouth, macerated angles, red fissures, sore, raw angles of mouth, erythematous, fissures, no advancing border or scales
angular cheiltiis
which BCC is characterized by a pink pearly telangiectactic papule, a rolled border, and a central depression, +/- ulceration? how common is it?
nodular BCC, 50-80% of cases
melanoma-acral
- A localized defect of irregular size and shape
- Loss of epidermis and some dermis
- Heals with scar
ulcer
what causes tinea cruris?
Tricophyton (rubrum, mentagrophytes)
varicella zoster
. Deep.
unilateral, erythema warm,patch/plaque. Tender.irregular, ill defined margins. May blister, erosion, ulcerate, flu like symptoms
cellulitis
venous lake
•A darkened plug of sebum and keratin that occludes the pilosebaceous follicle
comedone
o Entire skin surface is involved
o Generalized erythema and scaling
o Can be very severe
erythrodermic psoriasis
melanoma
what are the 6 functions of the skin?
secretion, excretion, protection, sensation, absorption, regulation
actinic keratosis
what are some tx for acrochordons?
electro dessication, cryothrerapy, bx if uncertain
basal cell carcinoma
- Well-circumscribed
- Elevated, superficial, solid lesion
- Slightly raised lesion
- May be caused by confluent papules
- Flat topped, plateau-like
- Size: > 1 cm
plaque
prodrome–fever, mailaise, HA, coryza. Redt Bilateral on Cheeks. Then generalized reticular, lacy rash, 1-4 days: slapped cheeks, 1-6 wks extremities/trunk rash, adults may present with achy joints
erythema infectiosum (5ths disease) slapped cheeks disease
what are the different types of burns?
· • Thermal
· • Cold (Frostbite)
· • Chemical
· • Electrical
· • Inhalation
· • Radiation
what are some of the differnt ways BCC can present?
nodular, superficial, pigmented, micronodular, morpheaform, rolled at edges, pearly
burrows
nevi
what causes rocky mountain spotted fever?
american dog tick, rocky mountain wood tick, bacteria: rickettsia rickettsii
erythema infectiosum
what is the tx for athletes foot?
change socks, air, hygiene, antifungals, topical antifungals like ketoconzaole 2%
keloid
scar that has grown outside original area of wound
o Solitary nodule
o Central keratotic plug
o Firm, often tender
o Disease course
o rapid growth to max. size in 3-6 weeks
o stable for wks to mos
o resorbs, leaving pitted scar
keratoacanthoma
what’s the tx for bed bugs?
self limiting within 1-2 wks if bugs gone, anti-histamine, anti-prurtic, get rid of bugs via professional services, wash things in hot water or freeze
what bacteria can cause cellulitis?
beta-hemolytici streptococci (2/3) (group A strep), staphylococcus aureus 1/3 (resident flora), pseudomonas, haemophilus
what bacteria causes meningococcemia?
N. meningitides
hyperpigmentation
what is the tx for folliculitis?
soap and water, benzoyl peroxide to slough off the extra skin, keflex, bactrim (with MRSA), if have spa folliculitis or use AB daily already, use cipro to “up your game”, pt ed: change razor, use shaving cream, can use hydrocortisone, esp if african american because their hair curls
a person has a dark brown, thickened, irregular surface with hair on their Trunk. it is greater than 20 cm–what do you do?
congenital hairy nevus–bx, 2-15% risk of MM
Are the most common cutaneous horns benign or malignant? what percentage of them are on top of AKs and what percentage are on SCCs or BCCs?
most are benign. 20% over AKS, 20% over BCCs and SCCs
Red base with hyperkeratotic white adherent scale
Becomes raised, larger
Over time, becomes nodular and ulcerated
squamous cell carcinoma
what kind of skin distribution is this?
grouped
- Small, circumscribed, superficial elevation
- Size: < 1 cm
- Contains purulent material (leukocytes), +/- fluid, which may be infected or sterile
pustule
keratosis pilaris
when pinched, a lesion that dimples that is flat and firm is best described as a…? does it continue to grow in size?
dermatofibroma; it will continue to grow to max size over months or years and then remain stable
erythema multiforme
what skin cancer is most common?
BCC
inverse psoriasis
•Hardening or induration of the skin
Caused by an increase in collagen, other connective tissue components, edema
sclerosis
wart
what bacteria causes folliculitis?
Usu. S. Aureus
Spa Folliculitis - P. Aeruginosa
what is a way to distinguish candida/yeast infections from bacterial?
yeast infections will have satellite lesions from spores
what causes erythema infectiosum?
Parvovirus B19
o Multiple, discrete
o Flat or elevated
o Red, pigmented, or skin colored
o +/- adherent scale
o Palpate: may feel rough like sandpaper
o Most are <6mm
some will develop into NMSC
actinic keratosis
what is this is a sign of?
o Pitting, subungual debris, oil drop sign, nail
o dystrophy and onycholysis may be seen
psoriasis–helps in ddx when no other skin abnormalities present
a primary raised lesion with transient, raised pink/red papules or plaques. often has erythamtous borders and pale centers. what’s an example?
wheal. i.e. hives
melanoma
diffuse pruritic rash, mucus membrane hyperemia, non pitting edema, hypotension, 3 organ systems involved. Myalgias. Strawberry tongue, fever, feel rotten, malaise, myalgias, ache, tingling hands and feet,
toxic shock syndrome
what causes molluscum contagiosum?
poxvirus
herpes simplex 1
reaction usually after 3-4 weeks initial infestation, or within 24 hours of reinfestation because immune system recognizes it, itchy rash that is wrose at night, burrows in interdigital web space, may have papules, nodules; may have crusts
scabies
What are some RFs of SCC?
fair skinned, caucasian, chronic sun exposure, FH, immunosuppresion, chronic ulcer, radiation,
what is a common, dense, firm papule or nodule that dimples? where are they most common?
lower extremities, UE above elbow, dermatofibroma
bulls eye rash (erythema migrans) in >50% of pts, 1-2 wks after exposure, hx of being in woods
lyme disease
hand foot and mouth
bulla (blister)
- Raised, circumscribed
- Size: > 0.5 cm
- Contains serous fluid
what variations are there of strawberry hemangiomas? what are their characteristics?
superficial-dull to bright red, proliferate 8-18 months, then disappear; deep can be cavernous, often multiple, ill defined, dark red/blue, persist, can ulcerate (pain)
plaque type psoriasis on scalp
single lesion, papule or pustule with wheal, two puncture wounds, surrounding erythema and edema, may have diaphoresis of surrounding tissue/limb or necrotic tissue
spider bite
what are some txs for dermatofibroma?
elliptical excision (linear scar), shave removal–but the DF may recur, cryosurgery (can lead to PIH), ILK if pruritic, esp need excision bx if enlarges beyond 2 cm–then especially a risk of DFSP
dermatofibroma
Inflammatory tinea capitis. Most severe. scalp, tender, boggy, fever, alopecia, lymphadenopathy
kerion–refer to derm
•Visible shedding of the stratum corneum (epidermal layer)
scale (2 lesion)
wart
· Primary lesion:
o Herald patch
o Solitary lesion; usually annular
o 2-6 cm, round-to- oval lesion
o MC on the trunk, neck, but can occur anywhere
· Secondarylesion: (1-2 weeks after primary)
o Generalized eruption, often trunk and prox. limbs
o Salmon-pink, 0.5cm- 1.5cm macules or patches; annular
“Christmas Tree Distribution” = long axis of each lesion follows skin lines
Collarette scale = inward facing, cigarette paper- like in appearance
o Trunk, extremities
o Typically spares palms & soles
o Atypical presentations exist; small papules more common in very young, pregnancy
pityriasis rosea
cellulitis
Chronic, superficial, asymptomatic, macule w/ fine scale, patches, vitiligo appearance. Mostly on trunk, affects lots of skin, very very slow onset, sharply marginated, fawn colored/brown/pink oval macule with fine powdery scale, can coalesce
tinea versicolor
what are the 7 different arrangements (configuration)?
isolated/solitary, discrete, confluent, linear, grouped, scattered, dermatomal
•Type of nodule, encapsulated containing fluid or semi-fluid substance, fluctuant
cyst
- Loss of superficial layers of upper epidermis by wearing away from friction or pressure
- Heals without scarring
- Red, oozes
erosion
melanoma
fissure
molluscum contagiosum
what would be in a differential dx for a dermatofibroma?
DFSP (dermatofibromasarcoma protuberans), neurofibroma, molluscum contagiosum, amelanotic melanoma
what skin disorder arises in people of fair complexsions, with chronic long term sun exposure, immunosuppressives, or people with HPV, chronic ulcers, HS, h/o radiation, PUVA, DLE, erose LP
SCC
What skin condition has rf of intermittent intense sun exposure, radiation, immunosuppression, fair skin, fitzpatrick type I or II blistering sunburns as child and is rare on dorsal hands?
bcc
skin tag
what percentage of outpatient visits are derm?
10%
what causes hand foot and moutH?
Coxsackie A16 (most) Enterovirus 71 (GI/fever)
macule
icthyosis vulgaris
telangectasia
bulla
what causes tinea corporis?
Tricophyton (rubrum, tonsurans), Microsporum Canis
pityriasis rosea
closed comedone
urticaria
Sudden rash after fever, no distinct rash, fever every night that goes away in AM. 5-15 day incubation. 3-4 days post fever have pink maculopapular rash. Otherwise asymptomatic rash mostly on trunk and neck, may have some on soft palate and base of uvula, otherwise healthy
roseola
which skin cx rarely metastasizes but can stil cause tissue damage?
bcc
lice
what are some characteristics of purpura? what is it called if <3mm? >5 mm?
non blanching, violaceous (red/purple) discoloration of skin, due to blood that has extravasated outside of vessel wall. may be palpable or non palpable. <3 mm=petechiae; >5 mm=ecchymosis
port wine stain
what factors contribute to a higher risk of malignancy of cutaneous horns? what cutaneous horns should you bx?
higher risk factors: older, male, wider base than height, pain, large size, induration/erythema at base. ALL. you don’t know if they are over malignant things or not.
what is the tx for rocky mountain spotted fever?
doxycycline
by what age will 70% of strawberry hemangiomas disappear?
most by age 7, may leave some scarring, telangectasia, anetodermatype skin changes (increased skin lasxity)
what other clinical manifestations would make you think that perhaps a cafe au lait spot could indicate neurofibromatosis?
if 6+ cafe au lait spots, if they are >1.5 cm in diameter; also needs 2+ feautres of neurofibroma to make this dx
what are the 7 different shape/pattern configurations?
annular, polycyclic, arcuate, serpingous, iris/target, reticulate, glaborous
what is the tx for chicken pox?
Supportive: oatmeal baths, calomine, skin soothers, sometimes antivirals
o Lesions start as poorly defined, red, firm, tender subcutaneous nodules, 2-6cm in size that fade over 1-3 weeks similar to a bruise and do not scar
o Extensor surfaces; bilateral but not symmetrical, mostcommononpretibialsurfaces. Canseeon head, neck, torso , arms and thighs.
o New lesions appear for 3-6 weeks
o Ankle edema and leg pain are common.
o May have prodrome of f lulike symptoms, fever, myaligias, and polyarthralgias a few weeks prior or with onset of lesions
o Arthralgias > 50% Erythema, swelling, tenderness, +/- effusion,
o morning stiffness MC in knees, ankles, wrists Synovial fluid is acellular May last for 6 months Resolves without adverse reactions
erythema nodosum
what causes thrush?
candida albicans
angular cheilitis
what kind of skin distribution is this?
linear
open comedone
what’s the tx for decubitis ulcers?
if you see bone, refer to orthopedist immediately, relieve pressure via turning and positional aids, apply healing dressings, debride, keep area moist, healing dressings, consider antibiotics if necessary
pustule
what is the tx for candida intertrigo?
Topical Anti-fungal,vinegar wet dressings, burrows sol’n, air, hygeine, also glucose control, barrier creams, but also need antifungal, just barrier cream won’t work
what condition is marked by permanent, flat, sometimes nodular, pink to dark bluish red growths that grow with the child and are like plaques and are always present at birth?
port wine stain
oral candidiasis
BCC
cutaneous horn
what is the tx for pilonidal disease?
refer to colorectal, smell is reall bad, not enough time in a clinical setting, can try I&D if absolutely necessary, add antibiotic if abscess present
candida intertrigo
vesicle
a lesion assoc with sun exposure, blue/black lesion on lips, ears, neck forearms, dorsum, hands, well defined, blanchable
venous lake
what kind of tx for erysipelas?
PO aggressive AB, elevate, supportive, treat other skin conditions, same tx as cellulitis
neurofibroma
what kind of skin distribution is this?
dermatomal
folliculitis
o Seasonal: worse in summer; better in winter
· Primary Lesion: firm, 1-2mm, skin-colored to erythematous papules
o Slowly progressing;Grouped lesion expand to arcuate or annular plaques (1-5cm)
o Centra ldepression,slightly hypo-or hyperpigmented
o Smooth, non-scaling
granuloma anulare
what is the tx for herpes simplex (HSV 1)?
Supportive & Topical/PO Antivirals—-ASAP when prodrome starts
what are the ABCDEs for evaluating pigmented lesions?
Assymetry, border, color, diameter, evolution, ugly duckling sign
typical patient: asymptomatic, has a dark brown pigmented papule
nevi
incubation 14-21 days, followed by prodome of malaise, tender lymphadenopathy, fever, ST, HA, and polyarthalgias, very small pink macules coincide w/ prodome, begin on face/scalp, spread downward, papular and then desquamate, papules fade w/in 3 days. Red petechiae may occur on soft palate,
rubella, german measles
candida balantis
wheal
what are the treatments for meningococcemia/
cefotaxime or ceftriaxone pLUS vancomycin (ampicillin if <1 yo), adults same +/- genamicin, tobramycin or amikacin follow up
seborrheic keratosis
what causes animal bites?
dogs, cats, humans 80% dog, pasturella multocida, P. canis, strep, staph
skin vs. pigmented (pink) slightly raised, flattened/smooth, esp on face, hands, limbs
planar (flat) wart
angioedema
hypopigmentation
Small , scaly, papules suddenly appear Trunk and extremities. Uniform lesions Spares palms and soles +/- pruritus , looks like droplets splashed on
guttate psoriasis
roseola
what do tumors and nodules have in common?
they both can be above, at, or below the level of the skin surface
skin colored, thrombosed capillaries (black spot) papules smooth or rough, can be anywhere on body but esp on hands
common wart
meningococcemia
melanoma
what microorganism causes toxic shock syndrome?
staph, strep
dermatophyte of Trunk/Body,start as flat scaly papules/macules, chronic, advancing scaly edge with clearing. Have raised border.borders extend, central clearing or brownish discoloration. May have pustules, vesicles, bullae, advancing edge
tinea corporis
prodrome=irritated skin, hypersensitivity. 3-5 days of localized symptoms, painful red macule–>papule–>vesicular. Surrounded by erythema. Vesicles gorup over 2-3 weeks, becoming pustular then scab over, leave white scar. very painful–may seem like other diseases until dermatomal rash breaks out.
varicella zoster
•Small, superficial blood vessels that become visible because they are dilated
telangectasia
erythema nodosum
, vesicles that burst., pustule, Honey-colored crust, characteristic stuck on appearnce polycystic. No other body-wide presentation, asymptomatic
impetigo
what are some risk factors for strawberry hemangiomas? in which case may they want to be removed?
premie, female, multiple, low birth weight; removed if in a place where they are in an area of significant functional/psych impact–like near eyes blocking vision
lots of swelling, no itching,
o 3 Prominent sites:
o Subcutaneous tissue:
§ Face including lips, hands, arms, legs, genitals
o GIOrgans: (MCininheritedtypes)
§ Stomach, intestines, bladder
ú Nausea, vomiting, colicky pain, diarrhea
o Upper airway/larynx:
§ Dyspnea, dysphagia
o Non-pitting swelling
o +/- pain & burning
o Pruritus typically absent
Marked periorbital/ perioral swelling +/- throat, tongue, hands, feet and/or genitals
angioedema
solar lentigo
what is the tx for actinic keratosis?
sun protection, some topical therapies depending on how threatening it is: cryotherapy, 5-fluorouracil or imiquimod, laser resurfacing, and chemical peels, photodynamic therapy
what does a superficial BCC look like?
usually on trunk, scaly, dry patch that doesn’t heal
o Location:
o Skin, mucous membranes, the genitalia, the nails, scalp,
o Most common sites: flexor surfaces of the wrists and forearms, legs just above ankles, lumbar region
wickham straie: white reticular pattern on erythematous base
o The 5 P’s:
o Pruritic (20% none)
o Planar (f lat-topped)
o Polyangular
o Purple (violaceous)
Papules
lichen planus
what causes bed bugs?
cimex lectularius, cimex hemipteru, leptocimex boueti
erosion
tx for xerosis
use cotton (breathable), no fabric softeners or bleachers, mild or free detergent, use mild or no soap, clip nails to lower risk of abrasion, avoid frequqent washing and drying, use oils, creams, ointments, etc., short cooler showers, emollients immediately after bathing
macules to papules/petechia to ecchymosis/ulcerations; wrists/ankles to palms soles to arms legs to trunk; classic is petechia on palms and soles, history of tick bite, fever, nausea, vomiting, myalgias, anorexia, headache, rash
rocky mountain spotted fever
tinea capitis
painful bump on “low back” or butt, painful to sit down, redness, induration, occasional drainage, very tender to palpation
pilonidal disease
what lesion develops early in healing process of a trauma (i.e. piercing), extends beyond normal bounds of trauma site, and is most commonly found on the trunk, neck, ears, and extremities?
keloid
10-15 day incubation, prodrome of cough, coryza (runny nose), conjunctivitis, koplik spots (blue/white) on buccal mucosa 2-3 days into prodome. Disappear at peak of rash, blanchable red macules 2-10 mm, 4th day: papules on face/neck/behind ears, become papules, looks like blue-white grains of sand on a red base, spread to trunk and limbs, clear in 3 days, leave brown stain behind, rash starts on face, hairline, and behind ears then coalesce into patches and plaques, spread cephalocaudally to trunk and limbs within 24-36 hrs, high fever >104, prodrome of cough, coryza, conjunctivitis (3cs)
rubeola (measles)
what are some tx for herpes zoster?
PO antiviral–try to get them on within first 24 hours,rest, topical analgesics,narcotics, steroids or sympathetic blocks if pain continues?
papule
- Circumscribed
- Solid lesion
- Size: < 1 cm
- Elevated above surrounding skin
· Small (1-2mm),rough folliculocentric keratotic papules (sometimes pustules)
o Extra keratin around hair follicle
· Erythematous papules with light-red halo
keratosis pilaris
what tx would you use for cellulitis?
PO AB, elevate, supportive to feel better–wet dressings, rest, elevation, IV AB if can’t keep things down. Draw line around it when first see them to see if it gets better with tx, otherwise if it moves much past the line (spreading) consider other options. Swab over wound—if something growing in wound—tx it, but not throughout their whole body, o Keflex 500 mg qid, Clindamycin 300 mg qid (penallergic), if originated from some other bacteria of something strange they stepped on–you need to figure out what that could be
what sings point to a dx of neurofibromatosis?
>6 cafe au lait spots, >2 neurofibromas, axillary freckling
nodule
- Palpable, solid lesion
- Size: > 1 cm in diameter
- Originate in dermal or subcutaneous tissue
- Lesion may be above, level with, or below the skin surface
tx for keratosis pilaris
mild cleansers, emollients,
· 12%ammoniumlactate(Lac- Hydrin, AmLactin) or urea cream, topical retinoids (Tazorac or Retin-A cream)
o breaks down the keratin
o only works if use continually
reassurance-not contagious
how do you treat tinea capitis?
oral/topical (not good if inflamed) antifungal shampoo, cleaning contamination, treat family
Asymptomatic, flesh-toned papule, most common face & neck, dome shaped, develop central umbilical punctum. Molluscum bodies under microscope. 1-6mm. Can last months to years. As they resolve, they may become inflamed, crusted or scabby and will having surrounding erythema as body fights it off. esp suspicious when hx of being in swimming pools
molluscum contagiosum
patch
Patch
- Circumscribed area of discoloration
- Neither elevated nor depressed relative to the surrounding skin
- Size: >1 cm
may or may not have pain, may be in stages, of erythema that does not blanch, partial thickness ulcer or blister, no bruising, full thickness, can see fat but not muscle or bone, or full thickness can see tendon, muscle, bone
ulcer
what virus causes warts?
HPV
pustular psoriasis
how do you dx lice?
history, class/daycare outbreaks, itchy head, use tongue depressor to pull hair back, find nits/louse
tiny 1-5 mm erythematuos papules, rare is urticaria or bullae
bed bugs
T or F: you should warn pts of downtime regarding tx for actinic keratosis
T
4-6 day incubation, small vesicles initially form in mouth, rhomboid. Then oval/square yellow vesicles on hands, feet, buttocks. Usu Lasts 7-10 days without complications. Vesicles change to bullae to erosions, nose/throat discharge
hand foot and mouth
what is the tx for lyme disease?
doxycycline, if post exposure for >36 hours but no sx, if sx give doxycycline for longer or another antibiotic
acute viral infection of grouped or solitayr macules to painful vesicles, eroding to crusts, psosible prodrome. May ulcerate. Lesions generally around for 2-6 wks, may have fever, feel rotten, usually on skin/mucous membranes,
herpes simplex 1
what are some characteristics of an epidermal cyst?
mobile, keratin filled, cheese like contents, central plug, can be inflamed if ruptured, grow slowly, persist indefinitely
chronic plaque psoriasis
what factors effect the depth of tissue damage?
temperature, blood supply to area, duration of contact, thickness of skin,
T of F: You include superficial (1st degree) burns in a TBSA
false
what type of burn would be indicated by dry, no oozing, blanch with pressure?
first degree (superficial)
what kind of burn would be indicated by blistering within 24 hours, and painful, red, weeping, mottled (base not a consistent color–may be a mix of white and red) and doesn’t blanch with pressure?
partial thickness-2nd degree
what kind of burn would be indicated by a whitish to black color (charred), no blisters, no pain, coagulated vessels, no capillary refill
3rd degree-full thickness
what kind of burn would be indicated by seeing bone, muscle or fat?
4th degree
what 3 things do you need to assess burn severity?
TBSA, comorbidities, depth of burn
What are the 3 ways to assess TBSA? Which is fastest? which is most accurate?
Lund-Browder–chart that takes into account different body types–most effective, rule of 9s, palm method–easiest but not fastest
what are the 3 mortalty risk factors with burns?
age >60, non superficial burns covering >40% of body, inhalation injury
what differentiates a minor from a major burn?
minor: Partial thickness burns <10% TBSA in patients 10-50 years old, Partial thickness burns <5% TBSA in patients <10 or >50 years old, Full thickness burns <2% in any patient without any other injury AND Isolated injury, May not involve the face, hands, perineum, or feet, May not cross major joints. May not be circumferential, anything beyond this is a MAJOR burn
what are the 4 steps to treating a minor burn?
cool the skin, debride with soap and water, topical therapies, dressing
what are some ways to cool the skin down after a burn?
take off hot clothing, take off debris, cool gel packs, never use ice!! (Don’t want to give them frostbite), Be mindful of their temp—don’t want to give them hypothermia, Monitor body temp—make sure it stays above 95!, Monitoring core temperature continuously to prevent hypothermia especially when burns are >10% TBSA, Keep body temperature above 95°F (35°C)
what are some reasons to break a blister?
o Large blisters may put pressure on the underlying wound surface.
o May be difficult to determine the burn depth.
o Components of blister fluid may be harmful to wound healing.
Blisters over a joint may hinder ROM.
what are some reaons not to break a blister?
o • Blisters may provide a natural barrier to infection.
o • Blister fluid may promote wound healing.
o • Wound desiccation may occur in the absence of topical dressings.
o She doesn’t break them to prevent infection—also she is sending them home though
This can happen in scarring. What is it called?
contracture
o A 28 year old man fell into the bonfire earlier tonight. He has superficial thickness burns to the palms of both hands and partial thickness and full thickness burns to his anterior thighs and bilateral circumferential forearms.
▫ Using the rule of 9s what is his TBSA?
18%
o A three year old child has bilateral circumferential second degree burns from the feet to the knees.
▫ Using the rule of 9s, what is the child’s TBSA?
would you suspect abuse in this case?
13%; yes suspect abuse–the bilateral burns suggest they were forced into hot water–call the police
what is the most important thing you can do after treating a burn?
keep it moist
what two things are the best for wound coverage?
dressing and topical antimicrobial
what are some examples of topical antimicrobials to put on burns after wards?
can use some OTC things like petroleum jelly, coconut oil; commonly used agents are silver sulfadiazine (thick white topical applied bid, not for pregnant women or infants, also really hard to wash off) , topical antibioticslike bacitracin or polymyxin (easier to apply and remove, can be used on the face and genitals, a triple antibiotic may cause skin irritation) and petrolatum gauze
T or F: Burns cannot continue to burn
F: Burns CAN continue to burn, you need to see them every day for a while to make sure they are healing ok, to watch for infection, and to continuously reassess burn size and depth, because this can change
when are burns considered major burns?
o 25% TBSA or greater 10 – 40 y/o
o 20% TBSA or greater in children <10 or adults > 40
o 10% TBSA full thickness burns
o All burns involving the eyes, ears, face (because if on face it affects senses, etc) , hands, feet, or perineum (these areas of skin are less thick and can burn easier)
o Burns across a major joint (Because it would immobilize them And have to be very careful of cosmetic scarring and scarring over joints)
o • All high-voltage electric burns, chemical or inhalation burns.
o • All burns complicated by major trauma.
o • All patients with burns and serious co-morbidities.
§ Older, broken bones, DM
o • Major burns are considered trauma and should be treated as such!
what is considered the “primary survey” for major burns?
ABCs (airway, breathing, circulation), remove hot/burned clothing, begin cooling
why is the airway so important to check in burn victims?
they may have inhaled something and a large % of inhalation victims develop complete airway obstruction and they may suddenly have throat swelling
what are some common signs of smoke inhalation?
persistent cough, stridor (wheezing on breathing in), wheezing, hoarsenss, deep facial or neck burns all the way around, black sputum or black matter in mouth, blistering or edema of oropharynx, depressed mental status, respiratory distress, hypoxia or hypercapnia,
how do you debride a minor burn?
clean with soap and water, debride dead skin or blisters >2 cm, use saline and gauze, use surgical scrub brushes, use enzymatic debriding agents like collagenase and bromelain
what is part of the primary survey of major burns?
abcS, remove burned/hot clothing/jewelry, begin cooling
inadequate fluid resuscitation is associated with increased ________?
mortality
why do burn victims lose so much fluids?
(1) the blood vessels are gone and there is no fluid to get to organs, or (2) (From Mccance) the capillaries become more permeable and let out more fluids, proteins, electrolytes and this decreases the capillary oncotic pressure (protein pressure). Thus the water doesn’t want to go back into the vessles but wants to stay in the interstitial space (remember water follows Na and proteins). All this edema can also trap vessels and nerves in the periphery.
what kind of fluid should a burn victim receive? what about a pediatric case?
burn victims should get lactated ringer solution, peds can start on this but monitor their glucose–they may need glucose as well. GIVE AT A VERY VERY STEADY RATE.
what is the parkland formula for giving fluids to adults who are burn victims?
4ml/kg for each % BSA/24 hours
· A 25 y/o male with TBSA of 30%. He weighs 70 kg. His burn occurred at 3 pm and it is now 4 pm. He was given 1L of NS in the ambulance…
• How much fluid is needed in the first 24 hours?
o • How much fluid should you give per hour in the first 8 hours?
• In the subsequent 16 hours?
· 4ml X 70kg X 30= 8400 ml
o Burn occurred at 3:00 it is now 4:00.
o ▫ 8 hour mark ends at 11 pm.
o ▫ He needs (8400ml/2)-1000 ml = 3200 ml/8 hours. (needs 50% in first 8 hrs)
o ▫ From 4 pm until 11 pm he needs 3200/7=457.1ml/hour.
o manage renal failure—you are not going to dump all this in if they can’t pee it out!
o • In the subsequent 16 hours? 4200ml/hour/16=262.5ml/hour
what other tests should you do on the major burn victim and why?
o CBC
o • Serum chemistries / electrolytes
o • BUN
o • Glucose
o • Urinalysis( drugs?)
o • Chest X-Rays (inhalation injuries)
o • ABG with carboxyhemoglobin ( how much c02 they still have)
o • ECG ( check heart—is there heart rhythm abnormal because of heart issues or from working hard from “third space” where fluid leaks out?)
o • Type of burn and screen (associated trauma)
o • X-Rays for associated trauma injuries
o • X-Rays for suspected child abuse
what is the parklands formula for kids?
3 ml / kg for each % TBSA/24 hours
▫ Consider adding dextrose in this age group due to increased risk of hypoglycemia
where can skin grafts come from?
o Autograft: from same patient
o Allograft: from a non-self source
what two kinds of skin grafts are used? what are their pros and cons?
full thickness–(contains epidermis and dermis) heals best and has least scarring, only set back is if the body will reject it or not. skin taken from groin, lateral thigh, lower abdomen, or lateral chest. If its over a really large area the full thickness may not take.
A split thickness is a piece of skin that has been stretched and holes punched in it.it contains the epidermis and a small amount of the dermis. they can be “meshed” to cover a greater surface areas. has terrible scarring.
what is an escaratomy? when is it used?
basically it opens up a part of your body that has been “casted over” and tight with eschar. If you don’t open it up it will swell so much it could occlude all the blood vessels and nerves, so it can save limbs. cut open the subcutaneous tissue from non burned skin–to non burned skin.
what steps can you take against infections for burns?
clean wounds with soap and water, no peroxide or other “cleaning” agents like hibiclens or betadine–this can inhibit healing process. apply topical antibiotics and cover with a clean dry dressing. usually systemic antibiotics are not needed. debriding helps against infection. give tetanus vaccine (unlesss only a superficial burn) if tetanus not up to date or give tetanus immunoglobulin if not completed sequence,
when should you refer a burn victim to a burn unit?
refer to burn unit–if partial thickness burn >10% TBSA, or any 3rd or 4th degree burns. refer with any electricl, chemical, or inhalation burns, and for burns on hands/feet, face, perineum/genitals, across major joints, or serious pre existing conditions, for children if hospital not set up for that, for anyone with special psych/emotional needs, or for burns with trauma
how do you spot child abuse in burns? what do you do if you see it?
o Common patterns or burns of abuse are contact and scald burns. also be suspicious if The history of the injury doesn’t mesh with the physical exam findings. Symmetrical burns are suggestive of abuse ▫Scald burns of the lower extremities suggest a forced immersion into something hot, like a child being lowered into a tub of hot water. • The index of suspicion may be greater with other physical exam findings of injury, like bruises or cuts.
If you see it–call police and then you are done and they and social work will take care of it. It may be uncomfortable, but its in the best interest of the child. we aren’t there to be friends with the parents. she often says, “ it is a suspicious injury, its not that I don’t believe you, but its is the law and a requirement that I call the police. if you are thinking they are a flight risk—bring the police with you and say I have called the police and they are here
how do you determine photodermatosis aka photosensitivty aka “sun rash”?
hx and physical exam: age of onset, timeline of eruption, FH, meds, appearance of skin, skin bx may be helpful, but you probably don’t need this
papulonodular lesions, symmetrically distributed on sun exposed skin, pruritic, sometimes angular cheilitis, history of getting in while getting sun exposure
polymorphous sun light eruption–basically an allergic reaction to the sun
what are some tx for polymorphous sun light eruption?
sun protection, topical corticosteroids, oral corticosteroids, photo therapy (like gettting yourself used to an allergen)
what are some treatments for sun burn?
self limiting: soothing are aloe, cool compresses, (milk compresses have been helpful in some people), oral otc analgesiscs for pain, hospital if very severe
what is phototoxicity? and what can cause it?
basically an exaggerated sunburn while taking certain compounds, like: tetracyclines (doxy), sulfonamides, NSAIDS, griseofulvin, tar compounds, thiazines, fluoroquinolones, phenothiazides, retinoids, st. john’s wort, can also be caused by lupus, pophyria, or dermatomyositis
begins with prodrome of fever and flu-like syndromes 1-3 days before skin eruption, membranes affected in >90% of people, skin detachment is <10% of TBSA, usually 2 diff mucous membranes at same time (oral, ocular, genital), coalescing erythamtous macules, then vesicles, and bullae on skin and mucous membranes, skin sloughs, lesions begin on face and trunk then spread rapidly, even on to palms and soles, positive nikolsky sign (gentle pressure will cause dermis and epidermis to separate),
OR if >30% TBSA what is it called?
steven johnson syndrome
if >30% TBSA then called toxic epidermal necrolysis
this is a MEDICAL EMERGENCY
what are some of the triggers of SJS or TEN?
triggers: allopurinol, anticonvulsants, sulfonamides (if not from a virus, this is the 2nd most common trigger), NSAIDS, infections, mycoplasma (CMV–cytomegalovirus)(1st MC trigger)
how do you tx SJS or TEN?
d/c causitive agent, REFER, tx like burn–wound care, fluids, prevention of infection
what is the pathophysiology behind frostbite?
environmental exposure to cold, direct exposure to freezing materials (i.e. ice packs), inhalation of hydrocarbons, Cooling of the nerves causes hyperesthesia or paresthesia, o Ice crystals form in the intracellular and extracellular fluids. This causes abnormal electrolyte balance within the cells, cell dehydration, lysis, and death, o The thawing process initiates an inflammatory response which causes progressive tissue ischemia, emboli within the microvessels, and thrombi in the larger vessels
what does a first degree frostbite look like?
1st degree: superficial, cold, numbness, clumsiness in area, skin insensate, white or graying in color, hard and waxy to touc, bullae may develop upon rewarming,central area of pallor and anesthesia of skin surrounded by erythema, no tissue infarction
what does a second degree frostbite look like?
2nd degree: cold, numbness, clumsiness in area, skin insensate, white or graying in color, hard and waxy to touch ,large blisters containing clear fluid surrounded by erythema and edema within 24 hrs of rewarming, no tissue loss
what does a 3rd degree frost bite look like?
cold, numbness, clumsiness in area, skin insensate, white or graying in color, hard and waxy to touch, deeper, blisters are hemorragic and more proximal, skin forms black eschar in one week or later,nerves are frozen and dead, may not be painful if tissue all dead
how do you treat a frost bite?
prevention, rewarming by placing affected area in water heated to 37-39°C (98-102°F). FASTER IS NOT BETTER. Rewarming by ambient heat is less consistent and may cause a burn. Air dry tissues or gently blot dry–no rubbing. Thawing is complete when tissue is red or purple and soft to touch. tx hypothermia if present. tx wounds with non stick gauze and very very puffy, dry, bulky dressings. elevate extremities to reduce edema, manage blisters (debride non hemorragic ones, leave hemorraghic ones), tetanus if needed, avoid topical antibiotics, aloe very may help, surgical consult, thrombolytic therapy if needed to save tissue (tissue plasminogen activator or heparin)
what are the symptoms and temp of mild hypothermia?
HTN, shivering, tachycardia tachypnea vasoconstriction 32.5-35 celsius (90-95 F), with time: apathy, ataxia, cold diuresis, impaired judgment
what are the symptoms and temp of moderate hypothermia?
atrial dysrythmias, decreased hr, rr, bp, temp 28-32.2 C or 82-90 F, decreased LOC, dilated pupils, no shivering, hyporeflexia decreased gag reflex,J wave on EKG, paradoxical undressing, brady cardia
what are the symtoms and temp of severe hypothermia?
apnea, coma, nonreactive pupils, oliguria, pulmonary edema, miimal to no activity on EEG, ventricular dysrhythmias/asystole, temp <28 or (82 F)
for what type of hypothermia could you tx it with external passive rewarming? how do you do this?
for mild hypothermia. passive external rewarming: take off wet clotohes, put dry clothes on, cover in blankets, patient must have intact thermoregulatory mechanisms, normal endocrine funcion, and adequate energy stores to create endogenous heat
in which case would you use active external rewarming? what is it?
for moderate or severe hypothermia; active external rewarming: application of heat directly to skin, effective only if intact circulation, be careful not to burn skin, use warm blankets, heating pads, radiant heat, warm baths, or forced warm air directly on patients skin, warm trunk before extremities, be careful of after drop: cold peripheral blood causing hear to act funny–can cause pH differences
when is active internal rewarming appropriate?
for very severe cases: active internal rewarming via warm IVF, warmed humidified o2, or extracorpeal blood warming with a cardiopulmonary bypass (most effective method) (this increases core temp by 1-2 degrees celsius every 5 minutes) or warm body cavities, need to be ready with shocks in case heart reacts
what are the goals of wound healing?
eliminate complications, restore function, reduce scarring
what are the steps of wound care?
CLEAN, hemostasis, anesthesia, wound irrigation (the solution to pollution is dilution), wound exploration, removal of devitalized/contaminated tissue, tissue preservation, closure tension, deep sutures if necessary, tissue handling during closure, dressings and follow up
what should you educate your pt on for wound healing?
pain during and after repair, scar formation (not something we can always control–do they get keloids) loss of function, infection prevention, cost of care, missed work, wound care
what are the stages of wound healing?
inflammatory phase (1-5 days, begins when hemostasis achieved, lymphocytes and granulocytes migrate to area to control bacterial growth and suppress infection), proliferative phase (epithelialization, neovascularization, and collagen synthesis), and remodeling
what 3 things might get in the way of a wound healing by itself?
infection, poor technique, underlying conditions
what is epithelialization of a wound during the proliferative phase?
migration of epithelial cells, establishing normal layers of epidermis, most evident in days 5-14
what is neovascularization of a wound during the proliferative phase?
new vessel formation, gives an erythamatous appearnce to wound (this is normal), evident by day 3 but must active by day 7
what is the collagen synthesis of the proliferative phase?
rapid mitosis of fibroblasts due to establishment of vascular supply and macrophage stimulation resuting in new collagen fibril production, begins day 2, peaks days 5-7, greatest collagen mass by 3 weeks
still not strong at this point, and mostly past point of infection, may look gooey
how long will wounds continue to remodel for?
several months, final appearnce may take 6-12 months, only then can therapies for scar formation be considered
what factors, besides infection, interfere with healing?
conditions that interfere: stasis dermatitis, chronic med conditions, advanced age, alcoholism, acute urema, severe anemia, bad nutrition, diabetes, peripheral vascular disease, nicotene use,
technical factors that interfere: inadequate wound prep, excessive suture tension, reactive suture materials, local anesthetics (may cause some problems with vascularization because epinephrine causes vasoconstricition),
anatomic factors that interefere: skin tension, pigmented skin, oily skin (more prone to infection), location of wound (feet or ankle–more swelling, or flexor or extensor surfaces), drugs (corticosteroids, NSAIDS, penicillamine, beta blockers, tobacco)
what kinds of things should you assess about the wound?
mechanism: what happend? (foreign bodies in wound?), when did it happen? any associated symptoms (like systemic things?), numbness? (checking for nerves here ), tingling? loss of function?
PMH: (diabetes, seizures, immunosuppression, prior scars (do they get keloids?), allergies, nicotine use, date of last tetanus, meds they are on, illegal drugs they may have taken (don’t want to overdose them), vocation/hobbies (hobbies could interfere with healing–i.e. if they are a “stubborn runner”), R or L handedness
physical exam: vitals, wound description (location, length, extent, depth, condition (clean, contaminated, sharp, irregular–looks like a nike swoosh) , motor sensation and function (VERY IMPORTANT)
what reactions can result form injection of local anesthesia?
cardiovascular reactions, excitatory central nervous system effects, vasovagal syncope secondary to pain or anxiety (fainting)
what are the 3 most commonly used anesthesias for wounds? which works fastest? which lasts longest?
lidocaine: most commonly used, fastest (4-10 minutes), good tissue preseving properties, lasts for 60-120 minutes, can add epinephrine to make it last longer and vasoconstrict
mepivacaine: 6-10 minute onset, lasts 30-60 minutes, more vasoconstricting than lidocaine, doesn’t require addition of epinephrine
bupivacaine: lasts longest (240-480 minutes), slowest onset of 8-12 minutes, can be combined with lidocaine
why would you add epinephrine to lidocaine? where would you NOT want to use this?
can add epinephrine to lidocaine to increase time duration by 30-50%, it also has a vasoconstricting effect to stop bleeding– so don’t use epinephrine in terminal circulation areas like ear, fingers, toes, penis
what are the 3 different injection techniques for anesthesia?
direct wound infiltration (for minimally contaminated lacerations)–inject between dermis and superficial fascia), can buffer with bicarbonate 1:10 to decrease burning from pH change;
parallel margin infiltratoin (field block)–fewer needle sticks, better for contaminated wounds because you aren’t pushing bacteria further in, inject very superficially through intact skin
digital nerve blocks (fingers and toes)–recommended for lacerations distal to level of proximal phalanx of finger or toe; inject along medial and lateral edges of finger or toe to get both nerves
what are the rough guidelines for timing of wound closures?
6-8 hours after injury is considered safe, our lecturer said he feels safe with 8-12 hours, maybe up to 16. anything over 18 or 24 hours he won’t consider, especially if it is already dry and granulated–you won’t help the healing process then
what are the different kinds of closures?
primary closure/intent (close fully with sutures, i.e. for very clean and uncontaminated lacerations with minimal tissue loss, within 6-8 hours)
secondary closure/intent: for infected areas or abscesses, ulcerations, punctures, animal bites. clean and irrigate and debride, but don’t suture. they will heal through granulation formation and eventual re-epithelialization
tertiary closure (delayed primary closure)–this includes bites or lacerations beyond the golden period, especially for high bacteria count. this involves converting the wound to a fresh wound by numbing it up, washng, and packing it with gauze for 4-5 days + and antibiotic. it it appears clean and uninfected, it may be closed
what lines should you follow, if possible, to decrease tension and improve healing?
langer’s lines
what should you do if you get into taking care of wound, and you see there is tingling or loss of function or its really complex??
call and REFER
what layers of dressing should go on a wound?
occlusive, dry, multilayered dressings, to decrease inflammation and increase re-epithelialization: first a nonadherent/permeable layer (not something that sticks), second an absorbent layer (so they don’t see all the weird gooey stuff), third a pressure top layer as needed.
make it look nice!
when would you use steri strips?
for superficial, straight lacerations under little tension, for lacerations with greater than usualy potential for infection, for elderly if skin too thin to suture, to support lacerations after suture removal (especially if lots of tension on it–steristrips are a good bolster), or for lacerations with flaps where sutures would compromise vascular supply (remember you are making ‘skin bridges”)
what are the advantages of using steri strips?
easy application, even distribution of tension, no suture marks, no need to remove sutures, application by non-providers
what are some disadvantages of using steri strips?
Don’t work well on oily surfaces, hair, joints, lax skin, gaping wounds, wounds under tension, young or uncooperative patients
when would you use stapling?
for sharp, linear, lacerations of scalp, neck, trunk, buttocks, extremieis (places with stretchy skin or lots of tension), or for temporary, rapid closure of extensive superficial lacerations in pts requirng immediate surgery for life threatening trauma
what are some advantages of staples?
Quick, tolerated well once placed
what are some disadvatanges of staples?
can’t be used if going to CT scan or take a MRI of the area
when would you use tissue adhesives?
on a fresh laceration withn the golden period, Lacs under low tension which are easy to approximate (he uses them a lot on the face if going with langers lines) Edges of wound are clean and even, closing without gaps Dry wounds with little to no bleeding
DON’T USE NEAR THE EYES!!
what are the advantages of tissue adhesives?
§ Flexible, bacterial barrier, high breaking strength, store at room temp, may be used on many wounds and lacs, especially good for the face, no need for anesthesia, can shower normally, works well on aged/thin/ corticosteroid- affected skin, peels off spontaneously in 5-10 days
when can tissue adhesives NOT be used?
on mucous membranes, hair bearing, or weight bearing areas
what is some pt ed for wound aftercare?
when to schedule suture removal (don’t say we will take them out in x amount of days, say we will check them in x about of days–pt expectations); don’t get in a hot tub, river, lake, pool, pat dry, can get wet or shower after 48 hours, expect gooeyness, redness (normal parts of healing), provide written instructions and unhurried verbal instructions,
if a patient calls 1-3 days after a wound with an infection–what do you do?
have them come in ASAP. that’s serious stuff, most wound infections appear after 4-5 days
what are some signs of infection?
excessive discomfort, mucopurulent discharge erythema (>5mm beyond wound margins), lymphangitic streaks, fever
what is a really great cosmetic suture but one where the whole thing can come undone if one stitch is broken?
the running stitch
what stitch creates a 2 layer closure with one stitch?
vertical mattress
which stitch is good for achieving an eversion of the wound and is often used in areas of high tensino like palms or soles?
horizontal mattress
which stitch is used to close wounds with straight incisions, with absorbable stitches under the epidermis
subcuticular running closure
when would you use a V-Y closure?
if there are skin flaps that have damage or non-viable edges
define “bite” in suturing
the amount of tissue taken when placing the suture needle in the ski or fascia. includes both depth and width from wound edge
define “throw” in suturing
each throw is a pass through the skin; each knot consists of a series of throws
· 12 month old boy with scaly rash, on and off since 3 months of age, worse in winter months
· Location scattered on body, but predominantly on face, wrists, ankles, inner elbows, and behind knees
· Itchy, child is uncontrollably scratching
· Family history of asthma and hayfever in child’s mother
atopic dermatitis
what’s the pathophysiology behind atopic dermatitis?
defective barrier function in the stratum corneum leading to the entry of antigens
o defective lipid (particularly ceramide) production
o various antigens react with antibodies to produce increased levels of IgE
o genetic predisposition to react to various environmental allergens
xerotic (dry, flaky), erythematous (red), scaly (eczematous), and lichenified (thickened) ill-defined patches and plaques
o location favors body creases
• flexural folds, behind knees, elbows, wrists, ankles
o may also have Dennie-Morgan folds (increased folds below the eye from constant rubbing–irritated), allergic conjunctivitis, hyperlinear palms are often seen
atopic dermatits
what are some tx for atopic dermatitis?
moisturize, esp after bathing, use creams rather than lotions, topical steroids to reduce inflammation (not for too long), antibiotics if S. aureus infection, esp if honey colored crust, humidifier, cotton clothing, avoid bleach, fabric softener, eliminate exacerbating factors
· 30 year old nurse with scaly rash on bilateral hands of 2 months duration
· Frequent patient contact at work, washes hands 25 times/day
· Worse on dorsal than on palmar surface; no rash elsewhere on body
· Scaly and itchy
· Symptoms mildly improved during a 1 week tropical vacation
irritant contact dermatitis
hx of sufficient exposure to a cutaneous irritant (i.e. something everyday at work), itching, pain, fissuring of skin, sx within minutes to hours
irritant contact dermatits
tx for irritant contact dermatitis
avoid irritating stimulus, moisturize frequently, use bland cleansers, can use topical steroids to reduce inflammation
· [Description: Chronic20Hand20Dermatitis] 45 year old beautician with rash of 2 months duration on hands
· Palmar surface worse than dorsal; rest of body is unaffected
· Red, itchy, and scaly
· Daily activities include handling hair dyes and cosmetics; has worked as a beautician for 20 years
allergic contact dermatitis
intense itching, 10 day minimumf or developing a specific sensitivity to a new conactant, rash within 12-48 hours of exposure again, o erythematous patches, papules, or vesicles
o linear or sharply defined rash suggests contact dermatitis
o site of dermatitis provides the best clue regarding the potential cause of ACD (e.g. face, eyelids, waistline, hands, feet)
allergic contact dermatitis
tx for allergic contact derm
can do patch testing to determine allergen, avoid substance (resolves after 2-4 wks of non exposure), topical steroids, topical immunomodulators, oral antihistamines for itching, wet compress to minimize inflammation, phototherapy
acute itching with sudden occurrence of blisters like tapioca on palms, soles, and lateral aspects of fingers, o typically resolve without rupturing, followed by desquamation (peeling)
dishydrotic eczema
what is the tx for dishydrotic eczema?
o topical steroids; occasionally brief courses of PO steroids may be necessary
o phototherapy helpful in those who have not responded to other measures
o Prognosis: course is chronic and intermittent course. Fewer episodes occur after middle age.
1+ circular lesions, 2-10 cm wide, may be as many as 20-50, itching, appear spontaneously on trunk and extremities, no irritating agent known
nummular eczema
what is the tx for nummular eczema?
o topical steroids, emollients (moisturize), systemic abx if S. aureus present (skin culture). Avoid irritants if they can be identified
o pruritus is intermittent; usually more noticeable at rest
o usually there is a past history of an acute or chronic skin condition
§ which caused them to scratch at it in the first place
o scratching is usually an automatic, reflexive habit
o common sites include scalp, nape of neck, extensor forearms and elbows, vulva and scrotum, upper medial thighs, knees, lower legs, and ankles
o slightly erythematous, scaly, well-demarcated, lichenified, firm, rough plaques with exaggerated skin lines are noted
o hyperpigmentation common
§ particularly for those with darker skin types
o patients may unconsciously scratch lesions when observed
you’ll notice this while they are talking to you
lichen simplex chronicus
what is a tx for lichen simplex chronicus?
break cycle of itching via topical or intralesional steroids, behavior modification, doxepin cream or capsaicin cream (chili peppers promote different nerve sensations to distract from itching), oral anithistamines, occlusive dressings, referall to psychiatrist
erythematous papulopustules that coalesce forming inflammatory plaques around the mouth or eyes
perioral dermatitis
what is the tx for perioral dermatitis?
topical (gel or cream) or systemic antibiotics, avoid ointments (plugging pores), avoid all cosmetics until clear, avoid steroids since this condition may occur from indiscriminate use of them
yellowing-red or white-gray, crusty, greasy or dry patches, usually sharply marginated on sebum rich areas, ranges from mild, patchy scaling to widespread, thick adherent crusts especially in areas of excessive sebum production like hair, eyebrows, eyelashes
sebhorreic dermatitis
what is the tx for sebhorreic dermaitits?
more frequent shampooing (from over productive hair glands), longer lathering; discontinue hair spray and pomades; shampoos containing salicylic acid, tar, selenium sulfide, or zinc are effective and may be used in an alternating schedule (i..e selsun blue or neutrogena t cell, alternate between 3) o treat seborrheic blepharitis (eyelashes) with baby shampoo
o anti-yeast creams (e.g. ketoconazole)
• where skin doesn’t have as much hair—behind ears, nasolabial folds
o topical steroids for acute flares, but may hasten recurrences and may foster dependence because of a rebound effect.
excessive blushing, rosy cheeks, papulopustules like acne, may report a gritty quality of eyes and facial edema (ocular rosacea)
rosacea
what are some tx for rosacea?
identify and avoid triggers (heat, alcohol, caffeine, extreme temperatures)
o sunscreen with both UVA/UVB protection
o topical or oral antibiotics
o avoid topical steroids
o vascular laser
• the laser selectively destroys superficial blood vessels
excessive sweating that impairs daily activities, at least 1 episode per week for past 6 months, onset before 25–later onset should prompt a search for secondary causes, focal sweating that stop during sleep, bilteral, relatively symmetric
hyperhidrosis
what are the tx for hyperhidrosis?
drysol or xerac solution for mild to moderates which decreases sweating, iontophoresis for hands or palms (dipping in water and minerals), botulinum toxin to paralyze sweat glands (works for 3-6 months), anticholinergics or sympathectomy for severe cases
hidradenitis suppurativa
tiny, fragile, clear vesicles in crops, asymptomatic, self limited, resolves in days, common in neonates from being tightly swaddled and sweat glands not developed
miliaria crystallina
deeper obstruction in epidermis, extremely pruritic, erythamatous papules, anhidrosis (unable to sweat)–this can lead to heat exhaustion, possible secondary infection
miliaria rubra
obstruction at dermal/epidermal junction from repeated episodes of miliara rubra, asymptomatic, flesh colored papules, may have increased sweating in unaffected skin and inability to sweat where affected
miliaria profunda
what is the treatment for miliaria?
crystallina and rubra will resolve on own, to help those with ruba or profunda: remove occlusive clothing, limit activity, provide air conditioning, move to cooler climate, can treat topically with lotions containing calamine, boric acid, or menthol; cool compresses; topical corticosteroids, topical antibiotics
how long do hairs in anagen, the growth phase, last?
2-3 years, this is 80-90% of follicles
how long does catagen, the involutional phase of hairs, last?
2-3 wks
how long are hairs in telogen?
3-4 months, 5-10% of follicles
what causes scarring in hair loss?
fibrosis and scar tissue that replace/damage the hair follcile
· 40 year-old female presents with gradual onset hair loss
· Affects vertex of scalp
· No hair loss elsewhere
· Family history early hair loss in father and grandfather
androgenic alopecia
what are the tx’s for androgenic alopecia?
topical minoxidil solution (reducesrate of hair loss/partially resotres hair loss), finasteride (only men), antiandrogens in women (Ocs, spironolactone), wigs, hair transplantation
· 32 year old male presents with sudden hair loss on crown of scalp
· Appears as a completely bald patch
· Personal history significant for hypothyroidism
· NOT a gradual thinning, well demarcated
alopecia areata
what is the tx for alopecia areata?
no cure, need to get into root of hair: intralesional steroid, corticodsteroids, minoxidil solution, anthralin, topical immunotherapy–introducing a 2nd antigen distracts the immune system so it doesn’t attack the hair follicles, wigs,
· 33 year old female with 2 month history hair loss
· Noticing increased amounts of hair on pillowcase, in brush, and in shower drain
· Hair loss is diffuse on scalp
· Recently had an appendectomy 3 months ago
telogen effluvium
what are the treatments for telogen effluvium?
no interventino needed, regrowth will occur, any reversible cause such as poor diet, iron deficiency, hypothyroidism, meds should be corrected
· 50 year old African American female presents with hair loss over entire frontal hairline
· Has occurred gradually over years
· No other hair loss on rest of scalp or body
· Has received no chemical treatments; styles hair in tight braids
traumatic alopecia
what is the tx for traumatic alopecia?
early recognition and d/c traction/chemical trauma, reversible in initial stages, with prolonged traction it can be permanent
· 25 year old female with hair loss of unknown duration on left tempo-parietal scalp
· Denies any recent stress or auto-immune disorders
· No hair loss elsewhere on scalp or body
irregular pattern of hair loss, and not diffuse
trichotillomania
furuncle
carbuncle
tx for carbuncles and furuncles?
warm compress to promote spontaneous drainae, antibiotics, surgical drainage for severe infections
what are some ways to tx hirsutism?
short term hair removal (waxing, shaving, bleaching, depilatory creams) or long term hair removal (electrolysis, laser), weight reduction, can use Ocs to decrease ovarian androgen production, spironolactone (to decrease sensitivity of androgen receptors–teratogenic), vaniqa, glucocorticoid therapy (to suppress andreal androgen production), refer to endocrinologist
hirsutism
how do you establish a dx of hirsutism?
r/o familial and drug induced causes, rule of androgen causes (can test androgen levels–elevated testosterone indicates ovarian source of androgens, elevated DHEAS indicates adrenal source), get a good hx: menses, age at menarche, pregnancies, OCP use, time course, weight history, meds, anabolic steroids, FM of irregular menses or hirsutism, acne or obesity, consider ordering other hormone tests like LH, FSH, prolactin, TSH
what are some causes of hirsutism?
with virilization: PCOS, ovarian/adrenal tumors, exogenous androgens, obesity; without virilization: idiopathic, drugs, hypothyroidism, excess growth hormone
painful, acneiform eruption that occurs after shaving,esp from pulling skin taut during shaving, shaving against the grain, or using double or triple edged razors (anything that makes the shave closer) PE: firm, skin colored or red papules, hyperpigmented with a hair shaft in center, can form pustules or abscesses from secondary infection
pseudofolliculitis
what is the tx for pseudofolliculitis?
chemical depillatories (hair broken off bluntly instead of sharply), topical antibiotic lotion for pustular involvement, OA for severe seconary inflammation, vaniqa (decreases rate of hair regrowth and density), tretinoin (exfoliate so hair doesn’t become trapped), electrolysis, laser hair removal (long term)
avoid close, frequent shaving, change razors, shower before shaving to soften the hairs so they have a more blunt tip, wash the area with a soft bristled tooth brush for several minutes with a circular motion to dislodge stubborn hairs, can lead to scarring or postinflammatory hyperpigmentation, secondary infection, or keloid formation
how do you do a nail resection?
Start them on an oral antibiotic first to prevent infection
provide a tourniquet
may need a Digital block or local anesthetic
Insert spatula device under toe so it is elevated away from skin and cut that part of the nail that is embedded
Can grow back unless nail matrix is cut
what are some treatments for ingrown toenails?
if mild to moderate: conservative tx: shoes with wider toe box, temporary surgical shoes, cut nail straight past area where embedded, warm soapy soaks for 3-4x/day for 10-20 minutes, analgesics for pain. Next approach: soak foot then elevate offending nail from soft tissue with pledget that has been dipped in antiseptic every day until nail grows beyond tissue, keep foot elevated. should get relief in first couple days. If moderate to severe with significant redness, pus pain: need to remove nail margin in a wedge resection or remove entire nail if don’t respond to conservative tx: can remove partial part of nail, or damage nail matrix with phenol prep or curreting or silver nitrate to granulation tissue. use oral antibiotics if concern for infection
ingrown toe nail
onycholysis
fungus invades nail bed and underside of nail plate, nail debris, thickened nail plate, subungal hyperkeratosis, onycholysis, discoloration from white-yellow to brown
distal subungal onychomycosis
invasion of superficial layers of nail plate, small white speckled patches on suface
white superficial onychomycosis
fungal penetration of a white color through proximal nail fold (least common, but mc in immunocompromised
proximal subungal onychomycosis
how do you do an I&D on a paronychia?
§ 11 or 15 blade used, continue warm soaks
§ Some people will do a digital block
§ use a local anesthesia
§ apply antiseptic too—before putting a blade into a dirty abscess
§ could use a 30 gage needle
acute: acute onset of local pain, swelling, tenderness of lateral fold of one nail, collection of purulent material at nail margin, usually only on one digit; chronic: multi factorial: RF of DM, immuno., contact irritants, exposure to moisture, C. albicans, present for 6 wks or more, bump has no fluctuance
paronychia
how do you treat a paronychia?
acute: warm soapy soaks 3-4 times per day for 15-20 minutes, may take oral antibiotics for severe cases or if immunosuppressed, I and D if abscess forms; for chronic: avoid moisture, wear gloves, topical antifungal, those with DM or immuno. May req more aggressive tx
how do you do a trephination?
o Small painless: No treatment required.
o Trephination is the process of drilling a hole in the nail, which releases the blood and pressure that contributes to pain.
§ Painless and relieves pain quickly
§ Retract cautery device as soon as pressure is relieved, don’t want to do any damage to nail bed
§ Could sanitize a safety pain, puncture nail, retract immediately and extracting the blood will provide relief
o Consider trephination if the hematoma is painful and acute (<24-48 hours).
o Trephination of hematomas covering >50% of the nail-bed is controversial.
what are some underlying pathologies that could be caused by clubbing of the nails?
idiopathic or secondary to pathologies in organs like lungs, heart, GI, skin, esp related to lung cancer if yellow and clubbed
what diseases can be indicated by pitting of hte nail plate?
psoriasis, alopecia areata, lichen planus
what are some causes of pincer nails?
inherited or acquired via certain meds, psoriasis, onychomycosis, tumors, underlying systemic disease
solitary round, dome shaped papulonodule from 1-10 mm containing gelatinous fluid (clear or yellow), asymptomatic on DIP or proximal nail plate
digital mucous cyst
1 infection: 2-20 day incub (avg 4 days) small painful grouped vesicles at site of contact, either pustules or erosions/ulcers, flu like symptoms common, regional lymphadenopathy, lesions and crusts heal in 2-6 weeks, immune response developed; recurrence shows antiodies, outbreak is less severe, fewer lesions, likely prodrome, heals faster
genital herpes
what causes syphilis?
bacteria: treponema pallidum
which STIs are reportable?
syphilis, chancroid
primary: 10-90 day incubation, then solitary, painless hard, indurated ulcer (chancre) and lymphadenopathy in 1-2 weeks, secondary: various derm changes like copper tinted lesions on palms, body, soles. Rash may be discrete, confluent, etc. variety of shapes, condyloma lata (heaps of wart like papules), flu like symptoms, tertiary (1-20 years after infection and early latent or late latent periods (>1 yr), get gummas: granulomatous reaction to bacteria in skin, bones, joints
syphilis
how to establish dx of syphilis?
need dark field microscopy to confirm, clinical, can do nontreponemal serologica tests to screen out stuff and treponemal tests
what causes chancroid?
haemophilus ducreyi
1-2 wk incubation, acute painful, red papule at contact site, becomes pusutle, ruptures to ulcer (with yellow gray exudate), bleeds, fluctuant adenitis, may also have anoexia, malaise, low grade fever, lymphadenopathy
chancroid
highly variable course, may persist years dormantly, incubation period=3 weeks to 8 months, spreads quickly over mucous membranes, symmetric, fleshy colored lumps, smooth, velvety surface, not painful, can coalesce
condyloma acuminate
tx for condyloma acuminate
very difficult–can do acetic acid, colposcic exam, topical podofilox gel or solution BID for 3 days, 4 days off, topical imiquimod, cryotherapy, electrocautery/curretage (MASK!), laser
tx for syphilis
report, early: give benzathine Penicillin G in single dose, late: (after 1 year) give benzathine PenG iM weeky x3 or doxycycline or tetracycline if PCN allergic, repeat titers at 3,6,12 and 24 months. Mandatory follow up
tx for chancroid
abx: pO or IM, azithromycin 1 g PO x1, ceftriaxone 250 mg IM x1, ciprofloxacin 500 mg BID x 3 days,treat with any suspiciou=n
what is the pathophysiology behind seborrheic dermatitis?
increased sebum and abnormal immune response to yeast pityosporum
