Dermatology Flashcards
What are nail findings in psoriasis?
- *Nail pitting
- Onycholysis
- Yellow-brown colour
- Thickening
- Dystrophy
List some derm conditions that have nail pitting:
- Psoriasis
- Dermatitis (rough coarse pits)
- Alopecia Areata (transverse rows of fine pits)
What is incontinentia pigmenti?
Neurocutaneous disorder - association > derm > dental > ocular
Are skin lesions in incontinentia pigmenti at risk of malignant changes?
No- they are benign
List findings associated w/ incontinentia pigmenti:
> Derm: alopecia, coarse hair
Dental: late dentition, hypodontia, impaction
Ocular: neovascularization, micropthalmos, strabismus, optic nerve atrophy
CNS: seizures, DD, hemiplegia or hemiparesis
What is pseudoporphyria
Skin condition
- Look like porphyria BUT without porphyrin metabolism issue
- Usually from NAPROXEN/ NSAID
= photosensitive + small hypo pigment scars in areas of trauma
Most common cause of pseudoporphyria
Naproxen
Tx: D/C due to permanent scars risk.
List two RF for pseudoporphyria
- fair skin
- sun exposure area
What does pseudoporphyria look like?
- vesicles + easy bruising
- > small hypo pigmented depressed scars in areas of small trauma
what does incontenti pigmenti look like?
Initial linear streak or vesicles that blister.
Classic= pigmented strip following Blashko lines
*always affect axillae + groin
T or F: most people with acne have endocrine abnormalities.
False
Testing for hyperandrogegism (i.e. PCOS) if (+) signs
- pre puberty= acne, early odour, axillary or pubic hair, bone age ++, accelerated growth
- postpuberty= infreq menses, hirsutism, alopecia, infertility, PCOS, clitromegaly, truncal obesity etc.
T or F: routine microbiologic testing recommended for patients with acne?
False
Do any acne treatments alter course of acne?
None except isotretinoin (accutane)
Is there evidence that diet triggers acne flares?
No; limited evidence.
Which season improves acne and which worsens?
- Summer= improve
- Worsen= winter
What is the best routine cleansing regiment for people with acne?
Soap + water.
- agents w/ keratolytic agent, salicylic acid may temporarily remove sebum but no significant change
Single or combo therapy should be used in patients with acne?
Combo therapy
*Note topical retinoid can be mono therapy if comedonal.
How to treat comedonal versus mild versus severe papulopustrular or nodular?
**Generally= Retinoid -> BP or Abx -> Isotretinoin
Comedonal= topical retinoid (or salicylic acid)
Mild Papulopustular= suggest inflam
= Benzoyl peroxide w/ topical ABX (i.e. topical dapsone, tetracycline, doxycycline) or Retinoid
*usually BP in am + retinoid night
Severe Papulopust. or Nodular
= topical retinoid + benzoyl peroxide + PO Abx
OR isotretinoin 1mg/kg/day
What is the only treatment for severe nodulocystic acne?
Isotretinoin
T or F: limited evidence for benefit of physical modalities for routine tx of acne (i.e. pulsed dye laser, glycol acid peel, salicylic acid peel)
T
Is Pregnancy is contraindication to isotretinoin (accutane)?
yes
Highly teratogenic.
What is baseline monitoring for isotretinoin?
liver function lipid panel (cholesterol, TG) pregnancy test
What is the advantage of benzoyl peroxide over topical Abx?
Decreases P. acnes. resistance to Abx
How long do you have to wait for acne treatment until state ineffective?
6-8 weeks
Most common topical Abx in acne treatment?
Clindamycin
Girl with blackheads only + mild acne. What do you recommend?
Topical retinoid acid (aka topical tretinoin)
What are blackheads?
open comedones.
Major Accutane side effects:
- highly teratogenic
- benign intracranial HTN
- depression w/ SI
- hepatitis (LFTs)
- hyperlipidemia (cholesterol, TG monitoring)
Describe the pathophysiology of acne (aka comedogenesis):
**Keratinization - Sebum - Bacteria - Inflammation
- Abnormal keratinization of follicular epithelium (impaction of keratinized cell)
- +++ Sebum
- Proliferation of Propionibacterium in follicles
- Inflammation
Child sucks on fingers. Vesicles on fingers with central area of ulceration and erythema. What is it? Tx?
Herpetic Whitlow
- pain ++
- min. 1 finger
- swell, red, tender
- heal within 2-3 wk; no tx
- if immunocompromised or severely infected= acyclovir
- do not lance
Do you ever lance herpetic whitlow?
NO
Which flesh coloured wart is caused by pox virus?
Molluscum Contagiosum
- commonly 1-10 y.o.
- skin to skin or indirect
- can appear anywhere (except palm, sole, scalp)
- Tx: reassure
- wash hand, no sharing towel, covering lesion necessary
- If Tx: cantharidin (beetle juice), cryosurgery (liquid nitrogen), curettage (painful)
Is the entire molluscum rash contagious?
yes
Tinea capitis treatment:
- Griseofulvin
- Alternative= Terbinafine (Lamisil) PO
- Alternative= PO Itraconazole
- Adjunct Shampoo (i.e. selenium shampoo)
Do not need to shave the head.
Hair broken with black dots on scalp. What type of infection is this?
Tinea capitis
- hair broken off by follicle
- black dot on scalp
- +/- fever, pain, local lymphadenopathy
Contagious skin infection from mite with burrow and red papule btwn finger, flexure, genital. ++ Itching (worse at night), papular, higher risk in First Nation, young, immunocompromised, bed sharing, poverty, overcrowding. Household has same thing. What is this?
Scabies.
- Sarcoptes scabiei
- Skin-to-skin (live off skin max 24 hr)
- usually papule (can be vesicle, pustule, nodule)
- itch worse at night
- peds: predilection from wrist + palm
- gold Dx: direct visualization via KOH or bx
- ink test (cover lesion w/ ink and remove w/ alcohol w/ tracking of burrows seen)
Who gets treated if one person has scabies?
Entire household contact (even without symptoms)
Goal: avoid re-infestation as symptom can take several wk to appear.
1st line treatment for scabies:
5% permethrin topical
- entire body
- min. 8-12 hr/put O/N
- re-tx in 7d
Why was lidocaine withdrawn as 2nd line Scabies tx:
Due to neurotoxicity.
Current 2nd line:
- benzyl benzoate
- sulphur jelly
When do you use PO ivermectin for scabies?
PO x 1. IF:
- immunocompromised
- institutional/ comm outbreak
How do you prevent scabies reinfection?
- Treat all household member regardless of symp.
- All bed linen + clothing next to skin= HOT wash + HOT dry
- If no hot water, put in sealed plastic bag x5-7d
- Vacuum floors
- Improve living conditions for First Nations
Alopecia with hair falling in clumps. No itch. (+) hair pull test.
Telogen Effluvium.
- reassure that normal hair growth return within 3-6 mo.
Alopecia due to hair pulling/ release tension. No itch. Anxiety + OCD tendency. Irregular pattern w/ mixed length + stubby hair.
Trichotillomania.
- If due to OCD= Tx clomipramine or fluoxetine
Alopecia. VERY ITCHY. Scales, pustules, kerion. Spots stay.
Tinea Capitis
Tx: anti fungal (Griseofulvin or Terbinafine or Itraconazole).+ adjunct shampoo
AI alopecia. No itch. exclamation point hairs on exam. regular pattern. nail pits + grooves.
Alopecia Areata
- resolution within 6-12 mo.
- recurrence common
- topical steroids effective in some
- intradermal injection option
What is Nikolsky sign?
with slight pressure the skin wrinkles and slide off and separate w/ dermis.
I.E. staphylococcal scalded skin, TEN
Population in Staph Scalded Skin:
infants +
always < 6
Bullous impetigo versus SSSS?
BI= local dx. Spread adjacent if blister ooze.
SSSS= toxin act at remote skin= spreading rash + slough
SSSS vs. TEN/SJS
TEN:
- allergic rxn (usually med)
- severe MM ++
- necrosis of full epidermal layer
SSSS:
- toxin from staph
- no MM (will do perioral)
- intraepidermal cleavage
Most common areas of SSS in neonate?
SSSS= staph scalded skin sys
- diaper
- umbilicus
Tx for staph scalded skin?
- Cloxacillin or Cephalosporin
- ** Clinda
- High risk MRSA or doesn’t respond= Vanco
Do you give steroids in SSS?
NO!
Slows down healing.
Avoid NSAID due to affect on kidney.
1 wk after amox. Red rash. Generalized. Spare folds. (+) MM. (+) Nikolsky's sign. DX?
Toxic epidermal necrolysis.
not SSS due to MM and spare fold
Most common precipitants for SJS or TENS?
Sulphonamides Pen/ Amox Anticonvulsant (phenobarb, phenytoin) NSAID Allopurinol
what % distinguish SJS versus TEN
BSA < 10%= SJS
BSA > 30%= TENS
in between is overlap dx
Tx of impetigo
Mupirocin 2% TID x 10-14d
Keflex IF strep, widespread, deep oral involvement.
What is Gianotti-Crosti?
Papular Acrodermatitis.
- Immunologic rxn to viral infection/immunization (1 wk after)
- monomorphic firm papule
- no MM
- benign and self-resolving (up to 2 mon)
Genital warts are caused by?
HPV 6 + 11
“Cauliflower like mass”
Inoculation during birth, sexual abuse, spread cutaneous.
Infant + small brown nodules on back and limbs. When touch wheal develops and then itchy. Dx?
Mastocytosis
- ++ mast cell in dermis Type= urticaria pigmentosa = most common; infant - early bullous or urticaria lesion that fade. - macular, nodular, brown - stroke-> red+ wheal, itch - spontaneous resolution; no tx needed
Plaque with scales. Pinpoint bleeding with removal of scale. What is this?
Psoriasis
Auspitz sign= pinpoint bleeding with removal of scale.
List 3 treatment modalities for psoriasis?
Emollient +
- Topical: steroids (solo if mild dx)
- Topical: Calcipotriol
- Topical: Tar Shampoo
- Phototherapy
- Systemic Tx: Immuno-suppressant (MTX)
- Systemic: Biologic (TNF-alpha inhibitor- infliximab)
Describe plaque psoriasis:
- red plaque
- sharply demarcated
- thick silvery scale
Key difference btwn Atopic dermatitis vs. Psoriasis vs. Tinea:
Tinea= annular, scaly, RED RAISED BORDER (thicker outside) + CENTRAL CLEARING, SPREAD if on steroids
Eczema= red, poorly defined, scaly, ++ ITCHY, flexure
Psoriasis= ROUND, WELL defined, silvery white SCALE, rare in flexures
Rash that follows Langer’s line. Initial large lesion on lower back. What is this?
Pityriasis Rosea.
- Herald Patch
- Langer line= Xmas tree
How long do you expect pityriasis rose to last? What tx do you offer? Contagious or not?
Rash ~ last up to 12 weeks.
Reassure. Emollient if scaling and PO antihistamine if need.
Not contagious.
What are infantile hemangioma?
Benign
Vascular
Neoplasm
What is the most common neoplasm/ tumor of infancy?
Hemangioma
infantile hemangioma RF:
prem
low BW
F
white
When do infantile hemangioma involute?
95% by 9 y.o.
When do you tx infantile hemangiomas
Location: airway, eye, face
Number: >5
Size > 5 cm
What is the first line tx for infantile hemangioma?
PO propanolol.
What is PHACE Syndrome:
P= posterior fossa anomalies H= hemangioma (large segment of face) A= arterial (cervical or cerebral) C= cardiac (coarc, VSD) E= eye (fetal vasc., morning glory) \+/- S = sternal, umbilical raphia etc.
What is the PHACE workup:
- Echo
- Baseline MRI + MRA
- Ophtho
- Ensure hearing passed
- Ensure no signs of hypothyroidism
- Ensure Neurodevelopment, SLP (brain), Dental hypoplasia
X-men Storm character… white hair… makes you think of?
Piebaldism
- AD
- associated with Waardenburg Syndrome
List some features of Waardenburg Syndrome
- AD
- piebaldism (white hair)
- deaf
- heterochromia (diff eye colours)
- wide set eyes
- low hairline
How many NF can you have till we are worried?
5
NF1 vs. NF2 vs. TS
NF1= AD
- optic glioma
- axillary or groin freckling
- neurofibromas
NF2= AD= neuro
- vestibular schwannoma
- eye + hearing + SC issue
TS= AD
- ash leaf spot
- shagreen patch
- cardiac rhabdomyoma
- ungal (nail)
- sz
What is the most common disorder seen with multiple cafe au lait?
NF1
Axillary or groin freckling + cafe au lait=
NF1
NF1 mnemonic?
need 2/7= CAFEFOGS
- Cafe au lait (min. 6 > 5mm in pre puberty and >15mm in post-puberty)
- Axillary freckling
- Fibroma (min. 2 of any type- cutaneous, subcut, plexiform)
- Eye= lisch nodules (brown spots on iris)
- FHX
- Optic Tumour (Glioma)
- Skeletal: bowing, pseudoarthrosis of tibia
CAFE FOGS mnemonic is what?
NF1
- Cafe au lait (min. 6 > 5mm in pre puberty and >15mm in post-puberty)
- Axillary freckling
- Fibroma (min. 2 of any type- cutaneous, subcut, plexiform)
- Eye= lisch nodules (brown spots on iris)
- FHX
- Optic Tumour (Glioma)
- Skeletal: bowing, pseudoarthrosis of tibia
hypo pigmented circle with nevi in middle
Halo Nevus
- body reacting to mole
- spontaneous regression
Atopic dermatitis. 1st line.
2nd line. 3rd line pharmacotherapy.
1st= topical corticosteroids 2nd= topical calcineurin inhibitors (i.e. tracolimus, protopic) 3rd= systemic (cyclosporine, steroids, Mycophenolate Mofetil, MTX)
What is erythema multiforme?
polymorphous eruption of targeted lesions
- any site +/- MM
- once there = stay
- HSV, Mycoplasma pneumonia, Meds (sulfa, anti-sz, penicillin), viral
- Tx: remove, oral histamine +/- topical corticosteroid
- resolve within 3wk
EM Minor= no MM= “Bull eye”
EM Major= MM= targeted, MM, <10% BSA; meds
SJS vs. EM Major
SJS= widespread blister with flat rash/macular + no target + MM severe
EM Major= MM= targeted, MM, <10% BSA
Erythema:
- Multiforme
- Migrans
- Marginatum
Multiforme: infection, meds, target, bull’s eye + pruritic; feet -> centripetal, 3 weeks
Migrans: rash appear migrate outward with central clearing; Lyme
Marginatum: trunk but face clear, ring like, no itch, transient eruption, few days, (+) strep (Jones Criteria)
T21 Alopecia Likely?
Alopecia Areata
Natural hx of alopecia areata?
Resolve within 6-12 mo.
Recurrence common
Topical steroid can be effective in some; +/- intradermal injection
Describe erythema toxicum
- benign
- peak DOL #2
- firm 1-2mm yellow-white papule on red flare base
- palm + sole fine
- resolve by 2 wk
Describe neonatal acne
- mean onset= 3 wk
- follicular comedone
- like teen (forehead + cheek)
- self resolve; disappear within 6 month
How do you treat poison ivy?
- Immediate decontamination
- Wash skin + supportive (cool wet cloth, calamine lotion, oatmeal bath)
- Systemic antihistamine
- Topical steroid
- +/- systemic steroid
Summer + linear vesicles + pruritic!!! Could be (think plant in summer)
Poison Ivy
Tx: - decontaminate + wash skin - systemic antihistamine - topical steroid \+/- systemic steroid
What it the natural history of infantile hemangioma?
- Precursor (colour change)
- Proliferation (rapid phase done by 5 mon, till 12 mo)
- Plateau till 18 mon
- Regression till 10 y.o.
- Residua (50% of pt)
Beard distribution of hemangioma means=
Subglottic hemangimoa
Most common complication of infantile hemangioma?
Ulceration
What’s the difference between capillary malformation and Hemangioma?
Hemangioma
= tumour
rapid growth + resolve
Capillary
= vascular malformation
- growth w/ child + persist
When do you worry about acquired nevi?
ABCDE
- asymmetry
- irregular not sharp border
- colour (typically even pigment)
- diameter (>6mm= flag)
- evolution/change
1st line treatment for Vitiligo?
Strong topical steroids
White Eczema?
Pityriasis Alba
- usually summer
- (+) eczema hx
- hypo pigment
- fine white scale
Tx: steroid
Monomorphous punched out lesions w/ red base
Eczema Herpeticum
Eczema herpeticum treatment
*Confirm w/ Cx from lesions.
If unwell, < 1, poor PO= IV acyclovir.
If well, local, U?O and fluid ok= acyclovir x 10d
Saline compress help wound healing
Treatment for Warts?
- no tx
- destructive
*> salicylic acid
> cryotherapy
> curettage
> laser - duct tape
- others…
SJS-TEN Management?
- Admit
- Supportive
- R/O med, infection
- IVIG
+/- steroids
What’s drug hypersensitivity Syndrome?
Morbilliform drug eruption +
… fever/ lymph/ pharyngitis/ Eosino./ LFT
- Non IGE
- 3-10d after med
Tx: D/C drug
antihistamine
topical steroid
List complications of atopic dermatitis:
- infection
- pigmentary changes
- scarring or lichenification
- sleep deprivation
- bullying
- depression
What are patients with psoriasis at increased risk for:
- Psoriatic arthritis
- Metabolic syndrome
- Cardiovascular dx
Acne severity scale:
Mild= comedones +/- few inflammatory lesion
Mod= comedones + signif inflam lesion
Severe= persistent, scarring, nodular
Rock hard= firm, lobulated nodule that is blue-purple or flesh. Is benign growth of hair follicle. Name?
Pilomatricoma
Don’t resolve on own
Big, Soft, Deep= Soft blue-purple irregular nodule. Painful. At birth and grow w/ child. Does not regret.
Vascular malformation
Flesh coloured mobile nodule. May express substance
Epidermal Cyst
Yellow-orange plaque w/ no hair that has been present since birth.
Nevus Sebaceous
- abN sebaceous glands
- grow proportionately w/ child
- persists
- Sx removal if nodules (as risk CA)
Domed papule that bleeds and crusts often.
Pyogenic Granuloma.
- benign growth of blood vessel
- can regress
- histology confirm dx
thus curettage + excise
T or F: Incontinentia Pigmenti is X linked dominant?
True
T or F: irritant contact dermatitis involves butt creases
False
- inner, upper thigh, buttock but SPARE crease
Nutritional deficiency that can present as dermatitis?
Zinc deficiency
- Acrodermatitis enteropathica
- AR
- diarrhea
- perioral, aural, diaper dermatitis
- irritable
Tx: zinc supp
Seborrheic dermatitis won’t get better… R/O
LCH
- Langerhans Cell Histiocytosis
Neonatal lupus rash usually =?
“Racoon Face”
Discrete round scaly papule.
- from maternal (usually asymp.) antibodies
- +/- heart block
+/- cardiomyopathy
Term w/ OB trauma. Rock Hard nodule.
Subcutaneous Fat Necrosis.
Which do you have to check in BW for kids w/ subcutaneous fat necrosis?
Hypercalcemia
*check until lesion gone
