Dermatology Flashcards
1
Q
What does annular mean?
A
ring shaped
2
Q
What is a cyst?
A
a soft, raised, encapsulated lesion filled with semisolid or liquid contents
3
Q
What does herpetiform mean?
A
in a grouped configuration
4
Q
What is a lichenoid eruption?
A
Violaceous to purple, polygonal lesions that resemble those seen in lichen planus
5
Q
What are milia?
A
small, firm, white papules filled with keratin
6
Q
What is a morbilliform rash?
A
Generalized, small erthematous macules and/or papules that resemble lesions seen in measles
7
Q
What does nummular mean?
A
coin-shaped
8
Q
What is poikiloderma?
A
skin that displays variegated pigmentation, atrophy, and telangiectases
9
Q
What are polycyclic lesions?
A
a configuration of skin lesions formed from coalescing rings or incomplete rings
10
Q
What is pruritis?
A
itching
Predominant symptom of inflammatory skin diseases
Commonly associated with xerosis and aged skin
11
Q
What is a macule?
A
a flat, colored lesion, <2cm in diameter, nonpalpable
Not raised above the surface of the surrounding skin
12
Q
What is a patch?
A
Large, flat lesions with a color different from the surrounding skin
nonpalpable, > 2cm
13
Q
What is a papule?
A
a small, solid lesion, <0.5cm in diameter
Raised above the surface of the surrounding skin and thus palpable
14
Q
What is a nodule?
A
a larger, firm lesion raised above the surface of the surrounding skin and thus palpable
> 0.5 cm to 5.0cm
15
Q
What is a placque?
A
a large ( > 1cm ), flat-topped, raised lesion
Edges can be distinct or blend in with surrounding skin
16
Q
What is a vesicle?
A
a small, fluid filled lesion, < 0.5cm in diameter
Raised above the plane of surrounding skin
Fluid is often visible and the lesions are translucent
17
Q
What is a pustule?
A
a vesicle filled with leukocytes
pus filled
18
Q
What is a bulla?
A
A fluid-filled, raised, often translucent lesions > 0.5cm in diameter
19
Q
What is a wheal?
A
A raised, erythematous, edematous papule or placque
Usually represents a short lived vasodilation and vasopermeability
20
Q
What is telangiectasia?
A
A dilated, superficial blood vessel
21
Q
What is lichenification?
A
A distinctive thickening of the skin that is characterized by accentuated skin-fold markings
22
Q
What is a scale?
A
excessive accumulation of stratum corneum
23
Q
What is a crust?
A
dried exudate of body fluids that may be either yellow or red
24
Q
What is erosion?
A
Loss of epidermis without an associated loss of dermis
25
What is an ulcer?
loss of epidermis and at least a portion of the underlying dermis
26
What is excoriation?
linear, angular erosions that may be covered by crust and are caused by scratching
27
What is atrophy?
an acquired loss of substance
may appear as a depression with intact epidermis or as sites of shiny, delicate, wrinkled lesions
28
What clinical manifestations are different between Cellulitis, Erysipelas, and an Abscess?
Cellulitis occurs in the deeper dermis and SQ fat whereas Erysipelas occurs in the upper dermis and superficial lymphatics and an Abscess will occur in the upper and deeper dermis
Cellulitis develops over a period of days whereas Erysipelas occurs acutely
Cellulitis can be purulent or nonpurulent whereas Erysipelas is always nonpurulent
Cellulitis has less distinct borders whereas Erysipelas is clearly marked
29
What epidemiology is different between Cellulitis and Erysipelas?
Cellulitis typically occurs in middle aged and older adults whereas Erysipelas typically occurs in young children and older adults
30
What are the clinical manifestations of Cellulitis and Erysipelas?
```
Erythema
Edema
Warmth
Bacterial breach in skin
UNILATERAL
Lower extremities involved
```
31
What are the risk factors for Cellulitis, Erysipelas, and an abscess?
```
Pressure ulcers
Trauma
Eczema
Impetigo
Tinea
Radiation Therapy
Edema due lymphatic drainage or venous insufficiency
Obesity
Immunosuppression
```
32
What bacteria causes cellulitis?
Strep and Staph aureus including MRSA
33
What bacteria causes Erysipelas?
Strep and S. pyogenes
34
What are the complications associated with Cellulitis, Erysipelas, and an Abscess?
Necrotizing fascitis
Bacteremia and sepsis
Osteomyelitis
Septic Joint
35
What is Cellulitis and Erysipelas hard to distinguish from?
Gout
DVT
Venus stasis dermatitis
36
What is your first line treatment for Cellulitis?
Nonpurulent: IV Cefazolin or Ceftriaxone
PO Penicillin or Amoxicillin or Bactrim
Purulent: IV Vanco plus Ceftriaxone plus Metronidazole or Vanco plus Unasyn
PO Doxycycline plus amoxicillin or Clindamycin
37
If the patients Cellulitis is caused by MRSA, what would you treat it with?
IV Vanco if Nonpurulent
| PO Bactrim if purulent
38
How long should you treat Cellulitis with Antibiotics for?
7-10 days
Improvement should be seen within 24-48 hours
39
What do you use to treat Erysipelas?
IV Cefazolin or Ceftriaxone
PO Penicillin or Amoxicillin or Bactrim
IV Vanco if caused by MRSA
40
What bacteria causes an Abscess?
Staph aureus including MRSA
41
What are the clinical manifestations of an Abscess?
```
Edema
Warmth
Erythema
Bacterial breach in skin
PAINFUL
Fluctuant/soft/movable
Red/Erythematous nodule
Can occur with or without cellulitis
Has a hard surrounding
Regional adenopathy
Systemic toxicity such as fever and chills
Often occurs on neck, face, or buttocks
```
42
What is furuncle?
infection of the hair follicle that causes an abscess
43
What is a carbuncle?
multiple hair follicles are infected
44
How would you treat an abscess?
IV Vanco plus Ceftraxone plus Metronidazole or Vanco plus Unasyn
PO Doxycycline plus Amoxicillin or Clindamycin
PO Bactrim for MRSA
45
What is Impetigo?
contagious superficial bacterial infection
46
What is the difference between primary and secondary impetigo?
Primary is a direct bacterial invasion of normal skin and secondary occurs at sites of skin trauma
47
What is the most common form of impetigo?
Nonbullous
48
What is nonbullous impetigo?
Papules form vesicles surrounded by erythema that then form pustules the enlarge, breakdown, and form thick adherent golden crusts
49
What is bullous impetigo?
Vesicles enlarge to form bulla with clear fluid that then become darker and rupture to leave thin brown crusts
50
What is bullous impetigo caused by?
S. aureus
51
Who and where does bullous impetigo effect?
Children and on the trunk
52
If you see what looks like bullous impetigo on an adult, what should you check them for?
HIV infection
53
What is ecthyma impetigo?
the ulcerative form of impetigo
Appear as punched out ulcers covered by yellow crusts
Lesions extend through epidermis and deep dermis
54
What is ecthyma impetigo caused by?
Strep pyogenes
55
What is sequelae impetigo?
Impetigo that occurs after 1-2 weeks of a strep infection
56
What are the clinical manifestations of sequelae impetigo?
Edema
HTN
Hematuria
Rheumatic fever
57
Who is impetigo most commonly seen in?
children ages 2-5
58
When is impetigo most commonly seen?
Summer and fall
59
Where is impetigo most commonly found?
Southeast US
60
How would you diagnose IMpetigo?
Honey colored, brown, or punched out crusty ulcers
Gram stain and culture
61
How would you treat mild impetigo?
Topical Mupirocin or Retapamulin
62
How would you treat severe and ecthyma impetigo?
PO Dicloxacillin or Cephalexin
63
What is Urticaria?
Hives
Welts
Wheals
Circumsized, raised, erythematous placques with central pallor
64
What are the clinical manifestations of Urticaria?
Intense itch
Can effect any area of the body
Lesions can be transient in nature
Lesions vary in size and shape
65
What is the severe form of urticaria?
Angioedema of lips, extremities, and genitals
66
What causes urticaria?
Caused by histamine and vasodilators being released by mast cells in the superficial epidermis
This is in response usually to something the patient is allergic to
67
What is the difference between acute and chronic urticaria?
Acute occurs for less than six weeks
| Chronic is recurrent most days of the week for more than 6 weeks
68
If you suspect that an allergy is the cause for a patients urticaria, what test could you do do diagnose this?
Serum test for allergen specific IgE anitbodies
69
What is the treatment plan for patients with urticaria?
Relieve the pruritis and angioedema because the lesions will resolve on their own typically
Use first or second Gen. antihistamines:
Diphenhydramine or Ranitidine
A steroid may be used if the patients symptoms are longer than 2-3 days or are severe
Angioedema requires immediate treatment with PO or IV prednisone
70
What is a lipoma?
Benign soft-tissue neoplasm
71
What are the clinical manifestations of a lipoma?
Contains mature fat cells enclosed in thin fibrous capsule
Superficial
Soft and painless SQ nodule
Round, oval, multilobulated
72
Where does a lipoma typically occur?
upper extremities and trunk
73
How large is a lipoma?
1 to > 10 cm
74
Where do 50% of lipomas develop?
SQ tissue
75
What is the treatment for a lipoma?
None if stable and asymptomatic
Surgical excision can be done if necessary
76
What is tetanus?
Nervous system disorder characterized by muscle spasms
77
What is tetanus caused by?
C. Tetani
78
What are the clinical manifestations of Tetanus?
Trismus (lockjaw)
Masseter muscle reflex pasms
Tonic contractions of skeletal muscles
No consciousness impairment
79
What is the incubation period for Tetanus?
8 days but depends on how far from the CNS the inoculation site is
80
What is the pathophysiology behind Tetanus?
C. tetani turns into vegetative rod-shaped bacterium-->
Produces metalloprotease tetanospasmin (tetanus toxin)-->
Toxin blockes neurotransmission that modulates muscle contraction
81
What is the treatment for tetanus?
```
IV Metronidazole
Pen G
Diazepam - for muscle contractions
Midazolam - paralyze patient if severe
Pancuronium or Vecuronium
IM Human tetanus immune globulin
Wound debridement
```
82
What are the clinical manifestations of an epidermal inclusion cyst?
```
Skin colored dermal nodule
Visible central punctum
Size can vary but usually smal
Lesions may be stable or get bigger
Spontaneous rupture can occur
Cheesy material comes out of it
Firm nodule
Asymptomatic
```
83
What disease are Epidermal Inclusion cysts associated with?
Gardener syndrome
84
Where do epidermal inclusions cysts most commonly occur and who do they occur in?
Face, neck, scalp, and trunk
Twice as common in men
Near hair follicle
85
What causes an epidermal inclusion cyst?
Result of trauma that causes implantation and proliferation of epithelial elements in the dermis
86
What is the treatment for Epidermal inclusion cysts?
Excision if symptomatic
None if asymptomatic
Intralesional injections with triamcinolone
87
What do you use to distinguish Necrotizine fascitis from cellulitis or an abscess?
LRINEC score
88
What score is associated with necrotizing fascitis?
> 6
89
What is acne?
Most common cutaneous disorder effecting adolescents and young adults
Inflammatory disease of pilosebaceous follicles
NO cure
90
What type of acne are women most prone to?
post-adolescent acne
91
What type of acne are men most prone to?
Adolescent acne
92
What are the four factors that cause acne?
1) Follicular hyperkeratinization
2) Increased Sebum Production
3) Cutibacterium acnes within follicle
4) Inflammation
93
What causes growth and secretory functions of sebaceous glands?
Androgens
94
What are some differential diagnoses of hyperandrogenism?
PCOS
Congenital adrenal hyperplasia
Adrenal or ovarian tumors
95
What is the onset of acne associated with?
Increase in DHEA-S levels as puberty hits
96
What are the four types of acne?
1) Inflammatory/Comedonal acne
2) Inflammatory lesions
3) Infant acne
4) Nodular acne
97
What are the causes of acne?
```
External factors
Medications
Diet
Family History
Stress
Insulin Resistance
BMI
```
98
What is the treatment for follicular hyperproliferation?
```
Topical Retinoids: Retin A
Oral Retinoid: Accutane
Azelaic acid
Salicylic acid
Hormonal therapies
```
99
What is the treatment for Increased sebum production?
Oral isotretinoin
| Hormonal therapies
100
What is the treatment for C. acnes proliferation?
Benzoyl peroxide
Topical or oral Doxycycline
Azelaic acid
101
What is the treatment for inflammation caused by acne?
Oral isotretinoin
Topical retinoids
Azelaic acid
102
Patients with what disease are prone to getting cellulitis?
Rosacea
103
What is Erythematotelangiectatic Rosacea?
```
Persistent central erythema
Flushing
Enlarged cutaneous blood vessels
Roughness and scaling
Skin sensitivity
Erythema congestivum
```
104
What is papulopustular rosacea?
Papules and pustules on central face
Mistaken for acne but this doesn't have comedomes
Inflammation extends beyond follicle
105
What is phymatous rosacea?
Thickened skin with irregular contours from tisue hypertrophy
Occurs most often on nose
Adult men
106
What is ocular rosacea?
```
Occurs in > 50% of pts. with disease
Can precede, follow, or occur simultaneously with other types of rosacea
Conjunctival hyperemia
Blepharitis
Keratitis
Lid margin telangiectasias
Abnormal tearing
chalazion
Hordeolum
```
107
Who does rosacea commonly occur in?
fair skinned individuals and adults over 30
| Mostly women
108
What causes rosacea?
Abnormalities in innate immunity
Inflammatory reactions to cutaneous microorganisms
UV damage
Vascular dysfunction
109
What are exacerbating factors of rosacea?
```
Exposure to extreme temps.
Sun
Hot beverages
Spicy food
Alcohol
Exercise
irritation from topical products
Emotions
Drugs
Skin barrier disruption
```
110
What is the treatment for Erythematotelangiectatic rosacea?
AVOID triggers
| Laser/light therapy
111
What is the treatment for Papulopustular rosacea?
Topical:
Metornidazole
Azelaic acid
Ivermectin
Oral:
Tetracycline, Doxycycline, or Minocycline
Isotretinoin
112
What is the treatment for ocular rosacea?
Lid scrubs
Warm compresses
Topical antibiotics like ilotycin
Refer to ophthalmologist
113
What is the treatment for phymatous rosacea?
Laser ablation and surgery
114
What is psoriasis?
inflammatory skin disease
Well-demarcated, erythematous placques with silver scales
Associated with psoriatic arthritis
115
What are the risk factors for psoriasis?
```
Genetics
Smoking
Obesity
Drugs
Infections
Alcohol
Vit. D deficiency
Stress
```
116
What is psoriasis caused by?
Immune mediated
Caused by hyperproliferation and abnomral differentiation of the epidermis, as well as, inflammatory cell infiltrates and vascular dilatation
117
What is chronic placque psoriasis?
Symetrically distributed
Found on scalp and extensor areas (elbows, knees, and gluteal cleft)
Itchy
118
What is the common type of psoriasis?
Chronic placque
119
What is Guttate placque psoriasis?
```
Abrupt
Multiple, small papules and placques
<1cm
Found on trunk and proximal extremities
Associated with recent strep infection
Children and young adult
```
120
What is Pustular Psoriasis?
```
LIFE THREATENING
SEVERE
acute onset
wide spread erythema, scaling, and sheets of superficial pustules
Malaise
Fevere
Diarrhea
Leukocytosis
Hypocalcemia
Can be caused by pregnancy, infection, and withdrawal of steroids
```
121
What is Erythrodermic psoriasis?
NON-LIFE THREATENING
uncommon
acute or chronic
Generalized erythema and scaling from head to tow
Caused by loss of adequate barrier electrolyte abnormalities
122
What is inverse psoriasis?
Found in intertriginous areas (inguinal, perineal, genital, axillary, etc. )
Can be misdiagnosed as a fungal or bacterial infection
123
What is nail psoriasis?
Seen after cutaneous type of psoriasis is diagnosed
Common in pts. with psoriatic arthritis
Nail pitting
124
How do you treat mild to moderate psoriasis?
```
Emollients
Topical Corticosteroids: hydrocortisone
Vitamin D analogs
Tar-T/Gel shampoo
Topical Retinoids
Anthralin
Tacrolimus or Pimecrolimus
```
125
How do you treat moderate to severe psoriasis?
Phototherapy in 25 treatments - usually UVB
Excimer laster in 10 treatments
Systemic therapies: Methotrexate
Biologics: Entanercept
126
What is alopecia?
Immune mediated disorder that targets active hair follicles (anagen) causing nonscarring hair loss
127
What are the clinical manifestations of Alopecia?
Smooth, circular, discrete patches of complete hair loss
Develops over a period of 2-3 weeks
Occasional itching or burning
Can spread into bizarre patterns
Can involve any and all body hair but typically occurs on scalp
Onychorrhexis
128
What is alopecia areata?
discrete patches
129
What is alopecia totalis?
entire scalp
130
What is alopecia universalis?
Entire body
131
What causes alopecia?
T-cells cause inflammation which disrupts the normal hair cycle
Hair follicle is then prematurely inactivated
132
What are the risk factors for alopecia?
```
Genetic
Severe stress
Drugs and vaccines
Infections
Vitamin D deficiency
```
133
What diseases are associated with alopecia?
```
Lupus
Vitiligo
Atopic dermatitis
THYROID DISEASE
Allergic rhinitis
Psoriasis
Down Syndrome
Polyglandular autoimmune syndrome type 1
```
134
What are characteristic signs to look for to diagnose alopecia?
Exclamation point hair at margins
| Swarm of Bees pathology
135
How do you treat limited hair loss?
Topical or intralesional corticosteroids
136
How do you treat extensive alopecia?
Topical immunotherapy
Minoxidil
Systemic therapies
137
What are the clinical manifestations of Hidradenitis Suppurativa?
Axillae is most common site but occurs in other intertriginous areas also
Primary lesions is solitary, painful, and deep-seated inflammed nodule
Chronic disease causes sinus tracts and scarring
138
Who does Hidradenitis Suppurative most commonly effect?
Women from puberty to age 40
| Usually african american women
139
What causes Hidradenitis Suppurativa?
Caused by follicular occlusion, follicular rupture, and the associated immune response
Ductal keratinocyte proliferation --> ductal pluggin --> expansion --> Rupture and release of contents --> immune response stimulated --> sinus tracts
140
What are the risk factors for Hidradenitis Suppurativa?
```
Genetics = 40% with first degree relative
Mechanical stress
Obesity
Smoking
Hormones
Bacteria
Drugs
```
141
What do we use to diagnose the clinical stages of Hidradenitis Suppurativa?
Hurley Clinical Staging
142
What is Hurley Stage 1?
Abscess formation
143
What is Hurley Stage 2?
Recurrent abscess formation with sinus tract formation and scarring
144
What is Hurley Stage 3?
Diffuse involvement of multiple interconnected sinus tracts
145
How do we treat Hidradenitis Suppurativa?
```
Prevent it:
Avoid skin trauma
Stop smoking
Weight management
Antiseptics
Emollients
Manage comorbidities
```
146
How do we treat Hurley Stage 1 HIdradenitis Suppurativa?
Topical Clindamycin
Intralesional corticosteroid
Punch debridement
Chemical peel
147
How do we treat Hurley Stage 2 Hidradenitis Suppurativa?
```
Oral tetracyclines for several months
Clindamycin or Rifampin
Oral retinoids
Antiadrenergic therapies
Punch biopsy of fresh lesions
```
148
How do we treat Hurley Stage 3 Hidradenitis Suppurativa?
TNF alpha inhibitors
Systemic glucocoritcoids: Prednisone
Cyclosporine
Surgery
149
What causes Molluscum Contagiosum?
Poxvirus, MCV 1-4
150
Who does Molluscum Contagiosum commonly affect?
CHILDREN
Sexually active adults
Immunosuppressed
151
How is Molluscum Contagiosum transmitted?
Direct skin to skin contact
Pools
Gym equipment
Spread by autoinoculation
152
What does Molluscum Contagiosum look like?
Non-pruritic flesh colored, dome shaped papules
3-6 mm
Curd like material inside
153
Where can Molluscum Contagiosum appear?
Anywhere but usually face, trunk, extremities, and groin
| Anyplace that kids like to put their hands
154
What are the differential diagnoses for Molluscum contagiosum?
Warts
| Milia
155
How would you diagnose Molluscum Contagiosum?
Clinical exam and history
| Punch biopsy
156
What is the treatment plan for Molluscum Contagiosum?
None; it is self-limited and will resolve after a few months to a few years
Tell patient to avoid autoinoculation
Topical Cantharadin or Cryotherapy have been used to speed up the healing process by mildly irritating the papules
157
What causes warts (Verruca)?
HPV
158
What is Verruca Vulgaris?
Common wart
159
What is Verruca PLana?
flat wart
160
What is Verruca Plantaris?
plantar wart
161
What increased the risk of getting Verruca vulgaris?
frequent water exposure
162
Who are most likely to get Verruca Vulgaris?
Patients ages 5-20
163
Where are Verruca Vulgaris typically found?
Hands
Palms
Periungual
Nail folds
164
What does Verruca Vulgaris look like?
Papules with a rough grayish surface and skin like projections
Pinpoint size to > 1 cm
165
Who are Verruca Plana most common in?
Children and young adults
166
Where do Verruca Plana typically occur?
Groups on face, neck, wrists, and hands
167
What do Verruca Plana look like?
2-4mm flat topped, flesh colored papules
168
Where are Verruca PLantaris found?
anywhere on the sole of the foot where there are usually pressure points
169
How do you diagnose Verruca?
Clinical exam or punch biopsy
170
How are Verruca treated?
65% will regress spontaneously within 2 years so they aren't typically treated
If they are extensive, causing issues, or not gone in 2 years they can be treated with:
Cryotherapy
Salicyclic Acid/Cantharadin
Occlusive Dressing
Intralesional injection of Bleomycin is only used in severe cases
171
What causes Tinea Versicolor?
Malassezia Furfur = a yeast
172
What does Tinea Versicolor look like?
Hypo or hyperpigmented macules that do not tan
Well defined, round macules with scaling on trunk, arms, or face
173
What is a differential diagnosis of Tinea Versicolor?
Vitiligo
174
How do you diagnose Tinea Versicolor?
KOH scraping --> spaghetti and meatballs (hyphae and spores) seen under microscopy
Wood's lamp --> Flourescent and orange or mustard colored
175
How do we treat Tinea Versicolor?
Daily Selenium sulfide shampoo for 15 min. for 7 days
Topical Ketoconazole cream daily for 3 weeks
Oral ketaconazole 200 mg daily for 2 weeks = severe cases and risk of elevated LFTs
176
What is Tinea Corporis caused by?
Dermatophytes
177
How does patient get Tinea Corporis?
comes in direct contact with organism
Often seen in wrestlers due to close contact
178
What does Tinea Corporis look like?
Annular with peripheral enlargement and central clearing
Scaly "active border"
Assymmetric disribution on face, trunk, and extremities
Pruritic
Papular, NOT flat
179
What is a differential diagnosis of Tinea Corporis?
Acute Lyme Disease --> this isn't scaly though and looks more like a target
180
How do we diagnose Tinea Corporis?
Positive KOH
| Fungal cultures
181
How do we treat Tinea Corporis?
Topical Antifungals:
| Naftin or Ketoconazole cream twice a day for 2 weeks
182
What does Tinea Pedis look like?
Scale and maceration on toe web spaces
Moccasin type distribution on plantar surfaces
Distinct borders
Pruritic feet
Inflammation and fissures can occur
183
How do we diagnose Tinea pedis?
Positive KOH
| Fungal culture
184
What is the treatment for Tinea pedis?
Keep feet dry
Zeasorb-AF (Miconazole) powder
Topical antifungal creams twice a day:
Naftin
Ketoconazole
Lotrimine
Lostrisone cream once a week if severe (steroid + antifungal)
185
What is causes Vitiligo?
Auto-immune destruction of melanocytes
Idiopathic
186
What are the signs/symptoms of Vitiligo?
Hypopigmentation macules
Focal or generalized pattern
Hair in vitiliginous areas can also become white
Seen in areas with microscopic trauma
187
How do you diagnose Vitiligo?
Clinical exam
Punch biopsy
Woods lamp --> Milky white appearance
188
How do you treat Vitiligo?
Sunscreen/avoiding sun exposure
Cosmetic coverups
Non-steroidal anti-inflammatory medications:
tacrolimus ( Protopic)
Pimecrolimus (Elidel)
Phototherapy:
UVB
Exciser laser
189
What causes Varicella (chickenpox)?
Varicella Zoster Virus
190
Who does Varicella most commonly occur in?
Children < 10
In tropical areas = teenagers
191
What is the incubation period for Varicella?
10-21 days
192
How is Varicella transmitted?
Direct contact with lesion
Respiratory route
193
How long is the patient infectious for with Varicella?
4 days before and 5 days after lesions appear
Once lesions are crusted over, they are no longer infectious
194
What are the clinical manifestations of Varicella?
Rash
Malaise
Low grade temp.
Faint macules that change to Teardrop vesicles on a erythematous base
Appears on extremities
Vesicles are first pruritic, then pustular, then crusted; all phases can appear
195
What complications can occur from Varicella?
Staph or strep infection from opening the lesions
196
What are adults who get Varicella at risk for?
Pneumonia
197
How do we diagnose Varicella?
Clinical exam
| TZANK SMEAR from vesicle --> multinucleated giant cells
198
How do we treat Varicella?
In healthy children < 13:
Supportive care like oatmeal baths, calamine lotion and antihistamines
AVOID ASPIRIN in any age group that has this disease
Immunocompetent adult > 13:
Oral Acyclovir within 24 hrs. for 5 days
Immunocompromised:
IV Acyclovir
Immunization
199
What is Herpes Zoster?
shingles
Reactivation of Varicella Zoster Virus
200
Where does Varicella Zoster Virus like to hide in the body?
Sensory dorsal root ganglion
201
What does the rash in Herpes Zoster correspond to?
Dermatomes
202
Who most commonly get Herpes Zoster?
patients older than 50
203
How do patients spread the virus?
Through direct contact only
204
What are the clinical manifestations of Herpes Zoster?
Prodrome of pain followed by rash along affected Dermatome
Pain feels like burning, electrical, or throbbing
UNILATERAL lesions
Papules and placques of erythema develop into vesicles which can become hemorrhagic or bullous
205
When do lesions typically appear in Herpes Zoster?
1-5 days after reactivation
206
How long do lesions usually last in Herpes Zoster?
2-3 weeks
Up to 6 weeks in the elderly
207
What sign is a red flag in Herpes Zoster patients?
Hutchinson's Sign:
Lesions on the side and tip of the nose
GET OPTHALMIC CONSULT immediately
208
What are the differential diagnoses of Herpes Zoster?
There are many if lesions have not appeared and patient only comes in with a chief complaint of pain
209
How do we diagnose Herpes Zoster?
Clinical exam is fine once lesions appear
TZANK SMEAR if not
210
How do we treat Herpes Zoster?
Antiviral Therapy within 3-4 days:
Valacyclovir or Famiciclovir for 7 days
Prednisone
Domboro solution
Pain management:
Aceteminophen or NSAIDS --> NO ASPIRIN
Narcotics
Lidoderm patch
211
How do we prevent Herpes Zoster?
Zostervax vaccine in patients over 60
212
What is a complication of Herpes Zoster?
Post herpetic neuralgia
213
How is herpetic neuralgia treated?
Nertontin
Tricyclic antidepressants
Gabapentin
214
Where does HSV-1 reside and what type of herpes simplex is it associated with?
Trigeminal ganglia
Oro-labial herpes
215
Where does HSV-2 reside and what type of herpes simplex is it associated with?
Presacral ganglia
Genital herpes
216
How is Herpes Simplex transmitted?
By direct contact with infected secretions:
Sexual intercourse
Autoinoculation --> Herpetic Whitlow
Vertical from mother to baby
217
What is the incubation period for Herpes Simplex?
2-20 days after exposure
218
How long is a patient with Herpes Simplex infectious for?
Lifelong infection that can come back again and again
219
What are the triggers for latent infections of Herpes Simplex?
```
Stress
Menses
Fever
Infection
Sunlight
```
220
Who is at an increased risk of getting Herpes Simplex?
Those with increased number of sexual partners
| Those whose first intercourse was at a young age
221
What are the clinical manifestations of Herpes Simplex?
Primary infections are asymptomatic usually
Fever
Myalgias
Malaise
222
What does Oro-labial herpes Simplex present as?
Tender grouped vesicles/blisters on erythematous base
ULcerative
"cold sore"
Last 1-2 weeks
Reoccurence present with tingling/itching before breakout
223
What does Genital Herpes Simplex present as?
Grouped blisters and erosions on vagina, rectum, or penis
1-2 weeks
224
What does Herpetic Whitlow Herpes Simplex present as?
Occurs on fingers and periungually
| Tenderness and erythema with deep seated blisters
225
How do you diagnose Herpes Simplex?
TZANK SMEAR --> Giant nucleated cells seen
Fluroescent anitbody test/Western blot --> HSV-1 vs. HSV-2
226
What is the treatment for Herpes Simplex?
No cure; decrease duration of symptoms, viral shedding, and time to health
227
What is the primary treatment for Herpes Simplex?
Acyclovir 200mg five times a day for 10 days
Valacyclovir (Valtrex) 1 gm twice a day for 10 days***
228
What is the Suppressive treatment for Herpes Simplex?
Acyclovir 400 mg twice a day
| Valtrex 1 gr. daily
229
What is the Recurrent treatment for Herpes Simplex?
Acyclovir 400mg three times a day for 5 days
Valtrex 2gm. twice a day for 1 day
230
What is Paronychia?
Inflammatory reaction involving the folds of the skin around the fingernail
Can be acute or chronic
231
What causes Paronychia?
A break in the skin associated with trauma to the eponychium or nail fold maceration of the proximal nail fold
232
What causes Acute Paronychia?
Agressive manicure
Nail biting
Staph aureus/Gram +
233
What causes Chronic Paronychia?
Frequent handwashing
Nail biting
Pseudomonas aeuginosa or Candida albicans
234
What are the clinical manifestations of Acute Paronychia?
Erythema
Swelling
Pain extending to the proximal and lateral nail fold
Starts red, warm, and painful swelling of skin around nail and then progresses to formation of pus that may separate the skin from the nail
235
What are the clinical manifestations of Chronic Paronychia?
Swollen
Erythematous
Tender without fluctuance
Nail can become thickened with transverse ridges
Occurs for > 6 weeks
236
What is the differential diagnosis of Paronychia?
Herpetic Whitlow
237
How do we diagnose Paronychia?
Fluctuant is usually bacterial so Culture and gram stain
KOH wet mount --> hyphae if acute and yeast if chronic
Clinical history and exam
238
What is the treatment for Acute Paronychia?
Warm water soaks 3-4 times a day
PO antibiotic for Gram + staph aureus:
Augmentin 2gr. per day for 5 days
Topical steroid cream
Incision and drainage if it becomes abscessed
239
What is the treatment for Chronic Paronychia?
Avoid inciting factors like moisture and manicuring
Warm soaks
Topical steroid cream
Antifungal:
Spectazole
240
What is onychomycosis?
Infection of finger or toe nails by yeast or fungi
241
Who is onychomycosis most common in?
Patients with other nail problems like nail trauma, immunocompromised, vascular insufficiency and Down syndrome
242
What agent causes onychomycosis of the hands?
T. Mentagrophytes
243
What agent causes onychomycosis of the feet?
C. albicans
244
What are the clinical manifestations of onychomycosis?
Nail thickening
Subungual hyperkeratosis = scale build up
Nail dystrophy
Onycholysis = nail plate elevation from nail bed
Asymptomatic
245
How do we diagnose Onychomycosis?
Positive KOH
Fungal/yeast culture
246
How do we treat Onychomycosis?
Very difficult to treat and there aren't a lot of options that are effective
Topical Agents:
Penlac Lacquer (Ciclopirox) solution
Jublia (Efinaconazole) solution
Lamisil 250 for 6-12 weeks is a PO med but the cure rate is <40% and you must check LFTs before, during, and after use
White vinegar soaks
247
What are Eczematous Eruptions?
Dermatitis and Eczema
Family of superficial, pruritic, erythematous skin lesions that can be red, blistering, oozing, or thickened skin
248
What is the most common type of Eczema?
Atopic Dermatitis
5-10% of the population has it
249
What type of reaction is Atopic Dermatitis?
Type 1 IgE mediated hypersenstivity reaction
250
What other diseases do patients with Atopic Dermatitis usually also have?
Asthma or allergic rhinitis
251
What are the Clinical Manifestations of Atopic Dermatitis?
"the itch that rashes"
```
Occurs on FLEXOR surfaces:
Neck
Eyelids
Face
Dorsum of hands and feet
```
Papules or plaques
Edema
Erosion
With or without scales or crusting
Persistent dry skin
Dennie Morgan lines
Hyperlinear palmar creases
252
What is Atopic Dermatitis characterized by?
Pruritis
Flexural lichenification
Occurs in infancy on face and extensor surfaces
Personal or family history of allergic rhinitis, asthma, or atopic dermatitis
Skin is inflamed, not dry
253
What can exacerbate Atopic Dermatitis?
Foods
Alcohol
Cold/hot/humid weather
Mites
254
What histology is seen in Atopic Dermatitis?
varies with stage of lesion
Older lesions:
Hyperkeratosis
Acanthosis = epidermal thickening
Excoriation
Staph colonization
Eosinophil deposition
255
What is infantile atopic dermatitis?
presents in first year of life
Appears on cheeks, chest, neck, and extensor/flexor extremities
Eruption can be generalized
Scaly, red, occassionally oozing lesions
Symmetric
256
What is adult/adolescent atopic dermatitis?
```
Will be seen more on flexor surfaces than extensors:
Hands
Wrist
Ankle
Feet
Nape of Neck
Eyelids
Vulva
Scrotum
```
Lichenified plaques are not as marked
Typically blends into surrounding skin
Post-inflammatory hyper/hypo pigmented changes occur
257
What are the differential diagnoses of Atopic Dermatitis?
Contact Dermatitis
Scabies
Psoriasis
258
How do we treat Atopic Dermatitis?
Topical Steroids for shorter period
High potency:
Betamethasone dipropionate
Clobetasol
Low potency:
Desonide
Dexamethasone
Antihistamines for itch:
Atarax (Hydroxasine)
Zyrtec (Cetrizine)
Topical Immunomodulators:
Tacrolimus (protopic)
Pimecrolimus (elidel)
Nonsteroidal:
Crisaborole (Eucrisa)
Biologic:
Dupilumab (Dupixent) --> SQ injection every 2 weeks
PO antibiotics:
Keflex (cephalexin) 500mg every day for 10 days --> secondary staph infection
259
What are the clinical manifestations of Nummular Eczema?
Coin shaped pruritic plaques and patches
Occur in clusters
Atopic pts.
Clear central space
Healing lesions display post-inflammatory hyperpigmentation
260
Where does Nummular Eczema usually occur?
Lesions on legs
261
How is Nummular Eczema diagnosed?
Clinical appearance
Negative KOH
262
What are the differential diagnoses of Nummular Eczema?
Tinea corporis
Positive KOH or fungal culture
263
How do we treat Nummular Eczema?
Acute:
Intermediate strength topical steroid --> Triamcinolone cream 0.1%
Severe --> high potency Clobetasol ointment with or without occlusion
Long-term:
Less potent topical steroid
264
What is Dyshydrosis?
Wet eczema
265
What causes Dyshydrosis?
Lesions occur from inflammation and foci of intercellular edema which becomes loculated in the skin of the palm and soles
266
What are the clinical manifestations of Dyshydrosis?
Small vesicles
Appear on hands and feet
Pruritis
267
How do we treat Dyshydrosis?
Cetaphil --> mild cleanser
Emollient barrier creams, protective gloves, and avoidance of irritants
Burrow's solution as an antibacterial astringent
Topical corticosteroids:
High --> Clobetasol Ointment for acute flare
Moderate --> Triamcinolone 0.1% or Fluocinoide 0.05% with or without occlusion
Protopic and Elidel for long-term management
268
What is contact dermatitis?
Applies to acute or chronic inflammatory reactions to substances that come in contact with the skin
269
What is Irritant Contact Dermatitis caused by?
Direct toxic reaction to rubbing, friction, maceration, or exposure to a chemical or thermal agent
270
What types of irritants can cause irritant contact dermatitis?
Alkalis
Acids
Soaps
Detergents
Diaper Rash
271
What are the clinical manifestations of Irritant Contact Dermatitis?
Erythematous
Scaly
Eczematous Eruption
272
How do we treat Irritant Contact Dermatitis?
avoid offending agent
273
What causes Allergic Contact Dermatitis?
Type IV Delayed Hypersensitivity reaction after an exposure to an allergic substance such as poison ivy, nickel, or chemicals
274
How long does it take before symptoms of allergic contact dermatitis appear?
a few days
275
What are the clinical manifestations of allergic contact dermatitis?
Well demarcated, linear, pruritic rash at site of contact
Itching/burning
Poison Ivy --> linear streaks of Juicy papules and vesicles
276
What is the differential diagnosis of Allergic Contact dermatitis?
Herpes Zoster
277
How do we treat Allergic Contact Dermatitis?
Remove the offending agent
Cool showers
Burrow's solution
Potent or super potent topical steroids
Severe cases may warrant a systemic steroid
278
What are the clinical manifestations of diaper dermatitis?
Erythema
Scaley papules and plaques
Neglecting the rash causes erosion and ulceration
279
What is diaper dermatitis caused by?
Overhydration of the skin
Skin is then irritated by chafing, soaps, and prolonged contact with urine and feces
280
What does diaper dermatitis spare?
The creases where the diaper doesn't make contact with the skin
281
What is the differential diagnosis for Diaper Dermatitis?
Candida albicans infection --> This is more beefy red
282
How do we treat Diaper Dermatitis?
Zinc oxide ointment
Frequent diaper changes
OTC hydrocortisone cream
Air it out
283
Who does Perioral Dermatitis typically occur in?
Young women and children
284
Where does Perioral Dermatitis typically occur?
Around the mouth
285
What does Perioral Dermatitis look like?
Clustered papulopustules on erythematous bases
May have scales
286
How do we treat Perioral Dermatitis?
Topical Antibiotics:
Metronidazole
Erythromycin
If severe use PO:
Minocyclin or Doxycycline
Avoid topical steroids
287
What causes Stasis Dermatitis?
Venous insufficiency
Incompetent valves --> decreased venous return --> increased hydrostatic pressure --> edema --> tissue hypoxia
288
Where is Stasis Dermatitis usually seen?
lower legs
289
Who is Stasis Dermatitis usually seen in?
women with genetic predisposition to varicosities
290
What are the clinical manifestations of Stasis Dermatitis?
Erythematous scale develops into erythema, edema, erosions, crusts, and secondary infections
Erythema will change to hyperpigmented skin that is thick with a WOODY appearance
Can develop ulcers
291
How do we treat Stasis Dermatitis?
Elastic compression stockings
Burrow's solution
Moderate Topical Steroid --> Desonide ro Triamcinolone cream
Use Keflex to treat secondary infection
292
What is Seborrheic Dermatitis caused by?
Yeast, P. ovale
293
Where is Seborrheic Dermatitis distributed?
Scalp
Face
Body folds
Areas where there are a lot of sebaceous glands
294
What are the clinical manifestations of Seborrheic Dermatitis?
Pruritic
Yellowish Gray
Scaly macules
Greasy look on body folds, face, and scalp
Cradle cap in infants
Dandruff in adults
295
How do we treat Seborrheic Dermatitis?
Scalp:
Zinc shampoo
Ketoconazole shampoo
Face and Intertriginous areas:
Low potency topical steroids --> Desonide or Valisone Cream
296
What are the clinical manifestations of Lichen Simplex Chronicus?
Chronic
Solitary
Pruritic
Eczematous Eruption
Caused by repetitive rubbing and scratching
Focal lichenification placque or multiple plaques
Hemosiderin staining
297
Where is Lichen Simplex Chronicus usually distributed?
Nape of Neck
Vulvae
Scrotum
Wrists
Extensor forearms
Ankles - pretibial area
Groin
298
What are the differential diagnoses of Lichen Simplex Chronicus?
Tinea Cruruls
Candidiasis
Inverse Psoriasis
299
How do we treat Lichen Simplex Chronicus?
Intermediate strength topical steroid --> Triamcinolone cream 0.1% PRN
Occlusion when able
Oral antihistamines
Protopic or Elidel 1%
300
What areas does Lichen Planus effect?
Skin
Mucous Membranes
Hair follicles
Flexor aspects of wrists, lumbar area, eyelids, shins, and scalp
301
What are the 4 P's of Lichen Planus?
Purple
Polygonal
Pruritic
Papule
Lesions
302
What are the clinical manifestations of Lichen Planus?
The 4 P's
Lesions are groups together
Reticular white lesions on buccal mucosa
Variations can be ulcerative
303
How do we treat Lichen Planus?
Potent topical steroids with occlusion
| Intralesional steroid injections
304
What else is Seborrheic Keratosis called?
Senile Wart
| Basal Cell Papilloma
305
Who does Seborrheic Keratosis usually occur in?
adults over the age of 60
306
What are the clinical manifestations of Seborrheic Keratosis?
"stuck on", flat or raised papule or plaque 1 to several cm in diameter
White, flesh-colored to tan, brown, warty, or smooth
May look like a barnacle on lower extremities
They start flat and then become raised
307
What is the treatment for Seborrheic Keratosis?
Nothing
308
What causes Kaposi Sarcoma?
Genetic factors
Hormonal factors
Immunodeficiency
Infection with HHV-8
309
What are the types of Kaposi Sarcoma?
Classic
HIV-associated
Endemic/African
Iatrogenic Immune Suppressed
310
Which type of Kaposi Sarcoma is aggresive and patient usually dies within 2 years?
Endemic/African type
311
What are the clinical manifestations of Kaposi Sarcoma?
Lesions start as red to purplish macules that then become infiltrative plaques and nodules or tumors
Lesions occur on mucous membranes or skin
Lesions are often found on lower extremities first and then on hands and arms much later
Lymphedema
Lesions start out painless and small but then become large and ulcerative
312
What would you see histologically in the early stage of Kaposi Sarcoma?
Endothelial cells of capillaries are large and protrude into the lumen like buds
Capillaries will become blocked and dilated
313
What would you see histologically in the late stage of Kaposi Sarcoma?
Proliferation of vessels around preexisting vesicles and adnexal structures
Capillaries become very large and protrude into the skin
314
What is the treatment for Kaposi Sarcoma?
```
HIV antiretroviral treatment
Radiation therapy
Cryotherapy
Surgical excision of individual nodules
Topical Alitretinoin (panretin) gel
Pulsed dye laser
```
315
What is actinic keratosis?
In situ dysplasia resulting from UV radiation that may progress to squamous cell carcinoma
316
What is the most common UV radiation to cause actinic keratosis?
UVA because it penetrates deeper and longer
317
Who is most effected by actinic keratosis?
White skinned
Men more than women
>50
Those who lead an outdoor lifestyle
318
What does the epidermis look like in patients with actinic keratosis?
Cellular atypia
Hyperkeratosis
Inflammatory infiltrate
319
What are the clinical manifestations of actinic keratosis?
Rough, "sandpaper" texture of lesions when felt
```
Lesions found in areas chronically exposed to the skin:
Face
Ears
Scalp
Dorsal hands
Forearms
Anterior legs
```
Multiple, discreet, flat or elevated verrucuous or keratotic, red, pigmented or skin colored lesions
Lesions may have a scale or can be smooth and shiny
3mm-2cm
320
What are the differential diagnoses for actinic keratosis?
Basal cell carcinoma
Seborrheic keratosis
Squamous cell carcinoma
Lupus Erythematosus
321
What is the treatment for actinic keratosis?
Cryotherapy--> be careful of bleaching of skin
Topical Medications:
Imiquimod 5%, 3X a week for one month or 3.75% daily for 2 weeks on and 2 weeks off for 2 months--> extenisve and broad lesions; causes erythema and crusting of skin
Ingenol Mebutate (Picato) --> Daily for 3 days to face or 2 days to body
5-FU --> twice a day for four weeks; extremely irritating to the skin; insurance typically covers this
322
When should an actinic keratosis be biopsied?
If it is not responding to treatment
There is a possibility it might be SCC
323
What is the prognosis for actinic keratosis?
Good if patient listens to patient education, covers up in the sun, and continues to treat lesions
Should follow up every 2-6 months
324
What two skin cancers are subtypes of Nonmelanoma SKin cancers?
Basal Cell carcinoma and Squamous cell carcinoma
325
What is the most common form of all cancers?
Nonmelanoma Skin cancers
326
When do nonmelanoma skin cancers usually occur?
In patients over the age of 55
327
Which type of skin cancer makes up the majority of Nonmelanoma skin cancers?
Basal Cell Carcinoma
328
What is basal cell carcinoma?
An epithelial tumor of basal keratinocytes
329
Which type of nonmelanoma skin cancer has the lowest risk of metastasis?
basal cell carcinoma
330
What are the risk factors for basal cell carcinoma?
Having white skin
Living close to the equator
Patients > 40
Outdoor lifestyle
331
What increases a patients risk of getting basal cell carcinoma 10 fold?
Immunosuppression for organ transplant
332
What are the clinical manifestations of Basal cell carcinoma?
Patient will report a slowly enlarging lesion that doesn't heal and bleeds easily
May have a "rolled edge"
Pearly and translucent
Occurs mostly on face, hands, and neck
Flat, firm, pale area that is small, raised, pink, or red, translucent, pearly, and waxy and the area may bleed following minor injury
Runs a slow course and becomes ulcerative --> Rodent ulcer
333
What are the types of Basal Cell Carcinoma?
Nodular
Superficial
Morpheaform (sclerosing)
Pigmented
334
What is the most common type of basal cell carcinoma?
Nodular
335
What does nodule BCC look like?
waxy, pearly, semi-translucent nodules or papules with "rolled edge" forming around a central depression that may or may not be ulcerated, crusted, and bleeding
336
What does Superficial BCC look like?
Dry, scaly lesions, superfical flat growths
may be misdiagnosed as eczema or psoriasis
Edge shows a threadlike, raised border
337
What does morphaeform (sclerosing) BCC look like?
White, sclerotic plaque with telangiectasia
Scar like in appearance
338
What does pigmented BCC look like?
Similar to nodular but has brown or black pigmentation
339
What are the differential diagnoses of BCC?
```
SCC
Sebaceous hyperplasia
Actinic keratosis
Eczema
Psoriasis
```
340
How do we diagnose BCC?
biopsy which will show large, round or oval tumor islands within the dermis, often with an epidermal attachment
341
What is the treatment for BCC?
```
Surgical:
Electrodessication and Curettage
Cryosurgery
Excision with margins
Mohs Micrographic Surgery
```
Topical:
5% Imiquimod
5-FU
Radiation
342
What types of BCC is Electrodessication and Curettage used for?
superficial lesions on non-hair bearing areas
343
What is the gold standard treatment for BCC tumors greater than 2cm and on facial areas?
Mohs Micrographic Surgery
344
What types of BCC is Imiquimod and 5-FU used to treat?
superficial BCC
345
What are the risk factors for having squamous cell carcinoma?
> 50
Male
Light skinned
Tobacco and alcohol use
Living close to the equator
History of previous NMSC
Immunosuppression
HPV
Cehmical carcinogens like arsenic, tar, and polyaromatic hydrocarbons
346
What are the types of squamous cell carcinoma?
SCC in sity = Bowen's disease --> full thickness of epidermis
Invasive --> Penetrates in dermis
347
What are the clinical manifestations of Squamous cell carcinoma?
Begins at site of actinic keratosis
Superficial papules, plaques or nodules, discrete and hard arising form an indurated, round elevated base
Lesions become large and ulcerated over months
Lesions are initially covered by crust
Invades underlying tissues
348
What does lower lip SCC look like?
starts as actinic cheilitis then progresses to local thickening of keratosis, then firm nodule that may grow outward as sizable tumor
occurs in patients with a history of smoking
349
What does Periungal SCC look like?
Presents with signs of swelling, erythema, and localized pain
commonly on nail folds of hands, resembling a wart
likely related to HPV
350
What are the differential diagnoses of SCC?
Actinic keratosis
Eczematous rash/atopic dermatitis
351
How do we diagnose SCC?
Biopsy --> Presence of Keratin or "keratin pearls"
352
What is the treatment for SCC?
Excision
Mohs
Radiation
353
Once a patient is diagnosed with SCC, what is their follow up plan?
Annual skin checks
354
What is the most deadly cancer?
Melanoma
355
What is melanoma?
Skin cancer of the melanocyte
356
What are the risk factors for Melanoma?
MMRISK
```
M --> atypical moles
M --> > 50 common moles
R --> Red hair and freckles
I --> Inability to tan
S --> Sunburn; sever and blistering
K --> Kindred/family history; usually in first degree relative
```
357
What is the greatest risk factor for metastasis of Melanoma?
depth of invasion
358
What are the clinical manifestations of melanoma?
Macular or nodular
Color varies from white to non-pigmented to dark black, blue, or red
Lesions borders tend to be irregular
Growth is quick or slow
Distribution can be on non-sun exposed areas also
359
What method do we use to check pre-existing nevi for melanoma?
ABCD method
A --> Asymmetry
B --> Border is irregular
C --> Color is varied and nonsymmetric
D --> Diameter is greater than 6 mm
360
What are the types of Melanoma?
Superficial spreading
Lentigo maligna
Nodular
Acral-lentiginous
361
What is Superficial spreading melanoma?
Does not have tendency for sun damaged skin
Tendency to have multidiscoloartion including black, red, brown, blue, and white
Borders tend to be more sharply defined
362
What is Lentigo Maligna Melanoma?
Start as macular and flat then become nodular
Most common on sun-damaged skin
Insidious slow growth
363
What is nodular melanoma?
Arise without apparent radial growth phase
Primarily in sun exposed areas of head, neck, and trunk
Smooth and dome shaped
Friable and ulcerated and bleeding
Quickly invades deeply and has a higher rate of metastasis
364
What is acral-lentiginous melanoma?
Most common in darker skin types
Light brown uniform pigmentation initially
On palms, soles, or nail beds
Lesions become darker, nodular, and may ulcerate
Many times, there is a delay in diagnosis
Should be concerned for this if you see lesion is spilling through proximal nail fold
365
What is the staging system used for melanoma?
TNM system:
T --> tumor; 1-4 based on Breslow thickness
N --> Lymph nodes; 0-3 based on spread
M --> Metastasize
366
When does melanoma automatically become Stage III?
When there is any lymph node involvement
367
When does melanoma automatically become Stage IV?
When there is metastasis
368
What is Breslow thickness?
The total vertical height of the melanoma, from the very top granular layer to the area of deepest penetration in to the skin
Ocular micrometer used to measure the thickness of the excised tumor
369
How do we diagnose melanoma?
Excisional biopsy
Palpate lymph nodes
LDH
For stage IIIa --> chest xray
For Stage IIIB/C --> fine needle aspiration of lymph involvement
For Stage IV --> Consider abdominal or pelvic imaging or PET scan
370
What is the treatment for melanoma?
Surgery --> simple excision for early stage or wide local excision for primary melanoma
Radiation --> used after surgery
Chemotherapy --> advanced malignant melanoma; Dacarbazine and Temozolomide
Adjunct therapy:
Cytokines (Intergeron Alpha and IL-2)
371
What is the follow up plan for patients who survive melanoma?
Full skin check by dermatologist every 6 months for 2 years
Self-skin checks once a month
Sun protection
372
How is measles transmitted?
Respiratory droplets
373
What is the incubation period for measles?
9-12 days
374
How long does it take for measles to clear?
4-7 days
375
What are the prodrome symptoms?
3 C's:
COugh
Coryza
Conjunctivitis
376
What are the clinical manifestations of Measles?
Fever and then rash will appear
Rash starts as macular or morbilliform rash on anterior scalp and behind ears
By day 2-3, the rash spreads down the trunk to the extremities
Erythematous papules will coalesce
Includes palms and soles of hands and feet
Lesions will fade chronologically
Descending rash that takes days
377
What is the diagnosis for Measles?
KOPLICK spots
378
What are Koplick spots?
pathognomonic white papules 1mm on buccal mucosa and pharynx
379
What is the treatment for Measles?
Supprotive care
Prevention through vaccination
380
What is Rubella caused by?
Toga virus
381
How is Rubella spread?
Respiratory secretions
382
What is the incubation period for Rubella?
12-23 days
383
Is there prodrome with Rubella?
No
384
What are the clinical manifestations of Rubella?
1-5 days of fever, malaise, sore throat, and headache
Pain with lateral upward eye movement
Posterior cervical, suboccipital, and postauricular Lymphadenopathy
Lesions are pale, pink morbilliform macules smaller than rubeola
Rash will begin on face and spread inferiorly covering the entire body within 24 hours
Forschemier's Sign
385
How long does it take for the rash to resolve?
Day 3
386
What is the Forschemier's Sign?
Petechiae on soft palate and uvula
387
What is the treatment for Rubella?
Supportive Care
Prevention with MMR vaccine
388
What is Fifth Disease (Erythema Infectiosum) caused by?
parovirus
389
How is Fifth Disease spread?
Respiratory droplets
390
When does Fifth disease usually occur?
late winter and early spring
391
When does viral shedding stop in Fifths disease?
by the time the rash appears
392
What is the incubation period for Fifth Disease?
4-14 days
393
What are the clinical manifestations of the 1st phase of Fifth Disease?
Abrupt asymptomatic erythema of cheeks that is diffuse and macular
SLAPPED CHEEK
394
What are the clinical manifestations of the 2nd phase of Fifth Disease?
By day 4, discrete erythematous macules and papules on proximal extremities and later the trunk
These will evolve into lacey reticular pattern by day 9
395
What are the clinical manifestations of the 3rd phase of Fifth Disease?
Eruption is reduced or invisible but will reoccur with exposure to heat or sunlight
396
What is the treatment for Fifth Disease?
Supportive Care
397
What is Pityriasis Rosea?
Acute, benign, self-limiting eruption
398
When is Pityriasis Rosea most common?
Spring/fall
399
What are the Clinical Manifestations of Pityriasis Rosea?
Herald patch
Over a period of 2 weeks, oval or elliptic erythematous patches with fine scale develop
Macular or papular lesions will develop on trunk, neck, extremities, and skin folds
Lesions will follow a christmas tree pattern
May be pruritic
May have prodrome of viral symptoms prior to rash
400
How long does Pityriasis Rosea last?
3-8 weeks
401
What is the treatment for Pityriasis Rosea?
Nothing, it resolves on its own
May prescribe antihistamines for the itching
402
What type of drug eruption is the most common?
Morbilliform
403
What drugs may cause morbilliform reactions?
Ampicillin
Amoxicillin
Bactrim
404
What is the pathogenesis behind morbilliform drugs reactions?
Type IV allergic reaction mediated by T-helper cells
405
What are the clinical manifestations of morbilliform drug reactions?
Erythema with macules and papules initially on trunk then generalizing within 2 days
Can present within first 2 weeks of exposure and up to 10 days after stopping
406
How do we treat morbilliform drug reactions?
Stop medication and it will clear within 2 weeks
Symptomatic relief like antihistamines or low potency topical steroids may be needed
407
What drugs cause fixed drug reactions?
Anything taken intermittently:
NSAIDS
Sulfonamides
Barbituates
408
What are the clinical manifestations of Fixed drug reactions?
Round/oval erythematous plaques that may be pruritic/burning or asymptomatic
Reoccur at same site with each exposure
Usually 6 or fewer lesions but often just 1
Can appear anywhere: commonly occurs on genitals or oral mucosa
Localized
409
What is the treatment for fixed drug reactions?
Antihistamines or topical steroids if symptomatic
410
What is Erythema Multiforme?
Self-limited eruption brought on by drug exposure, viral infections, or topical steroids
411
What are the clinical manifestations of Erythema Multiforme?
Lesions begin as macules and become papular, then vesicles and bullae form in the center of the papules
Localized to hands and feet or can become generalized
Mucosal lesions are painful and will erode
Fever and malaise may occur
Target like appearance
412
What is the treatment for Erythema Multiforme?
Avoid target substances
Severe reactions may require systemic steroids
413
What is SJS and TEN?
immune mediated, mucocutaneous, blistering drug reactions
414
What are the clinical manifestations of SJS and TEN?
Fever
Mucosal inflammation
Lesions begin on trunk and may be painful
TEN will exhibit a higher fever and more epidermal separation than SJS
415
What is the treatment for SJS and TEN?
Withdrawal of offending agent
Treatment at burn center for fluid and electrolyte imbalance
Wound care
Corticosteroid treatment
416
What type of disease is Bullous Pemphigoid?
autoimmune disease that causes separation of epidermis from dermis
417
What are the clinical manifestations of Bullous Pemphigoid?
Occurs in sixth decade of life
Prodrome of urticarial lesions
Bullae are large and may contain serous or hemorrhagic fluid
Occurs on axillae, thighs, groin, and abdomen
Usually self-limiting
Takes 5-6 years to resolve
418
How do we diagnose Bullous Pemphigoid?
Biopsy and Immunofluorescence
C3 will all be lined up on the epidermal-dermal junction
419
What are the Differential diagnoses of Bullous Pemphigoid?
Blistering Disease epidermolysis Bullosa acquista (EBA)
| Bullous Scabies eruption
420
What is the treatment for Bullous Pemphigoid?
Localized/LImited:
Potent topical corticosteroid --> Clobetasol ointment twice day with occlusion
Moderate/Severe:
Either Clobetasol or
Prednisone 0.5 to 0.75 mg/kg/day which should be tapered cautiously once remission is achieved
```
Immunosuppressive medications for patients who cannot tolerate steroids:
Azathioprine (Imuran)
MMF (CellCept)
Antibiotics
Tetracycline and Niacinamide combo
TCN or Doxy or Minocycline
Dapsone
Recalcitrant, IVIg, and plasmapheresis
```
421
What are the clinical manifestations of Pediculus Humanus Capitis?
LIce on scalp
Female louse can survive for more than 3 days off the human head
Presents with intense pruritis of the scalp with posterior cervical lymphadenopathy, excoriations, and small specks of louse dung on the scalp
Lice and nits may be present on hair shaft
422
What are the clinical manifestations of Pediculus Humanus corporis?
Lice feeds on body but infests clothing
Prefers cooler temps and will lay their eggs on fibers of clothing usually close to the seams
The adult female louse can survive as long as 10 days away from the human body without a blood meal
Associated with poor hygeine
Initially, small pruritic papules that progress due to scratching to crusted and infected papules
SPARES HANDS AND FEET
423
What are the clinical manifestations of Phthirus pubis?
Pubic lice/crabs
Less mobile and rest while attached to human hairs
They cannot survive off the human host for more than 1 day
Spread by close contact
Intense pruritis in affected area
Small blue macules can be present
424
What are the differential diagnoses of Pediculosis?
Scabies --> This won't spare hands and feet
Eczema
Delusions of parasitosis
425
What is the treatment for Pediculosis?
Topicals:
OTC Nix cream Rinse, RID action --> permethrin active ingredient; kills adult lice but not nits; repeat treatment in one week
Ovid lotion --> Most effective; kills both lice and nits; not for children < 6 months; apply to dry hair, sit for 8-12 hours then rinse
Elimite cream --> 5% permethrin; left on overnight; repeat in one weeks; not to be used in pregnant women
Bactrim
vaseline
426
What is the environmental eradication for Pediculosis?
Fomites should be washed in hot water and dried --> temps greater than 50-55C for at least 5 minutes
Seal potential fomites in plastic bags for at least 2 weeks so taht all the nits hatch and die without a blood meal
427
Who else should be treated for lice besides the patient infested?
Anyone in close contact with the patient like parents, siblings, etc.
428
What is Scabies caused by?
Infestation of Sarcoptes scabeie
429
What are the clinical manifestations of Scabies?
Pruritic lesions taht vary considerably from vesicles or papules, nodules located between web spaces of fingers, flexor aspects of wrists, axilla, antecubital area, abdomen, umbilicus, genital and gluteal areas and feet
Spares the face
BURROW is the pathognomonic of scabies
Likes warm areas
430
What does the Burrow in scabies look like?
Thin, short, gray brown, wavy channel on the skin
431
What is Crusted/Norwegian Scabies?
Seen in immunocompromised or debilitated patients
Crusts and scales teem with mites
Psoriasis like scaling around nails with crusting
Often misdiagnosed as psoriasis
Not very common
432
How do we diagnose Scabies?
History
Scraping
Biopsy
433
What are the differential diagnoses of Scabies?
Bite reaction
Atopic dermatitis
Delusions of parasitosis
434
How do we treat Scabies?
Topical Medications:
Permethrin 5% cream (Elimite) --> apply to all skin below the neck for 8-12 hours; repeat in one week
Lindane 1% lotion or cream (Kwell) --> More toxic and not for pregnant women or kids <2
Precipitated Sulfur ointment 6% --> Best for pregnancy or breastfeeding women; applied to all areas from the neck down and is washed off in 8-12 hours
Oral Medication:
Ivermectin (Stromectol) --> 200micrograms/kg/day for 2 days
After treatment --> bedding, clothing, and towels should be washed in hot water or removed for 72 hours; treat affected family members
435
What is the most common cause of necrotic arachnidism in the US?
Brown Recluse Spider Bite (Loxoscelism)
436
What are the clinical manifestations of Brown Recluse Spider Bite (Loxoscelism)?
Localized
Bite site becomes painful after 3 hours
Necrotic cutaneous loxoscelism, extensive necrosis develops with edema within 8 hours with bulla and surrounding erythema and ischemia that can extend to muscle
IN one week, central portion becomes gangrenous and dark
437
What is the treatment for Loxoscelism?
Rest, ice, and elevate site of bite
Analgesics
Tetanus prophylaxis
Surgical debridement
438
What are the characteristics of the Loxosceles Reclusa spider?
Most common in Midwest and southwest
Found in woodpiles, grass, and rocky bluffs and barns
Stings in self-defense
Identified by violin markings over cephalothorax and 3 sets of eyes
Light brown, 1 cm in length
439
What is the major toxin in Brown Recluse spider venom?
Sphingomyelinase
440
What are the characteristics of the Latrodectus mactans spider?
Found in continental US as well as Caribbean
Found in wood piles and outhouse seats
13mm long, shiny, black, with red hourglass shaped markings on abdomen
Long legs spread up to 4cm
Bites only when disturbed
441
What are the clinical manifestations of a Black Widow Spider bite (latrodectism)?
Locally limited to a small circle of redness around the immediate bite site
A central reddened fang puncture site surrounded by an area of blanching and an outer halo of redness is described as a target appearance
Systemically, pain/cramping within an hour that will spread to extremities and trunk
Tachycardia
Hypertension
Pulmonary edema
Fever
Chills
Vomiting
Violent cramps
Delirium or partial paralysis
Abdominal pain is most severe
442
How do we treat Latrodectism?
ACLS
Antivenom administered in the ER but there is a risk of allergic reaction
Analgesics like morphine
Antihistamine like benadryl
Tetanus
