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Dermatology Flashcards

1
Q

5 epithelial cell junctions

A

Tight J.: prevents paracell mvt of solutes
Adherens J.: cadherins (actin + E-cadherin)
Desmosome: keratin interactions (AutoAb: pemph vulg)
Gap J.: connexons permit electr/chemic communication
Hemidesmosome: keratin+basement mmbrn (AutoAb: bullous pemph)

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2
Q

Atopic dermatitis/eczema (RF, PE)

A

Chronic inflam/pruritus then lichenification
Fam Hx: asthma/eczema/allergic rhinitis
↑ risk of 2* skin infection (Staph aureus/HSV/molluscum)
Triggers: climate, food, skin irritants, allergens, emotions

Infants (face/scalp/extensor surf/NO diaper), children (flexor surf/neck), adults (flexor surf/eyelid/hand)

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3
Q

Eczema (dg, ttt)

A

dg: erythema toxicum neonatorom (d 1-3), benign, resolves in 1-2wks w/o ttt

Dg: clinical, KOH prep to r/o tinea
ttt: topical CS (#1), topical immunomodulator (>2yo, sparing CS)
CS intermittently to avoid skin atrophy
Skin care (↓ pruritus) + antihistamines

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4
Q

Contact dermatitis (PE, dg, ttt)

A

dg: latex allergy is a type I HS (not this)

Type IV HS / allergen (makeup/nickel/poison ivy/top AB)
Pruritus/rash (mimics the shape)
Spread to body: transfer of allergen (hands) or T lymphoc
Dg: clinical, patch test (after ttt of acute phase)
ttt: topical CS + allergen avoidance

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5
Q

Type I hypersensitivity

A

Anaphylactic and atopic
Ag cross-links IgE on presensit mast cells
Vasoactive amines (histamine) release
Fast

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6
Q

Type II hypersensitivity

A

Cytotoxic

IgM/IgG bind to Ag on bad cell: lysis by complement or phagocytosis

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7
Q

Type III hypersensitivity

A

Immune complex (Ag/Ab) activate complement, attract PMNs, release lysosomal enz
Serum sickness: Ab+foreign Ag deposit, fix to complement and damage tissue
Arthus reaction: Ab react to Ag, vascular necrosis/thrombosis

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8
Q

Type IV hypersensitivity

A

Delayed (cell-mediated)
Sensitized T lymphoc react to Ag, macroph activation
No Ab

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9
Q

Seborrheic dermatitis (PE, dg, ttt)

A

Chronic inflam / hypersensitivity to Malassezia furfur (in sebum/hair follicles)
Infants (diaper/scalp), children/adult (ears/eyebrows/nasolabial fold/midchest/scalp)
Severe in HIV/AIDS and Parkinson
Dg: clinical
ttt: selenium sulfide or zinc pyrithione shampoos (adult), topical antifungals +/- topical CS
Infant scalp resolves w/ bathing+emollients

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10
Q

Stasis dermatitis

A

Lower extremity, venous hyperTN by venous valve incompetence/flow obstruction
If unttt, inflam/exudation/hyperpigm
Stasis ulvers
ttt: early w/ leg elevation, compression stockings, emollients, topical steroids

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11
Q

Grouped vesicles + fever after eczema ttt w/ CS

A

Eczema herpeticum
Medical emergency
HSV infection spreads systemically (+ brain)
IV acyclovir immediately

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12
Q

Psoriasis (PE)

A

T-cell mediated infl
Dermal infl + epidermal hyperplasia (+ parakeratosis)
Extensor surf/scalp/lumbosacral/nails/pso arthritis (hands/feet)
Drugs that worsen (B-/lithium/ACEIs)

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13
Q

Psoriasis (dg, ttt)

A

Dg: clinical, Auspitz sign, biopsy (if uncertain)
ttt: topical steroids, calcipotriene (vitD), tazarotene (vitA)
Severe or w/ pso arthritis: methotrexate or antiTNF (etanercept/infliximab/adalimumab)
UV if extensive involv (CI in immunosuppressed)

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14
Q

Urticaria/hives (PE)

A

Histamine/prostaglandins from mast cells in type I HS
Superficial erythema/edema, acute/chronic (>6wks)
Dermal edema, may become confluent
Severe w/ extracut: tongue/angioedema/asthma/GI/joint/fever

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15
Q

Urticaria/hives (dg, ttt)

A

Trigger in acute: food/drug/virus/insect bite/sun/cold/heat
Idiopathic in chronic

Dg: clinical
ttt: systemic antihistamines
Anaphylaxis: epinephrine IM, antihistamines, IV fluids, airway!

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16
Q

Drug eruption (PE)

A

Mild morbilliform rash to life-threatening TEN
High suspicion in hospit ptts after 7-14d from drug expo
Any type of HS

Widespread eruption, symmetric, pruritic
Eosinophilia

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17
Q

Drug eruption (dg, ttt)

A

Disappear 1-2 wks of removal of drug
Dg: clinical, biopsy if unclear
ttt: stop drug, antihistamines + topical steroids

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18
Q

Erythema multiforme (PE, dg, ttt)

A 
Targetoid lesions, recurrent, +/- fever/myalgias/arthralgias/headache
Many triggers (HSV/mycoplasma)(Not drugs so #SJS)

Esp palms/soles
Major: skin + mucous membranes (#SJS)
Dg: clinical (Nikolsky sign neg)
ttt: just symptomatic

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19
Q

Stevens-Johnson sd / Toxic epidermal necrolysis (RF, PE)

A

Life-threatening exfoliative mucocutaneous ds
Often drug-induced immuno reaction
Epidermal separation: SJS <10%BSA, TEN >30%BSA

Severe mucosal erosions, widespread confluent erythem lesions; Nikolsky positive
Ass w/ sulfonamides, penicill, seizure meds, quinol, cephalosp, steroids, NSAIDs

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20
Q

Stevens-Johnson sd / Toxic epidermal necrolysis (dg, ttt)

A

SJS: degeneration of basal layer of epidermis
TEN: full-thickness eosinophilic epidermal necrosis
#dg: SSSS, GVHD, radiation therapy, burns

ttt: early dg + d/c drug
Thermoregul+e- disturb, 2* inf → cover skin + fluids/e-
Steroids? Cyclosporine? IVIG?

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21
Q

Erythema nodosum (etiologies, PE)

A

Panniculitis (infl of subcut adipose tissue)
Causes: inf, drug, chronic infl ds

Painful erythem nodules, ant shins, turn brown
+/- fever, joint pain
! false+ VDRL

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22
Q

Erythema nodosum (dg, ttt)

A

Dg: clinical + workup for underlying cause
ttt: underlying cause, NSAIDs/cool compresses, potassium iodide (if persistent)

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23
Q

Bullous pemphigoid

A

AutoAb ag. hemidesmosomal prot
Firm/stable blisters, Nikolsky neg, rare mucosal involv
Esp. >60yo, idiopath
Rare mortality
Dg: clinical +/- biopsy (w/ direct immunofluo)
ttt: steroids

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24
Q

Pemphigus vulgaris (etiologies, PE)

A 
AutoAb ag. desmoglein (intraepidermal)
Erosions, No keratinocyte adhesion
Nikolsky positive, common mucosal involv
Esp. 40-60yo
Ass w/ ACEIs/penicillamine/phenobarbital/penicillin
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25
Pemphigus vulgaris (dg, ttt)
Possible mortality Dg: clinical +/- biopsy (w/ direct immunofluo) ttt: high-dose steroids + immunomodulator (azathioprine, mycoph mofet, IVIG, rituximab)
26
Herpes simplex virus (PE)
Painful/recurrent/mucocutaneous/ +/- systemic sympt HSV-1 oral-labial; HSV-2 genital Direct contact→ 1* episode longer/severe→virus dormant in nerve gg Recurrences: cold sore (trigg by sun/fever); unilat genit herp ``` #dg: dermatitis herpetiformis (prurit papul/vesic/bull) elbow/knee/butt/neck/scalp ass w/ celiac ds ttt: dapsone + gluten-free ```
27
Herpes simplex virus (dg, ttt)
Dg: clinical, viral culture of lesion (accurate), direct fluores Ag (rapid) Multinucleated giant cells on Tzank smear AIDS-defin illness = symptom ulcers resist to antiviral >1mo ttt 1* episode: support ttt or acyclovir/famcyclovir (Icompet); antiviral in 72h of start (Icomprom or severe) ttt recurr: support (minor lesion) or acy/famcy/valacyclo to ↓ 2d ttt severe+fqt (>6/y): daily prophyl acy/famcy/valacyclo
28
Varicella-Zoster virus (PE)
Respiratory dropl/direct contact; incubation 10-20d Contagion 24h before eruption till crusted lesions Varicella: malaise/fever/headache/myalgia 24h before rash; pruritic lesions over 2-3d; crust; all stages at any time; adults more severe (+pneumonia/encephalitis) Trunk/face/scalp/mucous membranes Zoster: recurr of VZV in one nerve/dermatomal; intense pain then eruption; dissem in Icomprom; postherp neuralgia in older ptts.
29
Varicella-Zoster virus (dg, ttt)
Dg: clinical ttt: varicella self-lim (children) + vaccine available Adults: systemic acyclovir + pain control (gabap/TCA) Postexposure prophyl: rare (bcz ds/vacc in almost all). Icompetent adult: vaccine in 5d of expo Icomprom/pregnant/newborn: Ig in 10d of expo
30
Molluscum contagiosum
Poxvirus; esp children/AIDS Direct contact/sharing cloth Small flesh-colored papules, central umbilic, asymptom If giant: HIV or Icomprom Child (trunk/face); adult (genital/perineal); No palm/sole Dg: clinical; large inclusions on microsc ttt: curetting/freezing/trichloroacetic acid In kids, spontan resolution
31
Verrucae/Warts
HPV; benign or malignant (16/18) Direct contact; found on skin(hands)/mucous/epithelia Genital warts (condyloma acuminatum): HPV 6/11 Laryngeal warts in infants of affected women Dg: clinical; acetic acid for mucosal lesions (turn white); PCR of HPV (accurate) ttt: locally for genital W (cryoth/podophyllin/trichloroacetic acid/imiquimod/5-FU); monitor cervical lesions (! malign)
32
Impetigo (PE)
Inf of epidermis; esp child; direct contact By group A strep (complic by PSGN) or Staph Common type: pustul/crusts; face (mouth/nose/ears) Bullous type: bulla/crusts; acral; by Staph aureus, can evolve into SSSS
33
Impetigo (dg, ttt)
Dg: clinical ttt: Mild/local: topical AB (mupirocin) Severe (non-MRSA): oral cephalexin, dicloxacillin, erythromycin Severe + MRSA: oral TMP-SMX, clindamycin, doxycycline
34
Skin infections according to skin layers
``` Epidermis: impetigo Hair follicle: folliculitis Dermis: erysipelas, cellulitis Subcut fat: cellulitis, necrotizing fasciitis Fascia: necrotizing fasciitis Muscle: necrotizing fasciitis ```
35
Cellulitis (PE, dg)
Inf of dermis+subcut tissue; by damaged skin/systemic By staph or group A strep; communit-acqu MRSA RF: DM, IVDU, venous stasis, Icomprom Red, hot, swollen, tender skin +/- fever/chills Dg: clinical, cultures (dg+suscept) R/O abscess, osteomyelitis, necrotizing fasciitis
36
Cellulitis (ttt)
ttt: 5-10d oral AB IV if systemic toxic/comorbid/DM/extreme age/hand or orbital involv Mild/local: topical AB (mupirocin) Severe (non-MRSA): oral cephalexin, dicloxacillin, erythromycin Severe + MRSA: oral TMP-SMX, clindamycin, doxycycline
37
Erysipelas | Ludwig angina
Erysipelas: type of cellulitis; strep; dermis and lymphatics; raised indurated well-demarcated erythematous skin Ludwig angina: bilateral cellulitis of submental/submaxillary/sublingual; from infected tooth; dysphagia, drooling, fever, red warm mouth; death from asphyxiation
38
Scarlet fever | Salmonella typhi
Scarlet fever: sandpaper rash, strawberry tongue; Strep pyogenes; ttt Penicillin Salmonella typhi: small pink papules on trunk, groups 10-20, fever, GI sympt; ttt Fluoroquin and cephalo-3G Cholecystectomy for chronic carrier
39
Necrotizing fasciitis (PE)
Deep inf along fascia; Hx of trauma, recent surgery Mixed inf: anaerob + aerob bacteria (S aureus, E coli, Clostr perfring, Strep pyogenes) Severe acute pain/swelling then anesthesia; erythema; progression; purple near insult; necrosis Necrosis: crepitus (gas), putrid disch, bullae, severe pain
40
Necrotizing fasciitis (dg, ttt)
Dg: clinical exam + imaging ttt: surgical emergency (exploration + aggressive debridement, cultures) Broad-spectrum: peni G (if strep), clindamycin (↓ toxin); metronidazole or cephalo-3G (for anaerob) Fournier gangrene: necrot fasc localized to genital/perineal area
41
Folliculitis
Infl or inf of hair follicle If deeper: furuncle or hair follicle abscess Furuncle may dissemin to adj follicles: carbuncle RF: DM or Isuppression; eosinophilic folliculitis in AIDS Dg: clinical; KOH prep/biopsy if fungus or eosinophilic foll Pseudo aerug: hot tob folliculitis ttt: topical AB (mupirocin) for mild superf; oral cephalexin or cloxacillin if severe; clindamycin if MRSA
42
Acne vulgaris (PE)
Hormonal activ of sebaceous glds; Propionibacterium acnes Etiologies: medic (lithium/CS), occlusion (cosmetics) Puberty + several years 3 stages: comedonal (open/blackH; closed/whiteH); inflamm (comed rupture, papul/pust/nod/cyst); scar Severe cystic acne (esp male ado) Women 20s: cyclic flares, fewer comedones, esp chin
43
Acne vulgaris (dg, ttt)
Dg: clinical ttt: Mild/moderate: topical retinoids #1 (comed acne); topical benzoyl peroxide (kills Prop.acnes). If inadeq, add topical AB (clindamycin, erythromycin) Moderate-severe: topical ttt + oral AB (doxycycline, minocycline). If all fails, oral retinoids (isotretinoin) but stop all other ttt and OCPs + periodic check LFTs, choles, Tg
44
Pilonidal cysts (PE, RF)
Abscess in sacrococcygeal region/natal cleft Folliculitis → abscess→ inf (perineal bugs, Bacteroides) Esp 20-40yo male Tender, fluctuant, warm +/- purulent drainage, cellulitis RF: deep hairy natal cleft, obesity, sedentary
45
Pilonidal cysts (dg, ttt)
Dg: clinical ttt: incision + drainage then sterile packing of wound Local hygiene/shaving (prevents recurr) AB just if cellulitis (aerob + anaerob coverage)
46
Tinea versicolor
Malassezia furfur, yeast of normal skin flora RF that turns it pathogenic: humid, sweaty, oily skin, cushing sd, Isuppr Small scaly patches, pink/hypo/hyperpigm, chest/back Dg: clinical; KOH prep (spag+meatb) ttt: topical ketoconazole or selenium sulfide
47
Candidiasis (PE)
Any C, esp C albicans Icompet: superficial inf skin/mucous where moist (groin/skin folds/axillae/vagina/below breast) Infant/Isuppr: oral thrush; diaper (infants) Hx: AB, steroid, DM, Icompr Skin: erythem patches, small satellite lesions
48
Candidiasis (dg, ttt)
Dg: clinical; KOH prep (spores, pseudohyphae); culture (accurate) ttt: Oral inf: oral fluconazole, nystatin S/S, clotrimazole troch Superficial: topical antifung + clean/dry skin Diaper: topical nystatin
49
Dermatophyte infections
Tissues w/ keratin (skin, nails, hair) Trichophyton, Microsporum, Epidermophyton RF: DM, ↓periph circul, Icomprom, chronic maceration (athlete) Dg: clinical; KOH (hyphae); culture (accurate) ttt: topical antifungals; oral if spread/unresp T.capitis / Icompr: oral ttt to penetrate hair follicles
50
Dermatophyte infections (4 subtypes)
Tinea corporis: scaly pruritic, sharp irreg border, central clearing Tinea pedis/manuum: chronic interdig scaling or on soles Tinea cruris: groin Tinea capitis: scalp, scaling, hair loss; keroin (if large)
51
Lice (PE)
Live off blood; secrete toxins → severe pruritus Part dep on species: head, body, pubic Body contact; sharing cloth, hair access Inadeq hygiene, crowded living 2* bact inf (after pruritus, excoriation)
52
Lice (dg, ttt)
Dg: see lice or eggs on hair/cloth ttt: Head L or Pubic L: topical permethrin, pyrethrin, benzyl alcohol, mechanical removal Body L: wash+++ body/cloth/bedding
53
Scabies (PE)
Sarcoptes scabiei burrow into epidermis → pruritus Close contact 2* bact inf (scratching) Intense pruritus esp night, after hot shower Erythem papul, linear tracks Skin folds of hand, wrists, axillae, genitals
54
Scabies (dg, ttt)
Dg: Hx of pruritus in several fam mmbers Scraping tunnel + microsc ttt: 5% permethrin from neck down (head/toe: infants) + ttt surrounding; or oral ivermectin; wash everything
55
Decubitus ulcers
Continuous pression on skin → restrict microcircul → ischemic necrosis RF: bedridden ptts, underlying bony promin+lack of fat (sacrum/fat); incontin urine/stool macerate skin Dg: clinical ttt: #1 prevention (move ptts, special bed); routine wound care+hydrocolloid dressing (if low-grade); surgical debrid (if high-grade)
56
Gangrene
Necrosis of body tissue: wet, dry, gas Dry: by insuff bld flow to T (atheroscl); dull ache, cold, pallor; toes/fingers bluish-black. RF: DM, vasculopat, smoking Wet: bact inf (w/ skin flora); bruised, swollen, blistered w/ pus Gas: Clost perfringens inf; site of large trauma/surgery, comprom bld flow → anaerobic env.; bact destroy T; dirty wounds; !medical emergency
57
Gangere (dg, ttt)
Dg: clinical; X-ray (air in soft T) ttt: surgical debrid (+/- amputation) + AB Hyperbaric O2 (toxic to C.perfr) after debrid helps
58
Acanthosis nigricans
``` Hyperkeratotic + hyperpigmented skin; velvety app Intertriginous zones (neck, genitals, axillae) ``` Ass w/ DM, Cushing ds, PCOS, obesity, paraneopl (GI adenoK) ttt: not ttt; encourage weight loss
59
Lichen planus
Self-lim, recurr, chronic infl Skin, oral mucosa, genitalia Etiologies: drugs, HCV inf 6 P's: planar/purple/polygonal/pruritic/papules/plaques Wickham striae (white lines), Koebner phenomena (at site of trauma) ttt: topical CS (mild); systemic CS + phototherapy (severe)
60
Rosacea
Chronic disorder of pilosebaceous units; unclear etiology Middle-age, fair skin, esp female AbNl flushing after hot drinks/spicy food/alcohol/sun Early: central facial erythema w/ telangiectasias Later: papules, pustules Longstanding: rhinophyma Ocular rosacea → blepharitis, stye, chalazion ttt: topical metronidazole; oral doxycycline (if severe or ocular)
61
Pityriasis rosea
Acute dermatitis; unknown etiology Reaction to viral inf w/ HHV-7 Herald patch (erythem w/ periph scale) → multiple scaling papul/plaq w/ fine scale; Christmas tree pattern Dg: clinical; confirm w/ KOH prep (r/o fungal inf) ttt: rash heals 6-8wks w/o ttt; support ttt w/ lubrication, antipruritics, antihistamines
62
Vitiligo
Acquired loss of fction or absence of melanocytes 2* to autoimmune ds (serologic markers of AI ds) Sharp demarcated depigmented macules/patches Hands/face/genitalia ttt: topical steroids, tacrolimus ointment, UV, laser ! Sunscreen prevents burns
63
Eyelid lesions
Xanthelasma: soft yellow, medial, bilat; ass w/ hyperlipidemia and 1* biliary cirrhosis Hordeolum: painful acute gland inf (stye); S aureus; edge Chalazion: chronic infl painless cyst; blocked gland
64
Seborrheic keratosis
Skin tumor; No malignant potential Almost every person >40yo Exophytic, waxy brown, superf keratin cysts Dg: clinical (#dg melanoma) ttt: cryotherapy, shave excision or curettage
65
Actinic keratosis
Erythema, scale, flat; by sun exposure ttt to prevent transfo to SCC Face/arms, older ptts, multiple lesions Dg: clinical ttt: cryosurgery, topical 5-FU, topical imiquimod If carcinoma susp: biopsy then excision/curettage ! Sunscreen
66
Cutaneous squamous cell carcinoma (RF, PE)
#2 skin cancer; locally destructive; mets/death RF: sun expo, chemical carcinogens, radiation therapy, burns, chronic trauma, Isuppr Esp older ptts, sun-dam skin, after actinic keratoses Erythem ulcerated papul/nodul Marjolin's ulcer: rare type in site of scars/burns/ulcers Palmoplantar distrib: arsenic expo SCC that arise on lips/ulcers: ↑R of metast
67
Cutaneous squamous cell carcinoma (dg, ttt)
Dg: clinical; confirm w/ biopsy ttt: surgical excision or Mohs surgery If high metast potential: radiation or chemotherapy
68
Basal cell carcinoma
#1 skin cancer; slow, locally destructive; No metast RF: cumulative sun expo Sun expo areas; if on non-sun-expo + early in life, inherited basal cell nevus sd Many types, degrees of pigm/ulceration/depth of growth Nodular, superficial, sclerosing Dg: clinical; confirm w/ shave biopsy ttt: excision via curettage/cautery/cryotherapy/superf radiation; and Mohs surgery
69
Melanoma (RF)
``` #1 life-threatening dermato ds RF: fair skin, tendency to burn; intense bursts of sun expo; large congen melanocytic nevi, ↑nb of nevi, dysplastic nevi; Icomprom Familial atypical mole and melanoma (FAM-M) sd (predisp) ```
70
Melanoma (dg)
Begin in epidermal basal layer (melanocytes); metast ! early dg + ttt Malignancy determ by histo Screen: ABCDE (Asym, irreg Border, variat* Color, Diameter >6mm, Evolution (pruritus, new lesions)); dermoscopy Excisional biopsy on any susp lesion Stage: Breslow thickness and TNM
71
Melanoma (ttt)
Confined to skin: excision w/ margins; sentinel LN biopsy for staging If recurr/metast: chemoTh, radiationTh Early melanoma: ↑R of subsequent melanomas Late melanoma: ↑R of recurr or metast (! surveillance) Ulceration: poor prognosis
72
5 types of melanoma
Superficial spreading: 60%; any age; trunk men; legs women; early dg; slow horiz growth Nodular: rapid vertic growth; reddish-brown nodule w/ ulceration Acral lentiginous: palms/soles/nailbed; slow; asians/blacks Lentigo maligna: solar lentigo; on sun-dam skin of face Amelanotic: w/o pigmentation; from any of other types
73
Kaposi sarcoma
Vascular prolif ds; HHV-8 Multiple red/violac macules/papul/nodul then plaques Lower limbs, back, face, mouth, genitalia; GI, lungs HIV-ass KS: aggressive Dg: Hx, clinical, histo ttt: HAART if HIV+; radiation of cryotherapy (if small); systemic chemotherapy (if spread/internal) as Doxorubicin, paclitaxel, IFN-alpha
74
Mycosis fungoides (cutaneous T-cell lymphoma) (PE)
Slow, progress, neoplast prolif of T cells Chronic; esp men Early: pso-app plaqu/patch, pruritic; trunk, butt Later: skin tumors w/ palpable LN LN, spleen, liver involvement Sezary sd: leukemic phase of cutan T-cell lymphoma
75
Mycosis fungoides (cutaneous T-cell lymphoma) (dg, ttt)
``` Dg: clinical and histo; immuno charact; e- microscopy (Sezary or Lutzner cells = cerebriform lymphocytes) #dg: dermatitis. So every chronic/resistant dermatitis should have histo ``` ttt: phototherapy; steroids; chemoTh; retinoids; monocl Ab; IFN Localized: total skin electron beam irradiation Extensive/Advanced: radiation therapy
76
Cherry angiomas (hemangiomas)
#1 benign vascul tumor Small vascular red papules Anywhere; ↑ w/ age No ttt

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