Dermatology Flashcards
5 epithelial cell junctions
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)
Atopic dermatitis/eczema (RF, PE)
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)
Eczema (dg, ttt)
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
Contact dermatitis (PE, dg, ttt)
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
Type I hypersensitivity
Anaphylactic and atopic
Ag cross-links IgE on presensit mast cells
Vasoactive amines (histamine) release
Fast
Type II hypersensitivity
Cytotoxic
IgM/IgG bind to Ag on bad cell: lysis by complement or phagocytosis
Type III hypersensitivity
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
Type IV hypersensitivity
Delayed (cell-mediated)
Sensitized T lymphoc react to Ag, macroph activation
No Ab
Seborrheic dermatitis (PE, dg, ttt)
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
Stasis dermatitis
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
Grouped vesicles + fever after eczema ttt w/ CS
Eczema herpeticum
Medical emergency
HSV infection spreads systemically (+ brain)
IV acyclovir immediately
Psoriasis (PE)
T-cell mediated infl
Dermal infl + epidermal hyperplasia (+ parakeratosis)
Extensor surf/scalp/lumbosacral/nails/pso arthritis (hands/feet)
Drugs that worsen (B-/lithium/ACEIs)
Psoriasis (dg, ttt)
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)
Urticaria/hives (PE)
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
Urticaria/hives (dg, ttt)
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!
Drug eruption (PE)
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
Drug eruption (dg, ttt)
Disappear 1-2 wks of removal of drug
Dg: clinical, biopsy if unclear
ttt: stop drug, antihistamines + topical steroids
Erythema multiforme (PE, dg, ttt)
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
Stevens-Johnson sd / Toxic epidermal necrolysis (RF, PE)
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
Stevens-Johnson sd / Toxic epidermal necrolysis (dg, ttt)
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?
Erythema nodosum (etiologies, PE)
Panniculitis (infl of subcut adipose tissue)
Causes: inf, drug, chronic infl ds
Painful erythem nodules, ant shins, turn brown
+/- fever, joint pain
! false+ VDRL
Erythema nodosum (dg, ttt)
Dg: clinical + workup for underlying cause
ttt: underlying cause, NSAIDs/cool compresses, potassium iodide (if persistent)
Bullous pemphigoid
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
Pemphigus vulgaris (etiologies, PE)
AutoAb ag. desmoglein (intraepidermal) Erosions, No keratinocyte adhesion Nikolsky positive, common mucosal involv Esp. 40-60yo Ass w/ ACEIs/penicillamine/phenobarbital/penicillin
Pemphigus vulgaris (dg, ttt)
Possible mortality
Dg: clinical +/- biopsy (w/ direct immunofluo)
ttt: high-dose steroids + immunomodulator (azathioprine, mycoph mofet, IVIG, rituximab)
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
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
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.
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
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