Dermatology Flashcards
what are 4 risk factors for infantile hemangioma?
female
multiple gestation
prematurity
low birth weight
what is the natural history of infantile hemangioma
rapid growth out of proportion to Child’s growth, usually complete by 5 months
Plateau: ~12-18 months
Regression: ~18 months until 9-10 years of age
Residua: lasting skin changes in 50%
when do we worry about hemangioma of infancy?
Obstruction – Periorbital may impair vision – Large “beard-area” distribution-+/- airway IH • Associations – Mid-line lesions • Lumbosacral or mid-face – Large segmental on face: PHACES • Ulceration • Multiple
what is the treatment for infantile hemangioma?
95% require no treatment
– Anticipatory guidance
– Surgery or laser at later stage if not resolved
5% require treatment
first line- propranolol (Vision or airway threatening, significant cosmetic outcome)
oral corticosteroids also work but not first line
what should you monitor for a patient on propranolol for infantile hemangioma?
blood pressure
hypoglycemia
contraindications to propranolol for hemangioma
asthma, diabetes, PHACES
what is nevus simplex (storkbite)
40% of newborns
Naevus simplex is a common, benign capillary vascular malformation
It presents at birth as a pink or red patch and is most often observed on the nape of the neck, eyelid, or glabella (skin between the eyebrows)
Usually fade significantly except nuchal area
Nevus flammeus
port wine stain
persist lifelong
What doe PHACES stand for?
Posterior fossa brain malformations
Haemangiomas, particularly large, segmental facial lesions
Arterial anomalies
Cardiac (heart) anomalies and coarctation of the aorta
Eye abnormalities and Endocrine abnormalities
PHACES syndrome is PHACE syndrome plus:
Sternal cleft, supraumbilical raphe, or both
When do you worry about capillary malformations
– V1 distribution
• 10% have Sturge-Weber syndrome
– Lumbosacral capillary malformation (May have spinal abnormalities)
consider MRI
what is the difference between capillary malformation and hemangioma
capillary malformation- vascular malformation, grows with the child, never resolve
hemangioma- vascular tumor, rapid growth, resolve
When do you worry about nevi?
ABCD Asymmetry Border regularity Colour variety D- diameter >6mm worry E- evolution/change
what are the management options for nevi
Prevention – Sun Protection: • Sunscreen SPF 15 or greater • Hat, long sleeves/pants • Avoid direct sun 10:00am-4:00pm (seek shade) • Avoid tanning beds
- Review with patients: A B C D E
- Baseline photography for congenital, atypical
cafe au lait- what is the border like
irregular but sharp border
no scale
NF1 criteria
Need 2/7 criteria – >5 CALMS (>5mm prepuberty; >15 mm after) – Family history – Axillary or inguinal freckling – Specific bony abnormalities – 2 neurofibromas (or 1 plexiform neurofibroma) – Optic glioma – Lisch nodules (iris)
what is Vitiligo? tx?
autoimmune disorder that targets melanocytes Depigmented patches - Sharply marginated - No Scale - Tiny areas repigment
1st-line Tx= Strong topical steroids
what is commonly associated with post inflammatory hypopigmentation
eczema
poorly marginated, no scale
self-resolves, gets better with time
what is Pityriasis Alba? where do we see it? when? treatment?
pityriasis refers to its characteristic fine scale, and alba to its pale colour (hypopigmentation).
summer- often presents following sun exposure Hypopigmented Poorly marginated Fine white scale ** Face common
tx: 1% hydrocortisone for scale BID for 5-7 days
Hypopigment improves in time
what is tinea versicolor? tx?
common yeast infection of the skin, in which flaky discoloured patches appear on the chest and back
physical exam? Hypopigmented Can be hyperpigmented Sharply marginated Fine white scale*** Trunk, proximal limbs
Tx: Antifungal shampoo daily, 1-2 weeks (lathered to area)
topical antifungals
major criteria for TS
2 major features OR one major feature and 2 minor features
Hypopigmented macules >=3 – At least 5mm or bigger • Facial angiofibromas OR forehead plaque • Non-traumatic ungual or periungual fibromas • Shagreen patch • Subependymal nodule • Subendymal giant cell astrocytomas • Cardiac rhabdomyoma • Lymphangiomyomatosis • Renal angiomyolipomas
minor criteria for TS
Multiple randomly distributed pits in dental enamel • Hamartomatous rectal polyps • Bone cysts • Cerebral white matter migration lines • Gingival fibromas • Non-renal hamartomas • Retinal achromic patch • Confetti skin lesions • Multiple renal cysts
Staphlococcal Scalded Skin Syndrome? pain?fever? tx?
Bullous eruption from S. aureus toxins
pain is common
Fever and systemic symptoms uncommon
IV cloxacillin, some will add clindamycin
what is the treatment for scabies?
Permethrin 5% cream most effective
• Infants: treat whole body
• Older kids & Adults: treat from neck down
Leave on overnight and wash in am
• Re-treat 1 week later
Launder clothes/linen from last 3 days
what is the treatment for eczema herpeticum
• If unwell, <1 year, poor fluid intake, severe:
– Admit and treat with IV acyclovir
• If well, localized, good fluid intake, good f/u:
– Oral acyclovir for 10 days
what is the major agent for Tinea Capitis in North America? what are two fungus that cause it? tx?
T. Tonsurans major agent in North America
- Trichophyton (human reservoir)
- Microsporum (Cats and gods are reservoir)
Always Send Culture!!!
tx: oral terbinafine
SE terbinafine: liver enzymes, taste alteration, drug interactions, decreases pmns
clinical presentation for Tinea Corporis? tx?
Scaly, red plaques with central clearing
• Often have active border or leading edge
tx: Azoles: – ketaconazole – Miconazole – Clotrimazole • Allylamines: – Terbinafine • Ciclopirox Olamine NOT NYSTATIN
what is Pityriasis Rosea
Pityriasis rosea is a viral rash which lasts about 6–12 weeks. (?HHV6 or 7)
Characterised by a herald patch followed by similar, smaller oval red patches that are located mainly on the chest and back.
“christmas tree pattern”
tx: usually none
topical steroids or oral macrolides can help
molluscum contagiosum
Umbilicated, waxy, flesh-colored papules
• Often have surrounding dermatitis
• Resolving lesions: crusted, erythematous
• Can occur anywhere but groin/axillae common
• Can leave scars even with no treatment
what are some treatment options for molluscs contagiosum
Cantharidin • Applied to lesions by physician and washed 4 hours later – Curettage • Painful, needs topical anesthesia – Liquid nitrogen • Painful, can leave depigmented areas – Topical tretinoin • Immune enhancer – Imiquimod (off-label)
what is Verrucae? cause?
viral wart
HPV
tx: Best available evidence supports use of topical treatments containing salicylic acid, cryotherapy, curettage and cautery, laser, duct tape
SJS versus TEN
SJS <10%
TEN >30%
What are possible causes of SJS? (2)
- Infection: most common cause is MYCOPLASMA 2. Drugs: NSAIDs, sulfonamides, antibiotics, anticonvulsants
Treatment of SJS/TEN
Life-threatening! • Admit (severe may need ICU or burn unit) • Supportive management • History for all medications, infections • Consider mycoplasma and treatment • Treatments of bullous eruption: • IVIG (.75-1g/kg/day x 3 days) – Always in drug reaction – Consider in mycoplasma • Steroids (controversial)
Drug Hypersensitivity Syndrome
Morbilliform drug eruption WITH one or more of:
– Fever lymphadenopathy
– Pharyngitis Eosinophilia
– Elevated Liver Enzymes
what is the diagnostic criteria for atopic dermatitis
Pruritus • Early age of onset • Typical morphology and distribution • Chronically relapsing course • Xerosis • Personal or family history of atopy
what are some complications of atopic dermatitis
Complications • Sleep deprivation • Scarring or lichenification • Bullying, depression • Pigmentary changes • Infections
treatment for atopic dermatitis
Ointments are best
• Mild potency cortisone for face/groin/folds
– Eg. 1% hydrocortisone
• Moderate potency cortisone for limbs/trunk
– Eg. 0.05% betamethasone valerate
2nd line: Calcineurin inhibitors (Pimecrolimus, Tacrolimus)
what is the cause of Seborrheic Dermatitis
M. furfur
seborrheic dermatitis versus atopic dermatitis
Seborrheic Dermatitis • Thick, greasy scale • Scalp, face, groin • +/- itchy • No 2o infection tx: topical anti fungal
Atopic Dermatitis • Fine, white scale • Face, Flexors • Prominent itch • 2o impetigo common • Cause: – Excess inflammation – Barrier defect in skin tx: emollients, topical steroid
what is Alopecia Areata? what are the 3 patterns?
Sharply defined areas of hair loss • Skin below is normal – Patch Alopecia--one or more patches – Alopecia Totalis - all scalp hair lost – Alopecia Universalis - all body hair lost
tx: Potent topical or mid-potent injected steroids
• First-line
screen for autoimmune diseases
Increased incidence in Down syndrome
classification fo acne?
Mild:
– comedones &/or few inflammatory lesions
• Moderate:
– comedones & significant inflammatory lesions
• Severe:
• Persistent or recurrent inflammatory nodules
• Ongoing scarring
• Persistent purulent or serosanguinous drainage
what is Pilomatricoma
Benign growth of hair follicle • Firm, irregular, lobulated nodule • Often bluish-purple or flesh coloured • Head and neck common • Can be tender • Tend not to resolve on own
how do you confirm the diagnosis of mastocytoma?
Confirm diagnosis with Darier’s Sign
– Stroke lesion to produce urticaria (diagnostic test)
what is mastocytoma
Mastocytoma is most often diagnosed in an infant aged 0 to 3 months of age
dermal accumulation of mast cells forming one to thee solitary lesion
what is nevus sebacous
Birthmark of abnormal sebaceous glands • Always present at birth • Typically on head, scalp and neck • Yellow-pinkish plaque • Barely palpable • No hair within plaque • Often linear configuration Grows with child proportionately • Puberty: can thicken considerably – Hormonal stimulation of sebaceous glands • Persists permanently
Juvenile Xanthogranuloma
Benign collection of macrophages • At birth or early in life • Yellow-red papules with telangiectasia • Soft and well-circumscribed • Usually solitary, can be multiple • Asymptomatic • Regress over several years • Rarely associations (liver, eye)
Pyogenic Granuloma
reactive proliferation of capillary blood vessels. It presents as a shiny red lump with a raspberry-like or minced meat-like surface. Acute, red, domed papule • Often bleeds and crusts • Benign growth of blood vessels – During pregnancy, after trauma, idiopathic • Can regress spontaneously over months • Treatment options: – Preferred (histology confirms Dx): • Curettage • Excision
Erythema Toxicum Neonatorum
- Red macules, papules and pustules
- Palms and soles not involved
- between 24-48 hours of age
- Lesions last 1-2 days, new crops q few days
- Common in term infants; rare in prems
- Dx: clinical; smear of pustule: eosinophils
- Tx: none
Transient Neonatal Pustular
Melanosis
More common in term infants • More common in dark-skinned infants • Lesions always present at birth • Dx: Clinical; smear of pustule shows PMNS • Tx: none
neonatal acne
Develops in first few weeks
• Resolves by around 3 months
what is the cause of neonatal acne
• Caused by malassezia
what are the 4 stages of Incontinentia Pigmenti
Stage 1: erythema, vesicles, pustules (linear array of vesicles)
• Stage 2: verrucous, hyperkeratosis (wart-like lesions)
• Stage 3: HYPERpigmentation
• Stage 4: HYPOpigmentation, atrophy
Congenital Candidiasis
Onset from birth to first week
• Risk Factors:
– Prematurity
– Maternal history of vaginal candidiasis
• Eruption:
– Generalized red papules with pustules and scale
– Often palms and soles involved
• Systemic: baby unwell, temp instability
• DX: KOH for yeast cells and culture
• TX: Systemic antifungals
how does benzoyl peroxide work?
Reduces bacteria-does not induce resistance
is molluscum pruritic?
No!
what is first line treatment for black heads (comedomal acne)
topical retinoin
when do strawberry hemangioma usually appear
first or second month of life
An 8 month old child is brought in with several small brownish nodules on his back and extremities. The parents have observed that when they touch the nodule, wheals develop around it, it it transiently becomes erythematous and their child starts to scratch it. What is the diagnosis?
mastocytosis
Telogen effluvium
hair loss occurs approx 3 months after precipitative/stressful event
no treatment; complete regrowth occurs within a few months unless another stressful event occurs
alopecia arreata has increased incidence with what syndrome
Down syndrome
what is one medication that can cause a hypo pigmented scar after exposure to sunlight
NSAIDs
what are two causes of erythema multiforme
- herpes simplex
2. mycoplasma
what is the treatment for labial adhesions
topical estrogen cream
Child with trisomy 21 has three discrete hairless patches on scalp, no other findings.
Likely diagnosis?
What will you tell mom about the natural history?
alopecia areata
Many patients with limited patchy hair loss experience regrowth within one year, but recurrence is common
2 y/o with diffuse atopic dermatitis. He is compliant with steroid treatment but is not improving. What topical agent could be the next line?
tacrolimus
