Dermatology Flashcards
anicteric
without jaundice
actinic
changes from the sun
stucco keretosis
flat stuck on appearing legion with regular borders
senile angiomas
tiny red dots in older people
polycythemia vera
bone marrow produces too many RBCs and possibly WBCs and platelets and can cause pruritus and burning pain in hands
hodgkin’s lymphoma
cancer of the lymphatic system with many symptoms but include pruritus, fever, chill, swollen lymph nodes
erythema nodosum
violet or red subcutaneous nodules usually in pretibial area. Could be present in TB pt, oral contraceptives or Lupus pts
pruritus
itching
What primary skin disorders can cause pruritus?
xerosis, atopic dermatitis, contact dermatitis, venous stasis, lichen stasis, lichen planus, urticaria, dermatophytosis, psoriasis, scabies, pediculosis
What systemic disorders can cause pruritus?
renal, cholestasis, malignancy, MS, thyroid disorders, diabetes, venous stasis, Iron deficiency anemia, HIV, allergies, psychiatric
Emollient
usually used to treat pruritis.
Moisturizer
ie mineral oil, coconut oil, lactate and urea supply water.
Occlusives
reduce water loss e.g. petroleum jelly
Creams
absorb well and don’t feel greasy. Because creams contain alcohol they can sting! Also contain preservatives that may cause an allergic contact dermatitis.
Ointments
petrolium based so more of an emollient, less cosmetically acceptable. Ointments less likely to sting. Has propylene glycol/?irritant. Good for vulvar dermatosis.ointment more potent than same cream.
Lotions
more water than oil so easily absorbed and spread easily over large area. The higher prop of water to oil helps dry skin, go good in weeping dermatosis.
Gels
Gels have similar effect to lotions. helps to dry skin due to high proportion of water
Foams
dry easily without signif residue. Good for hair line. But $$
Potency of treatments
Super potent (class I) Potent (class II and III) Intermediate (class IV to V) Mild (classes VI to VII)
What is KOH scraping used for?
used to diagnose fungal infection
eczematous
scaling, crusting or oozing. synonymous with dermatitis
winter Itch
eczema brought on by winter or dry contions and aggravated by hot water/ drying soaps
Winter itch treatment
emollients and possibly mild to low potency topical corticosteroid to minimize itching
xerosis
dry skin
best treatment of xerosis
thick creams or ointments due to low water/ high oil content
contact dermatitis
any dermititis arising from direct skin exposure to a substance. Either an irritant or an allergen
allergic contact dermatitis
delayed-type hypersensitivity, requires initial sensitization, becomes more intense with repeated exposure, intense pruritus,
Acute allergic contact dermatitis presentation
erythema, edema, weepy, and vesicles
chronic allergic contact dermatitis presentation
lichenification, scaly and hyperpigmentation
atopic dermatitis affects who most often?
affects children genetically with environmental interactions also. personal or family hx of allergies, asthma, or allergic rhinitis
Treatment of atopic dermatitis
eliminate exacerbating factors disrupting epidermal barrier, emollients best applied immediately after bathing, daily topical corticosteroid, topical macrolide immunomodulators and possibly control pruritus.
factors to consider when prescribing a topical corticosteroid
pregnancy, potency, vehicle, amount, refills (avoid)
other atopic dermatitis therapies
phototherapy, oral calcineurin inhibitors, immunosuppressants (methotrexate), probiotics, oral essential fatty acids and chinese herbs possibly
widespread herpes simplex virus
known as eczema herpeticum. needs to be treated with antivirals immediately or IV
eczema herpeticum
numerous small red blisters with clear fluid with bright red halos surrounding. once they break they skin may be sore and pt may feel ill. needs to be treated immediately with oral antivirals or possibly IV
S. Aureus derm presentations
honey-colored crusting, folliculitis and pyoderma
localized S. aureus Rx
mupirocin (antibiotic)
Extensive S. aureus Rx
oral cephalosporin or penicillinase-resistant penicillins (antibiotics)
seborrheic dermatitis
inflammatory condition with overproduction of skin cells and sebum (greasy scales) found mostly on the scalp, face, nasolabial folds and mid upper chest, e.g. dandruff
seborrheic dermatitis causes
unknown but could be fungal/yeast causing redness flaking but it could also be that the flaking could be allowing an overgrowth of fungus…
cradle cap
seborrheic dermatitis found most commonly on infants head but also seen on face, ears, neck and diaper.
cradle cap treatment
usually resolves without treatment but white petroleum or mineral oil overnight and toothbrush to loosen scales or shampooing with baby shampoo and using soft toothbrush frequently
seborrheic dermetitis treatment
- low potency corticosteroid and/or 2% ketoconazole cream
- sulfa-based products
- shampoos with tar, selenium sulfide, pyrithone or ketoconazole
- off label use of tacrolimus or pimecrolimus for recalcitrant disease
causes of diaper associated dermatitis
irritant, candidal or allergic
irritant diaper dermatitis
usually surfaces in direct contact with diaper (buttock, lower abdomen and genitalia)
non-diaper associated dermatitis
scabies, herpes virus, psoriasis, bacterial
Tzanck test
use to diagnose blisters as herpetic
management of diaper dermatitis
- eliminate direct contact with feces and urine
- create topical barrier (petrolium, zinc oxide)
- powders (controversial)
- anti-fungal (make sure it is below barrier of ointment
- corticosteroids
- antibiotics (sulcrafate Rx labeled for duod ulcers also acts as physical barrier and has antibacterial activity. AVOID neosporin (neomycin) and bacitracin they contain inciting allergens.)
refractory diaper dermatitis
consider referral, immunodeficiency, nutritional deficiency, abuse, neglect or type 1 diabetes
prevention of diaper dermatitis
frequent diaper changes and barriers
dyshidrotic eczema
pruritic chronic recurrent vesicles lateral aspects of the fingers, palms and soles which desquamate and leave cracks
desquamate
to shed, peel off or come off in scales
what is dyshidrotic eczema when vesicle is large enough to be bullae called?
pompholyx
dyshidrotic eczema Rx
medium to potent topical corticosteroid
dyshidrotic eczema differential diagnosis
tinea (fungus) and contact dermatitis
venous stasis dermatitis contributing factors
1.venous hypertension, 2.chronic inflammation and 3.microangiopathy
venous stasis dermatitis
No fever, bilateral involvement (not cellulitis), notable varicosities, and hyperpigmentation.
venous stasis dermatitis treatment
mild topical corticosteroid and leg elevation and pressure, topical antibiotics avoided
venous stasis dermatitis prevention
unna boots for acute dermatitis and knee-high compression 20-40mmHg for prevention and review medications. can cause edema which will exacerbate
lichen planus
- The p’s = pruritic, shiny, purple, polygonal, and papules
- symmetrical on wrists, flexural surfaces of arms legs, lower back and genetalia
- linked to HepC
- knoeber phenomenon and wickums stria
psoriasis
similar to lichen planus except that it is on the extensor surface of knees and elbows as well as intergluteal cleft
knoeber phenomenon
present in lichen planus. occurs near site of injury
wickums stria
white, lacy pattern and erythematous erosion are present on buccal mucosa
wickums stria treatment
high potency topical corticosteroid, fluticasone spray or trimcinolone paste. 1% TID for 3 months and taper over 3 months chlorhexidine rinse or miconazole ointment for antimycotic concommitment
lichenoid drug reaction
unlike lichenoid platus, more eczematous,psoriasiform or scaly, frequently photodistributed, usually does not involve mucose and is uncommon to present wickham striae
lichen platus biopsy type?
deep shave or punch
lichen planus treatment
- topical or systemic corticosteroid
- retinoids
- immunosuppressants (mycophenolate)(must check for TB)
phototherapy
TB Testing
5mm, 10mm, 15mm. 5 mm is considered positive in immunocomprimised pts or if a person is in direct contact with an active TB pt whereas 15 mm or greater is considered positive in healthy pts.
lichen simplex chronicus (circumscribed neurodermatitis)
lichinified sqaumous hyperplasia pruritic skin, precipitated by emotions,
what does recalcitrant mean?
not responsive to treatment
lichen simplex chronicus treatment
soak in warm water, seal in moisture with topical corticosteroid ointment and possibly antihistamine
recalcitrant: intralesional triamcinolone, tacrolimus
nummular dermatitis
intensly pruritic patches (2-10 cm) on trunk and lower extremities. spontaneous. raised around the edges if fungus
nummular dermatitis differential diagnosis
tinea
nummular dermatitis Rx
potent topical steroid, and emollient post bathing
dermatitis herpetiformis
NOT HERPETIC, chronic recurrent pruritic vesicular eruption often on erythematous base and symmetrical pattern. IgA deposits in dermal papillae. autoimmune blistering associated with gluten sensitive enteropathy. increased risk of GI lymphoma. 90% have circulating antibodies to transglutaminase.
dermatitis herpetiformis treatment
dapsone (antibiotic) and gluten-free diet; although with good diet, you may not need dapsone
psoriasis risk factors
1-3% of worlds population. 1/3 have family history. men and women and all races equal. onset is bimodal 20 and 60 y/o. concordant among monozygotes more than dizygotes. associated with human leukocyte antigens (HLA) b13, 17 and 27
three types of arthritis
osteoarthritis, rheumatoid arthritis and psoriatic arthritis (can destroy the bone)
psoriasis exacerbating factors
stress, infection and medication (lithium and beta blockers)
psoriasis clinical manifestations
sharply marginated, scaly plaque on elbows, knees, presacral and scalp. Auspitz sign either plaque (80%), guttate, inverse, nail or pustular
plaque psoriasis
common in young adults, symmetricaly distributed erythematous, sharply defined and raised plaque (1-10cm) with thick silvery scale involving the scalp, elbows, knees and back. look for nail pitting, umbilicus and intergluteal cleft.
what drugs can exacerbate psoriasis?
BB lithium, antimalarial and less commonly ACE, NSAIDS, and terbinafine
considerations for treatment of psoriasis
based on severity (topical vs systemic), comorbidities (psychosocial), pt preference, evaluation of response. if they are put on immunocompromising medication or long term steroid, need to check for TB
mild-moderate psoriasis treatments
Can combine intermittently corticosteroid with topical retinoids or UVB intermittent steroid combo
- topical corticosteroids and emollients
- topical tar or topical retinoids (tazarotene)
- tacrolimus or pimecrolimus for facial or intertriginous areas
- methotrexate
- phototherapy
- biologics
retinoids
regulate epithelial cell growth
severe psoriasis treatments
Know when to refer
- phototherapy
- retinoids
- methotrexate, cyclosporin
- biologics or immunomudulatory
guttate psoriasis
small (less than 1 cm) droplike scaly plaques that appear abruptly and occur most often in children and adolescents. frequently triggered by prior staph infection
inverse psoriasis
reverse typical presentation on extensor surfaces. easily misdiagnosed as fungal or bacterial due to lack of scaling
what does intertriginous mean?
used to describe areas where skin rubs together
What is Auspitz sign?
bleeding where scales are ripped off in psoriasis
nail psoriasis
causes pitting (psoriatic involvement of the nail matrix), localized color change “oil drop”, severe confused with onchomycosis
generalized pustular psoriasis
severe, life-threatening complications. widespread erythema and sheets of superficial pustules. von Zumbusch varient. seen with withdrawal of systemic corticosteroid, pregnancy and infection
von Zumbusch varient
fever, diarrhea, leukocytosis, and hypocalcemia
psoriasis comorbidities
metabolic syndrome, cardiovascular disease, inflammatory bowel disease. moderate to severe psoriasis should be informed of increased risk for MI (check lipid panels)
How can we diagnose psoriasis?
H&P exam, rarely skin biopsy to rule out other conditions
psoriasis differential diagnosis?
seborrheic dermatitis, topic dermatitis and lichen simplex chronicus
psoriatic arthritis
coincidental skin involvement, arthritis can precede skin involvement, nail involvement is severe, distal interphalangeal joints spondyloarthropathies. severe destructive arthritis and deformaties = arthritis mutalins
what is arthritis mutalins?
form of psoriatic arthritis that is severe destructive arthritis and deformities
what drugs can exacerbate psoriasis?
BB lithium, antimalarial and less commonly ACE, NSAIDS, and terbinafine
considerations for treatment of psoriasis
based on severity (topical vs systemic), comorbidities (psychosocial), pt preference, evaluation of response. if they are put on immunocompromising medication or long term steroid, need to check for TB
mild-moderate psoriasis treatments
Can combine intermittently corticosteroid with topical retinoids or UVB intermittent steroid combo
- topical corticosteroids and emollients
- topical tar or topical retinoids (tazarotene)
- tacrolimus or pimecrolimus for facial or intertriginous areas
- methotrexate
- phototherapy
- biologics
retinoids
regulate epithelial cell growth
sever psoriasis treatments
Know to refer! phototherapy, systemic retinoids, methotrexate, cyclosporin, biologics and immunomodulary drugs (this one is important since you need to check for TB
intertriginous treatments of psoriasis
class 6 or 7, tacrolimus or pimecrolimus
treatment of nail psoriasis
physical maneuvers like shaving or nail removal
erythema multiforme major categories
Drug reaction
- SJS steven-johnson syndrome
- TEN toxic epidermal necrolysis
- SJS/TEN overlap
erythema multiforme minor
target or iris lesions generally found on extensor surfaces, palms, soles or mucosal membranes, possibly the result of herpetic flare or mycoplasma
erythema multiforme major
Favors the trunk. acute inflammatory symmetric macular, papular, urticarial, bullous or purpuric with history of recurrence. prodromal malaise and fever. necrosis and sloughing of epidermis can be seen.
Stevens-Johnson syndrome (SJS)
erythema multiforme major less than 10% body surface area
Toxic epidermal necrolysis (TEN)
erythema multiforme major more than 30% body surface area. about 50% begin with diffuse erythema, almost invariably drug induced.
SJS/TEN overlap
erythema multiforme major between 10-30% body surface area
Lesions on palms causes?
meningococcal, secondary syphilis or benign iris lesions.
Possible erythema multiforme causes
drugs like NSAIDs, allopurinol and anti -convulsants. even topicals. infections like mycoplasma. pneumonia may trigger SJS (may only be iris lesions)
erythema multiforme minor treatment
usually self limited. intervention is usually targeted at pain (burning) or pruritis in mild disease. If severe mucosal involvement, use systemic glucocorticoid. anti-virals are not very helpful due to late timing. If caused by drug, discontinue use.
erythema multiforme major treatment
discontinue med immediately, supportive multi-specialty team/burn unit, systemic glucocorticosteroids (not fully substantiated). no universal effective therapy
SJS and TEN history
drug exposure preceding symptoms (avg. 14 day), re-exposure to drug symptoms within 48 hours
SJS and TEN signs
erythroderma, facial edema, pain, palpable purpura, skin necrosis, blistering, mucosal erosion, swelling of tongue. prodrome
SJS and TEN lab abnormalities
lymphopenia, careful of demargination with glucocorticoids, mild ins in transaminases, overt hep in 10% TEN, Diagnosis is made by histology with full thickness epidermal detachement.
additional drug reaction pattern
Basically, there are many different types of drug reactions and we treat them accordingly. morbilliform, urticaria/angioedema (give steroid), anaphylaxis, hypersensitive vasculitis, exfoliative dermatitis/ erythroderma, hypersensitive syndrome, fixed drug eruption, photosensitive
acronym FLAP
used to diagnose strep, F = fever, L = lack of cough, A = adenopathy (anterior cervical nodes), P = pharyngeal exudates (white stuff on tonsils)
morbilliform
macular lesions 2-10mm
possible etiology = penicillin, other b lactams, carbamazepine, allopurinol
Rx: drug cessation, antihistamines for pruritis, and topical corticosteroids
pts with epstein barr or CMV will develop morbilliform if given ampicillin or amoxicillin
what are urticaria and how do they present?
Hives
acute or chronic
pruritic, erythematous, edematous plaque
can be accompanied by angioedema and/or systemic anaphalaxis
how do you treat urticaria if angioedema is developing near the mouth
systemic steroid
uriticaria cause
drugs, food, infection, systemic dz or idiopathic
How to treat severe reactions of urticaria?
drug cessation, antihistamines, epinephrine and corticosteroids.
increase eosinophils on CBC can possibly be a sign of what?
parasites
what should you think if someone has chronic urticaria?
malignancy or if eosinophils are high too then could be parasite
fixed drug eruption
Causes a lesion that will likely occur in the exact same spot if same Rx is given. commonly mistaken for spider bites
fixed drug eruption treatment
cessation of drug and given potent topical corticosteroid
Drugs that can cause photosensitivity?
thiazides (first line anti-HTN) and tetracyclines (common acne med). These are the drugs she emphasized out of everything: amiodarone, thiazide, tetracycline, furosemide, phenothiazines, sulfonamides, and psoralens
What particular concern do we have about warfarin (coumadin)?
anti-coagulant-induced skin necrosis
What particular concern do we have about lithium?
psoriasis, acne, hair loss
What particular concern do we have about iodides in amiodarone and radiocontrast material?
allergies to the iodide
what is cutaneous necrosis from warfarin caused by?
a reduction in protein c levels, which induces hypercoaguable state
drug eruptions are more likely in who?
pts with genetic predisposition, immunosuppressed and are also linked to accompanying viral infection (herpes virus 6)
percoset is a combination of what drugs?
oxycodone and acetominophen
what are the different combinations of percoset?
2.5mg/325 mg, 5/325, 7.5/500, 10/325 and 10/650
what is pityriasis rosa?
papulosquamous eruption that is self limited that occurs more commonly in the spring or fall,
Herald path on 50-90 % of cases with christmas tree distribution usually on torso
what is the likely cause of pityriasis rosa?
likely viral, possibly herpes virus 6 or 7
what is a herald patch?
One patch that is bigger than the rest. it is slighly raised and has a very thing scale (like cigarette paper)
what are some differential disgnoses for pityriasis rosea?
secondary syphilis, guttate psoriasis, tinea corporis, plus
treatment for pityriasis rosea?
usually none
if there is pruritis, medium potency topical corticosteroid
if sever itch, oral acyclovir promptly
Can last 2-3 months
Acne epidemiology
- preventant in adolescents
- activated by androgens therefore more common and severe in males
- tends to resolve in 3rd decade
- post-adolescent predominately affects women
If women have particularly bad acne, what else should you ask them?
if they have deepening of voice, decreased breast size, clitoromegaly, alopecia, oligomenorrhea and hirsutism since it could be caused by an adrenal or ovarian tumor
development of acne lesions
- a disease of pilosebaceous follicles
- follicular hyperkeratinization
- sebum production
- propionbacterium acnes (P. acnes) growth
- inflammation
Acne vulgaris is a disorder of the?
pilosebaceous follicles
What is involved in the pathogenesis of acne vulgaris?
- follicular hyperkeratinization
- sebum production
- propionbacterium acnes (P. acnes) growth
- inflammation
The accumulation of what material contributes to formation of comedones?
sebum and keratinous material
What contributes to the inflammation response in acne vulgaris?
Bacterial proliferation by propionbacterium acnes (P.acnes) and follicular rupture which releases proinflammatory lipids and keratin into dermis.
What interaction do kids in adrenarche and P.acnes have? (not sure if we need to know this?)
Sebaceous glands enlarge with adrenarche (the prepubertal period in which levels of DHEA-S rise) and sebum production increases. Sebum provides a growth medium for P. acnes, an anaerobic diphtheroid that is a normal component of skin flora. Microcomedones provide an anaerobic lipid-rich environment that allows these bacteria to thrive; they utilize triglycerides in sebum as a nutrient source by hydrolyzing them into free fatty acids and glycerol.
Inflammation results from the proliferation of P. acnes. Sequencing of the P. acnes genome has led to the identification of the following bacterial properties that may contribute to the inflammatory response [7,8]:
What three types of acne are there?
- solely comedonal
- papular or pustular inflammatory
- cyst or nodules (can cause scarring)
what acne would you use oral isotretinoin (accutane) with?
in cystic or nudular acne
what are closed comedones?
tiny, flesh non-inflamed bumps
what are open comedones?
slightly larger, black material aka black head
what are some diagnostic evaluations for acne?
endocrine function (if acne and abnormal growth of their hair), medication history, and/or examine skin for type and location
hirsutism
excessive hair growth on female where there normally is very little or none
acne external factors, things that seem to make acne better or worse.
- water cosmetics better
- scrubbing promotes inflammation
- soaps astringents remove sebum but do not decrease production.
- diet is controversial
- stress (corticotropin releasing hormone CRH)
Will topical steroids help erythema and inflammation associated with acne?
yes but the fluorinated will cause acne to form eruption
what is a good treatment of open comedones and pustular acne?
benzoyl peroxide
What history and physical questions are good to answer before prescribing for acne?
clinical type (comedonal, inflammatory, nodular), skin type (oily vs dry), scarring or hyperpigmentation (may warrant more aggressive), menstrual history, prior positive or negative therapy, medication history
what are some negative aspects of isotretinoin (accutane?
(accutane) very terratogenic, check liver and watch for mood swings, don’t prescribe to depressed, can possibly promote crohn’s disease, have them use chap stick
