Dermatology Flashcards
1
Q
alopecia areata
A
- non-scarring immune-mediated, targets anagen follicles
- ASSOC W/ OTHER AUTOIMMUNE
- sx: smooth, discrete circular patches of complete hair loss
- EXCLAMATION POINT HAIRS
- nail pitting, fissuring, trachyonychia (roughening)
- ALOPECIA TOTALIS (complete scalp hair loss)
- ALOPECIA UNIVERSALIS (complete body/scalp hair loss)
-tx: INTRALESIONAL CORTICO, TOPICAL CORTICO
2
Q
androgenetic alopecia
A
- progressive loss of terminal hairs on scalp
- DHT (dihydrotestosterone) leads to this
-sx: hair thinning and nonscarring hair loss mc on the temporal scalp, mid-front scalp or vertex area
- tx: MINOXIDIL
- ORAL FINASTERIDE (5-alpha reductase inhibitor)
3
Q
atopic dermatitis (eczema)
A
- atopic disease association (triad)
- altered immune rx –> T cell-mediated immune activation and inc IgE production
- triggers: heat, perspiration, allergen, contact irritants
- sx: PRURITIUS HALLMARK
- acute lesions: red, ill-defined blisters/papules/plaques
- later: dries, crusts over, scales
- MC IN FLEXOR CREASES
- DERMATOGRAPHISM
- NUMMULAR: COIN-SHAPED, sharply defined, esp on dorsum of hands, feet and extensor surfaces
- tx:
- ACUTE: TOPICAL CORTICO + ANTIHISTAMINES
- topical calcineurin inhibitors (tacrolimus, pimecromlimus) are alternatives to steroids)
- CHRONIC: daily hydration and emollients, oral antihistamines used for itching
4
Q
contact dermatitis
A
- tx: avoid irritants, topical cortico
- diaper rash: topical petroleum or zinc oxide to area
5
Q
dyshidrosis (dyshidrotic eczema)
A
- triggers: sweat, stress, warm weather, metals
- sx: pruritic “tapioca-like” tense vesicles on soles, palms and fingers (lateral digits)
- tx: TOPICAL STEROIDS, OINTMENTS PREFERRED, cold compress, burrow’s solution, tar soaks
6
Q
lichen simplex chronicus (neurodermatitis)
A
- SKIN THICKENING in pt W/ ECZEMA - 2ry to rubbing/scratching (itch/scratch cycle)
- sx: scaly, well-demarcated, rough hyperkeratotic plaques w/ EXAGGERATED SKIN LINES
- tx: AVOID SCRATCHING LESIONS, TOPICAL STEROIDS, antihistamines, occlusive dressing
7
Q
perioral dermatitis
A
-mc in young women, may have hx of topical cortico use
- sx: papulopustules on erythematous base, which may become confluent into plaques w/ scales
- may have satellite lesions
- SPARES VERMILLION BORDER
- tx: TOPICAL METRONIDAZOLE OR ERYTHROMYCIN
- oral: tetracyclines
- AVOID TOPICAL CORTICO
8
Q
lichen planus
A
- idiopathic cell-mediated immune response
- inc incidence w/ HEP C
-sx: 5 P’S: PURPLE, POLYGONAL, PLANAR, PRURITIC PAPULES w/ fine scales and irregular borders
-mc on flexor surfaces of extremities, skin, mouth, scalp, genitals, nails
+/- KOEBNER’S PHENOMENON (new lesions at sites of trauma)
-WICKHAM STRIAE: fine white lines on skin lesions or oral mucosa, nail dystrophy
- tx: TOPICAL CORTICO 1ST LINE
- antihistamines for itch, occlusive dressing
- 2nd line: PO steroids, UVB therapy, retinoids
9
Q
pityriasis rosea
A
- uncertain etiology (+/- associated w/ viral infections HHV7)
- primarily children or older adults
- inc in spring/fall, can mimic syphilis
- sx: HERALD PATCH (solitary salmon macule) on trunk –> general exanthem 1-2 wk later (smaller, itchy 1 cm round/oval) SALMON-COLORED PAPULES W/ WHITE CIRCULAR COLLARETTE SCALING ALONG CLEAVAGE LINES IN CHRISTMAS TREE PATTERN
- trunk and proximal extremities (face spared)
- resolves in 6-12 weeks
-tx: NONE NEEDED
-po antihistamines, topical cortico, oatmeal baths
+/- UVB phototherapy if severe and early in course
10
Q
psoriasis
A
-keratin hyperplasia (proliferating cells in stratum basale and stratum spinosum due to T cell activation and cytokine release –> greater epidermal thickness and increased epidermis turnover)
- sx: PLAQUE MC TYPE
- MC ON EXTENSOR SURFACES of elbows, knees, scalp, nape of neck
- NAIL PITTING
- AUSPITZ SIGN
- KOEBNER’S PHENOMENON (new lesions at trauma sites)
- Pustular: deep, yellow non-infected pustules that evolve into red macules on palms/soles
- Guttate: small, red papules w/ fine scales, discrete lesions
- Inverse: erythematous (lacks scale) mc seen in body folds (groin, gluteal fold, axilla)
- Erythrodermic: generalized erythematous rash involving most of the skin (worst type)
- Arthritis: inflamatory arthritis, joint stiffness >30 min relieved w/ activity; sausage digits, “pencil in cup” deformit on xray
- tx: MILD-MOD –> TOPICAL STEROIDS (HIGH) +/- vitamin d analogs (calcipotriene), topical retinoids/vitamin a
- MOD-SEV –> PHOTOTHERAPY UVB, METHOTREXATE, cyclosporine, retinoids, biologic agents
11
Q
pityriasis (tinea) versicolor
A
- overgrowth of MALASSEZIA FURFUR
- sx: hyper/hypopigmented
- dx: KOH PREP –> HYPHAE AND SPORES
- WOOD’S LAMP: YELLOW-GREEN FLUORESCENCE
- tx: TOPICAL ANTIFUNGALS (SELENIUM SULFIDE, SODIUM SULFACETAMIDE, ZINC PYRITHIONE, “AZOLES”)
- systemic: itraconazole or fluconazole if widespread or failed topical tx; must not shower 8-12 hours after bc azoles delivered to skin via sweat
12
Q
seborrheic dermatitis
A
- etiology unknown, maybe hypersensitive to MALASSEZIA FURFUR
- occurs in areas of high sebaceous gland oversecretion (scalp, face, eyebrows, body folds)
- worse during winter or w/ stress
-sx: CRADLE CAP INFANTS, DANDRUFF
- tx: topical selenium sulfide, sodium slufacetamide, ketoconazole
- systemic: oral antifungals (itra, fluc, keto, terbinafine)
13
Q
cutaneous drug reactions
A
- most cutaneous drug reactions are self-limited if DC’d
- triggers: foods, insect bites, drugs, enviro, exercise, infx
TYPE I: IgE MEDIATED (URTICARIA + ANGIOEDEMA)
TYPE II: CYTOTOXIC, AB-MEDIATED (drugs in combo w/ cytotoxic antibodies cause cell lysis)
TYPE III: IMMUNE ANTIBODY-ANTIGEN COMPLEX (drug-mediated vasculitis and serum sickness)
TYPE IV: DELAYED (CELL-MEDIATED) - morbilliform reaction (erythema multiforme)
- sx:
- EXANTHEMATOUS/MORBILIFORM RASH: MC SKIN ERUPTION - “bright-red” macules and papules that coalesce to form plaques; typically begins 2-14 days after med initiation (abx, nsaids, allopurinol, thiazides)
- URTICARIAL: 2nd mc type; occurs w/in minutes to hours after drug admin (abx, nsaids, opiates, radiocontrast)
- ERYTHEMA MULTIFORME: 3rd mc; target lesions may not always be present (sulfonamides, penicillins, phenobarbital, dilantin)
- FEVER, ABDOMINAL OR JOINT PAIN MAY ACCOMPANY THE CUTANEOUS RX
- less common: acneiform, eczematous, exfoliative, photosensitivity, vasculitis
- tx:
- discontinue offending med
- Exanthematous/Morbiliform –> oral antihistamines
- Drug-induced Urticaria/Angioedema –> SYSTEMIC CORTICO, ANTIHISTAMINES
- Erythema Minor –> symptomatic tx
- Anaphylaxis –> epi
14
Q
urticaria (hives) + angioedema
A
- TYPE I HSN (IgE) edematous reaction
- triggers: food, meds, infx, insect bites, drugs, enviro, stress, heat/cold
- MAST CELLS RELEASE HISTAMINE (causing vasodilation of venules –> edema of dermis + sq tissue)
-sx:
URTICARIA (BLANCHABLE, PINK PAPULES, WHEALS OR PLAQUES), often disappear w/in 24 hrs and new appear
-Dermatographism (pressure cause wheals in area)
-Darier’s sign - local urticaria appearing where skin rubbed
ANGIOEDEMA: painless, deeper form of urticaria affecting lips, tongue, eyelids, hands, feet and genitals
-tx: ORAL ANTIHISTAMINES, eliminate precipitant factors, corticosteroids, H2 blockers
15
Q
erythema multiforme
A
- TYPE IV HSN - acute self-limited
- skin lesions usually evolve over 3-5 days and last 2 wks
- mc in young adults 20-40y
-Associations: HSV MC, mycoplasma (esp kids), S. pneumo, SULFA DRUGS, BETA-LACTAMS, PHYNYTOIN, PHENOBARBITAL, autoimmune, malignancy
- sx:
- TARGET LESIONS, DULL “DUSTY-VIOLET”, PURPURIC MACULES/VESICLES OR BULLAE in center w/ pale rim and red halo; OFTEN FEBRILE
- EM Minor: target lesions distributed acrally; no mucosal membrane lesions
- EM Major: target lesions w/ INVOLVE MUCOUS MEMBRANE (oral, genital or ocular), more central lesions, NO EPIDERMAL DETACHMENT
- tx:
- symptomatic: dc drug, antihistamines, analgesics, skin care
- oral: STEROID, lidocaine, diphenhydramine mouthwash
16
Q
SJS + TENS
A
- MC AFTER DRUG ERUPTIONS, ESP SULFA AND ANTICONVULSANTS
- nsaids, allopurinol, abx
- infx less common - mycoplasma, HIV, HSV, malignancy, idio
- SJS = sloughing <10% of body surface
- TEN = sloughing >30%; may devo skin necrosis
- sx: FEVER + URI SX –> WIDESPREAD BLISTERS begin on trunk/face, red/itchy macules + mucous membrane involved W/ EPIDERMAL DETACHEMENT (+ NIKOLSKY SIGN)
- tx: like severe burns, pain control, prompt dc of offending med, fluid/electro replacement, wound care
17
Q
acne vulgaris
A
- INCREASED SEBUM PRODUCTION: inc androgens (inc sebaceous gland activity)
- CLOGGED SEBACEOUS GLANDS: d/t inc proliferation of follicular keratinocytes
- PROPIONIBACTERIUM ACNE OVERGROWTH (P. ACNE): part of normal flora that overgows in blocked pores –> lipase production by P. acne converts sebum into inflam fatty acids that damage healthy cells –> inflam response
- sx:
- comedomes
- inflammatory: papules/pustules surrounded by inflam
- nodular or cystic acne: often heals w/ scars
-dx + tx:
MILD: comedomes +/- small papules or pustules
-TOPICAL RETINOIDS, BPO, TOPICAL ABX, OCPs
MODERATE: comedomes, larger amounts of papules or pustules
- like mild + ORAL ABX (TETRACYCLINES - DOXY OR MINOCYLINE)
- SPIRONOLACTONE (K sparing diuretic)
SEVERE: nodular (> 5mm) or cystic acne
-ISOTRETINOIN –> HIGHLY TERATOGENIC (need 2 types BC)
18
Q
rosacea
A
- persistent vasomotor instability w/ lesion formation (inc capillary permeability)
- mc males >30 yo
- triggers: ETOH, INC TEMP (HOT DRINKS, HOT/COLD WEATHER, HOT BATHS, SPICY FOODS, MEDS)
- sx: ACNE-LIKE RASH + ERYTHEMA, FACIAL FLUSHING, TELANGIECTASIA, SKIN COARSENING, PAPULOPUSTULES W/ BURNING/STINGING, red eyes
- absence of comedones separates it from acne
- tx:
- topical: METRONIDAZOLE 1ST LINE, azelaic acid, ivermectin cream
- mod/sev: oral abx, laser
- LIFESTYLE MOD: SUNSCREEN, avoid tones, astringents, menthols, camphor, triggers
19
Q
actinic keratosis
A
-premalignant to SQUAMOUS CELL CARCINOMA (MC PREMALIGNANT SKIN CONDITION)
20
Q
seborrheic keratosis
A
- MC BENIGN SKIN TUMOR
- CRYOTHERAPY (cosmetic)
21
Q
HPV infections
A
-HPV infects keratinized skin, causing excessive proliferation and retention of the stratum corneum –> papule formation
-sx:
COMMON + PLANTAR WARTS (VULGARIS + PLANTARIS)
-firm, hyperkeratotic papules w/ red-brown punctations (thrombosed capillaries are pathognomonic), mc hands
FLAT WARTS (VERRUCA PLANA): numerous, small, discrete, flesh-colored papules 1-5 mm in diameter; typical on face, hands, shins
GENITAL WARTS (CONDYLOMA ACUMINATA): tiny, painless papules evolve into soft, fleshy, cauliflower-like lesions ranging from skin-colored to pink or red, occurring in clusters int he genital regions and oropharynx - may persist for months and may spontaneous resolve
- dx: MUCOSAL HPV (WHITENING OF LESION W/ ACETIC ACID APPLICATION)
- histology: koilocytic squamous cells w/ hyperplastic hyperkeratosis
- tx: MOST WARTS SPONTANEOUSLY RESOLVE IN 2 YRS
- verruca vulgaris and plantaris: topical otc salicylic acid, cryotherapy, electrocautery, laser
- condyloma acuminata: chemical, salicylic acid, cryo, laser
22
Q
vitiligo
A
- AUTOIMMUNE DESTRUCTION OF MELANOCYTES –> SKIN DEPIGMENTATION
- sx: irregular discrete macules and patches of depigmentation (commonly includes dorsum of hands, axilla, face, fingers, body folds, genitals)
- tx:
- local: topical corticosteroids; calcineurin inghib for facial involvement
- disseminated: systemic phototherapy may aid in repigmentation
23
Q
basal cell carcinoma
A
- MC TYPE OF SKIN CANCER IN US
- mc in fair-skinned w/ prolonged sun exposure, XERODERMA PIGMENTOSUM (genetic disorder w/ inability to repair damaged caused by UV light exposure)
- sx:
- SLOW GROWING, LOCALLY INVASIVE BUT LOW INCIDENCE METASTASIS
- flat, firm area w/ SMALL, RAISED, PEARLY/WAXY PAPULE AND CENTRAL ULCERATION + RAISED, ROLLED BORDER
- MC ON FACE, NOSE, TRUNK
- friable (bleeds easily)
- may have TELAGIECTATIC VESSELS
-dx: PUNCH OR SHAVE BX
- tx: ELECTRODESICCATION/CURETTAGE mc in nonfacial
- MOHS FOR FACIAL INVOLVEMENT
- small/superficial: imiquimod + 5FU for superficial nonfacial
24
Q
malignant melanoma
A
- UV RADIATION ASSOC W/ 80% CASES
- AGGRESSIVE, HIGH METS POTENTIAL
- inc in Caucasians, light hair/eyes; xeroderma pigmentosum
4 Major Subtypes:
- SUPERFICIAL SPREADING mc type 70% - may arise de novo or from pre-existing nevus
- Nodular - 2nd mc
- lentigo maligna
- Acral lentiginous - mc type on dark-skinned
- DESMOPLASTIC - MOST AGGRESSIVE
- sx: ABCDE
- usually >6 mm
- THICKNESS MOST IMPORTANT PROGNOSTIC FACTOR FOR METS
-dx: FULL-THICKNESS WIDE EXCISIONAL BX W/ LYMPH NODE BX
-tx: COMPLETE WIDE SURGICAL EXCISION
+/- adjuvant therapy in some high risk: a-interferon, immune therapy or radiotherapy
25
squamous cell carcinoma of skin
- 2nd mc type skin cancer
- OFTEN PRECEEDED BY AK, HPV INFX, sun, enviro exposure, xeroderma pigmentosum, chronic wounds
- HYPERKERATOSIS and ulceration
- BOWEN'S DISEASE = SCC IN SITU (SLOW GROWING)
- sx: RED, ELEVATED, THICK NODULE with adherent WHITE SCALY OR CRUSTED, BLOODY MARGINS
- dx: BIOPSY = atypical keratinocytes and malignant cells
- tx: WIDE LOCAL EXCISION, electrodesiccation and curettage, Mohs, radiation
26
kaposi sarcoma
- connective tissue cancer caused by HHV-8
- MC IMMUNOSUPPRESSED PT OR HIV (CD4 <100)
- sx: MACULAR, PAPULAR, NODULES, PLAQUE-LIKE BROWN/PINK/RED OR VIOLACEOUS LESIONS
- tx: HAART THERAPY
27
erythema nodosum
-PAINFUL, ERYTHEMATOUS INFLAMMATORY NODULES SEEN ON ANTERIOR SHINS, usually bilateral
- etiologies:
- ESTROGEN EXPOSURE, ocps, pregnancy
- Inflammatory disorders: SARCOIDOSIS, IBD, leukemia
- Infections: strep, TB, sarcoid, fungal (cocci)
- tx: generally self-limited
- nsaids, corticosteroids if persistent (and not infx)
28
impetigo
- occurs at sites of superficial skin trauma, FACE and extremities
- RF: warm, humid, poor personal hygiene
NONBULLOUS: VESICLES, PUSTULES --> "HONEY COLORED CRUST" MC TYPE
-regional lymphadenopathy, STAPH AUREUS MC, GABHS
BULLOUS: vesicles form large bullae --> rupture --> thing "varnish-like crusts", fever, diarrhea
-STAPH AUREUS MC, rare - usually seen in newborn/young
ECTHYMA: ulcerative pyoderma caused by GABHS; heals w/ scarring
- tx: MUPIROCIN (BACTROBAN) TOPICALLY DOC, tid 10d
- extensive/more areas systemic sx: cehpalexin
29
folliculitis
- superficial hair follicle infx w/ singluar or clusters of small papules or pustules, STAPH MC
- tx: TOPICAL MUPIROCIN, CLINDA, ERYTHROMYCIN
30
furuncle
- BOIL: deeper infx of hair follicle, tender
- FLUCTUANT ABSCESS W/ CENTRAL PLUG
-tx: I+D, HOT COMPRESS, oral abx
31
carbuncle
- larger, more painful, INTERLOCKING FURUNLCES / ABSCESSES W/ MULTIPLE OPENINGS + CELLULITIS
- tx: I+D, HOT COMPRESS, oral abx
32
cellulitis
-MC CAUSED BY STAPH AUREUS + GABHS/S.PYOGENES
- sx: MACULAR ERYTHEMA, NOT SHARPLY DEMARCATED, swelling, warmth, tenderness
- systemic sx (not common): fever, chills, lymphadenopathy, lymph tracking (LYMPHANGITIS), myalgias, vesicles, hemorrhage, necrosis may devo
- tx: abx X 7-10 days
- CEPHALEXIN, DICLOXACILLIN, clinda, erythromycin
- MRSA = iv vanc or linezolid, bactrim (po)
33
scabies
SARCOPTES SCABIEI - females burrow into skin to lay eggs, feed and defecate
- sx: INTENSELY PRURITIC LESIONS, LINEAR BURROWS common in INTERTRIGINOUS ZONES AND WEBS OF FINGERS/TOES, SCALP, usually spares neck and face
- INCREASED ITCHING AT NIGHT
- RED, ITCHY PAPULES OR NODULES ON SCROTUM, GLANS OR PENILE SHAFT PATHOGENOMIC FOR SCABIES
- dx: clinical, skin scraping of burrows w/ mineral oil to see mites/eggs under micro
- tx: PERMETHRIN TOPICAL (NIX) DOC
- LINDANE - DON'T USE AFTER BATH/SHOWER - CAUSES SEIZURES (inc absorption in open pores)
- all clothing, bedding placed in plastic bag at least 72 hours then washed and dried hot
34
pediculosis
- head, body, pubic lice
- sx: INTENSE ITCHING, PAPULAR URTICARIA NEAR LICE BITES
- tx: PERMETHRIN DOC
- 2nd line: Lindane - seizure risk if used after bath/shower)
-bedding/clothing washed in hot water and dried in hot drier; anything can't be washed placed in air-tight plastic bag for 14 days
35
molluscum contagiosum
- viral infection (poxviridae family) HIGHLY CONTAGIOUS
- mc children, sexually active adults, HIV
-sx: SINGLE OR MULTIPLE DOME-SHAPED, FLESH-COLORED TO PEARLY-WHITE, WAXY PAPULES W/ CENTRAL UMBILICATION - curd-like material may be expressed from center
- tx: NONE NEEDED (resolves 3-6 mo)
- curettage, cryotherapy, topical retinoids in severe
36
dermatophytosis
- fungal skin infx: TRICHOPHYTON, micosporium, epidermophyton
- infects keratinized tissues in stratum corneum of skin, hair and nails by ingesting keratin
- RF: increased skin moisture, immunodeficiency, peripheral vascuar dz
TINEA CAPITUS - ring worm --> annular, scaling lesions w/ broken hair, inflamed plaques w/ multiple pustules (KERION) w/ scarring and ALOPECIA --> PO GRISEOFULVIN
TINEA BARBAE - papules, pustlues and hair follicles
TINEA PEDIS - athletes foot --> TOPICAL ANTIFUNGAL
TINEA CRURIS - jock itch --> TOPICAL ANTIFUNGAL
TINEA CORPOSIS - plaques w/ circular rash, definied border, scaling --> TOPICAL ANTIFUNGAL
ONYCHOMYCOSIS - mc great toe --> ITRACONAZOLE AND TERBINAFINE; systemic griseofulvin, itra and terbi
37
pemphigus vulgaris
- autoimmune 2ry to desmosome disruption (link keratinocytes)
- ANTI-DESMOSOME / ANTI-EPITHELIAL AB
- mc young 30-40s
-sx: ORAL MUCOSAL MEMBRANE EROSIONS AND ULCERATIONS --> PAINFUL FLACCID SKIN BULLAE, leaving painful skin erosions that bleed easily
+NIKOLSKY SIGN (detachment of skin under pressure/trauma)
-dx: BX, IgG throughout epidermis
-tx: HIGH-DOSE CORTICO 1ST LINE
METHOTREXATE, local wound care
38
bullous pemphigoid
- chronic widespread autoimmune blistering skin disease
- ELDERLY 60+
- Type II HSN (IgG) autoimmune attack on the epithelial basement membrane
- sx: SUBEPIDERMAL BLISTERING (esp groin, axilla, abdomen, flexural areas)
- URTICARIA PLAQUES --> TENSE BULLAE (DON'T RUPTURE EASILY), ITCHY
- negative nikolsky sign
-tx: SYSTEMIC CORTICO, antihistamines, immunosuppressants
39
melasma
- RF: INC ESTROGEN EXPOSURE (OCP, PREGNANCY), SUN EXPOSURE, women w/ darker complexion
- sx: hypermelanotic symmetrical macules esp face/neck
- dx: WOOD'S LAMP: appearance unchanged
- tx: SUNSCREEN, HYDROQUINONE, retinoids, peels
40
brown recluse
- mc southwest and midwest
- sx: local burning and erythema for 3-4 hours --> blanched area (vasoconstriction) --> red margin around ischemic center "RED HALO" --> 24-72h after HEMORRHAGIC BULLAE THAT UNDERGOES ESCHAR FORMATION
- tx: LOCAL WOUND CARE, elevate, most heal spontaneous
- nsaids, tetanus prophylaxis if needed
- dermal necrosis - debridement, abx if 2ry infx
41
black widow
- sx:
- LACTRODECTISM local - asymptomatic or pain at bite site w/ onset of general sx 30m - 2h --> SYSTEMIC SX: MUSCLE PAIN, SPASMS, RIGIDITY (mc back, extremities, abdomen)
- usually limted and resolves 1-3 days
-Exam: BLANCHED CIRCULAR PATCH W/ SURROUNDING RED PERIMETER AND CENTRAL PUNCTUM
- tx:
- Mild: wound care, pain control
- Mod-Sev: opioids +/- musclue relaxers; antivenom reserved for pt not responsive to other tx
42
hidradenitis suppurativa
- chronic abscess of apocrine sweat glands or sebaceous cysts w/ tract formation
- mc obese women - axilla, groin, under breasts or anogential area
- tx:
- mild: topical clinda, interlesional injections of triamcinolone
- DEEP, RECURRENT: punch debridement if small, unroofing if larger w/ washout, I+D
- sx excision of apocrine glands might prevent recur
43
sebaceous cysts
- epidermoid or pilar cysts; both secrete keratin (not sebum) and don't originate from sebaceous glands
- sx: mobile masses of fibrous tissue and keratinous substance
- tx: cosmetic removal, I+D if infected
44
burn size
rule of nines - not used for 1st degree
-palm = 1% of TBSA
Minor burns:
<10% TBSA in adults
<5% TBSA in young/old
<2% full-thickness burn
-must be isolated injury
-must not involve face, hands, perineum, feet
-must not cross major joints; must not be circumferential
```
Major burns:
>25% TBSA in adults
>20% TBSA in young/old
>10% full-thickness burn
-involve face, hands, perineum, feet
-crossing major joints, circumferential burns
```
```
Rule of Nines
head/neck = 9% total back and front
upper limbs = 9% each
trunk = 36% total back and front
genitals = 1%
lower limbs = 18% each
```
45
burn management
Cleansing:
- wash mild soap and water
- DON'T APPLY ICE DIRECTLY
- CHEMICAL - IRRIGATE PROFUSELY 20 MIN
Debridement:
- sloughed/necrotic skin may be debrided
- escharotomy recommended for circumferential burns to prevent compartment syndrome
Blisters:
-ruptured should be removed
Pain:
-acetaminophen, nsaids, opioids
Antibiotics:
- topical should be applied to any non-superficial burn
- SILVER SULFADIAZINE commonly used 2nd/3rd (C/I IF SULFA ALLERGIES, PREGNANT, CHILDREN <2 MO, OR ON FACE - discoloration)
- aloe vera or topical abx (bacitracin) for superficial burns
Dressings:
- superficial burns don't require dressings
- partial/full thickness - dressing to prevent infx (non-adherent gauze and elastic gauze)
- fingers and toes individually wrapped to prevent maceration
IV Fluid Resuscitation: PARKLAND FORMULA
-LACTATED RINGERS 4ml/kg/%TSA - IV first 24h
(1/2 in 1st 8 hours and other 1/2 over next 16 hrs)
46
burn degrees
First: superficial
- epidermis
- dry, red, tender to touch
- cap refill intact
- heals w/in 7 days, no scarring
Second: superficial partial-thickness
- epidermis and superficial dermis
- red/pink, moist, weeping, blistering
- most painful of all types
- cap refill intact
- heals 14-21 days, no scarring but pigment change
Second: deep partial-thickness
- epidermis into deep dermis
- red, yellow, pale white, dry, blistering
- not usually painful, decreased 2 point discrimination
- absent cap refill
- heals 3w - 2mo, scarring common (may need graft)
Third: full-thickness
- extends through entire skin
- waxy, white, leathery, dry
- painless
- absent cap refill
- heals in months, doesn't spontaneously heal well
Fourth
- entire skin into fat, muscle, bone
- black, charred, eschar, dry
- painless
- absent cap refill
- doesn't heal well, usually needs debridement of tissues and reconstruction
47
smoke inhalation injury
-must r/o upper airway obstruction and CO toxicity
UPPER AIRWAY OBSTRUCTION
- smoke inhalation usually limited to upper airways (steam can travel to lower airways)
- sx of possible upper airway thermal injury: SURFACE BURNS OF THE NECK + FACE, HOARSENESS, SINGED NASAL HAIR, SOOT IN MOUTH/NOSE, BLACK SPUTUM
- respiratory stress may be apparent hours later
CARBON MONOXIDE TOXICITY
- neuro: headache, nausea, malaise, ams, seizures, brain hypoxia, coma
- cardiac: dysrhythmias, dyspnea, angina
- dx: MEASURE SaO2, INC CARBOXYHEMOGLOBIN, METHEMOGLOBIN
- tx: O2 100% NONREBREATHER 10-12L/min UNTIL CARBOXYHEMOGLOBIN <10%, may need hyperbaric O2 in severe
48
cyanide poisoning
- sx: rapidly devo coma, apnea (w/ severe lactic acidemia), cardiac derangements
- dx: H+P, cyanide levels
- tx: "cyanide kit" - amyl nitrite for inhalation, IV sodium nitrite or thiosulfate
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high voltage electric injuries
-sx:
CARDIAC ARREST (low voltage ac may produce ventricullar fib; high-voltage ac/dc may produce asystole)
RHABDOMYOLYSIS
neurological
- tx:
- tx thermal burns, telemetry
- admit if >600V even if asymptomatic; keep urine output at 100ml/hr and alkalinize the urine to protect kidney
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pressure ulcers
Stage 1: superficial, NONBLANCHABLE REDNESS that doesn't go away after pressure relieved
Stage 2: epidermal damage into DERMIS, resembles a BLISTER OR ABRASION
Stage 3: full thickness of skin and may extend into SQ
Stage 4: deepest, extends beyond fascia, extends into MUSCLE, TENDON OR BONE
- TX:
- wet to dry dressings, hydrogels
- 1+2 - local wound care, pain manage
- 3+3 - may need sx debridement
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dermatitis herpetiformis
- pruritic autoimmune skin disorder STRONGLY ASSOCIATED W/ CELIAC DISEASE --> IgA IMMUNE COMPLEX DEPOSITION IN DERMAL PAPILLAE
- sx: pruritic, papulovesicular rash on extensor surfaces and scalp
- tx: gluten-free diet, DAPSONE
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keloid
-excess production of type 1 and 3 collagen during wound healing; MC IN AA
- tx: CORTICOSTEROID INJECTION 1ST LINE
- 2nd: intralesional 5-FU, silicone gel sheets, pressure tx, cryotherapy
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pyogenic granuloma
- aka lobular capillary hemangioma
- mc in children / young adults esp after trauma (inc incidence in pregnancy - gingival involvement)
-sx: SOLITARY GLISTENING, FRIABLE RED NODULE OR PAPULE, evolves over period of weeks, mc arms hands, fingers, legs
- tx:
- pedunculated - shave excision or curettage and cautery of base
- nonpedunculated - surgical excision
- topical imiquimod or alitretinoin gel, injectable sclerosing agents
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pyoderma gangrenosum
-ulcerative skin lesion 2ry to immune dysregulation
+/- preceded by trauma
-ASSOC W/ INFLAMMATORY DZ (CROHNS, UC, IBD), RA
-sx: PAINFUL, NECROTIC ULCER W/ IRREGULAR PURPLE/VIOLET UNDERMINED BORDERS AND PURULENT BASE
- tx:
- HIGH-DOSE TOPICAL CORTICO or tacrolimus
- 2nd line: systemic cortico or cyclosporine if refractory to topical therapy
- 3rd: IVIG, cyclophosphamide
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erysipelas
Patient will be complaining of malaise, fever, chills, or nausea
PE will show intense and deeply erythematous, sharply demarcated elevated shiny patch
Most commonly caused by Streptococcus pyogenes infection (group A beta strep)
Treatment is:
Infections with systemic symptoms parenteral cefazolin, ceftriaxone or flucloxacillin
Mild to moderate infections (without systemic symptoms) oral amoxicillin or cephalexin
