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Emergency Medicine EOR > Dermatology > Flashcards

Dermatology Flashcards

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1
Q

What is bullous pemphigoid?

A

a rare, chronic acquired autoimmune subepidermal blistering skin disorder caused by linear deposition of autoantiboides (IgG) against hemidesmosomes in the epidermal-dermal junction

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2
Q

What are the characteristics of bullous pemphigoid?

A
  • bullous pemphigoid is a less sever than pemphigus vulgaris, does not affect mucous membranes and has a negative Nikolsky sign
  • large bullae and crusts located on axillae, thighs, groin, abdomen, more tense, less fragile and deeper than pemphigus vulgaris
  • diagnosis is made by skin biopsy with direct immunofluorescence exam shows deposition of IgG and C3 basement membrane
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3
Q

How do you tx bullous pemphigoid?

A

systemic corticosteroids

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4
Q

What is lice?

A

pruritic scalp, body or groin

  • nits are observed as small white specs on the hair shaft
  • body (corporis); pubic (pubis)
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5
Q

How is lice dx?

A

observation of lice and nits

-nits = ovoid, grayish-white eggs

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6
Q

What is the tx of lice?

A

launder potential fomites such as sheets in hot water (>131 F or 55 C)

  • permethrin topical is the drug of choice used in combination with wet combing)
  • capitis: shampoo to towel-dried hair and wash after 10 minutes then repeat in 9 days
  • pubis/body lice: permethrin cream apply to entire clean body from neck down then wash off after 8-12 hours
  • screen for other STIs in patients with pubic lice - abstain from sexual contact until the infestation clears
  • for eyelash infestation apply ophthalmic-grade petroleum jelly BID x 10 days
  • lindane = older topical treatment that can’t be used on infants, children, elderly due to neurotoxicity
  • children OK to return to school after the first application of treatment
  • for resistant cases consider oral ivermectin
  • treat all family members
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7
Q

What are the body percentages of burns?

A
  • rule of 9’s: head 9%, each arm 9%, chest 9%, abdomen 9%, each anterior leg 9%, each posterior leg 9%, upper back 9%, lower back 9%, genitals 1%
  • palmar method: patient’s palm equated to 1%
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8
Q

What is a 1st degree burn?

A

sunburn

-erythema of involved tissue, skin blanches with pressure, the skin may be tender

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9
Q

What is a 2nd degree burn?

A

partial thickness

-skin is red and blistered, the skin is very tender

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10
Q

What is a 3rd degree burn?

A

full thickness

-burned skin is tough and leathery, skin non-tender

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11
Q

What is a 4th degree burn?

A

into the bone and muscle

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12
Q

What is a minor burn?

A

<10 TBSA adults, <5 TBSA young/old, <2% full thickness, must not involve face, hands, perineum, feet, cross major joints or be circumferential

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13
Q

What is a major burn?

A

> 25% TBSA adults, >20% TBSA young/old, >10% full-thickness burn, burns involving the face, hands, perineum, feet, cross major joints/circumferential

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14
Q

What is the tx for burns?

A

monitor ABCs, fluid repletion, topical antibiotic

  • cleans with mild soap and water, don’t apply ice directly, irrigate chemical burns with running water x 20 min, topical antibiotic cream to superficial burns, fingers and toes wrapped individually to prevent maceration and gauze placed between them
  • children with >10% total body surface area and adults with >15% need fluid resuscitation = LR IV x24 hrs (1/2 in first 8 hrs, 1/2 in remaining 16)
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15
Q

What is pilonidal disease?

A

an abnormal skin growth located at the tailbone that contains hair and skin

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16
Q

What are the characteristics of pilonidal disease?

A
  • results from an abscess, sinus tract, at the upper part of the natal (gluteal) cleft
  • will usually present as a teenager with pain, discomfort and swelling above the anus or near the tailbone that comes and goes
  • often includes drainage of pus or blood
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17
Q

How is pilonidal disease dx?

A

clinical

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18
Q

What is the tx for pilonidal disease?

A

drainage and surgical removal of the cyst - look for sinus tract - remove hair, curette granulation tissue
-cefazolin + metronidazole or augmentin used empirically with cellulitis

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19
Q

What is cellulitis?

A

acute bacterial skin and skin structure infection of the dermis and subcutaneous tissue; characterized by pain, erythema, warmth, and swelling

  • margins are flat and not well demarcated
  • caused by staphylococcus and streptococcus in adults
  • h. influenzae or strep pneumonia in children
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20
Q

How is cellulitis dx?

A

culture taken of all purulent wounds and follow up in 48 hours

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21
Q

How do you treat mild cellulitis?

A

(MSSA) with cephalexin or dicloxacillin

  • cat bite with augmentin or doxycyline if PCN allergic
  • puncture wound with cipro (cover pseudomonas)
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22
Q

How do you treat methicillin-resistant staphylococcus aureus infection (MRSA)?

A
  • trimethoprim-sulfamethoxazole (TMP-SMZ) 1 DS tab PO BID
  • clindamycin 300-450 mg PO
  • doxycycline 100 mg PO BID
  • intravenous vancomycin or linezolid
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23
Q

What is a pressure ulcer?

A

sacrum and hip most often affected, reposition every 2 hours

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24
Q

What is a stage 1 pressure ulcer?

A

erythema of localized area, usually non-blanching over the bony surface

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25
Q

What is a stage 2 pressure ulcer?

A

partial loss of dermal layer, resulting in pink ulceration

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26
Q

What is a stage 3 pressure ulcer?

A

full dermal loss often exposing subcutaneous tissue and fat

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27
Q

What is a stage 4 pressure ulcer?

A

full-thickness ulceration exposing bone, tendon, and muscle

-osteomyelitis may be present

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28
Q

What is the wound management for stage 1 ulcer?

A

aggressive preventive measures, thin-film dressings for protection

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29
Q

What is wound management for stage 2 ulcer?

A

occlusive dressing to maintain healing, transparent films, hydrocolloids

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30
Q

What is wound management for stage 3-4 ulcer?

A

debridement of necrotic tissue, exudative ulcers will benefit from absorptive dressings such as calcium alginates, foams, hydrofibers, dry ulcers require occlusive dressing to maintain moisture, including hydrocolloids, and hydrogels

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31
Q

What are the risk factors for pressure sores?

A

age > 65, impaired circulation, immobilization, undernutrition, incontinence

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32
Q

How is a pressure sore dx?

A

based on observation and staged according to classification

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33
Q

What is the tx for a pressure sore?

A

debridement = depends on the extent of necrosis; surgical closure may be necessary; vacuum-assisted closure uses negative pressure to reduce wound edema and remove debris/reduce bacterial load

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34
Q

What is acute eczema?

A

rapidly evolving red rash; may be blistered/swollen

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35
Q

What is chronic dermatitis?

A

longstanding irritable area; often darker than surrounding skin, thickened (lichenified) and scratched

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36
Q

What is contact dermatitis?

A

well-demarcated erythema, erosions, vesicles

  • allergic: nickel, poison ivy, etc. type 4 hypersensitivity
  • irritant (diaper rash): cleaners, solvents, detergents, urine, feces
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37
Q

What is the tx for contact dermatitis?

A

avoid the offending agent

-burow’s solution (aluminum acetate), topical steroids, zinc oxide (diaper rash)

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38
Q

What is atopic dermatitis?

A

pruritic, eczematous lesions, xerosis (dry skin), and lichenification (thickening of the skin and an increase in skin markings)

  • most common on flexor creases (ex. antecubital and popliteal folds)
  • IgE, type 1 hypersensitivity
  • infant - face and scalp
  • adolescent - flexural surfaces
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39
Q

What is nummular eczema?

A

coin-shaped/disc shaped

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40
Q

What is the tx for nummular eczema?

A

high or ultra-high potency topical corticosteroids are first-line therapy for nummular eczema

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41
Q

What is seborrheic dermatitis (cradle cap)?

A

erythematous, yellowish greasy scales, crusted lesions

  • infants - scalp (cradle cap)
  • adults/adolescents - body folds
42
Q

What is the tx for seborrheic dermatitis?

A

ketoconazole shampoo

43
Q

What is perioral dermatitis?

A

young women, papulopustular, plaques, and scales around the mouth

44
Q

What is the tx for perioral dermatitis?

A

topical metronidazole, avoid steroids

45
Q

What are the causes of rash?

A
  • skin rashes can be due to underlying disease
  • skin rashes can be due to the environment
  • examples include hot and humid weather, excess sun exposure
  • other causes include irritating substances and allergies
46
Q

What is the presentation of rash?

A
  • area of irritated or swollen skin
  • itchy, red, painful, and irritates
  • it can also lead to blisters or patches of raw skin
  • rashes can be a symptoms of many different medical problems
  • rashes may basically be divided into two types: infectious or noninfectious
47
Q

What are noninfectious rashes?

A

eczema, contact dermatitis, psoriasis, seborrheic dermatitis, drug eruptions, rosacea, hives (urticaria), dry skin (xerosis), and allergic dermatitis

48
Q

What is an infectious rash?

A

can present with fever

  • for example, the rash in measles is an erythematous, morbillifrom, maculopapular rash that begins a few days after the fever starts
  • it classically starts at the head and spreads downward
  • systemic disease rashes
  • you see with jaundice, CRF, SLE, other autoimmune disease
49
Q

What is the tx for rashes?

A
  • differs according to which rash a patient’s diagnose

- common rashes can be treated using steroid topical creams such as hydrocortisone or non-steroidal treatments

50
Q

What are the pearls of rashes?

A

rashes are a clue as to what the patient may be exposed to or what infection or systemic disease they may have it is a piece of information that can help to the diagnosis of the patient

51
Q

What are the symptoms of mastitis/breast abscess?

A

nipple discharge, redness, warm skin

52
Q

What are the symptoms of breast cancer?

A

nipple discharge, breast discomfort, breast mass

53
Q

What are the symptoms of gynecomastia?

A

nipple discharge, breast enlargement, overweight

54
Q

What are the symptoms of inflammatory breast cancer?

A

nipple discharge, breast enlargement, redness

55
Q

What are the symptoms of hypogonadism?

A

nipple discharge, sexual dysfunction, reduced sex drive

56
Q

What are the characteristics of GU discharge?

A
  • infections of the vagina, such as yeast infection, bacterial vaginosis, trichomoniasis, human papillomavirus (HPV) or herpes
  • infection of the cervix (cervicitis)
  • an object in the vagina, such as a forgotten tampon
  • sexually transmitted infections (STIs), such as chlamydia or gonorrhea
  • various sex practices, such as oral-to-vaginal and anal-to-vaginal contact
  • vaginal medicines or douching
  • menopause: vaginal discharge, an absence of menstruation, anxiety
57
Q

What are the symptoms of abscess?

A

pain, redness, with or without discharge

58
Q

What is scabies?

A

a skin infestation caused by a mite known as the sarcoptes scabiei

  • pruritic papules = s-shaped or linear burrows on the skin
  • often located in web spaces of hands, wrists, waist with severe itching (worse at night)
  • can’t survive off human >4 days
59
Q

How is scabies dx?

A

often clinical, definitive diagnosis = microscopic observation of mite, egg or feces after skin scrape

60
Q

What is the tx for scabies?

A

topical permethrin 5% apply to the entire body, wash off after 8-14 hours, THEN = repeat in 1 week

  • all clothing bedding, towels washed and dried using heat and have no contact with the body for at least 72 hours
  • oral ivermectin 200 mcg/kg PO once, THEN = repeat in 2 weeks (take with meals)
  • for adults and children weighing at least 33 pounds who can swallow pills
  • do not use in pregnant/breastfeeding women
61
Q

What is a drug eruptions?

A

an adverse cutaneous reaction in response to the administration of a drug; usually within the past 6 weeks

  • skin reactions are the most common adverse drug reactions
  • severity can range from mild eruptions that resolve after the removal of the inciting agent to severe skin damage with multiorgan involvement
62
Q

How is a drug eruption dx?

A

clinical - consider bacterial, viral, underlying skin disease like cutaneous lymphoma

63
Q

What is the tx of drug eruptions?

A

monitor for signs of impending cardiovascular collapse (anaphylaxis, DRESS (drug rash with eosinophilia and systemic symptoms), SJS/TEN, extensive bullous reactions, generalized erythroderma)

  • withdraw offending agent
  • don’t rechallenge with drug causing urticaria, bullae, angioedema, DRESS, anaphylaxis
  • anaphylaxis or widespread urticaria = epinephrine 0.2-05 mg - prednisone to prevent a recurrence
  • antihistamines
64
Q

What are the characteristics of brown recluse bite?

A
  • brown violin on the abdomen
  • necrotic wound - local tissue reaction causes local burning at the site for 3-4 hours - blanches area (due to vasoconstriction) - central necrosis erythematous margin around an ischemic center “red halo” - 24/7 hours after hemorrhagic bullae that undergoes Eschar formation - necrosis
65
Q

What is the tx for brown recluse?

A

wound care, local symptomatic measures, delayed excision

66
Q

What are the characteristics of a black widow bite?

A
  • red hourglass on abdomen
  • neurologic manifestations - may not see much at bite site: toxic reaction: nausea, vomiting, HA, fever, syncope and convulsions
67
Q

What is the tx for a black widow bite?

A

wound care, local symptomatic measures, sometimes opioids, benzos; treat with anti-venom in elderly and kids

68
Q

What is erysipelas?

A

a distinct form of cellulitis notable for acute, well-demarcated, raised superficial bacterial skin infection with lymphatic involvement almost always caused by group A strep (strep pyogenes)
-symptoms may include redness and pain at affected site, fevers, and chills

69
Q

How is erysipelas dx?

A

culture and sensitivity

70
Q

What is the tx for erysipelas?

A
  • mild disease can be treated with Penicillin G (erythromycin/clindamycin for PCN allegy)
  • moderate: bactrim and penicillin/cephalexin
  • severe IMP or MER IV and linezoid BID or Vanco IV/Dapto IV
71
Q

What is Stevens-Johnson syndrome?

A

a rare, serious hypersensitivity complex that affects the skin and the mucous membranes
-it’s usually a reaction to a medication or an infection commonly caused y anticonvulsants and sulfa drugs

72
Q

What are the characteristics of Stevens-Johnson syndrome?

A
  • SJS is 3-10% of the body
  • it begins with a prodrome of flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters
  • layers of skin peel away in sheets (+) Nikolsky’s sign (pushing blister causes further separation from the dermis)
  • Stevens-Johnson syndrome (SJS) is a milder form of toxic epidermal necrolysis (TEN) with LESS THAN 10% of body surface area detachment
73
Q

How is Stevens-Johnson syndrome?

A

skin biopsy shows necrotic epithelium

74
Q

What are the ddx for Stevens-Johnson syndrome?

A

erythema multiforme, viral exanthems, drug rash

75
Q

What is the tx for Stevens-Johnson syndrome?

A

stop all offending medications, early admission to burn unit, manage fluid/electrolytes/nutrition, airway stability, eye care

  • IVIG
  • steroids used to be tx of choice but now thought to increase the risk of sepsis
76
Q

What is varicella (chickenpox)?

A

primary infections - clusters of vesicles on an erythematous base

  • dewdrops on a rose petal in different stages
  • it starts on the face and spreads down
  • varicella transmitted by respiratory droplets and has 10-20 day incubation period
  • acutely causes chickenpox - becomes latent in the dorsal root ganglion
  • symptomatic treatment may use acyclovir in special populations
77
Q

What is herpes zoster (shingles)?

A

varicella reactivation causing a maculopapular rash along one dermatome

  • identified via tzanck smear with visualization of multinucleated giant cells
  • zoster opthalmicus: shingles involving CCN V, dendritic lesions on slit lamp exam if keratoconjunctivitis is present
  • Zoster Oticus (Ramsay-Hunt Syndrome): facial nerve (CN VII) otalgia, lesions on the ear, auditory canal and TM, facial palsy auditory symptoms
  • herpes zoster vaccine is a live, attenuated virus vaccine - vaccination is recommended for immunocompetent adults > 60 years of age
78
Q

What is the tx for herpes zoster?

A

treat shingles with acyclovir, valacyclovir, and famciclovir - given within 72 hours to prevent post-herpetic neuralgia

79
Q

What is postherpetic neuralgia?

A

pain > 3 months, paresthesias or decreased sensation

-treat with gabapentin or TCA, topical lidocaine gel, and capsaicin

80
Q

What is toxic epidermal necrolysis?

A

a rare, life-threatening skin condition that is usually caused by a reaction to drugs

  • TEN is >30% of the body
  • (+) Nikolsky’s sign
  • very similar to Steven-Johnson syndrome - the difference is the age of the individuals (in toxic epidermal necrolysis older patients vs. SJS younger patient) and percentage of the body affected (in TEN >30% of body surface area affected vs. SJS <10% of body surface area affected)
81
Q

How is toxic epidermal necrolysis dx?

A

biopsy (necrotic epithelium)

82
Q

How is toxic epidermal necrolysis tx?

A

admit to burn unit with supportive care; consult ophthalmology if eyes affected; cyclosporine and possibly plasma exchange for severe cases

83
Q

What is impetigo?

A

a common pediatric bacterial skin infection that is highly contagious and auto-inoculable usually caused by staphylococcus aureus and group a beta-hemolytic streptococci

84
Q

What are the characteristics of impetigo?

A
  • impetigo typically begins as papules that progress to vesicles and surrounding erythema
  • over about one week, the vesicles eventually rupture and form a thick, adherent, golden crust, regional lymphadenopathy is a common finding
  • MC seen in children ages 2-5 years
  • the main symptom is red sores that form around the nose and mouth, the sores rupture, ooze for a few days, then form a yellow-brown crust
  • they are nonpainful and pruritic = “honey-colored” and weeping
  • most commonly caused by S. aureus
  • risk factors for impetigo include warm, humid conditions, poverty, crowding, and poor hygiene
  • secondary impetigo can occur at sites of minor abrasion or scratches
85
Q

How is impetigo dx?

A

gram stain and culture is recommended to determine bacterial etiology

86
Q

What is the tx for impetigo?

A

topical mupirocin, dicloxacillin, cephalexin for more severe illness

  • patients with suspected or confirmed methicillin-resistant aureus should be treated with doxycycline, clindamycin or trimethoprim-sulfamethoxazole
  • antibiotic treatment is usually for seven days
  • children may return to school 24 hours after starting antibiotics
  • complications: poststreptococcal glomerulonephritis
87
Q

What is urticaria (hives)?

A

skin rash triggered by a reaction to certain foods, medications, stress, or other irritants

  • symptoms include blanchable, pruritic, raised, red, or skin-colored papules, wheels or plaques on the skin’s surface; usually, disappear within 24 hours
  • (+) darier’s sign: localized urticaria appearing where the skin is rubbed (histamine release)
  • angioedema: painless, deeper form of urticaria affecting the lips, tongue, eyelids hand and genital
88
Q

How is urticaria dx?

A

extensive lab testing not indicated, skin or IgE testing limited to the specific history of provoking allergen

89
Q

How is urticaria tx?

A

hives usually go away without treatment, but antihistamine medications are often helpful in improving symptoms

  • second generation antihistamine blockers (H1) are first-line treatment (allegra, claritin, clarinex, zyrtec)
  • first-generation antihistamine for sleep disturbances: hydroxyzine/diphenhydramine
  • H2 antihistamines as adjuvants: cimetidine, ranitidine
  • steroids for exacerbations, avoid chronic use

if anaphylaxis give epinephrine: 0.3 - 0.5 mg; use 1:1,000 dilution for IM route and 1:10,000 for IV route
-peds: epinephrine 0.01 mg/kg SC/IV

90
Q

What is the presentation of itching?

A

an uncomfortable, irritating sensation that creates an urge to scratch the can involve any part of the body

91
Q

What are the common causes of itching?

A
  • itching can have causes that aren’t due to underlying disease
  • examples include hair regrowth, sunburns, insect bites, dry skin, or healing wounds
  • itching can result from
  • skin disorders (most common cause)
  • disorders of other organs (systemic disorders)
  • drugs and chemicals
92
Q

What are the skin disorders that cause itching?

A
  • dry skin (xeroderma and ichthyosis)
  • atopic dermatitis (eczema)
  • contact dermatitis
  • hives
  • insect bites scabies
93
Q

What are the systemic disorders that cause itching?

A
  • allergic reaction (food, drugs, bites, or stings)
  • disorders of the liver, such as jaundice
  • chronic kidney disease
  • psychogenic itching
94
Q

What is the tx for itching?

A
  • skincare measures (moisturizing the skin, and humidifying the air)
  • itching can usually be relieved by topical creams and steroids or systemic treatments such as benadryl, steroids, pepcid, etc.
95
Q

What are the pearls of itching?

A
  • itching usually results from dry skin, a skin disorder, or an allergic reaction
  • other causes may be a drug or a systemic disorder
96
Q

What is erythema infectiosum (fifth disease)?

A

parvovirus B19 - “slapped cheek” rash on face - lacy reticular rash on extremities, spares palms and soles; resolves 2-3 weeks; supportive care/anti-inflammatories

97
Q

What is hand-foot-mouth disease?

A

children < 10 years old caused by coxsackievirus type A virus - producing sores in mouth and a rash on the hands, feet, mouth and buttocks; usually clears 10 days
tx = supportive/anti-inflammatories

98
Q

What is measles (rubeola)?

A

The 4 C’s - cough, coryza, conjunctivitis and cephalocaudal spread

  • morbilliform - maculopapular, brick red rash on face beginning at hairline then progressing to palms and soles last - rash lasts 7 days
  • Koplik spots (small red spots in buccal mucosa with the blue-white pale center) precedes the rash by 24-48 hours
  • tx = supportive: anti-inflammatories, isolate 1 week after onset of rash
99
Q

What is rubella?

A

3-day rash, first appears on face spreads caudally to trunk and extremities and becomes generalized in 24 hours; cephalocaudal spread, teratogenic in 1st trimester (deafness, cataracts, TTP, mental retardation)

100
Q

What is roseola (sixth disease)?

A

herpesvirus 6 or 7, only childhood exanthem that starts on the trunk and spreads to the face
-high fever 3-5 days then rose pink maculopapular blanchable rash on trunk/back and face

Emergency Medicine EOR (12 decks)

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