Dermatology Fungal, Bacterial, Viral Flashcards
Skin
- Skin =
- Functions as our?
- Regulates aspects of el____ and m_____
- Skin: Largest organ in the body
- First line of defense from infections and caustic exposure
- Regulates aspects of elimination and metabolism
Skin Layers
(3)
Descriptions of each
Epidermis, Dermis, Subcutaneous fat
- Epidermis- outermost layer; waterproof barrier. Contains melanocytes and melanosomes that determine skin color/pigment.
- Dermis: 2 layers; primarily made of collagen the structural protein of the skin
- Subq: known as the panniculus. Lobules of lipocytes.
A small (usually less than 1cm in diameter), flat blemish or discoloration that can be brown, tan, red, or white and has same texture as surrounding skin
Macule
A small (less than 0.5cm in diameter), thin-walled, raised blister containing clear, serous, purulent, or bloody fluid
Vesicle
A solid, raised mass usually larger than 2cm in diameter with possible skin discoloration
Tumor
A small, firm, circumscribed, elevated lesion 1-2 cm in diameter with possible skin discoloration
Nodule
A circumscribed, pus or lymph filled, elevated lesion that varies in diameter and may be firm or soft and white or yellow
Pustule
A slightly raised, firm lesion of variable size and shape, surrounded by edema, skin may be red or pale
Wheal
A small, solid, raised lesion less than 1cm in diameter, with red to purple skin discoloration
Papule
A raised, thin-walled blister greater than 0.5cm in diameter, containing clear or serous fluid
Bulla
Derm Terms
- Essential to know the basic terms when _____ to colleagues and ____ what you see
- Always assess the (1) - pruritis, burning, pain and (1) signs - flat, raised, deep, superficial
- Primary lesions = (1) flat, nonpalpable <1cm ie lentigo VS. (1) >1cm ie vitiligo
-
Secondary lesions = cr___, ex_____, sc_____, sc____, er_____, etc
- Diagnostic details: Dis_____, Ev____, Co____, Con_____
- Essential to know the basic terms when communicating to colleagues and documenting what you see
- Always assess the subjective - pruritis, burning, pain and objective signs - flat, raised, deep, superficial
- Primary lesions = macule-flat, nonpalpable <1cm ie lentigo VS. patch >1cm ie vitiligo
-
Secondary lesions = crusts, excoriations, scars, scales, erosions, etc
- Diagnostic details: Distribution, Evolution (time period), Color, Consistency (blanch, texture, temperature)
Vehicles for Topical Medication Administration
(3)
- (1) → (1) → (1) → (1) (more potent than lotions so don’t want to use like on the head)
- Lotions, Creams, Ointments- most common
- Foams, solutions, Gels
- Consider the ____ of the body you’re treating and how ____ of an area
- Lotions → Creams → Gels → Ointments (more potent than lotions so don’t want to use like on the head)
- Lotions, Creams, Ointments- most common
- Foams, solutions, Gels
- Consider the part of the body you’re treating and how large of an area
Fungal Infections
(2)
Tinea (dermatophytes) - fungus
Interigo (candida) - yeast
Tinea Overview
Tinea = Dermatophytes (used interchangeably)
- Tinea =
- Majority caused by (3) fungi/dermatophytes
- Dermatophyte is fungus that invades and proliferates in the nonviable keratinized layer of skin—(1)
- Rarely ______ skin or hair follicle (Majocchi’s granuloma) → superficial
- Tinea means a superficial fungal infection of the hair, skin, or nails (does not go beyond epidermis)
- Epidermophyton, Trichophyton Rubrum (most common), Microsporum
- Dermatophyte is fungus that invades and proliferates in the nonviable keratinized layer of skin—stratum corneum
- Rarely penetrate skin or hair follicle (Majocchi’s granuloma) → superficial
Tinea Overview
- Classified =
-
Predisposing factors
- Gender (1)
- Environment (1)
- G____, Sw_____
- Wr______
- Sm______
- Hx (1)
- Transmitted =
-
Diagnosed =
- (1) is possible but takes up to 6 weeks for results
- (1) can also be used to confirm presence of dermatophyte
- Avoid using (1) → may exacerbates sx and confuse dx (Tinea Incognito)
- Classified according to Latin term for body location: capitis—head; pedis—foot; cruris—groin; corporis—body
-
Predisposing factors
- male
- humid environment
- gym, sweating
- wrestling
- smoking
- hx of diabetes/any immunosuppression
- Transmitted via direct contact with infected person, animal, or environment
-
Diagnosed via KOH slide (scrape of skin)– Looking for hyphae
- culture is possible but takes up to 6 weeks for results
- DTM (dermatophyte test medium) can also be used to confirm presence of dermatophyte
- Avoid using steroids → may exacerbates sx and confuse dx (Tinea Incognito)
If you suspect tinea but it could be eczema, treat the tinea first and if not improving then treat the inflammatory response bc if you use topical steroids first, won’t treat the tinea
Tinea Capitus
=
- Can be associated with scalp ____, chronically ____ hair (i.e. sweating), poor _____
- Causes: sharing ____, _____ tools
- More common in _____ children
- Incubation period of __- __ days
- Presence of (1) helps differentiate from alopecia (1) sign
- May have (1): swollen, boggy, fever, pain, lymphadenopathy, pus
Fungal infection of scalp → bald spots (secondary alopecia)
- Can be associated with scalp injury, chronically moist hair (i.e. sweating), poor hygiene
- Causes: sharing hats, barber’s tools
- More common in black children
- Incubation period of 2-4 days
- Presence of broken hair shafts helps differentiate from alopecia (black dot sign)
- May have Kerion: swollen, boggy, fever, pain, lymphadenopathy, pus
What do these pictures show?
1st pic =
2nd pic =
These are examples of what type of tinea capitus? Can we treat with topical antifungals?
1st pic: Alopecia- no hair shafts noted in bald spot
2nd pic: Tinea appears to have “black dots” d/t broken hair shafts within bald spot; Black Dot Tinea Capitus is one form
These are examples of non-inflammatory T. Capitus with scaling and well demarcated areas being affected. Note the broken hairs.
Cannot be treated with topical antifungal bc goes deeper into hair follicle
What do these pictures show?
This type may require what type of treatment?
Tinea Capitus Inflammatory Type with Kerion
- Always evaluate for and consider possibility of a secondary bacterial infection
- (oozing, wheeping, treat tinea + secondary bacterial infection)
- Inflammatory Type- often very pruritic. May have secondary bacterial infection. Includes significant inflammation of the scalp.
- This type may require treatment with PO antifungals, PO steroids, and/or PO ABX
Tinea Capitus Treatment
Rx (1)
- Other options (3), however all these can be (1)
- _____ Rx _____ as monotherapy, however use of (1) may discourage recurrence
- Who else do you treat?
- Instructions =
- Prevention =
- Also have your (1) checked if suspected partner in crime
Griseofulvin (Microsize PO x 4-6 weeks vs 8-12 weeks with food)
- Terbenifine (Lamisil), Itraconazole (Sporanox), Fluconazole (Diflucan) → Hepatotoxic
- Topical Rx ineffective as monotherapy, however use of antifungal shampoo on a weekly basis (ketoconazole 2% 1-3/week) can discourage recurrence
- Household members bc can be asymptomatic carriers
- Antifungal shampoo, leave on for 5min then rinse 3x/week
- Don’t share combs, towels, or hats
- Have pets checked by vet if suspected partner in crime
Tinea Corporis
AKA (1)
- Typically begins as p_____, cir_____, er______, d___, sc____ patch that spread _______ → ______ clearing
- Edges =
- Borders =
- Most common differential (1)
- May be seen in (3)
- Most common cause (1)
Ringworm
-
pruritic, circular, erythematous, dry, scaling patch that spreads centrifugally → central clearing
- raised edges
- well defined borders
- Nummular (coin shaped) eczema
- Adults caring for children with tinea capitus, athletes w/skin to skin sports (wrestling), immunosuppressed
- Trichophyon Rubrum (T Rubrum)
- DDX: nummular eczema, granuloma annulare, erythema anulare centrifugum (EAC), secondary syphillis. Depends on the body part that it presents with & hx of response to top roids or top antifungals*
- Consider differences in appearance in dark-skinned individuals*
Tinea Corporis Treatment
=
(2)
If immunosuppressed?
Topical Antifungals 1st line
- Imidazoles (econazole, ketoconazole, miconazole, etc)
- Terbinafine (Lamisil) or Ciclopirox (Loprox)- Ciclo also safe in pregnancy and breastfeeding
Oral tx if immunosuppressed
Tinea Cruris
AKA (1)
Effects (2) parts, (2) usually spared
- May be associated w sw_____ or ex_____
- Often self inoculation via (1)
- Presentation =
Jock Itch
Groin or “crural fold” (upper, inner thighs), Scrotum and penis usually spared
- sweating, exertion
- self inoculation via tinea pedis (spread via towels, hands)
- Begins as small erythematous patch w crust and scaling that spreads peripherally w curved (scalloped) well defined edges
Tinea Cruris Treatment
=
- If severe or nonresponsive to topicals?
- Treat (1) if present to prevent reinfection
- Keep area (2), Rx (1), clothing should be?
Topicals usual recommendation continue Rx 1 week past sx clearing: Usually requires 2-4 weeks tx - prepare pt!
- Oral agents x2 wks
- Tinea Pedis
- Keep area dry and well vented as much as possible, Zeazorb powder; boxers, not briefs; loose-fitting, cotton clothes
Tinea Pedis
AKA (1)
Causes (4)
- May be accompanied by what other condition?
- Presents as mac_____, hyper_____ p_____ in the (1) spaces or as dull _____ with scaling and hyperkeratosis on plantar surfaces of feet
Athlete’s Foot
Moisture/hyperhidrosis, Poorly ventilated shoes, Immunosuppression, Prolonged oral steroids
- Onychomycosis (nail fungus)
- Macerated, hyperkeratotic plaques in the interdigital web spaces or as dull erythema with scaling and hyperkeratosis on plantar surfaces of feet
Tinea Pedis Types
(3)
- Which type is most common?
- Always examine between (2) digits
- Assess for possible (1)
Interdigital, Moccasin, Vesiculobulous
- Interdigital
- 4th and 5th digits
- 2ndary bacterial infection
Tinea Pedis Treatment
=
- ___ - ___ weeks
- Severe cases or if immunosuppressed?
- Keep area ___ and well ____ as much as possible
Topical antifungals (Econazole, Nafitine, Ketoconazole, Terbinafine)
- 2-4 weeks
- Oral tx for 2 weeks
- Dry, Well ventilated
Tinea/Pityriasis Versicolor
=
Caused by?
Prevalent in what type of climate?
Common in ___ adults, especially in the _____
Chronic, asymptomatic, superficial infection
Yeast (Malassazia furfur or P. Ovale)
Warm humid climates
Young adults, Summer
- Very common for pt to report dyspigmentation in dark skinned individuals
- History of the eruption is very important!
- Used to be called tinea but is not from a dermatophyte, but yeast
Tinea Versicolor Presentation
- Fine scale, guttate (resembling drops) or nummular patches appear that are pink or brownish macules and patches in pale skin and hypopigmented macules in dark skin w/delicate scaling
- Typically asymptomatic
Tinea Versicolor Treatment
=
Rx (2) shampoos, must leave on skin how long?
Rx (1) PO ___mg, advise pt to exercise ___min later
(1) is ineffective for this condition
Topical, oral, shampoo application to skin. Takes several weeks to work and it often recurs
Selenium Sulfide or Ketoconazole Shampoos – must leave on skin at least 10 minutes, then rinse. Can be applied overnight and rinsed in AM.
PO fluconazole 300mg, advise pt to exercise 30 min later
X Terbinafine X
Tinea Versicolor Ddx
seborrheic dermatitis, pityriasis rosea, vitiligo, mycosis fungoides, confluent and reticulated papilomatosis
What is this rash called?
Tinea/Pityriasis Versicolor
Intertrigo
=
Inflammation caused by Candida Albicans d/t moisture, heat, friction, most commonly occurs in mucosal surfaces or skin folds
Intertrigo
- Risk factors
- Presentation (1)*
- Obesity, diabetes, recent ABX or steroid use, immunosuppression, chronic moisture or friction
- Erythematous patches, erosions, fissures, itching, burning. May have satellite lesions.
Intertrigo Treatment
=
Rx (2)
- Eliminate pre_____ factors
- Keep area dry via (3)
Topical antifungals BID until 1 wk after sx resolve; cont 2x/wk after to prevent recurrence
Nystain or Imidazole ointment
- Eliminate predisposing factors
- Clothing, Zeazorb, or Nystatin powders
Sample Case
48 yo overweight female with hx of HTN, GERD, and poorly controlled DM type II presents for eval of a rash that has been present in the bilateral inframammary creases for 2 months. She reports burning, itching, and states that fluid sometimes weeps from the area. She admits to sweating a lot and wearing tight bras. On physical exam, this is what you see, how would you document/describe the morphology of this rash? What diagnosis do you suspect?
Erythematous, not well defined, satellite papules, no oozing, is flat so not a plaque but a patch
Large erythematous poorly defined patch
Intertrigo (can be caused by candida but can simply be inflammatory from friction and moisture)
Onychomycosis
=
Nail infection typically caused by a dermatophyte, occasionally by mold or yeast
Onychomycosis
Diagnosis via (1)
If cannot isolate via above? (2)
KOH
Culture or nail clip
KOH exam is a simple skin test to check if an infection in the skin is caused by fungus. KOH stands for potassium (K), oxygen (O), and hydrogen (H), affected skin or nail is gently scraped with a small scalpel or the edge of a glass slide**. The scrapings from the skin are placed on a microscope slide and a few drops of a potassium hydroxide (KOH) solution are added
Onychomycosis Treatment
1st line =
- Can consider other oral antifungals but?
- Duration for fingernails (1), toenails (1)
- Consider (1) evaluation pre tx and 1-2w in
- Advise pt that they may not (1) for 6-12m
Oral terbinafine (Lamisil) considered 1st line
- lower efficacy/safety concerns?
- 6-8 weeks fingernails, 4 months toenails
- Hepatic eval
- May not see improvement for 6-12 months
Onychomycosis Notes
- When can you treat with just topical laquer?
- What should you absolutely do before starting an oral antifungal?
- (1) soaks for 20-30min also help
- If nail matrix is not involved
- CONFIRM DIAGNOSIS, must monitor for liver dx
- Apple cider vinegar soaks
Topical Antifungal Agents Chart
What is your diagnosis?
A) Tinea Versicolor
B) Onychomycosis
C) Tinea Capitus with Kerion
D) Tinea Corporis (facei)
E) Pityriasis Alba (not fungal) - tinea versicolor rarely presents on the face, so topical steroid may help better
Bacterial Infections
(3)-(4)
- Impetigo – superficial bacterial infection
- Usually a Staph or Strep infection
- Cellulitis- deeper in the skin
- Infection of dermis & subq
- Follicular (involving the hair follicle)
- Folliculitis
- Furuncle
- Carbuncle
- Hydradenitis Suppurativa
Impetigo
=
- Typically occurs where on the body?
- Most common skin infection in (1) ages _ - _
- Contagious?
- (1) → (1)
Superficial bacterial skin infection usually by Staph aureus, occasionally Group A Strep pyogenes
- face, hands, neck, extremities
- children 2-5yo
- highly contagious
- Papules → Vesicles golden crust
Non-Bullous vs. Bullous Impetigo
=
- Always (1) if any doubt of dx
- Classic “____ - ____” not seen in everyone
- Risk factors
- Climate (1)
- Hygiene (1), ___care
- Skin tr_____
- Hx of (1)
No blisters, localized 70% of cases VS. less common, starts as bullae, more widespread (typically does NOT scare-reassure pts and parents)
- Bacterial culture if any doubt of dx
- “golden-crust” not seen in everyone
- Risk factors
- Hot, humid climate
- Poor hygiene, daycare
- Skin trauma
- History of itching an insect bite
Impetigo Treatment
=
Rx (1)
- Consider tx in ____ if hx of frequent, repeat infx
Topical Antibiotics
Mupirocin 2% ointment TID for 5-7 days
- nares if hx of frequent, repeat infx
Impetigo Treatment for Severe, Bullous lesions
widespread, and not responsive to topical tx, if fevers is present
=
Rx (4), duration
Oral antibiotics
Dicloxacillin, Augmentin, Cephalexin, Clindamycin (if MRSA suspected), 10 days
Ask about hx of allergies, culture if not improving
Cellulitis
=
Causes (3)
Risk factors (4)
A bacterial infection involving the dermis, subcutaneous tissue, and fat
Typically staph and strep (beta hemolytic strep, strep pyogenes, MRSA), unless by an animal bite
After trauma or wound, surgery, venous stasis, recent hospitalization
Cellulitis Presentation
Usually occurs on ___ limb/s, most often on ____ legs
(4) symptoms
Usually occurs on one limb, most often on lower legs
Erythema, Edema, Tenderness, and Warmth
Cellulitis Treatment
(1) for 5-7 days
Rx (3) if MRSA is suspected
(2) Nonpharm maneuvers
(1) If S/S of systemic infection (fever, tachy, AMS), significant co-morbidities
Antibiotics
Bactrim, Clindamycin, Doxycycline
Elevate, Hydrate skin to prevent cracking if edema
Eval in ED and/or admission for IV antibiotics
Cellulitis Monitoring
Uncommon complications (3)
If hx very rapid progression, febrile, not responding to PO abx → consider (1) and do what?
(1) border of erythema, recheck in ___ hours (sooner if greater concern), we don’t expect to see a reduction within that time frame but want to ensure that (1)
Sepsis, Osteomyelitis, Necrotizing skin infection
Necrotizing fasciitis, send to ER
Outline border with a pen, recheck in 48h, just to ensure it’s not increasing
What does this picture show? Treatment requires?
Cellulitis w streaking (lymphagitis)
Requires oral antibiotics
Empiric Antimicrobial Therapy for Uncomplicated Cellulitis (excluding MRSA)
Empiric Oral therapy for Cellulitis caused by MRSA and beta-hemolytic streptococci
Superficial bacterial infection of hair follicle → Pus collects in epidermis, usually caused by staph aureus from nose or can be sterile
Folliculitis
A cluster of furuncles (boils)
A coalescence of several (2 or more) inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles
Carbuncle
A “boil” infection of the hair follicle extending into Subq tissue → small abscess formation
Furuncle
Inflammatory papules, pustules due to inflammation of follicles and perifollicular skin
Pseudofolliculitis Barbae (PFB)
Pseudofolliculitis Barbae (PFB)
- Most common in (1), but can occur in anyone, especially with c____, c____ hair
- Typically occurs immediately after (1), advise to use (1)
- Patient may report p___ or pr_____
- Complications (2)
- black men, coarse, curly hair (growth of tightly curled hairs within the follicle can cause an inflammatory reaction)
- Shaving, use electric clippers/razors
- pain, pruritis
- Post inflammatory hyperpigmentation (PIH), Keloids (less common)
Folliculitis Treatment
Treatment of choice Rx (1)
- PO abx?
- Discuss shaving techniques: not too ____ blades, no ___ blades, never ___ shave, use ____ water
- If recurrent, consider (1)
Topical Antibiotic Benzaclin gel combo
- Clindamycin phosphate 1% BID (lotion, foam, gel)
- Benzoyl Peroxide 5% as a wash or topical gel 1-2x daily
- rarely required, but may help if severely inflamed (doxy and minocycline)
- not too many blades, no dull blades, never dry shave, use warm water
- laser hair removal
Carbuncle Notes
A cluster of furuncles (boils)
- These are fluctuant masses. You can palpate the ____ filled cavity
- Often associated with (2)
- Definitive treatment =
- These are fluctuant masses. You can palpate the fluid filled cavity
- Poor hygiene, smoking
- I&D, middle pic would need I&D + abx
Furuncle Treatment
Only definitive treatment (1)
PO abx?
I&D if organized (fluctuant) - until organized, frequent warm compresses will either resolve or organize so can I&D
NOT recommended
Per CDC: I&D is treatment of choice except when…immunosuppression, severe local symptoms, systemic symptoms, high suspicious of MRSA, difficulty with draining the lesion or failure to respond to I&D. Always culture the fluid.
Chronic, inflammatory follicular occlusive disorder that affects intertriginous skin (folds like axilla and groin)
Hidradenitis Suppurative
Hidradenitis Suppurative
- Course =
- More prevalent in (1)
- Often sc______
- Inflammatory (3) that ____ and lead to permanent ______
- Tx = (1) then (1)
- Highly variable course
- women
- scarring
- Inflammatory nodules, fistulas, abscesses that flare and lead to permanent scarring
- PO abx then derm consult
Viral Skin Infections
(4)-(3)
Herpesvirus (Varicella, Zoster, HSV types 1 and 2)
Molluscum
Warts/HPV
Pityriasis Rosea
Viruses- 2 types- DNA stranded or RNA stranded; Herpesvirus: A medium-sized virus that contain double-stranded DNA. Produce latent, but lifelong infection, which may be intermittently clinically apparent . Includes Fully developed by tense vesicles, herpes simplex consisting of grouped vesicles on an erythematous base, zoster being made up of vesicles, sometimes hemorrhagic ones, that course along a dermatome of an adult usually, and varicella being characterized by widespread discrete vesicles in children as a rule.
Epidemiology of Herpes Simplex
(1) = children acquired, usually orolabial
- Referred to as (2)
- usually acquired around _____ age, 80-90% will test seropositive
(1) = usually associated with genital
- 22-25% of US population has it by age __, 10-20% will test seropositive
HSV Type 1
- “Cold Sore” “Fever blister”
- preschool age
HSV Type 2
- 22-25% of US population has it by age 35
Herpes Simplex Characteristics
- Transmission =
- Diagnosis* =
- Treatment = Rx (2)
- Cure =
- Virus enters via mucus membranes
- Viral culture
- Acyclovir 5x/day or Valacyclovir BID
- No cure
Herpes Simplex Virus Notes
One of the most prevalent infections worldwide
- Test w (1), not serologic testing because blood tests indicate an infection, but cannot confirm that a lesion is caused by HSV infection. Tx goals are to ______ the course of a current infection and prevent ______
- May have prodrome of 24 hrs of (3) sensations preceding the outbreak. May have flulike symptoms of HA, fever, nasal congestion.
- (1) is a common trigger and severity of outbreak may correlate w/severity of ____ exposure.
- Test w/viral culture, not serologic testing because blood tests indicate an infection, but cannot confirm that a lesion is caused by HSV infection. Tx goals are to shorten the course of a current infection and prevent recurrences
- May have prodrome of 24 hrs of tingling, itching, or burning preceding the outbreak. May have flulike symptoms of HA, fever, nasal congestion.
- UVB is a common trigger and severity of outbreak may correlate w/severity of sun exposure.
Herpes Simplex and Zoster
Infection becomes (1) in the nerve ganglion → then one day (1)
Infection becomes dormant/latent in the nerve ganglion → then one day it reactivates
The virus enters either through mouth or genitalia via mucous membranes or at a site of injury to the skin or via bodly fluids (saliva, semen, vaginal fluid..) . The virus enters vulnerable host cells and begins to multiply & can destroy the host cell causing and inflammatory reaction; otherwise it lays dormant/inactive (latent) & during this time the virus is not multiplying, and host cells remain healthy until something triggers the virus to begin multiplying again.
What is causing these lesions?
- 2 most common sites
- DDx (1)
- Ask about recent ____ hx. Pt is usually infected __ - __ weeks prior to outbreak.
Lesions are usually Type 1 HSV but can also be 2
- Most common site is vermillion border of lip and 2nd most common is near the nares, but can occur elsewhere on the body (ear, fingers, cheeks as in Eczema herpeticum).
- Impetigo (hx very important) sometimes treat for both, Hx of fluid filled bump = HSV
- Ask about recent sexual hx. Pt is usually infected 1-2 weeks prior to outbreak.
HSV Stages
(1) (no lesions) → (1) → (1) → (1) → (1) or
- All these stages happen usually over __ - __ days
- Prodrome is usually worst during the ___ outbreak. May have prodrome of (3) preceding the outbreak.
- When are you shedding the most virus?
- Ask about triggers like?
Prodrome (no lesions) → Papule → Vesicle cluster → Ulcer → Crusting or Faint Erythema
- 5-7 days
- Prodrome worst during 1st outbreak. May have tingling, burning, itching
- Tingling phase is when you are shedding the most virus, so don’t share drinks!
- UV exposure (beach, skiing), stress, illness, etc
HSV Education
Patient education is key!
- (1) and early (1) stages are most contagious
- Pt will often report tingling or itching prior to eruption
- (1) stage less infective
- The virus is _____ even when a person is asymptomatic
- The ___ outbreak is the worst (fever, pain, malaise) and may last weeks
- However, more than 10% of initial outbreaks are completely ______
- Subsequent outbreaks usually resolve within __ days
- Tell patient to avoid?
- Prodrome, early vesicular stages most contagious
- Golden crust stage less infective
- The virus is shedding when a person is asymptomatic
- The 1st outbreak is the worst (fever, pain, malaise)
- However, more than 10% initial outbreaks are completely asymptomatic
- Subsequent outbreaks usually resolve within 5 days
- Avoid close contact, kissing, sharing drinks or toothbrushes
What is this condition?
Caused more often by which HSV?
Herpetic Whitlow
HSV Type 1
- Occurs when digits are exposed to HSV*
- HSV infection may take the form of a felon or whitlow (an infection of the pulp of the fingertip). Tender, erythematous at the lateral nailfold. Deep-seated blisters develop 24-48 hrs after symptoms begin. Children may aquire d/t thumbsuckin or nail biting. Tends to occur in ppl w/hx of HSV. Children usually caused by HSV-1. 75% of cases in adults are HSV-2*
Herpetic Whitlow
- Common in peds due to? Common in adults who are?
- Very ______ due to deep vesicles
- Ddx (1)
- Tx (1)
- peds dt thumb or finger sucking, adult HCW
- Very painful dt deep vesicles
- Cellulitis
- Needs admission to hospital for IV antivirals
What is this condition?
Usual symptoms?
Avg incubation period?
Genital Herpes Simplex
Mild or asymptomatic
Avg 5 day incubation period
Genital Herpes Simplex in Females
Symptoms in women?
In women the major complaint is vaginal pain & dysuria (herpetic vulvovaginitis)
Active lesions contain live virus & are infectious. Persons w/recurrent genital herpes shed virus asymptomatically between outbreaks. Can occur through normal appearing skin. Most transmission of genital herpes occurs during subclinical or unrecognized outbreaks or while the infected person is shedding asymptomatically. Risk is 10% for partners in monogmous relationships). Symptoms can last up to 3 wks for initial outbreak. In recurrent outbreaks symptoms may last only a few days
35 y.o. female with 2 day onset or pruritic, painful rash that is worsening. Routine phlebotomy 4 days ago with application of Band-Aid to site. Afebrile and VS WNL. What is the most likely diagnosis? What would you treat with?
- Contact dermatitis
- Cellulitis
- Tinea corporis
- Hidradenitis suppurativa
- Contact dermatitis
- Cellulitis, Tx = oral abx
- Tinea corporis
- Hidradenitis suppurativa
Herpes Zoster/Shingles
- Cause (1)
-
Initial Presentation (1)
- After 5-7 days, patient will exhibit ______
- Pattern (1)
- Symptoms (1)
- Reactivation of varicella zoster virus (VZV)
- Papules, vesicles, pustules on an erythematous base
- After 5-7 days, patients will exhibit crusting
- Follows dermatome, unilateral, DOES NOT CROSS MIDLINE
- Very painful (especially in elderly)
- Caused by varicella zoster virus. Following natural infection or immunization, the virus remains latent in the sensory dorsal root ganglion cells. It begins to replicate at some later time, traveling down the sensory root into the skin. Other than immunosuppression & age, factors involved in reactivation are unknown. Elderly tend to have more pain. Lesions can develop on mucous membrane & genitalia. FOUR TIMES LESS LIKELY IN AFRICAN AMERICANS.*
- Young pts, duration of 2-3 wks. Elderly may have duration >6 wks.*
- Anything neck up → refer to ophthalm/ear doctor to make sure no vision or hearing loss*
Herpes Zoster/Shingles Dermatome
Which dermatomes are most frequently effected?
Thoracic dermatomes most frequently affected (55%) T3-L1 most common
Thoracic dermatomes are most frequently affected (55%) the cranial (20%, most being the trigeminal nerve), lumbar (15%), sacral (5%).
Herpes Zoster/Shingles Diagnosis
Usually diagnosed with history and clinical presentation alone however, best test is viral cx obtained from vesicular fluid
Herpes Zoster/Shingles Goals
-
Goals: _____ clinical course, provide an_____, prevent complications & decrease the incidence of (1)
- Rx(2) may not be enough; consider (1)
- Topical (1) patches may help
-
Goals: shorten clinical course, provide analgesia, prevent complications & decrease the incidence of postherpetic neuralgia
- NSAIDs and Acetaminophen may not be enough; consider tramadol
- Topical lidocaine patches may help
Herpes Zoster/Shingles Treatment
(1) within ___ hours of the onset of ____, reduce the s____ and d____ of acute ___, and incidence of (1)
Rx (3)
Oral antiviral agents started within 72 hours of the onset of rash, reduce the severity and duration of acute pain, and incidence of postherpetic neuralgia.
- Acyclovir/Zovirax: 800 mg 5 times daily x 7-10 d.
- Famciclovir /Famvir: 500 mg t.i.d. x 7 d. $$$
- Valacyclovir/Valtrex: 1000 mg t.i.d. x 7 d. $$$$
Herpes Zoster/Shingles Prevention
At what age?
Zostavax Vaccine
>60
(whether or not they have had herpes zoster, reduces risk of shingles by 51%)
Herpes Zoster/Shingles Ophthalmologic Involvement
Requires?
Can lead to (2)
Immediate ophthalmology consult
Can lead to corneal scarring and blindness
Is this Herpes simplex or zoster?
Likely Zoster. Doesn’t cross midline and is able to occur on mucous membranes.
Is this HSV or Impetigo?
What questions would you ask?
Taking a thorough history is key!
- Have you had this before?
- How long has it been there for?
- Did you notice a tingling or burning sensation prior to the eruption?
- Exposure/kissing someone?
- Apply any home remedies?
Smooth, skin-colored, dome-shaped, pearly papules with umbilicated centers (crateriform lesions)
Molluscum Contagiosum (MC)
Molluscum Contagiosum (MC)
- Cause (1)
- Transmission (1)
- Prevalence most commonly in (1)
- In adults is considered an (1)
- Can _____ and resolve (1) over several months
- Poxvirus
- Skin to skin contact with infected skin
- Most common in children
- Considered an STD in adults
- Can involute and resolve on its own over several months
Molluscum Contagiosum (MC) Treatment
Options to speed resolution can cause scarring, which is permanent but not common
- C______
- Cr____
- Manual removal with large bore _____
- Cantharidin (___)
- (1) /topicals
- Im_____ topicals
- Curette
- Cryo (liquid nitrogen)
- Manual removal with large bore needle
- Cantharidin (acid)
- 5-FU/topicals
- Imiquimod topicals
Topical treatments not as effective
Molluscum Contagiosum (MC) Differentials
(2)
- Note: Common for children to have lesions in _____ region, always be suspicious of (1) but many infections occur without any hx of it
Folliculitis, Basal Cell Carcinoma (BCC)
- Note: Common for children to have lesions in genital region, always be suspicious of sexual abuse but many infections occur without any hx of it
- BCC if only 1 or 2 lesions, but very rare in kids, more commonly diff dx of folliculitis - use magnifying glass, are they pustules or firm?*
Human Papilloma Virus (HPV) Verruca Vulgaris
AKA (1)
- Represents an infection of the (1)*
- What do the black dots represent?*
- Most commonly caused by what type of HPV? What types cause genital warts?*
Common Warts
- Represents infection of the keratinocytes*
- Black dots represent hemorrhage d/t trauma to dilated tortuous capillaries within the dermis*
- HPV 2 on body, HPV 6 and 11 in condyloma genital warts*
What condition is shown in these pictures?
- Caused by what type of HPV?*
- Description?*
- Ease of treatment?*
Plantar Warts (Verruca Plantaris)
HPV 1
- Hyperkeratotic papules that coalesce into plaques*
- Very difficult to treat bc skin on the soles of the feet is thickets, so important to manage patient expectations*
What condition is shown in these pictures?
Caused by what type of HPV?
Most common cause (1)
(2) populations primarily affected
Most common sites (4)
Highest rate of (1)
Verruca Planae (Flat Warts)
HPV3
Shaving
Children, young adults
Forehead, cheeks, nose, perioral
spontaneous remission
- HPV type 3. Children & young adults primarily affected. 2-4mm flat-topped papules that are slightly erythematous or brown on pale skin & hyperpigmented on darker skin. Generally multiple and grouped on the face, neck, dorsa of hands, wrists, or knees. Shaving can cause flat warts d/t autoinoculation. Warts tend to form linear formation (koebnerize).*
- Can be confused for lentigines or ephelides.*
Condyloma Acuminata
AKA (1)
- Typically worse during (2)
- Caused by HPV type (2)
- Educate on importance of safe ____
- Tx = ______ (can cause scarring and discoloration)
Genital Warts
- Worse during pregnancy and immune suppression
- HPV 6 and 11
- Educate on importance of safe sex
- Tx = freezing (can cause scarring and discoloration)
Pink pearly penile papules (don’t confuse with warts)
Treatment?
Micropapillomatosis Labialis
Do NOT treat - normal anatomical finding (sebaceous glands of corona)
Condyloma
DDx: skin _____, S____ K_____, M _
- Common in a____, e____, in____ folds
-
(1): Pedunculated, flesh or hyperpigmented color
- Benign and usually found in skin ____. Often a/w _____ gain
- Vary _____ in size from person to person
- Can differential by texture: warts are ____, MC are ____
- Common in axillae, eyelids, inguina folds
- Skin tags: Pedunculated, flesh or hyperpigmented color
- Benign and usually found in skin folds. Often a/w weight gain
- Vary greatly in size from person to person
- Can differential by texture: warts are rough, MC are smooth
24 yo male with no significant PMH, presents with a rash that appeared 10 days ago. He first noted a large spot on his lower chest and several days later states he saw a ton more spots appear. He reports the rash is completely asymptomatic. His ROS is unremarkable. He denies taking a new medications or supplements.
- Eczema
- Psoriasis
- Pitryasis Rosea
- Tinea Corporis
- Drug eruption
- Eczema - not itchy or symptomatic
- Psoriasis - not symptomatic
- Pitryasis Rosea
- Tinea Corporis - maybe that middle spot but doesn’t usually have a big eruption
- Drug eruption - no new meds
Pityriasis Rosea
=
A self-limiting viral exanthem with unknown cause, sometimes a/w URIs most common in healthy children and young adults age 15-40 yo
Pityriasis Rosea Characteristics
Starts with a “____ ____” on trunk
- Few days to weeks later → crops of ____ lesions, ____ colored, ____ shaped, ____ in height, and ______ of scale develop
- _____ face, hands, and feet
- Lasts __ - __ weeks
Starts with “Herald Patch” on trunk
- Few days to weeks later → crops of smaller lesions, salmon colored, ovoid shape (egg shaped), raised, colarette (smaller/tighter collar) of scale
- Spares face, hands, and feet
- Lasts 5-8 weeks
- An inflammatory process. Oval patches usually from neck to knees*
- Salmon-colored papular macular lesions that are first discrete & then may become confluent. Patches are oval and covered w/finely crinkles, dry epidermis which often desquamates leaving a collarette of scaling. Begins w/a herald patch usually larger than succeeding lesions. Herald patch may persist for 1 week before others appear.*
Pityriasis Rosea Treatment
Treatment is symptomatic, pruritis in 50% of cases
- Z___ oxide
- C_____ lotion
- Topical st_____
- Oral anti______, PO antivirals? PO steroids?
- Zinc oxide
- Calamine lotion
- Topical steroids
- Oral antihistamines
What form of Pityriasis Rosea is shown in these pictures?
Inverse Form
Affects axillae, groin, limbs, but spares trunk (note-same applies to inverse psoriasis)
