Dermatology III Flashcards
List 4 malignant neoplasms
1) Basal Cell Carcinoma (BCC)
2) Squamous Cell Carcinoma (SCC)
3) Melanoma
4) Kaposi Sarcoma
1) What is the most common cancer?
2) Demographic, age of onset, & etiology?
3) Where does it most commonly occur?
1) BCC
2) Onset >40 y/o, M>F, ultraviolet light (UVB)
3) In fair-skin (I-III) rare in brown & black skin (V-VI,) 70% on face/chest. “Danger sites”: medial/lateral canthi, nasolabial fold, post-auricular
Basal cell carcinoma (BCC):
1) List risk factors
2) Describe the Sx and speed of progression
1) Fair skin (I-III), albinos, light-colored eyes, red hair, prolonged sun exposure, northern European ancestry, older age, heavy sun exposure in youth, tanning beds
2) Slow growing, usually asymptomatic, but can bleed/scab or feel sensitive if on a nerve
What are the clinical & histologic sub-types of BCC?
1) Clinical: superficial, nodular, pigmented, morpheaform
2) Histologic: superficial, nodular, micronodular, infiltrative
Basal cell carcinoma (BCC):
1) DDxs?
2) How is it diagnosed?
3) Txs?
1) All smooth papules, melanoma, all non-painful ulcers (SCC, syphilis)
2) Clinical, confirmed microscopically with biopsy
3) Excision with primary closure
-Cryosurgery & electrosurgery (limited)
-Mohs is best for morpheaform & lesions in danger or cosmetically sensitive sites and scalp
-Topical (5-fluorouracil ointment & imiquimod) for superficial lesions below neck
-Treatment depends on location, size and type
1) What is the most common subtype of BCC?
2) What does it look like?
1) Skin-colored or reddish, translucent (“pearly”), well-defined, firm, smooth papule or nodule with telangiectasia
2) Erosions & melanin stipples; Ulceration with crust & rolled border
Pigmented BCC:
1) What colors can it be?
2) What does it feel/ look like?
3) DDxs?
1) Brown, blue, or black
2) Hard, firm; Round, oval, can be ulcerated
3) Superficial spreading melanoma, nodular melanoma
Morpheaform BCC:
1) What is this form also called? What % of BCC cases?
2) What does it look like?
1) Sclerosing BCC; 5-10% of BCC cases
2) Smooth, flesh-colored or light erythematous papules or plaques, atrophic. ill-defined borders.
-Scar-like appearance in some areas
Squamous cell carcinoma (SCC):
1) Demographic/ age of onset?
2) Risk factors?
3) What types of lesions can it present as?
1) >55 y/o, M>F
2) Sun exposure, light-colored skin, easily burns/poor tanning, outdoor occupations-pilots/truckers/farmers, immunosuppression (organ transplant, HIV,) chronic inflammation, industrial carcinogens
3) Solitary or multiple macules, papules, plaques, ulcers
SCC:
1) Is it always smooth?
2) What may it arise from?
3) Does it progress quickly?
4) How is it diagnosed?
1) Hyperkeratotic or scaling
2) May arise from AK
3) Can rapidly evolve
4) Biopsy (shave, punch, or excisional)
Squamous cell carcinoma (SCC)
1) How is it treated in situ?
2) What about invasively?
1) Imiquimod or 5-fluorouracil, curettage & electrodessication
2) Excision or Mohs surgery
Superficial SCC
1) What is the most common site?
2) How does it typically present?
3) What is a DDx?
1) Most common site = trunk
2) Slightly scaly, macules, patches, or thin plaques light red to pink in color. Telangectasias may be seen.
3) Actinic keratosis (AK)
Why is MMS the preferred method?
Offers superior histologic analysis of tumor margins while permitting maximal conservation of tissue compared with standard surgical excision
-Recurrence rates tend to be lower with MMS compared to other modalities, including standard electro-desiccation and curettage, radiation, and cryotherapy
What are some indications for Mohs Micrographic surgery (MMS)?
1) Lesions on nose, ears, eyes, lips, scalp, hands, and cosmetically sensitive areas
2) Aggressive histologic subtypes: infiltrative, sclerosing, morpheaform, or micronodular
3) Large tumors or tumors with indistinct clinical borders
4) Recurrent tumors
What is the leading cause of death due to skin disease and least common type of skin cancer?
Melanoma
1) What is the most common malignant tumor of the skin?
2) Demographic?
3) Etiology/ pathogenesis?
1) Melanoma
2) 1 in 4 cases before age 40
3) Lifetime risk 2% Caucasians, 0.1-0.5% non- Caucasian
Etiology & pathogenesis unknown (likely due to exposure to solar radiation)
1) What is the single most important prognostic factor for melanomas?
2) Describe this
3) How many major clinicohistologic types are there?
1) Tumor thickness at time of Dx
2) 10-year survival related to thickness in mm
<1 mm = 95%,
1-2 mm = 80%
2-4 mm = 55%
3) Four
List the different presentations of melanoma (4 major clinicohistologic types) and how common they are
1) Superficial spreading 70%
2) Nodular 15%
3) Lentigo 5%
4) Acral lentiginous 5-10%
What is the single most important Hx reason for close eval and possible referral of a spot?
History of a changing mole (evolution, including bleeding & ulceration)
What is the mnemonic for clinical features of pigmented lesions suspicious for melanoma?
A: Asymmetry
B: Border irregularities (ill-defined)
C: Color variation (variegation)
D: Diameter > 6 mm
E: Evolution (changing in shape, size, color, or is new)
1) What are some DDxs for melanoma?
2) How is melanoma diagnosed?
1) Melanocytic lesions, non-melanocytic lesions, benign nevi
2) Clinical, ABCDE criteria, “ugly duckling” sign
Melanomas:
1) Describe how to Dx
2) Describe Tx options
1) Excisional biopsy-must take wide margin (1 cm margin for every 1mm of lesion depth.) vs punch biopsy
2) Excision & histology, followed by re-excision with borders based on thickness of tumor (pathology report)
-Referral to centers with expertise in melanomas for intermediate-to-high risk patients
-Sentinal lymph node biopsy: All lesions >1 mm thickness & high-risk histologic features (ulcers)
Kaposi sarcoma:
1) What is it? What is it linked with?
2) How does it present? How many variants are there and who are they seen in?
3) Tx?
1) Systemic endothelial cell tumor
Linked with HSV-8 infection
2) Purple, brown, black patches, plaques, & nodules
4 clinical variants (seen in those with immunodeficiencies/ HIV/AIDS)
3) Radiation, chemotherapy, antivirals- typically responds to treatment
1) What is the difference between nevus and nevi? Benign or malignant?
2) What nevi can be dome shaped?
3) What are some other characteristics that can be found?
1) Nevus (single), nevi (plural); benign
2) Small congenital nevi, especially when on the face.
3) Sometimes they are mamillated (with small protuberances) and have hypertrichosis (increase in density and coarseness of hairs).
Congenital nevus:
1) What is it called when they’re >20cm (in an adult)?
2) When is the risk of developing melanoma is ~ 5-10% with congenital nevi?
3) What should a provider do for these?
1) Large or Giant
2) For large/giant congenital nevi
3) Monitor yearly with photos
What are groups of similar nevi sometimes called?
Signature nevi
Atypical nevi:
1) What are they also called? Benign or malignant?
2) What do they share clinical features with?
3) What do these increase the risk of? In who?
4) Demographic?
1) Dysplastic nevi; benign acquired melanocytic nevi
2) Melanoma: asymmetry, irregular borders, color variegation, diameter > 5mm
3) Increased risk of melanoma: pts with >50 nevi with >1 atypical nevi & 1 nevus >8 mm
4) Children & adults, M=F; 5% of Caucasian population, rare in Japanese
-Occur in almost all patients with familial cutaneous melanoma
Atypical nevi:
1) Where can they occur?
2) Where do they rarely occur?
3) How may they present?
4) How are they diagnosed?
1) Any location, most common on trunk & extremities
2) Rarely on chronically sun-exposed skin (face, hands)
3) Variegated color with tan, brown, black and pink macules
4) May have “fried egg” appearance
5) Clinical, dermoscopy, biopsy if suspect melanoma
1) What is a basic rule of biopsies?
2) Why?
3) What happens if this rule isn’t followed?
1) Never do a superficial shave biopsy of a pigmented lesion that is a possible melanoma.
2) Most important determinant of survival in melanoma is the Breslow depth, or tumor thickness, of the initial tumor.
3) If a shallow shave biopsy does not contain the entire depth of the lesion, that information is unknown.
Why not initially excise the entire lesion? Explain
It is best to biopsy the lesion in order to obtain histologic confirmation prior to surgical removal, as biopsy may have revealed:
1) A benign growth, in which case excision would have been unnecessary
2) A tumor different from suspected lesion that may have required a different management approach
3) Melanomas require large margins
1) What is a contraindication to skin biopsies?
2) When should you use caution?
1) Infection
2) If patient on blood thinners
Abscesses:
1) What are they & what’s the most common cause?
2) How do they usually present?
3) Risk factors?
1) Collection of pus in dermis or subcutaneous space; S. aureus (MSSA, MRSA)
2) Skin erythema, edema, warmth and fluctuance, very painful
3) Skin disruption or inflammation, edema, obesity, immunosuppression, pre-existing skin infection, skin breaks (toe web spaces)
Describe how to treat abscesses (4 things)
1) The patient needs to stop mashing it-may further damage surrounding tissue. Damaged tissue does not heal.
2) Must perform incision and drainage (I&D) irrigation
3) Have patient apply heat/warm compress afterwards
4) Do not typically need PO antibiotics
-Typically, will heal up after drainage without further antibiotics or treatment
Cellulitis:
1) What is it?
2) Where is it usually located?
3) What is usually the cause?
4) What are the typically Sx?
5) What may it progress to?
1) Diffuse, spreading infection of dermis & subcutaneous tissue
2) Usually on lower leg; unilateral
3) Group A Beta-hemolytic streptococci or S. aureus
4) Edema, erythema, pain, warmth
5) May progress to chills, fever, malaise (possible septicemia, hypotension, shock)
Cellulitis:
1) 2 DDxs?
2) Tx?
3) When should you admit?
1) DVT, necrotizing fasciitis
2) Antibiotics (IV vs PO) ex/ PO Cephalexin 500mg PO BID IV/IM Cefazolin 0.5- 1 gm q6-8 hr
Mark borders to monitor progress
3) Severe local symptoms, WBC > 10K, failure to respond to PO antibiotics, systemic symptoms
1) What is a similar form of cellulitis? What causes it?
2) Primary characterisitic?
3) Demographic?
4) Risk factors?
5) Other Sx?
1) Erysipelas; beta-hemolytic strep
2) “St. Anthony’s Fire” rash
3) Young & old
4) Prior episode, skin break, nephrotic syndrome, prior injury, HIV, alcoholism, obesity, pregnancy
5) Pain, malaise, fever, chills
Erysipelas:
1) Where is it on the body?
2) Tx?
1) Lower limbs & butterfly distribution on face, borders better defined than cellulitis, skin is shiny
2) IV vs PO antibiotics
-Cephalexin 500mg PO q12hr,
-Cefazolin 0.5 – 1 gm q6-8 hr
Impetigo:
1) What is it?
2) Who is it most common in?
3) Etiology?
4) Course of the condition?
5) Tx?
1) Contagious superficial bacterial infection
2) Most frequent in children 2-5 y/o
3) S. aureus, Group A strep
4) Papules progress to vesicles, surrounding erythema, then pustules, then honey-colored crust
5) Topical antibiotics (mupirocin) especially in nares BID x 5d, PO antibiotics as indicated for underlying infection -cephalexin 250-500 mg PO q 6-12 h x 5-7 d – will treat group A strep and S. aureus ( for <12 yo 25-50 mg/kg/d q6-8 2000mg/d max)
1) Who is the Rule of Nines for?
2) When should you transfer to burn unit?
3) What % is the palm?
1) Adults
2) 5-10% BSA
3) 1%
1) When is a burn considered severe?
2) What are the ABCs of burns?
3) What is the formula for fluid? (don’t need to memorize)
4) What is a predictor of worse burn outcomes?
1) >20% TBSA
2) Airway, Breathing, Circulation, Disability, Exposure
3) Parkland formula: adults: 4ml/kg x % TBSA, ½ given first 8 hrs = MLs of fluid needed in first 24 hrs
-Also Tetanus/pain meds
4) Hyperglycemia: predictor of worse outcomes
1) What is a lipoma? Is it benign?
2) Where is it most common?
3) What is the Tx?
1) Benign subcutaneous fatty tumor; soft round, lobulated, mobile
2) Most common on neck, trunk, & extremities
3) Reassurance or surgical removal
Epidermal inclusion cyst (EIC):
1) What is it?
2) What does it look like?
3) What is a key characteristic?
1) Benign growth of upper hair follicle, very common on scalp
2) Firm, dermal papule or nodule; overlying black comedone (punctum) on face, base of ears, or trunk
3) Expressible foul-smelling cheesy material
Epidermal inclusion cyst (EIC):
1) Size?
2) What can it mimic?
3) Tx options?
1) 0.3 cm – several cm
2) May become red & drain (mimics abscess)
3) None if asymptomatic-tell patients not to manipulate
I&D
-Surgical excision if symptomatic
Pressure ulcers:
1) Cause?
2) Who are they seen in?
3) Risk factors?
1) Body weight over bony prominence creates friction and pressure
2) Elderly/bedridden
3) Poor nursing care, lack of sensation, hypotension
1) Tx options for pressure ulcers?
2) What should you make sure isn’t happening?
1) Repositioning / reduce pressure; Antibiotics/Surgery
2) Consider osteomyelitis
What are the 4 stages of pressure ulcers?
Stage I-Non blanching erythema, skin intact
Stage II-Epidermis/dermis layer
Stage III-full thickness (to sub Q)
Stage IV-muscle and bone
Vitiligo:
1) What is it?
2) Who does it affect?
3) What may it involve?
1) White macules, complete absence/destruction of melanocytes
2) 1% population, all races
3) May enlarge to affect entire skin, often starts on knuckles or around mouth
Vitiligo:
1) What can it cause?
2) Tx?
1) Psychological problem
2) Oral PUVA psoralen (drug) and ultra-violet radiation
-Can use tinted creams/makeup to cover lesions in cosmetically sensitive areas
Melasma:
1) Who is it most common in?
2) What is it?
3) What can cause it? Explain
1) Very common females»>males 9:1
2) Hyperpigmented sharply demarcated macules in sun exposed areas, usually face malar/frontal; benign
3) Exposure to sunlight; can be idiopathic, but usually hormone related
-Pregnancy, OCP
-Some meds = anti-seizure, photosensitive meds (ATBs, anti-HTN)
Melasma Tx options?
1) Hydroquinone 3% soln, 4% crm azelaic acid 20% crm
Can be compounded or in combo with tretinoin or glycolic acid
2) PREVENT with sun blocks, hats, UV protectant on car windows
Lasers can worsen
Photosensitivity reactions:
1) What are they?
2) Where do they occur?
3) Prevention?
4) How to Tx the photoaging aspect?
1) Abnormal response to sunlight exposure
2) Only sun exposed areas
3) Sun block, UV blocking clothes, hats
4) Laser and prevention, hydroquinone
Photosensitivity reactions: What are the 4 types? Describe each
1) Sunburn type: Photoreaction to drugs (mimics sunburn)
2) Photoallergic rash: macules, papules or plaques
3) Urticarial: solar urticaria
4) Chr sun exposure = photoaging
How should you treat photosensitivity reactons?
Time, cool bath, avoid sunlight, NSAIDs as needed, topical steroids for sunburn if indicated
Syphilis:
1) What is the etiology?
2) What is a nickname for this condition?
3) How is it transmitted & what is its primary first Sx?
1) Treponema pallidum (spirochete)
2) “The Great Imitator/Masquerader”; 10 million cases annually
3) STI; painless chancre
Syphilis:
1) What are the secondary Sx?
2) Tx?
1) Maculopapular rash on trunk, extremities (palms and soles)
2) 2.4 million units penicillin G IM/IV QD x7d
List the classes of steroid potencies and give an example of each
(Use C = cream, F = foam, G = gel, L = lotion, O = ointment, S = solution)
Class 1: Very high potency
-Clobetasol 0.05% C F G L O
Class 2: High potency
-Fluocinonide 0.05% C G O S
Class 3: High potency
-Triamcinolone 0.1% O (good)
Class 4: Mid potency
-Triamcinolone 0.1% C
Class 5: Mid potency
-Hydrocortisone butyrate 0.1% cream
Class 6: Low potency
-Desoride 0.05% C L O (really only for babies)
Class 7: Low potency
-**Hydrocortisone hydrochloride: .25% CL; .5%, 1%, 2%, 2.5% CLOS,
Continuous daily Tx w. steroids for longer than ________ weeks is not recommended
4
List some adverse effects of topical steroids (that can happen w continuous daily use)
1) Bruising
2) Skin thinning
3) Tinea incognito
4) Prominent capillaries
5) Stretch marks
6) Localized pustular psoriasis
List 3 steroids and how to dose them
1) Clobetasol propionate 0.05% foam >12 yrs
2) Desonide 0.05% foam/ gel >3 months
3) Hydrocortisone butyrate 0.1% cream >3 months
