Dermatology -Jones Flashcards
Erysipelas effects which layers of the skin?
Upper dermis and superficial lymphatics
Cellulitis effects which layers of the skin?
Deeper dermis and subcutaneous fat
Abscesses effect which layers of the skin?
Upper and deeper dermis
Which skin/soft tissue infection is observed in middle-aged and older adults?
Cellulitis
Which microbe commonly causes erysipelas?
Beta-hemolytic streptococci
Which microbe commonly causes cellulitis?
Beta-hemolytic strep and staphylococcus aureus including MRSA
Which microbe commonly causes a skin abscess?
Staph aureus
Acute onset of sx, clear demarcation-butterfly involvement of face are manifestations of what?
Erysipelas
Localized sx developing over days, indolent course with less distinct borders is what?
Cellulitis
Cellulitis can present with or without
Purulence (pus)
Erysipelas is what
Nonpurulent (no pus)
A skin abscess is a collection of
Pus within the dermis of subq space
Furuncle
Skin abscess can develop via infection of hair follicle
Carbuncle
Multiple hair follicle infection-leading to skin abscess
Regional adenopathy and surrounding induration happen with what?
Skin abscess
Diagnosis of erysipelas
Raised above level of surrounding skin, clear demarcations
LRINEC Score
Laboratory Risk Indicator for Necrotizing Fasciitis
A LRINEC score above what can rule in NF
6
Some complications of soft tissue infections include
NF, Bacteremia and sepsis, osteomyelitis, septic joint
What empiric therapy is used in a moderate purulent soft tissue infection? (Furuncle, carbuncle, abscess)
TMP/SMX (Bactrim) or Doxycycline
What empiric therapy can be used for a severe purulent soft tissue infection?
Vancomycin, daptomycin, linezolid, televancin, or ceftaroline
What is the proper treatment of a mild nonpurulent soft tissue infection? (Cellulitis, erysipelas)
Oral Rx! Like penicillin, cephalosporin, dicloxacillin, or clindamycin
What is the treatment for a moderate nonpurulent soft tissue infection?
IV Rx! Penicillin, Ceftriaxone, cefazolin, or clindamycin
How do you treat a severe nonpurulent soft tissue infection?
Surgical inspection/debriedment along with empiric Rx (Vanco plus piperacillin/tazobactam)
What is found most frequently in children ages 2-5?
Impetigo
What is primary impetigo?
Direct bacterial invasion of normal skin
What is secondary impetigo?
Infection is at the site of skin trauma
The most common form of impetigo
Non-bullous
Papules progress to vesicles surrounded by erythema in what?
Non-bullous impetigo
The papules in non-bullous impetigo form into what?
They breakdown and form thick golden crusts
Bullous impetigo
Vesicles enlarge to form flaccid bullae with clear fluid, leaves brown crust
What is ecthyma?
Ulcerative form of impetigo
“Punched-out” ulcers covered with yellow crusts are from what?
Ecthyma
What microbe causes impetigo?
Staph aureus, occasionally beta-hemolytic strep A
Microbe causing bullous impetigo
S.aureus strain that cleaves the superficial skin layer
Microbe causing ecthyma?
Group A beta-hemolytic strep pyogenes
What topical therapy is used for limited non-bullous and bullous impetigo?
Mupirocin and Retapamulin
What oral therapy is used for extensive impetigo and ecthyma?
Dicloxacillin and Cephalexin
What are hives, welts, and wheals?
Urticaria
Urticaria can also be accompanied by what?
Angioedema
What is the duration of acute urticaria?
Less than 6 weeks
Chronic urticaria
Recurrent, with signs an symptoms recurring most days of the week for more than 6 weeks
Round oval vary in size 1 cm up to several
Urticaria
The angioedema in urticaria effects what parts of the body?
Lips, extremities, genitals
What mediates the reaction in urticaria?
Cutaneous mast cells in the superficial dermis
What is released by cutaneous mast cells in urticaria?
Histamine (itching) and vasodilator mediators (swelling)
What are some medications used to treat urticaria?
H1 antihistamines (Diphenhydramine, chlopheniramine, hydroxyzine, cetirizine, loratadine, fexofenadine) H2 antihistamines (Ranitidine, nizatidine, all end in -tidine) Glucocorticoids (Prednisone)
A common benign soft-tissue neoplasm
Lipoma
What do lipomas consist of?
Mature fat cells, enclosed by a thin fibrous capsule
What is a benign soft tissue neoplasm that occurs mainly on the upper extremities and trunk?
Lipoma
A cutaneous cyst with a visible central punctum
Epidermal inclusion cyst
Skin colored dermal nodule
Epidermal inclusion cyst
Where are epidermal inclusion cysts commonly located
Face, scalp, neck, and trunk
What syndrome are epidermal inclusion cysts seen in?
Gardener Syndrome (hereditary condition)
Treatment of epidermal inclusion cyst?
Excision of cyst or incision and drainage
What’s the most common cutaneous disorder affecting adolescents and young adults
Acne
Acne is a disease of
Pilosebaceous follicles
What are the 4 factors of acne?
- Follicular hyperkeratinization
- Increased sebum production
- Cutibacterium acnes within the follicle
- Inflammation
What happens in prepuberty to the sebaceous glands?
They enlarge and sebum production increases
Sebum provides a growth medium for?
C.acnes
What provides an anaerobic lipid-rich environment for bacteria in acne?
Microcomedones
What is another name for a white-head?
Closed comedone
What is another name for a black-head?
Open comedone
What leads to inflammatory papules and nodules in acne?
Proinflammatory lipids and keratin
What can cause infantile acne?
Elevated levels of androgens produced by immature adrenal glands in girls and immature adrenal glands and testes in boys
What serum level rises as puberty approaches?
DHEA-S levels
DHEA-S is related to acne how?
Onset of acne correlates with high levels of DHEA-S, high levels found in prepubertal girls with acne
What are some conditions where hyperandrogenism is seen?
PCOS, congenital adrenal hyperplasia, adrenal or ovarian tumors
What can worsen acne?
Repetitive mechanical trauma like scrubbing; ruptures comedones and promotes inflammatory lesions
Occlusion of pilosebaceous follicles leads to what?
Comedone formation
What are some drug-induced causes of acne?
Glucocorticoids, phenytoin, lithium, isoniazid, iodides, bromides, androgens
Can milk worsen acne?
Yes, increased levels of IGF are associated with consumption of milk. Hormones seem to exacerbate acne
Is insulin resistance related to acne?
It can stimulate increased androgen production and is associated with increased serum levels of IGF
What are the three classifications of acne?
- Comedones acne (noninflammatory)
- Inflammatory acne
- Modular acne
What are some diagnostic tools for acne?
Endocrine fx, DHEA-S, total testosterone and free testosterone
What can the rapid onset of acne suggest?
An adrenal or ovarian tumor
What is the treatment for follicular hyperkeratinization? (5)
- Topical retinoids
- Oral retinoids
- Azelaic acid
- Salicylic acid
- Hormonal therapies
What is the treatment for increased sebum production? (2)
- Oral isotretinoin
2. Hormonal therapies
What is the treatment for c. Acnes proliferation? (3)
- Benzoyl peroxide
- Topical and oral antibiotics
- Azelaic acid
What is the treament for inflammation in acne? (4)
- Oral isotretinoin
- Oral tetracyclines
- Topical retinoids
- Azelaic acid
Which acne symptoms can be treated with topical retinoids?
Follicular hyperkeratinization and inflammation
What are some examples of topical retinoids?
Retin-A, Tretin-X, Atralin, Avita, Refissa, REnova, Adapalene, Tazaotene
Which topical retinoid will you have to be careful of fish allergies?
Atralin
When should topical retinoids be taken?
Once daily at bedtime, watch for sun sensitivity!!!
What are some topical antimicrobials used to treat acne?
Benzoyl peroxide, Clindamycin, Erythromycin, Dapsone
What is important to note about topical combination products (used for acne)?
Used once daily, may bleach hair or clothing
What are some oral antibiotics used for acne?
Tetracycline, Doxycyline, Minocycline, Erythromycin, Trimethoprim-sulfamethoxazole, Azithromycin int. Dosing
What hormonal agents are used to control acne?
Combination oral contraceptives and Spironolactone
What oral retinoids are used to treat acne?
Isotretinoin, Accutane
What acne symptoms can be treated with oral retinoid?
Follicular hyperkeratinization, increased sebum production, and inflammation
How long can treatment take to work for acne?
4-6 weeks, may get worse before it gets better
What is a common skin disorder localized primarily to the central face?
Rosacea
What are the 4 main subtypes of rosacea?
- Erythematotelangiectatic
- Papulopustular
- Phymatous
- Ocular rosacea
Who is most likely to get rosacea?
Celtic and Northern European origin, adults over 30, and females (except for phymatous form)
What are some factors contributing to rosacea?
Vascular dysfx, UV damage, inflammatory rxns to cutaneous organisms, abnormalities in innate immunity
What are clinical features of erythematotelangiectatic rosacea?
Persistent central erythema, flushing, enlarged cutaneous blood vessels, roughness and scaling
Erythema congestivum
After an exacerbation of facial redness, return to baseline is slow (erythematotelangiectatic rosacea)
What are the clinical features of papulopustular rosacea?
Papules and pustules present in central face, can be mistaken for acne although there are no comedones
What are the clinical features of phymatous rosacea?
Exhibits tissue hypertrophy (thickened skin with irregular contours)
Commonly occurs in men, and involves the nose, chin, cheeks and forehead
What are the clinical features of ocular rosacea?
Occurs in more than 50% of patients with rosacea
Conjunctival hyperemia, blepharitis, keratitis, lid margin teleangiectasias, abnormal tearing, chalazion, hordeolum
What are some exacerbating factors to rosacea?
Extreme temps, sun, hot beverages, spicy food, alcohol, exercise, irritation from topical patterns, emotions (anger, rage, embarrassment), drugs (nicotinic acid, vasodilators), skin barrier disruption
How do you diagnose rosacea?
Assessment is key, biopsies rarely indicated, no serologic studies useful
How to manage erythematotelangiectatic rosacea?
First line: behavioral changes, sun protection, decrease alcohol
Second line: laser and light-base therapy
Rx: Topical Brimonidine and Oxymetazoline
How to manage papulopustular rosacea?
Topical: metronidazole, azelaic acid, ivermectin
Oral: tetracycline, doxycycline, minocycline, isotretinoin
How to manage ocular rosacea?
Lid scrubs, warm compresses, topical antibiotics (Ilotycin ointment), referral to ophthalmologist
How to manage phymatous rosacea?
Oral isotretinoin in early disease and laser ablation/surgery in advanced disease
Which skin disease is characterized by well-demarcated erythematous plaques with silver scales?
Psoriasis
Prevalence of psoriasis tends to increase when?
When farther away from the equator
What are the two peaks of age onset for psoriasis?
20-39 and 50-69 years
What role does genetics play in psoriasis?
40% with family history have it, concordat among monozygotic twins
Predisposing risk factors to psoriasis include
Smoking, obesity (increased proinflammatory cytokines), drugs, infections, alcohol, vitamind D deficiency
Which drugs can be risk factors for psoriasis?
Beta blockers, lithium, antimalarials
What types of infections can be risk factors for psoriasis?
Poststrep flares and HIV
What is the pathophysiology behind psoriasis?
Complex immune-mediated disease
Typical clinical findings of psoriasis
Scaling, induration and erythema, hyperproliferation and abnormal differentiation of the epidermis, inflammatory cell infiltrates, vascular dilitation
What are the 6 clinical categories of psoriasis?
- Chronic plaque
- Guttate
- Pustular
- Erythrodermic
- Inverse
- Nail
What is the most common variant of psoriasis?
Chronic plaque
Chronic plaque manifestations
Symmetrically distributed, found on scalp, extensor elbows, knees, and gluteal cleft
May be asymptomatic but pruritis is common
Guttate psoriasis manifestations
Abrupt appearance of multiple small psoriatic papules and plaques (usually less than 1 cm)
Strong association with recent infection (strep)
Guttate psoriasis is most commonly found on what parts of the body?
Trunk and proximal extremities
Which type of psoriasis can have life-threatening complications?
Pustular psoriasis
What are the manifestations of pustular psoriasis?
Most severe variant (von Zumbusch type), acute onset wide-spread erythema, scaling and sheets of superficial pustules
What is pustular psoriasis associated with?
Malaise, fever, diarrhea, leukocytosis, hypocalcemia
Some possible causes of pustular psoriasis
Pregnancy, infection and withdrawal of glucocorticoids
Which type of psoriasis is characterized by generalized erythema and scaling from head to toe?
Erythrodermic psoriasis
Complications arising from erythrodermic psoriasis include
Related to loss of adequate barrier; electrolyte abnormalities
Which areas of the body are affected by inverse psoriasis?
Inguinal, perineal, genital, intergluteal, axillary, inframammary
Inverse psoriasis can sometimes be misdiagnosed as what?
Fungal or bacterial infection
Patients with psoriatic arthritis are more likely to have
Nail psoriasis
How to diagnose psoriasis
Family history, clinical exam, skin biopsy, no lab tests
What is the management for mild to moderate psoriasis?
Emollients, topical corticosteroids, vitamin D analogs, topical retinoids, anthralin, tacrolimus or pimecrolimus (for face)
Which topical corticosteroids can be used to treat mild to moderate psoriasis?
hydrocortisone, triamcinolone, fluocinonide, betamethasone diproprionate, clobetasol
Which vitamin D analogs can be used for mild to moderate psoriasis?
Calcipotriol, calcitrol, tacalcitol, tar-t
What is the management for moderate to severe psoriasis?
Phototherapy, systemic therapy, and biologics
What are the options of phototherapy to treat psoriasis?
UVB alone or in combo with topical tar
Narrow band UVB in suberythemogenic doses
Home phototherapy machines ($$$)
What systemic therapies are used to treat moderate to severe disease?
Methotrexate (folic acid antagonist)
Cyclosporine (t cell suppressor)
Apremilast (phosphodiesterase 4 inhibitor)
What biologics are used to treat moderate to severe psoriasis?
Entanercept, Infliximab, Adalimumab, Ustekinumab (-umab)
What is a chronic immune-mediated disorder that targets active hair follicles causing hair loss?
Alopecia
Commonly presents with discrete patches on the scalp
Alopecia
What is alopecia areata?
Discrete patches of hair loss
What is Alopecia totalis?
Hair loss of the entire scalp
What is alopecia universalis?
Hair loss of hate entire body
What is the pathophysiology behind alopecia?
T-cell mediated inflammation, inappropriate trigger of immune response against follicular antigens
Does alopecia lead to the destruction of the hair follicle?
No
What are some risk factors for alopecia?
Stress, drugs, infections, vitamin D definciency, genetics
Alopecia develops over a period of what?
2-3 weeks
What else can develop in patients with alopecia?
Nail abnormalities- onychorrhexis (longitudinal fissuring of nail plate)
What are some associated diseases with alopecia?
Lupus, vitiligo, atopic dermatitis, thyroid disease, allergic rhinitis, psoriasis, Down syndrome, polyglandular autoimmune syndrome type 1
50% of patients with alopecia will what?
Recover spontaneously in a year
What can be a diagnostic tool when looking for alopecia?
Exclamation point hair at margins, skin biopsy, and peribulbar lymphatic inflammatory infiltrates surrounding the follicles
For limited patchy hair loss what is the treatment?
Topical or intralesional corticosteroids (triamcinolone, betamethasone dipropionate)
For extensive alopecia, what is the treatment?
Topical immunotherapy (DPCP, SADBE, DNCB)
How is the topical immunotherapy dosed when treating extensive alopecia?
2% solution is applied first to desensitize the pt, 1-2 weeks later 0.01% applied to affected area 1/week titration get up to 2%
DC after 6 mo if no improvement
What can be some second-line treatment for alopecia?
Minoxidil, Anthralin, and phototherapy
Some examples of systemic therapies for alopecia
Oral glucocorticoids, sulfasalazine, methotrexate, cyclosporine, biologics
What is hidradenitis suppurativa?
Hidros: sweat, Aden: glands
Chronic inflammatory skin condition, also known as acne inversa
What population tend have hidradenitis suppurativa more?
African American women
What is the patho behind hidradenitis suppurativa?
Plugging, rupture, and inflammation of follicle. Stimulates an immune response and leads to sinus tracts in the skin
What are the most common sites of HS?
Axillae, inguinal, inner thigh, perianal, inframammary, buttocks, scrotum, vulva
Hidradenitis suppurativa can be misdiagnosed as what?
Furunculosis or abscess
What are the 3 stages of hidradenitis suppurativa?
1: abscess formation
2: recurrent abscess formation with sinus tract formation and scarring
3: diffuse involvement multiple interconnected sinus tracts
What will be important to find in a clinical exam for a pt with hidradenitis suppurativa?
Typical lesions (inflamed nodules, sinus tracts) in the typical locations (axillae, groin) with relapse and chronicity Skin biopsy not necessary
How can a pt prevent hidradenitis suppurativa?
Avoidance of skin trauma, stop smoking, weight management, chlorhexidine 1/week, emollients
How can a pt in Hurley stage 1 (stage 1 of HS) manage it?
Topical clindamycin, intralesional corticosteroid (triamcinolone), punch debridement to evacuate inflammation, topical resorcinol (peel)
What is the management for Hurley stage 2 of HS?
Oral tetracycline (many months), clindamycin and rifampin, oral retinoids, antiadrenergic therapies, punch biopsy of lesions
What is the management of Hurley stage 3 of HS?
TNF-alpha inhibitors once weekly, systemic glucocorticoids (prednisone), cyclosporine, surgery