Dermatology Lecture 2 pt 1 Flashcards
1
Q
What are 4 types of insects/parasites we covered in this presentation?
A
Lice
Bedbugs
Scabies
Spider bites
2
Q
What is this parasite and what are the 3 types?
A
Pediculus humanus capitis (head louse)
- Pediculus humanus corporis (body louse, clothes louse)
- Pthirus pubis (“crab” louse, pubic louse)
3
Q
How do lice give us pruritus?
A
Pruritus occurs as an allergic reaction to lice saliva injected during feeding
4
Q
What is the first line treatment for lice?
A
Topical insecticides such as permethrin or pyrethrin. Ivermectin 2nd line
reapplication 7-10days to kill newly hatched lice
Nit combing
Disinfection or disposable of clothing, bedding, grooming supplies
5
Q
What condition? When do they feed?
A
Bed bugs. Feed at night on blood
6
Q
What type of rash do bed bugs produce?
A
-See macular popular rash with central
scab and moderate pruritis
- 2-5 mm erythematous papule or wheal with
central hemorrhagic punctum
7
Q
Treatment for bedbugs?
A
Get rid of source of bedbugs. Expensive cleaning of the home.
Tx is symptomatic
8
Q
What condition is this? Describe it
A
Scabies
Pruritic burrows, vesicles, and or nodule with excoriations and crusting
9
Q
What are scabie infections commonly located?
A
Between fingers, wrists, flexor aspects and waistline.
10
Q
How are scabies spread? Situations where commonly acquired?
A
Spread by prolonged skin to skin contact
* Frequently sexually acquired
* Common in crowded conditions
* Exposure to clothing, bedding, furniture used by an infested person
11
Q
Clinical features and symptoms of scabies?
A
May take up to 2 mos before S/S appear
- Infested but asymptomatic person can still transmit scabies
- Intense itching, usually worse at night
- Papular rash
- Burrows
- Areas of predilection:
—- Finger web spaces, Wrist, Elbow, Axillae, Penis, Nipples, Waist, Buttocks - Infection always a concern with intense scratching (MRSA, fungus)
12
Q
What type of infection?
A
Scabies
13
Q
What is the treatment for scabies?
A
Permetherin 5% Cream (Elimite)
* Apply to entire body from neck down
* Leave on for 8 hours then shower off
* Repeat the treatment just in case
- 48 hrs after first application (time interval varies)
- Can be used @ 2 mos old
14
Q
What are non-pharmacological treatment considerations for scabies?
A
15
Q
What is a condition that can develop in people that are immunocompromised that get infected with scabies?
A
16
Q
What are the two most concerning types of spider bites?
A
Brown recluse and black widow
17
Q
What spider is this? Where is it found?
A
Brown Recluse
Found in southern and midwestern US
Usually not aggressive
Hide in dark places:
–Rocks, logs, caves, closets, garages, attics
18
Q
How is a severe brown recluse bite described?
A
The lesion is a sinking macule, pale dead gray in color, slightly eroded in the center, with a halo of very tender inflammation and hemorrhage
19
Q
Describe minor brown recluse bites and what are mc location of bites?
A
Most bites are minor
* Erythema and edema
* Envenomation can cause tissue necrosis and hemolysis
MC location: arms, neck, lower abdomen
20
Q
Describe the typical brown recluse bite?
A
Painless or stinging sensation initially
- Within a few hours site is painful and pruritic
- Central induration with a zone of ischemia and zone of erythema
- In most cases resolves in a few days without tx
21
Q
What condition is this?
A
Minor Brown Recluse bit
22
Q
Describe a severe brown recluse bite and wound progression
A
- Spreading erythema with center of lesion becoming hemorrhagic and necrotic
with overlying bulla - Black eschar forms and sloughs weeks later leaving an ulcer and eventually a
depressed scar (not that common) - Can result in nerve injury and secondary infection
- DEBRIDEMENT AFTER FULLY EVOLVE
23
Q
What type of condition is this?
A
Severe Brown recluse bite
24
Q
What are systemic complications of Brown Recluse Spider bite?
A
Fever, chills, weakness, HA, n/v myalgia, arthralgia, rash, leukocytosis may
develop <72 hrs after bite
- Rare-hemolytic anemia, hemoglobinuria, renal failure
25
Treatment for Brown Recluse bite
* Clean the wound, cold packs, elevate
* Pain relief
* Antibiotics if indicated
* Tetanus update
* Debridement/Skin Grafting (extensive debridement has not been proven
beneficial)
* Monitor for signs of secondary complication
26
Black Widow Spider locations?
South Eastern US
Spin their web in dark places
* Under rocks, logs, barns, garages, outhouses
* Problem occurs when the web is disturbed or when spider is trapped
* Bites more common in summer or early autumn
27
Black Widow spider bites
Transmits strong neurotoxin
* The active component of the venom depletes neurotransmitters
28
Black Widow spider bite symptoms
The Black Widow cause neurologic overstimulation (muscle aches,
spasms, and rigidity)
* Painful cramps spread from bite site to large muscles of trunk and extremities
within 60 minutes
* Extreme rigidity and intense pain of abdominal muscles
* Pain usually subsides within 12 hours, but can return
* Other symptoms, tachycardia, diaphoresis, vomiting, weakness, hyperreflexia,
urinary retention, uterine contractions
29
Severe complication of black widow bites?
* Complications-Renal failure, respiratory arrest, cardiac failure, cerebral
hemorrhage. These occur in the elderly, young, and sick
30
Treatment for black widow spider bites?
* Clean wound
* Tetanus
* Analgesics
* Antispasmodics (Benzodiazepines, Calcium Gluconate)
* Anti-venom for moderate to severe bites unresponsive to care. Rarely
indicated and not readily available
31
What are 4 hair and nail conditions we talk about in this section?
Alopecia Areata
Androgenic (genic) Alopecia
Onychomycosis
Paronychia
32
What condition is this ? How is it defined?
Alopecia areata
It is a chronic, relapsing, immune-mediated, inflammatory disorder that affects hair follicles and results in nonscarring hair loss.
33
Describe the presentation of Alopecia areata?
Circular/patchy (areata) shape
Sharply outlined portion (unlike fungus condition) of the scalp with complete hair loss, without erythema, scale, atrophy, or scarring
Can be seen with SLE
34
What are the 3 types of Alopecia?
* Alopecia Areata- Discrete patches of loss
* Alopecia Totalis- Entire scalp is bald
* Alopecia Universalis- All hair bearing areas of body are bald
35
What is the general definition of Alopecia areata?
Recurrent non scarring alopecia that can affect any hair bearing area
* Scalp, beard, eyebrows
* Localized<50%, Extensive>50% involvement
36
What are the causes and clinical features of Alopecia areata?
Cause is unknown but believed to be autoimmune/genetic
-Clinical features
* Pt usually asymptomatic
* Possibly mild pruritis or burning
* Discrete bald patch with smooth non inflamed underlying skin
* Exclamation hairs are pathognomonic
37
What is this condition?
Alopecia areata
38
What clinical feature of alopecia areata is this picture demonstrating?
39
What is the diagnostic evaluation for Alopecia areata?
* Pull test-Pull from the periphery of patch. If hair easily pulls out disease is
active and more loss can be expected
* Dx made clinically
* Association with other diseases
* Thyroid testin
40
What is treatment options for alopecia areata?
* Depends upon extent of disease
* Topical or intralesional steroids
* Immunotherapy
41
Discuss treatment outcomes of alopecia areata?
* Wigs or hair prosthesis
* Disease is unpredictable
* Chance of regrowth great with limited dz, worse chance with extensive dx
* When hair regrows it will be white and fine
* No preventative tx
* Psychosocial suppor
42
What are other conditions that present similarly to Alopecia?
43
What is androgenetic alopecia?
Genetically determined patterned alopecia
* Affects men and women
* Progressive
* What occurs is a gradual conversion of terminal hairs to
indeterminate hairs to finally vellus hairs, “miniaturization”
* Disease of cosmetic concern
* Female pattern hair loss for women
44
General symptoms of androgenetic alopecia? How does it progress in men vs women?
* Patient may report increased hair shedding
-No pruritus or inflammation present
-Men tend to present with gradual thinning at temporal hairline
------* Gradual frontal recession
Women tend to present with thinning at crown of scalp. Women may notice widened part
45
What is this a picture of?
Hamiliton-Norwood scale
Shows progressive balding occurring from bitemporal recession, to frontal and/or vertex thinning to loss of all hair except for occipital and temporal margins.
46
What is this a picture of ?
Ludwig scale
47
How to diagnosis androgenetic alopecia?
* Labs- Hormonal testing for females (DHEAS and testosterone)
* Scalp biopsy-need 2 samples for both horizontal and vertical sectioning
48
Treatment for androgenetic alopecia?
* No cure
* Any tx is attempt to maintain not regrow
* Regrowth is possible not guaranteed
* Best to tx early
* Minoxidil (Rogaine)-Topical soln
* 2% and 5% strengths
* Finasteride (Propecia)-Oral medicine
-----* Not for use in females-teratogenic and can produce feminization in male fetus
* Spironolactone for females
49
Topical minoxidil MOA and ADR?
50
Oral Finasteride MOA and ADR
51
Non-pharmalogical treatments for androgentic alopecia?
* Surgical Treatment:
* Hair transplant
* Wigs
* Course is unpredictable
52
What is Telogen Effluvium?
-Prolonged resting phase of hair cycle
* Considered a non scarring alopecia
* Patient will complain of increased hair shedding
* There is no associated scalp inflammation, no balding spots
* Normal hair loss is 50-150 hairs per day
53
What are inciting factors for Telogen Effluvium?
* Surgery with general anesthesia
* Pregnancy, especially childbirth
* Significant weight loss in a short period of time
* Significant stress
* Febrile illness
* Dietary restrictions
54
What is the work up and treatment for Telogen Effluvium?
* Workup:
* Labs-CBC, thyroid, iron
* Usually done to rule out other causes
Treatment:
* Will resolve on its own but may take 6-12 mos for resolution and regrowth to occur
* No tx will speed up the process of resolution and regrowth
* Emotional Support
55
What is this condition?
Hirsutism
56
Definition of Hirsutism, causes, and treatment?
57
What is this condition? Describe it. Whats the etiology?
Onycomycosis
Thickened, discolored nail and debris on nail bed
T. rubrum most common, candida effects fingernails more than toenails
58
What are clinical features of onycomycosis?
Asymptomatic at first
-----Pt usually presents for cosmetic reasons
As disease progresses pt may c/o pain, numbness May interfere with walking, exercise, standing
Subungual hyperkeratosis
59
How do you diagnosis onycomycosis?
Laboratory: KOH, PAS Stain
oThis is more applicable if you suspect
another nail dz
60
What is treatment for onycomycosis?
Topical antifungal; combo topical/oral
Terbinafine (Lamisil), avoid with liver
disease
Itraconazile (sporanox)
61
What is this?
Fungal hyphae from KOH (onycomycosis)
62
What is this condition? Define it
Onycholysis (notice this different than onycomycosis)
Onycholysis is loosening of the nail plate with separation from the nail bed
63
What can cause onycholysis?
May be from:
* MINOR TRAUMA TO LONG FINGERNAILS
* PSORIASIS
* CANDIDA
* PSEUDOMONAS INFECTION
* HYPERTHYROIDSIM
Work-up based on suspected etiologies
64
What is this condition? describe it?
* Erythema, swelling, and
throbbing pain may extend to
proximal nail fold and
eponychium
65
Define Paronychia? What causes it?
Soft tissue infection that occurs around the fingernail (lateral and proximal nail folds)
Breakdown of the nail fold caused by cracks, fissures, trauma. Allows entryway for organisms
66
What are the two types of Paronychia? What causes them?
Acute-Painful/purulent-Caused by staph infection
Chronic (6Weeks+)-Swelling, non purulent-Candida often isolated but not causative
67
What are the clinical features of paronychia based on the different acuities?
Acute-Pain and swelling at the nail
fold, erythema, pus
Chronic (6 weeks+)-Erythema,
swelling, tenderness at nail fold
------* Nail plate may become thickened
and discolored
68
What are the diagnostic tests for paronychia?
* Bacterial culture
* KOH smear
* Imaging if osteomyelitis suspected
69
What is the treatment for paronychia?
* Acute-I&D and Oral Antibiotics if indicated
* Chronic-topical steroid for inflammation
70
What patient education should you give your patient about paronychia?
* Avoid nail biting
* Trim hang nails
* Trim nails flush to tip
* Avoid excessive moisture exposur
71
What is this condition? What can it indicate?
Splinter Hemorrhages
72
What is this condition? What does it indicate?
Beau's lines - transverse grooves on the nail
73
What is this condition? What does it indicate
Koilonychia "spoon nail"
Seen in iron deficiency anemia
74
What is this condition? What does it indicate?
Terry's nails- "white nails"
Looks like white color then red then white
75
What condition is this? What does it indicate?
Mee's bands - white transverse lines
76
What condition is this? What does it indicate?
Clubbing
Common in chronic hypoxia
77
What is Schamroth technique? What does it test?
When dorsal side of two fingers are placed it should show a diamond shape. If no diamond, then clubbing indicated
78
What are the common viral diseases presented in the presentation
Condyloma acuminatum
condyloma lata
exanthems
herpes simplex
herpetic whitlow
molluscum contagiosum
verrucae
varicella-zoster
echovirus 9
79
What are warts? What are the 3 types of Verrucae (warts)?
* Tan, brown, or pink cauliflower-like papules
Can occur anywhere
* Verruca Vulgaris -Common Wart
* Condyloma Acuminata -Genital Wart
* Plantar Wart -Wart @ bottom of foot
80
What causes verrucae (warts)?
Caused by Human Papilloma Virus (HPV)
* There are different types of HPV
* Typing is most important for genital warts as it determines low risk vs high risk lesions and development of cancer
81
What are the high risk subtypes of HPV?
High risk subtypes include 6, 11, 16, 18
82
Name condition
Verrucae
83
What is Condyloma Acuminatum and what is the diagnostic test for it?
* Soft, skin colored, fleshy verrucous (warts) occurring on anogenital, oral mucosa, or
intertriginous folds
Laboratory test is biopsy with immunofluorescence
84
At home treatments for condyloma acuminatum?
No therapy can eradicate HPV
* Trichloroacetic Acid or topical podophyllin, but may require multiple applications every 2-3 weeks
* Imiquimod 5% Cream (Aldara) for at home treatment
* Podofilox (Condylox) 0.5% solution or gel
85
Clinician administered treatment?
* Cryosurgery w/ liquid nitrogen
* Surgical Removal
* Carbon dioxide laser and electrodesiccation
* Trichloroacetic acid 80-90% (first choice in pregnancy) or bichloroacetic acid bicarbonate (used infacial peels in lesser dose)
* Electrocautery * 5-fluorouracil (Efudex)
86
What condition is this?
Condyloma acuminatum (aka genital warts) caused by HPV 2 virus (STD)
87
What is this condition?
Verrucous intertriginous plaques
seen in secondary syphilis.
88
Whats the difference between condyloma Acuminatum vs condyloma lata
Condyloma lata lesions are smooth, moist, and flat, while condylomata acuminatum lesions, though similar, are cauliflower-like, dry, and bulky.
Condyloma lata caused by syphilis vs condyloma acuminatum is caused by hpv 2
89
What are exanthems?
Generalize macular and/or papular skin eruption associated with systemic infection
-----Enanthem is referred to a mucosal rash
Not very itchy. Treatment: symptomatic
90
What are the 6 childhood disease that cause exanthems? How many are caused by virus?
1) Measles Virus Disease (Rubeola) (1st disease)
2) Scarlet Fever (2nd disease) caused by strep pyogenes (bacteria)
3) German measles (Rubella) (3rd disease) caused (Rubella virus)
4) Staphylococcal Scalded Skin Syndrome (4th disease) caused by staph aureus
5) Erythema infectiosum (fifth disease) caused by Parovirus B19
6) Roseola or Exanthem Subitum (6th disease) caused by Human Herpes Virus 6
91
What is this condition?
Measles Virus/Rubeola
92
General facts about measles virus/ rubeola?
Highly contagious, develop within 10 days of
exposure, last up to 2 weeks
* Rash generally starts on face and spreads down the trunk
93
Symptoms of Measles Virus/Rubeola?
4 Day fever (4D’s) and 3 C’s: Cough, Coryza
(cough, sneezing, rhinorrhea) and Conjunctivitis.
Koplik spots develop but resolve quickly
94
How to diagnose Measles/ Rubeola?
IgM antibodies can be drawn to diagnose
95
What is treatment of Measles and what complication can occur?
* Tx: supportive
* May lead to complications: Myringitis,
pneumonia, encephalitis
96
What condition is this? What causes it?
Scarlet fever (2nd disease)
Caused by Streptococcal Pyogenes
Develops from untreated post streptococcal pharyngitis
97
Symptoms of Scarlet Fever?
Nonpruritic rash on trunk and
extremities, typically extensor
surfaces
* Causes erythema marginatum
* May have “strawberry tongue”,
but can occur in Kawasaki as
wel
98
What happens if scarlet fever goes untreated?
Untreated infection develops
into Rheumatic fever, which can
lead to rheumatic heart disease
99
What condition is this?
German Measles (Rubella)
100
German measles (Rubella) symptoms
* Milder than Rubeola and rash starts the
same way: face to rest of body
* Rash is fainter than Rubeola
* Can have coryza type symptoms as well
* Supportive treatment advised
101
Rubella and pregnancy?
Can result in congenital rubella syndrome if patient is pregnant
* Pregnant mom should be concerned if her
other child has this. (congenital rubella syndrome)
102
What condition is this? What causes it?
Erythema Infectiosum (5th disease)
Parvovirus B19
103
Symptoms of Erythema Infectiosum (5th disease)
Rash does not involve cheeks only, can
spread to trunk
Rash appears AFTER low-grade
fever drops and URI symptoms pass
General happy baby enough symptoms look bad
104
Rare complications of Erythema Infectiosum (5th disease)
* Can cause hepatitis, myocarditis,
pneumonitis
105
Treatment for Erythema Infectiosum (5th disease). Special exceptions
Treatment: self limiting disease
Special concerns in anemic/sickle cell patients (can develop transient aplastic crisis)
And pregnant women: baby can develop hydrops fetalis
106
What condition is this?
Papular Purpuric Glove and Sock Syndrome
107
What can cause Papular Purpuric Glove and Sock Syndrome
* Parvovirus B19 (hydrops fetalis)
* Hepatitis B
* CMV
* EBV
* HHV6
* Measles
* Coxsackie B
* Various Drug Reactions
108
Common symptoms of Papular Purpuric Glove and Sock Syndrome
Can Mimic RMSF
* Lymphadenitis is common, and so is neurological or polyarthritis type symptoms
109
Diagnostic test and treatment for Papular Purpuric Glove and Sock Syndrome
* Diagnosis: Viral serologies (IgM/IgG) or
PCR, CBC to look for anemia
* Treatment is based on symptoms
110
What condition is this? What does it stem from?
Exanthem Subitum (6 th Disease) or Roseola
Stem from HHV6 and HHV7
111
Symptoms of Exanthem Subitum (6th Disease) or Roseola
* Morbiliform exanthem appears AFTER
high fever (> 40C) drops
* Febrile seizures can also happen (10-15%)
* Management is supportive
* non-pruritic
112
Rash and fever timing in exanthem viruses
Rubeola/measles: bad rash and high fever at same time
Rubella/german measles: mild rash and mild fever at same time
Erythema Infectiosum (5th disease): mild rash AFTER mild fever
Roseola (6th disease): bad rash AFTER high fever
113
What are the 8 human herpes viruses (HHV)
HHV1 – Oral HSV
HHV2 – Genital HSV
HHV3 – Varicella Zoster
HHV4 – Epstein-Barr Virus
HHV5 - Cytomegalovirus
HHV6/7 – Roseola or 6 th Disease
HHV8 – Kaposi Sarcoma
114
What is this condition? Describe
* Hand-foot-and-mouth disease
(herpangina)
* Tender vesicles and erosions in the
mouth of a patient with hand-foot-
and-mouth disease; secondary to
coxsackievirus.
115
Other symptoms of Hand-foot-mouth disease and treatment?
* Prodromal sx may occur: fever,
fussiness, abdominal pain, emesis,
and diarrhea
* Disease is self-limiting
116
What is this condition?
Herpes simplex virus (HSV 1)
grouped vesicles on an erythematous base
117
Diagnostics for HSV?
* Direct Microscopy - Tzanck Smear
-----Multinucleated giant cells seen
* Viral culture, but have to unroof the lesion
* Throat culture
* Antigen detection (HSV1 and HSV2 serology)
* PCR for serum antibodies (not during the active phase)
118
Treatment of HSV
Valacyclovir (Valtrex), Acyclovir, Famcyclovir (Famvir)
-daily suppressive therapy for frequent outbreaks
-Keratitis is treated with trifluridine
119
What is this condition?
Herpetic whitlow
* Painful pruritic lesions secondary to
HSV
Dx: Viral culture or PCR
* Tx: Oral acyclovir, topical does not
work
* I&D will make condition worse, so do
not unroof vesicles
120
What condition is this?
Molluscum Contagiosum
121
Clinical features of Molluscum Contagiosum?
122
Diagnosis and treatment of Molluscum Contagiosum
123
What is this condition?
124
Treatment for Varicella-Zoster?
125
Condition?
* Shingles (reactivated latent
phase of VZV or HZV) -
Dermatomal, grouped and
confluent vesicles and pustules
limited to a dermatome(s)
innervated by a corresponding
sensory ganglion. Pain and
burning are common symptoms
126
Condition?
127
Zoster (shingles) diagnosis and treatment
128
What is the treatment for Post Herpetic Neuralgia?
129
What condition?
Echovirus 9
Genetically identical to coxsackie A23 virus
* May mimic acute meningococcemia
* Fever, headache, sore throat, abdominal pain
and vomiting
* Dx: Viral PCR
* Tx: Managed as sepsis
