Dermatology-Peckham 2 Flashcards
What is a common pruritic inflammatory disease of skin, mucous membranes and hair follicles?
Lichen Planus
What are the 4 Ps involving Lichen Planus?
Purple, Polygonal, Pruritic, Papule
Where are the lesions grouped to in lichen planus?
Flexor aspect of wrists, lumbar area, eyelids, shins, scalp
Si/sx of Lichen Planus
Pruritic, lesions appear for <1yr, can cause hair loss and damage nails. Variations can be ulcerative
Potent topical steroids w/occlusion is the proper tx for what?
Lichen Planus
What can also be known as a benign “warty” growth
Seborrheic Keratosis
Seborrheic keratosis has what presentation?
“Stuck on” flat or raised papule or plaque. White, flesh colored to tan, brown, warty or smooth
Is tx required for seborrheic keratosis?
No
What is a vascular neoplasm brought on by genetic factors, hormonal factors, immunodeficiency or infection with HHV-8?
Kaposi Sarcoma
What are the 4 types of Kaposi Sarcoma?
- Classic
- HIV associated
- Endemic/African
- Iatrogenic
Kaposi Sarcoma presentation
Purplish macules that evolve to infiltrative plaques and nodules or tumors, often on lower extremities with lymphedema
Where can Kaposi Sarcoma also involve?
GI tract and lungs (very rarely)
What is the best Dx for Kaposi Sarcoma?
Biopsy
What progresses slowly with rare lymph node or visceral involvement?
Kaposi sarcoma
Some treatment options for Kaposi sarcoma include?
Radiation therapy, cryotherapy, surgical excision of individual nodules, topical Alitretinoin, dye laser
What are in situ dysplasias resulting from UV radiation that may progress to SCC?
Actinic Keratosis
What is the most common epithelial precancerous lesion?
Actinic keratosis
Who is at greater risk for actinic keratosis?
White men older then 50 with an outdoor lifestyle
The etiology of actinic keratosis
UVR leads to mutations in TP53 and deletion of the gene coding for p16 tumor suppressor protein
What is the pathophys behind actinic keratosis?
Epidermal lesion with atypical keratinocytes at basal layer that can extend upwards
Where is actinic keratosis most commonly found on the body?
Chronically sun exposed surfaces like the face, ears, scalp, dorsal hands, forearms, anterior legs
On palpation, what does actinic keratosis feel like?
Sandpaper texture, most times more easily felt than seen
Actinic keratosis clinical manifestations
Multiple discrete, flat or elevated verrucous or keratotic, red, pigmented or skin colored
What would be some differential diagnoses for actinic keratosis?
BCC, SCC, seborrheic keratosis, lupus
Is is appropriate to biopsy for actinic keratosis?
Yes, clinical/history Dx is also very important
Treatment for actinic keratosis is
Surgical: cryotherapy
Medical: Imiquimod or 5-FU
Is cryotherapy effective with actinic keratosis?
Yes with limited lesions. Goal is to produce cell death at -320F
What structures in the skin are more resistant to cryotherapy?
Collagen, blood vessels and nerves are more resistant that keratinocytes
What is the risk for cryotherapy?
Blistering, melanocytes are more sensitive so if often leaves hypopigmented spots
Imiquimod
For extensive broad and numerous AK lesions. its an interferon inducer that produces an immune rxn against lesion
What does imiquimod cause?
Erythema and crusting, but is less irritating than 5-FU
5-FU
Interferes with DNA synthesis, apply bid for 4 weeks
Ingenol mebutate
Used for AK, induces cell death. Apply daily x 3 days to face or 2 days to body
How should you follow up on a pt with AK?
Areas should smooth over, stubborn lesions should be biopsied for concern for squamous cell carcinoma
How is the prognosis for pts with AK?
Good with continued monitoring every 2-6 mos
How can a pt prevent AK?
Avoid sun exposure, use broad spectrum sunscreen, apply often
What are the most common form of all cancers?
Nonmelanoma skin cancers
What type of cancer is an epithelial tumor of the basal keratinocytes?
Basal Cell Carcinoma
Who has a greater risk for BCC?
Same as AK, white men 40 yrs or older with an outdoor lifestyle
What are some causes for BCC?
UVR, immunosuppression for organ transplant increases risk as well
What does BCC arise from?
Immature pluripotential cells associated with the hair follicle
BCC lesions
Flat, firm, pale area that is small, raised, pink or red, translucent, pearly and waxy, and the area may bleed following minor injury. May have “rolled edge”
A lesion that bleeds without significant pain or symptoms can be from what?
BCC
What is nodular BCC?
Most common, waxy, pearly, semitranslucent nodules or papules with a “rolled edge” forming around a central depression that may or may not be ulcerated, crusted and bleeding
Superficial BCC
Dry. scaly lesions, superficial flat growths may be misdiagnosed as eczema or psoriasis. Edge shows a “threadlike” raised b border
Morpheaform (sclerosing) BCC
Appear as a white sclerotic plaque w/ telangiectasia, scar-like in appearance
Pigmented BCC
Similar to nodular but brown or black pigmentation is present. Mostly found in dark skinned people
How can we diagnose BCC?
Biopsy; consists of large, round or oval tumor island within the dermis w/ and epidermal attachment
Tx for BCC
Permanently cure with best cosmetic result, surgical topical and radiation options
What are the topical txs for BCC?
5% imiquimod for non-facial superficial BCCs less than 2cm in diameter
5-FU for superficial BCC
What is a surgical option for a BCC?
E&C Electrodessication and Currettage, cryotherapy, excision with margins, and Mohs micrographic surgery
How can E&C be discribed?
For superficial lesions, use sharp curette to scape away friable tumor until normal dermis is felt. Then area is electrodessicated to cause necrosis of cells
When would cryotherapy be a good option for BCC?
For pts who are debilitated with medical conditions that preclude other types of surgery, generally not recommended
Excision with margins for BCC
Has a high cure rate 95%, less effective in treating recurrent BCC, better for primary lesions
What is the gold standard treatment for BCC?
Mohs Micrographic surgery
Mohs micrographic surgery
If tumor is >2cm and on facial area. Take small layer at a time and examined under microscope, gives smallest defect ensuring the best cosmetic potential
When would radiation be used for pts with BCC?
Older pts who are not candidates for surgery or where surgical excision will be disfiguring. Takes 5-25 visits, cure rate can be 80-95%
What is the prognosis for a pt with BCC?
Good is appropriate method of tx is used. Recurrent cancers are harder to cure. 100% survival if it hasn’t metastasized.
What type of cancer can arise from the malignant proliferation of epidermal keratinocytes?
Squamous cell carcinoma
What can put you at risk for SCC?
> 50yrs, light skinned males, tobacco/alcohol use, nonmelanoma skin cancer, HPV, immunosuppression, chemical carcinogens
What is characterized by the irregular nest of epidermal cells invading the dermis to varying degrees?
SCC
What are the two types of SCC?
SCC in situ (Bowen’s Disease) or invasive
Which layers does Bowen’s disease of SCC effect
Full thickness of epidermis
Which layers does invasive SCC effect
Penetrates into the dermis
Clinical manifestations of SCC
Begins at AK site, can be superficial papules, plaques, or nodules discrete and hard arising from indurated, round elevated base
Lower lip SCC
Starts as actinic chelitis, local thickening then a firm nodule, then can grow out as a sizeable tumor. Usually with hx of smoking
Periungual SCC
Presents with swelling, erythema and localized pain. Commonly in nail folds of hands resembling a wart
What is the histologic hallmark of SCC?
Presence of keratin of “keratin pearls” (well formed desmosome attachments and intracytoplasmic bundles of keratin)
Dx of SCC
Biopsy to find keratin pearls, lymphadenopathy on palpation in adjacent lymph nodes
What are the 3 treatment options for SCC?
Excision, Mohs, radiation
What is the prognosis of SCC?
Mohs 94-99%, metastasis associated with poor prognosis
Which pts have a better prognosis for SCC?
Pts w/ in-transit or regional metastasis as 1st site have better chance than those whose initial diagnosis included a distant nodal site
How often must pts with SCC come for follow ups?
Annual skin check every year
What is skin cancer of the melanocyte?
Melanoma
What does MMRISK stand for?
Moles: atypical Moles >50 common molves Red hair and freckles Inability to tan Sunburn Kindred/family history
Etiology of melanoma
Damage to DNA of melanocyte, non-inherited BRAF oncogene mutation, CDKN2A and CDK4 mutated tumor suppressor genes
Where does melanoma originate?
From melanocytes via the dermoepidermal junction
What is the greatest risk factor for metastasis?
Depth of the invasion
Clinical manifestations of melanoma
Macular, nodular, color varies from white non-pigmented to dark black blue or red. Lesions borders tend to be irregular, growth is quick or slow, distribution can be non sun exposed areas
ABCD of melanoma
Asymmetry, border (irregular), color (varied), diameter (>6mm)
Which type of melanoma does not have a preference for sun damaged skin?
Superficial spreading
Superficial spreading melanoma
Tendency to multicoloration including black, red, brown, blue, and white. Borders more sharply defined
Which type of melanoma starts as macular and flat then becomes nodular?
Lentigo Maligna
Which type of melanoma has an insidious slow growth?
Lentigo Maligna
Nodular Melanoma
Arise w/out radial growth phase, head neck and trunk, smooth and dome shaped, friable or ulcerated and bleeding
Which type of melanoma is common in darker skin types?
Acral-Lentiginous
Acral-Lentiginous melanoma
Light brown uniform pigmentation initially, on palms, soles, or nail beds. Lesion becomes darker, nodular and may ulcerate
Which type of melanoma typically has a delay in diagnosis?
Acral-Lentiginous
What can be the first sign of metastasis in melanoma?
Early mets occurring in lymphatics and regional lymphadenopathy
Melanoma metastasis
Lymphatics first, then satellite metastases appear as pigmented nodules, then spreads via blood stream to any site including skin, brain, lung, and bone
How is melanoma staged?
T (tumor) N (lymph node) M (metastasis)
What is the T stage for?
How far the tumor has grown in the skin. Assigned 0-4 based on the depth
What is the N stage for?
Assigned 0-3 based on whether it has spread to lymph nodes or lymph channels
What is the M stage for?
Based on which organs and blood levels of LDH
T1
Tumor 1.0mm or less
T2
1.01mm-2.0mm
T3
2.01mm04.0mm
T4
> 4.0mm
N1
One lymph node involved
N2
Two or three lymph nodes involved
N3
Four or more lymph nodes involved
M0
No detectable evidence of distant metastases
M1a
Metastases to skin, subQ, or distant lymph node, NORMAL SERUM LDH
M1b
Lung metastases, NORMAL LDH
M1c
Elevated LDH
What is Breslow thickness?
The total vertical height of melanoma, from very top granular layer to area of deepest penetration.
Less than 1mm Breslow thickness
5-yr survival is 95-100%
1-2mm Breslow thickness?
5-yr survival is 80-96%
2.1-4mm Breslow thickness?
5-yr survival is 60-75%
> 4mm Breslow thickness?
5-yr survival 37-50%
Melanoma Dx
Excisional biopsy preferred, take entire lesion out to see how deep it goes. Palpate lymph glands as well!
Melanoma workup
LDH can be prognostic, 3A: CXR, 3B/C: fine needle aspiration of lymphs, 4: Abdominal or pelvic imaging or PET scan
What is the surgical tx for melanoma?
Simple excision for early stage. For primary: wide local excision with sentinel lymph node biopsy or dissection
When can radiation be given for melanoma pts?
As an adjuvant to surgery in area where lymph nodes were removed, used to relieve symptoms caused by metastases to brain or bone
When is chemotherapy used for melanoma?
Advanced cases, to relieve symptoms and extend survival. Given in cycles lasting a few weeks
What are some adjunct therapies for melanoma?
Cytokines (interferon-alpha and IL-2) which can help shrink advanced melanomas, can also be used with chemo drugs
What is Vemurafenib used for?
Inhibits growth of melanoma w/ some mutated forms of BRAF for late stage melanoma
What is Dabrafenib used for?
BRAF inhibitor for an unresectable or metastatic melanoma
What is Trametinib used for?
MEK inhibitor for an unresectable or metastatic melanoma
Follow up for pts w/ melanoma
Every 6 mos full skin check, self skin checks 1/mo and sun protection
Which virus spreads via respiratory droplets and has an incubation period of 9-12 days?
Measles (Rubeola)
How long does it take for measles to clear?
4-7 days
Si/Sx of measles
Prodrome of cough, coryza, conjunctivitis, fever, then rash develops
What do the measles lesions look like?
Start as macular or morbilliform rash on anterior scalp and behind ears then by day 2 or 3 down the trunk to the extremities
What are Koplick spots?
Pathognomonic white papules 1mm on buccal mucosa and pharynx (measles)
Do the lesions for measles spread to the palms and soles?
Yes
What is the treatment of measles?
Vaccination w/live virus at 15 mo and 5 yrs, and supportive therapy (rest, fluids, etc.)
What is caused by the Toga virus?
Rubella, German Measles
How are the german measles spread?
Respiratory secretions, 12-23 incubation period
Si/Sx of German Measles
Pain with LATERAL UPWARD EYE MOVEMENT, lymphadenopathy, begins on face and spreads inferior covering body in 24h
What is Forsceimer’s sign?
Pitechiae on soft palate and uvula (German Measles)
What do the lesions look like in Rubella?
Pale pink morbilliform macules smaller than rubeola
What is the treatment for German Measles?
Vaccination with MMR, supportive therapy
A benign infectious exanthem caused by Parovirus
Fifth Disease (Erythema Infectiosum)
How is 5th disease spread?
Respiratory droplets
Erythema Infectiosum
Viral shedding stops by the time symptoms appear (when no longer infectious), incubation of 4-14 days
What are the 3 phases of Erythema Infectiosum?
- Abrupt erythema of cheeks (slapped cheek)
- Day 4-erythematous macules on proximal extremities and trunk evolving into lacy pattern by day 9
- Recurring stage with heat or sunlight
Treatment for 5th disease?
Supportive therapy
What is Pityriasis Rosea?
An acute benign self-limiting eruption common in spring/fall w/unknown cause
Herald Patch
2-5cm scaly lesion that may mimic tinea corporis (Pityriasis Rosea)
Si/Sx for Pityriasis Rosea
Over 2 weeks oval or elliptic erythematous patches w/fine scale. “Christmas tree” like pattern on trunk. Viral symptoms may occur
What do the lesions look like in Pityriasis Rosea?
Macular or papular lesions develop on trunk, neck, extremities. May be pruritic
How long does Pityriasis Rosea last?
3-8 weeks, resolves spontaneously
How can you treat Pityriasis Rosea?
Not needed, antihistamines for pruritis
The most common form of adverse drug eruptions
Morbilliform reactions
What is the patho behind morbilliform rxns?
Type 4 allergic rxn mediated by T-helper cells
Morbilliform rxns commonly caused by which drugs?
Ampicillin, amoxicillin, bactrim
Si/Sx of a morbilliform rxn
Erythema w/macules and papules intitally on trunk then generalizing w/in 2 days.
How long can the si/sx last for a morbilliform reaction?
Can present within first 2 weeks of exposure up to 10 days after
Treatment for morbilliform reaction?
Clears within 2 weeks of stopping medication, can use antihistamines and low potency topical steroids
A fixed drug reaction happens when?
Usually with meds taken intermittently, NSAIDs, Sulfonamides, Barbiturates
What do the lesions look like in a fixed drug reaction?
Round/oval erythematous plaques may be pruritic/burning or asymptomatic. Usually 6 or few lesions, usually 1
Where do the lesions appear in a fixed drug reaction?
Genitals or oral mucosa
What is the treatment for a fixed drug reaction?
Stop drug, if symptomatic can use antihistamines or topical steroid
What is a self-limited eruption brought on by drug exposure viral infections or can be idiopathic?
Erythema Multiforme
What drugs can cause erythema multiforme?
Sulfa, Barbs, PCN, Phenytoin
What do the lesions look like in erythema multiforme?
Begin as macules and become papular then vesicles and bullae form in the center of papules. Localized to hands and feet
Si/sx of erythema multiforme
Mucosal lesions are painful and erode, fever, malaise
Treatment of erythema multiforme?
Avoid target substances, sever reaction may require systemic steroids
SJS and TEN
Mucocutaneous blistering rxn from drug rxn
SJS is thought to be a severe variant of what?
Erythema Multiforme
TEN is thought so be a severe variant of what?
SJS
Si/Sx of SJS and TEN
Fever, mucosal inflammation. Lesions begin on trunk and may be painful, TEN exhibits higher fever and more epidermal separation then SJS
Tx of SJS and TEN
Withdrawal of offending agent, treatment at burn center for fluid and electrolyte imbalance, wound care
What is Bullous pemphigoid?
Autoimmune presents in 6th decade of life caused by autoantibodies, complement fixation, neutrophil and eosinophils
What type of antibodies bind to basement membrane in bullous pemphigoid?
IgG antibodies
What do the IgG antibodies activate?
Activates complement and inflammatory mediators, attracting cells to basement membrane and releasing proteases
Proteases lead to what?
Blister formation (Bullous Pemphigoid)
The blister is formed how?
By cleavage of the basal cells away from the basal lamina
What are the lesions like in bullous pemphigoid?
Bullae are large and may contain serous or hemorrhagic fluid. Targets the axillae, thighs, groin and abdomen
What is the course and prognosis of bullous pemphigoid?
Usually self-limiting over a 5-6 year period
How can you diagnose bullous pemphigoid?
Biopsy and immunofluorescence. C3 deposition is nearly always present in BP
Tx for localized or limited bullous pemphigoid
Potent topical steroid, Clobetasol with occlusion
Tx for moderate and severe bullous pemphigoid
Prednisone, once in remission can taper cautiously
What can be considered for pts that cant handle steroids? (bullous pemphigoid)
Immunosuppressive meds
What other meds have been helpful with bullous pemphigoid?
Azathioprine, Mycophenolate mofetil, the combo of Tetracycline and Niacinamide, TCN, Doxy or Minocycline (instead of TCN), Dapsone, Recalcitrant
What is pediculosis?
Lice
How long does it take the eggs to hatch on hair shafts?
One week
Pediculus humanus capitis
Scalp
Pediculus humanus corporis
Body
Phthirus pubis
Pubic area (crabs)
The female louse cannot survive for more than _ days off the human head
3
Where does the body louse live?
Not on the human body, lives in human clothing crawling onto the body only to feed at night
The adult female body louse can survive how long away from human body?
10 days
P.pubis are different from head and body louse how?
Shorter, broader body with large front claws, making it able to grasp the coarser pubic hairs
Heavy infestation of crabs can also involve where?
Eyelashes, eyebrows, facial hair, and the periphery of the scalp
How long can the pubic louse survive away from human body?
1 day
Si/sx of pediculosis capitus (head lice)
Present w/intense pruritus of scalp with posterior cervical lymphadenopathy, excoriations and small specks of louse dung on scalp
Si/sx of pediculosis corporis (body lice)
Initially small pruritic papules that progress to scratching, crusted and infected papules, Spares the hands and feet
Si/sx of pediculosis pubis (crabs)
Intense pruritis in affected areas, small blue macules can present
Dx of pediculosis
History, microscopic examination, biopsy
What are some topical treatment options for pediculosis?
OTC Nix cream Rinse, RID Acticin
What is the active ingredient in Nix cream rinse and RID Acticin
Permethrin. Acts as neurotoxin and paralysis of nerves in parasite leading to death
When should you repeat treatment?
One week later. Permethrin only kills active louse, not the nits.
Ovid lotion
Topical treatment for pediculosis. Most effective for head louse. NOT FOR CHILDREN <6mos. Apply to dry hair let sit for 8-12 hours
Elimite cream
Has 5% permetherin, leave on overnight and repeat in one week
What else can be used to treat pediculosis?
Bactrim and vasaline. *Treat entire family**
What is environment eradication?
Fomites should be washed in hot water and dried. Should be exposed to temps >50-55C for atleast 5 mins to kill any bugs left. Can also seal in a plastic bag for 2 days
What is an infestation w. the Sarcoptes scabiei
Scabies
Mites burrow into epidermis and deposit feces and lay eggs in what?
Scabies
What type of reaction happens with scabies?
Type 4 hypersensitivity reaction about 30 days after infestation
Scabies should be considered when?
Any patient with persistent pruritis not responding to topical steroids
Si/sx of scabies
Pruritic lesion vary from vesicles or papule, nodules located b/w web space of finers, flexor aspects of wrists, axilla, antecubital area, abdomen, umbilicus, genital gluteal areas, and feet
Where does scabies spare on the body?
Face
Burrow
Pathognomonic of scabies infestation, appearing as a thin short gray brown, wavy channel on the skin
Crusted/Norwegian scabies
Immunocompromised or debilitated pts. Crusts and scales teem with mites. Psoriasis like scaling around nails with crusting
Topical treatment for scabies
Permethrin, apply to skin for 8 hrs
Lindane not for pregnant or kids
Percipitated Sulfar best for pregnant pts, all for 8-10 hrs
Oral treatment for scabies
Ivermectin
After treatment: bedding, clothing, towels washed in hot water or removed for 72 hrs
Loxoscelism is what?
Brown recluse spider bite
How is the brown recluse spider identified?
Dark, violin-shaped markings over cephalothorax and 3 sets of eyes rather than usual 4
What does the brown recluse spiders venom contain?
Phospholipase enzyme, sphingomyelinase D which is a major toxin
Si/sx of brown recluse spider bite
Bite site painful after 3 hrs, necrotic cutaneous loxoscelism, extensive necrosis develops with edema w/in 8hrs with bulla and surrounding erythema and ischemia that can extend to muscles
Treatment for brown recluse spider bite
Rest, ice and elevation of site, analgesics, tetanus prophylaxis and surgical debridement
Si/sx of black widow spider (lactrodectism) bite
Locally limited to small circle of redness. Systemically: pain/cramping within an hour, tachycardia, HTN, PE, fevers, chills, vomiting, violent cramps, delirium or partial paralysis
Treatment of black widow spider bite
ACLS, antivenom administer in ER, analgesics (Morphine), antihistamine (Benadryl), tetanus
