Dermatology-Peckham 2 Flashcards
1
Q
What is a common pruritic inflammatory disease of skin, mucous membranes and hair follicles?
A
Lichen Planus
2
Q
What are the 4 Ps involving Lichen Planus?
A
Purple, Polygonal, Pruritic, Papule
3
Q
Where are the lesions grouped to in lichen planus?
A
Flexor aspect of wrists, lumbar area, eyelids, shins, scalp
4
Q
Si/sx of Lichen Planus
A
Pruritic, lesions appear for <1yr, can cause hair loss and damage nails. Variations can be ulcerative
5
Q
Potent topical steroids w/occlusion is the proper tx for what?
A
Lichen Planus
6
Q
What can also be known as a benign “warty” growth
A
Seborrheic Keratosis
7
Q
Seborrheic keratosis has what presentation?
A
“Stuck on” flat or raised papule or plaque. White, flesh colored to tan, brown, warty or smooth
8
Q
Is tx required for seborrheic keratosis?
A
No
9
Q
What is a vascular neoplasm brought on by genetic factors, hormonal factors, immunodeficiency or infection with HHV-8?
A
Kaposi Sarcoma
10
Q
What are the 4 types of Kaposi Sarcoma?
A
- Classic
- HIV associated
- Endemic/African
- Iatrogenic
11
Q
Kaposi Sarcoma presentation
A
Purplish macules that evolve to infiltrative plaques and nodules or tumors, often on lower extremities with lymphedema
12
Q
Where can Kaposi Sarcoma also involve?
A
GI tract and lungs (very rarely)
13
Q
What is the best Dx for Kaposi Sarcoma?
A
Biopsy
14
Q
What progresses slowly with rare lymph node or visceral involvement?
A
Kaposi sarcoma
15
Q
Some treatment options for Kaposi sarcoma include?
A
Radiation therapy, cryotherapy, surgical excision of individual nodules, topical Alitretinoin, dye laser
16
Q
What are in situ dysplasias resulting from UV radiation that may progress to SCC?
A
Actinic Keratosis
17
Q
What is the most common epithelial precancerous lesion?
A
Actinic keratosis
18
Q
Who is at greater risk for actinic keratosis?
A
White men older then 50 with an outdoor lifestyle
19
Q
The etiology of actinic keratosis
A
UVR leads to mutations in TP53 and deletion of the gene coding for p16 tumor suppressor protein
20
Q
What is the pathophys behind actinic keratosis?
A
Epidermal lesion with atypical keratinocytes at basal layer that can extend upwards
21
Q
Where is actinic keratosis most commonly found on the body?
A
Chronically sun exposed surfaces like the face, ears, scalp, dorsal hands, forearms, anterior legs
22
Q
On palpation, what does actinic keratosis feel like?
A
Sandpaper texture, most times more easily felt than seen
23
Q
Actinic keratosis clinical manifestations
A
Multiple discrete, flat or elevated verrucous or keratotic, red, pigmented or skin colored
24
Q
What would be some differential diagnoses for actinic keratosis?
A
BCC, SCC, seborrheic keratosis, lupus
25
Is is appropriate to biopsy for actinic keratosis?
Yes, clinical/history Dx is also very important
26
Treatment for actinic keratosis is
Surgical: cryotherapy
Medical: Imiquimod or 5-FU
27
Is cryotherapy effective with actinic keratosis?
Yes with limited lesions. Goal is to produce cell death at -320F
28
What structures in the skin are more resistant to cryotherapy?
Collagen, blood vessels and nerves are more resistant that keratinocytes
29
What is the risk for cryotherapy?
Blistering, melanocytes are more sensitive so if often leaves hypopigmented spots
30
Imiquimod
For extensive broad and numerous AK lesions. its an interferon inducer that produces an immune rxn against lesion
31
What does imiquimod cause?
Erythema and crusting, but is less irritating than 5-FU
32
5-FU
Interferes with DNA synthesis, apply bid for 4 weeks
33
Ingenol mebutate
Used for AK, induces cell death. Apply daily x 3 days to face or 2 days to body
34
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
35
How is the prognosis for pts with AK?
Good with continued monitoring every 2-6 mos
36
How can a pt prevent AK?
Avoid sun exposure, use broad spectrum sunscreen, apply often
37
What are the most common form of all cancers?
Nonmelanoma skin cancers
38
What type of cancer is an epithelial tumor of the basal keratinocytes?
Basal Cell Carcinoma
39
Who has a greater risk for BCC?
Same as AK, white men 40 yrs or older with an outdoor lifestyle
40
What are some causes for BCC?
UVR, immunosuppression for organ transplant increases risk as well
41
What does BCC arise from?
Immature pluripotential cells associated with the hair follicle
42
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"
43
A lesion that bleeds without significant pain or symptoms can be from what?
BCC
44
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
45
Superficial BCC
Dry. scaly lesions, superficial flat growths may be misdiagnosed as eczema or psoriasis. Edge shows a "threadlike" raised b border
46
Morpheaform (sclerosing) BCC
Appear as a white sclerotic plaque w/ telangiectasia, scar-like in appearance
47
Pigmented BCC
Similar to nodular but brown or black pigmentation is present. Mostly found in dark skinned people
48
How can we diagnose BCC?
Biopsy; consists of large, round or oval tumor island within the dermis w/ and epidermal attachment
49
Tx for BCC
Permanently cure with best cosmetic result, surgical topical and radiation options
50
What are the topical txs for BCC?
5% imiquimod for non-facial superficial BCCs less than 2cm in diameter
5-FU for superficial BCC
51
What is a surgical option for a BCC?
E&C Electrodessication and Currettage, cryotherapy, excision with margins, and Mohs micrographic surgery
52
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
53
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
54
Excision with margins for BCC
Has a high cure rate 95%, less effective in treating recurrent BCC, better for primary lesions
55
What is the gold standard treatment for BCC?
Mohs Micrographic surgery
56
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
57
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%
58
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.
59
What type of cancer can arise from the malignant proliferation of epidermal keratinocytes?
Squamous cell carcinoma
60
What can put you at risk for SCC?
>50yrs, light skinned males, tobacco/alcohol use, nonmelanoma skin cancer, HPV, immunosuppression, chemical carcinogens
61
What is characterized by the irregular nest of epidermal cells invading the dermis to varying degrees?
SCC
62
What are the two types of SCC?
SCC in situ (Bowen's Disease) or invasive
63
Which layers does Bowen's disease of SCC effect
Full thickness of epidermis
64
Which layers does invasive SCC effect
Penetrates into the dermis
65
Clinical manifestations of SCC
Begins at AK site, can be superficial papules, plaques, or nodules discrete and hard arising from indurated, round elevated base
66
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
67
Periungual SCC
Presents with swelling, erythema and localized pain. Commonly in nail folds of hands resembling a wart
68
What is the histologic hallmark of SCC?
Presence of keratin of "keratin pearls" (well formed desmosome attachments and intracytoplasmic bundles of keratin)
69
Dx of SCC
Biopsy to find keratin pearls, lymphadenopathy on palpation in adjacent lymph nodes
70
What are the 3 treatment options for SCC?
Excision, Mohs, radiation
71
What is the prognosis of SCC?
Mohs 94-99%, metastasis associated with poor prognosis
72
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
73
How often must pts with SCC come for follow ups?
Annual skin check every year
74
What is skin cancer of the melanocyte?
Melanoma
75
What does MMRISK stand for?
```
Moles: atypical
Moles >50 common molves
Red hair and freckles
Inability to tan
Sunburn
Kindred/family history
```
76
Etiology of melanoma
Damage to DNA of melanocyte, non-inherited BRAF oncogene mutation, CDKN2A and CDK4 mutated tumor suppressor genes
77
Where does melanoma originate?
From melanocytes via the dermoepidermal junction
78
What is the greatest risk factor for metastasis?
Depth of the invasion
79
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
80
ABCD of melanoma
Asymmetry, border (irregular), color (varied), diameter (>6mm)
81
Which type of melanoma does not have a preference for sun damaged skin?
Superficial spreading
82
Superficial spreading melanoma
Tendency to multicoloration including black, red, brown, blue, and white. Borders more sharply defined
83
Which type of melanoma starts as macular and flat then becomes nodular?
Lentigo Maligna
84
Which type of melanoma has an insidious slow growth?
Lentigo Maligna
85
Nodular Melanoma
Arise w/out radial growth phase, head neck and trunk, smooth and dome shaped, friable or ulcerated and bleeding
86
Which type of melanoma is common in darker skin types?
Acral-Lentiginous
87
Acral-Lentiginous melanoma
Light brown uniform pigmentation initially, on palms, soles, or nail beds. Lesion becomes darker, nodular and may ulcerate
88
Which type of melanoma typically has a delay in diagnosis?
Acral-Lentiginous
89
What can be the first sign of metastasis in melanoma?
Early mets occurring in lymphatics and regional lymphadenopathy
90
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
91
How is melanoma staged?
T (tumor) N (lymph node) M (metastasis)
92
What is the T stage for?
How far the tumor has grown in the skin. Assigned 0-4 based on the depth
93
What is the N stage for?
Assigned 0-3 based on whether it has spread to lymph nodes or lymph channels
94
What is the M stage for?
Based on which organs and blood levels of LDH
95
T1
Tumor 1.0mm or less
96
T2
1.01mm-2.0mm
97
T3
2.01mm04.0mm
98
T4
>4.0mm
99
N1
One lymph node involved
100
N2
Two or three lymph nodes involved
101
N3
Four or more lymph nodes involved
102
M0
No detectable evidence of distant metastases
103
M1a
Metastases to skin, subQ, or distant lymph node, NORMAL SERUM LDH
104
M1b
Lung metastases, NORMAL LDH
105
M1c
Elevated LDH
106
What is Breslow thickness?
The total vertical height of melanoma, from very top granular layer to area of deepest penetration.
107
Less than 1mm Breslow thickness
5-yr survival is 95-100%
108
1-2mm Breslow thickness?
5-yr survival is 80-96%
109
2.1-4mm Breslow thickness?
5-yr survival is 60-75%
110
>4mm Breslow thickness?
5-yr survival 37-50%
111
Melanoma Dx
Excisional biopsy preferred, take entire lesion out to see how deep it goes. Palpate lymph glands as well!
112
Melanoma workup
LDH can be prognostic, 3A: CXR, 3B/C: fine needle aspiration of lymphs, 4: Abdominal or pelvic imaging or PET scan
113
What is the surgical tx for melanoma?
Simple excision for early stage. For primary: wide local excision with sentinel lymph node biopsy or dissection
114
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
115
When is chemotherapy used for melanoma?
Advanced cases, to relieve symptoms and extend survival. Given in cycles lasting a few weeks
116
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
117
What is Vemurafenib used for?
Inhibits growth of melanoma w/ some mutated forms of BRAF for late stage melanoma
118
What is Dabrafenib used for?
BRAF inhibitor for an unresectable or metastatic melanoma
119
What is Trametinib used for?
MEK inhibitor for an unresectable or metastatic melanoma
120
Follow up for pts w/ melanoma
Every 6 mos full skin check, self skin checks 1/mo and sun protection
121
Which virus spreads via respiratory droplets and has an incubation period of 9-12 days?
Measles (Rubeola)
122
How long does it take for measles to clear?
4-7 days
123
Si/Sx of measles
Prodrome of cough, coryza, conjunctivitis, fever, then rash develops
124
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
125
What are Koplick spots?
Pathognomonic white papules 1mm on buccal mucosa and pharynx (measles)
126
Do the lesions for measles spread to the palms and soles?
Yes
127
What is the treatment of measles?
Vaccination w/live virus at 15 mo and 5 yrs, and supportive therapy (rest, fluids, etc.)
128
What is caused by the Toga virus?
Rubella, German Measles
129
How are the german measles spread?
Respiratory secretions, 12-23 incubation period
130
Si/Sx of German Measles
Pain with LATERAL UPWARD EYE MOVEMENT, lymphadenopathy, begins on face and spreads inferior covering body in 24h
131
What is Forsceimer's sign?
Pitechiae on soft palate and uvula (German Measles)
132
What do the lesions look like in Rubella?
Pale pink morbilliform macules smaller than rubeola
133
What is the treatment for German Measles?
Vaccination with MMR, supportive therapy
134
A benign infectious exanthem caused by Parovirus
Fifth Disease (Erythema Infectiosum)
135
How is 5th disease spread?
Respiratory droplets
136
Erythema Infectiosum
Viral shedding stops by the time symptoms appear (when no longer infectious), incubation of 4-14 days
137
What are the 3 phases of Erythema Infectiosum?
1. Abrupt erythema of cheeks (slapped cheek)
2. Day 4-erythematous macules on proximal extremities and trunk evolving into lacy pattern by day 9
3. Recurring stage with heat or sunlight
138
Treatment for 5th disease?
Supportive therapy
139
What is Pityriasis Rosea?
An acute benign self-limiting eruption common in spring/fall w/unknown cause
140
Herald Patch
2-5cm scaly lesion that may mimic tinea corporis (Pityriasis Rosea)
141
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
142
What do the lesions look like in Pityriasis Rosea?
Macular or papular lesions develop on trunk, neck, extremities. May be pruritic
143
How long does Pityriasis Rosea last?
3-8 weeks, resolves spontaneously
144
How can you treat Pityriasis Rosea?
Not needed, antihistamines for pruritis
145
The most common form of adverse drug eruptions
Morbilliform reactions
146
What is the patho behind morbilliform rxns?
Type 4 allergic rxn mediated by T-helper cells
147
Morbilliform rxns commonly caused by which drugs?
Ampicillin, amoxicillin, bactrim
148
Si/Sx of a morbilliform rxn
Erythema w/macules and papules intitally on trunk then generalizing w/in 2 days.
149
How long can the si/sx last for a morbilliform reaction?
Can present within first 2 weeks of exposure up to 10 days after
150
Treatment for morbilliform reaction?
Clears within 2 weeks of stopping medication, can use antihistamines and low potency topical steroids
151
A fixed drug reaction happens when?
Usually with meds taken intermittently, NSAIDs, Sulfonamides, Barbiturates
152
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
153
Where do the lesions appear in a fixed drug reaction?
Genitals or oral mucosa
154
What is the treatment for a fixed drug reaction?
Stop drug, if symptomatic can use antihistamines or topical steroid
155
What is a self-limited eruption brought on by drug exposure viral infections or can be idiopathic?
Erythema Multiforme
156
What drugs can cause erythema multiforme?
Sulfa, Barbs, PCN, Phenytoin
157
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
158
Si/sx of erythema multiforme
Mucosal lesions are painful and erode, fever, malaise
159
Treatment of erythema multiforme?
Avoid target substances, sever reaction may require systemic steroids
160
SJS and TEN
Mucocutaneous blistering rxn from drug rxn
161
SJS is thought to be a severe variant of what?
Erythema Multiforme
162
TEN is thought so be a severe variant of what?
SJS
163
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
164
Tx of SJS and TEN
Withdrawal of offending agent, treatment at burn center for fluid and electrolyte imbalance, wound care
165
What is Bullous pemphigoid?
Autoimmune presents in 6th decade of life caused by autoantibodies, complement fixation, neutrophil and eosinophils
166
What type of antibodies bind to basement membrane in bullous pemphigoid?
IgG antibodies
167
What do the IgG antibodies activate?
Activates complement and inflammatory mediators, attracting cells to basement membrane and releasing proteases
168
Proteases lead to what?
Blister formation (Bullous Pemphigoid)
169
The blister is formed how?
By cleavage of the basal cells away from the basal lamina
170
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
171
What is the course and prognosis of bullous pemphigoid?
Usually self-limiting over a 5-6 year period
172
How can you diagnose bullous pemphigoid?
Biopsy and immunofluorescence. C3 deposition is nearly always present in BP
173
Tx for localized or limited bullous pemphigoid
Potent topical steroid, Clobetasol with occlusion
174
Tx for moderate and severe bullous pemphigoid
Prednisone, once in remission can taper cautiously
175
What can be considered for pts that cant handle steroids? (bullous pemphigoid)
Immunosuppressive meds
176
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
177
What is pediculosis?
Lice
178
How long does it take the eggs to hatch on hair shafts?
One week
179
Pediculus humanus capitis
Scalp
180
Pediculus humanus corporis
Body
181
Phthirus pubis
Pubic area (crabs)
182
The female louse cannot survive for more than _ days off the human head
3
183
Where does the body louse live?
Not on the human body, lives in human clothing crawling onto the body only to feed at night
184
The adult female body louse can survive how long away from human body?
10 days
185
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
186
Heavy infestation of crabs can also involve where?
Eyelashes, eyebrows, facial hair, and the periphery of the scalp
187
How long can the pubic louse survive away from human body?
1 day
188
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
189
Si/sx of pediculosis corporis (body lice)
Initially small pruritic papules that progress to scratching, crusted and infected papules, Spares the hands and feet
190
Si/sx of pediculosis pubis (crabs)
Intense pruritis in affected areas, small blue macules can present
191
Dx of pediculosis
History, microscopic examination, biopsy
192
What are some topical treatment options for pediculosis?
OTC Nix cream Rinse, RID Acticin
193
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
194
When should you repeat treatment?
One week later. Permethrin only kills active louse, not the nits.
195
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
196
Elimite cream
Has 5% permetherin, leave on overnight and repeat in one week
197
What else can be used to treat pediculosis?
Bactrim and vasaline. *Treat entire family**
198
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
199
What is an infestation w. the Sarcoptes scabiei
Scabies
200
Mites burrow into epidermis and deposit feces and lay eggs in what?
Scabies
201
What type of reaction happens with scabies?
Type 4 hypersensitivity reaction about 30 days after infestation
202
Scabies should be considered when?
Any patient with persistent pruritis not responding to topical steroids
203
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
204
Where does scabies spare on the body?
Face
205
Burrow
Pathognomonic of scabies infestation, appearing as a thin short gray brown, wavy channel on the skin
206
Crusted/Norwegian scabies
Immunocompromised or debilitated pts. Crusts and scales teem with mites. Psoriasis like scaling around nails with crusting
207
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
208
Oral treatment for scabies
Ivermectin
| After treatment: bedding, clothing, towels washed in hot water or removed for 72 hrs
209
Loxoscelism is what?
Brown recluse spider bite
210
How is the brown recluse spider identified?
Dark, violin-shaped markings over cephalothorax and 3 sets of eyes rather than usual 4
211
What does the brown recluse spiders venom contain?
Phospholipase enzyme, sphingomyelinase D which is a major toxin
212
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
213
Treatment for brown recluse spider bite
Rest, ice and elevation of site, analgesics, tetanus prophylaxis and surgical debridement
214
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
215
Treatment of black widow spider bite
ACLS, antivenom administer in ER, analgesics (Morphine), antihistamine (Benadryl), tetanus
