Disease 3 Flashcards
factors in acne pathogenesis
- sebaceous gland hyperplasia
- abnormal follicular desquamation
- propoinibacterium acnes colonization
- inflammation
microcomedo
acne
non-inflammatory comedones
open: blackheads
closed: whitehead
inflammatory lesions in acne
papules, pustules, nodules, cysts
benzoyl peroxide
topical
kills P.acnes, mild comedolytic, mild inflammatory
limits development of P. acnes antibiotic resistance
can combine with retinoid
AE: irritation, bleaching, allergic
Tx: mild acne
salicylic acid
less effective than benzoyl peroxide
Tx: mild acne
topical antibiotics for acne
kill P. acnes, anti inflammatory
clindamycin, erythromycin
AE: irritation, colitis with clindamycin
not recommended as mono therapy: resistance, slow onset, not comedolytic
add benzoyl peroxide: Benzaclin/Duac, Benzamycin
topical retinoids
FIRST LINE
comedolytic, anti-inflammatory, enhance penetration of other compounds
Tx: acne
AE: irritation
combination products with antibiotics are expensive
tazarotene
topical retinoid
do not use in PREGNANCY
tretinoin
topical retinoid
adapalene
topical retinoid
systemic antibiotics in acne
moderate to severe inflammatory acne antibacterial, anti-inflammatory goal is maintenance with topical tetracycline, doxycycline, minocycline other: erythromycin, bactrim well tolerated
tetracycline
oral
Tx: acne
AE: GI, tooth stain
doxycycline
oral
Tx: acne
AE: photosensitivity, esophagitis
minocycline
oral
Tx: acne
AE: dyspigmentation, lupus, pseudotumor cerebri, SJS, DHS
erythromycin
oral
Tx: acne
AE: GI
oral contracepties
suppresses sebum
Tx: females with moderate to severe inflammatory/mixed acne
isotretinoin
oral
decrease sebaceous glands size/activity, prevent new comedones, inhibits P.acnes, anti-inflammatory
Tx: severe, scar, refractory
AE: dry lips, skin, eyes, nosebleeds, mild headaches, muscle aches, backaches, TERATOGEN, DEPRESSION, SKELETAL, IBD?
Tx of mild comedonal acne
topical retinoid
Tx of mild inflammatory/mixed acne
topical retinoid and topical antibiotic
Tx of moderate inflammatory/mixed acne
topical retinoid and topical antimicrobial and oral antimicrobial
Tx of severe inflammatory acne
minimal scarring: topical retinoid and topical antimicrobial and oral antimicrobial
scarring or multiple treatment failure: Isotretinoin
basic Tx for acne
gentle fragrance free cleanser: 1-2/day
oil free moisturizer with SPF 30 2x/day and as needed
avoid OTC acne washes and topical: too irritating and drying
What part of the diet could cause acne?
- high glycemic index diet may lead to hyperinsulinemia and stimulate androgen synthesis
- lots of milk
When should you refer patients to dermatologist for acne?
- severe acne (cysts, nodules, scars)
- no/poor response after 12 wks
- systemic antibiotics needed for more than 1 year
- isotretinoin being considered (females need OCP)
- acne associated with systemic disease
Rosacea
over 30 yrs, fair, female
relapsing and remitting
Sx: redness, flushing, pimples
Possible causes of rosacea
- inflammation
- Demodex folliculorum
- genetics
- vascular abnormalities
triggers of rosacea
- sunlight
- hot/cold
- exercise
- food
- alcohol
types of rosacea
- erythematotelangiectatic
- papulopustular
- phymatous
- ocular
Tx of rosacea
topical: metronidazole, azelaic acid, sodium sulfacetamide with sulfur
systemic: oral tetracycline
other: IPL, laser, sugery
perioral dermatitis
periorificial
women, 20-45 yrs
rash or pimples around mouth: nose, eyes, labia
papules, pustules, vesicles
Tx: discontinue topical steroids, topical antibiotics (mild), oral antibiotics (severe), may need topical non-steroidal anti-inflammatory
triggers for perioral dermatitis
- steroids (topical)
- OCP
- menstruation, pregnancy
- fluorinated toothpaste
- stress
- candida, demodex mites
folliculitis
follicular based papules/pustules on hair bearing areas
Tx: antibacterial soap/wash, topical antibiotics/antifungals
causes of folliculitis
most common: staph, strep, pseudomonas
fungal: Pityrosporum orbiculare
mites: Demodex folliculorum
mechanical
eosinophilic folliculitis
HIV, transplant patients
hidradenitis suppurativa (HS)
women
apocrine gland bearing areas: axillary, inguinal, inframammary folds
Sx: recurrent, persistant painful abscesses; chronic sinus tract drainage, scars
Tx: topical and/or oral antibiotics (mild)
Tx severe: IL steroids, TNFa inhibitors, surgery
risk factors for hidradenitis suppurativa
- obesity
- cigarette smoking
- family Hx
herpes simplex (HSV)
dsDNA: latent, recurrent, primary
cluster of monomorphous vesicle with erythematous base, punched out erosion and crusted papule
direct contact
primary infection: pain, burning, tingling, fever, malaise, LAD
recurrent: milder
trigger: fever, sun exposure, stress
Dx: Tzanck smear: giant multinucleated cells, viral culture, PCR
Tx: topical antiviral, systemic antiviral (oral or IV for moderate to severe)
HSV-1
perioral, lips, oral cavity
HSV-2
genital
herpes zoster (VZV)
dsDNA: latent in dorsal root ganglia
after 60, immunosuppressed
shingles: reactivation of latent VZV
trigger: trauma, stress, fever, radiation, immunosuppression
Sx: prodrome (pain, pruritus, burning), grouped over a dermatome, trunk most common
resolves in 3-5 weaks, postherpetic neuralgia
Dx: Tzanck smear, viral culture, PCR
Tx: oral antivirals, pain meds
prevent: vaccine
Vesicle location for VZV: trigeminal nerve
- V1: ophthalmic
- V2 or V3
- vesicles tip/side of nose (Hutchinson’s sign): nasociliary branch, eye: blindness
- facial palsy, ear: tinnitus, vertigo, deafness
molluscum contagiosum
dsDNA: Pox virus
cutaneous infection: pink to skin colored 2-10 mm dome shaped waxy papule with/out central umbilication
face, upper chest, extremities
transmit: skin to skin, auto inoculation, fomites
resolve spontaneously within months to years
may leave scar
Tx: nothing
other: cutterage, cryotherapy, cantharidin, topical retinoids, keratolytics, topical imiquimod, intraleional antigens, cimetidine
cantharidin
chemical vesicant extracted from blister beetle
Tx: molluscum
warts
dsDNA: HPV
benign, involute
transmit: hetero/autoinoculation, fomites traumatized skin
incubate: 1-6 mo
duration: most 2 years
cell mediated immunity
Dx: black dots
Tx: none, destructive or immunomodulatory if painful/extensive/enlarging/subject to trauma/comsmetic objection
Tx depends on: age, personality, number, size, location, previous Tx
verrucae vulgaris
common warts
hands: periungual, subungual, anywhere including mouth
single or multiple skin colored hyperkeratotic papule or plaques: dome shaped, exophytic, filiform (stalk)
Dx: black dots, disruption of normal skin lines
verrucae plantaris
plantar warts
most symptomatic: weight pairing surfaces
mosaic wart: coalesce into clusters
verrucae plana
flat warts face, neck, legs most common smooth, skin-colored to slightly tan/pink flat-topped thin papules and/or plaques few or many shaving can facilitate
condylomata acuminata
anogenital warts
transmit: sexual, perinatal, nonsexual hetero/autoinoculation, fomite
skin colored pink/tan soft papule 1-5 mm, usually multiple, may form large cauliflower-like masses
Sx: asymptomatic, irritation causing pain or bleeding
tinea capitis
3-7 yrs
scalp ringworm
fungal infection of skin and hair of scalp
trichophyton tonsurans (AA), microsporum canis (white)
risk: large family, crowded living conditions, low socioeconomic status
Sx: posterior cervical, sub-occipital LYMPHADENOPATHY
Dx: FUNGAL CULTURE
Tx: systemic antifungals, GRISEOFULVIN, ketoconazole shampoo or selenium sulfide, fomite education, terbinafine
M. canis: require higher does, longer course, can’t use terbinafine
tinea corporus
superficial fungal infection of skin
transmit: infected person or animal contact
young: M. canis > M. audouinii, T mentagrophytes
older child/adult: T. rubrum (if in young child, parent has tinea pedis and/ or onychomycosis), T. verrucosum, T. mentagrophytes, T. tonsurans
one or more well-defined angular scaly erythematous plaques with central clearing and a scaly, vesicular, papular, or pustular border
Dx: Hx, presentation, KOH prep (scrape active border), fungal culture
Tx: topical antifungal for 2-4 weeks, no improvement: reconsider Dx
systemic for severe/disseminated, IC’d host, Majocchi’s, tinea faciei
tinea manuum
men
skin of hands: red/scaling, chronic dryness
palmar or dorsal pattern
T. rubrum, T. mentagrophytes, E. floccosum
Dx: KOH, fungal culture
Tx: topical antifungal for dorsum; palms require oral anti fungal
tinea cruris
men
skin of groin: jock itch: pruritic, red, annular, scaly plaques over groin and medial thighs; penis and scrotum not affected
risks: obesity, heat, humidity
T. rubrum, T, menatgrophytes, E. floccosum
Dx: KOH, fungal culture
Tx: powder antifungal, oral anti fungal if refractory
tinea pedis
men
athlete’s foot: itching, scaling on soles, between toes; blistering
Moccasin, vesiculobullous
risk: occlusive shoes, communal pools/showers
Dx: KOH, fungal culture
tinea unguium (onychomycosis)
older males
nail infection
T. rubrum, T. mentagrophytes, E. floccosum
non-dermatophyte molds, yeasts
discoloration, thickening, onycholysis
pattern: distal subungual, proximal subungual, white superficial, candida
Dx: KOH prep (from sublingual debris), fungal culture/stain of nail clipping, PAS stain (periodic acid-Schiff)
Tx: systemic antifungals 6-12 weeks: terbinafine, itraconazole, fluconazole
risk: IS’d, DM, HIV, poor circulation, trauma, dystrophy
superficial fungal infections: dermatophyte
(tinea or ringworm)
soil, animals, humans
digest keratin, invade hair skin, nails
trichophyton, microsporum, epidermophytom
superficial fungal infection: yeast
tinea versicolor, candidiasis
kerion
tinea capitis
marked inflammation may cause scarring and permanent hair loss
rapid aggressive therapy
Tx: consider systemic steroids
griseofulvin
gold standard for tinea capitis
give with fatty food
AE: photosensitivity, morbilliform eruption, heme and hapatic toxicity, headache, GI
monitor: CBC, LFT
terbinafine
SE: dizzy, drug interactions, hepatotoxicity, heme, GI headache
monitor: CBC, LFT
moccasin tinea pedis
fine dry scale over soles
T. rubrum
vesiculobullous tinea pedis
vesicles/bullae on soles esp. insteps
T. mentagrophytes
tinea versicolor
pityriasis versicolor
adolescence
Malassexia furfur (Pityrosporum orbiculare or ovale)
multiple scaling, oval macules, patches and thin plaques over upper trunk, proximal arms, sometimes face and neck
hyper/hypopigmented
SUMMER
Tx: education (chronic), selenium sulfide or ketoconazole shampoo/lotion
severe Tx: systemic ketoconazole, fluconazole, use topical for maintenance
candidiasis
inertriginous, paronychia, angular chelitis
Tx: anti yeast cream, decrease moisture
chronic paronychia
nail dystrophy
candida albicans
Dx: stain/culture
Tx: topical ketoconazole if mild, oral fluconazole (monitor CBC, LFT)
