Each Derm Disease (per Card) Flashcards by Demetré Harris

A pt presents at onset of puberty with multifactorial disease of the pilosebaceous glands/ units

+excess sebaceous gland secretion
+duct obstruction
+bacterial colonization (P. Acnes)

Think

Acne Vulgaris

Can be Dx on presentation

Tx for the long haul
Mild soap and water, mild exfoliation, Avoid occlusion

Retinoids are effect over all sympotoms of acne
(Apply at bedtime)

+/benzaclin (benzoyl peroxide +clinda)

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What is the approach to mild inflammatory acne

Start with retinoid + benzoyl peroxide and topical ABX

If pustules remain after 2-4 weeks add oral ABX
-Doxy, tetra, or minocylcine

Min of 3 month trial

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Tx approach to moderate to severe acne

Start with triple therapy

Topical retinoid
+benzoyl peroxide
+ oral ABX
(Doxy, TCN, Minocycline)

Taper after 2-4 months

Consider intralesional steroid injections
(Triamcinolone)

If treatments fail: Refer to DERM for accutane

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If a female pt fails candidacy for accutane what is alternate treatments for mod to severe inflammatory acne

BCPs
Spironolactone
(if not a candidate for Accutane)

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A pt presents with signifigant inflammation, papules, pustules, NODULES, CYSTS, and SCARING
(Embarrassing lesions, missing school work)

With Sinus tracts and mild facial edema

MC to the face, neck, chest, and back

With a family Hx of acne on the male side

Think

Severe nodulocystic acne

Treat with referral to derm for accutane (oral retinoid)
(Isotretinoin)

Intralesional steroids for large nodules

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What is role of Isotretinoin

Approved indications

nodular acne
recalcitrant acne

Must be followed for 6months

Dc all tetracyclines and topical retinoids expecailly vit A

Order CBC, UA, LFTS, LIPIDS, and HCG!

Repeat labs at each f/u

MUST BE ON 2 methods of BC
Ask about family hx of IBD

Instruct pt to use SUNSCREEN!

Cannot donate blood and only give out 1 month of Rx at a time

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When should you D/c Isotretinoin

Pregnancy
(its highly teratogenic)

Signs of possible ICH
-HA with visual changes
Or not relieved by OTC
(Look for papilledema)

-mood swings with SI/ HI

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A 20-30 year old female pt presents with hormonally sensitive acne that flares with menses and occasionally begins during pregnancy

Is very inflamed red papules and comedones along the chin and jaw line

Think

Adult female acne

Tx with OCP
Spirinolactone
Tretinoin Cream (2nd line)

If all above fails: Erythromycin

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A young female pt presetns with mildly puritic and reccurnty small papules and pustules that “resembles acne:”

Confined to the chin and nasolabial folds with pustules on the cheeks adjacent to the nasolabial folds

CLEAR ZONE AROUND VERMILLIAN BORDER

Think

Perioral dermatitis

Assoc with use of moisturize creams

Tx with dc of creams + doxy for 2-4 weeks then tapper for 8 weeks

+/- 1% HC cream for Inflammation

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A pt presents with erythema , papules and pustules, telangiectasias, swelling of the cheeks and forehead with RHINOPHYMA 2/2 demodex folliculorum

Often in fair skinned people
That burns or stings

Think

Acne Rosacea

Treat with avoidance of triggers
+ sunscreen

Metronidazole works against the mite
Azelaic acid or tetra for severe or resistant

If refractory:
Isotretinoin or surgical correction of rhinophyma

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A pt presents with small non inflamed papules and comedones after application of oil/cream to the hair lin

Think

Pomade Acne/ Acne Cosmética

Tx with stopping the offfending agent

Benzoyl Peroxide 10% if tolerated for light exfoliation

Add tretinoin .025% at bedtime

Inflamed lesions - topical antibiotics

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A pt presents with sudden onset acne 2-4 weeks after starting a PO steroid

Is a teen or YA

Often pruritic in a uniform symmetric distribution

No scarring

Think

Steroid ACne

Tx by Dc steroid if able

Topically tx with benzoyl peroxide or sulfacetamide lotion

Hydroxyzine or diphenhydramine prn for itching

Should heal without scarring

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A pt presents with small epidermal cycsts WITHOUT opening around the eyes

2/2 sun damage or physical trauma

Think

Milia

Tx with incise over the lesion and extract contents if only a few lesions

If many lesions use tretinoin for several weeks until resolution

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A pt presents with “prickly heat”/ “heat rash”
2/2 sweat retention from occluded eccrine glands

Often in hot humid weather

Common in babies

Feels very stinging/ pruritic

Think

Miliaria

Tx is often self limited
Remove from warm environment to a cool area

Cool compress and antihistamines

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A pt presents with chronic suppurative, scarring of the skin and subQ tissue

Often with a familial hx of scarring acne

Hyperkeratosis over the apocrine glands with secondary bacterial infection

In the axialla, groin, or under the breasts

Usually is obese, always after puberty

Think

hHidradenitis Suppurativa

Has a DOUBLE COMEDONE
With sinus tracts and scarring

Tx with stop smoking
Long term ABX (Main stay)
(TCN, Doxy, Erytho, minocyline)

Hot compress

If large I&D cysts or abcesses

Or Intralesional injections if smaller

If communicating tracts the surgical excision and grafts
(Gen SRGRY consult)

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A pt presents with tender foliculitis, low grade fever, after shaving or a break in the skin
Anywhere hair is present…
Think

Staphylococcus Folliculitis

Treat with topical mupirocin or Clindamycin

If extensive the PO dicloxacillin or cephalexin

If recurrent the Clinda x 10 days
Wash area with hibiclens TID x5 days
Change towel and pillow case daily

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What is the tx for pseudo foliculitis barbae

modify shaving technique

hydrate and soften beard
wash with benzoyl
shave with grain

Rx: Topical steroids group VI -VII after shaving

Temporary profile

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Psuedo Folliculits barbae of the nape of the neck

Think

Acne Keloidalis Nuchae

Tx with no short or shave haircuts

If pustular or exudative then culture and treat with ABX x 3 months (TCN)

3 step plan for control:

Topical Clindamycin bid (Cleocin)
Fluocinonide (Lidex) bid 3-6months
Tretinoin .05% cream bid x 12 months

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What is the treatmetn for epidermal inclusion cysts

Will have a visible but dysfunctional pore

Can occur anywhere

No MGMT necessary if aS/s

If desire removal of non inflamed lesions along skin lines
Excise intact if possible

Inflamed: Intralesion injection and excision post inflammation reduction

If ruptured: Excision after I&D

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What is a Pilar Cyst

Similar to epidermal inclusion cyst but can calcify

Tx by excision

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A pt presents with rough skin that is DRY, with white scales that become thick brown scales
MC on the hands and Lower legs
+/- itching and burning

Think

Xerosis Cutis

Treat with Emolients and 12% lactate lotion

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A pt presents with allergic rhinitis, and asthma

Also has drying, hallmark pruritus and inflammation of erythematous lesions the FLEXOR creases that SPAREs the face (except eyelids)

MC in children

Think

Eczema

Part of the atopic triad

DX: clinical or IgE

Treat acutely with topical steroids and Anithistamines + wet dressings

If infected add ABX

Chronicly treat with mild soap (dove) , skin hydration and emollients BID S/p bath

Trigger avoidance and antihistamines for itching

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A pt presents with éczema that is coin shaped lesion in pts older than 50

Mc on the dorsum of the Hand, feet, or extensor surfaces

“Itch that rashes”

Think

Nummular eczema

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A pt presents with itching that precedes to vesicles of the hand or foot , symmetric distribution
“Tapioca like”

Scales to lichenification to crackling to fissuring

Think

Dyshidriotic Eczema / Pomphylx

Treat with antihistimes and avoid triggers

Start with potent steroids and wean to less potent steroids

+wet compress
+PUVA

LAST RESORT: methotrexate

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A elderly pt presetns in the winter with lower extremity dryness, that has intense itch that becomes a rash with dry scales on skin lines Think

Asteatotic Eczema Treat with emollients immediately s/p bath Group III-IV steroids and emollients Change bathing habits and avoid hot showers If severe then add wet compress and ABX

What is the treatment for Nummular eczema

Group I-III steroids + occlusion and emollients, and antihistamines for itch

A pt presents with a habitual scratch-itch- cycle that is red papules that become a red scaly plaque along the skin lines Think

Lichen Simplex Chronicus Treat by stop scratching, Group I ointment 1st gen antihistamine +/- kenalog

A pt presents with inflammation of the lower extremities 2/2 poor circulation With itching, scales, and hyperpigmentation that leads to ulcers Think

Stasis dermatitis Treat underlying condition + emollients and topical steroids

A pt presents with spiney keratotic papules on the EXTENSOR surfaces MC to the arms and legs Usually aS/s Think

keratosis pilaris Tx: lotions with urea or lactic acid Short course of steroid (mid potency)

A pt presents with ertythema, edema and vessicles that progress to bulluae after contact with nickel, or poison Ivy That is intensely itchy Think

Contact dermatitis Damage to the stratum corneum Treat with avoidance, and emollients Cool compress and if severe topical steroid

A pt presents with a blistering disorder that is a type II RXN that involves IgG and Desmoglein MC assoc with Myathenia Gravis Has universal involvement of the oral mucosa with skin blisters that progress to deep ulcers that Easily rupture And are NOT ITCHY Think

Pemphigus Vulgaris Dx with Bx ( IgG row of tombstones) Tx: refer to derm + prednisone +immunomodulaltors

A pt presents with the most common autoimmune subepithelia blistering d/o Mc in pts older than 60 and chronic Has a generalized bullous, puritic disruption of the epithelium Localized erythema plaque because dark red and cyanotic over 1-3 weeks then vesicles and bullae appear NEGATIVE Nikolsky sign Think

Bullous Pemphgoid Tx with GroupI topical AND oral steroids If severe treat as Pemphigus Vulgaris- refer to derm and treat with prednisone

A pt presents with chronic burning and puritic vessicles and also has celiac dz MC in white males, and is on the bilateral EXTENSOR surfaces, also on the scalp or butt Think

Dermatitis Herpetiformis Dx with punch Bx and test for celiacs Tx: Gluten free diet + dapsone (short term)

A DM pt presents with oval purple patches with advancing red border with a woody induration that progresses to ulcers on the ant Tib/fib Think

Necobius Lipoidica TxL topical or intralesional steroids Systemic PO steroids for 3-5 weeks And pentoxifylline for 1 month

A Dm pt presents with a ring of small red flesh colored papules That start flesh colored and progress to red, on the lat dorsal hands and feet Think

Granuloma Annular, Assoc with HIV! Tx: none necessary, Cosmetically: topical steroids and occlusion If disseminated: PUVA + dapsone

An obsese pt presents with a velvety hyperpigmented plaque Mc to the axilla Think

Acanthosis Nigricans Tx underlying cause Usually a D/o of insulin (DM or cushings) Ammonium lactate can soften the plaque Tretinoin cream can thicken the skin

A pt priests with lipid deposits, flat yellow plaques around the eyes think

Xanthomas Tx underlying dylipedma Can be eruptive (Small yellow with red halo) Tuberous (Slow painless plaques on the knees, elbows, extensors, or palms) (billiary Cirrohisis) ``` Or Tendonous (MC to the Achilles) ``` All are a sign of High Tri Gs

A pt presents with oval, raised, elongated, RUST colored infiltrates, that decrease in size with pressure applied, and progress to ulcers Assoc with HPV 8 And is classically seen in older men on the hands, feet, LE Think

Kaposi’s Sarcoma If on the trunk think AIDS/HIV Vascular cancer associated with HPV 8 Dx with Bx (Blood vessels with neoplastic epithelium) Tx with Nitrogen Cryo therapy Or excision +/- intralesional chemo (Vinblastine)

A pt presents with moist warm skin, that is smooth Has a bronze tint to the skin Thin hair, and clubbing concave finger nails (Thyroid acropachy) And pretibial myxedema Think

Hyperthyroidism Pretibial myxedema is on the front of the skins and has an orange peel appearance and is non pitting edema Also associated with graves Dz

A pt presents with swollen, cool, waxy dry skin, with increased wrinkles, eyelid puffiness, and a yellow tint to the skin (Carotemia) + alopecia to the lateral eyebrows + vitalligo Think

Hypothyroidism

A pt presents with red flat papules that coalesce to oval plaques Think adherent silvery scales +auspitz sign MC to the extensor surfaces +pitting/ oil spots on the nails That worsens with stress Think

Chronic plaque psoriasis Immune mediated skin/ joint dz Hyperkeratosis +koebner phenomenon If less than 5% Tx with group I/II topical steroids and taper Avoid tachyphylaxis with steroid holidays +/- salysilic acid to remove scales Topical D3 and steroids are the best combo

A pt with chronic plaque psoriasis that covers more than 5% TBSA What is the Tx

Biologics : methotrexate or cyclosporine

A pt prestns with a 2 week hx of strep or viral URI And now has sudden scaling papules on the trunk and extremities That SPARES the palms and soles Has a “teardrop” distribution of tiny red papules with thick white scales Think

Guttate psoriasis MC in children and YA Tx with throat culture And 1st line is UVB +emollients

A pt presents with deep creamy yellow pustules on the middle of the palm or foot That becomes a dry crust that does not rupture Think

Pustular psoriasis Treat with Group I topical (Clobetasol) +/- occlusion +/- PUVA Do NOT use PO steroids Encourage smoking cessation Generic Varient leads to lakes of puss and is fatal

A pt presents with red plaques in skin folds that a macerated and dispersed Think

Psoriasis inversus DDx candida

A pt presents with find white or yellow flakes, and red papules with an inflamed base, plus pruritus MC to the scalp, and scalp margins, eyebrows, and nasolabial folds “Dandruff” Think

Seborrhic Dermatitis Tx with proper hygiene, Ketoconazole shampoos and creams Selenium Sulfide Head and Shoulders Baby shampoo if at eye lids Topical steroids to reduce inflammation PRN +/-ABX Oral anitfungal if severe

How does seborrhic dermatitis present in infants

Cradle Cap

A pt presents with a HERALD patch (salmon colored) following a viral infection with HPV 6/7 Common in Children and YA MC tot he trunk and proximal extremities Is distributed in a Xmas tree like pattern Think

Pityriasis Rosea R/o syphillis infection No MGMT needed, only reassurance If severe: Prednisone + UVB Acyclovir or Erythromycin as needed

A pt presents with a purple, polygonal, planar (flat), pruritic plaque +wickams striae +koebner phenomenon MC to the hands, feet, ankles, wrists, involves the oral mucosa genitals and scalp Think

Lichen planus Dx with Bx Tx with Group I/II steroid and intralesion injection Steroids in the oral mucosa need added oral base Generalized: prednisone x 2-4 weeks treat itch with Hydroxyzine R/o SCC

What should you R/o in lichen planus

SCC

A pt presents with small smooth overly flat papules that becomes plaques (porcelain) and are atrophic Mc to the vulva, perianal region, and groin Think

Lichen Scelrosis Dx with Bx Tx with Clobestol BID x 1month + PUVA Has a high assoc with cancer risk

A pt presents with a nodular erythematous eruption on the extensor surfaces of the extremities With a low grade fever, arthralgias, and arthritis “Red nodes over the shins” Starts out tense and hard and becomes fluctuant Think

Erythema Nodosum Assoc with sarcoidosis Tx is self limited and NSAIDS

A pt presents with ulcerating skin dz associated with IBS That is a necrotic ulcer with a purulent base Think

Pyoderma Gangrenosum

A pt presetns with recurrent wheels And itching with SOB and dysphagia Has a firm red plaque/ faint pink with a central pallor Can present with an orange peel appearance and fades within 24 hours Think

Uticaria IgE Treat acutely with irritant avoidance H1/H2 blockers And be prepared for anaphylaxis Tx chronicly with 2nd gen antihistamines, H2 blockers Short course of steroid And diet elimination

A pt presents with deep swelling of the neck, tongue and face That is burning and painfully itchy +dysphagia, Dyspnea, abd pain Think

Angioedema Tx with removal of irritant IM/PO antihistamine And PO steroids if able to swallow Be prepared to treat anaphylaxis and airway

A pt present with a high fever, Cough, coryea, and conjunctivitis +koplik spots And a Erthyematous macular popular rash Think

Measles 2/2 viral measles Starts at the head/ faces and moves to the trunk and down Dx with IgG for measles Tx is supportive and isolation Contact the CDC Treat fever, give fluids, ect

A pt presents with red papules that become painful lesions on the hands feet and mouth Think

Hand Foot Mouth Dz 2/2 cocksackie MC in children under 5 Often on the dorsal surfaces Tx is supportive And give antihistamines and antipyretics Change the diet to accommodate oral sores

A pt presents with a slapped cheek appearing rash to the face Think

5th disease Aka erythema inectioiusm 2/2 parovirus b19 Tx is supportive Pt is not infectious during the rash phase

A pt presents with conjuctivitis, maculoapupular rash, tender edema to the extermeities, cervical adenopathy,a CN mucositis Think

Kawasaki’s Dz C/R/E/A/M Strawberry tongue is the dead give away Tx with immunoglobulin and aspirin

A pt has a cutaneous reaction following initiation of a new drug

Tx with dc the rx Antihistmines And PO/Topical steroids III-V (weaker/ mod)

A pt presents with target lesions, that are dark red macules with central color changes Mc to the dorsal hands, palms, soles, extensor limbs, and mucus membranes Think

Major or Minor erythema multiforme Major( mucus membranes) Minor (without) Tx: can heal spont, with 2 weeks Tx s/s with mild steroids, Anithistamines, orajel +/- prednisone and acyclovir MC CAUSE HERPES If lesions are on eyes; optho referral

A pt presents with mucosal lesions on the conjunctiva, nasal, oral , and genitals That progress to Bullae in 1-14 days Preceeded by a URI with a high fever 1-3 days prior Think

Steven Johnsons Covers 10% TBSA Detachment of the epidermis +severe necrosis Tx: D/c Rx and admit to burn unit IV fluids and optho consult as needed + ABX and Airway MGMT

A pt presents with full thickness necrosis, 2/2 Rx, and covers 30% TBSA Think

Toxic Epideraml Necrolysis Will have a red macular sun burn look +Nikolsky sign “Wet cigarrette paper look” Tx is refer to burn unit ASAP and Airway MGMT ``` Avoid Infections (MC CAUSE of death) ``` DO NOT GIVE STERIODS!