FINAL derm Flashcards
This is the most serious type of skin cancer, develops in the cells (melanocytes) that produce melanin — the pigment that gives your skin its color
It is becoming more common in people younger than 40, with a higher prevalence in women.
Melanoma
The first melanoma signs and symptoms often are:
A change in an existing mole
The development of a new pigmented or unusual-looking growth on your skin
(Melanoma doesn’t always begin as a mole. It can also occur on otherwise normal-appearing skin.)
To help you identify characteristics of unusual moles that may indicate melanomas or other skin cancers, think of the letters ABCDE. What do the letters stand for?
-A is for asymmetrical shape. Look for moles with irregular shapes, such as two very different-looking halves.
-B is for irregular border. Look for moles with irregular, notched or scalloped borders — characteristics of melanomas.
-C is for changes in color. Look for growths that have many colors or an uneven distribution of color.
-D is for diameter. Look for new growth in a mole larger than 1/4 inch (about 6 millimeters).
-E is for evolving. Look for changes over time, such as a mole that grows in size or that changes color or shape. Moles may also evolve to develop new signs and symptoms, such as new itchiness or bleeding.
Melanomas can also develop in areas of your body that have little or no exposure to the sun, such as the spaces between your toes and on your palms, soles, scalp or genitals.
These are sometimes referred to as hidden melanomas because they occur in places most people wouldn’t think to check.
Melanoma is more likely to occur in a hidden spot in people with which type of skin?
Dark-coloured skin.
Factors that may increase your risk of melanoma include:
Fair skin.
A history of sunburn.
Excessive ultraviolet (UV) light exposure.
Living closer to the equator or at a higher elevation.
Having many moles or unusual moles (dysplastic nevi).
A family history of melanoma.
Weakened immune system.
Basal cell carcinoma is a type of skin cancer that begins in the basal cells — a type of cell within the skin that produces new skin cells as old ones die off.
Most basal cell carcinomas are thought to be caused by?
Most basal cell carcinomas are thought to be caused by long-term exposure to ultraviolet (UV) radiation from sunlight
What is the most common presentation of basal cell carcinoma, and where does it most commonly occur?
Basal cell carcinoma often appears as a slightly transparent bump on the skin, though it can take other forms.
Basal cell carcinoma occurs most often on areas of the skin that are exposed to the sun, such as your head and neck.
Factors that increase your risk of basal cell carcinoma include:
Chronic sun exposure.
Severe sunburns.
Radiation therapy.
Fair skin.
Increasing age.
A personal or family history of skin cancer.
Immune-suppressing drugs.
Exposure to arsenic.
Inherited syndromes that cause skin cancer.
Complications of basal cell carcinoma can include:
A risk of recurrence.
An increased risk of other types of skin cancer.
Cancer that spreads beyond the skin. Very rarely, basal cell carcinoma can spread (metastasize) to nearby lymph nodes and other areas of the body, such as the bones and lungs.
This common form of skin cancer develops in the cells that make up the middle and outer layers of the skin.
Squamous cell carcinoma.
Squamous cell carcinoma of the skin most often occurs on sun-exposed skin, such as your scalp, the backs of your hands, your ears or your lips. But it can occur anywhere on your body, including inside your mouth, the bottoms of your feet and on your genitals.
Signs and symptoms of squamous cell carcinoma of the skin include:
A firm, red nodule
A flat sore with a scaly crust
A new sore or raised area on an old scar or ulcer
A rough, scaly patch on your lip that may evolve to an open sore
A red sore or rough patch inside your mouth
A red, raised patch or wartlike sore on or in the anus or on your genitals
Factors that may increase your risk of squamous cell carcinoma of the skin include:
Fair skin.
Excessive sun exposure.
Use of tanning beds.
A history of sunburns.
A personal history of precancerous skin lesions, such as actinic keratosis or Bowen’s disease.
A personal history of skin cancer.
Weakened immune system.
Rare genetic disorder. People with xeroderma pigmentosum, which causes an extreme sensitivity to sunlight, have a greatly increased risk of developing skin cancer.
A dome shaped, pearly tumour with telangectasias on the surface.
Basal cell carcinoma, squamous cell carcinoma, or malignant melanoma?
Nodular BCC.
A dome shaped, pearly tumour with telangiectasias, with central necrosis and erosion.
Basal cell carcinoma, squamous cell carcinoma, or malignant melanoma?
BCC.
What is the most common sun-exposed site for basal cell carcinoma?
The nose.
A smooth pearly nodule with telangiectasias and diffuse grey pigmentation.
Basal cell carcinoma, squamous cell carcinoma, or malignant melanoma?
Pigmented BCC.
If any suspicion that it may be MM, refer. The test says to biopsy, but Don said not to biopsy as this can accelerate MM.
Flat, less invasive lesions that tend to appear more on the trunk and extremities, often in multiples. Tends to appear earlier in life than other forms of this type of skin cancer. These circumscribed, round to oval, red, scaling plaques may be confused with eczema, psoriasis, extramammary Paget’s disease, or Bowen’s disease (SCC in situ).
Basal cell carcinoma, squamous cell carcinoma, or malignant melanoma?
Superficial BCC.
What is actinic keratosis?
Very common keratotic lesions with malignant potential. Most commonly found on sun-exposed areas of the elderly.
Usually consists of sharp yellow scale, can be tightly adherent to skin in early stages and develop a rough/sandpaper texture over time.
What estimated percentage of patients with actinic keratosis will develop squamous cell carcinoma in 1 or more lesions?
An estimated 20%
A full-thickness form of squamous cell carcinoma that is slow-growing and usually appears as a pink, scaly, well-demarcated patch.
Bowen’s disease.
A tumour on the lower lip most often indicates which form of skin cancer?
Squamous cell carcinoma.
The typical lesion has a pink to dull red, firm, poorly defined dome-shaped nodule with an adherent yellow-white scale.
Basal cell carcinoma, squamous cell carcinoma, or malignant melanoma?
SCC
30% of melanomas develop within a pre-existing ________.
Nevus.
Most melanomas that arise from a nevus tend to form superficial spreading melanoma - more common in white females.
What is acute paronychia
Bacterial infection of proximal and lateral nail fold, often called staph aureus
What kind of exudate is most common in bacterial infection?
Purulent exudate (has large number of leukocytes)
Differentiate gram positive from negative bacteria
Gram staining helps determine thickness of the wall to ID/ categorize bacteria. Crystal violet is the dye used. Peptidoglycans in the cell wall retain dye; a thick cell wall retains violet color; a thin does not.
Gram positive- stains purple or blue
Gram negative- stains pink or red
What bacteria are common pathogens in skin infections?
Staphylococcal, streptococcal pneumonia, cholera (mucous membranes), ?TB
T/ F bacteria is involved in the patho of acne vulgaris
True. In acne vulgaris, there are 4 causative factors:
1) hyperkeratinization of the follicular epithelium
2) excessive sebum production (caused by androgens and testosterone)
3) follicular proliferation of anerobic p. acnes
4) Inflammation and rupture of follicle from accumulated debris and bacteria
What is folliculitis?
Inflammation of hair follicle anywhere on body.
What is folliculitis caused by
Often staph aureus (most common) or pseudomonas (hot tub folliculitis). Can be fungal.
Patho of folliculitis
Bacterial infection spread by trauma/ itching/ shaving. Acneiform eruption becomes pustular, superficial. Leads to dome shaped pustules with small erythematous falos arising in a follicle. Can be tender.
Tx folliculitis
most respond to abx. minimize triggers like heat, friction, occlusion.
What are furuncles/ carbuncles?
Infected pocket/ abscess commonly caused by staph (localized redness) or strep (streaking). Furuncles are walled off masses and carbuncles are deep interconnected aggregates.
Most common bacteria causing furuncles/ carbuncles?
Staph (MRSA)
S&S/ dx of furuncles
-deep dermal or subcutaneous red, swollen, painful mass
-later points toward surface and drains through multiple openings
-afebrile
-gram stain, C&S indicated
S&S/ dx of carbuncles
-deep, tender, firm subcutaneous erythematous papules enlarge to deep seated nodules that can be stable or fluctuant within days
-often back of neck, upper back, lateral thighs
-malaise, fever, chills may precede or occur with height of inflammation
-gram stain, C&S indicated
Management of furuncles/ carbuncles?
-infection can spread to other sites
-recurrent furunculosis may be difficult to eradicate
-warm moist dressings
-incision and drainage are primary management for pointing, fluctuant lesions (refer to derm if on hands or face)
-systemic antibiotics if multiple lesions or signs of systemic illness (fever, malaise, spreading redness, increasing pain)
-Dicloaxacillin, cephalexin, clindamycin
-good handwashing will reduce # of & on skin. Use separate towels from others.
-follow up in 5-7 days to see if improving (2 days if using packing)
What is impetigo?
Superficial skin infection produced by streptococcus pyogenes, staph aureus, or both
Epidemiology of impetigo
Common (highly infectious), children have higher rates of infection (close physical contact), warm/moist/ humid climates and poor hygiene predispose
Time course impetigo
Self limited, but if untreated, may spread and last for weeks to months.
Signs and symptoms of impetigo
May occur after minor skin injury or within lesions of another dermatitis, however, often develops on normal skin.
Local or widespread; common on face.
Systemic symptoms infrequent.
Bullous- thin roofed bullae turn from clear to cloudy, collapse quickly leaving an inner tube shaped rim with central thin, fat, honey color stuck on crust. Lesions enlarge and coalesce. Minimal surrounding erythema. May have adenopathy
Non Bullous- vesicles or pustules rupture. Scaling border. Firm adherent crust is honey yellow to white brown; it accumulates.
Management impetigo
Antibiotic cream, or oral antibiotics for widespread lesions/ bullous impetigo.
What is cellulitis?
An infection of dermis and subcutaneous tissues characterized by fever, erythema, inflammation, and pain
What is cellulitis commonly caused by
Staph aureus, MRSA, group B strep
Epidemiology cellulitis
Diabetes, cirrhosis, poor lymphatic circulation, renal failure, poor nutrition, HIV, ETOH, cancer, chemotherapy, pre-existing skin issues and substance abuse are predisposing factors.
-Trauma and surgery are risk factors
Signs and symptoms of cellulitis
Redness, warmth, pain, vesicles, blisters. Skin is slightly raised and border is indistinct. Pain on palpation. Very common on lower extremities or ear.
Differentiate cellulitis from erysipelas
Cellulitis is bacterial infection of dermis/ subcutaneous tissues
Erysipelas is infection of superficial dermal layer (margins more clearly demarcated, may involve lymphatics and has streaking. Group A strep.
What do the following disorders have in common: Beau’s Lines, Onycholysis, Paronychia, Ingrown toenail, digital mucous cyst
They are all nail related disorders
What are Beau’s Lines?
Transverse depressions or ridges of all the nails that appear at lunula base
What causes Beau’s Lines?
Appear after a stressful event temporarily interrupts nail formation.
Causes: high fever, scarlet fever, hand-foot-and-mouth disease, chemo
How do we treat Beau’s Lines?
We don’t. Lines progress distally with normal nail growth, eventually disappear at free edge
What is Onycholysis
Separation of nail from nail bed starting at distal end and slowly progressing proximally
nonadherent part of nail is white, yellow or green-tinged
What causes Onycholysis?
nail trauma, repeated wet work, vigorous repeated manicuring (digging under nails), false nails allergy and psoriasis
What might we screen people who present with onycholysis for?
Screen patients with unexplained onycholysis for hyperthyroidism, asymptomatic thyroid disease and iron deficiency
How do we treat onycholysis?
cut separated portion of the nail. Promotes dryness and discourages infection.
Yeast can grow in space between the nail and nail bed. Treat with topical agents (fungoid tincture that contains miconazole). Consider oral fluconazole for resistant cases
What is paronychia?
Acute or chronic infection of the cuticle.
One or more fingers or toes may be involved
Risk factors for paronychia?
hands frequently exposed to moisture
What are the most common causative agents of paronychia?
Staphylococci and streptococci
True or false: Paronychia can be acute or chronic
TRUE
Treatment for paronychia
Abscess may develop, requiring incision and drainage. Pus can develop and expressed from the proximal nail fold. Nail plate is not typically affected, but can become discolored with ridges
Treatment: Topical application of thymol. Oral antifungals NOT effective because they do not penetrate affected tissues. Prevention is key by keeping hands dry
What causes ingrown toenails?
Results from increased lateral pressure either by poorly fitting shoes, excessive trimming of lateral nail plate or trauma
Usually large toe
Describe the patho of ingrown toenails, what are the signs and symptoms?
Dermis is penetrated by the nail/lateral nail fold, and broken skin becomes purulent and edematous as granulation tissue grows with the penetrating nail
pain and swelling
What is the treatment for ingrown toenail?
Treatment: removal of the penetrating nail with scissors/curetting granulation tissue and using silver nitrate sticks to treat small areas of granulation
Could lead to cellulitis which may require PO antibiotics
What is a digital mucous cyst? What does it look like?
Focal collections of mucin (macromolecules in mucus) that don’t have a cystic lining
Dome-shaped, pink-white, typically occur on the dorsal surface of the distal phalanx in middle-aged and elderly people
What is treatment for a digital mucous cyst?
Typically benign, no intervention if pain free and does not compromise any function
If treatment is needed: cryosurgery of the base:
Remove cyst roof w/ scissors, expel gelatinous exudate
Freeze the base
Treated site will be edematous and exudative, and a bulla will usually develop
Healing takes 4-6 weeks, and retreatment is frequently needed
Fancy word for genital warts
Condylomata acuminata
What are genital warts caused by?
HPV (human papilloma virus)
Is HPV common?
Estimated 75% of sexually active people in Canada will have HPV at some point
>100 types of HPV
Risk factors for genital warts
Multiple sexual partners & high risk partners
Unprotected sex
Immunocompromised
Smoking
Not vaccinated (The HPV9 vaccine [Gardasil] protects against types 6 and 11)
What strains of HPV typically cause genital warts? Risk for cancer?
90% caused by HPV type 6 or 11 (low risk for cancer), although often co-infection with other types of HPV common
T/F An HPV infection commonly remains latent so you don’t always get warts when you have it
True, Infection can remain latent
Usually 3 week – 8 month incubation period as well
T/F HPV is considered an STI
True, it the most common STI in the world apparently!
How do you acquire genital warts?
Acquired through sexual activity (even just skin to skin contact)
DO genital warts resolve on their own?
Warts may recur due to subclinical infection, re-infection, or immunosuppression
May resolve on own within a few months, but may also maintain or progress if not treated
Fancy word for warts
verrucae
What do genital warts look like?
I’m hoping he would say “cauliflower-like” on an exam?
Variable sizes, papules or plaques
Many shapes: flat, dome, cauliflower-like, filiform, fungating, pedunculated, cerebriform, plaque-like, smooth, verrucous, or lobulated
Colour varies: skin-coloured, white, hyperpigmented, brown, pink or red
1mm – several cm’s
Where are genital warts located
Located on genitalia, groin, perineum, anal skin, perianal skin, and/or suprapubic skin
Urethral, cervical, or anal involvement possible
If extensive, may interfere with defection or urination, or urethral bleeding
T/F genital warts may cause pruritis, pain, burning, or bleeding
True!
T/F We routinely do HPV testing for warts
False.
Dx of genital warts
Diagnosis usually based solely on clinical presentation and physical assessment
Limited to anogenital region and surrounding areas
Biopsy possible for definitive diagnosis, and to rule out malignancy
Assess for signs of other STIs: ulcerations, vesicles, or discharge & test accordingly
Patient teaching re: genital warts
Very common
Timing of infection cannot be confirmed as can take months to have symptoms (if fear or infidelity)
May be at risk of other STI
Should inform sexual partners as can transmit HPV (still chance if no warts)
What is Erythema Multiforme? Common cause?
An acute, immune-mediated condition affecting skin + mucous membranes (including genital)
- Produced by a cytotoxic immune response directed against keratinocytes expressing foreign viral or drug antigens
- Infections are the cause for ~90% of cases. Commonly in herpes simplex type 1 & 2. Other common cases are Mycoplasma pneumoniae, and upper respiratory tract infections.
Time course erythema multiforme?
- Usually self-limiting and resolves in 1 month without scarring
What is the key characteristic of lesions in erythema multiforme?
“target-shaped”
Characterized by numerous target-shaped skin lesions with many types of lesion morphologies (hence name multiforme): target lesions, erythematous macules and papules, urticarial-like lesions, vesicles, and bullae.
- Target lesions begin as dusky-red, round macules and papules that may burn and itch.
- Early lesions appear suddenly in a symmetric or CROP PATTERN on the palms, soles, backs of the hands and feet & forearms and legs. Bullae and erosions may be present in the oral cavity (NOT to be confused with SJS)
- This central area is surrounded by a pale area of edematous skin, which is in turn surrounded by a sharp discrete ring of erythema.
COld sores are caused by what viral infection?
Herpes simplex
Outline primary and secondary infection process of HSV. How does it travel within the body?
Primary Infection:
HSV enters nerve endings in the skin directly or travels down peripheral nerves to dorsal root ganglia (DRG) where it stays inactive
Recurrent Infection:
Occurs after symptomatic or asymptomatic primary infection
Local skin trauma, systemic changes reactivate virus
Virus then travels via peripheral nerves down to initial infection site
How is HSV trasmitted?
HSV spreads via resp. droplets, direct contact with an active lesion or Salva or cervical secretions containing virus
S&S of primary herpes simplex infection. What are the earliest signs?
Primary Infection:
Mostly asymptomatic
Early signs = Tenderness, pain, mild paresthesia
Later: lesions, grouped vesicles (more numerous and spaced out than secondary infection)
Localized pain, tender lymphadenopathy, headache, fever, generalized aches
Lesions on mucous membrane accumulate exudate, lesions on skin form crust
Gingivostomatitis + pharyngitis most frequent (Type1)
Vulvovaginitis/painful vaginal + cervical erosions in women w genital infection
May have proctitis, anorectal pain, discharge, constipation or tenesmus in men or women
S&s in recurrent infection with HSV
Early signs (same as primary) (tenderness, pain, paresthesia)
lesion formation with rapid formation of papules and then vesicles
dome-shaped, tense vesicles rapidly umbilicate
systemic symptoms rare
Time course of HSV
Primary Infection:
Early sins occur before onset of lesions 3-7 days after contact
Lesions last 2-6 weeks and heal without scaring
Recurrent Infection:
Early signs last 2-24 hrs
Lesions appear within 12 hrs
after 2 ~ 4 days vesicles rupture and form erosions or crust
crust sheds in ~8 days
recurrent disease
Herpes ZOster causes what skin condition?
Chickenpox & shingles
S&S of shingles?
- Have prodromal neuropathic pain before appearance of vesicular rash
- neuropathic pain (burning, gnawing)
- Vesicular rash/blisters (restricted to single dermatome)
- Pain, paralysis, itching and sensitivity after resolution of infection (post-herpetic neuralgia)
- Corneal scarring with enduring visual acuity deficits (if herpes zoster opthamicus)
Where does the latent zoster virus hide in your body before it presents as shingles?
- tracts along neurons to dorsal root ganglia (or trigeminal ganglion) to establish latent infection.
Who most commonly gets molluscum contagiosum
Most common in children under 10 and older adults
Risk factors for molluscum contagiosum?
Sexual activity
Contact sports
immunocompromised (previously late marker in HIV)
Warm moist environments like steam rooms, saunas, and pools
What causes molluscum contagiosum?
Belongs to poxvirus family
MCV1 and MCV2 as the most common genotypes of virus
How is molluscum contagiosum spread?
Spread by direct skin-to-skin contact, fomites (such as towels) and sexual contact
Can also spread on a person’s body via autoinoculation
Molluscum lesions are contagious until?
Remains contagious until the bumps are gone
Key word for molluscum? Characteristics of the lesions?
Umbilicated!
Presents as small 2-5mm flesh-coloured dome-shaped papules that often have dimple in center (“umbilicated”)
Lesions may be alone or grouped
Firm lesions
May have larger, more extensive lesions if immunocompromised (such as HIV)
May have inflammation, erythema and scaling around lesions
Can occur anywhere on the skin but most often trunk, axillae, face, genital regions
Does not occur on palms or soles
Considered STI when spread to genitals of adult
Diagnosis of molluscum
Diagnosis usually based solely on clinical presentation and physical assessment
Distinguishing feature is umbilication (central indent) in papules
Can be mistaken for many other skin conditions – skin biopsy can help differentiate
T/F molluscum is often left untreated as it is self-limiting
True
Patient teaching re: molluscum
Current sexual partners should seek treatment if symptomatic
Not protective (can get reinfected)
Preventing spread: try not to scratch, cover lesions with bandage, don’t share facecloths or towels, don’t shave if lesions on face, do not squeeze lesions, avoid contact sports unless can cover all lesions, and avoid sexual contact until lesions are treated and partners are assessed and treated
If going to be sexually active, ensure all lesions covered
Referral
What condition does this describe: -begins as a single circular demarcated “salmon pink” lesion (herald patch)(a) 3-10cm on trunk
Secondary lesions develop within 14-21 days and extend over the trunk and upper part of extremities (rarely on face) , forming “drooping pine tree” pattern
-occasionally preceded by headache, fatigue, sore throat development of lesions
Pityriasis Rosea
(not viral per se but is inflammatory rash that often is preceded by virus such as HSV)
