Inflammatory Conditions and Nail Disorders

Question 1

acne vulgaris

Answer 1

disease of sebaceous glands beginning at puberty

-present on face, neck, trunk

Question 2

follicular thickening

Answer 2

hyperkeratosis and thickening of the hair follicle above sebaceous duct–> blockage vs. regular shedding

• blockage= comedone
• follicle ruptures into dermis–>inflammatory rxn–>papules, pustules, nodules, and cysts

Question 3

sebum production

Answer 3

• circulating androgens stimulate, estrogens can suppress
• sebum formed by gland when cells of gland are broken down/converted into lipids
• P. acnes, found on normal skin flora, produce lipase–>breaksdown triglycerides–>FFAs
• FFAs are irritants and comedogenic

Question 4

open comedomes

Answer 4

• primary lesion

- blackheads (black from oxidation of tyrosine to melanin in follicular orifice

Question 5

closed comedomes

Answer 5

• primary lesion

- whiteheads

Question 6

secondary lesions

Answer 6

scarring and pitting excoriations

Question 7

associated findings of acne

Answer 7

pain or pruritis, emotional upset and depression

Question 8

treatment of acne

1. superficial acne
2. deep acne
3. both deep and superficial acne

Answer 8

multiple medications; address each patient individually, tailor plan to specific acne; promote good hygiene

1. topical agents
2. PO meds
3. topical and PO meds
   - practice prevention, NOT spot tx
   - once breakout has happened, damage already done, stress pt education
   - if cannot get acne under control–>refer derm

Question 9

nonpharmalogical tx

Answer 9

• ensure compliance of pt with therapy
• proper cleansing technique–>wash BID with facial cleanser
• avoid face creams, cold creams, or any type of grease on face

Question 10

tx for hormonal deep cystic acne

Answer 10

women only

• spiranolactone 100 mg qday
• low estrogen oral contraceptives
• if abx and hormonal approaches fail–>accutane (isotretinoin)

Question 11

tx of non-hormonal deep cystic acne

Answer 11

oral abx or accutane (if abx fail)

• amoxicillin 500 mg BID
• minocycline 100 mg BID

Question 12

tx of surface red bumps and papules acne

Answer 12

• topical abx–>clindamycin soln, lotion, or gel BID

- benzoyl peroxide agent

Question 13

tx of comedones (black heads and white heads)

Answer 13

exfoliating/keratolytic agents: retina A, taxorac, differin qhs to qohs

Question 14

isotretinoin: function and tx plan

side effects?

Answer 14

• inhibits sebaceous gland function and keratinization
• tx for 15-20 weeks, than an interval of 6 months, retreat as needed

side effects: teratogenic, hepatotoxic, extreme dry skin, hyperlipidemia

Question 15

papules and pustules occurring on face often with ERYTHEMA, FLUSHING, and TELANGIECTASIAS

-age 40-70

Answer 15

rosacea

tx:
prevention: avoid ETOH, hot beverages etc. (redness)
Topical: metronidazole BID; clindamycin, erythromycin solt.
systemic: abx like acne–>tetracycline, minocycline, doxycycline

Question 16

• females>males
• pruritus or burning
• discrete or clustered, papules or pustules around the mouth, nasolabial folds
• may become scaly or superinfected

Answer 16

perioral dermatitis

tx: wash gently with mild soap
- metronidazole (metrogel) qhs or BID
- discontinue steroid use
- oral abx: tetracycline 500 mg BID; minocycline 50-100 mg BID
- refer if persistent (patch testing for allergies)

Question 17

• inflammatory condition of apocrine gland
• AUTOIMMUNE condition
• lesions aseptic
• part of follicular _____ _____

Answer 17

Hidradenitis Suppurativa
Occlusion Tetrad:
1. acne conglobata
2. pilonidal cyst
3. folliculitis decalvans
4. hidradenitis suppurativa

tx: oral abx (helps inflammation), humira

Question 18

-one or more nails separated at the hyponycium
-signs of 2ndary infection
Etiology?
If all nails involved?

Answer 18

onycholysis: separation of nail from nail bed

Etiology: commonly idiopathic; systemic causes: psoriasis, eczema, tines, poor peripheral circulation

all nails involved: phototoxic rxn or thyrotoxicosis

tx: idiopathic–>resolves spontaneously
2ndary infection: may prevent reattachment
-keep nails clipped as short as possible to reduce further trauma

Question 19

• subungual hyperkeratosis, onycholysis, yellow-white in color
• yellow streaks/yellow oncholytic areas in central portion of nail plate

Answer 19

onychomycosis

tx: oral meds (check LFTs)–>lamisil; 3 mo for fingernails and 4 mo toenails
- sporonax: pulse dosing x 3 months
topicals: pen-lac lacquer (Ciclopirox)–> tx for 6 months

Question 20

• horizontal trough across nail plate of all nails

- 3 months post-precipitating event

Answer 20

Beau’s lines

tx: patient reassurance–>deformity will grow out within 4 months

Question 21

• posterior nail fold feels spongy
• nail becomes more curved
• distal phalanx enlarges

Answer 21

clubbed nail/fingers

tx: important physical sign and cause should be saught-rarely noticed by patient
- pulmonary, CV, and miscellaneous etiologies

Question 22

concavity of nails

Answer 22

Koilonychia
etiology: thinning and softening of nail plate; congenital cause, 2ndary to iron deficiency anemia, Reynaud’s, physical or chemical trauma

tx: treat underlying cause, nails usually return to normal

Question 23

minute “pits” which occur in a random or uniform pattern across nail plate
-usually all nails affected

Answer 23

pitted nails

etiology: inflammatory skin conditions–> psoriasis, alopecia areata, atopic dermatitis 2ndary to parakeratosis

Question 24

longitudinal depression in the nail

Answer 24

habit tic- habitually stroking top of thumb nail

• can be associated with anxiety
  tx: behavioral modification, occlusion of nail preventing occurrence

Question 25

white spots on nails

Answer 25

leukonychia- common complaint etiology: 2ndary to nail trauma - NO association with Ca deficiency

Question 26

red or brown pigmented, linear, splinter-like lesions

Answer 26

splinter hemorrhages: tiny subungual hemorrhages etiology: most commonly trauma, can be associated with SLE, endocarditis

Question 27

brown nails

Answer 27

nail hyperpigmentation etiology: most commonly from dyes (textile workers), nicotine, or other meds

Question 28

splitting of nail into its component layers

Answer 28

lamellar nail dystrophy etiology: 2ndary to repeated wetting and drying out of nails tx: reassurance! reinforce gloves while immersing nails in water

Question 29

proximal 2/3 of nail plate is white and the distal 1/3 normal pink nail bed

Answer 29

Terry's nails: rare etiology: CHF, hypoalbuminemia

Question 30

malignant melanoma vs. nail trauma

Answer 30

inspect nail fold for Hutchinson's sign: black discoloration of proximal nail fold at base of pigmented streak = melanoma

Question 31

abnormal, delayed rxn to sunlight exposure

Answer 31

polymorphic light eruption-->1st exposure to sun of the year-->autoimmune tx: mid-potency topical steroids

Question 32

- erythema and blistering of hand | - common with travelers to tropical destinations drinking citrus drinks

Answer 32

phytophotodermatitis: cutaneous phototoxic inflammatory eruption

Question 33

common inducers of drug-induced photosensitivity

Answer 33

tetracyclines, fluoroquinolones, NSAIDs, diuretics, retinoids (counsel pts when putting them on these meds)

Question 34

drug eruption: skin sxs, labs, txs.

Answer 34

-can mimic a wide range of dermatoses skin sxs: morbilliform, urticarial, papulosquamous, pustular, and bullous labs: CBC, CMP, ANA, punch biopsy tx: DISCONTINUE drug - antihistamines for pruritus and urticaria - epi for emergency - corticosteroids for severe cases

Question 35

a drug eruption can turn into? skin sxs? labs? tx?

Answer 35

erythema multiforme: acute, self-limited, and sometimes recurrant type IV hypersensitivity reaction skin sxs: lesion development over 10 days; macule-->papule-->vesicle-->bullae in center of papule, dull redness, TARGETOID LESIONS labs: HSV viral cx if indicated, biopsy to confirm dx tx: drug discontinuation; oral acyclovir; severe cases: prednisone

Question 36

erythema multiforme drug causes infection causes other

Answer 36

drug: sulfonamides, phenytoin, barbiturates, penicillin, allopurinol infection: s/p HSV infections, mycoplasma - idiopathic

Question 37

- generalized pruritis precede rash by several days | - severe mucocutaneous papules/vesicles develop to desquamation

Answer 37

-steven-johnson syndrome (<10% epidermal detachment) | -toxic epidermal necrolysis >30% detachment

Question 38

steven-johnson syndrome/toxic epidermal necrolysis Causes: 1. drugs 2. genetic factors 3. infectious causes

Answer 38

1. phenytoin, barbiturates, valproic acid, carbamazepine, sulfur derivatives (bactrim) 2. HLA antigens 3. HSV, HIV, coxsackie, influenza, hepatitis

Question 39

steven-johnson syndrome/toxic epidermal necrolysis 1. describe general sxs: prodrome vs. syndrome 2. labs 3. tx

Answer 39

1. prodrome: cough, HA, malaise, arthralgias Syndrome: inflammation and desquamation of oral mucosa, esophagus, pharynx, larynx, anus, vagina, urethra, sometimes severe ocular sxs 2. TNF-alpha, IL-2, IL-6, CRP, biopsy 3. agent withdrawal (if drug induced); admission; oral/IV prednisone; fluid management

Question 40

- large 3.0-20 cm deep seated subcutaneous nodules - only appreciated on palpation - bilateral on pretibial surfaces, possibly knees/arms, rarely face/neck - usually in women and due to oral contraceptives

Answer 40

erythema nodosum- inflammation in fat tx: tx underlying condition - when symptomatic: bedrest or compression stocking - NSAIDs, salicylates for 2-4 wks - systemic steroids (when you know cause and infections are excluded)

Question 41

- present for < 30 days | - large, transient wheals

Answer 41

acute urticaria antihistamines, avoid triggers

Question 42

large transient wheals for >30 days

Answer 42

antihistamines, mast cell stabilizers, and prednisone

Question 43

direct pressure on the skin-->urticaria secondary to an exaggerated response of the skin to trauma resulting in histamine release from mast cells

Answer 43

dermatographism condition ultimately resolves, but can take yrs

Question 44

ordinary urticarial swellings that are more paindul and pruritic after prolonged pressure

Answer 44

pressure urticaria recovery spontaneous

Question 45

same as urticaria except involves the deep dermis and subQ tissue

Answer 45

angioedema

Question 46

dermal papules and annular plaques

Answer 46

granuloma annular tx: topical vs. intralesional steroids

Question 47

- velvet-like hyperkeratosis - insulin-induced - most common on peripheral neck and flexural areas

Answer 47

acanthosis nigricans tx: keratolytics

Question 48

cholesterol deposition at medial canthus/upper eyelids

Answer 48

xanthelesma not easily treated

Question 49

- NON-blanchable small-vessel vasculitis - RA, IBD, SLE have been implicated - skin often asymptomatic, pts may report itching, burning, pain

Answer 49

hypersensitivity vasculitis tx: underlying condition if one is determined leg elevation and compression

Question 50

-descending vasculitis, usually after a strep infection

Answer 50

Henoch-Schoenlein Purpura tx: abx if followed bacterial infection

Question 51

irregular plaques and patches of orange-brown pigmentation on lower limbs

Answer 51

Schaumberg's disease | tx: none, leg elevation and compression can slow progression

Question 52

-lesions feel "wooden"

Answer 52

morphea -localized collagen deposition tx: often self-limited; topical steroids

Question 53

- chronic inflammatory condition mostly affecting genital areas - can obliterate vaginal structures-->atrophy and band-like sxs

Answer 53

lichen sclerosis tx: high potency topical steroids and refer to OBGYN

Question 54

autoimmune-mediated depigmentation

Answer 54

vitiligo tx: if lesions <6 mo old, can usually re-pigment using topical steroids or protopic ointment

Question 55

grouped excoriations, urticarial plaques, papules, and vesicles on the extensor surfaces of elbows, knees, buttocks, and back

Answer 55

dermatitis herpetiformis tx: gluten avoidance-->improvement of skin sxs can take several months [autoimmune blistering disorder assoc. w/ gluten-sensitive enteropathy]

Question 56

erythmatous, papular, urticarial lesions-->bullae form - bullae are large, tense, firm-topped oval or round lesions - mucous membrane not involved - (+) nikolski sign

Answer 56

bullous pemphigoid tx: PO/IV prednisone; azathioprine

Question 57

oral lesions-->sole sign for months before other lesions arise -skin: flaccid blister with painful affected skin

Answer 57

pemphigous vulgaris tx: coricosteroids- long term - sulfasalazine

Question 58

erythematous, confluent, macular BUTTERFLY eruption (MALAR rash) with fine scaling, erosions, and crust

Answer 58

systemic lupus erythematosus tx: depends on severity - hydrochloroqine

Question 59

localized loss of hair in round or oval patches WITHOUT skin inflammation -exclamation point hairs

Answer 59

alopecia areata [possible autoimmune process due to association with other autoimmune diseases] tx: no curative process; palliative for cosmesis - psychological support - tx underlying disease - tx options: intralesional/topical steroid, UVA therapy

Question 60

autoimmune hair loss with signs starting before age 40; can only affect scalp hair vs. affecting all scalp and body hair

Answer 60

alopecia totalis/universalis starts as alopecia areata and progresses to diffuse lose tx: none successful, only for early stage of alopecia areata

Question 61

- daily dramatic hair shedding | - preceding traumatic event 6-16 wks prior to hair loss

Answer 61

``` telogen effluvium (think beau lines) -regrows in 4-6/12 months ``` Tx: reassurance!!