Integumentary Flashcards
Principles of Derm Assessment: What would you do in the following situations?
1. If patient is otherwise well without systemic symptoms and other signs?
2. If the patient is miserable (highly symptomatic) but not systemically ill (without additional signs and symptoms)?
3. If the patient is systemically ill with constitutional s/s (fever, fatigue, loss of appetite, unintended weight loss, malaise, and/or others)?
4. What should you consider when presenting with a condition?
5. How would you assess if there are primary lesions only? What about primary and secondary lesions?
- When otherwise well, likely condition limited to the skin w/ few to minor symptoms (rosacea, keratosis pilaris [chicken skin at back of arm], seborrheic dermatitis)
- When miserable but not systemically ill, often uncomfortable with itch, burning, pain, or the like, such as scabies, herpes zoster (shingles), others
- When systemically ill with constitutional s/s, often has the dermatologic manifestation of a systemic ds, such as varicella, transepidermal necrosis, Lyme disease, systemic Lupus erythematosus, others
- Consider which pts (age, gender, ethnicity, risk factors, etc) are at greatest risk for the condition; ex: acne vulgaris more common in teens, young adults vs rosacea more common in adults age 30-60 years, though facial lesions are similar
- Where is the oldest lesion, and when did it occur? Where is the newest lesion, and when did it occur? This allows the examiner to assess the evolution of the skin lesions
Anaphylaxis
1. Definition
2. Causes
3. Symptoms
4. Treatment
- A severe, life-threatening hypersensitivity reaction; caused by immunoglobulin E (IgE)-mediated reaction to foods, insect stings, and drugs
- Main causes in outpt: food allergies
- acute onset (minutes to several hours)
- flushing
- hives
- angioedema
- dyspnea
- wheezing
- tachycardia or bradycardia
- hypotension
- hypoxia
- cardiac arrest
- acute onset (minutes to several hours)
- IMMEDIATE tx w/ epinephrine (1mg/mL) 0.3-0.5 IM on mid-outer tight.
- Repeat Q5-15 minutes PRN
- In anaphylaxis, there are NO absolute contraindications to epinephrine.
- CALL 911!
- IMMEDIATE tx w/ epinephrine (1mg/mL) 0.3-0.5 IM on mid-outer tight.
Rocky Mountain Spotted Fever (RMSF)
1. Definition/Population/Incidence/Etiology
2. Clinical presentation
3. Lab/Diagnostics
4. Treatment
- Most cases occur from April-Sept (spr-sum) in males, Native Americans, and ≥ 40 years
- Highest mortality if not treated during first 5 days.
- >60% occur in 5 states (NC, OK, AL, TN, MO) - *Abrupt onset of high fever
- chills
- severe headache
- nausea/vomiting
- photophobia
- myalgia
- arthralgia
→ followed by rash, erupts 2-5 days after onset of fever (rash: small red spots [petechiae] starting on wrist, forearms, and ankles [sometimes on palms and soles] then rapidly onto trunk until it generalizes); ~10% do not develop rash
- *Abrupt onset of high fever
- Clinical diagnosis
- First line: doxycycline (both children & adults)
- Use DEET-containing repellent on skin and permethrin on clothing
Description: Impetigo
“honey-colored” crusts, fragile bullae, pruritic
Description: Measles
Koplik’s spots are small, white, round spots on a red base on the buccal mucosa by the rear molars and appear 2-3 days before onset of symptoms
Description: Scabies
- Very pruritic, especially at night
- Serpiginous rash on interdigital webs, waist, axilla, penis
Description: Scarlet Fever
“Sandpaper” rash with sore throat (strep throat)
Description: Tinea versicolor
- Hypopigmented round-to-oval macular rashes, most lesions on upper shoulders/back
- not pruritic
Description: Pityriasis rosacea
- “Christmas tree” pattern rash (rash on cleavage lines)
- “herald patch” largest lesion, appears initially
Description: Molluscum contagiosum
Smooth papules 2-5 mm in size that are dome-shaped with central umbilication with a white “plug”
Description: Erythema migrans
- Red target-line lesions that grow in size
- Some central clearing
- early stage of Lyme disease
Description: Meningococcemia (rash)
- Purple to dark-red painful skin lesions all over body
- acute onset of high fever
- headache
- LOC changes
- rifampin prophylaxis for close contacts
**Life-threatening and CDC-reportable diseadse
Description: rocky Mountain Spotted fever
AKA: Rickettsia rickettsii from tick bite
- red spot-like rash that first break out on the hand, palm, wrist and foot, sole, ankle
- acute-onset high fever
- severe headache
- myalgias
Description: Brown recluse spider bite
- Bite area becomes swollen, tender, and red
- blisters appears within 24 hours
- center of lesion may form a purple-to-black eschar (10%), which becomes an ulcer when it sloughs up
Brown Recluse Spider Bites
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostic
4. Treatment
- Loxoscele reclusa – midwestern and southeastern US
- Deaths are rare but has occurred in <7 years → any child with systemic signs → hospitalization (condition may cause hemolysis) - fever
- chills
- nausea/vomiting
- mostly located on arms, upper legs, or trunk (underneath clothing)
- bite may feel like a pinprick (or painless)
- bite area becomes swollen, red, and tender
- blister appears 24-48 hours
- central area of bite becomes necrotic (purple-black eschar); when eschar sloughs off → ulcer, which takes severe weeks to heal
- fever
Erythema Migrans (early Lyme disease)
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostic
4. Treatment
- early Lyme disease rash
- Found most common in northeastern region of US - Classic lesion: expending red rash with central clearing, resembling a target; the “bull’s-eye” or target rash; appears within 7-14 days after a deer bite (range 3-30 days)
- rash feels hot to touch & rough texture
- common locations: belt line, axillary area, behind knees, and groin
- flu-like symptoms
- Lesion spontaneously resolves within a few weeks
- Classic lesion: expending red rash with central clearing, resembling a target; the “bull’s-eye” or target rash; appears within 7-14 days after a deer bite (range 3-30 days)
- Clinical diagnosis with Lyme ds workup
- DEET containing repellent on skin and permethrin on clothing and gear
Meningococcemia (Meningitis)
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostic
4. Treatment
- Systemic infection caused by Neisseria meningitidis (gram-); progresses very rapidly → death in several hours
* Fulminant cases → death in 48 hours
Morality rate: 13%; risk ↑ for those in close quarters like college students in dorms, nursery/day care, military barrack; asplenia, defective spleen (sickle cell anemia), HIV or complement immune system deficiencies, & infants (3m - 1y) - sudden onset of sore throat
- cough
- fever
- headache
- stiff neck
- photophobia
- changes of LOC (drowsiness, lethargy to coma)
- In some cases, abrupt onset of petechial (small red spots) to hemorrhagic rashes (pink to purple color) in the axillae, flanks, wrist and ankles (50-80%)
- hypotension and shock
- in 25%, cutaneous hemorrhage and DIC
- sudden onset of sore throat
- ↑ procalcitonin in bacterial meningitis
- CDC → vaccination esp for those at higher risk asap after exposure
- Rifampin BID x2 days & ceftriaxone 250 mg IM x1 dose for close contacts
- CDC → vaccination esp for those at higher risk asap after exposure
Herpes Zoster Ophthalmicus
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
Shingles Infection of the Trigeminal Nerve
1. sight-threatening condition caused by reactivation of the herpes zoster virus located on ophthalmic branch of the trigeminal nerve (CN V)
- more common in elderly patients
- sudden eruption of multiple vesicular lesions (which rupture into shallow ulcers with crust)
- located on one side of scalp, forehead, and side/tip of nose (if herpetic rash is seen on tip of nose, assume shingles until proven otherwise)
- ipsilateral eyelid swollen and red
- photophobia
- eye pain
- blurred vision
- sudden eruption of multiple vesicular lesions (which rupture into shallow ulcers with crust)
- Clinical diagnosis +/- cultures
- Refer to ophthalmologist or ED asap
Melanoma
1. Definition/Etiology
2. Clinical Presentation
3. Lab/Diagnostics
4. Treatment
- Type of skin cancer, high morality
Risk Factor:
- family hx of melanoma (~10%)
- extensive/intense sunlight exposure
- blistering sunburn in children
- tanning beds
- high nevus count/atypical nevus
- light skin/eyes - lesions can be anywhere, including retina
- dark-colored moles with uneven texture
- variegated colors
- irregular borders with diameter ≥6 mm
- may be pruritic
- If in nail beds (subungual melanoma) → may be very aggressive
- lesions can be anywhere, including retina
Acral Lentiginous Melanoma
1. Definition/Etiology
2. Clinical Presentation
- Most common type of melanoma in African Americans and Asians
- subtype of melanoma <5% - dark brown-to-black lesions are located on nail beds (subungual), palmar and plantar (sole of foot), and rarely the mucus membrane
- Subungual melanomas look like longitudinal brown-to-black bands on the nail bed
- dark brown-to-black lesions are located on nail beds (subungual), palmar and plantar (sole of foot), and rarely the mucus membrane
Basal Cell Carcinoma
1. Definition/Etiology
2. Clinical Presentation
- More common in fair-skinned individuals with long-term daily sun exposure
- RF: severe sunburns as a child - Superficial form (30%) looks pearly or waxy skin lesions with atrophic or ulcerated center that does not heal
- lesions can be white, light pink, brown, or flesh color
- may bleed easily with mild trauma
- Superficial form (30%) looks pearly or waxy skin lesions with atrophic or ulcerated center that does not heal
Actinic Keratosis
1. Definition/Etiology
2. Clinical Presentation
- High risk: light-colored skin, hair, and/or eyes
- older-to-elderly fair-skinned adults
- in some cases, may be a precancerous lesion for SCC
- early childhood hx of severe sunburns
- High risk: light-colored skin, hair, and/or eyes
- numerous dry, round, and red-colored lesions with a rough texture that do not heal
- lesions are slow-growing
- most common locations: sun-exposed areas (e.g., cheek, nose, face, neck, arms, and back)
- numerous dry, round, and red-colored lesions with a rough texture that do not heal
Subungual Hematoma
1. Definition/Etiology
2. Clinical Presentation
3. Treatment
1 & 2. Direct trauma to nail bed → pain and bleeding trapped between nail bed and fingernail/toenail
- if hematoma involves >25% of nail, high risk for permanent ischemic damage to nail matrix if blood is not drained
- draining (trephination) by straightening out one end of a steel paperclip or use 18h needle, heat it with a family until very hot → hot end pushed down gently (90º angle) until a 3-4 mm hole is burned on nail
- Nail is pressed down gently until most or all of blood is drained or suctioned with a smaller needle
- blood may continue draining for 24-36 hours
- draining (trephination) by straightening out one end of a steel paperclip or use 18h needle, heat it with a family until very hot → hot end pushed down gently (90º angle) until a 3-4 mm hole is burned on nail
Stevens-Johnson Syndrome (SJS) and Toxic Epidermal Necrolysis (TENs)
1. Definition/Etiology
2. Clinical Presentation
- SJS: less severe, involves <10% of body skin; mortality rate 10%
- TEN: more severe, involves >30%, mortality rate 30%
- Most common triggers:
* medications (allopurinol, anticonvulsants [lamotrigine, carbamazepine, phenobarbital], sulfonamides, and oxicam NSAIDs)
- RF: HIV infection (100x higher risk; 40x ↑ risk with trimethoprim-sulfamethoxazole), genetics, lupus, and malignancies
- SJS: less severe, involves <10% of body skin; mortality rate 10%
- lesions appear like a target (or “bull’s eye”)
- multiple lesions erupting abruptly; can be hives, blisters (bullae), petechiae, purpura, necrosis, and sloughing of the epidermis
- extensive mucosal surface involvement (eyes, nose, mouth, esophagus, and bronchial tree)
- may have a prodrome of fever with flu-like symptoms 1-3 days prior to rash
- lesions appear like a target (or “bull’s eye”)