Integumentary Flashcards
Anaphylaxis
S&S Angioedema and hives
flushing, hives, angioedema, dyspnea, wheezing, tachycardia or bradycardia, hypotension, hypoxia, or cardiac arrest
Cause: Food, insect sting, drugs
Immune globulin E
Onset: Acute onset
Minutes to several hours
Tx: Epinephrine IM 1 mg/mL 0.3mg to 0.5mg to mid-outer thigh
Repeat every 5 to 15 min
Rocky Mountain spotted fever (RMSF)
S&S: abrupt onset of high fever, chills, severe headache, nausea/vomiting, photophobia, myalgia, and arthralgia followed by a rash that erupts 2 to 5 days after onset of fever.
Rash: small red spots (petechiae) that start to erupt on the wrist, forearms, and ankles (sometimes the palms and soles). It rapidly progresses toward the trunk until it becomes generalized
10% have no rash
Tx: doxycycline
Prevention: DEET containing products
Brown recluse spider bites
Brown recluse spiders (Loxosceles reclusa) are found in midwestern and southeastern United States.
S&S fever, chills, nausea, and vomiting. Deaths are rare but more common in children (younger than 7). Any child with systemic signs should be hospitalized (the condition may cause hemolysis).
Most spider bites are located on the arms, upper legs, or trunk (underneath clothing). Bite may feel like a pinprick (or be painless). The bitten area becomes swollen, red, and tender, and blisters appear within 24 to 48 hours. Central area of bite becomes necrotic (purple-black eschar). When the eschar sloughs off, it leaves an ulcer, which takes several weeks to heal.
Erythema Migrans (Early Lyme Disease)
classic lesion: expanding red rash with central clearing that resembles a target. appears within 7 to 14 days and spontaneously resolves within a few weeks.
The rash feels hot to the touch and has a rough texture. Accompanied by flu-like symptoms.
Common locations: belt line, axillary area, behind the knees, and groin area.
northeastern regions.
Prevention: DEET-containing repellent on skin and permethrin on clothing and gear
Meningococcemia (Meningitis)
MEDICAL EMERGENCY
can progress very rapidly and cause death within several hours
C/b Neisseria meningitidis (gram neg)
S&S sudden onset of sore throat, cough, fever, headache, stiff neck, photophobia, and changes in level of consciousness. Rash in some cases
Risk factor: living in close quarters, asplenia, HIV
Vaccination for adolescents
Tx: Rifampin (twice a day for 2 days) and ceftriaxone 250 mg intramuscularly (one dose)
Shingles Infection of the Trigeminal Nerve (Herpes Zoster Ophthalmicus)
MEDICAL EMERGENCY
Cause: Reactivation of herpes zoster virus on trigeminal nerve
S&S: sudden eruption of multiple vesicular lesions on one side of scalp, forehead and sides and tip of the nose. If herpetic rash on nose, assume shingles. Eyelid can be swollen and red. C/o of photophobia, eye pain and blurred vision
Refer to ophthalmologist or ED
Melanoma
Dark-colored moles with uneven texture, variegated colors, and irregular borders with a diameter of 6 mm or larger
If in nail beds, may be very aggressive
Risk factors: fam hx, sunlight exposure, tanning beds, high nevus count, light skin/eyes.
Acral Lentiginous Melanoma
Sounds like “acra, ghana” and “Laos”
Most common melanoma in african americans and asains
Dark brown-to-black lesions on nail beds, palmar and plantar surfaces.
Basal cell carcinoma
Most common skin cancer
Pearly or waxy skin leasion w/ atrophic or ulcerated center that does not heal. Bleeds easily.
Risk factor: severe sun burn in childhood
Actinic keratosis
S&S: numerous dry, round, and red-colored lesions with a rough texture that do not heal. Slow growing.
Common locations: where sun hits, cheeks, nose, face arms, and back
High risk: light skin/hair/eyes
Subungual hematoma
Cause: Direct trauma to nail bed.
S&S: pain and bleeding trapped between nail bed and nail.
Complication: if 25% nail involved, risk of permanent ischemic damage.
Tx: draining
Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis
Multiple lesions start erupting abruptly and can include hives, blisters (bullae), petechiae, purpura, and necrosis and sloughing of the epidermis. Look like target.
Mucousal surface involvement (eyes, nose, mouth, esophagus, bronchial tree).
Can have prodomal of fever and flue like symptoms a few days prior
Triggers: medications (allopurinol, anticonvulsants, sulfonamides, NSAIDs)
Risk factors: HIV
Stevens–Johnson Syndrome and Toxic Epidermal Necrolysis difference
SJS is less severe (involves <10% body skin) compared with TEN (involves >30% body skin)
Pseudofolliculitis barbae (barber’s itch)
Caused by inflammation from the curly hair growing back into the skin.
The “treatment” is to let the beard hair grow for 3 to 4 weeks. Avoid shaving beard hair too short and too close to the skin.
affects up to 60% of African American men.
Acral
Distal portions of the limbs (i.e., the hand or feet [acral melanoma])
Annular
Ring-shaped (ringworm, or tinea corporis)
Exanthem
Cutaneous rash
Extensor
The skin area that is outside of the joint (e.g., front of knee, back of elbow)
Flexor
The area of the skin on top of the joint with skin folds (e.g., back of knees, antecubital space)
Flexural
Skin flexures are body folds (eczema affects flexural folds)
Intertriginous
An area where two skin areas touch or rub each other (e.g., axilla, breast skin folds, anogenital area, between the fingers/digits)
Maculopapular rash
Rash with color (usually pink to red) with small bumps that are raised above the skin (viral rashes)
Morbilliform
Rash that resembles measles (pink rash with texture)
Nummular
Coin-shaped, round (nummular eczema)
Purpura
Bleeding into the skin; small bleeds are petechial (RMSF), and larger areas of bleeding are ecchymoses or purpura (meningococcemia)
Serpiginous
Shaped like a snake (larva migrans)
Verrucous
Wartlike
Xerosis
Dry skin
The “A, B, C, D, E” of melanoma
A: Asymmetry
B: Border irregular
C: Color varies in the same region
D: Diameter >6 mm
E: Enlargement or change in size
Macule
Flat nonpalpable lesion <1 cm in diameter
Example: Freckles (ephelis), lentigo or lentigines (plural)
Papule
Palpable solid lesion ≤0.5 cm in diameter
Example: Nevi (moles), acne, small cherry angiomas
Plaque
Flattened, elevated lesion with variable shape >1 cm in diameter
Example: Psoriatic lesions
Bulla
Elevated superficial blister filled with serous fluid and >1 cm in size
Example: Impetigo, second-degree burn with blisters, SJS lesions
Vesicle
Elevated superficial skin lesion <1 cm in diameter, filled with serous fluid
Example: Herpetic lesions
Pustule
Elevated superficial skin lesion <1 cm in diameter, filled with purulent fluid
Example: Acne pustules
Lichenification
Thickening of the epidermis with exaggeration of normal skin lines due to chronic itching (eczema)
Scale
Flaking skin (psoriasis)
Crust
Dried exudate, may be serous exudate (impetigo)
Ulceration
Full-thickness loss of skin (decubiti or pressure injury)
Scar
Permanent fi brotic changes following damage to the dermis (surgical scars)
Keloids/hypertrophic scar
Overgrowth of scar tissue; more common in Blacks, Asians
Urticaria (Hives)
Erythematous and raised skin lesions with discrete borders that are irregular, oval, or round
Can be the start of anaphylaxis
considered chronic if it lasts longer than 6 weeks. Most cases are self-limited
Multiple etiologies
Ts: Eliminate the cause
Seborrheic Keratoses
Soft, wartlike, fleshy growths in the trunk that are located mostly on the back. Painless. Can range from light tan to black.
They start to appear during middle age (or later) and become more numerous as patient gets older.
Xanthelasma
Raised and yellow-colored soft plaques that are usually located under the brow or upper and/or lower lids of the eyes on the nasal side.
If younger than 40, rule out hyperlipidemia. If on fingers, may be familial hyperlipidemia
Melasma (Mask of Pregnancy)
Bilateral brown- to tan-colored stains located on the upper cheeks, malar area (cheeks and nose), forehead, and chin.
Cause: pregnancy, oral contraceptives
Usually permanent, can lighten over time
Vitiligo
Loss of epidermal melanocytes. White patches of skin
Develop and spread over time. Chronic and progressive. Can flare.
Risk factors: autoimmune disease
Refer to derm. Use sunscreen and avoid prolonged sun exposure.
Cherry Angioma
Benign small and smooth round papules that are a bright cherry-red color. Always blanch with pressure
Patho: nest of malformed arterioles in the skin
No treatment needed
Lipoma
Soft, fatty cystic tumors that are usually painless and are located in the subcutaneous layer of the skin. Asymptomatic unless irritated or ruptured
PE: feel smooth with a discrete edge
Can be surgically removed
Nevi (Moles)
Round macules to papules (junctional nevi) in colors ranging from light tan to dark brown. Often found in trunk and lower extremeties.
Junctional nevi: macular or minimally raised with colors ranging from brown to black.
Compound nevi: pigmented papules and vary in color from tan to medium brown.
Xerosis
Inherited skin disorder that results in extremely dry skin and may involve mucosal surfaces such as the mouth (xerostomia) or the conjunctiva of the eye (xerophthalmia).
Acanthosis Nigricans
Diffuse velvety thickening of the skin that is usually located behind the neck and on the axilla
Associated with diabetes, metabolic syndrome, obesity, and cancer of the gastrointestinal (GI) tract.
Acrochordon (Skin Tags)
Painless and pedunculated outgrowths of skin that are the same color as the patient’s skin
When twisted or traumatized (e.g., gets caught on a necklace), the outgrowth can become necrotic and drop off the skin.
More common with diabetes and obesity
Topical steroids and classes
Halobetasol propionate 0.5% (Ultravate)
Class I (super-high) Daily–BID (max 2 weeks)
Halcinonide 0.1% (Halog)
Class II (high) BID–TID
Triamcinolone acetonide 0.1% (Kenalog)
Class III (medium-high) BID–TID
Mometasone furoate 0.1% (Elocon)
Class IV (medium) BID–QID
Desonide 0.05% (Desonate)
Class V (low-medium) BID–QID
Fluocinolone acetonide 0.01% (Synalar)
Class VI (low) BID–QID
Hydrocortisone 1% (OTC; no Rx needed)
Class VII (least potent) BID–QID
Topical steroid treatment recommendations based on class
Super-high potency: Use for severe dermatoses (psoriasis, severe eczema) on nonfacial and nonintertriginous areas for up to 2 weeks. Works well on palms, scalp, and soles, which have “thicker” skin.
Medium-high potency: Use on mild-to-moderate nonfacial and nonintertriginous areas
Low-medium potency: Use on larger areas that need treatment
Low-potency: Use on eyelid and genital areas for limited duration. Ophthalmic form of topical steroid is used on eyelids.
(intertriginous: places that rub)
Can you use steriods for fungal infections?
No, it may worsen the infection. Stay away if fungus suspected
How long should you wait to apply steroid cream after bathing?
Within 3 minutes
What steroids should you avoid with children and sensitive areas? What is the potential adverse effect?
Do not use fluorinated topical steroids. Use class 7 (least potent) topical steroids, such as 0.5% to 1% hydrocortisone.
Hypothalamic–pituitary–adrenal (HPA) axis suppression may occur with excessive or prolonged use (>2 weeks), especially in infants and children, or with use of potent to ultrapotent topical steroids. These agents can cause striae, skin atrophy, telangiectasia, acne, and hypopigmentation.
Psoriasis
Inherited skin disorder in which squamous epithelial cells undergo rapid mitotic division and abnormal maturation. The rapid turnover of skin produces the classic psoriatic plaque.
S&S: pruritic erythematous plaques covered with fine silvery-white scales along with pitted fingernails and toenails. If psoriatic arthritis will c/o painful red, warm and swollen joints
Types of phenotypes: plaque (80%), guttate, inverse, erythrodermic, and pustular psoriasis.
Tx: Topical steroids, topical retinoids (tazarotene), tar preparations (psoralen drug class)
Severe disease: Methotrexate, cyclosporine, biologics (etanercept, adalimumab)
Koebner phenomenon
New psoriatic plaques form over areas of skin trauma
Auspitz sign
Pinpoint areas of bleeding in the skin when scales from a psoriatic plaque are removed
Actinic Keratoses
Precancerous precursor to squamous cell carcinoma
S&S: Numerous dry, round, and pink-to-red lesions with a rough and scaly texture that do not heal. Slow growing. Common locations are sun-exposed areas.
TX: refer to derm for biopsy (GOLD STANDARD)
Tinea Versicolor
Superficial skin infection caused by yeasts Pityrosporum orbiculare or P. ovale.
S&S: multiple hypopigmented round macules, “appear” after skin becomes tan, asymptomatic
DX: Potassium hydroxide (KOH) slide: Hyphae and spores (“spaghetti and meatballs”)
Tx: Topical selenium sulfide and topical azole antifungals such as ketoconazole (Nizoral) and terbinafine (Lamisil) cream twice a day × 2 week. May take several months for pigment to return
Atopic Dermatitis (Eczema)
Infants up to 2 years of age have a larger area of rash distribution compared with teens and adults. The rashes are typically found on the cheeks, entire trunk, knees, and elbows.
Older children and adults have rashes on the hands, neck, and antecubital and popliteal space (flexural folds).
The classic rash starts as multiple small vesicles that rupture, leaving painful, bright-red, weepy lesions. The lesions become lichenified from chronic itching and can persist for months. Fissures form that can be secondarily infected with bacteria.
Associated with atopic disorders such as asthma, allergic rhinitis, and multiple allergies
Tx:
Topical steriods are first-line (hydrocortisone & triamcinolone acetonide)
Oral antihistamines for itching
Avoid drying the skin, will make itching worse
Contact Dermatitis
Inflammatory skin reaction caused by direct contact with an irritating external substance
Types: Irritant and allergic
S&S: bright-red and pruritic lesions that evolve into bullous or vesicular lesions; easily rupture and can be painful. When rash dries, becomes crusted, pruritic and lichenfied.
Tx: remove irritant, topical steriods. Calamine lotion or oatmeal baths
Superficial Candidiasis
Patho: yeast Candida albicans
S&S: bright-red shiny lesions that itch or burn, may have satellite lesions.
Thrush: severe sore throat with white adherent plaques with a red base that are hard to dislodge on the pharynx
Tx: Nystatin powder/cream
OTC topical antifungals are miconazole and clotrimazole
Systemic: Oral fluconazole
Keep skin dry and aerated.
Cellulitis
Acute skin infection of the deep dermis and underlying tissue, usually caused by gram-positive bacteria.
Types:
-orbital and peritonsilar: refer to ER
-Purulent: S. aureus (gram+) or MRSA
-Nonpurulent: streptococci usually
-Cat bites: pasturella multocida (gram-)
-Dog bites: P.multocide, P. canis
-Puncture wounds foot: may be pseudomonas aeruginosa
-Vibrio vulnifuces: exposure to brackish water or salt water
S&S: acute onset, pink/red skin, poorly demarcated w/ advancing margins. Warm to touch, may have abscess or puss.
Clenched fist injuries
These injuries have a high risk of infection to joints (e.g., knuckles), fascia, nerves, and bones (osteomyelitis; especially if punched in the mouth or bitten by a human).
Refer to ED for treatment.
There may be a foreign body embedded, such as a tooth (x-ray needed), and/or a fracture.
Necrotizing Fasciitis (“Flesh-Eating” Bacteria)
Reddish to purple-colored lesion that increases rapidly in size. May have bullae. Infected area appears indurated (“woody” induration) with complaints of severe pain on affected site.
Folliculitis
Infection of hair follicle(s). May involve several follicles.
Small (1-mm) round lesions filled with pus with erythema. Usually self-limiting.
Tx: Avoid shaving or scrubbing area.
Consider mupirocin (Bactroban) ointment or cream.
Furuncles (Boils)
An infected hair follicle that fills with pus (abscess).
S&S: round red bump and is hot and tender to the touch, can rupture and drain purulent green-colored discharge
Tx: Apply antibiotic ointment twice a day and cover with dressing until healed.
For small boils, use warm compress twice a day. If abscess is >2 cm, incising and draining of abscess and/or empiric antibiotic treatment may be adequate.
If located over a joint, refer to ED. Rule out osteomylitis
Carbuncles (Multiple Abscesses)
Carbuncles are several boils that coalesce to form a large boil or abscess.
Dx: C&S, CBC if fever. Suspect necrotizing fasciitis? Refer to ED
Tx: If rapid progression, diabetic, immunocompromised, joint involvement, refer to ED
Mild:
-Nonpurulent cellulitis (non-MRSA): Dicloxacillin
-Penicillin allergic: Azithromycin
-Suspect MRSA: Bactrim DS
-Td booster
Should improve in 24-48 hr
Erysipelas
A subtype of cellulitis involving the upper dermis and superficial lymphatics that is usually caused by group A Streptococcus.
For facial erysipelas, assume it is MRSA
S&S: Sudden onset of one large hot and indurated red skin lesion that has clear demarcated margins. Usually on the lower legs (the shins) or the cheeks. W/ fever and chills. Hospitalization is recommended, since patient may be bacteremic.
Dog and cat bites
P. multocida (gram negative) most common
Dogs also –> capnocytophaga canimorsus (gram negative).
Cat bites have a higher risk of infection than dog bites.
Signs of infection: redness, swelling, and pain, and systemic symptoms may develop within 12 to 24 hours.
Tx: Amoxicillin–clavulanate (Augmentin) 875 mg/125 mg orally twice a day × 10 days.
Penicillin allergy –> Doxycycline + Bactrim
Do not suture
Tetanus
What animals are likely to have rabies?
Consider bats, raccoons, skunks, foxes, and coyotes
Check rabies vaccine on domestic animals
Rabies rarely seen in rodents such as mice, rats, squirrels, hamsters, guinea pigs, or rabbits.
Hidradenitis Suppurativa
Chronic and recurrent
Inflammatory disorder of the apocrine glands Results in painful nodules, abscesses, and pustules in the axilla (most common location), mammary area, perianal area, and groin
Classified: Stage 1 –> 3 (severe)
S&S: recurrent episodes of painful, large, dark-red nodules, abscesses, and pustules. Pain resolves when the abscess drains and heals.
Risk factors: smoking & obesity
Tx: no cure
Stage 1: Either systemic or topical antibiotics (clindamycin) & oral abx (tetracycline)
Stage 2/3: Topical & oral abx (Clindamycin)
Avoid high-glycemic food
Smoking cessation, weight loss, sitz baths, warm compress. Derm referral
Impetigo
Acute superficial skin infection caused by gram-positive bacteria (beta Streptococcus or Staphylococcus aureus)
Common with children ages 2 to 5 years
S&S: Acute onset, itchy pink-to-red lesions, evolve into vesiculopustules that rupture.
Bullous –> large blisters that rupture easily. After rupture, red, weeping, shallow ulcers appear. Have honey crusts
Dx: C&S
Tx: Cephalexin (Keflex), dicloxacillin
Penicillin allergy: azithromycin, clindamycin
No bullae –> topical mupirocin
Clean lesions with antibacteial soap
Children do not return to school until 48-72 hr after initiation of treatment
Meningococcemia (Meningitis)
Spread by respiratory droplets
Bacterial = MEDICAL EMERGENCY
Risk factor: close quarters
S&S: sore throat, cough, fever, headache, stiff neck, photophobia, change in LOC. Petechial or hemmorrhagic rashes. Hypotension & shock
Tx: exposure - rifampin
Vaccination (MCV4 or Menactra) in first year of college
MPSV4 or Menomune for preteens and teens
DX: LP, blood cultures, CT/MRI
Tx: Ceftriaxone (Rocephin) 2 g IV every 12 hours plus vancomycin IV every 8 to 12 hours
Early Lyme Disease
Erythema migrans
Caused by tick bite infected with borrelia burgdorferi
Can present with just rash or rash and flue like symptoms
Rash is target like in shape, warm to touch and rough texture. Appears 7-14 days after tick bite
Dx: two part testing
EIA first, if + cont, if - no lyme
IFA next, if + lyme, if - no lyme
Can have false negative antibody for 4-6 weeks
Tx: Doxycycline for early disease only
Rocky Mountain Spotted Fever
Dog tick borne illness caused by Rickesttsia rickettsiii
More common in south east and central southern states
S&S: fever, chills, headache, N/V, photophobia, myalgia, arthralgia, followed by a rash 2-5 days after fever
Do not delay treatment! Treat empirically. Can result in death with delayed treatment
Dx:
Antibody titer, must collect acute and convalescent samples 2-4 wks apart. Cannot diagnose on one sample.
Tx: Doxycycline 100 mg orally or by IV twice a day × 7 days or for 2 days after temperature becomes normal
Varicella-Zoster Virus Infections
Chickenpox (varicella) and herpes zoster (shingles) comes from the same varicella-zoster virus (VZV)
Chicken pox - first infection
Prodrome of fever, pharngitis, and malaise. Rash within 24 hr, pruritic vesicular lesions. Rash over 4 days. stars on head and spreads to body
Lasts 1-2 weeks
Infectious 1-2 days before symptoms until all lesions crust over
Shingles - reactivation
Acute onset of papules and vesiclues on a red base that rupture and become crusted. Follow dermatomes. Can be painful. Can last 2-4 weeks. Contagious from onset of rash until crusted over. Treat within 48-72 hours in immunocompromised and >50 yrs to avoid postherpetic neuralgia.
Dx: can be clincal diagnosis
Gold standard is PCR
Tx: Acyclovir (Zovirax) five times per day or valacyclovir (Valtrex) twice a day × 10 days for initial breakouts and 7 days for flare-ups.
Most effective when started 48 to 72 hours after the appearance of the rash.
Herpetic Whitlow
Infection of the finger caused by herpes simplex 1 or 2
Transmitted through contact to cold sore or genital lesions
S&S: Acute onset, painful red bumps and lesions on fingers. Ask about other herpes symptoms.
Tx: NSAIDs for pain, acyclovir
Avoid sharing personal items, cover lesions until healed
Paronychia
Bacterial infection of proximal or lateral nail (cuticle)
Causative agent: S. auerous, strep, pseudomonas
Chornic cases may be a/w onychomycosis
S&: acute onset pain in finger, eventually forming an abscess. Most common fingers thumb and index. May have h/o bitting nail, hang nail
Tx: warm soaks, mupirocin, I&D
Pityriasis Rosea
Viral
S&S: oval lesions with fine scales. Follow skin folds. Can has a “christmas tree” pattern. Can be pruritic.
“herald patch” - the first lesion, appears 2 wks prior to break out. 2-5 cm in diameter, oval.
Tx: Self-limiting, resolves in 6-8 wk
If sexually active, rule out secondary syphilis.
Scabies
Infestation of Sarcoptes scabiei mites, female lays eggs under skin
Can be asymptomatic for 4-8 weeks
Pruritis can last for 2-4 weeks after treatment due to sensitivity to feces
Spread through close contact
S&S: pruritic rash that is worse at night,
serpiginous (snakelike) or linear burrows
can be vesicular, papular or have crusts
Rash on webs of the hands, axillae, breasts, buttock folds, waist, scrotum, and penis
Dx: use wet mount to look for eggs
Tx: Permethrin 5% (Elimite): Apply cream from the neck to the sole of the feet after bathing or showering. Wash off after 8 to 14 hours. Repeat treatment in 7 days.
Treat all family memebrs at the same time
Bedding used 3 days prior and during treatment shouold be washed on high setting or placed in plastic bags for 72 hours
Norwegian scabies
Severe form of scabies
Affects the elderly and immunocompromised.
Lesions are covered with fine scales (looks like white plaques) and crusts
Involves the nails (dystrophic nails), scalp, body; absent-to-mild pruritus; very contagious.
Treat with oral ivermectin combined with a topical agent (permethrin).
Tinea infections
Infection of the superficial keratinized tissues by tinea organisms
Dx: fungal culture, KOH slide
Tx: Most cases of tinea can be treated with topical antifungal medication except for tinea capitis and moderate-to-severe onychomycosis or tinea unguium (toenails).
Topical azoles/imidazoles: Clotrimazole (Lotrimin Ultra), naftifine (Naftin) once a day or twice a day, miconazole (Monistat) twice a day, ketoconazole (Nizoral) shampoo/cream once a day
Avoid topical steriods unless severe, can reduce effectiveness of anti-fungal
Tinea Capitis
(Ringworm of the Scalp)
Black dot tinea capitis (BDTC) is the most common
Spread by close contact and fomites (shared hats, combs).
Systemic treatment only (topicals are not effective).
Asymptomatic scaly patch that gradually enlarges. Hairs break off easily by the roots (looks like black dots), causing patchy alopecia.
“Black dot sign:” Broken hair shafts leave a dot-like pattern on scalp.
Gold standard: Administer griseofulvin (microsize/ultramicrosize) daily to twice a day × 6 to 12 weeks.
Avoid hepatotoxic substances (alcohol, statins, acetaminophen), monitor LFTS.
Avoid sharing combs, headgear, towels, pillows, and clothes with others.
Complications
Kerion: Inflammatory and indurated lesions that permanently damage hair follicles, causing patchy alopecia (permanent).
Tinea Pedis
(Athlete’s foot)
Scaly/dry form: scales are present
Moist form: Moist lesions found in toes, strong odor
Can spread to fingernails from itching
Keep toes dry after showering/bathing
Tinea Corporis or Tinea Circinata
(Ringworm of the Body)
Ringlike pruritic rashes, collarette of fine scales that slowly enlarge with some central clearing.
Topical azole antifungals (topical terbinafine 1%, butenafine 1%) for 2 to 3 weeks
Tinea Cruris
(“Jock Itch”)
Perineal and groin area has pruritic red rashes with fine scales
May be mistaken for candidal infection (bright-red rashes with satellite lesions) or intertrigo (bright-red diffused rash due to bacterial infection).
Tinea Manuum
(Hands)
Pruritic round rashes with fine scales found on the hands.
Check for scratching of foot (athlete’s foot).
Tinea Barbae
(Beard Area)
Scaling occurs with pruritic red rashes.
Tinea unguium
Onychomycosis
Tinea of fingers
Most common type: Distal subungual onychomycosis.
Most common location: Great toe
S&S: Opaque, yellow, thickening with scales under fingernail. Fingernail can fall off (onycholysis)
Dx: Fungal cultures or KOH slide
TX: Systemic unless mild
Continuous dosing - terbinafine x 12 weeks
Pulse dosing - need baseline LFTs. Intraconazole for one week per month, 3-4 cycles
Mild-to-moderate cases: Topical antifungals such as efinaconazole (Jublia) and ciclopirox (Penlac).
Acne Vulgaris (Common Acne)
Mild
Found on face, chest, shoulders and back
Can be closed comedomes (noninflammatory), open comedomes (blackheadS), w/ or w/o papules
Tx: topical retinoids, clindamycin
start slow, may purge, photosensitivity. Should improve in 4-6 weeks
Acne Vulgaris (Common Acne)
Moderate
papules & pustules w/ comedones
Tx: topical retinoid is first line
W/ inflammatory, add antibacteril (clindamycin, erythromycin)
Can do oral antibiotic if not effective (tetracycline, minocycline, doxycycline, erythromycin) for 3-4 weeks
**tetra okay if over 13 yr b/c teeth discoloration
Can use birth control (Desogen & Yaz)
Try to avoid dairy
Acne Vulgaris (Common Acne)
Severe
S&S of mild/moderate plus painful, indurated cysts, nodules, abcesses, and pustules
Tx: isotretinoin (Acutane)
Category X - extremely teratogenic
Must be in iPLEDGE program to prescribe
Must have 2 forms of contraception, monthly pregnancy results to pharmacist, can only prescribe one month at a time
DC if severe depression, visual disturbance, hearing loss, tinnitus, GI pain, rectal bleeding, uncontrolled hypertriglyceridemia, pancreatitis, hepatitis.
Rosacea (Acne Rosacea)
Chronic and relapsing
More likely with fair skin
chronic and small acne-like papules and pustules on nose, mouth and chin
Telangiectasias (spider veins) on nose and cheeks
Tx: symptom management and avoidance of triggers (spicy food, irritating skin care, sunlight, alcohol). Frequent moisturization
Can use topical antibiotic like metronidazole and azeleic acid gel. Low-dose oral tetracycline or minocycline given over several weeks.
Complications:
Rhinophyma: Hyperplasia of tissue at the tip of the nose from chronic severe disease
Ocular rosacea: Blepharitis, conjunctival injection, lid margin telangiectasia
Molluscum Contagiosum
Caused by poxvirus
More common with children
Spread with direct skin-to-skin contact
Considered an STD if in genital area in sexually active adolescent
S&S: dome shaped papules with umbilication
TX: should resolve in 6-12 months
Partial-thickness burns
(2nd degree)
Red-colored skin with superficial blisters (bullae); the burn is painful.
TX: Use water with mild soap or normal saline to clean broken skin (not hydrogen peroxide or full-strength Betadine). Do not rupture blisters. Treat with silver sulfadiazine cream (Silvadene) or triple antibiotic ointment such as Polysporin (bacitracin zinc and polymyxin B) and apply nonadherent dressings. Apply biologic dressings (e.g., DuoDERM), Tegaderm.
Alternative medicine: Use a topical application of honey or aloe vera.
Sulfadiazine can damage the eyes (do not use near the eyes). Pregnant or breastfeeding women should not use this agent.
Full-thickness burns
(minor burn)
Rule out airway and breathing compromise.
Painless. Entire skin layer, subcutaneous area, and soft tissue fascia may be destroyed.
Smoke inhalation injury is a medical emergency.
Suspect inhalation injury if facial burns, electrical burns, or burns on cartilaginous areas such as the nose and ears (cartilage will not regenerate). Also suspect if burns are on >10% of body, are circumferential (risk of compartment syndrome), and cross major joints
Superficial-Thickness Burns (First-Degree)
Erythema only (no blisters); painful (e.g., sunburns, mild scalds)
Cleanse with mild soap and water (or saline); cold packs for 24 to 48 hours
Intact skin does not require topical antibiotics; apply a topical OTC anesthetic such as benzocaine if desired or aloe vera gel
Rule of nines
Child
Arms: 9% each
Legs: 14% each
Trunk: 18% anterior trunk, 18% posterior trunk
Adult
Arms/head: 9% each
Legs/trunk: 18% each leg, anterior trunk, and posterior trunk
Cutaneous Anthrax
Caused by Bacillus anthracis (gram-positive rods).
S&S: papule that enlarges in 24 to 48 hours and develops eschar (necrosis) and ulceration. Arms, neck, and face.
Ask about history handing animal hides, hair or wool.
TX: Cutaneous anthrax (naturally acquired): Doxycycline twice a day, ciprofloxacin twice a day, levofloxacin twice a day for 7 to 10 days (if bioterrorism suspected, treat for 60 days).
Without treatment, 20% of people with cutaneous anthrax may die.
Postexposure prophylaxis (bioterrorism suspected): Doxycycline 100 mg orally twice a day × 60 days.
Smallpox (Variola Virus)
“eliminated” in 1977
S&S: flu-like symptoms, numerous large nodules on face, arms and legs.
Tx: tecovirimat (Tpoxx)
If vaccinated within 2-3 days of exposure, can lessen symptoms.
Phases of wound healing
Hemostasis: Constriction of local blood vessels, platelet aggregation, fibrin (clot) formation
Inflammation: Macrophages and lymphocytes proliferate, presence of inflammatory mediators such as cytokines and leukotrienes
Proliferation: Proliferation of basal and epithelial cells (angiogenesis)
Remodeling: Remodeling of collagen, scar formation (cicatrix)
Categories of Wound Healing
Primary healing (primary closure): Wound is closed within 24 hours by suturing or applying tissue glue or butterfly strips (so that edges of wounds are well approximated). Causes the least amount of scarring.
Secondary intention: Wound is left open with formation of granulation tissue and scarring. Wound heals from the bottom of the wound up. Wound edges are not well approximated. Causes more scarring than primary closure.
Tertiary intention (delayed primary closure): Wounds with heavy contamination or poor vascularity (crush injuries) are best left open to heal by secondary intention (granulation) and wound contraction. Then the wound edges are approximated in 3 to 4 days. Produces the most scar tissue.
