MDT S/S/TX Flashcards
What issue/Tx
A contagious, superficial, intraepidermal infection occurring prominently on exposed areas of the face and extremities
-Infected patients usually have multiple lesions.
-Satellite lesions appear beyond the periphery.
-Most common form is formation of vesiculopustules that rupture, leading to crusting with a characteristic golden appearance
Impetigo
-Remove crusts; clean with gentle washing 2 to 3 times daily; and clean with antibacterial soap, chlorhexidine, or Betadine.
-Washing of entire body may prevent recurrence at distant sites.
Vanilla Staph:
(a) Nonbullous (minor spread, treat 7 days; widespread, treat 10 days); bullous (treat 10days)
(b) Mupirocin (Bactroban) 2% topical ointment applied TID for 5 to 7 days (nonbullous only)
(c) Dicloxacillin: Adult 250 mg PO QID
MRSA:
(a) Clindamycin, tetracyclines, or trimethoprim-sulfamethoxazole. Oral doses given for7 days are usually sufficient.
(b) Clindamycin 300 mg q6-8h
-Severe bullous disease may require IV therapy such as nafcillin or cefazolin.
What issue? What Tx?
(1) abrupt onset of follicular erythematous papules or pustules, with pruritus & pain in hairy areas.
(2) Rash occurs on hair-bearing skin, especially the face (beard), proximal limbs, scalp, and pubis.
(3) The clinical hallmark - hair emanating from the center of the pustule
Folliculitis
-ANTISEPTIC/SUPPORTIVE CARE IS USUALLY ENOUGH.
What issue?
(1) Red papules or pustules appear in the affected skin Lesions can be both painful and/or pruritic.
(2) Occurs in any area where the hair is shaved (scalp, posterior neck, groin, legs).
(3) Scarring and hyperpigmentation may result from this condition.
(4) Keloid formation is often a problem in affected skin, especially in African-American people.
Pseudofolliculitis Barbae
Tx for Mild to Moderate PFB
Treatment Approach 1 - Medical Treatment with Grooming Modifications
-Either a topical retinoid or eflornithine 13.9% (if available) and a temporary waiver of facial hair standards for up to 60 days
Tx moderate to severe PFB
Treatment Approach 2 - Laser Hair Reduction with grooming modifications
What issue / tx
An acute bacterial infection of the dermis and subcutaneous (SC) tissue
1) Presents with the (4) classic signs of inflammation:
-(a) Erythema
-(b) Edema
-(c) Tenderness to palpation
-(d) Elevated skin temperature surrounding area of infection
2) Location:
-(a) Unilateral lower-extremity involvement is typical and systemic symptoms are usually absent
3) Typically occurs near surgical wounds and trauma sites.
4) Symptoms.
-(a) Pain, itching, and/or burning
-(b) Fever, chills, and malaise
5) Physical Exam
-(a) Localized pain and tenderness with erythema, induration, swelling, and warmth
-(b) Regional lymphadenopathy
-(c) Purulent drainage (from abscesses)
Cellulitis
Treatment
(1) Demarcate area w/a sharpie to measure progress once you start treatment.
(2) Immobilize and elevate involved limb to reduce swelling.
(3) Sterile saline dressings or cool aluminum acetate compresses for pain relief.
(4) Compression stocking for edema.
(5) Acetaminophen +/- NSAIDs for pain relief.
(6) Tetanus immunization if needed, particularly if there is an open (traumatic) wound.
(7) Antimicrobial treatment:
-(a)Non-purulent cellulitis (target treatment toward â-hemolytic streptococci and MSSA)
—1)Cephalexin 500 mg PO q6h
—2)Dicloxacillin 500 mg PO q6h
-(b)Purulent cellulitis (probable CA-MRSA)
—1)Clindamycin 450mg PO
—2)Trimethoprim-sulfamethoxazole (TMP-SMX) 1 DS tab PO BID
—3)Doxycycline 100 mg PO BID
-(c)Human/animal Bites
—1)Amoxicillin + clavulanic acid (Augmentin)
What Dx/ Tx
(1) Most frequently occurs in the extremities (Predilection for the lower leg) and may mimic DVT.
(2) Initially there is pain, erythema, edema, cellulitis and high fever.
(3) The pain is progressive, relentless, and severe and is often out of proportion to the severity of the physical findings.
(4) Skin exam may be unrevealing early on, or may be confused with cellulitis or abscess; may see blistering, crepitus, soft tissue edema, erythema, discoloration, necrosis, bullae, vesicles, or ulceration.
Necrotizing Fasciitis
Treatment
(1) Prompt and wide surgical debridement is the CORNERSTONE of treatment.
(2) Broad-spectrum antibiotics should be administered once diagnosis of NSTI is suspected.
Disposition
(1) Immediate medevac is required for this patient.
(2) Close contacts of patients and health care workers do not require chemoprophylaxis with antibiotics (good to brief the CoC on)
What issue/tx
(1) Acute presents with localized pain and tenderness. The nail fold appears erythematous and inflamed, and a collection of pus usually develops. Early in the course, cellulitis alone may be present. An abscess can form if the infection does not resolve quickly.
(2) Develops along the nail margin (proximal and lateral nail folds), manifesting over hours to days with pain, warmth, redness and swelling.
(3) Pus accumulates behind the cuticle, sometimes spreading beneath the nail or deeper into the lateral nail folds.
Paronychia
Treatment
(1) Early treatment with warm compresses or soaks.
(2) Antibiotic therapy if warranted that includes coverage for Staph and strep.
(3) Bactrim/Septra DS in areas where MRSA is common and based on results of sensitivity testing.
(4) Fluctuant or visible pus should be drained using scalpel blade inserted between the nail and nail fold.
(5) Skin incision is unnecessary
What issue / Tx
(1) Condition is characterized by severe pain, exquisite tenderness, and tense swelling of the distal digit with erythema. There may be a visible collection of pus or palpable fluctuance.
(2)Septa between the pulp spaces limits the spread of infection, resulting in an abscess, creating pressure and necrosis of adjacent tissues.
(3)Underlying bone, joint or flexor tendons may become infected.
Felon
Treatment
(1) Prompt incision, with division of the fibrous septa to ensure adequate drainage.
(2) Should be performed by Dermatologist if available.
(3) IDC should treat with antibiotics.
Disposition
(a) Medevac for IND
(b) Light Duty, no use of affected hand until signs of infection have resolved andwound has healed.
What Dx/Tx
(1) Rash appears 2-6 weeks after exposure.
(2) Intense pruritus that worsens at night is a cardinal feature.
(3) A burrow is the classic lesion; a linear, curved or S-shaped slightly elevated vesicle orpapule up to 1-2 mm wide.
-(a) Finger webs, wrists, sides of the hands and feet, the penis, buttocks and scrotum.
-(b) Burrows may obscured by scratching and secondary lesions.
-(c)Partners will also be symptomatic.
Scabies
Treatment
(1)Treatment is twofold:
-(a)Killing scabies mites & removing infestation
-(b)Controlling the dermatitis & pruritus, which can persist for months after effective eradication of the mites.
(2)Permethrin 5% or Lindane 1% applied to entire skin surface from the neck down, including under the fingernails and toenails an in the umbilicus.
(3) After 12 hours patient will bathe.
(4) Treatment regimen should be repeated in 1 week.
(5) Topical steroids may be used to control pruritus and inflammation after treatment with a scabicide.
(6) All clothes and bedding must be washed in hot water or put in a hot dryer at the time of application.
What issue / Tx
1) Occurs most commonly in intertriginous areas such as the axillae, groin, digital web spaces, glans penis, and beneath the breasts.
2) Intertriginous infections manifest as pruritic, well demarcated, erythematous patches of varying size and shape; erythema may be difficult to detect in darker skinned patients.
3) Primary patches may have adjacent satellite papules and pustules; the contents of which dissect horizontally under the stratum corneum and then peel it away.
–(1)Results in a red, denuded, glistening surface with a long, cigarette paper-like, scaling and advancing border.
Candidiasis
Treatment
(1)Affected skin should be kept dry and exposed to air as much as possible.
(2)Topical Azole class antifungals:
–(a)Miconazole (Monistat)
–(b)Clotrimazole (Lotrimin-AF)
–(c)Ketoconazole (Nizoral)
(3) Allylamine class antifungals:
–(a)Terbinafine (Lamisil)
–(b)Relief is almost immediate, but treatment should be continued for 10 days.
What issue/ Tx
(a) Scaling, round or oval pruritic plaques characterized by a sharply defined annular pattern with peripheral activity and central clearing (ring-shaped lesions).
(b) Papules and occasionally pustules/vesicles present at border and, less commonly, incenter.
(c) Pruritus may or may not be present.
Tinea Capitis
Treatment
(a) Topical
–1)Superficial lesions respond to antifungal creams.
–2)Clotrimazole, Miconazole or Terbinafine applied BID for a minimum of 2weeks.
–3)Continue treatment for at least 1 week after resolution of the infection.
–4)Extensive lesions or those with red papules require oral therapy.
(b) Oral
–1) Griseofulvin (ultra-microsize) 250 po mg QD x 2 weeks or Fluconazole 150 mg once a week for 3-4 weeks.
–2) Secondary bacterial infections are treated with oral antibiotics.
What issue/Tx
(a) Well-marginated, erythematous, half-moon-shaped plaques in crural folds that spread to medial thighs; advancing border is well defined, often with fine scaling and sometimes vesicular eruptions.
(b) Lesions are usually bilateral and do not include scrotum/penis (unlike with Candida infections).
(c) May migrate to perineum, perianal area, and gluteal cleft and onto the buttocks in chronic/progressive cases.
(d) The area may be hyperpigmented on resolution.
Tinea Cruris
Treatment
a) Fist-Line:
–1) Topical antifungal cream (terbinafine, miconazole, clotrimazole, ketoconazole)applied 2 times a day for 10 to 14 days.
–2) Absorbent powders (+/- antifungals) help to control moisture and prevent re- infection.
(b) Refractory, inflammatory or widespread infections:
–1) Itraconazole 200 mg orally once a day or terbinafine 250 mg orally once a day for 3 to 6 weeks may be needed in patients who have.
–2) Resume topical antifungal cream once symptoms are controlled.
What issue / Tx
(a) May progress to fissuring or maceration in toe web spaces.
(b) Symptoms include itching, burning, and stinging of interdigital webs and plantar surfaces. Pain may indicate secondary infection.
(c) Most often presenting with asymptomatic scaling.
(d) May present with the classic “ringworm” pattern, but most infections are found in toe webs or on the soles.
(e) May progress to fissuring or maceration in toe web spaces.
(f) Wood lamp exam will not fluoresce unless complicated by another fungus, which is uncommon.
Tinea Pedis
Treatment
(a) Open-toed sandals when possible.
(b) Wear shower shoes in showers.
(c) Dry between toes after showering and frequent sock changing.
(d) Absorbent, non-synthetic socks preferred (Cotton).
(e) Antifungal powders.
(f) Recurrence is prevented by wearing wider shoes and expanding the web space.
(g) Powders are used to absorb excess moisture
(h) Topical Treatment
–1)Topical medications applied BID for 2-4 weeks. (Clotrimazole, Miconazole, Terbinafine)
(i) Oral Treatment
–1) For extensive/acute infections consider oral antifungals. May be started in combination with topical antifungal agents.
–2) When cleared by oral rx, begin maintenance therapy with topical antifungals as recurrence is common.
–3) Secondary bacterial infection is treated with oral antibiotics (common in heavily macerated lesions).
What issue / Tx
Presentation
(a) Velvety tan, pink or white macules that do not tan.
(b) Color is uniform in each person but may vary between people.
(c) Fine scales that are not visible but are seen by scraping the lesion.
(d) Central upper back, chest, and proximal arms (same areas as the highestconcentration of sebum).
(e) Typically asymptomatic, but a few patients note itching when overheated.
(f) Appearance is often the patient’s major concern.
Tinea Versicolor
Treatment
(a) Topical
–1) Topical treatment is indicated for limited disease.
–2) Selenium Sulfide 2.5% applied from neck to waist wash off after 5-15 minutes, repeat daily x 7 days. Repeat weekly x 1 month, then monthly for maintenance.
3) Ketoconazole 2% shampoo chest and back, wash off after 5 minutes. Repeat weekly.
(b) Oral
-1) Oral treatment is used for patients with extensive disease and those who do not respond to topical treatment.
-2) Cure rates may be greater than 90%.
–a) Ketoconazole 400 mg in a single dose with exercise to point of sweating after ingestion. Single dose is not always effective.
—b) Fluconazole 300 mg (2 capsules weekly x 2 weeks) has similar efficacy.
–3) Oral Terbinafine is not effective for this condition.
What Dx/Tx
(1) Nail discoloration, subungual hyperkeratosis, onycholysis, splitting of the nail plate, and nail plate destruction
(2) Potential complications include pain, transmission of fungal infection to other body sites, concurrent tinea pedis.
(3) Most patient concerns are based on cosmetic appearance and not functional deficit.
Onychomycosis
Pretreatment diagnostic testing:
–(a) Confirmation of infection is required prior to treatment due to potential for liver toxicity of treatment with oral antifungals.
–(b) Potassium hydroxide (KOH) preparation (confirms presence of infection) andfungal culture (determines the type/species of the actual infecting organism).
Treatment
–(a) Treatment is not done on deployment due to inability to perform LFT testing.
–(b) Oral antifungal therapy is considered the gold standard for onychomycosis; higher complete cure rates & shorter course of treatment compared with topical therapy.
What Dx/Tx
(1) Rash appears 2-6 weeks after exposure.
(2) Intense pruritus that worsens at night is a cardinal feature.
(3) A burrow is the classic lesion; a linear, curved or S-shaped slightly elevated vesicle orpapule up to 1-2 mm wide.
-(a) Finger webs, wrists, sides of the hands and feet, the penis, buttocks and scrotum.
-(b) Burrows may obscured by scratching and secondary lesions.
-(c)Partners will also be symptomatic.
Scabies
Treatment
(1)Treatment is twofold:
-(a)Killing scabies mites & removing infestation
-(b)Controlling the dermatitis & pruritus, which can persist for months after effective eradication of the mites.
(2)Permethrin 5% or Lindane 1% applied to entire skin surface from the neck down, including under the fingernails and toenails an in the umbilicus.
(3) After 12 hours patient will bathe.
(4) Treatment regimen should be repeated in 1 week.
(5) Topical steroids may be used to control pruritus and inflammation after treatment with a scabicide.
(6) All clothes and bedding must be washed in hot water or put in a hot dryer at the time of application.
What issue / Tx
(1) Prodromal symptoms are reported in as much as 69% of patients and typically include some variation of the following:
-(a) Malaise, mild fever, headache, sore throat, cough, or mild URI or GI symptoms.
-(b) Begins with a solitary herald patch that appears on the trunk or proximal limbs that precedes secondary eruption by 7-14 days.
-(c) Herald patch: a 2-5 cm round or oval, sharply delimited, pink or salmon-colored lesion on the chest, neck, or back.
-(d) Within 7-14 days, oval lesions similar in appearance to the herald patch, but smaller, appear in crops on the trunk and proximal areas of the extremities.
-(e) Lesions range from 0.5 to 2 cm oval papules and plaques, and have a scaly, slightly raised border (collarette) and resemble ringworm (tinea corporis).
-(f) Lesions are distributed with long axes along cleavage (Langer’s) lines:
–1) “Christmas tree pattern” on back
–2) V-shaped pattern on upper chest
–3) Mild to moderate pruritus is a common complaint. However, in rare cases patients may experience severe pruritus on lesions.
–4) The rose or fawn color is not as evident in patients with darker skin. Lesions generally resolve spontaneously after ~ 45 days.
Pityriasis Rosea
Symptomatic treatment of pruritus:
1) Non-sedating oral antihistamines (centrizine, loratidine, fexofenadine)
2) Sedating antihistamines if sleep interrupted (benedryl/atarax).
3) Topical corticosteroids commonly used, however, drains AMAL meds due to size or eruption (logistically dumb).
additional info
–5) No treatment or symptomatic treatment is indicated for most patients.
–6) If you’re not actively treating the patient, you’re on the hook for educating the patient why.
What dx / Tx
(a) The hands are most often affected. Both dorsal and palmar surfaces can be affected.
(b) Erythema, dryness, painful cracking or fissuring and scaling are typical. Vesicles may be present.
(c) Tenderness and burning are common and predominate the itching.
(d) May show juicy papules and/or vesicles on an erythematous patchy background with weeping and edema.
(e) Persistent, chronic version is characterized by lichenification, patches of erythema, fissures, excoriations and scaling.
(f) Open skin may burn on contact with topical products.
Irritant Dermatitis
Treatment
(a) Early diagnosis, treatment and preventative measures can prevent the development of a chronic irritant dermatitis.
(b) Medium or high-potency topical steroid ointment applied BID for several weeks can be helpful in reducing erythema, itching, swelling and tenderness.
(c) Antihistamines (except for their sedative effect) are ineffective in contact dermatitis.
(d) Frequent application of a bland emollient to affected skin is essential.
What Dx / Tx
(a) Characterized by vesicles, edema, redness and extreme pruritus. Strong allergens such as poison ivy produce bullae.
(b) Distribution first confined to the area of direct exposure. May spread beyond areas of direct contact if exposure is chronic.
(c) Itch and swelling are key components of the history. Itch predominates the burning sensation.
(d) The hands, forearms and face are the most common sites. May also affect limited skin sites such as the eyelids, dorsal aspect of the hands, lips, tops of the feet and genitalia.
ACD
Treatment:
(a) Identify and remove the etiologic agent.
(b) Apply wet dressings with Burrow’s solution every 2-3 hrs.
(c) Topical class I–II glucocorticoid preparations. In severe cases, systemic glucocorticoids may be indicated.
(d) Educate patient, detailing potential sources of exposure.
What Dx/Tx
(a) Flares are common with stress/illness.
(b) Parallels increased sebaceous gland activity
(c) Positive family history; no genetic marker is identified to date.
(d) Intermittent active phases with burning, scaling, and itching, alternating with inactive periods; activity is increased in winter and early spring, with remissions commonly occurring in summer.
(e) Red, greasy, scaling rash in most locations consisting of patches and plaques with indistinct margins.
(f) Red, smooth, glazed appearance in skin folds.
(g) Minimal pruritus
(h) Chronic waxing and waning course
(i) Bilateral and symmetric
(j) Most commonly located in hairy skin areas: scalp and scalp margins, eyebrows and eyelid margins, nasolabial folds, ears and retroauricular folds.
Seborrheic Dermatitis (Dandruff)
tx
(a) Adults tend to have chronic and recurrent disease; patients should know that the aim of treatment is control rather than cure.
(b) Can be treated with shampoos containing:
-1) Zinc pyrithione (Head & Shoulders)
-2) Selenium Sulfide (Selsun Blue)
-3) Ketoconazole (Nizoral)
-4) Salicylic Acid (T/Sal)
-5) Coal tar (T/Gel)
(c) Daily facial washing with antidandruff shampoo or soaps diluted with water is also effective.
