Miscellaneous Disorders - Exam 2 Flashcards
______ are localized asymptomatic skin disorder manifesting with hyperpigmented, velvety plaques typically located in flexural and intertriginous regions. What are they commonly seen with? What race?
Acanthosis Nigricans
common seen with skin tags
African Americans 25x more likely than whites
What is the likely etiology of acanthosis nigricans?
Stimulation of insulin-like growth factor receptors and tyrosine kinase receptors on keratinocytes and fibroblasts
What are the 8 types of acanthosis nigricans?
obesity
malignancy
drug induced
syndromic
acral
unilateral
benign
or
mixed
What dz are closely related to AN?
diabetes
insulin resistance
high body mass index (BMI)
metabolic syndrome
polycystic ovarian syndrome (PCOS)
If AN is related to malignancy like going to be ______
gastric carcinoma
What drug is closely related to AN?
Niacin MC
What are the 2 causes of syndromic AN?
A = Hyperandrogenism, insulin resistant, acanthosis, acromegaly
B = Autoimmune and Diabetes
Where are acral AN commonly found?
Elbows, knees and knuckles
What are unilateral AN related to?
Nevoid (Epidermal Nevus)
What is benign AN related to? What is mixed AN?
Rare autosomal dominant type
mixed: any 2 or more of the AN types
Where is AN typically seen?
It is typically seen in the neck folds (“dirty neck” appearance) and axillae
The inguinal and inframammary folds, antecubital and popliteal fossae, and elbows and periumbilical region may also be involved
Where are rare sites of involvement for AN? If you see a rarely form of AN, what should you think?
Rarer sites of involvement include velvety plaques on the knuckles, palms (“tripe palms”), soles, eyelids, periorally, near mucosal surfaces, or generalized
These rarer forms of AN are more closely related to malignancy
What will AN look like on the oral mucosa/lips?
have thickening and papillation and usually lack hyperpigmentation
How do you dx AN? What tests could you order?
clinical dx
AIC or fasting plasma testosterone/dehydroepiandrosterone sulfate
What is the tx for AN? What topical treatments are helpful?
tx the underlying cause
usually insulin insensitivity
topical: topical retinoids and/or vitamin D analogs may help improve appearance of lesion
In a pressure injury, where does the breakdown of skin occur? What is the pathophys?
Breakdown of the skin and underlying tissue resulting from unrelieved soft tissue pressure between bony prominence and external surface
non-relieving pressure/shearing forces results in diminished blood supply leading to cell death
What are the risk factors for a pressure injury? Which one is MC?
impaired mobility (MC)
contractures/spasticity
impaired sensation
aging skin
incontinence/fistula (skin maceration)
malnutrition
hypoproteinemia
anemia
What are the common locations for a pressure injury? Who is the MC pt?
sacrum/hip (70%)- MC
LE: malleolar, heel, patellar, pretibial
MC in acute hospitalized patients: think ortho and ICU pts
Pressure injuries place patients with same risk factors at _____ greater risk of death
4.5 times
In a pressure injury, where is the wound wider?
wider at the base and the inspection can be deceiving to the untrained eye
may require pain medication administration for adequate exam
When is NPUAP staging used in pressure injuries? Does it change as it heals?
used for initial evaluation and diagnosis and for description and documentation purposes only. NOT used in the evaluation of wound progression
stage is NOT changed upon healing (aka reverse staging)
**Draw the different staging pressur ulcers chart
_______ intact skin and non-blanchable hyperemia. What stage? What does a blanchable lesion mean?
stage 1 pressure injury
blanchable erythema, skin firmness, change in sensation or temp may precede stage I injury
What stage?
stage 1 pressure injury
intact blister or loss of epidermis with exposed dermis and subq tissue is NOT visible. wound bed is viable, pink/red, moist and NO granulation or eschar tissue. What stage?
stage II
stage II pressure injury
stage II pressure injury
full thickness skin loss, exposed subcutaneous tissue/adipose
no fascia, muscle, tendon, ligament, cartilage or bone visible, may have scar tissue, may have eschar, may slough and have epibole
What stage?
What is an epibole?
stage III pressure injury
epibole- rolled wound edge
stage III pressure injury
stage III pressure injury
stage III pressure injury
full-thickness skin/tissue loss
exposed fascia, muscle, tendon, ligament, cartilage and/or bone
eschar tissue
epibole
undermining/tunneling may be present
What stage?
stage IV pressure ulcer
stage IV pressure ulcer
full thickness skin and tissue loss obscured by slough or eschar
removal of obscuring tissue will reveal
What stage?
What should you NOT do?
unstageable
usually stage III or IV if obscuring tissue was removed
Do NOT remove a stable eschar for staging purposes
generally intact skin
deep red, maroon, or purple discoloration
blood filled blister
unable to visualize
What stage?
Suspected deep tissue injury
necrotic/granulation tissue, subcutaneous tissue or deeper structures
Unstageable pressure injury
suspected deep tissue injury
suspected deep tissue injury
What labs should you order in a pressure injury?
ESR, WBC
wound culture via punch bx
bone bx if concerned for osteomyelitis
What is the broad tx of a pressure injury?
reduce/eliminate underlying risk factors
redistribute pressure: reposition every 2 hrs or sooner and bed elevation to < 30 degrees, minimize friction/shear forces with proper transferring and turning techniques
remobilization
Clean skin with mild cleansing agents and keep dry
control pain
abx if indicated
What is the tx for stage I pressure injury? stage II? stage III/IV?
Stage I: cover with transparent film for protection
Stage II: transparent or hydrocolloid dressing
Stage III/IV: debridement
**What is the CI for hydrocolloid dressing?
CI in active infection
What are the 4 things you need to monitor for in pressure injury healing?
size in cm
exudate amount
tissue type (sloughing, eschar)
Score (0-17) will decrease with healing
How long does it usually take for a stage I or II pressure injury to heal? stage III or IV? What is the MC complication?
Stage I & II heal in 1-2 wks
Stage III & IV health in 6->12 wks
MC complication: infection
What is Hidradenitis suppurativa? What areas are common?
Chronic suppurative disease of the apocrine gland bearing skin areas
axillae, inguinocrural and anogenital regions; scalp(rarely)
What is the MC pt with HS? What are the risk factors? **What are the 2 RF specifically mentioned in class?
Females> Males
Onset: beginning at puberty
occlusive dress, trauma, obesity, smoking, host defence defects, hormones, genetics
**obesity and smoking
What is the pathophys behind HS?
- perifollicular inflammation
- hyperkeratinization of follicular epithelium with occlusion and dilation of the follicle
- follicular rupture and release of intrafollicular debris into the dermis with increased inflammation
- formation of tunnels filled with debris and/or fluid that connect to the surface of the skin and to the base of other ruptured follicle
Open comedones are characteristic
Nodules with sinus tracts (inflamed or noninflamed)
Abscesses
Scarring
Sinus tracts lead to dermal contractures and ropelike elevation of the skin
What am I?
What is usually in the hx?
Hidradenitis suppurativa (HS)
History of recurrent painful suppurative lesions which heal leaving scars
What are 3 complications of HS?
Secondary infection
Fistulas to urethra, bladder, and/or rectum
Chronic inflammatory reactions
What are the tx options for HS?
Intralesional glucocorticoids
Oral antibiotics
Isotretinoin
Biologics
Surgery
What is the immediate tx of acute HS lesions?
Intralesional steroid followed by I&D abscesses
oral abx: B-lactamase PCN, Cephalosporins, Augmentin, Clindamycin
oral steroids to decrease pain/inflammation
What is the tx for recurrent HS lesions?
abx PLUS retinoids (clinda PLUS isotretinoin)
biologics: adalimumab (Humira) or infliximab (Remicade)
What is the tx for chronic recurrent HS lesions?
Surgical Treatment: small excision of chronic recurrent nodules or sinus tracts
complete excision of lesions with wide margins
address psychosocial complications
What are the lifestyle modifications to education your pt with HS?
______ is the abnormal response to light, usually sunlight, occurring in minutes, hours, or days of exposure and lasting weeks, months and even longer. What are the 3 types?
photosensitivity
sunburn
rash
urticarial
______ Chronic repeated sun exposures over time result in polymorphic skin changes that have been termed dermatoheliosis or photoaging
chronic photosensitivity
A _____ type response with skin changes simulating a normal sunburn such as in phototoxic reactions to drugs or phytophotodermatitis
A ____ response with macules, papules, or plaques, similar to eczematous dermatitis
_____ responses are typical for solar _____
sunburn
rash
Urticarial, urticaria
3 different types of photosensitivity
______ A phototoxic reaction that presents as an acute, delayed, and transient inflammatory response of normal skin after exposure to UVR from sunlight or artificial sources
acute sunburn
Pruritus, pain and tenderness
may develop headache, malaise even after short exposure
What am I?
What is a severe presenation?
acute sunburn
If severe sunburn, patient can present “toxic” with flu like illness
Fever, chills, fatigue, weakness, tachycardia
When does an acute sunburn s/s typically present? Describe it in words
Develops after 6 hours and peaks after 24 hours
Confluent bright red erythema confined to sun-exposed areas and sharply marginated at the border between exposed and covered skin. May have vesicles and bullae. As edema and erythema fade, vehicles and blisters dry to crusts, which then shed
What is the tx for an acute sunburn?
Cool, wet dressings and topical glucocorticoids
Aloe Vera
NSAIDs
What is the tx for a severe acute sunburn?
Bedrest and oral fluids
“Toxic” patients may require hospitalization for IV fluid replacement
What are the 3 prevention strategies for an acute sunburn?
SPT I/II should avoid sun exposure between 10AM and 2PM
Adequate sunscreen use and proper reapplication
Clothing - UV-screening cloth garment
_____ is an adverse reaction of the skin that results from an interaction between UVR with a chemical or drug. What are the 2 types?
Photosensitivity: Drug/Chemical Induced
Phototoxic reactions
Photoallergic reactions
_____ a photochemical reactions that presents like an irritant contact dermatitis or sunburn. What is the associated timing? What is the pathophys?
phototoxic reactions
subtype of Photosensitivity: Drug/Chemical Induced
minutes to hours onset of eruption after exposure
direct tissue injury
__________ is formed that initiates an immunologic response, manifests in skin as a type IV immunologic reaction and presents like an allergic eczematous contact dermatitis. What is the associated timing? What is the pathophys?
Photoallergic reactions
subtype of Photosensitivity: Drug/Chemical Induced
24-48 hours onset of eruption after exposure
Type IV delayed hypersensitivity response
What is the tx for an phototoxic reaction?
remove offending agent and tx conservatively
think sunburn
What is the tx for an photoallergic reaction?
remove offending agent
antihistamines
steroids
treat like contact derm
_____ is also called dry skin or asteatosis, refers to a condition of rough, dry skin texture with fine scale and occasionally fine fissuring. What will the pt complain of?
xerosis
Often pruritic
What is the pathogenesis of xerosis?
Pathogenesis involves a decrease in the amount of lipids in the stratum corneum and a deficiency in the water-binding capacity of this layer
The incidence of xerosis increases with _____. nearly all individuals over the _____ have some degree of xerosis
age
age of 60
In more advanced xerosis, the _____ may begin to exhibit a _____ pattern of superficial cracks and fissures with erythema
stratum corneum
polygonal
Where are the MC locations of xerosis?
lower extremities, trunk, and dorsal hands, usually sparing the head, neck, palms, and soles
What questions/pt educations points are important in xerosis?
Inquire about bathing habits (frequency, type of soap used, water temperature)
Hot water, frequent or prolonged bathing, and the use of soaps worsen xerosis
Take a complete medication history
encourage bathing in luke-warm bathing and to apply moisturizers within 60 seconds of getting out of the shower
too frequent bathing can also exacerbate factors
humidifiers
mild soap substitutes, nothing with fragrance
How do you dx xerosis?
clinical dx
What am I? How is it inherited? What is it?
ichthyosis
autosomal dominantly inherited condition of abnormal cornification leading to scaling and desquamation and presents as fine, fish-skin-like scale.
When is Ichthyosis more commonly seen? What age range does it usually begin?
It is more prominent in winter and in climates with low relative humidity
The condition usually begins in childhood between 3 and 12 months of age and follows a favorable course in which the scaling alleviates in intensity by adulthood.
What are the tx options for Ichthyosis? Where is it most prominent? You should look for _______ and _____
Hydration, lubrication, and keratolysis are the mainstays of therapy
The condition is usually most apparent on the extensor extremities.
Look for accentuated palmar creases and scaly palms.
How do you dx Ichthyosis? What does acquired ichthyosis make you think?
clinical dx but can skin bx
Cases of acquired ichthyosis warrant a search for an underlying systemic disease or malignancy
What is the tx for Ichthyosis?
Emollients are the mainstay of therapy. Creams applied after bathing help the epidermis retain water
non-drying soaps and cleansers
soaking with mechanically exfoliating
humidifiers
may use keratolytic agent containing an alpha hydroxy acid, salicylic acid, or urea can be used but only if localized areas, topical retinoids, topical vit D, mid-potency steroid cream
