Module 11: Dermatology (a) Flashcards
1
Q
Common Growths
-Actinic Keratosis
A
- Gritty or sand-paper-like rough macule or thin pápula
- Sun-exposed skin
- Actinic keratosis very rarely becomes squamous cell carcinoma — 1:100 to 1:1000 risk
- Treatment
- Liquid nitrogen application
- 5-fluoruracil cream
- Imiquimod cream
2
Q
Common Growths
-Seborrheic Keratosis
A
- “Stuck-on” usually brown to black thin pápulas to plaques
- Trunk and head & neck > extremities
- Benign
- Treatment
- NOT Necessary
- If irritated — Liquid nitrogen application
3
Q
Acne Vulgaris & Rosacea
A
- Chronic papulopustular eruption affecting the pilosebaceious units of the face and trunk
- Acne Vulgaris Types — Comedonal, papulopustular, nodulocystic (Conglobata), Fulminans
- Acne Rosacea Types — Classic, Granulomatous, pyoderma faciale — Flushing more common
- Primary Lesions — Red pápula/nodule, pustule, comedones (white and black heads)
4
Q
Acne Vulgaris
-Grades 1-4
A
- Mature closed comedo - “White head”
- Open comedo - “black head” — oxidized lipids
- Grade 2 — Papular: Red inflamed pápulas
- Grade 3 — Papulopustular: Pustules
- Grade 4 — Nodulocystic: Furuncles that have nodulear/cystic appearance
5
Q
Acne Vulgaris Therapeutic Agents
A
- Topicals
- Retinoids (tretinoin, adapalene) — comedolytic & shrink sebaceous glands — NOT for pregnant women - Spironolactone — Okay for women — NOT given to men d/t risk of gynecomastia — Anti-androgen activities — NOT for kidney dz
- Oral contraceptives — Yasmin — only for adjunctive therapy
6
Q
Acne Vulgaris Therapeutic Agents
-Oral Antibiotics
A
- Tetracycline — 500 mg BID -TID — Photosensitivity, GI upset - empty stomach
- **Doxycycline — 100 mg QD - BID — Photosensitivity, $$
- **Minocycline — 100 mg QD — Dizziness, BLUE skin pigmentation
- Erythromycin — 500 mg bid-TID — GI upset
**Doxycycline and minocycline are most commonly prescribed
Above antibiotics have anti-inflammatory properties
7
Q
Acne Vulgaris Therapeutic Agents
-Oral Isotretinoin
A
- Nodulocystic acne or refractory acne — 120-150 mg/kg per course W/ FOOD
- A/Es TERATOGENICITY, EXTREME xerosis, increased LFTs & triglycerides
- ALL women of child-bearing potential must list 2 forms of contraception to register
- Mixed evidence of risk of colitis — U.C.»_space;> Crohn’s) 2x
For Topical and oral retinoids, ACNE may become worse prior to getting better
8
Q
Acne Vulgaris Therapy
-Grade 1 Comedonal Acne
A
- Tx w/ topical tretinoin cream or gel at bedtime
- Apply a small amount (pea-sized) to affected regions of the face
- Apply to Dry face, NOT wet
- Try applying every other night if irritating - Consider adding topical antibiotic or topical benzoyl peroxide in the morning
9
Q
Acne Vulgaris Therapy
-Grade 2: Papular Acne
A
- Add oral antibiotic if moderately severe or if chest and back are involved
- Continue oral antibiotic for at least 6-8 wks then slowly decreased daily dose to avoid flare-ups - DO NOT abandon a given therapy until a 6 wk trial has been completed
TEST 6-8 weeks
10
Q
Acne Vulgaris Therapy
-Grades 3-4: Papulopustular/Nodulocystic Acne
A
- If severe, consider ISOTRETINOIN
- REFER to Dermatology
- STOP all other Acne Treatment - Contraceptive Counseling is IMPORTANT — Oral contraceptives are safe w/ isotretinoin
11
Q
Pitfalls of Therapy for Acne Vulgaris
A
- NOT waiting 6-8 weeks to establish a response to starting therapy
- Ignoring impact of cosmetics, skin cleansers, hair lubricants, picking, OCPs, occupational exposures, stress, and hormones on a patients acne
- Poor patient education on how to counteract the drying effects of topical therapy
12
Q
Acne Rosacea Therapeutic Considerations
A
- No Comedones — NO place for topical comedolytics (Tretinoin, benzoyl peroxide)
- C. Acnes bacteria NOT important — Topical erythromycin and clindamycin NOT helpful
- Vascular instability leads to “FLUSHING”
Acne Rosacea has “BACKGROUND ERYTHEMA” Papules, pustules are on top of the redness
13
Q
Therapy for Acne Rosacea
A
- Metronidazole cream or gel BID
- Azelaic acid cream or gel BID
- Ivermectin 1% cream BID
- If moderately severe ADD oral antibiotics
- Doxycycline, minocycline
- Erythromycin
14
Q
Pitfalls of Acne Rosacea Therapy
A
- NOT waiting 6-8 weeks to establish a response to starting therapy
- Ignoring impact of cosmetics, skin cleansers, skin care products, topical steroids, stress
- Triggers for Flushing
- SUN Exposure, ETOH, Chocolate,
15
Q
Psoriasis
-Info
A
- Chronic eruption of “scaly plaques” on the extensor surfaces that may involve the scalp and nails
- Primary lesion — WELL-DEFINED PLAQUE — Thick silvery scale — pitting of nails is diagnostic
- Usually develops in 40’s to 50’s years olds
16
Q
Psoriasis Types More Common in HIV?
A
- Inverse & Erythrodermic psoriasis
- Severe Psoriasis can occur after RAPID PREDNISONE TAPER**TEST
- If a patient has a hx of Moderate Psoriasis and has been on steroids recently, think of that as the cause for SEVERE Psoriasis
17
Q
Psoriasis
-Therapeutic Modalities Topicals
A
- Topical steroid creams & ointments
- Topical Calcipotriene cream & ointment
- Topical tazarotene (Retinoid) gel
- Phototherapy (UVB & PUVA)
- Oral methotrexate, acitretin (retinoid), or cyclosporine, apremilast
18
Q
Psoriasis
-Therapeutic Modalities Injectables
A
- Humara
- TNF
- IL 12/23
- IL-17A
- IL-23
19
Q
Psoriasis
-Topical Steroids and Potency
A
- NEVER use class 1 or 2 topical steroids on face or skin folds
- Can PERMANENTLY Thin the skin
20
Q
Limited Plaque Psoriasis Therapy
A
- Topical Steroids
- Class 1 or 2 for short 14 day control
- Class 3-4 for daily maintenance therapy
- Topical calcipotreine .005% cream DOVONEX — Apply BID +/- topical steroids
- Topical tazarotene .1%, .05% gel TAZORAC — QD +/- topical steroids — NEVER for pregnant women
21
Q
Eczema
-Info
A
- Inflamed, pruritic skin (dermatitis) not due, exclusively, to external factors (allergens, sunlight, cold, heat, fungus, etc)
- Types:
- Atopic (most common starting as a child)
- Asteatotic - only in winter
- Hand & Nummular - Primary lesion is ILL-DEFINED scaly red patch
- Diagnostic — R/O external factors as the sole cause of eruption
22
Q
Atopic Eczema
-Pathophysiology
A
- Genetic and environmental factors play a strong role
- Histology — Spongiosis = intercellular edema w/in the epidermis — Acute and chronic inflammatory cells
- T cell mediated cytokine release — TH2 type
- More likely to be seen in urban settings not rural settings
- Psoriasis = TH1 cells — Eczema is TH2 cells
23
Q
Therapy of Mild to Moderate Eczema
A
- Correct Diagnosis — R/O allergic or irritant contact dermatitis, dermatophyte infections, & drug reactions
- Good skin care
- Mild super fated skin cleanser — Lukewarm not hot showers, lubricate skin frequently w/ unscented or fragrance free lotions/creams - Topical Steroids — Only for flares
- Class 1 or 2 for short term (14 days) — For Children, use class 3 or 4 d/t to thin skin (mometasone cream) - Consider topical or oral antibiotics if crusted
- Topical tacrolimus or pimecrolimus $$$ for refractory disease
- both meds are calcineurin inhibitors that inhibit T cell proliferation
- NO skin atrophy
- FDA concerned about long-term use — Dermatologists are NOT concerned
24
Q
Therapy for Severe and Widespread Eczema
A
- Dermatology REFERRAL
- Oral or intramuscular steroids
- Phototherapy
- Oral methotrexate — cyclosporine — NOT for children
- Dupilumab injections — Anti-IL-4 — Look for A/E conjunctivitis
25
Q
Urticaria
-Info
A
- Pruritic transient plaques caused by local release of histamine in the skin
- Types - Acute and chronic (Chronic >6 wks)
- Physical (Cholinergic, pressure, heat - Primary lesion — wheals
- Key diagnostic — TRANSIENT lesions — <12-24 hrs
26
Q
Urticaria
-Pathophysiology
A
- Exposure of allergen to lungs, gut or skin
- Type 1 hypersensitivity reaction:
- IgE mediated mast cell degranulation
- Release of histamine and other chemical mediators
- Increased capillary permeability and tissue edema
27
Q
Urticaria Therapy
A
- ID allergen and avoidance — drugs, pollen, chemicals, food, bacteria, preservatives, malignant tumor
- Antihistamines (Avoid systemic steroids) — Loratadine, cetirizine, fexofenadine, atarax
- If Chronic >6 wks — Consider adding cimetidine (Tagamet) 400 mg bid-TID
- If severe and chronic consider omalizumab (Once monthly injection* — blocks binding of IgE to IgE receptor in mast cells
28
Q
Dermatophyte Infections
-Info
A
- Superficial fungus infection of the skin caused by dermatophyte fungi
- Types — Tinea corporais, capitais, cruéis, Mannum (hand), Pedis, unguium (nail)
- Primary Lesion is WELL-DEFINED red PATCH. Or yellowish nail w/ Subungual crumbling
- Diagnostic Keys — ID of hyphae on KOH exam or fungus culture
29
Q
Therapy of Dermatophyte skin infections
-Localized skin involvement
A
- Topical Antifungals cream
- Miconazole 2% BID
- Clotrimazole 1%
- Ketoconazole 2% QD bid - Nystatin has NO EFFECT on dermatophyte fungi — Only works for Candida
- AVOID combination products w/ steroids — Can cause permanent skin atrophy
30
Q
Therapy of Dermatophyte skin infections
-Widespread skin involvement
A
- Terbinafine 250 mg daily x2-3 wks
2. A/E — Abnormal taste, GI upset, increase LFTs
31
Q
Tinea Capitis
A
- You lose hair with Tinea capitis, NOT with Eczema
- Topical agents are INEFFECTIVE
- For Children — Oral Griseofulvin 8 weeks
- For Adults — Terbinafine 2-8 weeks
- Selenium sulfide or Ketoconazole shampoo daily — Reduces infectivity
32
Q
Therapy of Dermatophyte Nail Infection?
A
- TERBINAFINE 250 mg daily for 6 wks (fingers) or 12 wks (toes) DRUG OF CHOICE
- VICKS VAPOR RUB helps w/ nail fungus ** Once daily for 1 year until nail grows out
33
Q
Tinea Versicolor
A
- “Spaghetti and meatball” appearance or “grapes & vines”
- Caused by malassezia fungi
- Treatment — Ketoconazole 1% or 2% shampoo (as a body wash and leave on for 5 minutes
- RARELY oral antifungals
34
Q
Scabies Infestation
Info
A
- Infestation of the skin d/t to the ectoparasita sarcoplasma scabei
- Primary lesion: Linear burrow, excoriated pápulas
- Diagnostic Keys — Scabies prep, others itching, head and neck spared
—Involves HANDS and WAISTLINE
-Scabies is larger in children
Types of scabies — Classic & Crusted
35
Q
Scabies
-Diagnostics
A
- Mineral oil prep — Scrape any place where pt is itching and put it on the prep
36
Q
Classic Scabies s/Sx’s
A
- 1st infestation to time of itching can be 2 to 6 weeks
2. Treat entire household when one person is infected
37
Q
Classic Scabies Therapy
A
- Permethrin 5% cream (Elimite) — Applied to all skin sparing face for 8-12 hours as a single application — May repeat in 1 week
OR - Oral Ivermectin 200 mcg/kg/dose x1 dose — repeat in 2 weeks Must repeat to kill eggs
-All personal contacts should be treated
-Topical steroids - Class 3-4
-Oral antihistamines — It may take 3-4 wks for itching to completely resolve — Pt’s need to shed dead mites, feces and eggs so itching will stop
38
Q
Crusted Scabies
A
- SEVERE form of scabies with 1000’s of mites
- Markedly thickened scaly crusted skin
- Color is creamy grey to yellow
- Erythema to erythroderma present in background
- RISK factors
- Immunocompromised, elderly, disabled, debilitated - May have little to no itching — delayed and difficult diagnosis — HIGHLY Infectious
Appearance of DRY CRACKED SAND ***TEST
39
Q
Treatment of Crusted Scabies
A
- Combined treatment ivermectin + permethrin cream
2. Very complicated treatment
40
Q
Pyoderma
A
- Bacterial infections of the skin, usually d/t staph/strep
41
Q
Pyoderma
-Impetigo?
A
- Honey-colored crusted “erosions” lesions
2. Primary lesion is a pustule — appearance of herpes simplex 2 but less clustered
42
Q
Pyoderma
-Folliculitis
A
- Follicular pustules or papule’s
43
Q
Pyoderma
-Furuncle
A
- Boils.. Multiple furuncles are called furunculosis
44
Q
Pyoderma
-Therapy?
A
- Obtain a swab culture for bacterial ID and antimicrobial sensitivities
- Empiric Tx before culture results
- Clindamycin 300 mg TID -QID x 7-14 days **
- Trimethoprim-sulfa DS bid x 7-14 days - Topical mupirocin (Bactroban) ointment has excellent Staph/Strep action
