Module 5 Dermatology Flashcards
Patho of Acne Rosacea
- Cause is unknown
* Possibly linked to immune-mediated Inflammation
Complications of Acne Rosacea
•Ocular Rosacea
Risk factors for Acne Rosacea
- Age
- Fair skinned
- Female
Subjective data for Acne Rosacea
- Facial flushing
- “I always look red”
- “I have bumps and fluid filled bumps on my face”
Objective Data for Acne Rosacea
- Facial erythema
- inflammatory papules and pustules
- watery and irritated eyes
- No Comedones noted
Differentials for Acne Rosacea
- Adult acne vulgaris
- Photodermatitis
- Seborrheic dermatitis
- Contact dermatitis
Testing for Acne Rosacea
None
Management of Acne Rosacea
•Topical or oral antibiotics –Metronidazole 1% or 0.75% gel or lotion BID for 3-4 months –Azelaic acid 15% gel or cream BID fo2 months –Plexion Cleanser –Tetracycline 250-500mg BID –Doxycycline 100-200mg/day –Minocycline 50-100mg/day •Nonpharmacologic –Skin care
Patient education for Acne Rosacea
- Long-haul
- Patience and understanding of the treatment
- Routine follow up necessary
Referral for Acne Rosacea
Dermatologist. Ophthalmologist, Mental Health Provider
What is Acne Vulgaris
a condition of the pilosebaceous follicles
Complications of acne vulgaris
•Keloids •Medication adverse effects –Renal impairment –DVTs –Hyperkalemia
Risk factors for Acne Vulgaris
- Family history of acne
- Allergies
- Certain medications can cause acne
- Hormonal factors
- Seasonal factors like less sunlight
- Facial products
Subjective/Objective data for Acne Vulgaris
- Variety of lesions including comedones, papules, pustules, and nodules on the face, chest, back, and shoulders
- “Pimples”
- Red bumps
- Black bumps
- White bumps
- Pain
- Scarring
Differential Diagnoses for Acne Vulgaris
- Closed comedones acne, milia and suspicious hyperplasia
- Open, comedonal acne, dilated pore of Weiner, and Favre-Racouchot syndrome
- Inflammatory acne, rosacea, and perioral dermatitis
- Fungal, flat warts, molluscum contagiosum, folliculitis
- Tuberous sclerosis
- Facial angiofibroma
- Adnexal tumors
Testing for Acne Vulgris
May be done to find cause
- Total testosterone
- DHEAS
- Androstenedione
- Luteinizing hormones
- Follicle stimulating hormone
- Lipid profile
- Glucose tolerance testing
Management of Acne Vulgaris
1st:cleansers->topicals->t.antib->po antib
•Nonpharmacologic
–Mild cleansers
•Pharmacologic
1st–Retin-A, Differin, Tazorac, azelaic acid, benzoyl peroxide, salicylic acid
–Topical antibiotics (not recommended in mono-therapy)
–Oral antibiotics
–Hormone therapy: combined OC-prog only makes it worse
–Retinoid therapy
Patient education for Acne Vulgaris
- Adherence is key
- Treatment is a longhaul
- Follow-up visits are necessary
Referral for Acne Vulgaris
Dermatologist, Mental Health Professional
What is Cellulitis?
Bacterial infection most often caused by
Streptococcus or Group A B-hemolytic streptococci
Complications of Cellulitis
- Severe systemic infection
- Osteomyelitis
- Periorbital cellulitis
- Death
Risk factors for Cellulitis
- Immunocompromised at greater risk
* Obesity
Subjective data for Cellulitis
- Redness
- Pain
- Drainage
- Swelling
- Feverish
- Warmth at the site
- Chills
- Malaise
Objective data of Cellulitis
• Unilateral (most often a limb) • Inflamed • Red • Hot • Swollen • May or may not have open sore visible • Fever • Tender to touch
Differential diagnosis of Cellulitis
- Deep vein thrombosis
- Osteomyelitis
- Thrombophlebitis
- Neoplastic disease
Testing for Cellulitis
- CBC with differential
- Creatinine
- Bicarbonate
- Creatinine phosphokinase
- Purulent focus culture
- Gram stain
- Radiographs or ultrasound
Management of Cellulitis
- Systemic antibiotics (PCN, Amox. Augmentin preferred x 5d unless allergic)
- Rest, elevate, compression, educate
- Refer if I&D needed or other (p.278)
Patient education for Cellulitis
- Complete entire course of antibiotics
- Notify the office if symptoms are worsening
- Keep area dry clean and elevated
- Educate on the prevention of skin infections
Referral for Cellulitis
• Immediate referral for severe complications
What is Eczematous Dermatitis
pruritic inflammatory skin disorder which has exacerbations and remissions
Subjective data with Eczema
- Dry patches on skin
- Crusting and oozing from skin sites
- Severe itching
- “An itch that rashes”
- Thickened area on skins
- Symptoms on upper extremities
Objective data of Eczema
- Pattern of rash / itch of inner folds
- Linear excoriations
- Boarders are undefined
- Rash in folds, wrists, dorsa of feet, face, and neck
- Fissures on palms of hands
- Well-demarcated area of erythema, scaling, or crusting at the site of exposure
Differentials for Dermatitis
- Mycosis fungoides
- Immunodeficiency (especially with severe itching and with recurrent infection)
- Scabies
Dermatitis Testing
- Primarily none
* Could do KOH, skin biopsy, skin patch testing (contact dermatitis)
Management of Eczema
Management: •Nonpharmacologic –Elimination diet –Phototherapy –Avoid: rubbing alcohol , Scratching, Goal is management of pruritis, Triggers
•Pharmacologic
–Antihistamines
–Emollient
–Topical corticosteroids
• Hydrocortisone 1% apply to affected area twice daily x2 weeks
•Triamcinolone for acute persistent flare ups
Treatment of Allergic Dermatitis
Steroids for allergy & education to avoid allergen (ex. poison ivy)
Treatment of Irritant Dermatitis
Avoid the irritant, protect the skin with gloves, petroleum or other hypoallergenic barrier, avoid detergents and use alcohol- based cleansers that do not remove natural barriers and preserve skin integrity
Complications of Oral Herpes
- Complications are rare but can occur in those who are already immunocompromised
- Possible complications include aseptic meningitis, urinary retention, cutaneous dissemination, bacterial superinfection, arrhythmia multiform, and spontaneous abortion
Risk for Oral Herpes
Female
Black
- Contact with a person who has an active lesions or sections
- Contact with a person how has the know virus
- Open cuts and sores
- Immunocompromised
Subjective data of Oral Herpes
• Primary, latent and recurrent – Prodrome of burning – Blister on the mouth – pain at site
Objective data of Oral Herpes
• Primary, Latent, Recurrent
– Single or multiple vesicles
– Tender to touch
Differentials of Oral Herpes
- Erythema multiforme
- Impetigo
- Varicella
- Herpes Zoster
Diagnostics of Oral Herpes
• Thorough history and physical • Lab conformation for new cases – Cutaneous herpes simplex viral culture • Serologic testing – Does not differentiate between type one and type two so used with caution
Treatment of Oral Herpes
• Initial episode – Acyclovir 400mg PO 3 times daily for 7-10 days – Valacyclovir 1gm PO daily for 7-10 days – Famciclovir • Recurrent episode – Acyclovir 400mg PO BID x5 days – Valacyclovir 500 PO BID for 3 days – Famciclovir • Suppression – Acyclovir 400mg PO BID – Valacyclovir 500mg or 1gm PO daily – Famciclovir
Patient education for Oral Herpes
- Start treatment at onset of prodromes for recurrent
- Avoid contact when you have an active lesion
- Understand that you can transmit even if you have no lesion or when using suppressive therapy
- Explain the risks of neonatal transmission during pregnancy to both female and male
- Lip balm with sunscreen when exposed to UV light to avoid
Referral for Oral Herpes
• Obstitrican/MFM if patient is pregnant
Patho of Herpes Zoster
- Virus that lies dormant after initial infection
- Virus replicates
- Penetrates the epidermis
- Replication is multifactorial
- Can spread by contact and air and live for hours to two days
Complications of Herpes Zoster
- Blindness
- Motor paralysis
- Facial palsy
- Pneumonia
- Hepatitis
Risk factors for Herpes Zoster
- Age
- Immunosuppressed
- Previous Varicella infection
- Pregnancy
- Very young
- Unvaccinated
Subjective data of Herpes Zoster
- Painful itching, then eruption of blisters
- Burning, stabbing, aching sensation
- Feverish
- One-sided rash on the trunk of body
Objective data of Herpes Zoster
- Unilateral rash
- Low-grade fever
- Erythematous and maculopapular clusters of clear vesicles
- Tender to touch
Differentials for Herpes Zoster
- Allergic dermatitis
- Dermatitis herpetiformis
- Contact Dermatitis
- Coxsackievirus
Testing for Herpes Zoster
- PCR analysis
- Tzanck preparation
- DFA test
- Viral culture
- Alkaline phosphatase, bilirubin, C-reactive protein
- WBC
Treatment of Herpes Zoster
• Antiviral within 72 hours of onset
– Valcyclovir 1,000 mg orally three times daily for seven days
– Famciclovir 500 mg orally three times daily for seven days
– Acyclovir 800 mg orally five times daily for 7 to 10 days
• Pain management
– NSAIDS
– Gabapentin
– Pregabalin
– Amitriptyline
– Acetaminophen
Patient education for Herpes Zoster
- Notify early of symptoms
- Use moist dressings, pain management, and bedrest to relieve discomfort
- Susceptible individuals while you are infectious
Referral for Herpes Zoster
If on face
What is Intertrigo
Bacterial or fungal disorder that occure in persistent skin to skin contact, friction, moisture, warmth and inadequate ventilaition
Complications of Intertrigo
- Unusual to have complications with topicals
- With systemic antifungal’s complications would be hepatotoxicity
- Note that oral ketoconazole is no longer approved as a treatment due to this reason
Subjective data for Intertrigo
• Moist glistening plaques, pustules • Odor • Discharging • Pain, fever
Objective data for Intertrigo
• Red patches • Moist glistening plaques, pustules • Odorous • Discharging • Tender to touch • Warm to touch
Diagnostics of Intertrigo
- KOH microscopy
* Liver function test
Treatment of Intertrigo
• Removal of the infecting organism • Exudate the lesions treated with drying agents – Aluminum sulfate soaks • Topical anti-fungal • Oral anti-fungal
Patient education of Intertrigo
- Caution patients on over-the-counter steroid creams
- Absorbent powders help reduce moisture and prevent reinfection
- Take the antifungals for the duration as directed to prevent recurrence
Patho of Skin Cancer
- Pathogenesis is multifactorial
- Heavy sun exposure: Causes immunosuppressio UVR is a carcinogen and promotes tumor growth
- Normal aging process: Thinner, frail skin, susceptible to insult
Complications of Skin Cancer
Disfigurement, death
Risk factors for Skin Cancer
- Heavy sun exposure with no UV protection -Aging
- Family hx
- Prior hx of other cancer
Subjective data for Skin Cancer
- Open sores that do not heal, burn, itch, or crust over -Change in the size or shape of a “skin spot,” lesions, or mole
- Change in color
- A pearly looking skin spot
Testing for Skin Cancer
Skin biopsy:Shave, Punch or Excisional
Patient education for Skin Cancer
- Yearly skin exams
- Limit sun exposure
- Use protective clothing
- Use sunscreen (SPF >15)
- Seek prompt care within 4-6 weeks for nonhealing wound
What is Melanoma (Skin Cancer). Referral?
Malignant melanoma is the most fatal, one person dies per hour
Derm or surgeon
Most common form of Cancer
Basal Cell Carcinoma
Subjective of Basal Cell Carcinoma
Pearly / Shiny, visible vessels – Normal skin color or slightly pigmented
Treatment of Basal Cell Carcinoma
Electrodessication and curettage
Objective of Squamous Cell Carcinoma
-Scaly / Scabby, bleeds easily, sore that does not heal, “volcano shape” -Bleeds easily
Treatment of Squamous Cell Carcinoma
Total excision
Objective of Actinic Keratosis
Key: precursor for squamous cells carcinoma
A rough, scaly patch on the skin caused by years of sun exposure
Patho of Lice
- Wingless insects and survive by feeding on human blood-adhere to the shaft of the hair and fibers of clothing
- Belong to the Anoplura family
- Feed several times per day
- They lay 5 to 10 eggs per day
- Their louse pierces the skin and injects its saliva into human blood
Complications of Lice
- Sleep disturbances
* Impetigo from scratching
Risk factors for Lice
- Can affect anyone
- More common in school age
- Sharing combs/brushes
- Sharing hats
- Sharing bed-linens
Subjective data for Lice
- Itching
* “Something crawling”
Objective data for Lice
- Nits and louse on clothing or body of the individual
- Lice on the back of the head, neck, and behind the ears
- Linear excoriations on the body
- Hyper pigmentation with linchenification
Differentials for Lice
- Seborrheic dermatitis •Scabies
- Eczema
- Insect bites
- Psoriasis
Testing for Lice
Wood lamp if indicated
Treatment of Lice
-First line:
•Nix
•Permethrin 5%- Apply to dry hair and rinse after 10 minutes
•Ivermectin lotion 0.5%
Patient Education for Lice
- Use a Nit comb
- Comb through 2 times
- Hygiene practices
- Discard infested clothing and linen
Patho of Scabies
- Mite-Causes poorly defined pruritic eruption
- Female mite is responsible for the infestations
- Burrows into the stratum corneum, laying two to three eggs per day
- The eggs reach maturity in 28 to 30 days and then start a new cycle
Risk factors for Scabies
- Highly contagious •Common in overcrowded and low socioeconomic environments
- Prolonged skin-to-skin contact like sexual activity
Subjective data for Scabies
•Intense itching at night
Objective data for Scabies
- Intraepidermal burrows
- Small Papules
- Burrows located on the wrist, genitalia, breast, buttock, webs of fingers
Differentials for Scabies
- Seborrhic dermatitis
- Insect bites
- Impetigo
Testing for scabies
Scraping of a burrow and microscopic identification of mites, eggs, or feces
Treatment of Scabies
First line:
•Permethrin 5% cream
•Repeat in one week
Patient education for Scabies
- Identify and treat household contacts
- Wash all clothing and bedding in hot water
- Remind patients that symptoms can last for two weeks after treatment
Patho of Pruritis
-Itchy skin that is uncomfortable and you have an irritating sensation that makes you want to scratch.
•Itchy skin is often caused by dry skin. It’s common in older adults, as skin tends to become drier with age
•Multi-factorial
Complications of Pruritis
•Chronic pruritis •Interruption of daily activates •Decreased sleep •Onset of anxiety or depression •Skin injury •Scarring
Risk factors for pruritis
- Age
- Other skin conditions
- Internal disease
- Nerve disorders
- Psychiatric conditions
- Irritation and allergic reactions
Subjective data for Pruritis
- Redness
- Scratch marks
- Dry, cracked skin
- Constant sensation to scratch
Objective data for Pruritis
- Redness
- Scratch marks
- Bumps, spots or blisters
- Dry, cracked skin
- Leathery or scaly patches
- Excoriation
Differentials for Pruritis
- Parasitic infection
- Liver disease
- Fungal infection
- Viral allergy
- Dermatitis
Testing for Pruritis
CBC, TSH, LFT, Chest X-ray
Treatment of Pruritis
•Nonpharmacologic –Remove causative agent if possible –Use creams, lotions, or gels that are soothing –Avoid stress –OTC allergy medication –Cool compresses –Avoid scratching •Pharmacologic –Corticosteroid creams and ointments •Triamcinolone 0.25% to 0.1% apply to wet skin –Other creams and ointments –Oral medications –Light therapy (phototherapy)
Patient teaching for Pruritis
- Mild cleanser
- Increase hydration
- Adherence to daily Moisturizing
Referral for Pruritis
•Dermatologist, Mental Health Provider
Patho of Psoriasis
- Chronic, inflammatory, autoimmune disorder
- Characterized by dermal hyperproliferation
- Genetic association
Complications of Psoriasis
• Infection • Guttate psoriasis • Erythrodermic psoriasis • Pustular psoriasis
Risk factors for Psoriasis
Family hx
Monozygote twin
Subjective data for Psoriasis
• Scale like patches • Areas bleeding easily • Patches on elbows, knees, scalp, genitals, intergluteal folds • “Raindrop” plaques
Objective data for Psoriasis
• Well circumscribed erythematous maculopapular lesions covered in silvery white scale (Image, p. 320) • Pitting of nails [p.318] • Well demarcated lesions • Patches on elbows, knees, scalp, genitals, intergluteal folds
Differential for Psoriasis
- Seborrhea
- Atopic dermatitis
- Pityriasis rosea
- Gout
Testing for Psoriasis
• None, diagnosis is based
on presentation
• *You could do a biopsy
Treatment of Psoriasis
- Reduce epidermal proliferation and decrease inflammation
- Topical corticosteroids
- Ointments are preferred
- Occlusion with clear plastic wrap can increase efficacy of therapy
Patient education for Psoriasis
- Educate about chronic nature and need for long term control to prevent sequelae
- Adherence to prescribed medication
- Avoid injury to skin
- Avoid certain medications
Referral of Psoriasis
- Dermatologist if unresolved
* Rheumatologist
Patho of Tinea Pedis (Athletes foot)
Superficial infection-Usually dermatophytes or yeast
• There are typically three major sources that are responsible for the transmission of dermatophytes
• Human to human
• Animal to human
• Soil to human or soil to animal
• Three weeks before symptoms appear
Risk factors for Tinea Pedia (athletes foot)
- Post-puberty
- Age
- Gender
- Immunity status
Subjective data for Tinea Pedis
- Itching
- Foot odor
- Skin appears to be tearing
- Skin is red
Objective data for Tinea Pedis
- Skin is erythematous
- Scaling eruption between the toes and the souls, and sides of the feet
- Ulcerations and inflammation
Differential for Tinea Pedia
- Atopic Dermatitis
- Contact Dermatitis
- Folliculitis
- Psoriasis
Patho of Tinea Ungunium/Onchomycosis
Fungus in nails, fingers or toes
Subjective and Objective data for Tinea Unguium/Onchomycosis
- Yellowish-brown discoloration
- Greenish tinge on nail
- thicker nail the normal
Patho of Tinea Corporis
Fungus in skin-worse after sun exposure
Subjective data of Tinea Corporis
- Red patches
- Worse after sun exposure
- Mildly itchy
- Looks like scales
Objective data for Tinea Corporis
- Appears as tissue thin coating of fungus on skin
- Scaly
- Regions often have slightly elevated borders
Patho of Urticaria
- Red, itchy welts that results from a skin reaction
- Symptom not disease
- Immediate hypersensitivity to an allergen or antigen that appears as itchy lesions on the skin
- Vascular reaction in upper dermis of skin – Type 1 IgE mediated
- Allergen
- Nervous reaction
Risk factors for Urticaria
None
Subjective data for Urticaria
- Acute onset of raised red areas
- Pruritus (itch) before lesions appear
- Swelling
- Triggered by heat, stress, exercise
- Cleared up within minutes
Objective data for Urticaria
•Confluent circular erythematous rash
Differentials for Urticaria
•Dermatitis
Testing for Urticaria
None
Treatment of Urticaria
•First-line H1 blocker –Loratadine (Claritin) –Fexofenadine (Allegra) –Cetirizine (Zyrtec) –Desloratadine (Clarinex) •H2 blockers –Cimetidine (Tagamet) –Famotidine (Pepcid) •Anti-inflammatory meds
Patient education for Urticaria
•Benign symptom
Patho of Verruca (non-genital warts)
Caused by HPV
• Virus contacts broken skin and enters the epidermal epithelial cells and replicates.
Complications of Verruca
- Pain
- Decreased activity
- Altered gait or deformity (plantar warts)
- Scarring
- Damage of nails with treatment
- Nerve damage is rare but can occur if treatment is vigorous in areas of superficial nerves
Risk factors for Verruca
- Decreased immunity
- Chronic wet hands/feet
- Family
- Showers
Subjective data for Verruca
- May be asymptomatic
- May describe painful area
- “I have a wart/warts”
Objective data for Verruca
- Projections (filiform)
- Round domes (common)
- Flat (plantar)
- Single of groups
- May form plaques (mosaic warts)
Differentials for Verruca
- Carcinoma/Melanoma
- Actinic Keratosis
- Secondary syphilis
- Molluscum contagiosum
- Foreign body
- Face - perioral dermatitis
- Hands/feet - periungual warts, actinic Keratosis
- Psoriasis
- Lichen planus
Testing for Verruca
Inspection
Treatment for Verruca
• Topical Application
– Salicylic acid & duct tape
– Imiquimod 3.75% or 5% cream (Aldara)
– Podofilox .5% twice daily for 3 days, off for 4 days, repeat
– Sinecatechins 15% apply three times daily for up to 16 weeks.
– TCA or BCA must be applied by the health care provider
• Cryotherapy
• Laser Ablation
• Surgical
**There is no Cure-Rule out melanoma first
Patient education for Verruca
- Requires commitment
- May be painful
- Soak and debride
- Warts are benign
- May take years to completely resolve
- Side effects of the medication
Referral for Verruca
- Dermatology - large warts or cosmetically sensitive areas
* Podiatry - plantar warts
Which is the most occlusive vehicle?
Ointments
Which is the least occlusive vehicle?
Solution
Which vehicles should be used for dry conditions?
Ointments, cream, lotion
Which vehicle should be used for wet conditions?
Solution, gel
Order the vehicles from least potentiating to most potentiating?
solution, gel, lotion, cream, ointment
