Nail, inflamm nodules, pruritic disorders Flashcards
Pitting
pitting
Pitting
is associated with
psoriasis, eczema, and alopecia areata
transverse ridging
transverse ridging
transverse ridging
is associated with
eczema, paronychia, psoriasis
Beau Line
Beau Line
general and associations
▸ transverse depression affecting all nails, due to
acute systemic illness stopping nail growth
▸ Associated with high fever, measles, mumps,
pneumonia, strep infections, heart attack,
COVID-19, injury, chronic conditions, eczema,
psoriasis, zinc deficiency, and more
ONYCHORRHEXIS
ONYCHORRHEXIS
ONYCHORRHEXIS
general and association
▸ longitudinal bridging of the nail plate
▸ Associated with increased age, lichen planus, psoriasis, onychomycosis, Darier disease, or a
habit of picking
LONGITUDINAL GROOVE
LONGITUDINAL GROOVE
association
associated with digital myxoid cyst or wart overlying the proximal nail matrix
MEDIAN CANALIFORM NAIL DYSTROPHY
MEDIAN CANALIFORM NAIL DYSTROPHY
general
▸ presents as a feather, Sentra, longitudinal ridge with a for tree pattern usually involving both
thumbnails
▸ Associated with repetitive trauma
ONYCHOGRYPHOSIS
ONYCHOGRYPHOSIS
general
▸ A thick, hard, curved nail plate in the shape of a Rams horn
▸ Associated with increase age, psoriasis, or trauma
LEUKONYCHIA
LEUKONYCHIA
general
▸ White nails
▸ May be familial, associated with hypoalbuminemia or chronic renal failure
▸ Transverse – thought to be due to manicuring
KOILONYCHIA
KOILONYCHIA
general
▸ thin, spoon shaped nail
▸ Can occur in normal children and adults
▸ Associated with iron deficiency anemia,
diabetes, protein deficiency, connective tissue
disease, exposure to solvents
ONYCHOMYCOSIS
ONYCHOMYCOSIS
general
▸ Fungal infection of the nails
▸ Dermatophyte - Trichphyton rubrum, Tinea interdigitale
▸ Yeast - Candida albicans
▸ Increasingly common with increased age.
▸ Often results from untreated tinea pedis or tinea manuum
ONYCHOMYCOSIS
clin man
▸ Subungual hyperkeratosis, onycholysis, scaly or flaky patches under the nail, pits, brittle nails
ONYCHOMYCOSIS
Dx and Tx
▸ Diagnosis: KOH exam, Periodic Acid-Schiff test - most sensitive
▸ Practice: PAS nail clipping
▸ Boards: oral terbinafine because they are the most effective
▸ Practice: Topical antifungal agents like ciclopirox lacquer, efinaconazole
topical solution.
▸ Over The Counter: Vicks
PARONYCHIA
PARONYCHIA
general, etiology
General:
▸ Inflammation of the skin around a finger or toenail
▸ Acute (<6 weeks) or Chronic
▸ Etiology:
▸ Skin flora - Staphylococcus aureus, Group A streptococcus
▸ Oral flora if nail biting
▸ Chronic - Candida
▸ Pathophysiology
▸ Commonly occurs after penetrating skin trauma
PARONYCHIA
clin man
▸ Rapid onset of painful erythema and swelling to the proximal and/or lateral nail folds, usually within 2
to 5 days of localized trauma.
▸ May have purulent discharge or superficial abscess
PARONYCHIA
Tx
mild, moderate, MRSA, Abcess, nail biter
▸ Mild: warm water or antiseptic soaks with chlorhexidine, povidone-iodine + topical antibacterial agent
▸ Moderate: oral antibiotic- cephalexin, dicloxacillin, augmentin if nail biting
▸ MRSA: trimethoprim sulfamethoxazole DS, clindamycin, doxycycline
▸ Abscess: incision and drainage, followed by warm soaks +/- antibiotics if cellulitis present
felon
felon
general
Closed space infection/ abscess of the fingertip pulp space
▸ Can be a progression of paronychia
▸ Most commonly occurs after penetrating skin trauma
Felon
Clin man and Tx
With and without fluctuate
Clinical Manifestations:
▸ Severe throbbing pain, erythema, swelling, and fluctuance to the pad of the fingertip
▸ Treatment:
▸ Early without fluctuance - elevation, warm water/saline soaks, oral antibiotics (cephalexin)
▸ Fluctuant - incision and drainage
Lipoma
general
▸ Benign, subcutaneous tumors composed of mature adipocytes enclosed by thin, fiber outs capsule.
▸ Most common benign soft tissue neoplasm
Lipoma
clin man
▸ Soft, painless, subcutaneous nodules that are easily mobile
▸ Most commonly found on the trunk, neck, upper extremities
Lipoma
Dx and Tx
▸ Diagnosis: clinical
▸ Indications for biopsy: pain, rapidly enlarging, firm, restricts movement
▸ Treatment: observation
▸ Can be excised for cosmetic purposes or if symptomatic
EPIDERMAL INCLUSION CYST
EPIDERMAL INCLUSION CYST
General
Benign, encapsulated, subepidermal nodules filled with fibrous tissue and keratinous material
▸ Most common in 30s and 40s, males: females affected 2:1
▸ Pathophysiology: Results from plugging of the follicular orifices
EPIDERMAL INCLUSION CYST
Clinical Manifestations
▸ Asymptomatic, skin colored dermal, freely mobile, compressible cyst or natural, often with a clinically visible central punctum
▸ Ruptured, infected cyst become fluctuate, painful, larger, erythematous +/- foul-smelling discharge
EPIDERMAL INCLUSION CYST
Dx and Tx
clinical
Treatment
▸ Not infected: no treatment necessary. ILK. Can be excised for cosmetic purposes or recurrently symptomatic
▸ Infected: incision and drainage
FURUNCLE & CARBUNCLE
definition
Furuncle: deep infection of the hair follicle
Carbuncle: coalescence or interconnection of several furuncles into a
single mass with purulent drainage from multiple follicles
Etiology: Staphylococcus aureus, Streptococcus
FURUNCLE & CARBUNCLE
FURUNCLE & CARBUNCLE
Tx
▸ Mainstay: incision and drainage
▸ Antibiotics: trimethoprim-sulfamethoxazole, doxycycline, clindamycin
HIDRADENITIS SUPPURATIVA
general
Painful, chronic, inflammatory supportive condition involving the skin and subcutaneous tissue
HIDRADENITIS SUPPURATIVA
risk factors
Obesity, females, smoking, history of acne, family history
HIDRADENITIS SUPPURATIVA
clin man
Recurrent, painful, deep-seated inflammatory nodules and abscesses, draining tracks, and fibrotic
hypertrophic scars that most commonly affects intertriginous skin
HIDRADENITIS SUPPURATIVA
HIDRADENITIS SUPPURATIVA
Dx and Tx
Lesions/ sinus tracts/refractory
Dx: Clinical
Treatment:
▸ Lifestyle Modifications: avoid high glycemic foods, smoking cessation, local skin care, eliminate
irritants, weight loss
▸ Inflammatory lesions only: topical clindamycin+/-Antiangiogenic drugs, metformin
▸ Inflammatory lesions with sinus tracks or scarring: oral tetracycline (doxycycline) or Clindamycin +
rifampin
▸ Refractory: Surgical excision
scabies
scabies
general
A highly contagious skin infection due to the mite Sarcoptes scabiei
▸ Pathophysiology:
▸ Female mites burrow into the skin to lay eggs, feed, and defecate - these particles are what precipitate
a hypersensitivity reaction
scabies
clin man
Hallmark
Multiple, small, evidence papules with excoriations, linear burrows (hallmark)
▸ Red, itchy happy wheels or nodules on the scrotum, genitalia, or body folds are pathognomonic
▸ Intense pruritus, especially at night
scabies
Dx
clinical, mineral oil prep
scabies
Tx
Drug of choice: topical permethrin x 2 applications 1 week apart (for pregnant)
▸ Oral available for non-pregnant adults
▸ Lindane: cheaper option but cannot be used after bathing - increased risk of seizure. Contraindicated in
pregnancy, children<2 years old
Scabies
general measures
Treat all close contacts
All clothing, bedding, etc. should be placed in plastic bags for at least 72 hours, then washed and dried
using high heat
PEDICULOSIS
general
Person to person transmission through either direct contact, fomite exposure, or sexual transmission
▸ Strongly related to poor hygiene practices.
▸ Can affect any body part and serve as a vector for disease
▸ Head lice: girls>boys, most commonly affecting children ages 3–12 years old
▸ Body lice: typically live in the seams of clothing or bedding and move onto the skin to feed
PEDICULOSIS
clin man
Chief complaint: pruritus
▸ May visualize lice or nits - white, oval shaped egg capsules at the base of hair shafts
PEDICULOSIS
Tx
Head lice: drug of choice: topical permethrin x 2 applications 1 week apart, fine-tooth combing to remove nits
▸ Alternative: Malathion, lindane (remember this is neurotoxic)
▸ Body lice: hygiene practices are first line, topical permethrin 5% cream
▸ Pubic lice: topical permethrin 1% cream or pyrethrins, typically repeat in 10 days after initial treatment
▸ Treat all sexual contacts
Pediculosis
general measures
hygiene improvement
▸ contact items should be laundered in hot water with detergent and dried and hot dryer for 20 minutes, toys
that cannot be washed or place an airtight plastic bags for two weeks - avoid sharing contact items
LICHEN PLANUS
general
Acute or chronic inflammatory mucocutaneous papulosquamous dermatitis
▸ Cell mediated immune response
▸ Most commonly seen in middle-aged adults
▸ Increased incidence with hepatitis C infection
▸ Can be medication induced, associated with graft vs. host, or lymphoma
Lichen Planus
Lichen Planus
Lichen Planus
clin man
6, borders, phenomenon
6P’s: purple, polygonal, planar, pruritic, papules or plaques with fine scaling
▸ Borders May have wickham’s striae - fine, gray white lines on the skin and/or oral mucosa
▸ Koebner’s phenomenon - trauma induced lesions
lichen planus
Dx and Tx
Diagnosis: clinical
Treatment:
▸ High or super-high potency topical corticosteroids, Oral antihistamines
▸ Intralesional corticosteroids
▸ Generalized or refractory: oral glucocorticoids
▸ Most patients have spontaneous resolution in 6-12 month
LICHEN SIMPLEX CHRONICUS
general
Skin thickening secondary to repetitive rubbing and scratching
LICHEN SIMPLEX CHRONICUS
clin man
Scaly, well demarcated, rough, hyperkeratotic plaques with exaggerated skin lines
LICHEN SIMPLEX CHRONICUS
Tx
no Dx mentioned..
Avoid scratching the lesions
▸ High potency topical corticosteroids, antihistamines
▸ Intralesional kenalog commonly used in practice
LICHEN SIMPLEX CHRONICUS
NEURODERMATITIS
Neurodermatitis
general
Diffuse excoriations secondary to chronic itch, repetitive rubbing, scratching, and/or picking at skin
▸ Can see lichenified skin as a secondary finding
▸ Associated with mood disorders
neurodermatitis
Dx and Tx
Diagnosis: clinical
▸ Treatment: antihistamines, topical corticosteroids, wound care
▸ Avoidance of scratching
▸ Management of mood disorder
