Name the rash Flashcards
(264 cards)
1
Q
abrupt onset erythematous scaly photosensitive rash (not malar) or discoid that seems to have slightly scaly, papule or annular patterns with crusted margins
A
subacute cutaneous lupus erythematous
can present witn annular with central clearing or papulosquamous with patchy erythematous plaques and papules and both forms can be seen in pts.
SCLE- has a fine scale that can leave post inflammatory hypo or hyperpigmentation. Seen with anti Ro/SSA antibodies, with prevalence of 75%.
about 50% of SCLE also have SLE.
NOT The same as a SLE rash.
SLE rash will present as acute cutaneous lupus erythematosus which will have malar (butterfly) rash. and also will have rash on hands and feet.
2
Q
gradual onset of symptoms, malar or discoid rash
A
SLE
3
Q
subacute cutaneous lupus erythematosus distribution of rash is / can be:
A
photosensitive rash (shoulders, forearms, neck, upper torso)
4
Q
no cytopenia, positive anti-Ro/SSa antibodies and normal complement levels and immune complexes
A
subacute cutaneous lupus erythematosus
5
Q
see anemia, leukopenia, positive dsDNA and anti Sm and ANA, low complement levels and increased immune complexes
A
SLE - malar rash- see erythema and scaling over the cheeks and bridge of nose with sparing of the nasolabial folds.
6
Q
Is subacute cutaneous lupus erythematosus the same thing as SLE?
A
no, they are two separate entity but SCLE is associated with SLE. 50% of SCLE will develop SLE 10% of SLE will also have SCLE
7
Q
Do patients with subacute cutaneous lupus erythematosus develop serositis or neurological dx?
A
No. But like SLE can have renal involvement
8
Q
What causes subacute cutaneous lupus erythematosus?
A
idiopathic drug (BP meds, lipid lower agents, PPI, antihistamines)
9
Q
Lab findings with subacute cutaneous lupus erythematosus?
A
anti Ro /SSa abs, normal complement and no cytopenias
10
Q
Treatment of subacute cutaneous lupus erythematosus?
A
sun protection, topical steroids, cessation of offending drugs
11
Q
pruritic ovoid lesions 1-10 cm in size. Can initially be erythematous exudative or crusted patches that eventually evolves into scaley lesions with central clearnings on legs or upper extremities
A
nummular ezema
12
Q
symmetrical plaques on scalp, elbows, knees, and back which are erythematous and sharply defined borders
A
plaque psoriasis -
Also sudden worsening of plaque psoriasis may be a result of a new HIV infection.
13
Q
pruritic erythematous plaque with fine loose yellow and greasy scales
A
seborrheic dermatosis has sebaceous glands wand seen on scalp chest or intertriginous areas
14
Q
pruritic round erythematous scaly patches or plaques with progressive borders and a clearing center
A
tinea corporis
15
Q
what is this rash?
A
Poison ivy - streak lesions see contact dermatitis
16
Q
What is this rash?
A
Nummular eczema - presents as single or multiple round papules and plaques that are highly pruritic. Seen on extremities and serous drainage can occur.
17
Q
What is this rash?
A
herpes zoster rash
18
Q
What is this skin lesion?
A
acute tinea pedis- can have pruritic bulla or vesicules on feet.
Can see a dermatophyoid reaction
Can be seen on soles, mid foot, palms and interdigital areas.
19
Q
What is this skin lesion?
A
Plaque psoriasis-
Plaques can be symmetrically on extensor surfaces and rarely seen on face.
seen as erythematous sharply demarkcated lesions covered in a silvery scale.
Treat mild psoriasis <5% BSA with topical corticosteroids and vitamin D analogs.
20
Q
What is this skin lesion?
A
tinea corporis - see a ring of erythema and scaling as opposed to diffuse crusted lesions.
21
Q
What is this skin rash?
A
seborrheic dermatitis
22
Q
Name the condition
A
simple scabies (<50 mites)- see small erthyematous non descript papules. Not blisters. generally located between webs or spaces between fingers.
Sarcoptes scabiei mite which burrows into the skin and spreads via person to person contact.
_Intensely pruritic rash in the flexor surfaces of wris_t, lateral surfaces of fingers, finger webs. Can involve the back and head and shows up excoriations with small crusted red papules.
Tx: topical permethrin 5% cream or oral ivermectin
23
Q
Name the rash
A
Discoid lupus
can be treated with topical tacrolimus
see erythematous scaly plaques that develop and atrophy and have pigmentary changes over time. Seen on sun exposed spots and this is chronic onset.
24
Q
Name the rash
A
Atropic dermatitis
Can be treated with topical tacrolimus
25
Name the rash
Plaque psoriasis
occurs on extensor surfaces like knees, elbows, ands and feet
Note the silver scale on a salmon colored patch
Can be treated with a topical vitamin D analogue called Calcipotriene
26
Name the rash
annular granuloma. erythematous or violaceous plaques without scale
Treat with topical steroid.
27
where does squamous cell carcinoma occur?
in areas of sun exposed skin. Can develop along sites of chronic wounds, chronic inflammation and or scarring.
Toher risk factors include PUVA phototherapy, radiation, industrial carcinogens (arsenic) smoking, immunosuppressive treatmetn and rarely inherited disorders like xeroderma pigmentosa or oculocutaneous albuminism.
28
How diagnose squamous cell carcinoma?
shave, punch, or excisional biospy that extends to at least the mid reticular dermis is dieal.
29
Name the skin lesion
Squamous cell carcinoma
30
Name the skin lesion
pyogenic granuloma. Benign vascular tumor fo the skin and mucosa that presents as a erythematous dome shaped papule that grows rapidly but then stabilizes over weeks to months. THe lesion is friable and bleeds easily with minor trauma
. They develop over a period of a few days to weeks.
31
Name the skin lesion
Calciphylaxis. Seen in ESRD on HD with elevated calcium phosphorus product. Extremely painful subcutaneous nodules that progress into necrotic ulcers. Areas of high adiposity such as abdominal wall, buttocks, and thighs are most commonly affected.
32
Name the skin lesion
Gout tophi. Seen in the ear or soft tissues and paritcularly the articular structures or bursae. Appears as white chalky tumors and they are not painful or tender and do not ulcerate.
33
Name the skin lesion
rough scaly, erythematous macules or papules and are typically seen on chronically sun exposed skin. Progress to squamous cell carcinoma.
Actinic keratoses are seen in close proximity to SCC and can resemble early SCC or SCC in situ (Bowen's dx) and see bleeding, tenderness and a palpable underlying substance that may be SCC and needs biopsy.
34
Name the rash
Contact dermatitis
Note how there is low level exposure to allergens (nickel, rubber, leather dyes) and see itching, scaling, lichenification - see it at points of contact with jewlery (neck ear lobes) and clothing fasteners
35
Name the Rash
Lichen simplex chronicus or neurodermatitis
thickened skin from excessive scratching and rubbing. Seen with anxiety disorders and in areas that are reachable
36
Name the rash
Pityriasis rosea (PR)
Affects the trunk, neck, proximal arms and seen in adolescents and adults. Thought to be a viral etiology and seen with a nonspecific mild flu like course prior. PR starts with a single large scaly slamon colored lesion (herald patch) and see numerable lesions afterwards. Oriented like a christmas treat. Supportive care. UV light.
37
Name the rash
tinea versicolor. See hypo or hyperpigmented patches affecting trunk neck or porximal limbs. May have a fine scale but unlike pitiarysis rosea, these are flat. More insidious onset.
38
Name that rash
Secondary syphilis rash and happens weeks to months after primary syphilis. No herald patch and papulosquamous eruption and this is found on palms and soles of feet and trunk.
Also see patchy hair loss, cervical LAD, and mild hepatitis.
39
Name the rash
Lichen Planus - 5 P polygonal planar, pruritic, purplish, plaques on wrists hands trunk and legs. Fine white lines termed WIckham striae may be present on plaque surface
40
Name the rash
Guttate psoriasis - scattered erythematous scaley papules and plaques. FOllows a streptococcal infeciton. This is thicker and more prominent scale than pityriasis rosea.
41
Name the rash
Pyoderma granrenosum.
Seen with systemic disorder (IBS, arthropathies, hematologic malignancies and sometimes infections). Seen with rapidly developing painful purulent ulcer with violaceous undetermined border
42
new rash on abdomen that started 3 weeks ago and started to worsen without pruritis. Has DM2. Name the rash
What can cause it?
Intertrigo. This is an infectious or non infectious skin inglammation in the intertriginous areas (inguinal perineal, genital or intergluteal or axillary or inframammary areas).
Most commonly from candidal intertrigo. But other fungi grow as well. Candidal develop erythematous plaques or erosions with satellite papules and pustules. Can be painful or pruritic if there is skin breakdown
43
Diagnosis of intertrigo
clinically based on risk factors or via potassium chloride (KOH) preparation and will see budding yeast with septate hyphae.
RF: skin friction from obesity, increased moisture (tight clothing or hyperhidrosis) or diabetes or immunosuppression, occluded skin.
Look for lesions that have erythematous macerated plaquws with peripheral scaling.
44
Treatment of intertrigo
topical antifungals (miconazole, nystatin, terbinafine) these are initial treatment. ALso need to use skin drying agents and then address the underlying cause alowing for predisposition
45
Name the rash
inverse (intertriginous) psoriasis - can mimic intertrigo. These have smooth patches or plaques in skin folds instead of extensor surfaces
46
When do we use topical steroids with people who have intertrigo?
Use a low potency glucosteroid ointment that can be used with intertrigo when there's significant pruritis, pain and burning.
47
Patient had a recent infection about 1-3 weeks ago (with URI or GI symptoms) and has a acute onset of painful erythematous lesions with fever \>38 C. On biopsy see neturophilic infiltrate without vasculitis. Name the rash
Sweet Syndrome (acute febrile neutrophilic dermatosis)
Seen 1-3 weeks post infections, IBS, or pregnancy. Can also be seen in malignancy associated cases (hematological malginancies) but also can be seen with solid tumors. Can also have this with drugs (Granulocyte colony stimulating factor)
48
Presentation of Sweet Syndrome?
abrupt onset of painful edematous papules, plaques, and nodules which are red or violaceous lesions that can have pustles or central yellowish discoloration similar to target lesions. THese lesions are seen asymmetrically on head, neck, upper extremities.
Can have pathergy (lesion at cutaneous injury site) even with minotr trauma.
See burning and tenderness and fever \>38 and possible systemic symptoms of arthralgias, myalgias malaise and headache
49
What is seen on biopsy of Sweet syndrome?
see neutrophilic leukocytosis without leukocytoclastic vasculitis and so there's only dense neutrophilic infiltrate
Called acute febrile neutrophilic dermatosis.
50
what do you do if someone has Sweet syndrome as PCP long term?
Since they can be associated with cancer and if hte patient doens't already have a known malignancy, need to age appropriate cancer screening.
51
Treatment of Sweet Syndrome?
\<5% of body area or mild Sweet syndrome can get topical steroids
If more extensive body area or moderate Sweet Syndrome, you need to treat with systemic glucocorticoids.
It dramatically improves with steroids.
52
Name the rash and condition associated with this.
SLE malar rash
Erythema and scaling over the cheeks and bridge of the nose with sparing of the nasolabial folds.
53
Name the rash
**discoid lupus rash** that present as a photosensitive patches of various sizes that are erythematous and well defined.
This is how discoid lupus rash looks healed.
54
Name the rash.
Pt has hepatitis C infectious and has palpable purpura, arthralgias, renal disease with low serum complement and neuropathy.
THis is essential mixed cryoglobulinemia - Seen with Hep C infectious. ALso see membranoproliferative glomerulonephritis (renal dx), and low serum complement and neuropathy.;
The purpuric skin lesions are in the lower extremities and they progress to necrosis and gangrene.
55
Name the rash
miliaria - heat rash. These are due to blockage of eccrine sweat ducts in teh setting of increased heat or humidity. THis is common in new borns and young kids but can also be seen in adults with fever, increased sweating or tight fitting clothes.
56
what causes miliaria?
obstruction of the sweat glands in the superficial stratum corneum causes miliaria crystallina which presents as a small thin walled non inflammatory vesicle that resembles dew drops.
57
erythematous papules or pustules that are itchy and a prickly heat after being stuck in the heat or humid area. Name the rash
Miliaria rubra - from ductal obstruction deeper within the epidermis and this treatment is includes sweat reduction with cool baths and compresses and light or loose clothing.
58
milia the same thing as miliaria?
No. Milia is excess keratin pocket and found under the eyes or near eyes. Miliaria is a heat rash that improves with sweat reduction, cool baths, compresses, and light or loose clothing.
59
Name the rash?
folliculitis - from bacteria or fungal causes. Due to inflamed hair follicles, cause erythematous pustular eruption. can be asymptomatic or cause significant pruritis and pain.
60
Name the rash
grouped vesicles nad pustules on a erythematous base in a dermatomal distribution.
61
Name the rash
**Keratosis pilaris** - is from _retained keratin from plugged hair follicles_
can sometimes be puritic or pustular lesions in the upper arms, face, trunk, or lower extremities.
It is worsened in cold and dry climates and sometimes appears similar to goose bumps.
62
What is the rash?
This is urticaria. Caused by well circumscribed erythematous patches, papules, plaques, and can be diffuse. THis is associated with significant pruritis.
63
Name that rash
sudden in onset and tender and patient just started OCPs
**Erythema nodosum,** form of panniculitiis.
Sudden in onset and tender found on anterior legs. Seen with **abx, drug reactions (esp OCP and hormone replacement)**, infectious and systemic dx
note that these are erythematous papules or plaques. See improvement after stopping medication (2 days)
64
Name the rash. thick claudiflower like skin lesion around nail plate
**Wart** or a **cutaneous verrucae**
Caused by _HPV infection_ which enters through tiny cuts on skin abrasions after contact. It can be on plantar, perungual, palmar, or genital areas. Seen in people who bite their nails, have occupations with hands being wet (dishwaters)
65
Treatment of periungual warts
topical salicyclic acid for 2-3 weeks and then the dead wart tissue sloughs off.
Tx is continued for another 1-2 weeks to prevent recurrence and eliminate residual virus.
66
Name the skin lesion on face
Filiform wart are made up of long, thin projections of skin, giving them a distinctive appearance. They often occur around a person's eyes or lips. These warts are also called digitate or facial warts. They are harmless and usually disappear without treatment
removed via shave or snip excision and given topical lidocaine prior to procedure.
67
unilateral erythematous intensely pururitic and ulcerative lesion confined to the nipple and areola you need to consider
paget's dx of the breast
can see pain and burning prior to development of lesion
68
diagnosis of Pagets disease of the breast
biopsy
many also have underlying breast malignancy with intraductal carcinoma and ductal carcinoma in situ
69
Name that rash
Candidal mastitis
see pruritic erythematous areolar lesion with deep sharp pain out of proportion to the examination. See this with DM and candidal infections and not mastitis or in local intertriginous areas.
70
what is this condition.
this is crusted scabes which is an overwhelming infestation with thousands (compared to \<50 with simple scabies) and this is seen in elderly or HIV pts. Crusted scabes has little to no itching and presents insidiously with poorly defined erythematous patches thatp rogress to prominent scales and crusting and malordorous fissures. Affected areas are palms, extensor surfaces, of hands and elbows and scalp, ears, feet and toes.
71
DIAGNOSIS of crusted scabies
skin scraping or dermatoscopy showing mites and eggs.
72
treatment of simple scabies
topical permethrin
73
Treatment of crusted scabies
oral ivermectin and topical application of a keratolytic agent (20% urea ointment) and permethrin
74
Name the rash
eczema - erythematous plaque with thickened skin and lichenification (increased skin markings or excoriations) rash is pruritic and commonly involves the neck antecubital fossa popliteal fossa face wrists or forearms
75
Name the condition
psoriasis - well defined erythematous scaley plaques involvinv ghe scalp extensor surfaces of the elbows knees and external ear and back. Psoriasis can be more severe in HIV pts with palms feet nails and wide spread erythroderma.
76
what caused this hair loss?
Tinea capitus. See non scarring patches of hair loss and seen in kids. See erythematous scaly patches of underlying skin. Treat with oral terbinafine.
77
Name the reason for hair loss
discoid lupus erythematosus - see hair loss with fribosis and scar tissue that eventually permanently destroys hte hair follicule.
78
Name the reason for hair loss
alopecia areata - see smooth circular patches of hair loss with exclamation points at the margins. Develops over a few weeks in ppl \<30 yrs old and will see some nail pitting (sometimes). Resolves on its own but may need steroid injections for treatment.
79
Name the condition
This is **vasculitis** with skin ulceration and necrosis from **essential mixed cryoglobulinemia.**
Can see palpable purpura on legs, arthralgies, membranoproliferative glomerulonephritis and low serum compelments and cutaneous vasculitis and neuropathy.
Will need _serum cryoglobulins, hep C status checked_, **complement levels will be low**, and **can have false positive ANA and RF.**
80
Name that rash
begin as painful erythematous patches followed by rapidly appearance of several small sterile pustules which become confluent "lakes of pus"
seen on palms and soles or digits. NO systemic symptoms.
this is **pustular psoriasis** which is a form of psoriasis which arises in people with history of plaque psoriasis.
RF are pregnancy, infection, withdrawal of systemic or high potency topical steroids.
81
Treatment of pustular psoriasis (short term and long term)
**initial treatment is supportive:** hydration, local skin care and systemic antibiotics if secondary infection is present.
Definitive management is **long term systemic retinoids** (acitretin) or immunosuppressive agents like **cyclosporine, methotrexate, infliximab**
see recurrent episodes commonly
82
generalized pustular psoriasis manifestations
painful erythematous patches followed by rapidly by appearance of several small sterile pustules which can be confluent and this can have systemic manifestations of fever, mailaise, arthalgias and desquamation and an increased risk for sepsis.
83
clinical manifestation of disseminated gonococcal infection
acute septic monoarthritis or as a triad of dermatitis (usually 2-10 painlfess pustules on distal extremities,) tenosynovitis and polyarthralgias.
84
HSV virus is seen as a
clusters of vesicles on a erythematous base. Disseminated HSV is seen with severe immune suppression and can spread to the viscera
85
Name the rash.
guttate psoriasis- occurs in kids and young adults. seen 2-3 weeks after a streptococcus pyogenes infection (pharyngitis)
86
acute onset small erythematous rash scaly papules and plaques and widespread lesions that spare palms and soles of feet.
what is it? When does it occur?
How to treat it?
guttate psoriasis - seen on trunk and proximal extremities and doesn't affect soles or palms. usually acute onset 2-3 weeks after strep infection.
Treatment is observation (spontaneous resolution is common) and ultraviolet light phototherapy. It can turn into chronic psoriasis
87
Moth eaten alopecia along with a maculopapular rash and hepatitis with LAD
think secondary syphilis.
Secondary syphilis is associated with:
- systemic symptoms of fever, mailaise, headache, anorexia, diffuse LAD, maculopapular rash on entire trunk, extremities of palms and soles, condyloma latum (painless wartlike lesions) and LAD with epitrochlear nodes,
mild hepatitis and uveitis and meningitis.
88
What is this rash?
Erythema multiforme - target shaped lesion that is associated with HSV infection. seen on extensor surfaces of extremities (hadns and feet)
89
pt has Hodgkin lymphoma on chemotherapy, and gets a blood transfusion a few days ago. pt how has a generalized erythematous maculopapular rash with fever, anorexia, right upper quadrant pain and profuse watery diarrhea (7-8L per day). See pancytopenia on labs and transaminitis. What do they have?
transfusion associated Graft versus host disease. occurs immunocompromised pts because of donor RBC lymphocytes attack host cells and causes subsequent destruction of bone marrow and most cases are fatal.
Prevention is giving irradiated blood products (NOT WASHED).
90
Name the rash / skin lesion.
Kaposi sarcoma. Seen in immunodeficient HIV state. Seen on lower extremities and may have LAD.
91
Name the skin lesion
ESRD pt with use of warfarin. Painful lesion and not warm to palpation.
Calcifphylaxis. Called calcific uremic arterolopathy.
Seen in ESRD and renal transplant pts. people taking warfarin are at greater risk.
Painful subcutaneous nodules that can be violacious or plaquelike. They then progress to ischemic or necrotic nodules and become infected and can lead to sepsis.
92
labs related to calcifphylaxis
Labs show high PTH, phosphorus, calcium and calcium phosphate product.
Imaging may show soft tissue calcium deposition but not needed for diagnosis.
93
calciphylaxis on biopsy
calciphylaxis results on biopsy show
arterial calcification/occlusion with subintimal fibrosis which can differentiates calciphylaxis from other disorders (vasculitis, cryoglobulinemia, nephrogenic systemic fibrosis and warfarin necrosis)
94
treatment of calciphylaxis
local wound care
avoiding trauma,
maintaining _calcium phosphorus product\<55_ and
**increasing dialysis sessions,**
parathyroidectomy,
**IV sodium thiosulfate** and
**decreasing immunosuppression in renal transplant pts**
possibly stopping warfarin.
95
What is the rash that is seen after a left heart catherization? what can it be indicative of this?
livedo reticularis (seen in multiple conditions) but after a left heart catherization you should think about cholesterol atheroembolism.
96
Name the rash
erythema multiforme (EM) and it's a target shaped rash from an immune medited disorder that is usually triggered by a bacterial or viral infection like HSV
lesions have 3 color zones: dusky center (often with a small bulla or crust)
pale surrounding zone
erythematous peripheral border
seen on extensor surfaces of distal extremities. Can see mucosal lesions in 70% of cases
lesions last for 1-2 weeks before healing but can recur in HSV associated cases
97
treatment of erythema multiforme
symptomatic (topical steroids, oral anti-histamines, anesthetic mouthwash
HSV is most common cause of erythema multiforme but it doesn't help to give antivirals to help short the course of EM.
98
when do we recommend prophylactic antivirals for HSV induced erythema multiforme
when there's frequent outbreaks.
99
Name the lesion
typical bulls eye or erythema migrans lesions. from lyme dx and ixodes tick bites. See a flu like illness with a localized erythematous rahs with central clearing.
erythema migrans are much larger and they expand over time and seen in the axillary or inguinal area compared to erythema multiforme
100
delayed hypersensitivity response to exogenous agent like latex, soaps/cleaning agents, cosmetic products and topical medications
allergic contact dermatitis.
101
Name the rash- it's intensely pururitic. patient recently used a new face cream.
contact dermatitis - see development of erythematous, indurated and pruritic plaques around contact site. Can see edema, drainage and vesiculation with bullae.
continued exposure chronically can lead to dry scaly skin.
102
Treatment of allergic contact dermatitis
stop offending agent and may benefit from topical steroids for significant discomfort
103
Diagnosis of allergic contact dermatitis
Clinical diagnosis based on history. Some cases may need skin biopsy or patch testing for confirmation
104
name the rash. Pt has new fever and chills and not itchy. Rash is warm to the touch
erysipelas - see superficial skin infection of the upper dermis and subcutaneous fat. See well dermarcated plaques and erythema, edema, and warmth
105
Name the rash
Steven Johnson's syndrome
Life threatening emergency.
106
what is necrobiosis lipoidica?
asymptomatic skin lesion that appears indurated yellowish plaques with central atrophy and often located on shins. Inflammatory skin disorder seen on DM2.
107
diagnostic criteria for pyoderma gangrenosum
it's a rare neutrophilic ulcerative skin disease that starts as a tender papule, pustule or vesicle that is rapidly progressive ito form a painful ulcer with purulent base and ragged violaceous borders
Can be single or multiple.
108
DIagnosis of pyoderma grangrenosum and tx
diagnosis of exclusion - needs skin biopsy which is non specific in PG but needs to rule out venous ulcers, panniculitis, cutaneous cancer.
Mild localized PG (superficial lesions) needs to be treated with high potency topical corticosteroid or topical tacrolimus. Systemic steroids with or without cyclosporin is usually for extensive PG or failure to respond to local inteventions.
109
pyoderma gangranosum is asociated with
can be associated with trauma or aggrevate PG with pathergy.
Can have underlying systemic disorder like inflammatory bowel dx or arthropathies (RA) or hematological conditions (like AML)
110
Tender erythematous nodule or plaques
erythema nodosum . this is result of delayed hypersensitivity to antigens in drugs or other conditions like strep infection. DO not ulcerate and resolve without scarring 2-8 weeks later.
111
name the skin condition
Vitiligo- acquired skin depigmentation (localized or generalized) due to progressive autoimmune destructio nof melanocytes. Seen by age 20-30 yrs
well defined and depigmented lesions. Diagnosis is clinical.
112
what medical conditions is associated with vitiligo?
autoimmune thyroid dx and type 1 DM. STudies showed a higher incidence of autoimmuen thyroid dx in vitiligo (up to 20%) compared to non vitiligo pts.
Vitilgo often preceds htyroid dx and so people who have vitiligo need screening for thyroid and DM1 dx.
113
Treatment of vitiligo
repigmentation with topical corticosteroids (preferred) topical calcineurin inhibitors and ultraviolet light.
114
what is this skin lesion?
cutaneous squamous cell carcinoma - second most common skin cancer (1st is basal cell carcinoma)
RF for cutaneous squamous cell - increasing age, light color skin, sun exposure (UV light) chronic skin inflammation (Burns, scars, ulcers and inonizing radiation exposure (cancer or acne therapy)
Poorly differentiated SCC can appear as fleshy, soft, granulomatous papules and nodules with less hyperkeratosis than those seen in well differenitaed lesions.
115
Squamous cell carcinoma
seen on head neck trunk extremities, oral mucosa and anogenital areas.
These lesions can bleed, become necrotic or cause pain and pruritis. Biopsy confirms diagnosis.
116
What is this skin lesion?
Seborrheic keratosis. seen as a stuck on appearnce with sharply demarcated papules and plaques. This is a benign hyperpigmented lesion on trunk, face/neck and extremities.
117
What is this skin lesion?
Malignant melanoma- seen by pigmented lesions with assymetrical shape and irregular borders and color variation of brown and black. see increasing diameter \>5mm and evolution of appearance over time.
Non pigmented melanoma may occur too.
118
What is this skin lesion?
Verruca vulgaris - cutaneous wart that grows irregularly and ulcerates. They grow in sun exposed areas similar to SCC. These are due to HPV and usually develop faster than the 3-4 yrs.
119
what is this skin lesion?
what happens long term with this lesion?
keratoacanthoma (KA) low grade squamous cell carcinoma that develops on sun exposed skin in middle aged to elderly (usually fair skinned pts)
see rapidly growing in several weeks followed by a variable period of lesion stability (several months) and several spontaneous resolution in several weeks.
Look for solitary dome shaped skin colored nodule with central hyperkeratotic keratinous plug
120
What is this skin lesion?
This is basal cell carcinoma. Slow growing papule or nodule wiht pearly rolled border and overlying telancgiectasia
ulceration can be seen and bleeding can be seen after trauma
121
What is this skin lesion?
molluscum contagiosum - this is from pox virus and seen as multiple small dome shaped papules with central umbilication like a donut/ seen in children and sexually active adults. Will spontaneously disappear.
122
What is this skin lesion?
prurigo nodules - seen as cutaneous lesions that occur in chronically rubbed or scratched skin. See dome shaped firm papules and nodules (0.5-2cm) that are eroded and ulcerated and crusted.
123
what is this?
hidradenitis supprativa- intially a solitary painful inflammed nodule in intertriginous area, abscess formation with purulent or serosanguineous drainage and multiple recurrent nodules with sinus tracts comedones and scarring.
124
what is this skin lesion?
Common wart from HPV. Seen on ppl who handle meat, poultry and fish and those who have atopic dermatitis.
Tx: observation and most will resolve in 2 years or so but can try for liquid nitrogen use or salicylic acid. But no liquid nitrogen on periungual warts due to the risk for nail bed dystrophy
ALso seen on immunocompromised pts HIV who develop waarts. Seen on plantar and palmar surfaces and digits.
125
how do you treat this skin lesion?
This filiform wart can be treated with a snip and shave excision
126
what to do for treatment of hidradenitis suppurative?
general (all patients) weight loss and smoking cessation, daily skin cleansing of affected areas.
But also need to divided into Hurley Stages and tx is based on that.
127
what is Hurley Stage 1 treatment for hidradenitis suppurativa?
Hurley stage 1 (mild disease)
topical clindamycin and intralesional steroids or oral antibiotics for flare ups.
Continue to lose weight, smoking cessation, daily skin cleaning of affected area
128
Hurley Stage 2 treatment for hidradenitis suppurativa
Hurley stage 2 (moderate disease with nodules and sinus tracts and scarring)
**Oral tetracyclines** (preferred)
**oral clindamycin + rifampin in refractory cases**
continue to lose weight, smoking cessation and daily skin cleasning of affected areas
129
Hurley Stage 3 treatment for hidradenitis suppurativa
**Hurley stage 3** (severe disease with _diffuse involvement and extensive sinus tracts_)
**Biological TNF-alpha (infliximab)**
**Oral retinoids (acitretin)**
**surgical excision**
continue to weight loss, smoking cessation, daily skin cleansing of affected areas
130
hidradenitis suppurativa starts as a
solitary, painful, inflamed nodule and that can last several days to months before progressing to an abscess with purulent or serosanguineous dranage.
Improve after drainage but can also form sinus tracts, comedones and significant scarring.
131
what are the risk factors for hidradenitis suppurativa?
weight and obesity, smoking and mechanical stress on skin (friction and pressure)
132
skin conditions associated with systemic dx
133
Name the rash
This is rosacea. Seen with facial erythema, telangiectasias, papules or pustules and episodic flushing over the cheeks, nose or chin. Precipitated by heat, acute stress, medications and other rapid body temperature changes
134
how to treat rosacea?
topical metronidazole is most frequently used.
135
What is this rash ? what to check if the patient has a sudden new appearance and worsening of this rash?
Seborrheic dermatitis. **Need to check HIV** as this rash can happen as a new presentation of HIV and CD4 \<400.
136
what is seborrheic dermatitis
this is a common inflammatory disease that affects the areas with sebaceous glands like the scalp, face (eyebrows and nasolabial folds) external ear canal and posterior ear, chest and intertriginous areas. Seen in all age groups but with greater frequency in Parkinson's dx and as a new presentation of HIV.
137
How to treat for seborrheic dermatitis?
topical steroids and topical fungal cream. If it doesn't improve or get worse, screen pt for HIV\>
138
what is this?
if you see this, where do you need to examine?
How to treat this?
**condyloma acumulata** - from HPV (low oncogenic risk types 6 and 11)
_Non friable, non tender caudiflower appearance_ without LAD.
Need to examine for other sites for h**igh risk HPV (from types 16 18 and 31)** changes on **urethra**, **anal canal,** and **cervix**.
Tx is topical therapy with **tricholoroacetic acid** and **podophyllotoxin.**
139
What is this condition?
Xerosis of the skin. Dry skin and treat with moisturizers
140
what is this rash?
describe the characteristics and what medical condition is associated with this?
How to diagnose and how do you treat it?
lichan planus. Seen sometimes with hep C.
Has four P's: pruritic, purple, polygonal papules or plaques and they happen on flexural surfaces of ankles and wrists. Notice the white lacy markings is called Wickham's stria.
Diagnosis is clinical and based on appearance and distribution. Can get punch biopsy. Tx with topical high potency steroids. If don't respond need systemic steroids or phototherapy
141
eczematous rash with pruritis in exposed allergens
allergic contact dermatitis
142
what is this rash?
Necrobiosis lipoidica diabeticorum (NLD) - frequent skin condition of diabetics but can be seen in non diabetics. They may precede the osnet of DM2 and so anyone with this rash should be screened for DM2.
See pretibial areas- erythematous papules that later evolve into annular lesions with a yellowish brown hue, dilated blood vessels, and central epidermal atrophy. PTs are asymptomatic
143
what is seen on biopsy of necrobiosis lipiodica diabeticorum?
see interstitial granulomatous dermatitis which confirms diagnosis.
144
what is this rash?
Discoid lupus.
lesions are red, scaly plaques with pigmentary changes and hyperpigmented rims and these are seen on face scalp and years. can be present on extremities and chest but uncommon to see discoid lesions below the neck without lesions also on the neck.
145
what are symptoms and findings of hypersensitivity reactions?
Morbilliform rash (nonspecific and seen with many conditions)
See vasculitis or palpable purpura (seen on this page)
also can see erythroderma
146
what is this?
pretibial myxedema (thyroid dermopathy) - see non pitting edema and skin colored brawny indurated plaques in pre tibial areas. Seen with other features of Grave's disease like ophthalmology.
147
staph toxic shock syndrome clinical features
148
Name the rash and treatment
seborrheic dermatitis.
Tx with low potency steroid cream and antifungal cream
SD affects areas with high sebaceous glands like scalp (Dandruff) face, nasolabial folds, eyebrows, external ear, chest, and intertriginous areas. Thought to be related to growth of lipid dependent Malassezia fungus. Worsened in Parkinson's dx and HIV pts.
149
what worsens this rash?
seborrheic dermatitis is worsened in winter months, stressful periods.
Tx with topical steroid to control inflammation and itching and antifungal creams or shampoos or combo of each.
150
why are not high potency steroid creams used on the face?
because it can lead to discoloration, skin atrophy, and telangiectasias.
use the least potent for hte shortest amount of time to minimize adverse effects.
151
urticaria treatment algorithm
152
Name this rash. It is localized itching on arms followed by a rash that worsens for a few hours before spontaneously resolving and has been going on for \>6 weeks. Rash is on arms, legs, and back. No trauma, insect bites, travel history or sick contacts. NO fevers and normal BP.
this is chronic urticaria \>6 months or episodic symptoms lasting \>6 weeks. Due to mast cell activation in superficial dermis and releases multiple mediators (histamine) that cause pruritis and localized swelling in upper layers or skin. Seen with angioedema
153
what is chronic urticaria caused by:
physical stimuli (cold temperature or skin pressure),
serum sickness,
systemic disorders like autoimune disease or vasculitis
malignancy.
Often can have idiopathic causes.
154
how to treat chronic urticaria?
start with second gen non sedating antihistamine (loratadine). If needed dose can be increased to 2-4 times the standard dose.
Second line tx: first gen antihistamine, leukotriene receptor antagonist and H2 blocker. If continues refer to subspecialist for immunosuppressive agents.
155
what is pemphigus vulgaris (PV)?
This is a serious autoimmune vesiculobullous dx in which blister formation results in loss of cohesion between epidermal cells. See flaccid bullae rupture easily and cause painful erosions.
Lesions start in oropharyngex and then spread to involve the skin, predilection to scalp, face, back, chest, axila, and groin.
Characterized by flaccid bullae that rupture easily.
+ Nikolsky sign on skin.
156
Positive Nikolsky sign
separation of epidermis from base layer by applying minimal pressure.
157
antibodies against pemphigus vulgaris
antibodies against desmoglein (adhesion molecule present in epidermal cells). Requires a skin biopsy for diagnosis in lesion area with routine histology and biopsy from perilesional skin for immunofluorescence
158
treatment of pemphigus vulgaris
Tx is with IV or systemic steroids. Can give adjuvant immunosuppressive agents like azathioprine, cyclophosphamide, mycophenolate mofetil to help provide steroid sparing therapy.
Need to be followed by dermatologist.
159
Name this rash. Seen on arms legs, cetnral back and buttocks with diarrhea and weight loss
dermatitis herpetiformis seen with celiac dx. See erythematous papulovesicles on extensor surfaces. It's itchy
see erosions and excoriations and rarely any oral mucosal involvement.
160
what is the lesion seen here and what should you do next if you see this?
Nail pitting which is seen with psoriasis. Need to do a greater skin exam. If you see this, can treat with topical corticosteroids.
Mild nail psoriasis involving 1-2 digits can be greated with topical steroids or vitamin D analogs. Widespread nail involvement needs TNF alpha or methotrexate.
161
how to treat mild nail pitting related to psoriasis?
Mild nail psoriasis (involving 1-2 digits): **topical steroids** or **vitamin D analogs.**
Widespread nail involvement: **TNF alpha inhibitor** or **methotrexate.**
162
nail clubbing is associated with
intrathoracic neoplasms, intrathoracic suppurative diseases (lung abscess, bronchiectasis) , fibrotic lung disease cyanocongenital heart disease.
163
yellowing of nails
bronchiectasis or tuberculosis.
164
what does hypothyroidism do to nails?
makes nails brittle but hypothyroidism does not cause pitting of nails. (psoriasis does).
165
Diet controlled DM2 and has mild puritic rash in axillary areas and wood's lamp shows red flourescence in affected areas. What is this rash?
Erythrasma
See well demarcated pruritic red brown plaques in the interdigital (between toes) and interiginous areas. Seen with a fine cigarette paper scale.
Superificial skin infection caused by Corynebacterium minutissimum which can be seen in healthy pts
166
Diagnosis of Erythrasma is
wood's lamp with seeing coral red appearance and this is red color is due to the production of porphyrins by the bacteria
Can have a false negative if pt just washed or bathed.
167
how to treat erythrasma?
Limited dx
extensive dx
limited disease is treated with: topical antibiotics (clindamycin 1%
Topical antifungals (miconazole) can also be used esp if concerned for a coexisting dermatophyte infection.
Extensive dx (multiple sites)- use oral macrolides (erythromycin or clarithromycin)
168
what is this rash?
inverse psoriasis. Seen on intertriginous areas such as axillae and inframammary areas.
Plaques are erythematous, well demarcated, do not have typical psoriatic scale and frequently non pruritic.
169
what is this rash?
this is microsporium or tinea corporis infection. This can affected healthy individuals but also those with some level of immunosuppression.
Lesion is erythematous ring shaped well demarcated plaque that can be associated with pruritis and diagnosis is made by showing septate hyphae on KOH skin scrapings.
170
What is this rash? developed after a 10 day course of amoxicillin.
What is this caused by?
When does this rash arise?
**Cutaneous small vessel vasculitis (CSVV)** which is a skin isolated leukocytoclastic vasculitis.
Can be caused by **drug exposure** (penicillin, cephalosporin, sulfonamides, phenytoin, NSAID, and allopurinol), **infection** (Hep B, Hep C, HIV) and unknown causes
Happens **7-10 days post drug exposure** or infection with palpable purpura or petechiae
171
is there any visceral organ involvement with this rash?
what is seen on labs with this rash?
This is leukocytoclastic vasculitis and a cutaneous small vessel vasculitis. Generally no visceral organ involvement (kidney, lung, heart) and suggests a systemic vasculitides like MPA, GPA
Labs how low serum complement levels, elevated ESR.
172
IF there's a new cutaneous small vessel vasculitis, what is the next step of management
order a UA (rule out renal involvement), stool guiac studies, sterological studies (ANA, ANCA, cryoglobulin,) not necessary for a skin biopsy
Treatment is with medication induced cutaneous small vessel vasculitis is to stop the offending drug and supportive care. Rash will improve in days to weeks of drug cessation. Find underlying disorder.
173
What is this rash?
what is long term management for screening?
Heliotrope rash - seen as a violaceous periorbital rash in upper eyelid. Seen with inflammatory dermatomyositis or polyositis
Screen those pts for cancer because they are at 5x risk for cancer
Screen with age appropriate cancer screenings.
For high risk pts with suspicious features get:
CT c/a/p
UA for hematuria
Serum Ca125 and Ca19-9
PSA serum
EGD
174
What is this rash?
what other rashes are associated with this condition?
Gottron's papules - seen on the metcarpophalangeal joints
Seen with inflammatory myositis or myopathic process like dermatomyositis or polymyositis.
Other rashes are: V-sign, Shawl sign and Heliotrope rash.
175
If you see this rash, and the patient has arthralgias and muscle weakness where do you look next ?
also what are some elevated labs?
what does this pt have?
Look at hands for Gottron's papules. Pt has a heliotrope rash on eyelids - look for violacous rash present.
See mildly elevated Creatine kinase and ESR/CRP
This patient likely has inflammatory myositis
176
PT presents after syncope. Had 6 days of fever, throbbing pain behind eyes, diffuse myalgias and abdominal pain and fever improved 2 days ago but has had a red rash on her trunk and upper and lower extremities. Also had epistaxis and syncope episode. Came back from south of Mexico 10 days ago.
what does this patient have?
Pt has Dengue fever; common cause of fever from traveler returning from Caribbean and parts of Asia and South America.
See 1st part of illness 3-5 days with myalgias and retroorbital pain and -headache. THen they see bleeding complications. As symptoms improve there is a macular or maculopapular rash (islands of whtie on a red sea) and then they may develop capillary lead syndrome with edema, effusions and hypotension and shock and severe hemorrhage.
177
What is this skin lesion?
melanocytic nevi - common benign pigmented lesions found on the skin of most indivudals.
Corolation can be variable from tan to jet black and tend to \<6 mm in diameter and symmetrical and homogenous surface wiht sharp borders.
Nevi are in teh sun exposed areas and
178
Suspicious nevus should be examined for the following clinical features in melanoma:
asymmetry (if a lesion is bisected it's not identical)
border irregularities
color variation (brown, red, black, blue/gray and white
diameter\>6mm
evolving: lesion changing in size, shape, and color, and new lesion
179
what is this skin lesion?
melanoma
- see ABCDE
more of these criteria means higher chance of melanoma
180
what should be done with management for this skin lesion?
melanoma and needs excisional biopsy with a 1-2 mm rim of normal appearing skin.
181
pt in ED with rash that has been present for 3 days and getting worse. Has headache, malaise, fever, no neck pain, no nausea or vomiting. Temperature is 101. what does she need to get? What is this rash?
herpes zoster or herpes ophthalimicus.
Needs IV acyclovir and urgent ophthalmology consult
182
what is this rash?
How to treat this rash?
What happens if we dont treat this rash?
papulopustular rosacea -see the sterile papules with pustules in central face. seen in pts who have pre-existing erythematotelangiectic rosecea (flushing, erythema, telangiectasias)
Tx with oral antibiotics- tetracycline, doxycycline, minocycline or erythromycin
Untreated papulopustular rosecea can lead to persistent erythema, sebaceous hyperplasia nad fibrosis. Rosecea occurs in 30-60 with fair skin, light hair, and light eye color.
183
who gets rosacea?
pts 30-60 yrs with fair skin, light hair, light eye color. Pathogenesis is unknown but likely from inflammatory reactions to cutaneous microorganisms and ultraviolet light damage and vasomotor dysfunction.
184
what is used to treat mild to moderate rosacea?
topical antibiotic like metronidazole and topical azelaic acid can help.
Need to educate pt on gentle skin care, sun protection, avoidance of flushing triggers like hot drinks, hot/cold weather, ETOH, spicy foods.
185
patient is has a gluten alergy and complains of weight loss and arthralgias. what is this rash on her butt?
**dermatitis herpetiformis** - looks like a herpes rash. But this is seen with Celiac dx. See this as a pruritic rash with inflammatory papules, vesicles, bullae on the extensor surfaces, elbows, knees and upper back and buttocks.
Tx with topical dapsone
186
what is seen with erythematotelangiectatic rosacea?
flushing, erythema and telangiectasias.
Need to avoid flushing triggers like hot drinks, hot/cold weather, alcohol and spicy food and be educated on using gentle skin care, sun protection.
187
why don't we like long term steroids to the face?
because topical steroids can create something similar to rosacea AND it can also cause atrophy of skin, telangiectasia, and periorificial dermatitis.
188
what is this rash?
actinic keratoses - solar keratoses
Rough, scaly, erythematous macules and papules in fair skinned individuals. See sun damaged skin and chronic sun exposure are major risk factors for those lesions and accounting for their usual detection on the balding scalp, face, lateral neck, and distal upper and lower extremities. CAN PROGRESS TO SCC.
Easier to feel than see and so must palpate the skin.
189
When do you biopsy actinic keratoses
if lesion is \>1 cm in diameter, indurated, ulcerated, tender, or rapidly growing or lesions fail to respond to therapy. Need to biopsy to rule out squamous cell carcinoma. Progression to SCC is low but 60% of cutaneous SCC came from AK.
190
How to treat actinic keratoses
Treat with destructive therapies (cryosurgery, curettage, shave removal),
topical medications (topical 5 FU, imiquimod)
photodynamic therapy
Prevention is by sunblock, avoidance of sun exposure, and protective clothing and continuous monitoring for cutaneous malignancies
191
what is on his scalp?
psoriasis
192
what is this?
This is seborrheic dermatitis. Affects the sebaceous glands (eyebrows, nasolabial folds nad external ear canal and posterior ear, and scalp and chest. It is pruritic and can have erythematous plaques with fine loose greasy scales. Dandruff is amild form of seborrheic dermatitis.
pictured is severe atypical diffuse form of seborrheic dermatitis
193
what are these spots?
Solar lentigines - liver spots or age spots.
Benign and asymptomatic and pigmented macules that appear on fair skinned individuals on sun exposed spots of skin including the face, upper chest and shouldes and forearms and dosral hands. THese coalesce to form irregular patches.
Lenitgo maligna is a malignant lesion of melanocyte orgin.
194
what is used to treat discoid lupus?
Lenalidomide
195
What is this rash and where is seen with?
malar rash or the butterfly rash. It spares the nasolabial fold. Seen with SLE
196
how to treat SLE induced dermatitis
197
topical dapsone is used to treat
acne
198
isoretinoin is used for
severe nodular acne but teratogenic.
Can be used for bullous SLE dermatitis but has toxicity that limits its use.
199
what is this skin condition?
Tinea versicolor, a superficial yeast infection caused by Malassezia furfur. See hypopigmented and hyperpigmented or erythematous macules and patches. See fine dusty appearing scale on affected skin and become more common and obvious in summer months and favor oily areas like chest, back and upper arms and neck and intertriginous areas.
Can have mild puritis.
200
How to treat tinea versicolor?
localized tx?
extensive tx?
failed localized tx?
Tx with topical ketoconazole terbinafine, selenium sulfide (treament of choice)
if extensive widespread dx or failed topical tx, treat with oral ketoconazole, itraconazole, fluconazole
201
how to diagnose tinea versicolor?
need a skin scaping with KOH solution and should see curved hyphae and round yeast cells that appears like sphagetti and meatballs under microscope
202
What is this rash?
Secondary syphilis rash. --present as brown macules, papules, small plaques in a gneralized distribution.
see this in palms and soles and pt may have history of chancre.
203
how do we treat this condition?
Plaque psoriasis. Can treat with topical vitamin D analogues calcipotriene because this is mild to moderate plaque psoriasis b/c \<5% of body surface
If there is moderate to severe dx 5-10% of body surface or disabling lesions of face, palm, and sole-
need systemic therapy with: methotrexate, or TNF-Alpha inhibitors like etancercept, or phototherapy
204
What is this condition?
This is generalized vitiligo- vitiligo vulgaris- seen in the skin around the body orifices like the mouth, nose, eyes and in sun exposed areas.
VItiligo are areas that are completely depigmented and .
205
treatment of psoriasis is
206
how do we treat this lesion?
this is **mild to moderate plaque psoriasis** _(\<5% of body surface)_ so can treat with **topical high potency corticosteroids**
or topical vitamin D derivatives
207
what is this rash?
chronic discoid lupus erythematous DLE
- seen more in women than men, affects AA, and hispanics.
See red to violaceous inflammed and scaly round (discoid) lesions. WIth time may see increased infalmmation that may lead to pigmented changes with increasing inherent scale. Once they heal they have an atrophic hypopigmented scarring center with hyperpigmented peripheral borders in the area of primary lesion.
208
what is this rash?
This is discoid lupus with permanent scarring alopecia.
Discoid lupus is seen on head, neck and arms since it's photosensitive. See this rash in the area of the hair follicles and it can cause follicular plugging and see hair loss.
Discoid lupus can occur up to 25% of SLE pts and can also occur in isolation without other SLE components.
DLE pts do have risk for developing mild SLE. DLE will have low titer ANA and anti RO is rarely positive
209
diagnosis of discoid lupus is
clinical but can get biopsy if in question (from psoriasis or lichen planus or eczema).
Tx: sunscreen, protective clothing, topical corticosteroids or calcinurin inhibitors (tacrolimus), hydroxychloroquine is for lesions refractory to topical therapy
210
what is this?
lichen planus. Intensely pruritic when they ulcerate
Lichen planus also seen with porphyria cutanea tarda and Hep C. May also see leukocytoclastic vasculitis too.
211
what is this?
psoriasis
212
what is this?
subacute cutaneous lupus with a photosensitive rash that presents as erythematous scaling papules and plaques on neck, upper chest and arms.
It doesn't cause scarring or atrophy of the skin
213
what is this rash?
Vitiligo
214
Pt has developed this skin rash after being in the sun. what to check in terms of labs?
Porphyria cutnea tarda (check Hep C)
see fragile photosensitive skin with vesicles and bullae.
Can also see leukocytoclastic vasculitis (pictured) and lichen planus too.
215
Pt suddenly develops worsening non pruritic skin rash and has pain and stiffness of hands in past several days and see extensive scaly erythematous plaques on scalp, hands, arms, torso, legs and seen below?
What to check in pt?
this is diffuse plaque psoriasis. If you see this, you should check for HIV.
HIV can acutely worsen: psoriasis, seborrheic dermatitis, see disseminated molluscum contagiosum (donut shaped) and recurrent herpes zoster infections.
216
psoriasis in HIV pts is
more extensive
affects intertriginous rather than extensor areas, skin inversus psoriasis, can e associated with systemic symptoms like fever.
See rapid onset with HIV infection.
217
what also triggers atypical wide spread psoriasis?
smoking, alcohol abuse, withdrawal from systemic steroid therapy and strep infections and acute HIV.
Strep infections can cause guttate psoriasis (pictured)
218
what to check if this patient has intensely pruritic papules and vesicles on dorsum forearms, knees, and buttocks and some nonspecific arthralgias, weight loss and abdominal pain. See this rash.
This is dermatitis herpetiformis which is seen with Celiac dx. Need to check anti tissue transglutaminase antibody
See this on dorsal forearms, knees and buttocks. Can have associated weight loss, diarrhea, and arthralgias.
219
what are some systemic skin manifestations of inflammatory bowel disease?
erythema nodosum (painful erythematous nodules on lower legs
pyoderma grangrenosum (painful, enlarging, ulcerating nodules with violaceous border (described as undetermined)) .
220
what is associated with erythema nodosum?
Sarcoid - Logfren's
inflammatory bowel disease
OCPs
strep pharyngitis
coccidioides
this is a panniculitis
221
what are the skin manifestations of diabetes?
acanthosis nigricans - look for velvety brown plaques in flexural regions
Necrobiosis lipiodica (annular, yellowish brown lesions with central atrophy) pictureed
Hidradenitis suppurativa - painful inflamed nodules wiht hyperpigmentation and scarring in flexural surfaces.
222
what medical condition is this skin lesion associated with? what test do you order if you encounter this?
this is acanthosis nigricans - velvety brown plaques een in flexural surfaces and associated with DM2
screen for diabetes - A1c or fasting serum glucose or 2hr OGTT
223
what is causing this hair loss?
**androgenic alopecia** or female pattern baldness and this is driven by hormonal (circulating androgens and genetic factors) and seen in time. Depends on genetics and family history is similar to their pattern of hair loss
Women tend to lose hair at the vertex and center scalp and sparing of hairline.
224
most common cause of hair loss
treatment?
androgenic alopecia- diagnosis is based on clinical findings and testing (biopsy if other causes are possible)
treatment is based on minoxidil 1st line for both men and women but men can use 5 alpha reductase inhibitors (finesteride)
225
What is the cause of this hair loss and how can you tell?
**alopecia areata** - see smooth circular areas of complete hair loss rather than large areas of thinning.
226
What is telogen effluvium?
227
what is this intensely itchy rash associated with?
HIV?
Fe deficiency?
lung cancer?
hep C infection?
UC?
this is dermatitis herpetiformis and this is asociated with Celiac's dx and iron deficiency anemia due to poor absorption
If biopsied will show neutrophilic infiltrate, piapplary microabscesses and sub epidermal vesicles.
Direct immunoflurescence of perilesional skin shows granules of IgA deposits in derma papillae and is more specific than light microscopy alone
228
what is this skin lesion associated with?
this is lichen planus with pruritic purple papules or plaque with fine white streaks on it
Seen with leukocytoclastic vasculitis and due to cryoglobulinemia and seen with Hep C
229
what to check if someone has this rash that appears suddenly?
this is molluscum contagiosum and need to check HIV
230
pt presents with this hand rash. what is this person at greater risk for?
**development of cancers like ovarian, lung, colorectal cancer, and non hodgkin lymphoma**
This is **Gottron papules** and seen with **dermatomyositis.**
231
what is this rash?
Young person with high spiking fever that occurs every day. See particular arthritis and this non pruritc rash that ppeas only with fever. Labs show mild leukocytosis, elevated LFTs and splneomegaly with high ferritin at 3000.
This is acute adult onset Still's dx - see inflammatory disorder iwth high daily recurring fevers and polyarthirtis and transient salmon colored rash.
232
what is this?
**seborrheic keratosis**
if you see explosive onset of these on same individuals think GI malignancy **(leser-trelat sign)**
233
what is this skin lesion?
basal cell carcinoma - slow growing papule or nodule with pearly rolled border and overlying telangiectasia and can see ulceration with bleeding following trauma.
234
what is this skin lesion?
lentigo maligna - slowly evolving type of melanoma insitu that occurs on sun damaged skin on the face and neck of older individuals and it appears as an atypical macular lesion characterized by irregular shape and variegated color and variable size.
235
what is this?
cutaneous neurofibromas which are soft flesh colored or hyperpigmented papules and nodules \<2cm in diameter
they are benign skin lesions that occur sporadically and typically solitary in healthy adults.
applies direct pressure to some neurofibromas may cause them to retract into the skin and see a button hole sign.
look for neurofibromatosis
236
what is this?
It disappears if this is compressed
Venous lake
## Footnote
**benign lesion** seen on lips and ears of elderly pts and they appear as gray blue to purple papulonodules and represent dilated venules in the superficial dermis. **_They disappear when compressed_**
They bleed easily after minor trauma
Tx: electrosurgery if lesion is causing bleeding or cosmetic unacceptable. Can also get pulsed dye vascular laser which can remove lesions without scarring.
237
what is this?
**blue nevi.**
smooth surfaced, dome shaped melanocytic papule that develop from macules
tend to be \<1 mm in diameter.
they do not disappear with compression and do not ususally appear on the face, ears, or hips.
found on buttocks, sacral area and dorsum of hands.
238
what is this?
basal cell carcinoma
slow growing papule with pearly rolled borders and overlying telnagiectasia. Found on t**_he upper lip more often_**.
239
pt has rash on her hands and she has periungual swelling on her fingers and some stinging pain and burning at finger tips. works as manicurist for past ten years and worn artificial nails for past 2 yrs.
fingers are mildly warm, edematous and tender to palpation. has fissures at the distal fingers.
This is not mechanic's hands.
This is **allergic contact dermatitis** due to articial nails. it's a delayed hypersensitivity to latex, nickle, soaps, cleaning agents and cosmetic products, rubber and formaldehyde
articial nails contain formaldehyde and acrylates
see periungual edema and eczema and nail dystrophy and periungual hyperkeratosis and fingertip dermatitis
240
what is this?
**acute paronychia** - bacterial infection (most commonly Staphylococcus aureus) see nail fold and surrounding tissues.
Clinical findings include swollen and tender nail folds (posterior or lateral) and often with purulent fluid collection.
241
what is this rash?
**herpetic whitlow** - due to inoculation of the herpes virus into broken skin. See developing tingling and burning of the hand associated with a vesicular rash.
242
what is this?
**psoriasis of the nail** - see nail plate pitting and nail bed salmon patches and onchycolysis- distal separation of the nail plate from inflamed underlying nail bed.
243
rash starts after starting a new drug. What is this rash?
Drug eruption starts within days to weeks of starting a new medication and they are generalized and always pruritic
244
what is this? It's a bump that he noticed last month and appears to be slightly larger. No recent trauma. No tenderness to palpation or drainage. Doesn't change shape when pinched at edges.
**epidermal inclusion cyst.** _Benign nodule_ containing epidermis that produces Keratin and occurs when epidermis becomes lodged in the dermis due to the trauma or comedones. No history of trauma or acne. Can occur anywhere in body but common around the face, neck, scalp, or trunk.
_can remain stable or gradually increase in size_. they can occasionally rupture and result in significant infalmmation and involve surrounding tissue.
it's _diagnosed clinically_. See **dome shaped, firm, freely moveable cyst with nodule with a central punctum (small dilated pore like opening)** and larger more inflamed lesions have a thick yellowish white and cheesy malodorous discharge. They can resolve but can reocurr.
can have this removed for cosmetic reasons but not needed. can become infected and see drainage.
**Gardner's syndrome**- see colon cancer and epidermal inclusion cysts on extremities.
245
what is this skin lesion
**comedones** seen with acne vulgaris- see impacted cells in the lumen of a sebaceous follicle. **Open comedones** (black heads) usually appear black with a wide open orifice and no central punctum
246
What is this skin lesion?
**dermatofibroma** - benign fibroblast proliferation that appears a firm hyperpigmented nodule that is seen in lower extremities. it's non tender and _fibrous component that may cause dimpling in the center when the area is pinched_. See "dimple" or "buttonhole" sign.
247
what is this skin lesion?
this is a **lipoma** or a benign solitary, painless subcutaneous nodule with normal overlying epidermis. Lipomas are soft and rubbery and do not have a central punctum.
248
What is this ulcer?
**chronic venous ulcer** from chronic venous insufficiency.
Treat with **compression stockings, weight loss, aspirin** can help. Leg elvation for 20-30 minutes tid qid. leg exercise helps.
_contraindications to compression stockings_: moderate to severe PAD and active cellulitis.
249
what is this lesion?
**molluscum contagiosum,** self limited and localized skin infection from pox virus. seen in kids, adults, adolescents through skin to skin contact and contaminated fomites
can see this appear with acute HIV or immunosuppressive states.
Can have pruritis or inflamed lesions with surround erythematous patches or plaques.
Tx is **cryotherapy, cantharidin, podophyllotoxin if treatment is needed.**
250
what is this patient's rash?
started abruptly and has this on soles and palms of hands.
diffuse rash that is macular and papular and involving the enitre body (with palms and soles)
Secondary syphilis
251
what is this rash?
had fever, pharyngitis, malaise and followed by diffuse macular rash that progresses into papules and vesicles and there are vesicles in different stages of healing and development. some have crusting.
This is Varicella zoster
252
what is this condition?
This is **senile (solar) purpura** which is a cutaneous syndrome of older adults characterized by intermittent ecchymotic lesions primarily seen on hands and forearms.
This arrises due to blood vessel fragility after years of sun related damage to the dermis. _Platelet counts and coagulation tests are normal_ and **diagnosis is made on clinical appearance.**
This is a **benign condition and requires no intervention**. lesions resolve spontaneously in a few weeks but they can cause residual hyperpigmentation due to hemosiderin deposition.
_Topical steroids and AC will increase_ frequency of episodes.
253
vitamin C intake can cause
scurvy, which causes perifollicular hemorrhage and petechiae and easy bruising.
these lesions are palpable and not restricted to forearms or hands.
254
skin associations with polyartheritis nodosa or PAN?
see erythema nodosum, purpura, or livedo reticularis.
seen with Hep B and C and hairy cell luekmia
see mononeuritis multiplex causing sensory or motor deficits in radial, ulnar, or peroneal distribution with foot drop or wrist drop.
255
Skin tags are associated with
insulin resistance
pregnancy
crohn's dx
256
what is this?
**acrochordons** (skin tags) benign outgrowths of normal skin that appear as soft flesh colored or pedunculated papules.
Seen with DM2, pregnancy, and Crohn's dx.
they appear at areas of friction (axillae, neck, inframammary areas and groin) can become irritated when rubbed or caught on an object (jewelry)
diagnosis is based on clinical appearance.
Tx is not required but can be removed for cosmetic reasons if irrtated
removal by forceps or cryosurgery or electrodessication.
257
What is this?
Seborrheic dermatitis
if new or worsening acutely check HIV
258
large and firmer than skin tags and occur sporadically as solitary lesions in adults. They can be pushed deeper into the skin on palpation and pressure and form a "button" hole sign.
neurofibromas
259
woman has new anorectal lesions and has on and off constipation. three new boyfriends in past year and not using protection. What is this?
how to diagnose it?
This is **anorectal herpes.**
See _multiple shallow vesicular lesions with an erythematous base._
See fever, headache, malaise, tender LAD and painful genital lesions and dysuria.
Need to **get a PCR testing ,** **direct fluorescence antibody** and **type specific serological tests**.
Treat with acyclovir.
260
what is mycosis fungoides?
**Cutaneous T cell lymphoma** which is a low grade cutaneous lymphoma wiht skin homing CD4 T cells. _Course is indolent and involves the skin first_ and with time can spread to lymph nodes, blood and viscera.
light micoscopy of sections of involved skin show hematoxylin eosin
**histological diagnosis** is band-like **lymphocytic infiltrate in papillary dermis** and lymphocytes residing in epidermis and typical **_cribriform lymphocytes in the dermis and epidermis Pautrier's microabscesses._**
261
young person gets herpes (varicella) zoster rash. what to check for?
**HIV 1/2 antigen** and **antibody combo immunoassay**
Test for HIV antibody and test for HIV p24 antigen. p24 antigen becomes detectable a week before antibody in acute infection.
262
how to treat this condition?
pt has red nose and rosy cheeks that is worse in the sun and when he drinks wine and exercises. has a few papules and ruddy appearing bulbous nose and no comedones.
This is rosecea and seen in caucasians
predilection towards women \>30 years old
**phymatous rosecea** causes tissue hypertrophy of the nose and affects _adult men._ can cause tissue hypertrophy of the chin, cheeks, and forehead.
**treatment** is with **avoiding triggers:** extreme temperatures, sunlight, spicey foods, EOTH, and acute psychological stresors and menopausal hot flashes
need frequent skin moisturizing, avoidance of harsh chemicals and gentle skin cleansing are all recommended as well.
**mild erythema** treat with **topical brimonidine**
if **papules treat** with **metronidazole, azeliac acid or ivermectin.**
treat **severe rosecea** = oral antibiotics.
263
what is this rash called?
**sporotrichosis**
- fungal infection with adequate immune system which shows an nodule that later ulcerates and see lymphangitic spread.
latency of exposure can be 3 weeks.
264
Treatment of sporotrichosis is with
itraconazole or previously saturated potassium iodine and terabinafine can be used as a possible first line agent.
