Non-Infectious Skin Lesions and Sports Dermatology -- not on exam 2

Question 1

Blisters (3)

Answer 1

1. If they are tense, they may need to be drained
2. Need to be covered once they are open to reduce friction
3. Prevention: Petroleum jelly on a “hot spot” can decrease the incidence of these blisters

Question 2

Calluses and Corns (4)

Answer 2

1. Very thickened stratum corneum
2. Can occur on feet or hands depending on activity
3. Response to friction so patient should avoid over trimming
4. Can use pumice stone or file but should not share tools.

Question 3

Jogger’s Nipples (3)

Answer 3

1. Occurs in endurance athletes
2. Cover nipples with Band-Aids
3. Vaseline with loose clothing help to prevent chaffing

Question 4

Abrasians (4)

Answer 4

1. Turf burn, mat burn, road rash are all names
2. Epidermis is scraped away
3. Clean with soap and water
4. Apply antibiotic ointment and cover

Question 5

Black nails (5)

Answer 5

1. Occurs in runners, cyclist and tennis players
2. Repeated trauma of the nail against the show
3. Subungal hematoma
4. May need drainage by HCP if painful
5. Prevention- Keep nails short cut and making sure the toe box is adequate; shoes must fit

Question 6

Piezogenic Papules (5)

Answer 6

1. Papules resolve when the patient is non-weight bearing
2. Papules can usually be compressed
3. They mostly occur over posterior and lateral border of the heels
4. They are often bilateral
5. No treatment is required.

Question 7

Painful Piezogenic Papules (5)

Answer 7

1. Restriction of weight-bearing exercise
2. Weight loss
3. Compression stockings
4. Foam rubber foot pads, or foam-fitting plastic heel cups
5. Consultation with orthopedist or podiatry

Question 8

Acne Mechanica (3)

Answer 8

1. Occlusion and pressure for the padding and face equipment in football, ice hockey, and field hockey
2. Clean after work out with benzoyl peroxide wash or astringent
3. Will improve once the adolescent is not longer wearing the face equipment

Question 9

Pitted Keratolysis (5)

Answer 9

1. Intense odor
2. Pits in the epidermis on the feet
3. Needs antibacterial soup
4. Topical benzoyl period is helpful
5. Topical antibiotic such as clindamycin or erythromycin.

Question 10

Mastocytomas (6)

Answer 10

1. Composed of Mast cells
2. Red or red-brown nodules
3. Multiple in urticarial pigmentosa
4. May urticate or form a blister
5. Avoid vigorous rubbing, hot baths, aspirin, alcohol, ibuprofen, and codeine
6. Cyproheptadine (Periactin) for treatment if needed

Question 11

Dyshidrotic eczema (pompholyx) (4)

Answer 11

1. Dyshidrotic eczema presents as very pruritic vesiculopapules on the palms, soles, and sides of the fingers.
   - The vesicle fluid has been compared to tapioca pudding.
2. After healing, they often leave behind a mark with a mahogany color, called post-inflammatory hyperpigmentation.
3. Many patients have a history of atopic dermatitis, and many have coexisting tinea pedis
4. The mainstay of treatment is potent topical steroids

Question 12

Dyshidrotic eczema (pompholyx) location cues to vesicles on feet (4)

Answer 12

1. Dorsal foot: contact dermatitis, insect bites
2. Sides of feet and toes: dyshidrotic eczema
3. Soles: tinea pedis (often with scaling and interdigital maceration)
4. Balls, heels: friction blisters

Question 13

Lichen striatus (2)

Answer 13

1. Rare, idiopathic popular eruption of childhood characterized by the sudden onset of flat‐topped, skincolored or hyperpigmented papules arranged in a linear configuration along the lines of Blaschko
2. The eruption typically resolves spontaneously in a few months to four years. Histology reveals a lichenoid lymphocytic infiltrate with overlying acanthosis and dyskeratosis.

Question 14

Herpes Simplex (7)

Answer 14

1. Herpes simplex viruses 1 and 2 cause painful, grouped vesicles on an erythematous base
2. Vesicles may appear pustular (white to yellow)
3. Tends to recur in the same place
4. HSV 1 favors the mouth and nose
5. HSV 2 favors the genitalia, buttocks, thighs
6. Perianal erosions or ulcerations in immunosuppressed patients are usually HSV
7. Often don’t see vesicles, just the erosions
   - Look for bright red rim on erosion
   - Pain and recurrence suggests HSV

Question 15

Herpes simplex bathing suit distribution (4)

Answer 15

1. Recurrent vesicles on genitalia, buttocks, or thighs, are HSV until proven otherwise
2. HSV usually has bright red borders and may present as pustules, or erosions
3. Severe perianal HSV may occur in HIV or other immunosuppression
4. Single genital ulcers could be syphilis or chancroid as well

Question 16

What Tests are used to confirm diagnosis of herpes simplex? (4)

Answer 16

1. Tzanck prep can be used to confirm herpes family viruses, but it does not differentiate them from one another. It requires scraping the base of an active vesicle or erosion. Results are immediate.
2. Viral culture can be performed when there is fluid present, but it is less helpful once crusts have formed. Results in 1-3 weeks. Not as helpful for VZV. The gold standard for HSV.
3. Direct fluorescent antibody (DFA) test can differentiate HSV 1 and 2, as well as VZV. Like Tzanck prep, scrape the base of a vesicle or erosion. Results in 48 hours.
4. The HerpSelect test is a blood test, which uses IgG antibodies to differentiate past exposures to HSV 1 and 2 but not VZV. Results in days to weeks.

Question 17

HSV Treatment (2)

Answer 17

1. Acyclovir is a safe, cheap, and reliable treatment for HSV; Should be started immediately at first sign of recurrence
   * Acyclovir can be used in pregnancy
   * Intravenous acyclovir is available for generalized HSV or VZV in the immunocompromised
2. Famciclovir and valacyclovir are more expensive but have easier dosing

Question 18

HSV Treatment for Recurrent Episodes

Answer 18

Mounting evidence shows that patientinitiated, oral antiviral therapy works best; Patients start taking at earliest sign of outbreak (burning, pain, itching, etc.)

Question 19

Therapy regimens for HSV (3)

Answer 19

1. Acyclovir 800 mg TID x 2 days
2. Famciclovir 1 gram BID x 1 day (manufacture is pulling this drug off the market)
3. Valacyclovir 2 grams BID x 1 day

Question 20

Tinea Pedis (6)

Answer 20

ATHLETES FOOT

1. Tinea pedis may have fine scales on the sole and between toes
2. Vesicles often appear on bottom of foot
3. Scrape the roof of a vesicle to improve sensitivity of KOH exam
4. Most common in adolescents and rare in prepubertal children
5. Warm moist environment promotes it
6. Transmitted on the floors of locker rooms, swimming pools and household contact

Question 21

Types of Tinea Pedis (4)

Answer 21

1. Moccasin: Diffuse erythema, scaling, and maceration on the plantar surface of the feet
2. Interdigital: Most common and is erythema, scaling and maceration in web spaces
3. Inflammatory: Acquired from animals, presents with vesicles, pustules, and blisters on feet
4. Ulcerative: Interdigital distribution but with more erosions and ulcers

Question 22

Treatment of Tinea Pedis (7)

Answer 22

1. Counsel on foot care to prevent recurrence
2. Keep feet dry; change absorbent socks daily
3. Wear flip flops in locker rooms, pool decks, etc.
4. Use antifungal powders in shoes
5. Azoles (miconazole, clotrimazole) are fungistatic and must be used twice daily
6. Allylamines (terbinafine, naftifine) and benzylamines (butenafine) are fungicidal
7. Cure rates are better with fungicidal antifungals, but generic azoles are usually cheaper