Part 18 Flashcards
Leser trelat sign
A sudden increase in seborrheic keratosis #’s suggestive of internal malignancy in the body
Pyogenic granuloma
A benign acquired vascular lesion of the skin 2ndary to skin trauma, lobular and extremely friable
Dermatofibroma
Benign cell proliferation that appears like a wad of scar tissue that dimples down upon pinching, more common in females due to shaving trauma
Keloid treatment
Only intralesional steroids will help
Epidermal inclusion cyst
Mobile subcutaneous nodule often with overlying punctum that does NOT arise from sebaceous glands, have a foul smelling white discharge, sterile and do not require antibiotics
Milia
Tiny epidermoid cyst often on the face and tends to resolve in infancy but may persist if occur in adulthood
Skip areas
Spots of superficial basal cell carcinomas that remain low in the dermis and continue to replicate even after excision of all the visible lesion - can be avoided by performing mohs procedure to ensure excising what is missed
Important pre-existing factors when considering dermatologic procedure (4)
- anticoagulant/bleeding
- immunosuppression
- diabetes
- cardiovascular disease (the epi injection can be a big deal)
Shave vs punch vs excisional biopsy
- A shave takes a superficial layer and says nothing about the depth of the lesion, but can allow for wide excision, does not scar
- A punch biopsy is a deep incision all the way to the fatty layer of tissue to see how deep a lesion is
- excisional is removal of the entire lesion (diff from incisional which is partial), done in the case of suspect of melanoma within a few cm margins of extra spacing
PUVA
Combination of psoralen and UVA therapy used to treat skin conditions, with the psoralen making it more sensitive to the UV allowing for deep penetrating work on the skin
Actinic keratosis, if left untreated, can degranulate and turn into…
….squamous cell carcinoma
The key to painless lidocaine injections is….
….slow speed of injection with a small diameter needle
Cellulitis differs from erysipelas in that it…
…affects deeper dermis and sub Q opposed to the superficial dermis and has poorly demarcated borders
Necrotizing fascitis
Flesh eating, rapidly spreading infection of deep fascia with inflammation leading to necrosis, can be idiopathic or due to trauma or surgical wounds and has a mortality rate of 30% requiring surgical treatment and antibiotics quickly
Fournier’s gangrene
Necrotizing fasciitis of the perineum region
Predominant infection obtained from dog/cat bites
Pasteurella multocida
___% of cat bites become infected, ___% of dog bites do
80, 5
2 booster vaccines for animal bites
-tetanus -rabies
Pseudofoliculitis barbae
Refers to razor bumps of the beard
Nikolsky’s sign
Slight rubbing of skin resulting in exfoliation and wet appearance of skin indicating staph scalded skin syndrome
Community acquired MRSA vs Hospital acquired differentiaion
Considered community acquired if not undergone any medical procedure or hospitalized within the past year
CA (3) and HA (2) MRSA treatment
Community: -Sulfamethoxazole (bactrim) -tetracyclines -clindamycin Hospital: -vancomycin -linezolid
Ways to test for fungal infections (3) and which is the gold standard
-KOH prep -culture (gold standard but takes time) -woods lamp
Cornyebacterium minitussiumm
Causes erythasma, and is NOT a fungus but fluoresces with a woods lamp with a bright coral red color
All types of tinea respond to the same oral and topical agents except…
…tinea versicolor
“one hand, 2 feet syndrome”
Refers to moccasin type presentation of tinea pedis where an affected hand shows unilateral scalingin creases and indicates to look at feet for tinea pedis
Pitted keratolysis and what is the recommended treatment
A bacterial in origin condition often mistaken for tinea pedis or plantar warts that has much lowered severity of itchiness and pain and appears as little pitted spots on soles of feet, treated with drysol (aluminum chloride)
Tine corporis treatments (2)
-Topical antifungals for at least 2 weeks (sue even if goes away visually) -oral antifungals if resistant but watch liver function
If dermatitis is treated with topical steroids, it will initially appear ___ and this is called ____
better, tinea incognito
___ agents do not work for tinea capitis
TOPICAL
Inflammatory tinea capitis is a dermotologic emergency because…
…it can lead to permanent balding and scarring
Tinea versicolor (pityriasis versicoor)
A yeast infection not a dermatophyte, can cause some itching and can appear very variantly but does not have visible scale until rubbed with finger or scalpal blade (differentiates from tinea corporis)
Tinea versicolor (pityriasis versicolor) treatments (3)
-Topical shampoos (selenium sulfide) -imidazole creams -oral medications such as fluconazole but monitor liver
Seborrheic dermatitis
Also known as dandruff, common inflammatory rxn to eyast that thrives on seborrheic skin and causes inflammation to normal flora, chronic condition that can be controlled but not cured
Seborrheic dermatitis treatments (2)
-Topical shampoos (selenium sulfide) -imidazole creams
Diaper candidiasis treatments (1) and what treatment should be avoided
-nystatin cream Combination therapieswith high potency steroids
Keratolytic agents
Drugs that promote the shedding of the stratum corneum layer of skin causing peeling to extensive desquamation
Salicylic acid drug class and function
Keratolytic agent, promotes desquamation by disllolving intracellular cement that binds scales to stratum corneum used in low conc. to treat dandruff, seborrheic dermatitis, acne, psoriasis, warts, and corn
Salicylic acid ADR
-salicylism (same as in aspirin thru absopriton of skin) casuing tinnitus and hyperpnea
Benzoyl peroxide function
First line drug employed topically to treat mild to moderate acne, penetrates stratum corneum or follicular openings unchanged converted metabolically within epidermis promoting keratoysis and suppressing growth of P. acnes (does not cause resistance)
Dapsone function
Topical agent that provides modest decrease in inflammation often as an alternative to benzoyl peroxide
Tretinoin drug class and function
Retinoids, derivatives of vit A, approved for treatment of mild to moderate acne thru decreasing cohesion between epidermal cells remove existing comedones aand preventing formation of new plugs
Isotretinoin (accutane) ADR’s (7)
- nosebleeds
- inflamation of lips
- dryness and itching of skin, nose and mouth
- loss of night vision
- UV sensitivity
- psychological effects
- teratogenic during pregnancy
iPledge program
FDA mandated program to manage accutane related teratogenicity requires 2 active forms of birth control
Methotrexate drug class and function
Immunosuppressent, cytotoxic agent that targets tissues with high growth rate, only should be used when severe psoriasis has not responded to safer therapy
Methotrexate ADR’s
- systemic administration can result in toxic effects
- GI effects
- bone marrow suppression
Cyclosporine drug class and function
Immunosuppressant that can treat moderate to severe psoriasis
Tumor necrosis factor antagonsists function
Inhibition of TNF suppresses immune function reducing inflammation in psoriais, very effective but can increase risk of opportunistic infections
Interleukin 12/23 antagonists function
Human monoclonal antibody directed againast interleukins 12 and 23 that promte inflammatory response, to decrease psoriasis
Ketoconazole function
Antifungal cream and shampoo for seborrheic dermatitis
Finasteride (propecia) drug class and function
5-a reductase inhibitor, Indicated for treatment of hair loss of males, inhibits conversion of testosterrone to DHT causing decrease in DHT conc. in scalp
Flurouracil function
PO antineoplastic agent used for topical treatment of multiple actinic keratoses and superficial basal cell carcinoma thru interupting DNA and RNA synthesis
Tacrolimus (protopic) oitnment drug class and function
Calcineurin inhibitor (immunosuppressent) used to treat severe atopic dermatitis by reducing local immune response
UVA vs UVB
UVA is 95% of terrestrial UV radiation and penetrates skin much more deeply causing most skin aging, UVB is 5% and main cause of tanning and sunburn
SPF to sunburn protection relationship
As SPF increases, protection increment becomes smaller, with values greater than 30 providing minimal benefit and products not being allowed to be labeled above 50 (just called 50+)
Mupirocin (bactroban) function
Inhibitor of protein synthesis and thus bactericidal topical agent against MRSA often used to treat impetigo or intranasal use for elimination of nasal carriage of S aureus
2 DOCs for scabies and pediculosis (lice)
permethrin and malathion
Permethrin function
Agent of choice for mites and lice, toxic to them and their ova killing them by causing paralysis with minimal side effects
Malathion function
Agent of choice for mites and lice, has enzyme that kills lice and ova as an insecticide, devoid of significant ADR’s
The lowest risk for skin cancer development is fitzpatrick skin type ___, the highest risk is fitzpatrick skin type ___
VI,I
3 common types of skin cancer and info about them
80% - Basal cell carcinoma (arises stratum basale), typically does not metastasize and is locally destructive
20% - squamous cell carcinoma (arises epidermis), substantial risk of metastasis and AK is precursor
1% - melanoma (melanocytes in stratum basale), most aggressive and most likely to metastasize
Pathologic staging of melanoma (2 ways)
- breslow thickness (preferred)
- clark level
Golden rule of diagnosis of skin cancer
Always obtain full thickness specimen, not shave biopsy
Koplik’s spots
Red spots with bluish white centers that appear in the mouth as an enanthem before exanthem spreading systemically indicative of measles infection
Measles symptoms
Severe cough, nasal congestion, photophobia, koplik’s spots 24-48 hrs before exanthem outbreak
Exanthem definition
A skin eruption that comes quickly and affects several areas at a time, a rash essentially
Enanthem definition
A mucus membrane eruption that comes quickly and effects several areas at a time
Hand foot and mouth disease
Caused by coxsackievirus A16 spread via fecal oral route often in kids resulting in low grade fever, sore throat, and lymphadenopathy, with 90% developing enanthem oral lesions followed by red macules that become pale, white, oval vesicles on palms, soles, face, and buttocks
Scarlet fever
Contagious disease produced by strep toxin, see strawberry tongue, N/V/D, and fever greater than 101 derees, really fine rash begins on neck and face and spreads over 48 hrs sparing the palms and soles and has sandpaper quality with pastia’s sign
Rubella
Contagious viral infection with nonspecific signs and symptoms but can have conc. to unborn causing fetal anomalies (blueberry muffin lesions), see a rash on neck or face that fades in 24-48 hrs, ask patient if they or anyone they are in contact with is pregnant
Congenital Rubella Syndrome triad of clinical effects
-Cardiac malformation -hearing deficits -ocular anomalies
Fifth disease
Parovirus B19/erythema infecetiosum, common in children 4-10. primary cause of aplastic crisis in sickle cell children, results in congenital anemia if in utero infection or hydrops fetalis, has 3 stages of facial erythema (slapped cheeks), net pattern erythema (fishnet on extremities) and recurrent phase (eruption fades and reappears next 2-3 weeks)
Kawasaki disease
Children disease with febrile phase for greater than 5 days, swelling and redness on hands and feet, and cervicallymphadenopathy, if left untreated can see arteritis
Kawasaki disease treatment (2)
-high dose aspirin -IVIg
Reye’s syndrome
Rare condition that affects liver and brain and has been shown to be caused by aspirin in children
Psoriasis primarily targets the ___ surfaces and eczema on the ___ surfaces
Extensor, flexor
Koebner’s phenomena
Tendency for psoriasis to occur at sites and in shapes of where trauma to the body has occurred
Lichen planus vs psoriasis
Lichen planus is very smooth and often found on flexor surfaces and only lasts for a period of time, psoriasis is very rough and lasts an entire lifetime
Psoriatic arthritis
Condition occuring in 5-10% of patients with psoriasis, results in distal phylangial “pencil in cup” appearance
Calcipotriene (dovonex) for psoriasis treatment
Vit D3 analogue that inhibits cell proliferation and is safe to apply topically on skin without affeecting Ca2+ body conc. for treatment of psoriasis
Bed bugs
Red blood sucking insects that hide during day and emerge at night to feed, saliva causes itches and welts in most patients, capable of living one year without food, cannot transmit disease
Bed bugs treatments (3)
- prevention looking for smears on bed linen
- topical steroid creams
- laundering, pesticides, heating, freezing, vacuuming
Crusted/Norwegian scabies
Rare form of severe scabies only present in immunocompromised patients
Malar rash
Lesion that occurs when systemic lupus is active, a classic rash in sun exposed areas that spares nasolabial folds and knuckles and is nonpruritic
Sicca syndrome/sjogrens
Associated autoimmune disease occurs with lupus, indicated by dry eyes, sandy feeling in eye, dry mouth
Positive ANA
A cardinal feature of lupus erythmatosus, indicates 90% likely positive, chances of false positive increases in older patients
Dermatomyositis
Rare inflammatory muscle and skin disease that typically presents with a violet colored red rash that does not spare the knuckles followed by proximal skeletal muscle weakness and inflammation, gottron’s papules are pathognomonic finding, often autoimmune and co-occurs with malignant tumor (and resolves with their clearance)
Gottron’s papules
Round 1cm red flat topped papules that occur ofer the knuckles and alongside the sides of fingers pathognomonic for dermatomyositis
Signs of Crest syndrome (5)
- telangiectasia
- raynauds
- esophageal dysfunction
- sclerodactyly (claw hand)
- Ca2+ deposit buildup
Wegner’s granulomatosis and how does it relate to pharyngitis
Inflammatory dz of the blood vessels that if left untreated can be fatal, has subtle onset and is caused by autoantibodies against proteinase 3, often have sore eye, ear, and stuffy nose and SORE THROAT (keep it on differential for pharyngitis)** as well as microscopic hematuria
How long to avoid contact sports after mono infection?
1 month resolution of symptoms
“bull neck” is a common finding of what condition?
Diptheria
Diptheria signs and symptoms (3)
- sore throat, malaise
- spots of gray and white exudate pseudomembrane
- bull neck
Scarlet fever as a result of strep pharyngitis infection signs and symptoms (3)
- sandpapery red reash
- strawberry tongue
- pastia lines in the antecubital fossa
Centor score
Addition of 4 variables to determine likelihood of follow up for culture to confirm suspected positive, with higher scores increasing probability of positive culture and 1-2 variables only requiring rapid strep initially
Trismus
Inability to fully open jaw (limited motion, lockjaw)
2 most common benign nonhereditary sources of pediatric neck masses and 2 most common benign hereditary ones
1) cervical adenitis
2) cat scratch disease
1) branchial cleft anomalies
2) thyroglossal duct cyst** (usually inferior to the hyoid and soft cystic)
90% rule for pediatric neck masses
90% are inflammatory or congenital, higher likelihood of malignancy in adults
Recall the anterior and posterior triangles of the neck
anterior: mandible, SCM, midline
Posterior: clavicle, SCM, trapezius
Standard of diagnosis for neck mass
Fine needle aspiration biopsy
Removal of parotid tumors raises this complication during the procedure…
…facial nerve palsy
Carotid body tumor (paraganglioma) and diagnosis (3)
A highly vascular usually benign neck mass affecting chemoreceptors of the carotid body, pulsatile and if functional can cause flushing or HTN from catecholamine release, requires clinical diagnosis and plasma 24 hr urine for catecholamines followed by confirmatory angiogram or CT
Bartonella henselae and treatment (1)
Cat scratch disease transmitted by flea or kitten over period of few weeks see regional lymphadenopathy, erythema, and tenderness, treated with macrolide antibiotics
Most common causative agent of acute otitis externa
P aeruginosa
2% acetic acid solution
Very cheap, safe, and effective bactericidal OTC agent for otitis externa often completely treating it on its own
Fluorquinolones for otitis externa (Cipro + hydrocortisone), (cipro + dexamethasone), (ofloxacin)
Preferred prescribed today as no ototoxicity or local rxns, used topically
Cough mech of action
Important defense reflex of respiratory tract starting with deep inspiration followed by closure of glottis and forceful contraction of chest and abdominal wall against closed glottis, that then opens and with high velocity propels mucus, debris, and foreign material from lower respiratory system
Opioid antitussives names and mech of action
(codeine and hydrocodone) Suppress cough decreasing intensity and frequency acting on CNS respiratory centers in medulla raising cough threshold
Dextromethorphan definition
OTC derivative of morphine with no analgesic or addictive properties at recommended doses, used in most OTC cough preps, has not been shown to be safe or effective in young children and at high doses can be abused
Reye’s syndrome
Rare disorder following viral illness most commonly, occurs in children and can result in brain and liver damage as a result of giving ASA to children
Decongestants used to relieve the symptoms of common cold (2)
-phenylephrine (OTC and not very effective) and pseudoephedrine
Choanal atresia
Absence or impaired development of nasal passage
The nasolacrimal duct empties into this part of the nose resulting in rhinorhea when crying
Inferior meatus
Translumination of the sinus
If seeing light shines thru the hard palate that implies air and that it is clear, however if it does not emit then that implies a fluid filled cavity
Pott’s puffy tumor
Superiosteal Abscess and osteomyelitis of the frontal bone that is tender, pitting, requires I and D and IV antibiotics
Most common pediatric illness causing stridor (6-36 months)
Croup/acute laryngotracheobronchitis
Croup/acute laryngotracheobronchitis presentation
Starts with URI symptoms, low grade fever, within 1-2 days develop hoarseness, barking cough, respiratory distress, symptoms resolve within 3-7 days but most can last 2 weeks
Westley croup score
A survey to score symptoms between 0-12 ranging severity with 12 being impending respiratory failure in a patient with croup
Croup diagnosis (3)
- primarily clinical
- AP neck radiograph presenting with steeple sign
- CBC and other basic shit
Croup treatment (mild and significant (3))
- Mild can be done at home with management
- significant respiratory distress will require oxygenation with ventilatory support (bag ventilation mask but potentially intubation (rare less than 2%)), single dose dexamethasone .6mg/kg oral, IM, or IV, or nebulized racemic epi
Epiglottitis
Acute inflammation caused by bacterial infection typically of epiglottis and surrounding tissues, uncommon in US more common in populations lacking against Haemophilus influenza type B immunization, viruses do not typically cause but can predispose to bacterial infection, sees RAPID* symptom progression, often present with sore throat, dysphagia, hot potato voice, tripoding
Classic clinical triad of epiglottitis
Drooling
Dysphagia
Distress
Epiglottitis diagnostic studies (3)
- secure the airway first**
- nasopharyngoscopy/laryngoscopy
- thumb sign on x ray
Ludwig angina
Rapidly progressive gangrenous “woody” or brawny cellulitis of the sublingual and submaxillary spaces of the neck typically odontogenic in source from 2nd and 3rd molars most commonly, presents as bilateral submandibular swelling with elevated protruding tongue and airway compromise is a potential complication
Procedures employed to remove foreign body (2)
Chest x ray followed by Rigid bronchoscopy
Dentition through the life cycle
- 2 sets of teeth
- 20 deciduous teeth 6 month to 2 years
- shed between ages 6-12
- replaced with 32 permanent teeth
Crown of tooth
Portion of tooth exposed to oral cavity, covered in enamel which is the hard white substance covering it acting as the hardest material in the body
Root of tooth
Portion of tooth under gums extending into the bone
Vincent’s angina (trench mouth)
Polymicrobial opportunistic infection from poor oral care, painful bleeding gingiva, fever, etc
How to differentiate between oral thrush and leukoplakia
Oral thrush can be removed manually and has red spot underneath, leukoplakia cannot
Familial Adenomatous polyposis (FAP) manifestation oral exam (what study is required immediately upon diagnosis)
Growth of multiple torus (slow growing bone on palate or mandible) that require immediate colonoscopy as cancer will develop
Most common causative pathogen of croup
parainfluenza virus
Chronic hoarseness associated with otalgia is often concerning for
Laryngeal carcinoma
Mild, moderate, and severe croup treatments
Mild - dexamethosone
Moderate - nebulized epi + dexamethasone
Severe - nebulized epi + dexamethasone + admission
Polypoid corditis (reinke’s edema)
Edema results in vocal fold mass with progressive deepening of the voice (low pitch and husky) in smokers or those with laryngopharyngeal reflux
