Pediatric Dermatology Flashcards
What is the pathogenesis of acne vulgaris
- increased sebum production
- follicular hyperkeratinization
- proliferation of cutibacterium acnes ( C. acnes)
- inflammation
why does acne vulgaris tend to start during puberty?
- androgen stimulation of the pilosebaceous unit
- changes in keratinization at the follicular orifice
MC places for acne
face
back
upper chest
(places with greatest density of sebaceous follicles)
what medications can cause eruptions of acne vulgaris
- systemic/topical corticosteroids
- anabolic steroids
characteristic lesion types for acne vulgaris
- open comedones (blackheads)
- closed comedones (whiteheads, noninflammatory base)
- erythematous inflammatory papules
- pustules
How would drug induced acne differ from acne vulgaris
drug induced acne has monomorphic inflammatory papules and pustules rather than open and closed comedones (black/whiteheads)
Describe the classification for mild acne
- <20 comedones
- <15 papules/pustules or nodules/cysts
- <30 total
describe the classification for moderate acne
- 20-100 comedones
- 15-50 papules/pustules or nodules/cysts
- 30-125 total
Describe the classification for severe acne
- > 100 comedones
- > 50 papules/pustules or >5 nodules/cysts
- > 125 total
If a patient presents with pruritic acne, what is the likely cause and how is this diagnosed
- pityrosporum folliculitis
- KOH prep
What is the treatment for pityrosporum folliculitis
ketoconazole
Treatment for noninflammatory comedonal acne
topical retinoids
what are examples of topical retinoids
- tretinoin
- tazarotene
- adapalene gel
- trifarotene
What are the side effects and CI of topical retinoids
- SE: photosensitivity and dryness
- CI: pregnancy!!
must have 2 negative pregnancy tests prior to starting an oral retinoid and must use 2 forms of birth control.
What is the treatment for mild papulopustular acne
- topical antimicrobial (BPO + Abx)
- PLUS retinoid
What is the treatment for moderate papulopustular acne
- topical retinoid + oral ABX + BPO wash
- hormonal therapy
what is the treatment for severe nodular acne
- topical retinoid + oral ABX + BPO wash
- hormonal therapy
- can use isotretinoin (accutane) as MONOtherapy.
what is the indication for topical antibiotics? when would you use this as monotherapy
mild-moderate inflammatory (papulopustular) acne.
NEVER used as monotherapy! at least used with BPO
what topical antibiotics are used for mild-moderate inflammatory acne
topical clindamycin
topical erythromycin
clindamycin is used more because resistance is emerging for erythromycin
when do you use oral antibiotics and which antibiotics are used?
moderate papulopustular or severe nodular acne
- tetracyclines (tetra, doxy, mino)
- Macrolides (erythro, azithro)
What antibiotics should be used for moderate papulopustular or severe nodular acne in pregnant patients
Macrolides
when do you use isotretinoin
severe/resistant nodular/cystic acne
this IS monotherapy, do NOT use with antibiotics
what are the CI for isotretinoin
Pregnancy
tetracycline use.
what is the iPLEDGE requirements
For patients starting oral retinoids.
- 2 birth control forms
- 2 negative pregnancy tests
- CMP, Lipids and pregnancy testing monthly
when should you consider stopping oral retinoids or adding a lipid lowering drug
- > 700mg/dl lipids
MC form of alopecia
androgenic alopecia
what is the pathophysiology of androgenic alopecia
DHT causes terminal follicles to transfer into vellus like hair follicles
when does androgenic allopecia tend to occur in women vs men
Men - after puberty as early as 20’s and fully expressed by 40
women - MC after 50
what would you see on a biopsy of androgenic alopecia
telogen phase follicles and atrophic follicles
what would a trichogram show for androgenic alopecia
increase in telogen hairs
what lab studies should be conducted in a patient with suspected androgenic alopecia
- free and total testosterone
- DHEAS
- Prolactin
What is the treatment for androgenic alopecia
- topical minoxidil/rogaine BID
- oral finasteride (MEN only)
- oral Spironolactone for females
atopic dermatitis is mediated by…..
IgE
Where is atopic dermatitis MC found on the body
Face, scalp, torsos, extensors (MC in the flexures)
what is the atopic triad
- atopic dermatitis (eczema)
- allergic rhinitis (hay fever)
- asthma
what characterizes atopic dermatitis
dry skin and pruritus. Consequent rubbing leads to the itch/scratch cycle.
what is the itch/scratch cycle
itching causes increased inflammation and lichenification which leads to further itching.
what results as a consequence of atopic dermatitis due to decreased barrier function
- impaired filagrin production
- reduced ceramide levels
- increased trans-epidermal water loss
acute inflammation in atopic dermatitis is associated with a predominance of which IL
IL 4 and IL 13
acute vs subacute vs chronic atopic dermatitis
- acute: erythema, vesicles, bullae, weeping, and crusting
- subacute: scaly plaques, papules, round erosions, crusts
- chronic eczema: lichenification, scaling, hyper and hypopigmentation
Darker skinned individuals are more commonly known to experience what subtype of atopic dermatitis
follicular
what is the hallmark symptom of atopic dermatitis
intense pruritus
treatment for atopic dermatitis
- avoid triggers and use gentle facewash/moisturizers
- Clearance with low strength steroids
- antihistamines for pruritis
what is the preferred low potency topical steroid for localized atopic dermatitis
desonide
what are the medium potency topical steroids that can be used for atopic dermatitis
triamcinolone
mometasone
fluocinolone
what is irritant contact dermatitis
acute inflammatory reaction that occurs after a single exposure to an offending agent. it is confined to area of exposure and therefore is SHARPLY marginated and NEVER spreads.
what is allergic contact dermatitis
inflammatory reaction that is caused by an allergen that elicits a type 4 hypersensitivity reaction. tends to involve the surrounding skin and may spread beyond infected sites
what is the difference in the presentation of acute vs chronic contact dermatitis
- acute: erythema, vesicles, and bullae
- chronic: scaling. lichenification, fissures, and cracks
What is the treatment for contact dermatitis
- avoid triggers
- topical steroids (max 2 weeks on, 2 weeks off then repeat)
- oral steroids
- PUVA therapy can be used.
what is the etiology of diaper dermatitis
- cutaneous candidiasis
- ICD
- miliaria
what is the presentation of typical diaper dermatitis
shiny erythema with dull margins
what is the presentation of a diaper dermatitis caused by maliaria
multiple papulopustular lesions/pruritus
what is the management for diaper dermatitis
- proper diaper hygiene (frequent changes, disposable, tight fitting)
- keep area dry and allow air flow
- barrier creams (zinc oxide/petroleum jelly)
- candidiasis = nystatin, clotrimazole, econazole
what is perioral dermatitis
erythematous papulopustular eruption involving the nasolabial folds, upper and lower cutaneous lip, and chin
what is the etiology of perioral dermatitis
topical steroids
what is the treatment for perioral dermatitis
- discontinue the steroids (taper!!)
- apply topical flagyl or erythromycin
advise pt that it may flare prior to subsiding
what are the 3 degrees of burns
1st - only epidermis
2nd - epidermis and dermis
3rd - full thickness
what burns are most common in which age groups
young - scalding burns
older - open flame
what classifies a minor burn
- <10% BSA for 1st and 2nd degree
- <2% for 3rd degree
what is the treatment for 1st, 2nd and 3rd degree burns
-1st degree: cold compress and analgesics
-2nd degree: silvadene and analgesics
-3rd degree: referral to burn center
what is the treatment of electrical burn
-watch for entrance or exit wounds
-EKG
-CK
-UA (myoglobinuria)
-BMP (rhabdomyolysis)
what is considered an immediate drug reaction
occurs less than 1 hour of last dose with urticaria, angioedema, and anaphylaxis
what is considered a delayed drug reaction
occurs >1hr but usually before 6hrs, occasionally weeks/months after initiation of drug use.
erythematous eruptions, fixed eruptions, or systemic reactions
which viruses cause eruptions with the administration of PCN
- EBV
- CMV
what is the MC of all drug reactions
exanthematous drug reaction
what characterizes an exanthematous drug reaction
bright red, maculopapular rash that is symmetric. starts on the trunk and spreads to extremities.
can be itchy, scale and desquamate
what is the tx of an exanthematous drug reaction
- identify and DC offending agent
- topical steroids and antihistamines for relief of symptoms
what is a fixed drug eruption
drug reaction characterized by a solitary erythematous patch/plaque that will recur at the same site if re-exposure of offending agent occurs
what is the clinical presentation of a fixed drug eruption
- pruritus
- burning pain
- sharp marginated macule
- dusky red color
Tx for fixed drug eruption
- remove offending agent
- non eroded = topical steroid
- eroded = topical antimicrobial
what is drug induced hypersensitivity syndrome
skin eruptions with systemic symptoms and internal organ involvement
what is the etiology of drug induced hypersensitivity syndrome
- Antiepileptic drugs (phenytoin, carbamazepine, phenobarb)
- sulfonamides (antimicrobials, dapsone, sulfasalazine)
What are the clinical findings for drug induced hypersensitivity syndrome
- onset 2-6 wks after drug initiation or increase in drug dosage
- fever, malaise, facial edema, LAD and HSM
- maculopapular eruption
oropharyngeal mucosal lesions (cheilitis, erosions, pharyngitis, tonsilitis)
what is the diagnostic criteria for drug induced hypersensitivity syndrome
- cutaneous drug eruption
- hematologic abnormalities
- systemic involvement (LAD<2cm, elevated LFTs, elevated BUN/Cr)
what is the treatment for drug induced hypersensitivity syndrome
- stop/substitute ALL suspected medications
- mild/mod reaction = topical steroids
- mod/severe reaction = oral steroids w long taper
- oral antihistamines for symptoms.
what are pustular drug eruptions
acute febrile eruptions that are often associated with leukocytosis after drug administration
what is the presentation of pustular drug eruptions
- sterile pustules on erythematous base starting in intertriginous folds and/or the face
- fever
- leukocytosis
what is the prognosis of pustular drug eruptions
pustules resolve over 2 weeks followed by desquamation 2 weeks later
what is erythema multiforme
acute hypersensitivity reaction affecting the skin and mucous membranes
what is the MCC of erythema multiforme
HSV
what is the clinical presentation of erythema multiforme
- erythematous, papular or urticarial type lesions (may precede bullae by months)
- followed by tense, firm topped bullae
- mucosal lesions
- constitutional symptoms (fever, weak, malaise, fatigue)
- usually BILATERAL AND SYMMETRIC
what are the characteristics of erythema multiforme minor
- little/no mucosal involvement
- has vesicles but no bullae
- no systemic symptoms
- confined to extremities and face
what are the characteristics of erythema multiforme major
- mucosal involvement
- confluence of lesions
- nikolsky sign
- constitutional symptoms
what is the MCC of MAJOR erythema multiforme
drug reaction
what is the treatment of erythema multiforme minor
- antihistamines
- low dose topical steroids
- valacyclovir if HSV
what is the treatment for major erythema multiforme
- remove offending agent
- IV fluids
- magic mouthwash
- systemic steroids for severe
what is the magic mouthwash formula
viscous lidocaine, benadryl, and maalox
treatment for recurrent erythema multiforme
daily prophylactic antiviral therapy
what is the MCC of impetigo
MSSA and MRSA
where does impetigo typically occur
- minor breaks in the skin
- around the nose
- atopic dermatitis
- traumatic wounds
what is bullous impetigo
exfoliative toxin A leads to loss of cell adhesion in the superficial epidermis
who is bullous impetigo MC in?
newborns and older infants
what is the clinical presentation of non-bullous impetigo
- erosions with honey colored crust
- regional LAD
- often asymptomatic but can be painful and tender
what is the clinical presentation of bullous impetigo
- vesicles that progress quickly into bullae
- no erythema
- negative nikolsky sign
- lasts 1-2 days then collapses to leave erosions with crusts
How do you diagnose impetigo
- non-bullous = clinical
- bullous = gram stain and culture
what is the treatment for impetigo
- warm water soaks and topical mupirocin
- keflex or erythromycin for widespread infection
- MRSA = doxy (critical = vanc/linezolid)
Where are common places to see lice outbreaks
- schools
- daycare centers
- nursing homes
- dorms
- prisons
what is the presentation of pediculosis capitis
- lice and nits in hair
- itching
- maculae cerulae
- occipital lymphadenopathy
what is maculae cerulae
purpuric stains on the skin of the occipital scalp and nape of neck
How do you diagnose pediculosis capitis (lice)
- visualization
- woods lamp
What is the treatment for pediculosis capitis
- permethrin (nix)
- removal of nits
what is the clinical presentation of pitryasis rosea
-single herald patch initially (oval flat/raised papule/plaque)
-christmas tree like pattern on trunk
-salmon colored patches
Diagnosis of lichen planus
biopsy
what is the presentation of lichen planus
- flat topped papules
- sharply defined
- whickham striae
- on flexor surfaces
what is the treatment for lichen planus
topical triamcinolone under occlusion
what is the MCC of pitryiasis rosea
HHV 6 and 7
what is the management for pityriasis rosea
- spontaneous remission in 6-12wks
- oral antihistamines
- topical steroids or oral prednisone taper
(basically symptom management until spontaneous remission)
what is scabies
hypersensitivity reaction to mites that burrow into and just below the stratum corneum of the epidermis.
causes HIGHLY pruritic eruption!!
how long after infestation do symptoms begin in scabies?
2-6 weeks after initial infestation
what is the clinical presentation of scabies
- worse at night esp right after getting in bed
- scratching in exam room
- burrow is a fine, thread like line with terminal tiny black speck
- classically SPARES head and neck
Diagnosis of scabies
- clinical
- dermoscopy to visualize mites within the terminal end of a burrow.
- “scabies prep”
true/false a negative scabies prep rules out scabies
false. mites can be difficult to isolate so false negatives are common
crusted scabies is MC in which patient group
immunocompromised or institutionalized patients
what is crusted scabies
thousands to millions of mites
what is the treatment of crusted scabies
- topical permethrin full body application
- PLUS oral ivermectin (days 1,2,8,9,15 and sometimes 22 and 29)
what is the treatment for regular scabies (10-20 mites)
permethrin
what is the MC etiology of SJS/TEN
Drugs
what is the presentation of SJS/TEN
- constitutional symptoms
- NVD, skin tenderness
- positive nikolsky
- full thickness epidermal detachment
- mucosal involvement
SJS vs TEN
- SJS: <10% body surface
- SJS/TEN: 10-30%
- TEN: >30%
what is the treatment for SJS/TEN
- IV fluids and parenteral nutrition
- IV pain meds
- wound care (wet dressing w burrow solution)
- IV steroids/IVIG early!
what is the presentation of tinea capitis
- grey patch with broken off hairs
- black dot appearance
what is a kerion
- inflammatory mass in which remaining hairs are loose
- boggy, purulent, inflamed nodules
what is favus
- perifollicular erythema and matting of hair
- thick/yellow crusts
how do you diagnose tinea capitis
- woods lamp
- direct microscopy
- fungal culture
- bacterial culture
How do you treat tinea capitis
- PO griseofulvin or terbinafine
- ketoconazole shampoo
what is the presentation of tinea cruris
large scales with well demarcated plaques and central clearing in the upper thigh and adjacent inguinal and pubic regions
what is the treatment for tinea cruris
topical ketoconazole
what is the presentation of tinea corporis
sharply demarcated plaques with central clearing and crusting
what is the treatment for tinea corporis
topical antifungal
if large surface area use topical terbinafine
Presentation of interdigital tinea pedis
- dry scaling
- maceration
- between 4th and 5th toes
presentation of moccasin tinea pedis
- scaling with erythema
- papules at margin
- bilateral
Presentation of inflammatory tinea pedis
vesicles or bullae with clear fluid
presentation of ulcerative tinea pedis
extension of interdigital onto the plantar and lateral foot
What is the treatment for tinea pedis
Topical antifungal
what is the etiology of tinea versicolor
overgrowth of malassezia furfur
MC IN ADOLESCENTS
what is the presentation of tinea versicolor
- seen in oily skin
- itching
- macules, patches, and plaques
- NOT contagious
how do you diagnose tinea versicolor
KOH prep showing hyphae and budding yeast (looks like spaghetti and meatballs!!)
what is the treatment for tinea versicolor
- selenium sulfide or zinc pyrithione
- topical ketoconazole
what is the presentation of urticaria
- pruritic, raised, well circumscribed areas of erythema and edema
- dermatographism
what is the treatment for urticaria
- evaluate in ED
- antihistamine + famotidine + steroid
- chronic is PRN antihistamine
what is the etiology of verrucae
HPV
what are the MC areas to see verrucae
- hands/fingers
- knees
what is verruca plana
flat, skin colored verruca MC on face
how do you treat verruca
- file and then use SA
- cantharone
- cryotherapy
