Rashes 3 Flashcards
Valtrex for lip sore dose and sig
500 mg BID x 5 days
Can give to pts who have 2-3 outbreaks per year to have on hand
For occasional pimples on forehead
Cleocin T gel BID to dry them up
Which labs to order on Accutane pt
CBC CMP lipids hCG monthly x 5 months
If LFT >700 stop
If > 400 talk to docs
Which 3 recommendations for solar purpura
Dermamend
RUTIN 500 BID OTC
DermaBlend foundation with spray
Intergluteal rash (macerated)
MC cause
Toilet wipes are MC cause
Could be dermatitis or Inverse psoriasis
Mometasone
Suppurative
Pus formation
SE of minocycline (2)
HA, dizziness
Lupus like : joint aches and dizzy
Rosacea of scalp sx
Tx
Follicular based papules can be itchy and painful
Is rosacea same as folliculitis acne necrotica militaris
Doxy (minocycline if doxy doesn’t work, HA dizziness) Betameth lotion BID T Gel (for irritation) and TSal (for flaking) every day alternate
T Gel and T Sal - what conditions to use in
T Gel for irritation and T Sal (for flakiness)
Scalp psoriasis
Rosacea of scalp (Acne Necrotica Maliaris)
Another name for rosacea of scalp
Acne Necrotica Miliaria
Stasis dermatitis flare
Was given RUTIN and fluocinonide
When retain fluid, it seeps into skin and in skin, it breaks down into hemosiderin and it is very rash and itch provoking so need Job stockings or Ted Hose daily.
If fluid just sits there - it can cause ulcers
So the only 3 options for tx:
- hose
- elevation
- PCP to give you diuretics
For ITCH:
1 lbs of TAC for legs (and back - looked like ID reaction from Stasis)
Allegra could help itch!
Tx for intergluteal rash
HC 2.5 BID prn (don’t need 2 weeks on/off)
If nothing helps with GA, which oral tx
Plaquinile
Pityriasis amiantasia is a form of
Psoriasis
Inject at 90 degrees about .1 per each 1 cm area
Digital mucous cyst cause and tx
Indicative of arthritis
It sunovial joint fluid due to inflammation of joints
Tx: dont LN2 or EDC because can cause deformity of nail matrix
- can lance it (18 G or 11 blade) and jelly comes out but will refill in couple days (sometimes doesn’t refill)
- definitive tx - hand surgeon but even then it can refill
Scalp Psoriasis tx
Betameth oint BID indefinitely T Gel (to decrease redness and itch) and TSal to decrease scale
RTC 8 wks - if not better, do IL Ken 5 mg (so 10 mg 50-50)
Perfect distribution for Pityriasis Roses (PR)
Upper arms and mid thighs
Also trunk
From neck down to mid thighs
If recurrent BCC Or SCC, what tx
Always excise
SE of Plaquinil and what conditions for
Nausea
Rare risk of anemia and blindness
For interstitial GA
Pt edu about GA
In Adult - benign rash that comes and goes, no cause, may resolve over many years on its own, Tx options are plaquenil pill - SE nausea, blind, anemia
Or light therapy or topical steroid
Drugs.com
Tx for Grover’s
If itchy - TAC and Allegra
Pimple should resolve in how long and when to bx
In 2-3 weeks
If there at 4 weeks, do bx
For pruritic nodules ILKen, use what dose (dilute)
Direct Ken 10 without saline
How to tx GA?
Topical steroids then IL KEN
Plaquinil
What medical history question to ask pt suspected of LP
History of hepatitis?
Tab tx for LP and how long
Flagyl BID x 3 weeks
If pt with contact derm’s is not improving, what is the next step
TRUE allergy test
LPP follow up - what to look for
Improvement in crusting
New hair loss (pull test)
No pain or itch?
If all of the above good, continue Nizoral shampoo and RTC 8 weeks
If not better on Betameth and Nizoral shampoo, then IL Ken (5mg?)
Whic medication increases risk of SCC by 7 times
HCTZ
Tx for Scalp psoriasis and pityriasis amyantasia
Betameth lotion BID
Alternate T Gel and T sal, wash daily
If not better, IL Ken 50-50 (so 5 mg)
Groin intertrigo tx
Mometasone and ketokonazole
White boxes
Will get worse in summer so y=use above for flares and hairdryer with ZAsorb powder for maintenance
Which chemist drug is good for Merkel Cell
Ketruda
Asx bump on R deltoid
-Put on Doxy 100 BID x 1 week
-Plus Do punch Bx for H&E (neoplasm of uncertain ETIOLOGY) - came back GRANULOMATOUS DERM’S
- So do another punch for fungal culture
- Plus order labs: CBC, CMP, Cocci, Quant TB Gold
SED RATE
(Or do 2 punch bxs for H&E and for fungal culture)
What to do when Bx is back as GRANULOMATOUS DERM’S
Do another punch for fungal culture
PLUS labs: CBC, CMP, cocci, quantiferon TB Gold, SED Rate
Acne militaristic Necrotica is and tx
Extra facial rosacea on Scalp
Pain and itchy bumps
Doxy 20 BID 3 month supply (+1 rf) and Nizoral (bc rosacea and seb derm go together, anti fungal, anti yeast and anti bacterial/inflammatory)
How can GA present in kids
Pale pink plaque with rased border but without scale and with bumpy center of plaque (papules sticking out through plaque)
Tx TAC oint on rim only
The resolving lesions are flat patches and brown (will go away)
Benign rash - deep inflammation so not epidermal (no scale)
Goes away in 2 years
When does GA go away on its own
In 2 years
Is nummular eczema common in kids
No
OTC supplement for solar purpura
RUTIN 500 BID
If do punch for culture, how must submit specimen
With preservative free lido (or saline??)
What to ask putting pt on Flagyl and what for
SE of Flagyl
For LP BID x 3 weeks
Ask if any liver or health problems
SE: not a drop of alcohol, dizziness, neuropathy, (numbness/tingling in toes and fingers), upset stomach
+ cont on Betameth BID 2 weeks on/off (for body)
What top steroid to use for neck rash
Mometasone BID for itch
What strength of IL Kenalog for pruritic nodules
10 mg (don’t dilute) Inject .2-.3 per nodule
When does LP clear on its own?
8-10 months
Which rash presents with URI first?
Pityriasis Rosea (PR) - first URI, then 2-4 weeks later get itchy spots: tx betameth BID2 wks on/off PLUS Allegra QD. GOes away in 6 weeks!! Pink oval along skin lines
Guttate psoriasis
Tx for acute paronychia/ingrown toenail
Keflex 500 TID
Bactrian oint QD
See podiatrist
Ring worm tx and presentation
Papules in a ring OTC lamisil (?)
Onychorhexis is and tx
brittle nails
Nailtique #?
Biotin
Decrease hand washing
Bluephritis
Inflamm of eye lids
Tx: Allegra and aquaphor
Normal pimple should last how long
7-10 days
If doesn’t resolve in 2-3 week, must bx
How to select IL Ken concentration for Keloids
And RTC
Start with IL KEN 10 , if keloiddecreases by 50% - correct dose, if not increase dose
RTC in 4 weeks
Common culprit of eyelid dermatitis
Nails
Eye drops
Shampoo
Hair spray
What to ask pts when putting on Aczone
Sulfa allergy
Onychogriphosis
Huge nails
Pseudo folliculitis Barbae tx
Cleocin T and differin
GROW hair OUT, don’t shave
Wart tx
Best is LN2 q 4 weeks and compound W together
Which labs to order when starting pt on Humira
Which SE
SIG
Labs; CBC (infection or leukemia), CMP, Hep C, Hep B CORE Ab and antigen, HIV, QUantiferon TB GOld,
SE: cancer and infection
Q2 weeks injection
Which labs for Otezla
And SE
SIG
No labs except CMP to see kidney fx
-Ask if any kidney problems or joint pains
Tabs QD
SE: HAx 1 month, goes away, use Tylenol
DIarrhea with coffee x 1 month
Depression
Why loss
Only 60% effective, least effective and least SE
Humira SE
Increased infection and cancer
Inj q 2 weeks
Cosentyx
Strongest and newest - dont’ know all SE Q4 wks
Stronger than Stilara for severe psoriasis
Tx option for BSA >10% of psoriasis
Light tx or systemic
Methotrexate SIG and SE
Sig: 1 tab Q week
SE: Anemia, N/V, liver damage (cant drink at all) - if tx for 1-2 yrs, do liver bx
Which psoriasis areas are covered by insurance
Hands, feet, buttocks, scalp
If joint pains (but not occasional wear and tear)
No breast feeding on which Psoriasis med
Cyclosporine
Add Folate to which psoriasis med
Methotrexate
Anti TNF psoriasis med
Humira and Enbrel
Which one of systemic Psoriasis tx’s can’t get pregs on
Methotrexate
Nummular eczema in LE can be worsened by what condition
Edema so use hose during day and elevate legs
Which systemic med can increase sweating
Prednisone
Aldara is FDA approved for which cancer and in which distribution
On BCC Superficial ONly and ONLY below neck
Superficial BCC is one which has cell skipping around like pebbles and recurrence rate is higher so excision is good, EDC is good, Aldara for below neck
Tx for TINEA Pedis
Fungus
Lamisil BID x 3 weeks and spray OTC weekly
Dry well after shower and color safe bleach for socks
Name for xerotic dermatitis
Asteototic dermatitis
Which test to order in dermatomyocitis
Which is the #1 underlying cause of it?
TRANS VAGINAL US (ovarian cancer)
On which drugs can’t get pregs (7)
Spironolactone Doxy Accutane Tazorac Retinol (Clindamycin only for pregs?) Class 1 steroids Methotrexate
When see something dark inside a digital mucous cyst, it’s called
Tindle effect
When there is plaque with no scale, it’s
Lichenified plaque
When does GA resolve on own
In 2 years
What to always ask a pt with acne (2 things)
Anything on back and chest?
How much milk?
Micaceous definition
Sparkly brilliant resemble mica
Use what for itch in LP
Antihistamines - hydroxyzine and Allegra
HIves started 2 days ago, took Benadryl
Any new meds? No
Get Allegra BID, if doesn’t work do Doxepin rx
How to tx Balanitis
Sweat leads to infection with yeast or fungus; it comes and goes with increase in sweating and heat
For flares: ketoconazole cream
For maint: ZAsorb powder daily
To decrease flares:
- boxers instead of briefs to increase airation bc increased moisture causes increased rubbing and leads to yeast accumulation
- keep body dry - hair dryer
- no HOT water, use Vani soap
- ZAsorb QD: absorbs moisture and has microconazole in it (antifungal and anti yeast)
- worse in AZ during mansoon season
- there is no infection or cancer - just area of accumulated moisture and irritation due to increased rubbing which causes break in skin and yeast gets in
OK to use TAC for face?
Ok only for 1 week BID (if giving pt TAC for FUDEX on arm)
How to explain stasis derm to pt
More of a a vein problem - don’t get blood back to heart, consequence of circulation and blood pulls down to LE
No hot shower, vani
Hose, elevate, PCP diuretics
Check arms
Cervical itch is called
Nostalgia parasthetica (in central upper back)
After accident
Tx: TAC, if not better - capsaycene cream (jalapeño juice)
White nail is
Normal white part near proximal nail fold is
Leukonychia
Lunula
What is in the compounded topical for onychomycosis and what allergy to ask pt about
Topical itraconazole + DMSO (tastes like rotten egg when absorbed) + ibuprofen
Check if pt has IBU allergy
How often to get labs checked on pt on Stilara
How often administered
Recommend what preventative steps for pt
Ask what?
What is CI in Stilara
Once a year: CBC CMP Cocci TB HIV
Inj q3 months
Get PNA and Flu shots (ok 18+ if immunosuppressed) AND healthy life style because risk for heart attack (and stop smoking)
Ask if any f/c/cough or site rxn?
LIVE VACCINES are CI so can’t do shingles
Can’t get pregs on which meds (7)
Tazorac
RetinA(Clindamycin ok)
Spironolactone!! Must be on OCP tubal ligation or condoms Doxy Methotrexate Class 1 steroids Accutane
White nails
Terry nails (leukonychia)
Prurigo Nodules and excoriation
White gloves, clip nails QD, NAC
RTC 8-10 wks
Can inject with kenalog
Not warts
Psoriasis on nails tx before systemics
Betamethasone oint AM
TAZORAC PM
Psoriasis tx and if not better when RTC
Beta BID 2 on off
If not better:
Beta AM and Tazorac .1% PM (decreases scale and increases penetration)
OR
Continue Beta BID 2 on off and DOVONEX
If not better, ECZEMER laser (light tx)
If psoriasis pt has joint pains, do what
Referrals to rheumatology
Good starting systemic drugs for widespread psoriasis
And don’t use which systemic biologic?
Start with Humira or Stilara (both good starting points)
Don’t use Enbrel - not as good as Humira
If not better on above, use Cosentyx or trump is
Pt with psoriatic plaques tx options (BSA<10)
FIrst Beta BID on/off RTC 8 weeks NOt better : - Beta AM and TAZORAC .1% PM (not pregs) (to decrease scale and increase penetration) OR -Beta AM and DOVONEX PM NOT better on above: IL KEN 3.3, (if 50% better, ILK 5mg) In not better: EXCIMER LASER
Which psoriasis areas does DOVONEX work well on
What other tx for those areas
Intergluteal and inguinal creases
Use Mometasone BID (not 2 wks on off)or Protopic (or HC 2.5 BID not 2 wks on off)
If pt not improving on scalp psoriasis tx, ask what
Are you picking at it? Be gentle
Scalp psoriasis tx
Beta BID (not 2 on/off) with TGEL TSAL
If not better: IL KEN
If not better: Ask if picking and EXCIMER laser
Female psoriasis with 25% BSA and h/o breast cancer 8 years ago, tx options
Not otezla - not approved
Not humira bc SE cancer
Light tx only!
Psoriasis pt with 25 BSA and h/o MM, can’t do what tx and do what biologic
Can’t do light rx and can’t do Humira
Can only do Otezla with h/o cancer
what does interstitial GA look like and distribution
And what’s on DDx if in a certain distribution
Faint red ubiquitous papules across lower abdomen/fold (intertrigo distribution) and lateral thighs bilaterally BLANCHABLE!!!, granulomatous papules = under skin without scale (unless dry skin all over)
Looked like pink solid tapioca
DDX: TMEP if only on thighs (talengictasia macularis which is cutaneous mastocytosis)
Name of huge BCC on nose
Fibroepithilioma Pinkus
18 yo F NP with primarily comedians acne and some inflammatory,
Tx plan
- Epiduo QAM for comedonal, rtc 8 wks
- Not better at 8 wks:
- ask if tolerating EpiDuo ok, is it too drying, DID YOU USE IT??
- increase to Tazorac 0.1% cream PM with Efficlar or Clindamycin AM
- OR EpiDuo BID - Not better in 8 wks:
- Facials with Tina (stop tazorac 1 week BF)
- OCP with PCP (Yaz, Yazmin or orthotricyclen)
TMEP is
Talengiectasia Macularis Eruptiva Perstans (cutaneous form of mastocytosis)
15 yo boy with very inflammatorya acne on face, chest, back with early scarring, tx plan
-Face: epiduo plus Doxy 100 QD
Back/chest: PanOxyl wash x 10 min (use old towels)
Which advise to give ALL pts with rash
Lukewarm shower only, no hot
Which drugs for back and chest acne
Spironolactone (must be on OCP, birth control, C/I pregs
Pityriasis roses disctribution and tx
Upper arms, upper back, chest and neck
TAC for body and mometasone 0.1% cream BID for neck
Luckwarm shower, outside sun TIW 10-15 min
Which topical is good for both seb derm and rosacea
Sulfa based
Sulfacetomide wash or lotion or ophthalmic drops (for eye lid rosacea or seb derm)
Never undermine which excisional biopsy?
When suspect MM
Uniform pink red rash on neck, do what
Press - dermatographism
Rash on bottom of feet is called
Palmoplantar pustulosis (psoriasis form)
Beta BID 2 wks on off
On off weeks - Protopic and urea
How often is excimer laser
Twice a week for 8 wks
30 yo with jawline acne tx plan
Start with spironolactone 50 mg QD (can’t get pregs,hCG negative)
EpiDuo AM and Clindamycin HS
If not better, add aczone pm and cont spironolactone
If still not better in 8, increase spironolactone to 100
20 yo F with severe comedonal and some inflammatory acne on face and back (not jaw, couple on jaw) (Tx plan)
Start on EpiDuo AM and Doxy 100 PM
(EpiDuo has retinol to open up pores and BP to open pores and decrease inflammation)
Clindamycin wouldn’t help as much with inflammation and don’t want to confuse pt with too much
Back: PanOxyl is good but doxy will work and don’t want to overwhelm
What to use on back acne and pt instructions
PanOxyl - let sit 10 min (old towels)
Also doxy, spironolactone
Cicatricial Pemphigoid is aka
Benign mucosal pemphigoid
Name of dermatitis due to contact with plant and distribution
Phytophotodermatitis (usually in spring or summer when plants, fruit juice or veggies bloom): limes, lemons, celery, etc
Itchy blisters in forearms or LE, irregularly distributed or LINIAR with PIH after a few days which persists for months
Due to UVA contact with plant chemical Psoralens (contact with plant may be Brief or unnoticeable)
Vs PhotoContact Dermatitis which is when products like fragrances, sunscreens, disinfectants are hit by UVA
Classic distribution for perioral dermatitis
Chin, nasolabial folds and inner or outer eyes
Can extend to neck
NP with hair loss (20 yo F)
What questions to ask
What labs to order
- does it ITCH, flake, pain, inflammation
- how long, sudden or gradual
- any new meds
- PERIODS regular, acne problems?
- any h/o of anemia, thyroid, b deficiencies, irregular periods
- any recent surgeries, illnesses, hospitalizations
- any family members with hair loss
- when last checked CBC and thyroid (repeat in 1 year)
- seen anyone before and their workup
What type of hair loss does discoid lupus (DLE) get vs systemic lupus
DLE - scarring alopecia
Systemic lupus - get non scarring alopecia
Keflex sensitivity is judged by sensitivity to which other abs
PCN oxacillin
Labs to order for diffuse hair loss
CBC, TSH, Iron and TIBC,
testosterone, DHEA and
ANA (systemic lupus and DLE cause loss)
Which drug to tx Lupus
And SE
Need clearance from which specialty and which labs
Plaquinile
SE: deaf, anemia, seizures,retinopathy, liver toxicity
Need clearance from ophthalmologist - baseline exam (and monitor?)
Need CBC, CMP, G6PD, PORPHORINS (bc if high, plaquinile makes you sick, vomit), anything else?
Which are mast cell degranulating drugs
Avoid in which dz
Carry what with you?
NSAIDS, opioids (codeine,morpheme), alcohols, thiamine (B1), anesthetic (procaine)
ASA, scopolamine, BB, cough meds (Vanco/AmphoB)
Must avoid above meds in TMEP
Carry an Epi-Pen in case of anaphylaxis
TMEP is rare form of generalized cutaneous mastocytosis
Which labs to order for TMEP
CBC
TRYPTASE
Which labs to order for TMEP and why
CBC
TRYPTASE (bc mastocytosis)
Name of sign when you get small bleeding after layers of scale have been scraped off psoriatic plaques or papules
Auspitz sign
Distribution of dyshydrotic eczema vs palmoplantar pustulosis
Sides of fingers vs palms and soles (yellow pustules that turn brown when drain)
What is the #1 question to ask a person presenting with hand dermatitis, dyshydrotic eczema or palmoplantar pustulosis
Do you SMOKE?
Our hands and feet have nicotine receptors and it causes flares every time you smoke. Plus, smoking makes available tx less effective - so work with PCP to stop smoking
Which tx for hyperhydrosis
Drysol
Apply to hands HS for 10 min then apply lotion (or Beta oint for PPP) and gloves, wash off in am
Name of itch on the back that causes macular amiloidosis
Notalgia Parasthetica
Cause of PalmoPlantar Pustulosis (PPP)
And dz associations
genetic mutation or increased # of eccrine sweat glands
Can be ass’d with autoimmune dz (celiac, thyroid, DM1), chronic plaque psoriasis, strep throat, TNF meds
Form of psoriasis
LPP tx and RTC
Risk of tx
How to describe LPP to pt
ILK Ken 5 mg and hold beta lotion for 6 weeks (or on spots not injected)
Risk of ILK is indentations
RTC 6 weeks for more injection
Pt edu: LPP is a scarring alopecia with itchy follicular papules
Percent of cancer tx success with excision vs EDC vs MOHS
Excision is 95%
MOHS is 99%
EDC is 90%
With BCC - pebbles skipping over a creak
If a red bump on nose, do what
Metro and RTC in 6 weeks to make sure gone
Pt had yellow points with blood vessels
When pt has breast implants and you need to do a bx
Pull skin up with fingers (ask MA) and very superficial when injecting (just intradermal till blanch)
Another name for dyshydrotic eczema
Pompholyx
Dyshydrotic eczema distribution and other sx
Ask pt about what other parts and daily habits
Mostly interdigital and extends to palms (but not on dorsal fingers/hands) and severe itch
Ask if on feet, if smokes, how often washes hands, what soap uses
MC cause of contact derm is
Frangrance, preservative or dye
Descriptions of hand dermatitis
Fissured eczematous plaques
What condition/rash on neck can be exacerbated by heat and sweat
Tx
Dermatographism (easy release of histamine with pressure, heat and sweat). Normal - 5% of ppl have it
Tx: Allegra 180
Dyshidrotic vs hand eczema distribution
hand dermatitis is more dorsal
Dyshydrotic is more palms and interdigital
How does Lichen Amyloidois look like
Real waxy, in eczema prone skin (also dorsal forearms and shins)
Name of overhealing wound
And TX
“Proud flesh” = overgranulation tissues
TX: use topical cortisone to calm in down (Beta BID if on scalp
Don’t use cautery or silver nitrate sticks)
How often to see pts on transplant meds vs chemo
On transplant meds (cyclosporine, izothiaprim):
Q 8-10 weeks if h/o many skin cancers,
Q 6 months if h/o of some cancers
Q 1 year if no skin cancers
Chemo: q 1 year
If acne pt is not improving on Doxy 100 BID, what’s next step
Change to minocycline 50-100 mg QD (if >6 months - staining)
SE: HA, Dizziness, joint pains (lupus like syndrome)
If HA and dizziness - let me know: drug crosss BBB so more of it in CNS = pseudomotor cerebri cause dizziness, nausea, vision changes and HA
Papule derma of eye - HA and vision changes
[Occasional dizziness and HA is ok, but daily and bad HA means papiledema of eye)
IF JOINT PAINS - STOP!!
If not better on minocycline (or only 75% better) - discuss Accutane after 6 months of Abx)
What dose to start Accutane on?
Start with 40 mg QD and stop everything else
RTC 1 month: if tolerates well and good labs, increase to 60 mg QD x 4 months
Dose: 1 mg/kg
10 yo female with comedonal and inflamm acne 50/50: starting tx and what if not better
EpiDuo AM
Not better in 8 wks: comedowns better but not inflammatory: add Clindamycin
What to always tell a female pt on Benzoyl P, retinoids and doxy for acne
Can’t take during pregs
What to always ask a female pt who presents for acne
Periods regular?
Anything on back?
What to ask each patient when putting on an anti biopics
Taking blood thinner Coumadin?
DOXY (recommend checking INR)
Keflex is least interaction with Coumadin
What to suspect and check with recurrent mouth sores
Cyclic neutropenia (check CBC) HIV (check it) B12, folate, zinc, riboflavin deficiency Lupus (check ANA) Iron levels
Eccrine gland tumor and looks like
Spiradenoma adenoma
DF (deep seated)
Name of ear drops for ear seb derm and SIG
DermOtic Oil 0.01%
Sig: 5 drops in each ear BID
Plus Nizoral shampoo QOD
Itching around bra area is called (and cause)
Notalgia Parasthetica
Caused by arthritic changes in spine, herniated disc, back injury
Female pt with 3 wk itchy rash DDX :
Started on legs and arms, resolved with ILK but returned on legs and chest/back so was given Prednisone
(Non scaly, excoriated pink papules on chest and polygonal on legs. JMO: non-scaly (=dermal, almost urticarial) edemnatous erythematous BLANCHEABLEj oval almost bug0bite like MONOMORPHOUS (all same) plaques (along skin lines on chest DDx and difference)
ALWAYS ASK PT WHAT when itchy rash
Ask if ORAL involvement
Dermal Hypersesitivity Rxn vs BP (urticarial pemphigoid) [not PRosea bc no scale and PR is epidermal (with scale)
Do 2 punch bx: H&E and DIF (results in 2 weeks when take out stitches)
If stasis derm rash not improving on TAC and hose, do what, what could be and RTC when to do what
Rx Beta oint, Xyzal 5 mg for itch qHS (can be sedating, stronger than zertec)
Might also have contact derm so derm handout
RTC 6 wks: if not better, do TRUE allergy testing
What can pts do to flatten a scar s/p EDC or excision
Massage it BID for 10 min
If excision, massage after 2 months bc don’t want to break deep stitches
When pt rubs a rash a lot, the resulting skin changes are called
Lichen Amyloid
If get a cyst or lipoma on back of neck or head, do what
Refer to ENT Dr Bassett to r/o cyst/lipoma vs LAD
If dog bit, do what (2 things)
Augmentin 875/125 BID x 10 days Tetanus shot (go to PCP to be UTD)
What does fixed drug eruption look like and MC meds (also what advice to pt)
Usually solitary: Round oval with purplish dusky center when acute and significant PIH when resolves
MC: ABX, NSAIDs, ASA, even food coloring
Keep a diary of when appears - food color or med
Which abx for folliculitis
Doxy BID x 10 days
Psoriasis severity classification by BSA
MILD MOD SEVERE
Mild < 3%
Moderate 3-10%
Severe >10%
Otezla approved for mod to severe
Which immune cell releases histamine and heparin in response to an allergic reaction
Mast cell
Describe mastocytosis
When population of mast cell accumulates in 1 tissue (eg skin, bone marrow, liver, GI, lymph node, spleen)
When mast cell is activated, it releases heparin and histamine into surrounding skin, causing inflammation that causes blood vessels to leak (resulting in localized itch, swelling,redness and at times blistering (this is a normal response in insect bites - mosquito triggers mast cell activation)
Rubbing the area of mastocytosis can also active mast cells (Darier sign: wealing following stroking of skin)
What does H&E stand for?
Haemotoxylin and eosin staining
What blood test suggest systemic involvement in mastocytosis?
Tryptase
Which OTC cream to use for oral LP and regular LP
Aloe Vera can help
Questions to ask when initiating Flagyl, get which labs, what dz for and Sig plus duration
- Drink any alcohol so need LFTs (a sip can cause flushing, can’t drink 2 weeks after stop pills)
- Rare SE: neuropathy and dizziness
Check CBC (for blood dyscrasia) and CMP (need LFTs) for Flagyl Check Hep B (surface Ab and Ag), Hep C Ab for LP
Sig for LP: 500 BID x 4 wks (30 days)
C:I with Antabuse
What labs are helpful (not critical) to check with Flagyl
CBC (for blood dyscrasia) and CMP for LFTs (can’t have any alcohol or Antabuse for 14 days post tx)
What labs to check for pt with new LP
Heb B surface Ab and Ag, Hep C Ab
Name of fluid filled cyst
Hydrocystoma
Which labs to order for TMEP (and what is the systemic name)
Systemic Mastocytosis
Get TRYPTASE and CBC
Which labs to order for cutaneous lupus (and if initiate Plaquinile)
CBC, CMP and Porphyrin for Plaquinile (bc causes adverse rxn if por is high)
CBC, CMP, ANA, ENA
Which drugs trigger Subacute Cutanous Lupus Erythematosus (SCLE)
Lamisil, thiazides, CCB, griseofulvin, ACE inhibitors
Which labs and test to order when starting Plaquinile
What are the side effects of Plaquinile
CBC, CMP and Porphorin (can’t start if high por) before starting
CBC and CMP q 1 month?? For 6 months
Also see ophthalmology for baseline exam BF tx and Qyr
SE: Anemia and blindness
Which subtype of MM is 100% due to sun exposure
Lentigo Maligna (is invasive)
What is the MC med to cause Mycosis Fungoides like rash
Statins (Lipitor)
Can real MF be differentiated from drug induce MF on bx?
No
Drugs: Lipitor / statins
Takes months to go away after stopping
What does Mycosis Fungoides look like
Ring worm (t corporis)
Does doxy work for FFA as well as for LPP?
Yes
Plaquinile is for
GA, LP and SCLE Lupus ( or was it for TMEP?)
Don’t undermine which excision?
MM excisions bx (take 2 mm margins)
If re-freeze a spot within 6 months, what to remember
Can’t charge Medicare for 2nd freeze within 6 months (they pay whistleblowers)
If LFTs are elevated during Accutane, ask what and do what
Ask if was drinking alcohol (Alk Phos and ALT)
Recheck CMP in 1 week to make sure LFT down and no alc
What is the best topical for Rosacea (and generic of it)
Also, rosacea tx
Soolantra (ivermectin) is best - compound is cheaper if not improving on Doxy (100 if severe, 20 BID if ok) and metro cream/gel)
Is metro gel or cream more effective?
Cream is better bc less drying
Crazy eczematous rash with desquamation all over body due to malnutrition (which nutrients)
Erythroderma (due to Niacin/B3 and lipid depletion)
Tx: TAC and see nutritionist
Metro cream or gel SIG
BID if 0.75%
QD if 1%
If big SCCIS, how to tx
Instead of EDC, do FUDEX x 3 weeks
In pt with psoriasis, NEVER forget to look at what? (3) and ask what
NAILs
Elbows and knees
Palms and soles
Anything in the groin
Doxy is for 5 conditions
LPP/FFA HS GA Acne Rosacea
LPP tx
Clobetasol solution or Betameth lotion BID (no need for break)
DOXY 100 qHS
Tug Test done
RTC 8 wks
ILK and bx if not improved to r/o T.E. Vs androgenetic alopecia vs LPP
C&C
Curette, derm moncels, then freeze
Stop Accutane at which triglyceride level (and bring to JMO attention at which level)
stop at 400
Bring to attention at 200
Repeat LFTs when on Accutane at which numbers
When slightly above, recheck in 1 week to be back to normal and stop drinking
What is better for bruising than other products
Arnica (can do oral or topical)
Works better than RUTIN or dermamend
What makes HS worse
Smoking
If dyshydrotic eczema or hand dermatitis not improving on tx, next step
TRUE allergy test
If AK to base, do what
Re-bx
What areas are considered aggressive for SCC
Penis, lip, ear
Tx for moderately differentiated SCC on trunk vs face
Trunk - excise
Face - always MOHS
Name of little fibrous bumps on face and associated with which dz
Angiofibroma (associated with tuberous sclerosis)
If eczema is not improving on topical steroid, next step
Bx to r/o eczema vs TINEA vs Mycosis Fungoides (cutaneous T Cell lymphoma) and
Workup for Humira
CBC CMP HEP C Ab, HEP B Surface Ag and Ab and core Ab, HIV TB Quant Gold, COCCI Serology
CXR PA LAT
Benign tumor of follicular differentiation / cyst of follicular matrix
Pilotrixoma
Form due to calcification
When can’t find prior bx spot because healed too well
Localization bx (“prior shave bx SCC”)
How to tx and explain venous stasis ulcer
It’s a circulation problem (venous insufficiency), not a lesion. Not healing and pain due to edema or venous insufficiency or LipoDermatoSclerosis (fibrotic change in skin and subQ fat due to Venous insufficiency) (so see vascular surgeon to eval)
Tx: lymphedema clinic, vascular surgeon (Dr. D’Souza), hose and elevation
RTC 4-8 wks, add wound care and AQUAPHOR BID to soften scab if not healing
+ TRENTAL 400 TIC (Pentoxifylline): any h/o of bleeding or ulcers? Not a blood thinner, increases RBC flexibility and stimulates finrinolysis.
SE: nausea +/- v, dizziness, heartburn
NIACIN is 3rd line (also fibrinolysis)
Champaigne bottle leg is called
LipoDermatoSclerosis (LDS)
3 drug options for venous stasis ulcers
1st line: Stanozolol but too many SE (so hose, elevate an diuretic)
2nd line: TRENTAL 400 TID (can increase to 800 TID)
3rd line: NIACIN 100-150 TID to 5/day (helps hyperlipidemia associated with LipoDermatoSclerosis LDS)
TOC: comp and stanozolol
How to explain to pt upset that lesion wasn’t picked up 1 month ago during regular skin check
It looked like an SK (inflamm. Papule or lichenoid keratosis) and it’s not standard of care to bx a benign looking lesion (portal for infection). TOday the top has been scraped and irritated and can’t tell if there is a malignant process involved (papules can change). An iSK can’t be differentiated from SCC clinically. GUarantee that we look at all suspicious lesions carefulully with dermatoscope. At that time, it looked benign but today, it’s hard to tell what’s underneath - could still be just an irritated SK due to scratching so best to bx today
A month ago could have been a smaller SK and they can grow, causing irritation and itch.
Fitzpatrick skin type 1, 2 3 4 5 6
1: always burns, never tans (pale, blue/green eyes, blond/red hair)
2: burns easy, tans poorly (fair skin, blue eyes)
3: tans after initial burn (darker white skin)
4: burns minimally, tans easily (light brown skin, Hispanic??)
5: rarely burns, tans dark (brown skin)
6: never burns, always tans dark (black or dark skin)
Chronic eczema like rash around anogenital area
Extramammory Paget Dz
If painful would s/p excision persists due to edema, do what
- hose and elevate
- increase diuretics through PCP
- pain is due to swelling/edema: lymphedema clinic to massage the fluid up
- consult vascular surgeon (D’Souza)
- LIDOCAINE PATCH QD but cut out center so it doesn’t touch the incision!
- (the med that make RBCs more flexible TRENTAL (rental)
Oral meds for GA and other tx
Doxy, Plaquinile 200 QD
Allopurinol has more SE than plaquinile (anti malerials)
1st line tx after topicals: Plaquinil or narrow band light
What is oral TRENTAL for and MOA
Anti TNF
Can use for LIpoDermatoSclerosis and severe stasis dermatitis
Can be used also for GA (at Mayo)
Never take which supplement with Doxy
ZINC (binds to doxy and decreases absorption)
Plaquinil (anti malarial) is for
LP and GA
HS tx
Runs in families, worse in heat and humidity
Anything in axilla? It’s recurrent boil like bumps in groin and folds called HS, - acne like process comes and goes where there is heat and sweating. There is tx but no cure. Not contagious as opposed to regular boil which can be staph infection.
To decrease flares:
- No SMOKING
- keep area dry: boxers> briefs
- no hot, shower after workouts
- ZAsorb AF powder after shower
- ZINC gluconate = anti-inflammatory (in between flares but NEVER with DOXY)
Bacteria get involved and make things worse: PanOxyl soap - let sit 5 min (use OLD towels)
For mild flares: CLEOCIN T GEL BID
For big flares: Doxy 100 HS (1 hr bf lay down: upset stomach) [never with ZINC]
Name of muscles for Botox
Globella
Irritant contact derm on lips/mouth
No mints, gum
Arm and hammer toothpaste
HC 2.5% for itch and redness and aquaphor for maintenance
No metal cups, mouth washes, OTC lip balms
Pruritic skin or rash > 2-3 months labs
R/o:Anemia, kidney, liver, TSH
- BP : bx or blood
- Contact derm
- on exam: picking (neurotic excoriation can be confused with scabies so ask if picking at them just cause they are there?)
Tx and recommendations for neurotic excoriation and what to ask pt
- Are you picking at these just because they are there?
- Labs: CBC, CMP, TSH, liver
- DDx: scabies
- white cotton gloves and CUT NAILS
- Do labs
- Allegra 180 QD or BID
- NAC 600 BID - helps break the habit of picking at these
- RTC 6 wks
If pt comes in with itchy rash that’s all excoriated and wants the cause
Can’t tell you what it was bc the rash is gone (no fresh lesions) and just excoriation left. So not sure what happens but my suspicion is something internal (or external)
External: what soap, new laundry detergent? Any new meds?
Internal: had you thyroid/kidney/liver checked? Anemia?
How to tx any recurrent skin cancer
MOHS (any place)
Ok to excise infiltrating aggressive BCC unless recurrent = MOHS
Name of pimples on scalp and tx
Acne militarism Necrotica (extra facial rosacea)
Tx: T Gel shampoo (tar) QD and beta valerate 0.1% lotion
No hot shower and sweating makes worse
Also can do: abx and isotretinoin
What 2 conditions present as pustules/bumps acne on scalp
Malassezia folliculitis (more upper forehead, chest and shoulders, less scalp): less inflamed, more comedonal like, monomorphous on chest
vs
Acne Miliaris Necrotica (rosacea of scalp) is more inflamed, acne/pustules and excoriated.
How to tx dark liver spots
HQ called into walgreens ($120) (Triluma)
Laser - by Tina
How to tx sebatious hyperplasia
Resurfacing Laser to flatten it (Dr. B)
Cautery if low maintenance
Do skin tags come back? What causes them
Yes, they come back
Cause: friction and run in families
Can use LN2 if small or cut off after numbing
Solitary red bump on nose that doesn’t look exactly like anything, do what
Cleocin T lotion to dry up (in case rosacea) and “RTC 4 weeks to ensure resolved. See picture”
How to tx milia and what it is
Benign superficial cysts filled with keratin. No tx necessary. Can resolve with retinoids or extractions (Tina)
What are the possible causes of dermal hypersensitivity reaction (back on bx)
Urticaria (how long do spots last if I were to draw a circle around it)
Bug bite (arthropod assaults): check feet for bug bites
Drug reaction (any new Meds or OTC in last 3 months?0
Fungal hypersensitivity reaction
Exogenous allergens
4 high risk areas for SCC (does same count for SCCIS??)
And other SCC Mets risk factors
MOHS: Lip, ear, temple, penis
(Do same areas apply to SSCis??)
MOHS: Other RF for Mets of SCC: >2 cm, >2 mm deep, neural involvement, to fat
SCC on Finger always Mohs
Never shake which bottle
Botox when diluting it with saline - or it will denature (only gently swirl it)
100 unit bottle Botox - add to it 2.5 cc saline to get 4 units per .1 dilution
DIF is ordered for which skin disorders
Punch bx for lupus, Dermatitis Herpetiformis, lichenoid tissue rxn, vasculitis, BULLOUS PEMPHIGOID (along with blood labs of itch or urticaria without blisters)
Cysts have what percent chance of coming back
40% chance of coming back (if 1 cell is left)
Sebatious carcinoma is associated with
Colon/bladder cancer (refer to oncology for full work up),
Muir Torre - colon cancer etc
