Rashes 5 Flashcards
Which rashes are type 4 hypersensitivity reactions
- Allergic Contact Derm
- Lichenoid Drug Eruptions
- Morbilliform drug reaction
- Drug hypersensitivity reaction
- Erythema Multiforme
- SJS
Oral LP - which oral meds
-Plaquinil has 50% chance of working (but won’t know unless we try it)
SE: anemia, rarely irritates the liver, extremely rare is Blindness (occurs 3-5 years out due to cumulative exposure, if tx 6 months -shouldn’t get blindness)
Labs: CBC, CMP (Liver), baseline eye exam and annual
-MTX (if Plaquinil doens’t work)
NO PREGS
LIVER bx once reach 1.5 g total
Higher risk of liver dz: if drink ALCOHOL (no Alc at ALL), DM, Kidney dz, obesity
Hormonal acne distribution
Can be chin only Or along jawline (Hormonal is only inflammatory acne - not comedonal along chin or jaw) Spironolactone 50 qAM Plus Doxy
Generalized GA - what oral meds
Try Doxy first (can clear but not as well as Plaquinil )
-Plaquinil
Niacinomide is C/I in which case
C/I in pts on statins
Used in BPemphigoid, along with doxy
BP oral meds
-Doxy 100 mg BID x 3 months WITH
Niacinomide 500 mg BID (C/I STATINS!!!!)
Keep on Doxy as long as need it
- MTX is also good (can do 7.5 mg/wk instead of 15) (no alcohol, liver bx at 1.5 grams, kidney fx)
- Dapsone
Generalized LP oral meds
1) Prednisone 3 week taper: 40 mg (wk1), 20 mg (wk 2 and 1 and stop)
2) Metro 500 BID x 3 weeks (can’t drink) PLUS Clobetasol if itchy
3) Sun: 20 min each side TIW w/o SS on affected areas or light laser tx
+ TAC jar in all cases
What to do if Rosacea is not improving on Metro, then Doxy 20 mg BID Plus Cleocin T gel BID (then added Sulfacetamide-sulfur 10%-5%) cleanser)
D/C doxy and Cleocin T gel
Start Soolantra samples x 3-4 weeks and if works, call in PA or compound ivermectin with KETOCONAZOLE (bc rosacea goes together with seb derm redness)
Chronic itching on outer labia without visible skin changes
Dermatitis can look like extra mammory PAGET dz, so get bx
Can never use Plaquinil in which pts
Never in PSORIASIS
Plaquinil can be used in which conditions and never in which
- oral LP (but can cause LP rash)
- generalized GA
- never in Psoriasis
What tx if have a fluffy scaly 1 patch/plaque that looks like T Versi or Numm eczema (and what questions to ask
- Any recent ST? Virus? (Herald patch of Pytiriasis Roses)
- If KOH negative for spaghetti and meatballs, still do Ketoconazole in pm (to cover fungal cause can scratch top layer off)
- And do HC 2.5 AM for Numm Eczema
If pt present with T.Corporis and Numm eczema patches, what tx
Do Lamisil BID x 3 weeks because TAC will make it worse
Then start TAC at 4-6 weeks (RTC in 4 )
Axillary freckling
- Neurofibromatosis
- or Dowling Degos
What always to check when putting a pt on antibiotics
If on warfarin!!!
Don’t worry if on oral blood thinners (pradaxa)
Keflex 500 TID - has least potential to interact with Warf but still tell them to have PCP check INR weekly
What to do and ask when see a wierd rash
Bx on 1st visit
Are you picking at these? Pain/itch?
Where not to use iodine and why
Near eyes, can cause blindness
Pt comes in with very itchy rash all over body
Tx for poss scabies (permethrin 5% in AM, neck down including groin and under fingernails , clean bathroom and sheets with bleach, and 1 week later) and Clobetasol cream 2 onoff,
PLUS 4 mm PUNCH Bs for BP
If better but not gone and BP bx negative - do TRUE testing and clobetasol for derm unspecified and allergic contact derm
If negative TRUE testing, do CBC and BP labs, cont clobetasol
If BP not better on doxy, use what
Dapsone (if hx of cancer because can’t use Cellcept/MTX cause immunosuppressive)
Can’t use Valtrex in whom
Pregs (use acyclovir 800 5 times per day x 7 d for shingles)
Kidney dz
Valtrex 1 g TID x 7 days fo shingles
If pt calls with rash from Doxy, do what
Come in today or tmrw - likely sunburn
Do that for all rash reactions from new meds
What is the name of chemical in nail polish and in eye makeup remover that irritates skin
Micro deposits of Macrolides
And Cathon C A in makeup
How to explain Psoriasis to pt
So a couple of things to consider when it comes to Ps. It’s chronic genetic condition that comes and goes and we can treatment options but no cure. Ps does something interesting called kebnarization - if you scratch or rub the area, it will spread and won’t improve if don’t stop.
When palmoplantar psoriasis, ask what?
Smoking?
If see new patient, ask what
Name of PCP
Lichenoid inflammation on path could be sign of
Lupus
If pt has spots of concern on face that don’t look like anything, do what
HC 2.5 and RTC 4 weeks to recheck
If seb derm - likely facial seb derm that’s rubbed so Keto shampoo and HC for face and RTC 4-6 weeks
How to explain shingles to pt
Pain on 1-10?
It’s reactivation of chicken pox, it stays in spinal canal and can be triggered by stress, illness. A lot of inflammation along nerve so pain. Neurontin - start 1 tab first day, BID 2nd day and TID 3rd day.
For sleep: ALovil??
No shingles shot for 6 month bc just inaculated yourself (FDA approved after 50 yo but insurance covers only
Contagious - no chem wards, no newborns, only to naive people
Once crusts over, not contagious anymore. If person had shingles or had vaccine, it’s not contagious
ACCUTANE labs (and what to tell pt) and conversation
CBC, CMP, Lipids q 1 month (fasting) hCG
So when acne is not improved after 6 months of antibiotic use, we are concerned with lifelong scarring. Everything has risk and will go over the risks and side effects of Accutane but keep in mind that we minimize that risk with monthly labs. On the other hand, the risk of undertreating is lifetime scarring. After treatment, in 2 out of 3 pts, acne can recite but for some abx (doxy) works better after Accutane.
The logistics of being on Accutane if you decide to do it is having monthly office visits and labs done x 5-6 months.
SE: dryness for all (eyes, lips: chapstick, visene)
At 2 months, acne will get worse because being pushed to the surface
Depression
No Pregs
High cholesterol and liver/pancreas irritation (but we watch labs)
Loose link to Chrohns or UC (no FH?)
Rare: joint or muscle pains (maintenance weights are ok but not other, running a lot ok), muscles heal slowly when lifting wgts
Sun exposure (less than Doxy)
So 3 choices: continue current, Minocycline or Accutane
If do minocycline - can only do 6 months, SE happen more often
SE: dizziness, HA, staining of skin, cartilage, gums/teeth (4-5% chance), drug induced hepatitis or jnt pain.
Not bactrim bc no longer recommended for acne bc can have TEN (Toxic Epidermal necrolysis of skin)
Once hormonal acne is regulated on Yaz, what to do with Abx?
Stop it
Explain dermatomyocitis and which labs
It’s an autoimmune condition that makes you itch. 25% of DM pts have malignancy on inside that’s causing it so need to see oncology for eval (Dr. Genhock)
So no cream will help cause it’s coming from inside
Joint pains? Cough? - need rheumatology because pt has weakness and difficulty swallowing (Dr. Solomon)
LABS: aldolase, CK (for DM),
Itchiness: BP, CBC, CMP, Sed Rate, SPEP (high M spike = cancer)
DM pt had severe anemia, high Sed rate, kidney dz (can’t get rid of toxins in body causing itch and leg swelling), high M-spike on SPEP (protein in bone marrow —> leukemia)
Leukemia can cause anemia, kidney dz, skin itching
(DM bc rash on fingers and weakness - did bx
What other meds for shingles and what meds CI in pregs
Neurongin gaba 300 1, BID day 2, then TID
Amitriptyline 10 mg qHS prn pain, may cause sedation
Valtrex 1 g TID x 7 days
Acyclovir 800 5 per day x 7 days if pregs
Diclofenac is used for what and can do what
FOr arthritis pain and AKs so can cause rash
HS education
Genetic, not uncommon, boil like process in areas of rubbing. It’s not caused by bacteria it INGROWN hair (sterile).
Things that make it worse: sweat, tight clothing, shaving, SMOKING
Tx: Doxy 100 with food q HS x 2 weeks for flares
Cleocin T get
WARM COMPRESSES
Losing WEIGHT (bc chafing makes it worse)
Can culture if squeeze out
What at home remedy for HS
Warm compresses 10 min BID
KP pt edu and locations
Low and upper back, arms, shoulder, CHEEKS, thighs, abdomen
20% of people get it, harmless bumps which are plugged hair follicles. Due to hair follicles that grow at angle. If pick, looks worse. No overall harm.
Amlactin helps soften but hard to get rid of (laser or chemical peels don’t help)
Dapsone is used for what and SE (ask what?)
Dermatitis Herpetiformis (gluten)
BP
Interstitial granulomatous dermatitis (LP, GA)
Originally for Leprosy
- Congestive HF? On any heart meds?
-SE: Sulfa based drug!!!!
Anemia, liver irritation (rare), neuropathy (numbness in hands/feet), rash (DRESS) but in general people do well on it
Baseline LABS: G6PD (to make sure can metabolize it) CBC CMP Iron and TIBC, B12, folate
Standing order (write for weekly x 6 mo): CBC, CMP
Labs q1 week for 1st month, then Q2 weeks x ____?
Can start low dose
What type of drug is Dapsone and when is it C/I
SULFA allergy because sulfa based
Does BP ever go away
Tx options
Eventually goes away but can take 8-10 years
Doxy first, Cellcept/MTX (immunosuppressive
So not if hx of cancer)
Dapsone if h/o cancer
Explain LP
Benign rash that itches, sometime no reason, sometimes drugs cause it. Produces pink bumps that last 8-10 months. No one knows what causes it but it’s nothing serious going on.
As far as tx:
Start with Betameth cream BID 2 on/off (forehead Mometasone BID) and RTC 6 weeks (will talk about d/c Crestor, metformin if not clear in 6 weeks - wont’ know unless change drugs)
For infection on lower legs, use which topical
Silvadene oint and cipro (for G- and G+ coverage)
If discharge is clear “soupy” - pseudomonas
Bug bites, ask what
Where did you get them? Where do you work
- can start permethrin 5% apply tonight, wash off in AM and repeat in 7 days
Color safe bleach linens and clothes, vacuum floors
Let us know if your partner gets infected
Flagyl SE
No Alcohol and baseline CMP for liver fx
SE: n/v, flushing if drink, rarely dizziness and vision
Next step in HS tx if not improved on abx, PanOxyl and Cleocin T gel
What differentiates early HS from folliculitis or furuncle
Presence of scarring in HS and recurrence of boils
Next step: surgery if no NEW lesions and 1 won’t go away, for 1 lesion that’s left while the rest of spots are under control with medication
(Otherwise chasing them, also can recur after surgery)
Start: Doxy 100 BID and if improved, can decrease to Doxy QHS, if not improved - surgery
Daily Doxy for life is OK per JB - less resistance in HS (because not bacteria based? More anti inflammatory action of abx)
Can also try colorless Castellani Paint
Humira (TNalpha inh) approved for severe HS
Which medication is notorious for LP rash break out
HCTZ
Oral LP tx
Fluocinonide 0.05% Gel BID 2 wks on/off
Which rashes show up in photo distribution
Dermatomyocitis (aldolase, CK= creatinine phosphokinase)
Lupus (ANA, ENA, sed rate)
Photodermatitis (med or chemical touches skin but rash shows up only when skin is exposed to sun)
Drug reaction
Look at what on all rashes (3)
MOUTH (no mucosal involvement)
Nails
Feet
Melasma causes and tx
Must do what after all treatments
Causes: hormonal: OCP or pregs, or sun
Females of child bearing age
Tx: triple cream (Ozelaic acid 20% better than HQ)
Other Tx: chem peels and fraxel
MUST WEAR SS!!!!
Androgenetic alopecia to pts and tx
Common type baldness
Women: women’s rogaine and viviscal
How to tx nail fungus with oral tabs, what instructions to Pt
Lamisil 250 mg QD x 6 weeks, (NO ALCOHOL!!!), total of 3 months
1st: CMP baseline
Recheck nails in 6 weeks
Tinactin spray shoes once a week, may need to throw out shoes, color safe bleach on sock, hair dryer on feet
What is Pityriasis Capitis
Uninflamed form of Seb Derm (dermatitis). With scaly patches
Oily skin
Genetic
Immunosuppressed, stress
Bluephritis: scaly red eyelid margins
Pruritic Nodule is aka
Lichen Simplex Chronicus
Acne EpiDuo education/instructions on how to use
Wash face and wait 30 minutes to apply, can apply Cetaphil lotion 30 min after Epi if too drying
Pea size amount and rub in, avoid creases
Inflamm acne in 13 yo F
Use Doxy 100 q HS and EpiDuo AM, if back: PanOxyl 5 min, old towels
Cetaphil cleanser and lotion
No dairy - use almond milk
“Widespread” TINEA Versicolor tx (extensive): oral +/- topical
And what contracindications
Itraconazole 200 mg BID x 5 days (up to 7 days) WITH COLA and SWEATING
Same yeast as dandruff (all people have it but grows out of control with increased sweating and decreased showering)
( no liver problems?) 36% Hepatic damage if long term use (not with 5-7 day use)
BLACK BOX: rare CHF, heart arrhythmias (call PCP to find out)
Don’t use with Advair (why?)
Can add: ketoconazole BID for at least 4 weeks and Nizoral 2% shampoo - suds to body for 5 min
Once T.Versi is gone - will have PIH for a few months but no scale
Or diflucan (no black box)
Onychomycosis sereve - tx and pt instructions
Clip for culture, KOH of foot
Oral Lamisil 250? QD x 3 months total (recheck at 6 weeks), works 50% of time.
BASELINE CMP and another CMP at 6 weeks
Ketoconazole cream, Lamisil OTC or OTC LOTRIMIN BID x 3 weeks (to whole food, between toes and under nails) Color safe bleach all socks Tinactin spray q week of shoes Dry well between toes, use hair dryer Change shoes
1 year to grow out nails to see result, keep clipping.
Which drug can cause granulomatous dermatitis
TNF alpha, BB, ACE, CCB, Statins! antidepressants, anticonvulsants
Telogen Effluvium due to DRUGS and after beginning drug, when does hair loss start
BB ACE STATINS NSAIDS OCP Heparin/warfarin
(d/c only after all labs checked)
Starts after 2-4 months
Chemo therapy
OCP Anticonvulsants (Valproic acid) etc Lithium and antidepressants Statins, NSAIDs, Levodopa
Labs for Hair loss
All and TE: CBC, serum iron and TIBC, TSH, (B12 and
Folate Dr B)+/- ANA (if discoid lupus or SLE)
Review ALL MEDS
Genetic pattern hair loss (androgenetic - due to androgens in male, female pattern hair loss of form of androgenetic but not due to high androgens: hair tufts thin out). Check for PCOS in women (acne, irregular menses, excess body hair)
Tx for Pattern and TE: Rogaine 2% or %5 (more irritating), Viviscal or biotin, goal to stop or slow hair loss progression,not regrowth, some have regrowth
(spironolactone, finasteride to block androgens)
Tx Pattern: ORAL ROGAINE 0.25 mg daily and spironolactone 25 mg daily : significant increase in growth
Tx x 6 monthsbefore benefits
RPR (platelet rich plasma) - Dr. Nuara
TE happens in 2-6 months after stress. Other causes: thyroid, anemia, dieting.
Rogaine is CI in what pts
PREGS
Dermal Hypersensitivity Rxn
If bx, what’s on DDx
(Always ask WHAT questions in any itchy rash?)
DHR is aka urticarial Dermatitis
Bx: DHR vs Pemphigoid (urticarial phase), vs Urticaria
(Ask: Any MOUTH or eye involvement, go to ER if eye,mouth, throat sx (ST)
Dermal HR is aka (?) urticarial dermatitis
Edematous erythematous BLANCHEABLE oval bug bite MONOMORPHOUS plaques ALONG SKIN LINES (w/o scale?)
#1 cause is Drug reaction Any cough, fever/chills/night sweats, wgt loss, UTD on PE?
Fishing labs: CBC CMP TSH, Sed rate, (TB?)+/- hepatitis panel
BP180 and 230 r/o BP!!!!
Cocci, SPEP (S protein for leukemia)
CXR
Usually can’t find cause
Do 2 punch bx: for H&E and DIF. r/o DHR vs above (or vs Dermatitis - can do shave for DHR vs Dermatitis)
Indolent definition
Lazy (wanting to avoid activity)
Medicine: causing little or no pain
What to look for in longitudinal melanonychia that could be MM vs b9
MM if one of any: - >2/3 of nail plate length - grey or black in addition to brown - irregular brown pigment - granular pigmentation - and/or nail dystrophy Also: - Hutchinson’s sign (pigment extends into fold) - Variation in color/thickness throughout band - Width >3 mm - Blurred borders - H/o MM - Thumb, index or big toe - Change in existing b9 melanonychia - New pigment (esp no trauma) - Recurrent bleeding at same spot
What is Hutchinson sign in nail and sign of what
Pigment extending to nail fold (sign of MM)
Types of Melanonychia and causes
Types:
- longitudinal (full nail lenght0
- partial longitudinal
- transverse (across, rare) radiation,meds
- Grey: melanocytic Activation (increased melanin production and deposition). Causes: pregs, trauma, tight shoes, biting, meds, Addison’s
- Brown: Melanocytic Hyperplasia (increased melanocytes): causes 1) benign nevus or lentigo ra (freckles) 2) MM
B9: regular parallel < 3mm
MM: irregular with loss of parallel and dots (single nail: index, thumb, or toenail)
Common in darker skinned people (have multiple of different color intensity) but concern in whites if 1 finger
(Interstitial) Granulomatous Dermatitis
Description of rash, sx, causes, bx, tx
MONOMORPHOUS pink papules w/o scale becoming confluent plaques
Ddx: LP, GA (thyroid/DM), Lichenitides Causes: #1 - Drugs (BB, CCB, ACEi, statins, antidepressants, anticonvulsants, TNF alpha) #2 - Infections (TB, Cocci) #3 - Autoimmune (RA, lupus, etc) #4 - Malignancies (h/o smoking - order CXR) (GA - thyroid or DM) If ACUTE ONSET - malignancy IF Olds - poss cancer, if young - HIV
It’s benign rash, not contagious, typically NOT ITCHY, not uncommon.
Sometimes no cause. Other times associated with thyroid dz, DM or drugs.
How do you feel? F/C/cough/night sweats?
JNT PAIN? Smoking? Prostate screen, UTD colonoscopy?
Need to rule out:
- thyroid and DM for GA ddx (yearly PE?)
- Other autoimmune - lupus, RA (no h/o jnt pains, OA is ok)
So here is what I suggest: blood work to r/o:
- Valley Fever (cocci), TB, RA factor, CBC, CMP, Sed Rate
- CXR (former smokers too)
Why not spep????
Tx: not the easiest thing, we can be as aggressive as you want (no itching in this pt). Start with topical class 1 steroid compounded cream (not covered by insurance).
Another option is light tx (TIW x 8 weeks, risk of UV light causes skin cancer and sunburns sometimes)
Success rate with all tx is 50%, rash comes and goes, could be 10 years
- Plaquinil sometimes works (it’s for lupus and malaria):
SE: nausea,, anemia, liver irritation, BLIND - eye exam base and q1yr. - outside SUN: 20 min on 1 side and 20 on other TIW MWF (use SS on face and neck to avoid Sk cancer)
- If not tx, will stay the same and won’t hurt you at all
Bad seb derm in eye creases
Ketokonazole cream and shampoo as wash
HC 2.5% ointment 5 days on 5 days off (avoid glaucoma). HC won’t make seb derm worse
Scleroderma
Must refer to cardiology, Pulmonology, rheumatology, kidney disease
EAC erythema ANNULARE Centrifugum
Causes and tx
Causes:
Fungus Dermatophyte infection, blue cheese/tomatoes, malignancy or meds
Tx: betamethasone Bid 2 on 2 off. Rtc 6 weeks
Visual fx says hard to tx.
Check for TINEA - and treat
Epidermolysis Bullous Acquisita
EBA
Blistering disease if blister is negative for BP (Sonora BP 180 (902107) BP230 (903850)
(basement membrane zone BP180 IgG Ab (units/volume) in serum or plasma in EMA 53842-1 and for BP 230 53843-9)
Bx blister at the edge for BP
Order: “collagen 7 Elisa antibody serum test Test: 2010905 Draw in plain red tube Refrigerate Send to ARUP in Utah” In specialty lab - u of Utah
Dx on note: bullae
Necrobiotic xanthogranuloma (NXG)
form of non-Langerhans histiocytosis characterized by the development of red-brown, violaceous, or yellowish cutaneous papules and nodules that evolve to form infiltrated plaques. The periorbital skin is the most common site for NXG.
Worse in go BP
While on MTX - ok to use prednisone for flares?
Sebaceous Adenoma
Plus tx plan
Associated with
Vs
Excision
Muirr Torre
Tricholemmoma ass’d with Cowdens?
Freckles
Ephelides
What looks like KP on dark skin
Lichen Nitidinus
NXG
Necrobiotic Xanthogranuloma
Pre cancer
Actinic keratosis
