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Rashes 5 Flashcards

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1
Q

Which rashes are type 4 hypersensitivity reactions

A
  • Allergic Contact Derm
  • Lichenoid Drug Eruptions
  • Morbilliform drug reaction
  • Drug hypersensitivity reaction
  • Erythema Multiforme
  • SJS
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2
Q

Oral LP - which oral meds

A

-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

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3
Q

Hormonal acne distribution

A 
Can be chin only
Or along jawline
(Hormonal is only inflammatory acne - not comedonal along chin or jaw) 
Spironolactone 50 qAM
Plus Doxy
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4
Q

Generalized GA - what oral meds

A

Try Doxy first (can clear but not as well as Plaquinil )

-Plaquinil

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5
Q

Niacinomide is C/I in which case

A

C/I in pts on statins

Used in BPemphigoid, along with doxy

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6
Q

BP oral meds

A

-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
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7
Q

Generalized LP oral meds

A

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

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8
Q

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)

A

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)

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9
Q

Chronic itching on outer labia without visible skin changes

A

Dermatitis can look like extra mammory PAGET dz, so get bx

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10
Q

Can never use Plaquinil in which pts

A

Never in PSORIASIS

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11
Q

Plaquinil can be used in which conditions and never in which

A
  • oral LP (but can cause LP rash)
  • generalized GA
  • never in Psoriasis
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12
Q

What tx if have a fluffy scaly 1 patch/plaque that looks like T Versi or Numm eczema (and what questions to ask

A
  • 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
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13
Q

If pt present with T.Corporis and Numm eczema patches, what tx

A

Do Lamisil BID x 3 weeks because TAC will make it worse

Then start TAC at 4-6 weeks (RTC in 4 )

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14
Q

Axillary freckling

A
  • Neurofibromatosis

- or Dowling Degos

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15
Q

What always to check when putting a pt on antibiotics

A

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

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16
Q

What to do and ask when see a wierd rash

A

Bx on 1st visit

Are you picking at these? Pain/itch?

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17
Q

Where not to use iodine and why

A

Near eyes, can cause blindness

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18
Q

Pt comes in with very itchy rash all over body

A

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

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19
Q

If BP not better on doxy, use what

A

Dapsone (if hx of cancer because can’t use Cellcept/MTX cause immunosuppressive)

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20
Q

Can’t use Valtrex in whom

A

Pregs (use acyclovir 800 5 times per day x 7 d for shingles)
Kidney dz

Valtrex 1 g TID x 7 days fo shingles

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21
Q

If pt calls with rash from Doxy, do what

A

Come in today or tmrw - likely sunburn

Do that for all rash reactions from new meds

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22
Q

What is the name of chemical in nail polish and in eye makeup remover that irritates skin

A

Micro deposits of Macrolides

And Cathon C A in makeup

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23
Q

How to explain Psoriasis to pt

A

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.

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24
Q

When palmoplantar psoriasis, ask what?

A

Smoking?

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25
Q

If see new patient, ask what

A

Name of PCP

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26
Q

Lichenoid inflammation on path could be sign of

A

Lupus

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27
Q

If pt has spots of concern on face that don’t look like anything, do what

A

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

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28
Q

How to explain shingles to pt

A

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

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29
Q

ACCUTANE labs (and what to tell pt) and conversation

A

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)

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30
Q

Once hormonal acne is regulated on Yaz, what to do with Abx?

A

Stop it

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31
Q

Explain dermatomyocitis and which labs

A

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

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32
Q

What other meds for shingles and what meds CI in pregs

A

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

33
Q

Diclofenac is used for what and can do what

A

FOr arthritis pain and AKs so can cause rash

34
Q

HS education

A

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

35
Q

What at home remedy for HS

A

Warm compresses 10 min BID

36
Q

KP pt edu and locations

A

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)

37
Q

Dapsone is used for what and SE (ask what?)

A

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

38
Q

What type of drug is Dapsone and when is it C/I

A

SULFA allergy because sulfa based

39
Q

Does BP ever go away

Tx options

A

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

40
Q

Explain LP

A

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)

41
Q

For infection on lower legs, use which topical

A

Silvadene oint and cipro (for G- and G+ coverage)

If discharge is clear “soupy” - pseudomonas

42
Q

Bug bites, ask what

A

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

43
Q

Flagyl SE

A

No Alcohol and baseline CMP for liver fx

SE: n/v, flushing if drink, rarely dizziness and vision

44
Q

Next step in HS tx if not improved on abx, PanOxyl and Cleocin T gel

What differentiates early HS from folliculitis or furuncle

A

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

45
Q

Which medication is notorious for LP rash break out

A

HCTZ

46
Q

Oral LP tx

A

Fluocinonide 0.05% Gel BID 2 wks on/off

47
Q

Which rashes show up in photo distribution

A

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

48
Q

Look at what on all rashes (3)

A

MOUTH (no mucosal involvement)
Nails
Feet

49
Q

Melasma causes and tx

Must do what after all treatments

A

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!!!!

50
Q

Androgenetic alopecia to pts and tx

A

Common type baldness

Women: women’s rogaine and viviscal

51
Q

How to tx nail fungus with oral tabs, what instructions to Pt

A

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

52
Q

What is Pityriasis Capitis

A

Uninflamed form of Seb Derm (dermatitis). With scaly patches

Oily skin
Genetic
Immunosuppressed, stress

Bluephritis: scaly red eyelid margins

53
Q

Pruritic Nodule is aka

A

Lichen Simplex Chronicus

54
Q

Acne EpiDuo education/instructions on how to use

A

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

55
Q

Inflamm acne in 13 yo F

A

Use Doxy 100 q HS and EpiDuo AM, if back: PanOxyl 5 min, old towels

Cetaphil cleanser and lotion
No dairy - use almond milk

56
Q

“Widespread” TINEA Versicolor tx (extensive): oral +/- topical

And what contracindications

A

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)

57
Q

Onychomycosis sereve - tx and pt instructions

A

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.

58
Q

Which drug can cause granulomatous dermatitis

A

TNF alpha, BB, ACE, CCB, Statins! antidepressants, anticonvulsants

59
Q

Telogen Effluvium due to DRUGS and after beginning drug, when does hair loss start

A

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
60
Q

Labs for Hair loss

A

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.

61
Q

Rogaine is CI in what pts

A

PREGS

62
Q

Dermal Hypersensitivity Rxn
If bx, what’s on DDx
(Always ask WHAT questions in any itchy rash?)

A

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)

63
Q

Indolent definition

A

Lazy (wanting to avoid activity)

Medicine: causing little or no pain

64
Q

What to look for in longitudinal melanonychia that could be MM vs b9

A 
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
65
Q

What is Hutchinson sign in nail and sign of what

A

Pigment extending to nail fold (sign of MM)

66
Q

Types of Melanonychia and causes

A

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

67
Q

(Interstitial) Granulomatous Dermatitis

Description of rash, sx, causes, bx, tx

A

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
68
Q

Bad seb derm in eye creases

A

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

69
Q

Scleroderma

A

Must refer to cardiology, Pulmonology, rheumatology, kidney disease

70
Q

EAC erythema ANNULARE Centrifugum

Causes and tx

A

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

71
Q

Epidermolysis Bullous Acquisita

EBA

A

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

72
Q

Necrobiotic xanthogranuloma (NXG)

A

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.

73
Q

Worse in go BP

A

While on MTX - ok to use prednisone for flares?

74
Q

Sebaceous Adenoma

Plus tx plan
Associated with
Vs

A

Excision
Muirr Torre
Tricholemmoma ass’d with Cowdens?

75
Q

Freckles

A

Ephelides

76
Q

What looks like KP on dark skin

A

Lichen Nitidinus

77
Q

NXG

A

Necrobiotic Xanthogranuloma

78
Q

Pre cancer

A

Actinic keratosis

Dermatology (8 decks)

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