Rashes Flashcards
Which dietary substance can exacerbate atopic derm?
What else can exacerbate it?
Nickel in diet
Also stress and weather changes
As well as dry skin
Rash on right arm antecubital fossa
12 yo male
With excoriations and fissures
1) Do you have a history of Asthma or allegirs like runny nose, itchy eyes, sneezing? No
2) Do your parents have any asthma or allergiesNo
3) does this ever happen in the back of the knees?
4) What is the name of the soap you use in the shower :
- with atopic dermatitis, harsh soaps can trigger itchiness so use gentle soaps like Cerave Cetaphil or unscented dove
- only lukewarm water and thick cream within 3 min of shower - also Cerave Cetaphil (dry skin aggravates itchiness)
- gentle laundry detergent like ALL FREE AND CLEAR and no dryer sheets
5) Tx: 1. Triamcinolone 0.1% cream BID-TID 2 days on, 2 days off until rash clears (keep it in the fridge)
2. MUPIROCIN OINT for 2ndary IMPETIGO (fissures in skin)
3. Zertec 1 tab in AM
4. HYDROXYZINE 10 mg 1-4 tabs HS (grogginess subsides after 4 days)
List of dx
Which supplement needs to be added in seborrheic dermatitis
Zinc
Nuts like cashews, beef, lamb
SE of systemic corticosteroids
Glaucoma OSTEOPOROSIS (add vit D and calcium, DEXA scan by pcp) HTN/ DM Obesity Straie Adrenal suppression
Depression
Which labs to order when new rash?
ASO IgE (allergies and atopic derm) CBC (anemia can cause itch) CMP (kidney fx) TSH (hypothyroid causes skin dryness=itch) Vit D (correlation with high IgE)
Which retinoids is ok to combine with BP wash
Differin (adapalene)
Which stage of hair growth is attacked in alopecia areata?
Anagen stage - growth stage
(A in Alopecia, A in Anagen)
It’s not an autoimmune disorder but immune system attacks follicles in anagen stage, inflammatory T cell attack hair follicles and follicular melanocytes which breaks off anagen hairs, leaving a tail that grows out (“exclamation hairs”)
Rx: kenalog injections (IntraLesional Kenalog)
And fluocinonide solution to spots
Stages of hair growth
Anagen - growth
Catagen- intermediate
Telogen - rest/shedding
What to do when labs come back with high ASO (did I mean to say IgE?)
What Med do you start a patient on?
Antihistamines for underlying allergies
- zertec Q AM
- montelukast Q HS (because IgE is above 600)
- HYDROXYZINE 10 or 25 Q HS (1-4 tabs)
For rash, start TAC 0.1%
Acanthtosis
Epidermal hyperplasia (thickening) of basal and Spinosal layers
In Alopecia Areata, ask pt about history of which Illnesses?
Thyroid disorder %1 Autoimmune disorders (vitiligo #1)
Ophiasis is
Form of Alopecia Areata:
- loss of hair along temporal area
Very hard to tx
Will need wig
1) What percent of Alopecia Areata has family history?
2) Which onset of AA has the worst prognosis
1) 25% have FH
2) childhood onset is worse prognosis
(adult onset is better prognosis - adult with 1 patch: probably will go away on its own )
Ophiasis is bad prognosis - hard to tx
Name an extracutaneous finding in Alopecia Areata
10% have nail pits (which are evenly spaced compared to psoriasis pits)
1) What type of Hair loss is Alopecia Areata? Permanent or not
2) AA is associated with which antigens?
1) Not permanent - non scarring hair loss
2) Human Leukocyte Antigens (HLA - no HLA in milder forms)
Treatment for Alopecia Areata
- can regrow on its own within 2 years
- IL kenalog 2.5-5 (gets rid of lymphocytes)
- Squaratic acid tx - poison ivy like solution applied to scalp and lymphocytes go after it. 50-60% develop contact sensitization (contact derm allergy?)
- methotrexate
- topical steroids (clobetasol soln) not as effective
- oral steroids for widespread loss (totale and universale)
Which drugs can induce Telogen Effluvium?
ACE #1
BB, blood thinners (Coumadin is big), lithium, levodopa
When does Telogen Effluvium usually start?
2 months after a stressful event like divorce, surgery, child birth, Illness/fever
Must remove stressor or
Becomes chronic
Which labs to order with Telogen Effluvium?
THYROID (TSH)
CBC iron panel (B12 to rule out pernicious anemia (body can’t absorb B12)
+/- ANA but can have false positives
How many hairs lost per day in Telogen Effluvium?
150-400 or more (normal daily shedding is 100-150)
What type of test do you have to perform during physical exam in or with hair loss
Hair pull test:
4-5 Hair come out with ROOT (with ball WITHOUT sheath) of 40 pulled (in Telogen Effluvium)
Tx for Telogen Effluvium
Resolves spontaneously within few months but must stop stressor
Minoxidil 5% (rogaine) - avoid touching other areas as SE is unwanted hair growth
Also punch bx
Etiology of Telogen Effluvium
Stressful event causes Premature conversation if anagen (growth) hairs into Telogen (rest) hairs which end up shedding 2 months later
Max dose of lido 1% per day is
Without Epi- 300 mg per day or 30 ml
With Epi - 500mg per day or 50 ml
1 % lido is 10 mg/ml
Digital mucous cyst
Around cuticle
Due to arthritis - Synovial fluid comes out when lance it
If firm - could be cancer but lance it first to see what comes out
SE of Accutane
H/O CROHNS Disease (makes CROHNS worse) Liver/pancreas Cholesterol Muscle joint paint Depression CI in PREGS (2 forms of birth control)
Changes in night vision
Abd pain and nausea
Dry skin: mouth
Can’t donate blood
Can’t get pregs
Paronychia
Inflammation of skin around nail (can be fungal or bacterial)
Trachyonychia
Washboard nails/sandpaper
Which drugs can cause LPP (Lichen Planopilaris)?
Lisinopril, BB, HCTZ, Planoquil
Foxy, NSAIDs
What does LPP look like?
Porcelain scar like areas on scalp with adherent scale around follicles (area around follicles can also be red, inflamed)
Can be itchy, with perifollicular crusts and inflammation (Use Doxy for that)
20% of patients with LPP have which disorders?
Hypothyroidism and 20% have wickem straie in mouth
What is the cause of LPP
Cause unknown - imm system attacks hair follicles leading to permanent hair loss (could get sued bc permanent hair loss could be prevented)
No cure - only prevention
Vs AA - is reversible hair loss and autoimmune
When is Valcyclovir contra-indicated?
Kidney problems
What patient population is LPP prevalent in?
Post menopausal women
Tx for LPP
Betamethasone lotion BID for itching - 2 weeks on, 2 weeks off, 2 weeks on. Etc
Nizeral (ketoconazole) shampoo OTC QOD for inflammation
If no improvement on Above, oral Doxy (SE: abdominal and sunburn)
Then IL Ken?
LPP Eventually goes away - meaning the progression goes away but scarring is permanent??? Unless area is already scarred
How to describe LP (Lichen Planus) to patients?
Common pruritic inflammatory condition of skin
What are the most common extra-cutaneous presentations of LP
Mouth witchem straie and nail (split, ridges, onycholysis) in 5-10% (always check)
Most common areas for LP
Flexor writs, dorsal hands, low back, legs
Shins (rare risk of SCC), medial things, ankles
Axialla
Trunk low back
Anus, Glans penis, vulva (dispareunia) ddx:lichen sclerosis
Maybe face, palms, soles
Which type of LP has a risk of SCC
3% risk in vulvovaginal and ORAL LP
Hypertrophic LP on shin looks like LP (path can’t tell the difference?) so do IL kenalog and if it goes away - it’s LP
Which drugs can trigger LP?
LISINOPRIL BBs Furosemide Metformin Also for LPP: doxy NSAIDs plaquinile
Takes weeks before improvement after stopping the offending med
Which diseases are associated with LP?
Hepatitis C virus
Hep B vaccines
Primary biliary cirrhosis
Which skin rash on the shin looks like SCC and can’t be differentiate on path?
Hypertrophic LP looks like SCC on shin (and path can’t tell apart)
GIve IL Kenalog and it is goes away - it’s LP
Tx for LP
1) Class 1 Topical steroids
2) Protopic (elidel) for groin, axila - also great for Lichen sclerosis)
3) SUNLIGHT - go outside
4) Oral steroids OR
5) Flagyl (metronidazole) 500 mg BID x2-3 weeks
NO ALCOHOL but if comes back
6) plaquinil and methotrexate
Thyroid is associated with which skin diseases?
Lichen Planopilaris LPP
Apolicia Areata (associated with higher incidence of autoimmune disease)
Telogen Effluvium (which is caused by stressful event - stress lowers thyroid which causes hair to fall out)
Rarely granuloma Annulare??
What is Squaric Acid used to treat?
Alopecia Areata (immune cell stack the squaric acid which is like applying poison ivy on scalp)
Patient presents with pruritic papules or plaques on frost, dorsal hand or anckle or lower back - what else to check during exam?
Mouth for wickem straie (in pt presenting with Lichen Planus)
And NAILS (10% have splitting, Ruffin, chycholysis)
Check nail in what skin diseases?
Alopecia Areata (evenly spaced compared to psoriasis )
Lichen Planus (rudging, splitting)
Psoriasis
QUESTIONS:
Nail involvement in LPP like LP?
THyroid also in LP or only in LPP?
Most common areas for Lichen Planus?
Wrists, dorsal hands, ankles and lower back
Shins can be affected (with gut rate papules)
What is the characteristic finding of a LP papule or plaque
Whickem straie (fine white lines cross the plaques)
Cause of Lichen Planus (according to derm tens)
Prevalence/frequency of LP
Autoimmune disorder where T cells attacks an unknown protein in skin cells and mucosal keratinocytes
Affects 1 % of people (either mouth or skin)
Oral LP
Wickem straie can be painful with ulcers (risk of SCC with mouth LP - must do dental exam Qyr
Often around tooth filling/crown - gold or mercury. TOgether with contact derm
Difficult to tx oral LP:
1) Topical lass 1 ointment or gel in mouth
2) Kenalog in orabase dental paste
3) NO PROTOPIC - affects kidney (bu ok on lip)
4) oral steroids
5) IL Kenalog
6) Is flagyl also used if all above fails like in regular LP?
Which skin disorder is Flagyl used for 3-4 weeks?
Lichen Planus
Can LP clear on its own?
Yes, within 8-10 months
Can mouth LP be related to drugs?
No
Which hair loss disease is often mistaken with androgenic alopecia but it’s a subtype of LPP?
Frontal Fibrosing Alopecia - affects anterior scalp, forehead and brows with sparse lonely hairs
What to ask a patient before starting on oral contraceptives?
Any h/o blood clots, breast or ovarian cancer, SMOKER, >35 yo
SE of spironolactone
Breast tenderness. CI in PREGS
Irregular menses
Increase in urination (poss dizziness)
(In men: gynecomastia)
CI in PREGS
Check K if >40 yo (must have good kidney function)
Peri oral dermatitis
Form of rosacea
Can have cracked lip corner
Sometime nose and eyes
Tx:
Metro gel 0.75 Bid
Cetaphil
Doxy 20 mg BID WITHOUT food (NO PREGS) to speed up metro gel
(Of pt on OCP - any time given abx- can interfere with OCP so use condoms)
Use arm and hammer toothpaste
No gum or mouthwashes
Fluoride makes worse
Can take multivitamin
NO CORTISONE - makes it worse (after making better at worse)
Dyshydrotic Eczema
How many time do you wash ur hands
TAC pint Bid
No hand sanitizer
3most common causes of neck irritant contact dermatitis
Necklaces (have nickel or cobalt)
Perfumes (even if apply else where end up on neck)
NAIL POLISH (even clear has microacralades)
TX: memetazone BID
Skin on neck is very thin
Use hypo allergenic products - means without preservatives and fragrance. Some fragrance free products use fragrance to mask odor) so we recommend vanicream soap and moisturizer
Liquid soaps have preservatives so use bar soap
Leg edema is a SE of which Med
Gabapentin
Best Med for kidney or liver related itch
Gabapentin
SE
Leg edema
Sedation
Tx for itch if nothing works
UVB light TIW
lay outside 20-30 min TIW
What other drug works for kidney or liver itch?
Cholesteramine
Which antimalerial medication is contraindicated in psoriasis but works great for Tumid Lupus
Plaquinile
First 2 questions when pt presents with itchy rash
And which test to do on pt who presents with itch
Any new meds
What products do you use
Do pen test for dermatographism
CREST is part of which disease
Scleroderma (limited cutaneous)
Calcinosis Reynaulds Esophagial dysmotility Scrodactaly Telangectasias
Morpheus is
Localized scleroderma
Systemic sclerosis is
Systemic scleroderma
LP is
Common pruritic inflammatory condition
What other 2 body areas can LP affect
Mouth - wickham straie
Nails
1 tx for Hydradenitis supparativa
Doxy x12 weeks
Women- spironolactone with OCP bc no pregs
Granuloma annulara is associated with which 2 diseases
DM and thyroid
H/o lupus or RA or TB or cocci?
Chron joint pains?
Feeling well otherwise?
Tx:
IL Kenalog
Or cortisone cream
Do labs for cocci
Harmless rash- comes and goes and disappears in 8 years
Reason unknown
Check valley fever
Dyshidrotic eczema
Comes and goes, in ppl predisposed to sweating , worse with SMOKING, stress and water
Worse by nickel (avoid food beans choc asparagus)
Worse with smoking
Decrease washing
Vani soap and cream Hypoallergenic No hand sanitizer No neosporin No hot water
Avoid touching nickel, detergents, solvents, water - use gloves
Worse with sweating - OTC CertainDry antiperspirant for hyperhydrosis- apply hs with gloves and wash off in am (could cause shaffing but could help)
TX
BETAMETH cream Bid 2 was on/off
Protopic in weeks off
ZERTEC or Allegra day and hudroxyzone 25 HS (don’t drive after taking it)
Perioral dermatitis is a subtype of?
Rosacea
Perioral (Perineal?) derm tx
Clindamycin gel bid together with minocyclin 50 qHS to kick start medication
Improving so changed to Clindamycin in am and elidel pm (stopped abx)
Also on sulfacetomide wash 10%/ (what’s 4.5%about?)
Elidel qd or Bid (fda approves for eczema)
What to tell scalp psoriasis patients to make sure
Make sure they are not abrasive when washing hair and when combing hair cause will make psoriasis worse
Dyshydrotic eczema is caused by
Palmoplantar hyperhidrosis (related to sweating) Ho of atopic derm Genetics Contact with irritants like water detergent Friction Contact allergy to nickel Tinea Rxn to drugs
If LP without oral involvement, it’s most likely cause by what?
Drug induced: Lisinopril #1 Atorvastatin HCTZ METFORMIN (guy started 6 months ago and 2 months later rash) CCB is rare
Drug induced LP distribution is more on legs (can be small hypertrophic guttate plaques or large plaques (with white film over if moisturized)
GRANULOMA annulare can be caused by which diseases?
And is associated with which 2 disorders
Order which labs
Cocci, TB, RA (chronic joint pains) and lupus ??? Not true
DM, thyroid (and RA)
Order CXR ?
Order cocci Serology and quantiferon Gold (for TB)
Which is not to use in perioral dermatitis?
CORTISONE - will make better then worse
Use arm and hammer toothpaste
No gum
No mouthwashes
Fluoride makes worse
How to tx dyshydrotic eczema
Betamethasone cream BID 2 was on/off (not on face or groin)
Protopic on weeks off
For itch - Allegra 180 day and hydroxizone HS
Smoking makes worse
Do not touch nickel Decrease hand washing - wear gloves No hot water No neosporin No hand sanitizer Only hypoallergenic soap and moisturizer
What makes dyshydrotic eczema worse
Mix of contact derm (water, detergents) and adult eczema
Triggered by stress and sweaty palms
Smoking (must stop)
Weather changes?
Irritants like water, detergents, solvents
Nickel (try low nickel diet?)
What warning to give a patient on OCP
Anytime take antibiotics, there is a chance it will interfere with your birth control so use condoms while on abx
Tx for LP
- Topical class 1 betameth oint BID
- PROTOPIC (never mouth) or Elidel (both calcineurin inhibitors):
IS THIS FOR WEEKS OFF STEROID? - Sun light outside 20-30 min TIW
- Oral steroids OR
- Flagyl 500 BID x 2-4 weeks (no alcohol)
Never use Protopic where?
Mouth (affects kidneys)
But ok to use on lips
Make sure not to use what with perioral dermatitis?
Steroid cream (makes it initially better then worse)
Which labs to order when putting pt on plaquenil
CBC
CMP
Lichenoid keratosis
Vs bcc: no skin lines in bcc when stretch it
Which blood labs to order in AA
TSH
Which organism causes seb derm
Pitirosporum (Malassezia) yeast (non pathogenic yeast) was
What often causes scalp folliculitis
Pitirosporum (Malassezia) yeast
Micro pustules which are not too inflamed
Tx for for LPP (oral Med)
Doxy 100 with dinner or 20 bid without food
Plus betameth lotion bid
Plus ILken 5 mg (mix IL Ken 10 50-50
What other disorder does Rosacea commonly coexist with?
Seb derm
Oral med for LPP and FFA
Doxy
Betameth lotion BID
Plus IL Ken 5 mg
Circinate
Circular in appearance
Sx of LPP and FFA and tx for them
Itchy, scaly
For itch. Betameth lotion BID
For perfollicular crusting and inflammation - DOxy 100 with food or 20 BID without food
NP presenting with hair loss, what to ask, what to examine, what to do and how to tx
Ask:
- thyroid issues (Telogen and AA), autoimmune, feeling ok? (AA)
- irregular menses (evidence of androgen excess - hirsutism, acne, menses, deep voice)
- Last PE (CBC, anemia, B12)
- new meds?
- what meds on (BB.AC, Lithium, BLOOD thinners, levodopa - Telogen loss; LPP: ACE/BB/HCTZ, doxy, NSAID, plaquinil)
- any stressful events in last 2-4 months
- SMOKER??? (RF in female with adrogenetic loss)
- Anyone else in family
Check:
NAILS (10% of AA, even spaces as opposed to Psoriasis)
