skin Flashcards
common causes of rash
allergens, infections, collagen vascular disease, toxic, drugs, metabolic
life threatening rashes
anaphylaxis, angioedema, bacterial endocarditis, meningococcal meningitis, severe thrombocytopenia, Kawasaki syndrome, TSS, toxic epidermal necrolysis (TEN)
flat, non-palpable skin lesion
macule–>patch(>1cm)
elevated, firm circumscribed skin lesion
papule–>nodule(1-2cm)
elevated firm rough skin lesion (>1cm) flat top
plaque
elevated, irreg. shaped cutaneous edema
wheal
elevated, circumscribed, superficial, not into dermis, filled with serous fluid
vesicle–>bulla (>1cm)
like vesicle but pus
pustule
superficial dilated blood vessels
telangiectasia
1 cause: chronic etOH
allergic skin reaction
urticaria, hives
suspect bacterial endocarditis
Oslar nodes and Janeway lesions
if wet purpura in mouth worry about
severe thrombocytopenia (as low as 2000) infectious etiology
peds
Kawasaki
skin sloughs off, typ. medication related, tachy
toxic epidermal necrolysis (TEN)
also SJS w/ sulfa drugs
present w. purpura, fever, altered, neck stiffness
meningitis
K-OH prep
highlights fungal infection
basal cell carcinoma
- caucasians
- pearly white lesion, pt may scratch–>bleed
- slow growing tumor
- 30% lifetime risk M>F
BCC risk factors
-UV sunlight, tanning, chronic arsenic exposure, radiation, long term immunosuppr. tx (transplants)
BCC dx
- pearly/waxy translucent in light papule
- best obs. w/ stretched skin
- erythematous patch >6mm or non-healing ulcer in sun exposed areas
- shave or punch biopsy: bests of basaloid cells in dermis, sep. from adj stroma by thin clefts
BCC tx
- electrodessication and curettage: not able to histologically confirm complete removal
- surgical excision
- Mohs surgery: take out one slide at a time til histologically confirm no more BCC (imp. on face, lips, nose, etc)
BCC topical/non-surg tx
- 5-fluorouracil: pyrimidine antimetabolite, interferes w. DNA synthesis
- Imiquimod (Aldara): unknown mechanism, TLR7 agonist, induces cytokines (INF-a)
radiation therapy for BCC
typically avoided
used in pt. who are nonsurgical candidates
-admin. in 4+ fractions, limits side effects, gives normal skin time to heal while cancerous cells cannot repair themselves as quickly
benefits of radiation tx
-cosmetically sparing, noninvasive, painless, nonsurg. candidates
BCC follow up
monitor pt annually
metastatic basal cell
deeply invasive/large lesions >10cm2
- missed w. poor examination, altered elderly pts
- reg. lymph nodes, lungs, bones, skin, liver
- Vismodegib (Erivedge): Hedgehog pathway inhibitor
squamous cell carcinoma
non-healing ulcer/wart nodule
recurring, bleeding lesion, dry, scaly
dorsum of hand, arm, nose
-sun damage, fair skinned ind., transplant recipients
SCC risks
2nd most common
UV radiation, tanning, arsenic exposure, smoking, high fat/meat diet, immunesuppr (transplant >5 yrs, HIV, long term glucocorticoid use)
genetic risk factors for SCC
xeroderma pigmentosum, v. rare
epidermolysis bullosa
albinism
Fanconi’s anemia
other SCC risk factors
Chronic lymphocytic leukemia (CLL)
meds:
Voriconazole(longterm anti fungal)
BRAF inhibitors (Vemurafenib and Dabrafenib) used to tx metastatic melanoma, but do not stop, cut out SCC
Actinic Keratosis
-develops into SCC
-chronic sunlight exposure–>excess keratin buildup
-
SCC dx
complete skin and regional exam
-lymph node exam
biopsy
SCC tx
surgical excision
Mohs
electrodesiccation and curettage
radiation therapy: for non surg candidates, if extensive perineural or large nerve involvement, LN involvement
SCC follow up
every 3 mos w/ LN exam for 1 year, then every 6 mos thereafter
malignant melanoma
UV radiation exposure cutaneous acral: palms, soles mucosal ocular/uveal
inc. risk for malignant melanoma
- Irish/European, fair
- more freckles
- Fam Hx
ABCDE of malig mel
Asymmetric Borders-irregular Color-variations Diameter->pencil eraser Evolution-take pic to monitor changes
staging of malig mel
> 4 mm deep: systemic chemo (T4, metastatic)
- thickness, ulcerated or not
- regional LN
stage 1A-1B
wide excision
stage 1B (0.76-1mm)
wide excision +/- INF
stage III
LN dissection and INF
stage IV
systemic therapy (chemo)
wider margins do not have added benefit with tumor thickness
> 4mm (grow deeper)
sentinel LN biopsy if..
> 1mm depth
-less if high risk features: ulceration, elevated MR, regression signs, BT>=0.75 mm
complete LN dissection
radiation after
stereotactic radiosurgery
for brain metastases: hottest around lesions to spare rest of brain tissue
chemotherapy meds
Ipilimumab
Dabrafenib + trametinib
Pembrolizumab
Nivolumab
other chemo meds
Vemurafenib Dabrafenib Trametinib Imatinib Dacarbazine Temozolomide Alb-bound palitaxel IL-2 Dacarbazine or temozolomide-based combo Pacliltaxel Pacliltaxel/carboplatin
BRAF inhibitors
Vemurafenib, dabrafenib
-MAP kinase pathway inhib. (inhib. BRAF V600E)
SE: edema, HA, rash **SCC of skin! arthralgia
MEK inhibitors
Trametinib
-rev. and sel. inhib. mitogen-act EC kinase (MEK) downstream from BRAF (combine with BRAF inhibs.)
SE: *cardiomyopathy, rash, anemia, hemorrahge, liver inflamm.
CTLA-4 inhibitors
Ipilimumab
blocks CTLA-4, allows for enhanced T-cell activation and prolif
SE: (hyperactivates Imm. sys) colitis, dermatitis, hepatitis, hypophysitis, thyroiditis
Anti-PD-1 Monoclonal Ab
Nivolumab
Pembrolizumab
inhib. PD-1 activity by binding PD-1 rec. to block ligands PD-L1/2, releases PD-1 pathway med inhib of IR (anti tumor response)
SE: e-lyte abnormalities, cytopenia, rash
Ipilimumab
enables prolif of T cells thru CD28 or CTLA-4–>inc. signalling–>T-cell activation
- works in 10-15% pts
- takes 1-4 mos (diff. to monitor)
- may look worse on CAT scan after tx before gets better
50% BRAF mutations in
skin lesions, not as common in others
BRAF inhibitors (vemurafenib)
shuts down cascade of DNA replication
combine BRAF and MEK
to inc. survival
largest challenge w/ BRAF/MEK combo w/ PD1 inhibitors
poor side effects w/ PD1 inhibs.
PD1 inhibitors
releases shut down of CTL, allows immune response
scaly
psoriasis, xerosis, pityriasis
vesicular
shingles, herpes simplex
weepy/crusted
impetigo
pustular
acne, folliculitis
figurate
erythema mulitform
bullous
bullous pemphigoid, pemphigus vulgaris
nodular
erythema nodosum
morbilliform
drug rash, viral exanthema
erosive (umbilicated)
vesicular dermatitis
ulcerative
decubiti, herpes simplex, cancers
biliform rash
chest and neck (drug reaction)
honeycombing rash
face and chin-impetigo rash
impetigo
chin, crusty, weepy lesion
melanocytic nevi (normal moles)
atypical/dysplastic nevi
> 6mm, irreg borders, irreg. pigment
-5-10% adults
separated keratosis
“stuck on” lesion, waxy
not worrisome
could transition into something worse
malig mel
flat or raised, suspected in any lesion w/ appear. change, varying colors
ABCDE
most common malig mel etiology
“superficial spreading” comes from dysplastic nevi
-acral lentinginous in all skin types (palms/soles)
malig. mel tx
excision and re-excision (Mohs)
margins depend on size/thickness
LN biopsy for high risk/thick lesions (sys. chemo)
atopic dermatitis
pruritis, exudative eruptions on face, neck, wrists, hands, skin folds
- hx of allergies, rhinitis
- tendency to recur
- typ. childhood (
atopic dermatitis
wet: dry it
dry: moisten
acute weeping: oatmeal astringent soaks, high pot. corticosteroids
tx for subacute or scaly lesions
(dry, red and pruritic)
mid-high pot. steroids, wean to emollients
tx for chronic dry lichenified lesions
nightly occlusion to hold in moisture (silvadene, vaseline)
high pot corticosteroids
aquaphor
atopic dermatitis maintenance tx
constant appl. of moisturizers, sparing used of corticosteroids
lichen simplex chronicus
itching, scratching, dry, leathery lesions
-trauma, exposure
*exaggerated skin creases
-well circum. scaly plaque
neck, wrists, forearms, lower legs, scrotum, vulva (vulva: biopsy)
-often appear psoriatic
-risk of invasive superinfection
lichen simplex chronicus tx
high dose topical corticosteroid +/- occlusion
antihistamins to prevent itching
(dis. may remit to other sites)
psoriasis
-AI, may have no sympts or itching
-scalp, elbows, knees, palms, soles, nails
-“silver scales” on erythematous plaque, occurs in creases
limited (10% BSA)–>moderate–>generalized (>30%) disease
continuum w/ rheumatoid arthritis
psoriasis tx
numerous sm. plaques (mild-mod disease): phototherapy, home UV lights
lg plaques: v. high pot steroids 2-3 wks BID then pulse
-vit. D analogs
-scalp: tar shampoo, salicylic acid gel
*never use SYSTEMIC (ORAL) corticosteroids (lead to severe rebound)
severe psoriasis tx
UVB tx 3x week psoralen plus UVA (PUVA) methotrexate acitretin (pustular) cyclosporin anti-TNF agents, DMARDs
pityriasis rosea
oval scaly eruption on trunk Herald path-->then eruptions "christmas tree" distribution occasional pruritus resolves in 6 wks
seborrheic dermatitis and dandruff
dry scales w/ underly. erythema
-face, scalp, eyelids, ears, presternal inter scapular areas
acute or chronic
-pruritis is inconsistent mild–>severe
tx for seborrhea
scalp: shampoos w. zinc pyrithione, selenium, ketoconazole
tar shampoo
facial: mild c.steroids, ketoconazole cream 2x daily
intertrig. : low pot. c.steroids 5-7 days
eyelids: baby shampoo
fungal inf. of skin
tinea corporis (body) tinea circinata (body) tinea cruris (groin) tinea manuum (foot) tinea pedis (foot) tinea versicolor (pityriasis versicolor) (cent. up. trunk) -dx with 10% KOH prep, Cx, skin biopsy
tinea corporis/circinata
ring-shaped, exposed areas, +/- itching (often) can be severe in HIV pts
tx: topical antifungals (PO griseofulvin if severe)
tinea cruris (“jock itch”)
- groin, sparing scrotum
peri. spread, sharply demarcated, central clearing - assoc. pedis, onychomycosis
- reoccurs after tx
tx: antifungal powder, top. antifung. cream, oral griseofulvin/itraconazole if severe
lyme disease should not..
ITCH
-think fungal- tinea
ringworm
tinea manuum/pedis
scaling, itching btw toes along foot -can prog. to moist macerated areas -common in LE cellulitis pts tx: macerated: aluminum subacetate soaks, br.spec antifungal creams dry/scaly: OTC topical anti fungal
tinea versicolor (pityriasis versicolor)
velvety pink, tan macules (also white, tanning resist.)
fine scales
upp trunk/chest
yeast on microscopic exam (Malassezia-“spaghetti and meatballs”)
tx: selenium sulfide lotion, Ketoconazole PO if severe
cutaneous lupus
chronic cut. lupus and discoid lupus
- scaling, atrophy, dyspigmentation, telangiectasia, photosensitive
- head, scalp, face, ears
tx: avoid sun, photosens. drugs, radiation therapy - high pot. steroid creams
cutaneous T-cell lymphoma (Mycosis fungoides)
loc/gen erythematous patches/plaques >5 cm
-trunk
severe pruritis
tx: diff. PUVA, retinoids, other skin. dir tx
vesicular dermatoses
HSV 1 & 2
herpes zoster (shingles)
vesiculobullous eczema
porphyria cutanea tarda
HSV
recurrent sm. vesicles on an erythematous base (orolabial/genital distribution)
-post-stress, trauma, sun
-viral cx, abx test +
-1st episodes may present as gingivostomatitis or sev. genital outbreak w/ flu sumps and lymphadenopathy
(ppl test + for HSV)
-shingles should not typ. recur
herpes zoster
pain along dermatome distribution–>grouped vesicular lesions
(occ. fall outside if >20 lesions), typ. not dissem unless pt. is IC
-face, trunk
varicella zoster virus
tx: zostavax >50yo
Hutchinson’s sign
shingles on nose
must consider optic nerve is involved
Ramsay-Hunt syndrome
shingles in ear, must consider ear drum is involved, Bell’s palsy
can lead to systemic infection
Herpetic whitlow
lesion on finger/thumb (HC workers, sexual activity(autoinoculatoin) finger/thumb suckers)
HSV 1* or 2
herpes/shingles tx
oral antiviral: acyclovier, valacyclovir w/in 72 hours
-abx if secondary cellulitis
tx only shortens duration by 1-2 days BUT **dec. risk of post-herpetic neuralgia!!* (esp. elderly)
vesiculobullous eczema
“tapioca” vesicles on palms, soles, sides of fingers
multiloculated large blisters
recurs over lifetime
tx: topical & systemic steroids, chronic prob–> steroids abort the flares
porphyria cutanea tarda
non-inf./inflamm. blisters on sun-exp. sites
- assoc. liver disease
dx: PE, abn. LFTs, elev. ur porphyrins
tx: phlebotomy, eliminate etOH,
impetigo
superficial blisters w. some opaque/purulent material
- rupture easily, weep–>crusted superfic. erosions
dx: Gs often + for GPC in clusters/pairs (staph or strep, MRSA)
tx: top. bacitracin or mupirocin(bactroban) chlorhexidine/bleach baths, occasional oral coverage
contact dermatitis poison ivy
erythema, intense pruritus–>dev. of blisters: weeping, crusting
autoinoculation, spread by scratching, look for exposure hx
tx: was oil w/ dish soap
severe: mid-pot steroid creams
m. severe: tapering prednisone
acne vulgaris
onset of puberty op/closed comedones (white/black heads) most common severe: papular, pustular, cysts, nodules, scarring -face, upper trunk
tx of acne vulgarism: comedones
face wash, topical retinoids, benzoly peroxide, top. abx
tx of acne: mild papular/cystic
top. clindamycin/eryth w/ benz peroxide, poss. tretinoin cream
tx of acne: mod pap/cystic
oral tetra, doxy, minocycline, OCTs, topical
tx of sev. acne
isotrentinoin, intralesional injection, laser dermabrasion, oral and topical agents
rosacea
chronic, neurovasc. component, telangiectasias, flush
glandular as well
exacerb. by hot foods, etOH, emotions, sun
tx: avoid triggers, also tetra/doxy/mino
folliculitis
hairy areas typ.
itching, burning, pustular formation
staph, strep, MRSA
“hot tub”: diffuse pruitis, rash in exposed areas, pseudomonas, clears spontaneous (no abx)
candida tx
topical: miconazol, nystatin powders
clotrimazole, ketoconazole creams/lotions
oral: flucanazole, voriconazole
nystatin swish and swallow
MRSA
v. indurated w/ min. purulence
may req. drainage, some spont. drain
tx: trimethoprim/sulfa, doxy, clindamycin
–>rarely causes sys. inf.
steven johnson syndrome
dry, cracked bleeding lips,
red rash, stinging sensation, skin peeling
stop offending medication!!
erythema multiforme
sudden onset of syst. erythematous skin rxn
target lesions having clear centers
mild, self-lim post-viral inf. or med rxn OR
major, life threatening: SJS, TEN
erythema multiform tx:
stop offending agent!
TEN: burn unit for massive skin exfoliation
steroids, IVIG
erythema migrans
bullseye, with Lyme disease
bullous pemphigoid
tense blisters in flexural areas, subepiderm. blisters, gen >60 yo
pemphigus vulgaris
flaccid blisters, crusts, erosions, acantholysis
any age
BCC
pearly papule >6mm, non healing, sunexp. area, “rat bite” lesion, bleeding
tx: Mohs, removal
SCC
nonhealing ulcer, long term sun exposure, often begins as actinic keratosis
tx: Mohs, excisional, top. retinoid acid
Kaposi’s sarcoma
brown/black flecks, classically on chest
HIV+, males (anal sex)
can be in bowels–>bleed to death
Pediculosis
(lice!)
pruritus w/ excoriations, nits(eggs) on hair shafts, lice on skin, clothing
direct contact needed (can’t jump)
tx: permethrin cream rinse (Nix), high temp laundering
erythema nodosum
painful, erythematous nodules on ant. aspects of shins, below knees
mostly women (10:1)
-recent viral proc., drug rxn, underly. IBD
-lasts about 6 wks, can reflare
erythema nodosum tx
NSAIDS, time
cellulitis
may come in w. flu-like symptoms: fever, chills, body aches, nausea typically GAS (redness, blisters) (staph causes pus, boils, abscesses)
cellulitis tx
cephalosporins: cefalexin, (4x day, low compliance), cephadroxil, cefuroxine
clindamycin
not her favs: bactim, amoxicillin
vs IV: ancef (ceph) or vancomycin
cellulitis vs decubitis ulcer
the latter needs wound care, typ. IV abx, doppler to ensure perfusion
scabies
*extremely itchy* ask about bugs extremely contagious chest, classically on fingers topical permetherin oral ivermectin
what can cause low grade fever/fatigue for weeks
CMV Coxsackie Parvovirus Mono (*viruses*!) or smoldering diverticulitis, abscess
non infectious causes of low grade fever/fatigh for weeks
malignance (>50)
joint pains: rheumatoid arthritis
AI diseases
LPE
