skin conditions 5 and 6 Flashcards
what are the viral exanthams
- measles
- rubella
- fifth disease
- varicella
- zoster
what is another name for measles
rubeola
how is measles spread
- respiratory droplets
- incubation of 9-12 days
- clears in 4-7 days
si/sx of measles
- prodrome of cough, coryza, conjunctivitis
- fever
- descending rash of papules that coalesce
- rash includes palms and soles
- koplick spots*
what are koplick spots
- white papules 1 mm on buccal mucosa and pharyn
- occurs during measles
treatment for measles
- prevention- vaccine
- supportive
what another name for rubella
german measles
how is rubella spread
- respiratory droplets
- incubation- 12-23 days
- caused by toga virus
si/sx of rubella
- no prodrome
- 1-5 days fever, malaise, sore throat, h/a
- pain with lateral upward eye movement
- lymphadenopathy*
- pale pink morbilliform macule (smaller ran rubeola)
- starts of face, spreads to whole body in 23 h
- forscheimers sign*
what is forscheimers sign
- pitechiae on soft palate of uvula
- occurs in rubella
treatment of rubella
- prevention- vaccine
- supportive
how is fifth disease spread
- respiratory droplets
- viral shedding stopped by the time rash appears
- incubation of 4-14 days
whats another name for fifth disease
erythema infectiosum
si/sx of fifth disease
- 3 stages
- 1: aburpt asymptomatic erythema on cheeks (slapped cheek)
- 2: day four discrete erytematous macules and papules on proximal extermitities and trunk, lacey reticulate pattern
3: recurring stage d/t heat or light
treatment for fifths disease
supportive
how is pityriasis caused
- unknown
- thought to be previous viral exposure
si/sx of pityriasis rosea
- herald patch**
- oval erythematous patches with fine scaes
- macular or papular lesions on trunk, neck, extremities following skin folds
- christmas tree pattern
- can be pruritic
- lasts 3-8 weeks
what is a herald patch?
- 2-5 mm scaly lesion that may mimic tinea corporis
- happens in pityriasis rosea
treatment for pityriasis rosea
- not needed
- can give antihistamine for pruritis
morbilliform reactions
- most common adverse drug eruption
- type IV allergic reaction mediated by t helper cells
- commonly from ampicillin or amoxicillin
si/sx of morbilliform rash
- erythema with macules and papules initially on trunk then generalized within 2 days
- can present within first 2 weeks of exposure up to 10 days after d/c
treatment for morbilliform rash
- clears w/ in 2 weeks d/c
- symptomatic relief: antihistamines, low potency topical steroids
when do fixed drug reactions occur
- usually with meds that need to be taken itermittently
- NSAIDs
- sulfonamides
- barbituates
si/sx of fixed drug reactiosn
- oval/round erthematous plaque
- pruritic, burning, or asymptomatic
- reoccur at same site with each exposure
- usually 6 or fewer lesions
- 50% of lesions appear on genitals or oral mucosa
treatment for fixed drug reactions
- symptomatic: antihistamines and topical steroids
erythema multiforme
- self limited eruption
- d/t drug exposure, viral infection, or ideopathic
- usually sulfa, barbs, phenytoin
si/sx of erythema multiform
- begins as macules -> papular -> vesicles -> bullae
- localized to hands and feet, can become more generalized
- targetoid appearance
- mucosal lesions are painful and erode
treatment for erythema multiforme
- avoid target substances
- severe reaction can require systemic steroids
SJS and TENS
- mucocutaneous blistering reaction from drugs
- thought to be an immune response
si/sx of SJS and TENS
- fever
- mucosal inflammation
- lesions begin on trunk and may be painful
- TEN- higher fever, more epidermal sepearation
treatment for SJS or TEN
- treatment at burn center for fluid and electrolyte imbalance
- wound care
- ? steroid treatment
bullous pemphigoid
- autoimmune process
- usually in 60s
- IgG antibodies bind to basement membrane -> inflammation -> protease release -> blister
- Ab separate epidermis from dermis
si/sx of bullous pemphigoid
- prodrome of urticarial lesions
- bullae are large and can have serous or hemorrhagic fluild
- axillae, thigh, groin, abdomen
course of bullous pemphigoid
- usually self limited
- can last 5-6 years
differential dx for bullous pemphigoid
- epidermolysis bullosa acquisita
- bullous scabies erruptions
dx of bullous pemphigoid
- biopsy and immunofluroescence
- C3 deposition is almost always present
treatment for bullous pemphigoid
- potent steroids
- clobetasol ointment
- PO prednisone
- if very severe can give immunosuppressants
- tetracycline + niacinamide
what are the 3 types of lice
- pediculus humanis capitis- scapl
- p. humanis corporis- body
- phthirus pubis- pubic area, crabs
p. humanis capitis
- cant live more than 3 days off human head
- easily dislodged
- lay eggs on most fabric
p. humanis corporis
- lives in human clothes
- prefers cooler temps
- can live 10 days off the human body
p. pubis
- looks like a crab
- large claws -> grasp to coarser hair in groin, perianal, axillary areas
- heavy infestations can involve eyebrows, facial hair, eye lashes
- less mobile
- can only survive for 1 day off human
si/sx of p. capitus
- intense pruritus of scalp
- posterior cervical lymphadenopathy
- may see lice, nits, or dung
p. corporis si/sx
- small pruritic papules
- progress d/t scratching to rusted and infected papules
- spares hands and feet
- usually d/t poor hygiene
p. pubis si/sx
- intense pruritus in affected areas
- small blue macules
- spread by close physical contact
differential diagnosis of pediuclosis
- scabies
- eczema
- delusions of parasitosis
treatment of pediculosis
- OTC Nix cream rinse, RID acticin
- ovid lotion
- elimite cream
- bactrim
- vasaline
- wash clothes/sheets etc. and expose to high heat
- seal objects in plastic bag for 2 weeks
- ppx treat family members
scabies
- infestation of sarcoptes scabiei
- burrow into epidermis and deposit feces and lay eggs -> irritation
- type IV hypersensitivity reaction 30 days after infestation
- should be considered on any pt with pruritus not responding to topical steroids
si/sx of scabes
- vesicles, papules, or nodules
- found between fingers and toes, flexor aspect of wrists, axilla, antecubital area, abdomen, umbilicus, genitals, gluteals, feet
- spares the face
- burrows**
crusted/ norwegian scabies
- immunocompromised pts
- crusts and scales teem with mites
- psoriasis like scaling around nails with crusting
differential dx for scabies
- bite reaction
- atopic dermatitis
- delusions of parasitosis
treatment of scabies
- permethrin cream- apply for 8-12 hours, repeat in one week
- lindane lotion- more toxic
- precipitated sulfur ointment
- PO ivermectin
- after treatment was all clothes, bedding etc..
- treat family members
loxoscelism
- bite from a brown recluse spider
where are brown recluse spiders found?
- commonly in midwest and southwest
- woodpiles, grass, rocky bluffs, barns
- stings in sell defense
- has violin shaped markings on body
what is in the brown recluse spider venom
- phospholipase enzyme called sphingomyelinase D
- breaks down proteins
si/sx of brown recluse spider bite
- localized sx
- pain after 3 hours
- extensive necrosis and edema within 8 hours
- bulla surrounding erythema and ischemia can extend into muscle
- 1 week- gangrenous and dark
treatment for brown recluse spider bite
- rest, ice, elevate bite
- analgesics
- tetanus prophylaxis
- surgical debridement
latrodectism
- black widow spider bite
where are black widow spiders found?
- continental US
- caribbean
- wood piles and outhouses
- red hourglass shaped markings on abdomen
si/sx of black widow spider bite
- central reddened fang puncture site with area of blanching and outer halo of redness- target appearance
- systemic pain/ cramping in one hour
- tachycardia
- HTN
- pulmonary edema
- fever, chills, delirium
- vomitting
- partial paralysis
- abdominal pain is severe*
treatment for black widow spider bite
- ACLS
- anti-venom
- analgesics
- antihistamines
- tetanus
what is lichen planus
- pruritic inflammatory disease of skin, mucous membranes, and hair follicles
- mostly affects adults
- T cell reaction -> keratinocytes undergo apoptosis
si/sx lichen planus
- four P’s
- purple
- polygonal
- pruritic
- papules
- on flexor aspects of wrists, lumbar area eyelids, shins, scalp
- reticulate white lesions on buccal mucosa
- lesions for < 1 year
- can cause hair loss and nail damage
treatment for lichen planus
- potent topical steroid
- intralesional steroid injection
seborrheic keratosis
- senile wart
- basal cell papilloma
- over 90% of adults over 60 have these
- occurs in all races
presentation of seborrheic keratosis
- “Stuck on” appearance
- white, flesh colored, tan, brown
- can be warty or smooth
kaposi sarcoma
- vascular neoplasm
- usually in HIV pts
- infection with HHV8
- 4 types but HIV associated is most common
si/sx of kaposi sarcoma
- red/purple macules -> infiltrative plaques and nodules or tumors on mucous membranes
- often on lower extremities
- presents later on arms and hands
- lymphedema
- becomes painful and ulcerated
- internal involvement possible
histology of kaposi sarcoma
- capillaries are large and protrude into lumen
- proliferation of vessels around existing vessels
- spindle cells found in nodular lesions
clinical course of kaposi sarcoma
- variale
- progresses slowly with rare lymph node or visceral involvement
- almost never fatal
- death usually d/t unrelated cause
treatment of kaposi sarcoma
- antiretroviral HIV tx
- radiation
- cryotherapy
- surgical excision of individual nodules
- topical alitretioin
- pulsed dye laser
actinic keratosis
- in situ dysplasia d/t UV radiation
- can progress to SCC
- thick scaly growths
- most common epithelial precancerous lesion
epidemiology of actinic keratosis
- white > darker skin
- men > women
- > risk with outdoor occupation or lifestyle
- most common >50 y/o
pathophysiology of actinic keratosis
- atypical keratinocytes at basal layer that can extend upward
- epidermis shows atypia, hyperkeratosis with inflammatory infiltrate
clinical manifestations of actinic keratosis
- found on chronically sun exposed surfaces
- drivers sides
- multiple discrete, flat, or elevated verrucous
- keratotic, red, pigmented, or skin colored
- may be scaley, smooth, shiny
- rough sandpaper texture
- usually felt more easily than seen
differential dx for actinic keratosis
- BCC
- seborrheic keratosis
- SCC
- lupus erythematosus
dx of actinic keratosis
- clinical/ hx
- biopsy if palpable dermal component, “pearly” appearance or failed tx
tx of actinic keratosis
- based on number of lesions, persistence of lesions, and pt tolerability
- cryotherapy
- imiquimod
- 5-FU
- picato
- be sure to follow up with pt
prognosis of actinic keratosis
- good
- continue to monitor for 2-6 mo depending on number of lesions and maintenance tx
basal cell carcinoma
- epithelial tumor of basal keratinocytes
- invades dermis
- rarely metastasizes
- slow growing
epidemiology of BCC
- white > dark skinned
- geography - closer to equator
- age > 40
- outdoor lifestyle/ occupation
- immunosuppression increases risk by 10X
pathophysiology of BCC
- immature pluripotent cells associated with hair follicle
- mutations activate pathway that controls cell growth
- activates oncogenes and tumor suppressor genes
clinical manifestations of BCC
- slowly enlarging lesion that does not heal, bleeds easily
- mostly on face, head, neck, hands
- appears as flat, firm, pale area
- small, raised
- pink or red, translucent or pearly**
- rolled edge
- can become ulcerative- “rodent ulcer”
- bleeds without significant pain or sx
- ulceration may burrow deep into subcutaneous tissue
types of BCC
- nodular
- superficial
- morpheaform (sclerosing)
- pigmented
nodular BCC
- most common type
- waxy, pearly, semitranslucent nodules or papules
- rolled edge
- central depression that may become ulcerated, crusted, or bleed
superficial BCC
- dry scaly lesion
- superficial flat growths
- can be misdx as eczema or psoriasis
- threadlike raised boarder
morpheaform (sclerosing) BCC
- white sclerotic plaque
- tenagiectasia
- scar like appearance
pigmented BCC
- similar to nodular
- brown or black pigmentation
- usually in darker skin
differential dx of BCC
- SCC
- sebaceous hyperplasia
- actinic keratosis
- eczema
- psoriasis
dx of BCC
- biopsy
- large, oval, or round tumor islands within dermis
- often epidermal attachment
treatment of BCC
- goal= cure with best cosmetic results
- reoccurrence usually from inadequate tx
- usually seen in first 4-12 mo after tx
- surgical, topical, or radiation tx
topical tx for BCC
- imiquimod
- 5-FU
- best for superficial BCC, less invasive
surgical options for BCC
- electrodisseication and Currettage for superfical lesions
- cryosurgery (not common)
- excision with margins- high cure rate
- mohs micrographic surgery- gold standard (takes small layer at a time and checked under microscope until all cancer cells removed)
radiation for BCC
- not often used unless lesions are large
- usually old pts who aren’t candidates for surgery
- can take 5-25 visits
prognosis of BCC
- good if appropriate tx used early
- recurrent cancers are much harder to cure
- 100% survival if it has not metastasized
- can impinge on vital structures
squamous cell carcinoma
- many arise from actinic keratoses
- can metastasize
- arise from malignant proliferation of epidermal keratinocytes
epidemiology of SCC
- > 50 y/o
- male > female
- light skin > dark skin
- tobacco and/or alcohol use
- geography
- hx of previous non-melanoma skin cancer
- immunosuppression
- HPV
- chemical carcinogens
pathophysiology of SCC
- UVR, PUVA
- smoking (oral ca)
- HPV 16, 18, 31, 35
- irregular nests of epidermal cells invading into dermis
- TP53 mutation
types of SCC
- in situ (bowen’s disease)- full thickness of epidermis
- invasive
clinical manifestations of SCC
- begings at site of acitinic keratosis on sun exposed areas
- superficial papules, plaques, or nodules
- hard
- become larger, ulcerated, covered by crust
- lesions are moveable at first but then become fixed
lower lip SCC
- starts as actinic chelitis
- local thickening on keratosis then firm nodule
- usually hx of smoking
periungual SCC
- signs of swelling, erythema, local pain
- commonly in nail folds of hands
- resembles warts
differential dx for SCC
- actinic keratosis
- eczematous rash
- atopic dermatitis
dx of SCC
- biopsy- reveals “keratin pearls”
- lymphadenopathy*
treatment of SCC
- excision
- mohs
- radiation
prognosis of SCC
- Mohs surgery provides best cure rates
- if metastasized, associated with poor prognosis
- regular f/u required
melanoma
- skin cancer of melanocytes
- least common skin cancer
- most deadly
melanoma risk factors
- M- mole atypia
- M moles > 50
- R red hair and freckling
- I inability to tan
- S sunburn, severe/ blistering
- K kindred/ family history
etiology of melanoma
- damage to DNA of melanocytes -> oncogene and tumor suppressor gene mutations
- UVR
- genetics
pathophysiology of melanomas
- originate from melanocytes via dermoepidermal junction
- half will dev in preexisting nevi
- usually prolonged, noninvasive radial growth
- tumor nodule dev- vertical growth
what is the greatest factor risk for metastasis in melanoma
- depth of invasion of melanoma lesion
clinical manifestation of melanoma
- macular or nodular
- color varies
- lesions boarders are irregular
- growth is quick or slow
- distribution can be o non sunexposed spots
superficial spreading of melanoma
- does not have a preference for sun damaged skin
- tends to be multicolored
- boarders are more sharply defined
lentigo maligna
- macular and flat then nodular
- most common on sun damaged skin
- insidious slow growth
- type of melanoma
nodular melanoma
- arise without apparent radial growth phase
- primarily sun exposed areas of head, neck, trunk
- smooth and dome shaped
- friable or ulcerated and bleeding
acral- lentiginous
- most common in darker skin types
- light brown uniform pigmentation initially
- on palms, soles, or nail beds
- lesion becomes darker and nodular
- can ulcerate
- usually delay in dx
- type of melanoma
melanoma metastasis
- early mets via lymphatics and regional lymphadenopathy mya be first sign
- satellite mets appear as pigmented nodules around site of excision
- spread via blood mainly to brain and lung
what are the markers for melanoma metastasis
- cancer at other organs- usually brain and lungs
- elevated LDH
breslow thickness
- total vertical height of melanoma
- ocular micrometer is used to measure thickness
- smaller the thickness the better the survival
dx of melanoma
- excisional biopsy
- palpate lymph nodes
melanoma treatment
- surgery- simply excision for early stage
- wide local excision with sentinel LN biopsy or elective lymph node dissection = mainstay
- radiation- usually at metastatic sites as palliative care
- chemo- not often used
- frequent follow ups
