Skin Disorders Flashcards
1
Q
How many different skin phototypes are there and what is this classification called? (TN)
A
- Fitzpatrick
- Phototype I (lightest) to VI (darkest)
2
Q
How should a skin lesions be described? (TN)
A
-
SCALDA
- Size and surface area
- Colour – hyperpigmented, hypopigmented, erythematous
- Arrangement – solitary, linear, reticulated, grouped, herpetiform
- Lesion morphology – macule, patch, papule, plaque, nodule, tumour, vesicle, bulla
- Distribution – dermatomal, intertriginous, symmetrical/asymmetrical, follicular
- Always check hair, nails, mucous membranes and intertriginous areas
3
Q
What are 8 different morphologies of lesions and differentiate based on size. (TN)
A
4
Q
Differentiate between a cyst and pustule and an erosion and ulcer. (TN)
A
- Cyst: epithelial-lined collection containing semi-solid or fluid material
- Pustule: elevated lesion containing purulent fluid (white, grey, yellow, green)
- Erosion: disruption of the skin involving the epidermis alone; heals without scarring
- Ulcer: disruption of the skin that extends into the dermis or deeper; heals with scarring
5
Q
What are 7 secondary morphological lesions? (TN)
A
- Crust: dried fluid (serum, blood, or purulent exudate) originating from a lesion (e.g. impetigo)
- Scale: excess keratin (e.g. seborrheic dermatitis)
- Lichenification: thickening of the skin and accentuation of normal skin markings (e.g. chronic atopic dermatitis)
- Fissure: linear slit-like cleavage of the skin
- Excoriation: a scratch mark
- Xerosis: pathologic dryness of skin (xeroderma), conjunctiva (xerophthalmia), or mucous membranes
- Atrophy: histological decrease in size and number of cells or tissues, resulting in thinning or depression of the skin
6
Q
What is purpura and the three different types? (TN)
A
- Purpura: extravasation of blood into dermis resulting in hemorrhagic lesions; non-blanchable, 3mm-1cm in size
- Petechiae: small pinpoint purpura, <3mm in size
- Ecchymoses: larger flat purpura, >1 cm in size, aka a “bruise”
7
Q
What are 10 different patterns and distribution of skin lesions? (TN)
A
- Acral: relating to the hands and feet (e.g. hand, foot and mouth disease)
- Annular: ring-shaped
- Follicular: involving hair follicles (e.g. folliculitis)
- Guttate: lesions following a “drop-like” pattern (e.g. guttate psoriasis)
- Morbilliform: a maculopapular rash resembling measles
- Reticular: lesions following a net-like pattern (e.g. livedo reticularis)
- Satellite: lesions scattered outside of primary lesions (e.g. candida diaper dermatitis)
- Serpiginous: lesions following a snake-like pattern (e.g. cutaneous larva migrans)
- Target/Targetoid: concentric ring lesions, like a dartboard (e.g. EM)
8
Q
Provide possible diagnoses for each type of skin lesion: brown macule, discrete red papule, red scales, vesicle, bulla, pustule, oral ulcer and skin ulcer. (TN)
A
9
Q
Eczema
What should be considered in the differential diagnosis for eczema?
A
- Atopic dermatitis (Eczema)
- Contact dermatitis
- Seborrheic dermatitis
- Impetigo
- Psoriasis
- Candidiasis
10
Q
Eczema
What is the atopic triad? (DFCM)
A
- Asthma
- Allergic rhinitis
- Atopic dermatitis
11
Q
Eczema
How does atopic dermatitis look like on the skin? (DFCM)
A
- Erythematous papules, patches and plaques with poorly defined borders
- Dry skin and pruritus – leads to Itch Cycle – can lead to lichenification and inflammation
12
Q
Eczema
What should be considered in patients with atopic dermatitis as a potential complication? (DFCM)
A
- Secondary Impetigo
13
Q
Eczema
Where do atopic dermatitis typically affect infants and children? (DFCM)
A
- Infants: cheeks, scalp, extensor surfaces
- Spares diaper area
- Children: face, neck, flexural surfaces
- Increased lichenification
14
Q
Eczema
In patients with suspected atopic dermatitis that have crusted or vesicular lesions, what test could be performed? (DFCM)
A
- Viral cultures to rule out HSV infection
15
Q
Eczema
What are 4 important points to educate to patients and parents about the management of atopic dermatitis?
A
- Emollients – Cetaphil or Vaseline
- Ceramide containing – CeraVe or Restoraderm
- Shower with warm (not hot) water, use emulsifier oil or Oatmeal in baths and use emollient after
- Keep house cool and humidified
- Clothing
- 100% cotton
- Mild detergents – i.e. Ivory Snow
- Rinse laundry twice if possible
- No fabric softener or bleach
- Children
- Don’t play in grass or leaves
- Apply moisturizer to face before feeding
16
Q
Eczema
What is first-line treatment for atopic dermatitis?
A
- Topical steroids
17
Q
Eczema
How should the dose of topical steroids for atopic dermatitis be determined?
A
- Tailor potency to disease and degree of lichenification
- BID to QID for low and mid potency
- OD to BID for high and ultra high potency (max 2-4 weeks)
- Mild potency: face, groin and any joints
- Hydrocortisone (Hyderm or Emo-Cort) 1% or 2.5%
- Moderate potency for <2 weeks is okay
- Betamethasone valerate (Betaderm) 0.05% or 0.1%
- High potency – consult with Derm
- Betamethasone dipropionate (Diprosone) 0.05%
- Ultra-high potency
- Clobetasol propionate (Dermovate) 0.05%
- Ointment > Cream > Lotion in terms of potency
- Avoid ointment for open lesions and intertriginous folds
18
Q
Eczema
What are 5 potential adverse effects of topical steroids for atopic dermatitis? (TN)
A
- Atrophy
- Striae
- Telangectasia
- Corticosteroid acne
- Tachyphylaxis
- ***No adrenal suppression or growth changes until regular use of high-potency steroids
19
Q
Eczema
What is second-line therapy for atopic dermatitis?
A
- Topical Calcineurin Inhibitors
- Pimecrolimus 1% (Elidel)
- Tacrolimus 0.03%, 0.1% (Protopic)
20
Q
Eczema
How would topical calcineurin inhibitors be prescribed for atopic dermatitis?
A
- Used for short-term (BID therapy) or long-term intermittent therapy (2x/week) for Mod-Severe
- Pimecrolimus currently not approved for maintenance therapy
- For use in patient >2 years of age
21
Q
Eczema
What is the benefit of topical calcineurin inhibitors over topical steroids and what are the potential risks?
A
- No skin atrophy – may be better for face, neck and skin folds
- No tachyphylaxis
- Black-box warning: ?link to lymphoma or immunosuppression
- Side effects: transient skin irritation or burning, pruritus
22
Q
Eczema
What can be used to treat atopic dermatitis refractory to topical treatments or with widespread disease?
A
- Phototherapy
23
Q
Eczema
What would be a Mild Approach and Moderate-Severe Approach long-term for atopic dermatitis?
A
- Mild
- Steroids are first-line for flares once daily
- Return to emollient-only treatment after flares
- Moderate-Severe
- 2x/week steroids with emollient use for maintenance
- Get control with higher potency, then taper strength
- Or Calcineurin Inhibitors BID
- Consider phototherapy
- 2x/week steroids with emollient use for maintenance
24
Q
Seborrheic Dermatitis
What is seborrheic dermatitis called in infants? (TN)
A
- Cradle Cap
25
# Seborrheic Dermatitis
**What is the uninflamed form of seborrheic dermatitis called? (TN)**
* Pityriasis capitis (Dandruff)
26
# Seborrheic Dermatitis
**How does seborrheic dermatitis typically appear? (TN)**
* Greasy, erythematous, yellow, scaling, minimally elevated papules and plaques in areas rich in sebaceous glands, can look moist and superficially eroded in flexural regions
27
# Seborrheic Dermatitis
**What is the suspected pathophysiology of seborrheic dermatitis? (TN)**
* Malassezia spp. (YEAST)
28
# Seborrheic Dermatitis
**What can be used to treat seborrheic dermatitis on the face? (TN)**
* Ketoconazole (Nizoral) cream daily or BID + mild steroid cream daily or BID
29
# Seborrheic Dermatitis
**What can be used to treat seborrheic dermatitis on the scalp? (TN)**
* Salicylic acid in olive oil or Derma-Smoothe FS lotion (peanut oil, mineal oil, fluocinolone acetonide 0.01%) to remove dense scales
* 2% ketoconazole shampoo (Nizoral)
* Shampoos used twice weekly for at least 1 month
* Ciclopirox (Stieprox) shampoo
* Shampoos used twice weekly for at least 1 month
* Selenium sulfide (Selsun Blue) or Zinc pyrithione (Head and Shoulders) shampoo
* Shampoos used twice weekly for at least 1 month
* Steroid lotion (betamethasone valerate 0.1% lotion BID)
30
**What are the two mechanisms of contact dermatitis? (TN)**
* Irritant
* Allergic
31
**What are the top ten allergens identified in contact dermatitis? (TN)**
* Nickel sulfate – jewelry, belt buckles
* Neomycin sulfate – topical antibiotic in Polysporin
* Balsam of Peru – fragrance material
* Fragrance mix – fragrance components for allergen testing in cosmetics
* Thimerosal – preservative used in vaccines, contact lens solution, cosmetics
* Sodium gold – jewelry, dentistry, electronics
* Formaldehyde – colourless gas
* Quaternium-15 – component in shampoos, moisturizers, conditioners, soaps
* Cobalt chloride – cosmetics, jewelry, buttons, tools
* Bacitracin – topical antibiotic in Polysporin
32
**How does irritant and allergic contact dermatitis present clinically?**
* Irritant (Right)
* Usually the hands (palmar surface)
* Burning and pruritus
* Erythema, dry and fissured skin
* Less distinct borders
* Allergic (Left)
* Exposed skin areas, often the hands (dorsal surface)
* Pruritus is the dominant symptoms
* Erythema, vesicles and bullae
* Distinct angles, lines and borders
33
**What is the evidence for steroid use for contact dermatitis?**
* Irritant – No evidence
* Allergic – Good evidence
34
**What should management be for contact dermatitis?**
* Irritant
* Avoidance of irritants
* Wet compresses with Burow’s solution
* Trial cool compresses, calamine lotion and colloidal oatmeal baths
* Topical/oral steroids
* Allergic
* Consider patch testing if persistent
* Avoid allergen and its cross-reactants
* Wet compresses soaked in Burow’s solution (drying agent)
* Steroid cream (e.g. HC 1%, betamethasone valerate 0.05%, betamethasone valerate 0.1% cream; BID)
* Systemic steroids prn (prednisone 1 mg/kg, taper over 2 week)
* Antihistamines not effective, sedation probably helps the most
35
**What is the prevalence of psoriasis in Canada? (DFCM)**
* 1.7%
36
**At what ages does psoriasis incidence peak? (DFCM)**
* 20-30 and 50-60
37
**What type of disease is psoriasis classified as? (PBSG)**
* Autoimmune with a genetic predisposition
38
**How does psoriasis typically appear on the body? (DFCM)**
* Erythematous papules coalescing into plaques with silver-white scales, and well-defined borders
39
**What areas of the body are classically affected by psoriasis? (DFCM)**
* Elbows
* Knees
* Sacral-gluteal region
* Scalp
* Lower back
* Palms and Soles
40
**What are 7 possible triggers of psoriasis? (DFCM/PBSG)**
* Physical trauma (e.g. vaccinations, tattoos, sunburn)
* Stress
* Infections (e.g. HIV)
* Medications (e.g. systemic glucocorticoids, oral lithium, interferon, beta-blockers)
* Alcohol
* Cigarette smoking
* Cold weather with low humidity
41
**What is important to determine on clinical history in a patient presenting with psoriasis?**
* Family history (1/3 of patients)
* No or mild pruritus, sometimes painful
* Localization of lesions: scalp, elbows, knees, and lower back
* Arthritis
42
**What areas should be examined specifically in patients with psoriasis as they are often missed? (PBSG)**
* Scalp
* Ears
* Nails
* Natal cleft
* Genitalia
43
**How does the majority of psoriasis appear? (PBSG)**
* 80-90% is Plaque Psoriasis
* Sharply demarcate erythematous papules and plaques with a silver scale
* Bathing can remove the scale
* Often symmetrical
44
**What is inverse psoriasis and what are 2 diagnoses to also consider in the differential? (PBSG)**
* **Inverse psoriasis**: plaque psoriasis with minimal scaling in the intertriginous areas (axillae, groin, natal cleft, under breasts)
* **Intertrigo**: moist, erythematous lesions in intertriginous areas
* **Cutaneous T-cell lymphoma**: erythematous patches/plaques in intertriginous areas, diagnosis confirmed with skin biopsy
45
**What is guttate psoriasis, in what patients is it more common, what areas of the body does it affect, and what is a common precipitant? (PBSG)**
* **Guttate Psoriasis**: small papules of short duration (weeks to months)
* Usually in those \<30
* Evidence on trunk, proximal limbs or face (does NOT affect palms/soles)
* Commonly precipitated by URTI (streptococcal)
46
**What are 2 diagnoses to also consider for guttate psoriasis? (PBSG)**
* **Secondary syphilis**
* **Pityriasis rosea**: 1-2 weeks after vague viral episode, a single patch appears on trunk (Herald patch) and similar smaller lesions along skin cleavage lines (associated with human herpes virus type 6)
47
**What are 2 signs on history associated with psoriasis? (DFCM)**
* **Koebner phenomenon**: new psoriatic lesions appearing at site of injury or trauma
* **Auspitz’s sign**: bleeding after removal of psoriatic scales
48
**What % of psoriasis patients have scalp involvement? (DFCM)**
* 86% - pruritus and scaling
49
**What % of psoriasis patients have nail involvement and what are they? (DFCM)**
* 25% - pitting, leukonychia, red spots in lunula, nail plate crumbling, subungual hyperkeratosis, onycholysis, splinter hemorrhage, oil spot
50
**What should be considered in the differential diagnosis for psoriasis?**
* Seborrheic dermatitis
* Lichen simplex chronicus
* Atopic dermatitis
* Tinea corporis
* Secondary Syphilis
* Mycosis fungoides
* Often are sharply demarcated and red, but limited scale and can itch
51
**What potential comorbidities of psoriasis need to be investigated for?**
* Psoriatic arthritis
* Depression
* IBD (Crohn’s)
* Lymphoma
* Metabolic syndrome
* CAD
52
**What % of patients with psoriasis are affected by psoriatic arthritis? (DFCM)**
* 30%
53
**How is psoriasis severity defined? (PBSG)**
* Extent of body surface area (BSA) involvement
* Mild: \<5%
* Moderate: 5 to \<10%
* Severe: ≥10%
* Involvement of hands, feet, facial or genital regions
* Estimated using the palm (subject’s flat hand and thumb together, includes fingers) which ~1% of the total BSA
54
**What topical treatment should all patients with psoriasis do?**
* Emollients (moisturizers) daily applied to entire body after shower/bath
* Helps to minimize skin irritation and decrease likelihood of new lesions at the sites of minor trauma
55
**What are 4 different types topical therapies for psoriasis?**
* Steroids
* Vitamin D Analogues
* Calcineurin Inhibitors
* Retinoids
56
**What are 6 different forms of vehicles for topical therapies for psoriasis? (PBSG)**
* Ointments
* Creams
* Solutions
* Oils
* Lotions
* Foams
57
**What is an advantage of using foam formulations as a topical therapy for psoriasis? (PBSG)**
* Quick drying
* Ease of application
* Lack of fragrance
58
**How much topical agent is typical required to cover the whole body? In a patient with a 10% BSA involvement, how much would be required? (PBSG)**
* 30 g required to cover the whole body
* 10% BSA = 3 g BID or 6 g daily
* i.e. 60 g tube of ointment should last the patient 10 days
59
**What are the different topical steroid doses that can be used for psoriasis?**
* Moderate: Betamethasone valerate (**Betaderm**): 0.05% or 0.1%
* Only for the most mild cases or as foam for the scalp
* Higher potency has longer disease free intervals
* High: Betamethasone dipropionate (**Diprosone**): 0.05%
* Comes in lotion for use on scalp
* Ultra-High: Clobetasol propionate (**Dermovate**): 0.05%
60
**For which areas of the body are low potency corticosteroids recommended to be used? (PBSG)**
* Thin-skinned areas: face, body folds, genitals
61
**How frequently can topical steroids be applied per day for psoriasis? (PBSG)**
* Daily to TID (depending on type)
62
**What are examples of mild, moderate and high potency topical steroids for scalp psoriasis? (PBSG)**
* Mild: Hydrocortisone 2.5% BID-TID
* Moderate: Betamethasone valerate 0.1% lotion BID-TID
* High: Betamethasone dipropionate 0.05% OD-BID
* Ultra-High: Clobetasol propionate 0.05% shampoo OD, spray BID
63
**What are known adverse effects associated with topical steroids? (PBSG)**
* Burning
* Irritation
* Pruritus
* Dryness
* Atrophy
* Contact dermatitis
* Rosacea
* Striae
* Purpura
* HPA axis suppression
64
**What topical treatment for psoriasis is considered “steroid sparing”? (DFCM)**
* Topical Vitamin D3 analogues
65
**What other topical treatment can be used on its own or with steroids for psoriasis?**
* Vitamin D Analogues – better effect when combined with steroids
* Dovonex (Calcipotriene) and Vectical (Calctriol)
* **Dovobet** – Betamethasone dipropionate + Calcipotriol
* Comes in ointment or lotion
* Scalp gel can be applied once daily at bedtime, washout in morning
* Slower onset of action, but longer disease-free intervals
66
**What are known adverse effects associated with topical vitamin D analogues? (PBSG)**
* Burning
* Pruritus
* Edema
* Peeling
* Dryness
* Erythema – mitigated with ongoing use
67
**What is the maximum amount of topical Vitamin D analogues that should be used? (DFCM)**
* \<40% BSAS or \<100 g/week
68
**In what patients should there be caution in the use of Vitamin D analogues for psoriasis?**
* Renal failure – can cause Hypercalcemia and PTH suppression
69
**What are 2 examples of topical calcineurin inhibitors for psoriasis and their indications?**
* Pimecrolimus (Elidel) or Tacrolimus (Protopic)
* For use in patients \>2 years of age
* Less effective for plaque psoriasis
* First-line for **facial** or **intertriginous** psoriasis
* Important as steroid sparing agents if need to use continual therapy
70
**What is an example of a topical retinoid that can be used for psoriasis and its indications and side effects?**
* Tazarotene (Tazorac) – 0.05% or 0.1%
* Side effects (often peri-lesion) – itch and burning
* Use every-other-day or with steroid/moisturizer to decrease SE
* As good as steroids, but longer disease free interval
71
**Which topical therapy for psoriasis has the most ADEs? (DFCM)**
* Topical retinoids
72
**What is a good topical therapy for scalp psoriasis? (DFCM)**
* Mid to high potency topical corticosteroids (e.g. Betamethasone dipropionate) and calcipotriol
* Available shampoo formulations: clobetasol propionate solution or shampoo
73
**Does scalp psoriasis cause hair loss?**
* No
74
**What is a good topical therapy for psoriasis on the palms and soles?**
* Clobetasol with occlusive dressing
75
**When should systemic treatment be considered for psoriasis?**
* \>5% of body surface area (BSA) involved
* Genitals, hands, feet or face involved
76
**What are options for systemic treatment in psoriasis?**
* Phototherapy + Systemic (Methotrexate, Biologics)
77
**What are 2 systemic immunosuppressives that can be used for psoriasis? (PBSG)**
* Methotrexate
* Cyclosporine
78
**What are 3 severe toxicities that are associated with methotrexate use? (PBSG)**
* Liver
* Renal
* Bone marrow
79
**What is prescribed with methotrexate to protect against adverse reactions such as stomatitis? (PBSG)**
* Folic acid
80
**What are 4 biologic agents that can be used for psoriasis? (PBSG)**
* Adalimumab (Humira)
* Etanercept (Enbrel)
* Infliximab (Remicade)
* Ustekinumab (Stelara)
81
**How often should phototherapy be used for psoriasis and what type of wavelength is required? (PBSG)**
* Phototherapy 1-4x per week
* UVB – higher success rates and low risk of malignancy
* UVA used in tanning beds – risk of skin cancer and carcinogenesis
82
**What is the prevalence of acne among those aged 12 to 24 years? (CMAJ/PBSG)**
* 85%
83
**What is the medical term for common acne? (CMAJ)**
* Acne vulgaris
84
**Describe the pathobiology of acne.**
* Follicular hyperproliferation and abnormal desquamation – the normal dead cells are blocked from leaving the follicle by hyperkeratinization
* Increased sebum production – an androgenic effect
* Propionibacterium acnes proliferation
* Inflammation
85
**What are 4 diagnoses to consider in the differential diagnosis of acne. (DFCM/PBSG)**
* Rosacea – telangiectasia and no comedones
* Perioral dermatitis – erythematous papules on chin and nasolabial folds, with a thin rim sparing around the vermilion border
* May occur spontaneously or with topical steroid use
* Pseudofolliculitis barbae – ingrown hairs in the beard area of individuals with curly hair who shave closely
* Milaria – heat rash with nonfollicular papules, pustules and vesicles
* Bacterial Folliculitis – variable distribution that spreads with shaving or scratching
* Hidradenitis suppurativa – painful boils and sinus tracts
* Sebaceous hyperplasia – no erythema
86
**What should women with acne be asked about specifically? (DFCM)**
* Signs of hyperandrogenism (PCOS)
* Hirsutism
* Acanthosis nigricans
* Menstrual irregularity
87
**What complications of acne are more common in individuals with darker skin? (PBSG)**
* PIH
* Keloid scarring
88
**What is first line therapy for patients with acne in skin of colour to reduce PIH? (PBSG)**
* Topical retinoids
* Azelaic acid (Finacea) – indicated for acne rosacea
89
**What are the 3 categories of acne based on severity? (CMAJ)**
* Comedonal acne (NONinflammatory)
* Small white papules (closed comedones) – white heads
* Grey-white papules (open comedones) – black heads
* Mild-to-moderate Papulopustular acne
* Inflammatory lesions that are mostly superficial
* Severe acne
* Deep pustules and/or nodules, which may be painful, may extend over large areas and can lead to tissue destruction
90
**What is a rare subtype of severe acne? (CMAJ)**
* Conglobate acne: extensive inflammatory papules, nodules and cysts
* Can lead to disfiguring scars
91
**What was considered superior efficacy in the CMAJ guidelines on acne? (CMAJ)**
* Statistical significant (p \< 0.05)
* Clinical relevance (minimum 10% difference in lesion counts)
92
**What is first-line treatment for comedonal acne and mild papulopustular acne? (CMAJ)**
* Topical therapies
* Retinoids OR
* Benzoyl peroxide OR
* Fixed-dose combinations of retinoids with benzoyl peroxide or Clindamycin
* BPO/clinda
* BPO/adapalene
93
**What topical therapy can be tried if the initial first-line options fail for comedonal acne or mild papulopustular acne? (CMAJ)**
* Clindamycin/Tretinoin fixed-dose combination
94
**What is a second-line option for comedonal acne or mild papulopustular acne if topical therapies fail? (CMAJ)**
* Combined oral contraceptives + Topical
* Systemic antibiotics + Topical (only for Mild papulopustular)
95
**What is the first-line option for moderate papulopustular acne? (CMAJ)**
* COC or Systemic antibiotics + Topical
96
**What is the first-line treatment option for severe papulopustular/nodular acne? (CMAJ)**
* Oral isoretinoin
97
**If a patient with severe acne is unwilling, unable or intolerant to oral isoretinoin, what treatment can then be tried? (CMAJ)**
* Systemic antibiotics with topical BPO +/- topical retinoid OR COC
98
**Summarize the clinical treatment algorithm for acne. (CMAJ)**
99
**What type of topical formulation is better for dry or sensitive skin and what type for oily skin? (CMAJ)**
* Cream/Lotion for Dry/Sensitive
* Gel for Oily
100
**What are 4 points to educate patients about with acne?**
* Acne is NOT a hygiene problem
* There is NO relationship to diet
* Acne causes stress, NOT vice versa
* Acne usually worsens the week before menses
101
**What should patients be advised to do to help with acne that does not involve pharmacotherapies?**
* Limit face washing to 1-2x daily with mild soap (or soapless cleanser)
* Neutrogena Oil Free Acne wash or Cetaphil or CeraVe
* Dove bar soap or body wash
* Consistency with washing/treatment is key
* Gently wash face (men)
* Use water-based or non-comedogenic makeup, sunscreen and lotions rather than oil-based
102
**What are common adverse effects related to all topical acne therapies? (CMAJ)**
* Dryness
* Redness
* Burning
* Irritation
* Peeling
103
**What doses can benzoyl peroxide be prescribed in? (CMAJ)**
* Benzoyl Peroxide 2.5%, 5% 10% gel, cream or lotion
* 10% not for comedonal
104
**What is the primary active ingredient in Proactiv? (PBSG)**
* BPO
105
**What are 3 types of topical retinoids and which seems to be inferior? (CMAJ)**
* Tretinoin 0.025%, 0.04%, 0.05% gel or cream (Retin A, Stieva A)
* Inferior
* Adapalene 0.1% and 0.3% gel or cream (Differin)
* Tazarotene 0.1% gel (Tazorac)
106
**What is the fixed-dose combination of adapalene-BPO? (CMAJ)**
* Adapalene 0.1% and BPO 2.5% gel (TactuPump)
* Adapalene 0.3% and BPO 2.5% gel (TactuPump Forte)
107
**What is the fixed-dose combination of clindamycin-BPO? (CMAJ)**
* Clindamycin 1% and BPO 5% gel (BenzaClin, Clindoxyl)
108
**What is the fixed-dose combination of clindamycin and tretinoin? (CMAJ)**
* Clindamycin 1.2% and tretinoin 0.025% (Biacna)
109
**What topical acne treatment can be effective for hormone acne (premenstrual) that occurs near the jawline?**
* Dapsone (Aczone)
110
**What is the use of systemic (oral) antibiotics for acne on their own not recommended? (CMAJ)**
* Selection of antibiotic resistant bacteria
* Addition of BPO recommended to limit the emergence of antibiotic resistant bacteria
111
**What are the preferred systemic (oral) antibiotics for acne and why? (CMAJ)**
* Tetracycline or Doxycycline
* Minocycline associated with an increased risk of drug-induced lupus and hepatitis
112
**Which COC combinations have been shown to be effective for the treatment of acne? (CMAJ)**
* Ethinyl estradiol 20 ug and levonorgestrel 100 ug (Alesse)
* Ethinyl estradiol 20 ug and drospirenone 3 mg (Yasmin)
* Ethinyl estradiol 35 ug and norgestimate 180, 215 or 250 ug (Tri-cyclin 21)
* Ethinyl estradiol 35 ug and cyproterone acetate 2 mg (Diane-35)
113
**What are potential adverse effects associated with topical retinoids for acne?**
* Erythema
* Scaling
* Dryness
* Pruritus
* Burning
* Photosensitivity
* Potential exacerbation of acne within the first few weeks
114
**What is a contraindication to use of topical retinoids and what ages are they recommended in? (CMAJ)**
* Pregnancy
* Tazarotene category X
* Adapalene and Tretinoin category C
* Adapalene and Tazarotene for patients ≥12 years of age
* No age limitation for Tretinoin
115
**What should patients using topical retinoids be counselled about?**
* Avoid prolonged exposure to the sun and wear sunscreen
* Avoid waxing or laser hair removal due to skin fragility
116
**What are potential adverse effects associated with topical BPO for acne?**
* Contact dermatitis (1-2%)
* Can cause severe reaction
* Health Canada recommends spot trial on 1 or 2 small affected areas for 3 days to ensure no hypersensitivity symptoms develop
* Erythema
* Peeling
* Dryness
* Can bleach clothing, bedding, and hair (use old sheets and wear old t-shirt in bed)
117
**What are potential adverse effects associated with topical dapsone for acne?**
* Dryness
* Erythema
* Sunburn
* Contact dermatitis
* Methemoglobinemia and hemolytic anemia
* Contraindicated in pregnancy and breastfeeding
118
**How long should systemic antibiotics be prescribed for acne?**
* 3 months – then stop and maintain with topical treatment
119
**How is Accutane (Isotretinoin) prescribed for acne?**
* Initial 0.5 mg/kg divided BID for 1 month, then increase to 1 mg/kg
* Total dose is 120-150 mg/kg (often takes 4-5 months)
120
**What do females need to do before starting Accutane (Isotretinoin)?**
* 2 contraceptive methods 1 month pre-treatment to 1 month post-treatment
121
**What are potential adverse effects associated with Accutane (Isotretinoin) for acne?**
* Cheilitis
* Conjunctivitis
* Dry mucous membranes of the nose and mouth
* Xerosis
* Photosensitivity
* Less common:
* Arthalgias
* Myalgias
* CNS – headache, nyctalopia (inability to see in dim light or at night), pseudotumor cerebri
122
**What do patients treated with Accutane (Isotretinoin) need to be monitored for?**
* Hypertriglyceridemia
* Elevated total cholesterol
* Reduced HDLs
* LFT and Platelets
123
**What bloodwork should be performed in patients on Accutane (Isotretinoin)?**
* Initial and at 2 weeks
* CBC, ESR, beta-HCG (2 tests before beginning), glucose, lipids, AST/ALT, INR, Bilirubin and Albumin
* Monthly
* Beta-HCG, Lipids, AST/ALT, INR, Bilirubin and Albumin
124
**How can rosacea be differentiated from acne? (TN)**
* Rosacea has NO comedones
* Rosacea distributed more along central face and has symptoms of flushing
125
**How does rosacea typically appear? (TN)**
* Dome-shaped papules +/- pustules
* Flushing, non-transient erythema and telangiectasia
* Central face: forehead, nose, cheeks and chin
* Remissions and exacerbations
126
**What is rosacea on the nose called? (TN)**
* Rhinophyma: distinct swelling caused by lymphedema and hypertrophy of subcutaneous tissue
127
**What can be exacerbating factors for rosacea? (TN)**
* Heat
* Cold
* Wind
* Sun
* Stress
* Drinking hot liquids
* Alcohol
* Caffeine
* Spices (triggers of vasodilation)
128
**How is rosacea diagnosed? (TN)**
* Presence of 1 or more of the following primary features:
* Flushing (transient erythema)
* Nontransient erythema
* Papules and pustules
* Telangiectasia
* May include one or more of the following secondary features:
* Burning or stinging
* Dry appearance
* Edema
* Phymatous changes
* Ocular manifestations (blepharoconjunctivitis, keratitis, iritis)
* Peripheral location
129
**What are 3 general recommendations to manage rosacea? (TN)**
* Trigger avoidance
* Avoid topical corticosteroids
* Make-up to mask erythema
130
**What are specific 1st line rosacea treatment? (TN)**
* Oral tetracyclines (250-500 mg PO BID)
* Topical metronidazole
* Oral erythromycin (250-500 mg PO BID)
* Topical azelaic acid
131
**What is being promoted a new topical option for rosacea? (CMA POEM / Cochrane)**
* Doxycycline and Tetracycline are effective
* Doxycycline 40 mg dose may be as effective as 100 mg dose (less side effects)
* Oral tetracycline similar to Topical Metronidazole in effectives for papulopustular rosacea
* Topical Brimonidine 0.33% gel (alpha agonist) reduces redness for up to 12 hours after use
* Topical Ivermectin effective, similar to topical metronidazole
* Oral isotretinoin more effective than doxycycline 100 mg
132
**What are the 3 stages of hair growth? (TN)**
* Anagen = growth stage
* Catagen = transitional stage
* Telogen = resting stage
133
**When a patient presents with alopecia, what is important to determine initially and how can this be determined? (TN)**
* Scarring (Cicatricial) vs Non-Scarring (Non-Cicatricial) Alopecia
* Non-scarring: intact hair follicles on exam
* Scarring: absent hair follicles on exam
134
**What acronym can help remember the important causes of alopecia? (TN)**
* **TOP HAT**
* **T**elogen effluvium, tinea capitis
* **O**ut of Fe, Zn
* **P**hysical: trichotillomania, “corn-row” braiding
* **H**ormonal: hypothyroidism, androgenic
* **A**utoimmune: SLE, alopecia areata
* **T**oxins: heavy metals, anticoagulants, chemotherapy, vitamin A, SSRIs
135
**What are 5 types of non-scarring (non-cicatricial) alopecia? (TN)**
* Androgenetic alopecia
* Physical
* Trichotillomania
* Traumatic: ‘corn-row’ braiding
* Telogen effluvium
* Anagen effluvium
* Alopecia areata
136
**What is the differential for non-scarring alopecia? (TN)**
* Autoimmune
* Alopecia areata
* Endocrine
* Hypothyroidism
* Androgens
* Micronutrient deficiencies
* Iron
* Zinc
* Toxins
* Heavy metals
* Anticoagulants
* Chemotherapy
* Vitamin A
* Trauma to the hair follicle
* Trichotillomania – causes scarring on DermNet
* ‘Corn-row’ braiding – causes scarring on DermNet
* Other
* Syphilis
* Severe illness
* Childbirth
137
**How does androgenetic alopecia appear for men and women? (TN)**
* Males: fronto-temporal areas progressing to vertex, entire scalp may be bald
* Females: widening of central part, “Christmas tree” pattern
138
**What are 5 treatment options for androgenetic alopecia? (TN)**
* Minoxidil (Rogaine) solution or foam
* Spironolactone in women
* Cyproterone acetate (Diane-35) in women
* Finasteride (Propecia) in men
* Hair transplant
139
**What are potential precipitants of telogen effluvium? (TN)**
* **SEND** hair follicles out of anagen and into telogen
* **S**tress and **S**calp disease (seborrheic dermatitis, allergic contact dermatitis)
* **E**ndocrine (hypothyroidism, post-partum)
* **N**utritional (iron and protein deficiency)
* **D**rugs (acitretin, heparin, lithium, interferon, beta-blockers, valproic acid, SSRIs)
140
**How long after exposure to the precipitant does hair loss occur with telogen effluvium and how long for it to regrow? (TN)**
* 2-4 months after exposure
* Regrowth within a few months
141
**What are potential precipitants of anogen effluvium? (TN)**
* Chemotherapeutic agents, other medications (e.g. Levodopa, Colchicine, Cyclosporine), exposure to chemicals (thallium, arsenic)
142
**How long after exposure to the precipitant does hair loss occur with anogen effluvium and how long for it to regrow? (TN)**
* Hair loss 7-14 days after single pulse of chemotherapy
* Most clinically apparent after 1-2 months
* Reversible, follicles resume normal growth few weeks after agent stopped
143
**What is the pathophysiology of alopecia areata? (TN)**
* Autoimmune
144
**What are 2 subtypes of alopecia areata? (TN)**
* Alopecia totalis: loss of all scalp hair and eyebrows
* Alopecia universalis: loss of all body hair
145
**What sign can be found on clinical exam in alopecia areata? (TN)**
* “Exclamation Mark” pattern: hairs fractured and have tapered shafts)
146
**What are 4 diseases that can be associated with alopecia areata? (TN)**
* Pernicious anemia
* Vitiligo
* Thyroid disease
* Addison’s disease
147
**What are management options for alopecia areata? (TN)**
* Intralesional triamcinolone (corticosteroids)
* UV or PUVA therapy
148
**In a patient with suspected scarring (Cicatricial) alopecia, what should be done? (TN)**
* Biopsy
149
**What are 2 types of lesions seen in pityriasis rosea? (TN)**
* “Herald patch” – precedes other lesions by 1-2 weeks
* “Christmas Tree” pattern – lesions follow skin tension lines (Langer’s Lines) parallel to ribs on back
150
**How do lesions in pityriasis rosea appear? (TN)**
* Red, oval plaques/patches with central scale that does NOT extend to edge of lesion (collaret)
* Some plaques may be annular (ring-shaped)
* Sites: trunk, proximal aspects of arms and legs
* Varied degree of pruritus
151
**What is believed to be the cause of pityriasis rosea? (TN)**
* HHV6/7
* May follow a few days after a URTI
152
**What treatment options are available for pityriasis rosea? (TN)**
* None required as will clear spontaneously in 6-12 weeks
* Topical corticosteroids when PIH is a concern or if uncomfortable
* Oral erythromycin for 2 weeks
* May clear up faster
* Oral acyclovir for 7 days
* May clear up faster
153
**What are the 3 most common genera of dermatophytes infecting humans? (DFCM)**
* Trichophyton
* Microsporum
* Epidermophyton
154
**How can the diagnosis of a fungal (dermatophyte) skin infection be confirmed? (DFCM)**
* Potassium bromide (KOH) microscopy of a skin scraping
* Shows hyphae or Mycelia or with Fungal Culture
155
**What tool can be useful for the diagnosis of a fungal skin infection? (DFCM)**
* Wood’s lamp (UV-A light) – Tinea Versicolor
156
**What is in the differential diagnosis for a fungal skin infection? (DFCM)**
* Eczema
* Contact dermatitis
* Acne
* Folliculitis
* Psoriasis
* Lichen planus
* Trauma/irritation
157
**What are 8 types of fungal skin infections? (DFCM)**
* Tinea Capitis
* Tinea Corporis (Ringworm)
* Tinea Barbae
* Tinea Faciei – non-bearded areas
* Tinea Cruris (Jock Itch)
* Tinea Pedis (Athlete’s Foot)
* Tinea Mannum - hands
* Tinea Unguum (Onychomycosis)
* Tinea Versicolor (Pityriasis Versicolor)
* Candida intertrigo
158
**How does Tinea Capitis appear, where is it located and what can it be associated with? (DFCM)**
* Scaling, itching and erythema of the scalp, eyelashes and eyebrows
* Can also present as patchy **alopecia**, black-dot alopecia, occipital adenopathy, or a kerion (sterile inflammatory scalp mass)
* More common in children, mainly black
* Very contagious, may be transmitted from barber, hats, theatre seats, pets
159
**How does Tinea Corporis appear and where is it located? (DFCM)**
* Annular lesions, with scaly, well demarcated border and central clearing
* Trunk, limbs, face
* May be hyperpigmented in darker-skinned persons
160
**How does Tinea Barbae appear, where is it located and whom it is more common in? (DFCM)**
* Inflamed pustules, erythema and scaling on neck and beard area
* More common in farm workers
161
**How does Tinea Cruris appear and where is it located? (DFCM)**
* Sharply demarcated areas of redness, scaling and pruritus on the medial thigh
* Central clearing
* Pruritic, erythematous, dry/macerated
* No satellite lesions
162
**How does Tinea Pedis appear, where is it located and what is a potential complication? (DFCM)**
* Interdigital scaling, erythema, itching and sometimes blisters seen on the foot
* Can also present as scaly, erythematous and hyperkeratotic lesions on the sole and sides of foot (refererd to as Moccasin Ringworm)
* Strep cellulitis is a potential complication
163
**How does Tinea Unguum (Onychomycosis) appear, where is it located and what can it be associated with? (DFCM)**
* Thickened, raised, discolored, and cracked nails
* More common in elderly, diabetic, and immunocompromised patients
* Can be seen on the hand or foot
164
**What are the best predictors of onychomycosis on clinical exam? (CMA Infopoem)**
* Plantar desquamation
* Interdigital tinea pedis
* Previous diagnosis of fungal disease in the feet and subungual hyperkeratosis
165
**What are 2 topical option for the treatment of onychomycosis and their effectiveness? (TN/UTD)**
* Jublia (Efinaconazole) 10% solution
* Applied directly to the nails once daily for 48 weeks
* 1 drop per nail (2 drops for great toenail)
* 4 weeks after 48-week treatment, complete cure achieved by 15-18% vs 3-6%
* Penlac (Ciclopirox) 8% nail lacquer
* Applied directly to the nails once daily for 48 weeks
* After 48-week treatment, complete cured achieved by 7% vs 0.4%
166
**What is the recommended length of treatment for tinea unguum (onychomycosis)? (TN/UTD)**
* Terbinafine (Lamisil) 6 weeks for fingernail or 12 weeks for toenails
* 76% cure rate after 3-4 months (UTD)
167
**What would a green discolouration of the nails suggest and what would be the treatment?**
* Pseudomonas nail infection
* Vinegar soaks x15 min TID for 1 month
168
**How does Tinea Versicolor appear and where is it located? (DFCM)**
* Hypo or hyperpigmented circular macules on the trunk and extremities
169
**How does Candida intertrigo appear and where is it located? (DFCM)**
* Erythematous, macerated and pruritic plaques with peripheral scaling and satellite lesions
* Typically occurs in moist area of friction such as groin, buttock, axillae and skin folds
170
**How should topical antifungals be applied and how long should their treatment be continued for? (DFCM)**
* Applied to the affected and surrounding area (1-2 inches beyond rash)
* Treatment continued for 1 week after the symptoms are gone
171
**In which fungal skin infections is systemic antifungal therapy recommended? (DFCM)**
* Tinea capitis
* Tinea barbae
* Onychomycosis
* Patients that have failed topical therapy
172
**What are 3 classes of topical antifungal agents and examples of each and their indications? (DFCM)**
* Azoles – clotrimazole (Canesten), ketoconazole (Nizoral)
* Dermatophytes, tinea versicolor, candida
* Allylamine – terbinafine (Lamisil)
* Dermatophytes and tinea versicolor
* Polyene – Nystatin
* Candida
173
**What is the toxicity concern associated with terbinafine? (TN)**
* Liver toxicity
* CYP 2D6 inhibitor
174
**What is the recommended management for Tinea Capitis? (TN)**
* Terbinafine (Lamisil) x 4 weeks
* Oral agents required to penetrate the hair root where dermatophyte resides
* Adjunctive antifungal shampoos or lotions for patient and HOUSEHOLD CONTACTS
* Selenium sulfide shampoo 2.5% 3x per week
175
**What is the recommended management options for Tinea Corporis, Tinea Cruris, Tinea Pedis and Tinea Manuum? (TN)**
* Topical:
* 1% clotrimazole
* 2% ketoconazole
* 2% miconazole
* 1% Terbinafine (Lamisil)
* Lotriderm (Clotrimazole & Betamethasone) BID for up to 2 weeks
* Oral:
* Terbinafine
* Itraconazole
* Fluconazole
* Ketoconazole (if extensive)
176
**What are 5 types of bacterial skin infections? (DFCM)**
* **Erysipelas** – bacterial infection of the superficial dermis and superficial lymphatics
* **Cellulitis** – bacterial infection of the deeper dermis and subcutaneous fat
* **Folliculitis** – bacterial infection of the hair follicles with purulence in the epidermis
* **Furuncle** (**Boil**) – bacterial infection of a hair follicle with purulence extending beyond the dermis into the subcutaneous tissue
* **Impetigo** – contagious bacterial infection of the superficial skin commonly seen in the pediatric population
177
**How can erysipelas and cellulitis be differentiated on exam? (DFCM)**
* Erysipelas – RAISED lesions with WELL DEMARCATED borders, exhibit intense erythema, warmth and edema
* ACUTE onset of symptoms
* RAPID PROGRESSION to systemic symptoms of fever/chills
* Cellulitis – NOT RAISED, SOMEWHAT demarcated, exhibit erythema, warmth and edema
* SLOW onset of symptoms
* May develop purulence or an underlying abscess requiring incision and drainage
178
**What are the 3 types of impetigo? (DFCM)**
* Non-bullous – mix of vesicles and pustules, form thick, characteristically GOLDEN-crusted exudates
* Bullous – vesicles form yellow-brown bullae that can burst to form a BROWN crust
* Ecythma – ulcerative lesions extend through the epidermis deep into the dermis, “PUNCHED-OUT” appearance
179
**Where is impetigo commonly seen? (DFCM)**
* Children aged 2-5
* Common on face and extremities
180
**What would be the treatment for early folliculitis, mild folliculitis or mild impetigo, and moderate/severe folliculitis or impetigo? (DFCM)**
* Early Folliculitis = hot compresses and anti-septic cleansers daily
* Mild = mupirocin 2% or fusidic 2% cream applied topical TID
* Moderate/Severe = Keflex or Cloxacillin or Clindamycin or Erythromycin (all PO)
181
**What are 3 types of oral antibiotics that can treat community acquired (CA)-MRSA? (DFCM)**
* TMP/SMX PO
* Doxycycline
* Clindamycin
182
**What are 2 types of IV antibiotics that can treat CA-MRSA? (DFCM)**
* Vancomycin IV
* Linezolid PO/IV
183
**What are 3 types of parasitic skin infections? (TN)**
* Scabies
* Lice (Pediculosis)
* Bed bugs (Hemiptera)
184
**What is scabies characterized by? (TN)**
* Skin infection due to Sarcoptes scabiei (MITE)
* Superficial burrows
* Intense pruritus (especially nocturnal)
* Secondary infection
185
**How does the primary scabies lesion appear? (TN)**
* Superficial linear burrows
* Inflammatory papules and nodules in the axilla and groin
186
**Where does scabies typically affect? (TN)**
* Axillae
* Groin
* Buttocks
* Hands/Feet (especially WEB SPACES)
* Sparing of head and neck (except in infants)
187
**How long do scabies mite remain alive on clothing/sheet? (TN)**
* 2-3 days
188
**How long is the incubation period for scabies? (TN)**
* 1 month then pruritus begins
189
**How should scabies be managed? (TN)**
* Bathe, then apply permethrin 5% cream (i.e. Nix) from neck down to soles of feet (must be left on for 8-14 hours) and requires 2nd treatment 7 days after first
* Change underwear and linens – wash with detergent in hot water cycle then machine dry
* Treat family and close contacts
* Mild potency topical steroids and antihistamines for symptoms management
190
**How does lice typically present? (TN)**
* Intensely pruritic red excoriations, morbilliform rash, caused by louse (a parasite)
191
**What are the 3 locations that lice can present? (TN)**
* Scalp lice: nits (i.e. louse eggs) on hairs
* Red excoriated skin
* Pubic lice: nits on hairs
* Excoriations
* Body lice: nits and lice in seams of clothing
* Excoriations (mainly shoulders, belt-line, buttocks)
192
**How should lice be managed? (TN)**
* Permethrin 1% (Nix cream rinse) (Ovicidal) or Permethrin 1% shampoo
* Comb hair with fine-toothed comb using dilute vinegar solution to remove nits
* Repeat in 7 days after first treatment
* Shave hair if feasible
* Change clothing and linens
* Wash clothes and linens used 2 days prior with detergent in hot water cycle then machine dry
* Put un-washable items in a sealed bag for 2 weeks
193
**What is an expensive option to treat head lice? (CMA Infopoem / NEJM)**
* Topical Ivermectin 0.5% ($260 per 4 oz bottle)
* Applied once to scalp
194
**What treatment has been shown to be better than Permethrin for the treatment of lice? (TFP)**
* Dimeticone (NYDA) (silicone based product that suffocates lice and is applied to dry hair, left 8 hours, then repeated after 1 week)
* 4% or 9.2% concentrations
* NNT = 3-4 compared to permethrin for lice
195
**What causes bed bugs? (TN)**
* Cimex lectularius – small insect that feeds mainly at night
* During day bedbugs hide in crevices in walls and furniture
196
**How does bed bugs typically present? (TN)**
* Burning wheals, turning to firm papules, often in groups of three – “breakfast, lunch and dinner” in areas with easy access (face, neck, arms, legs, hands)
197
**How should bed bugs be managed? (TN)**
* Professional fumigation of home
* Topical steroids and oral H1-antagonists for symptomatic relief
* Definitive treatment is removal of clutter in home and application of insecticides to walls and furniture
198
**What are most lower-limb ulcers? (PBSG)**
* Venous stasis ulcers
199
**Differentiate between venous stasis ulcers and arterial ulcers. (PBSG)**
* Venous Stasis Ulcers: caused by skin injury in patients with impaired venous circulation
* Arterial Ulcers: caused by lack of blood flow distal to an area of vessel occlusion
200
**What is the definition of a pressure ulcer (decubitus ulcer)? (PBSG)**
* Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction
201
**What are 5 risk factors for venous stasis ulcers? (PBSG)**
* Pregnancy, obesity, immobility, prolonged standing/sitting, leg trauma
* Venous impairment (post-phlebitic syndrome, DVT, varicose veins, previous vein surgery, valve incompetence in perforator veins)
* History of venous insufficiency ulcers
* CHF
* Nephrotic syndrome
202
**What are 4 risk factors for pressure ulcers? (PBSG)**
* Pressure on skin greater than arteriolar pressure (leads to hypoxia and compressive forces)
* Friction, pressure and shearing forces from sitting or lying or from transfer/rolling methods
* Moisture (sweat, feces, urine)
* Immobility, Incontinence, Dietary Inadequacy
203
**How do venous stasis, arterial and pressure ulcers appear clinically? (PBSG)**
Type of Ulcer
Clinical Clues
Venous stasis
* May be large, relatively superficial and with RED/YELLOW base
* Signs of venous pressure – EDEMA
* “Champagne glass” ankle may be present
* Often significant drainage
* Peripheral pulses palpable
Arterial
* Commonly distal with well-defined borders, a “PUNCHED-OUT” appearance
* Often over the MEDIAL-MALLEOLAR region
* DRIER and DEEPER than venous ulcers, with minimal granulation tissue
* Typically covered with pale pink, yellow or black eschar
* Often PAINFUL
Pressure
* Located over areas of pressure (e.g. HEELS, TROCHANTERS, SACRUM)
* Initially NON-BLANCHABLE erythema, increasing to open areas
204
**What should be assessed in all patients presenting with lower-extremity ulcers? (PBSG)**
* Clinical assessment
* Palpable pedal pulses
* Capillary refill
* ABPI (Ankle Brachial Pressure Index)
205
**How are pressure ulcers staged? (PBSG)**
* NPUAP staging
* Stage 1 – intact skin, non-blanchable redness, localized (usually over bony prominence)
* Stage 2 – partial-thickness loss of dermis, shallow and open
* Stage 3 – full-thickness tissue loss, subcutaneous fat may be visible (no tendons, muscles or bones), may be undermined or tunnelled
* Stage 4 – full-thickness tissue loss, bone exposed, tendon or muscle visible or palpable, slough or eschar may be present
* Unstageable – full-thickness tissue loss, base of ulcer bed covered by slough or eschar
206
**What are signs of a spreading wound infection? (PBSG)**
* Wound breakdown
* Spreading erythema
* Induration
* Discolouration
* Warmth
* Crepitus
* Lymphangitis
* Pain
* Malaise
207
**What are 3 indications to swab a wound for cultures? (PBSG)**
* Signs of spreading or systemic infection
* Lack of response to appropriate antibiotic treatment
* Protocol requirements for antibiotic-resistant organisms
208
**How should a wound be swabbed? (PBSG)**
* Clean the ulcer with warm tap water or saline first
* Remove unhealthy tissue
* Place the swab onto “clean” viable tissue, rotate and press firmly to obtain fluid from beneath the surface of the wound
209
**What are 4 practices to prevent pressure ulcers? (PBSG)**
* Education patients and caregivers about ischemic pain as a response to pressure
* Move or reposition the patient to take pressure off
* Maintain skin integrity through regular cleansing, moistening and inspection
* Ensure adequate nutrition, ideally including a daily protein intake of 1.2-1.5 k/kg body weight
210
**What is recommended for all patients at risk of pressure ulcers? (PBSG)**
* **High density foam** mattress/seating
* **Sheepskin** may be used over top of regular mattresses where high density foam mattresses are unavailable
211
**What is recommended for prevention of venous leg ulcers in patients with venous hypertension, leg edema or postphlebitic syndrome? (PBSG)**
* Continuous and indefinite awake-time use of compression stockings
212
**What are 4 principles of managing wound infections? (PBSG)**
* Appropriate dressing and dressing changes
* Wound drainage and cleansing
* Debridement as necessary
* Antimicrobial therapy
213
**How much should a wound improve to indicate appropriate wound healing? (PBSG)**
* 30% reduction in wound measurement (length x width x depth) at 3-4 weeks
* Most pressure ulcers show signs of healing within 2 weeks
214
**What are factors that can impair wound healing? (PBSG)**
* Nutritional status
* Ischemia
* Hepatic/Renal/Cardiac disease
* Medications
* Systemic steroids
* NSAIDs (topical Voltaren)
* Anti-neoplastics
* Age
* Smoking
* Psychosocial status
215
**What should be considered when ulcers do not heal despite standard care? (PBSG)**
* Biopsy – to rule out malignancy
216
**What are 6 ways to treat venous leg ulcers? (PBSG)**
* Elevate legs
* Calf pump exercises
* Regular or range-of-motion exercise
* Weight management
* Skin care
* Compression therapy
217
**What is required prior to initiating compression therapy in patients with venous leg ulcers? (PBSG)**
* ABPI
218
**At what ABPI can compression therapy be used and how much? (PBSG)**
* ABPI ≥0.8 mmHg
* 40 mmHg compression stockings
219
**What is the benefit of keeping wounds moist? (PBSG)**
* Level 1 evidence
* Decrease healing time
* Less pain
* Less risk of infection
* Require fewer dressing changes
* Cost-effective
220
**What is the benefit of debriding necrotic tissue in a skin ulcer? (PBSG)**
* Inhibit bacterial growth
* Promote wound healing
221
**What are 5 ways to debride a wound or skin ulcer? (PBSG)**
* Sharp (scalpel or scissors)
* Mechanical – superficial loose or necrotic exudate
* Enzymatic
* Autolytic (hydrocolloid or hydrogel dressings)
* Biosurgery or Maggot Larvae
222
**What characteristics are associated with dermatofibromas? (TN)**
* Button-like, firm dermal papule or nodule, skin-coloured to red-brown colouring
* Majority asymptomatic but may be PRURITIC and/or TENDER
* Legs \> Arms \> Trunk
* **Dimple Sign**: lateral compression causes dimpling of the lesion
223
**What should be done to treat bothersome dermatofibromas? (TN)**
* Excision
* Cryosurgery
224
**Differentiate between corns vs warts vs calluses. (TN)**
* **Corns**: whitish yellow central translucent keratinous core
* **Warts**: bleed with pairing, black speckled central appearance due to **thrombosed capillaries**
* **Calluses**: layers of yellowish keratin revealed with paring
225
**Where are corns commonly found? (TN)**
* Dorsolateral 5th toe and dorsal aspects of other toes
226
**How can corns be treated? (TN)**
* Relieve pressure with padding or alternate footwear, orthotics
* Paring, curettage
227
**Differentiate between keloids and hypertrophic scars. (TN)**
* Keloids – extended BEYOND margins of original injury with claw-like extensions
* Hypertrophic scar – confined to original margins of injury
228
**What are risk factors for melanoma? (DFCM)**
* Intermittent intense sun exposure (like BCC, unlike SCC)
* Immunosuppressive therapy
* Family history of MM
* Family history of pancreatic cancer
* High number of common nevi
* 1 or more atypical/dysplastic nevi
* Should screen more often if have dysplastic nevi
* Prophylactic excision is not recommended as most melanoma develop de novo, but having dysplastic nevi increases that risk
* Light skin phenotype (Fitzpatrick 1/2)
229
**What are the screening recommendations for melanoma? (DFCM)**
* General Population – routine TBSE and counseling on SSE NOT recommended
* No risk factors
* High risk (5-10x) – screen by PCP annually for skin cancer, counsel about SSE (self-skin exam) and SCP (skin cancer prevention) by PCP
* 2 or more of the following:
* 1st degree relative with MM
* 1 or more atypical nevi
* Many (50-100) nevi
* Naturally red or blonde hair
* Tendency to freckle
* Skin that burns easily and tans poorly or not at all
* Outdoor occupation
* Childhood in lower altitudes
* Tanning bed use in teens and 20s
* Radiation therapy as adult
* Very high risk (\>10x) – TBSE by dermatologist or trained PCP on yearly basis, counsel about SSE and SCP
* Immunosuppressive therapy
* Personal history of skin cancer
* 2+ 1st degree relatives with MM
* \>100 nevi total or 5+ atypical nevi
* \>250 PUVA treatments for psoriasis
* Radiation therapy for cancer as a child
230
**What is in the differential diagnosis for melanoma?**
* Dysplastic nevus
* Traumatized nevus
* Pigmented basal cell
* Dermatofibroma
* Seborrheic keratosis
231
**What are 4 types of NMSC? (DFCM)**
* BCC
* SCC
* Bowen disease (SCC in situ)
* AK (solar keratosis, senile keratosis)
232
**What is the most common human cancer? (DFCM)**
* BCC
233
**Where are BCC commonly found? (DFCM)**
* Nose
234
**Which of BCC or SCC poses a greater metastasis risk? (DFCM)**
* SCC
235
**What is the risk of cancer associated with AKs? (DFCM)**
* Develop into SCC (1/1000)
236
**What are biopsy options for NMSC (except AKs)? (DFCM)**
* Shave biopsy
* Punch biopsy
* Deep shave (SCC and Bowen’s)
237
**What are options for field therapy in patients with a history of Bowen’s disease or AKs? (DFCM)**
* 5-FU (2-3 weeks)
* 5% Imiquimod (8-10 weeks)
* 3% Diclofenac gel (AKs)
238
**What should be asked on history for suspicious skin lesions?**
* A – Asymmetry
* B – Borders irregular
* C – Colour changing or multiple
* D – Diameter \>6 mm
* E – Evolving
* ABCDE Rule
* 97% sensitivity if use on criteria, but only 43% specificity
* Can consider biopsy if 1 criteria present
* Consider referral if evolving +1 other criteria
239
**What are the 4 types of melanoma? (DFCM)**
* Superficial spreading
* Nodular
* Invasive lentigo maligna melanoma
* Acral lentiginous melanoma
240
**How do most melanomas present?**
* Superficial spreading (70% of all melanomas)
* Asymmetry and color variegation are characteristic
* Majority arise de novo, only ¼ from dysplastic nevi
* Nodular also possible
* Discrete nodular, usually with dark pigmentation (although may be amelanotic as well)
241
**What are two specific types of melanoma that can appear on specific locations of the body?**
* Lentigo Maligna
* Acral Lentiginous
242
**How does lentigo maligna appear typically?**
* Usually arises in areas of sun-damaged skin, particularly on the head and neck
* Freckle-like, tan-brown macule and gradually enlarges and develops darker or lighter asymmetric foci and raised areas, which signify dermal invasion
243
**How does acral lentiginous appear typically?**
* Shows the asymmetry and color variegation of typical melanomas
* They are distinguished clinically by their locations on the palms, soles or nails
244
**How should all suspicious skin lesions be investigated?**
* Biopsy all suspicious lesions
* Excisional biopsy with 2mm of regular skin surrounding is best
* Can do punch biopsy if lesion is large
* Any concerning brown lesion should be biopsied – Don’t Watch and Wait
245
**How should melanomas be excised/treated? (DFCM)**
* Leave it to plastics
* In situ melanomas can have margins of 0.5-1 cm
* \<1mm thick can have 1cm margins
* \>1mm thick can have 2cm margins
246
**What is pemphigus vulgaris?**
* Autoimmune blistering disease of the skin and mucous membranes
247
**What is in the differential diagnosis for pemphigus vulgaris?**
* Mouth ulcers
* HSV
* Aphthous ulcers
* Erythema multiforme
* Wide-spread erosions
* Bullous pemphigoid
* Bullous drug eruptions
* Pyoderma gangrenosum
* Impetigo
248
**How does pemphigus vulgaris appear?**
* Flaccid, non-pruritic, painful epidermal bullae/erosions
* Typically begin in oropharynx, then spread to skin
* Nikolsky’s Sign – pressure around a lesion leads to an erosion
249
**What is pemphigus vulgaris associated with?**
* Thymoma
* Myasthenia gravis
* Malignancy
250
**What is the treatment for pemphigus vulgaris?**
* High dose steroid – prednisone 1mg/kg
* May require long-term or other immunomodulator
* Refer immediately
251
**What is bullous pemphigoid?**
* Autoimmune bullous eruption
252
**How does bullous pemphigoid typically appear?**
* Pruritic, tense, subepidermal bullae on an erythematous or normal base
* Prodromal urticarial for weeks to months that evolve into bullae
* Locations – lower legs, medial thighs, groins, flexor forearm, axillae
253
**What is the treatment for bullous pemphigoid?**
* High dose steroid – prednisone 1mg/kg
* May require long-term or other immunomodulator
* Refer immediately
254
**How does cutaneous T-cell lymphoma appear?**
* Progressive patches/plaques with telangiectasia
* May wax and wane
* May be pruritic
* May have scale
255
**How is cutaneous T-cell lymphoma diagnosed?**
* May need repeated skin biopsy
* Keep a high degree of suspicion when presumed Psoriasis or Dermatitis does NOT respond to appropriate treatment
256
**What is the treatment for cutaneous T-cell lymphoma?**
* Topical alkylating agents for localized disease
* Chemotherapy for extensive disease
257
**How does Stevens-Johnson syndrome present?**
* Prodrome of flu-like symptoms for 1-3 days
* Vesicles and bullae develop over a few days
258
**What are potential triggers of SJS?**
* Medications – 50-80%
* Allopurinol, Antibiotics, Antipsychotics, Antiepileptics, NSAIDs
* Septra has a 20x risk compared to any other drug
* Infections – 15%
259
**How should patients with burns be managed?**
* Fluid resuscitation
* Tetanus prophylaxis
* Early intubation if suspect inhalation injury
* Closed space, unconscious, noxious chemical
* Escharotomy – in circumferential full thickness burns
260
**How should fluid be replaced in burn patients?**
* Parkland Formula = 4cc/kg/%TBSA with RL in first 24h
* ½ in first 8 hours, ½ in remaining 16h
* 0 hour = time of burn (therefore if present 3h after burn, give ½ in 5h)
* Add normal fluid maintenance to this formula
* Urine output 50cc/hr (Adult) or 1cc/kg/hr (Children)
261
**What are specific things to look for with chemical and electrical burns?**
* Chemical – high volume irrigation before other treatment
* Electrical – look for entrance and exit
262
**When can a patient presenting with a burn be discharged?**
* Asymptomatic
* No significant cutaneous injury
* No urine heme
* Normal ECG
* Observed 4-8h
263
**When should a patient presenting with a burn be admitted?**
* Partial thickness 15-20% (\>10% if \<5y or \>60y)
* Full thickness 2-5%
* Smoke inhalation, high voltage electrical, circumferential
264
**What can be prescribed for patients topically for burns?**
* Flamazine 1% (Silver Sulfadiazine)
* Apply to a thickness of 1/16 inch once or twice daily
* Contraindicated in newborns, pregnancy, and lactation
* Chlorhexidine
* Bismuth-impregnated petroleum based gauze (e.g. Xeroform)
265
**What can be given to patients for post-burn pruritus?**
* H1 and H2 antihistamines (diphenhydramine, cetirizine, cimetidine)
* Aloe vera, Vaseline based products, cocoa butter
266
**What is Wegener’s Granulomatosis?**
* Systemic vasculitis of small blood vessels
267
**What diagnostic triad is used to diagnose Wegener’s?**
* Necrotizing granulomatous vasculitis of respiratory tract
* Glomerulonephritis
* C-ANCA positive
268
**How does Wegener’s present clinically?**
* Chronic rhinosinusitis, nasal ulcerations, bloody discharge
* Cough, SOB, hemoptysis, chest pain, CXR nodules
* Renal failure
* Skin lesions – irregular ulcers and erythematous plaques/papules and subcutaneous nodules
269
**What is the treatment for Wegener’s?**
* Steroids and Cyclophosphamide
* Dialysis if needed
270
**What is systemic lupus erythematosus (SLE)?**
* Chronic inflammatory multi-system disease of unknown etiology
271
**What patients are at increased risk of SLE?**
* 10% have family history
* F:M = 10:1, with onset during reproductive years (13-40)
* More common in blacks and Asians
* Can be secondary to drugs
272
**What is the criteria to diagnose SLE?**
* 4 or more of 11 must be present serially or simultaneously
* “4, 7, 11 rule” à 4 out of 11 criteria (4 lab, 7 clinical)
* **4 RASHES**
* **4** rashes: Malar rash, Discoid rash, Oral Ulcers, Photosensitivity
* **R**enal – proteinuria (\>0.5 g/day or \>3+ dip) or Cellular Casts (RBC, Hb, granular, tubular, mixed)
* **A**rthritis - ≥2 joints, symmetric, large or small, non-erosive
* **S**erositis – Pleuritis, Pericarditis
* **H**ematologic – Hemolytic anemia, Leukopenia, Lymphopenia, Thrombocytopenia
* **E**xcitation – seizures or psychosis
* **S**erology
* ANA (98% SN, not SP)
* Anti-dsDNA and Anti-Sm (not SN, but \>95% SP), anti-phospholipids or false positive VDRL
* **SOAP BRAIN MD**
* **S**erositis
* **O**ral ulcers
* **A**NA
* **P**hotosensitivity
* **B**lood
* **R**enal
* **A**rthritis
* **I**mmune
* **N**eurology
* **M**alar rash
* **D**iscoid rash
273
**What investigations should be performed in patients suspected of having SLE?**
* CBC, GBCL, ESR, CRP
* ANA (sensitive), anti-dsDNA (specific), C3, C4
* ANA should be ordered when a patient has 2 organ systems of potential SLE origin that are otherwise unexplained
* ENA panel ordered when ANA positive
* Anti-dsDNA increases and Complement decreases with increasing disease severity
* Urinalysis, ACR
* Consider arthrocentesis for Cells, Culture and Crystals
274
**What are treatment options for the different complications of SLE?**
* Rituximab to treat underlying SLE pathology
* Cutaneous lupus – sunscreen and hydroxychloroquine
* Arthritis – NSAIDs, hydroxychloroquine, steroids, methotrexate
* Nephritis and Neuritis – steroids, cyclophosphamide
* Serositis – NSAIDs, steroids
* Thrombocytopenia – steroids, IVID, splenectomy
* Avoid exogenous estrogen – no OCP or HRT
275
**What are potential causes of drug induced lupus?**
* Anticonvulsants (phenytoin)
* Antihypertensives (hydralazine)
* Antiarrhythmics (procainamide)
* Isoniazid (INH)
* OCP can exacerbate
276
**How does drug-induced lupus differ from SLE?**
* Relative to SLE has:
* Abrupt onset
* Middle aged presentation
* No gender preference
* No racial discrimination
* Less cutaneous, renal, neurologic and hematologic involvement
* Similar joint, hepatic and constitutional symptoms
277
**What laboratory findings are expected in patients with drug-induced lupus?**
* Anti-histone positive
* Anti-Smith/dsDNA negative
* Complement normal
278
**What is the treatment for drug-induced lupus?**
* Discontinue offending agent
279
**What are two well-known types of drug reactions?**
* Erythema multiform
* Serum sickness
280
**What is the etiology of erythema multiform?**
* Infection: HSV, Mycoplasma
* Drugs: Sulfa, Penicillin, NSAIDs, anticonvulsants, allopurinol
281
**How does erythema multiform typically appear?**
* Classic “Bull’s Eye” pattern +/- bullae or erosions
* Bilateral and Symmetric – usually asymptomatic rash
* Can have mucosal involvement
* Fever, Malaise, Weakness
282
**What is the treatment for Erythema multiform?**
* Stop Drug
* Topical steroids, oral antihistamines
* Acyclovir if HSV
283
**How does serum sickness present?**
* Symmetric drug eruptions with fever, arthralgia, LAD and rash
* 5-10 days after the drug
284
**How should serum sickness be managed?**
* Symptomatic treatment with NSAIDs, Antihistamines
* Oral steroids for more severe reactions
* Temp \>38.5
* Extensive arthritis
* Extensive rash
