Various Derm Dz (Brooks) Flashcards
two types of sweat glands
- apocrine: larger; only in axillae, inframammary, groin and genital; release secretion into hair follicles
- eccrine: all over body; palms, soles, forehead;release sweat directly onto the skin
hidradenitis suppurative
- Chronic, suppurative, inflammatory condition of the aprocine gland.
- Common in intertriginous skin regions: axillae, groin, perianal, perineal, inframammary skin
- Characterized by recurrent “boils” and draining sinus tracts with subsequent scarring.
- Pain, fluctuance, discharge and sinus tract formation are characteristic.
epidemiology of hidradenitis suppurativa
- F>M
- MC in AA
- 2nd and 3rd decades of life
- males: anogenital
- females: axillary
general pathophys behind HS
- follicular plugging within apocrine gland bearing skin –> mechanical stress in intertriginous regions –> immune response
- secondary bacterial involvement
- rupture and reepithelialization cause sinus tracts to form
risk factors for HS
- obesity and smoking***
- hyperandrogenism
- OCPs
- Acne
- PCOS
- lithium
S/S of HS
- initially painful, inflammatory nodules and abscesses
- 0.5 - 3cm in size
- may drain
- eventually form scars
if there is infection in chronic HS, what are the common pathogens?
- staph aureus
- staph epidermidis
Hurley clinical staging system for HS
I: abscess formation w/o sinus tracts or scarring
II: widely separated, recurrent abscesses w/ tract formation and scarring
III: diffuse, multiple interconnected tracts and abscesses
HS increases the risk for what other disease?
- squamous cell carcinoma
- if concerned, bx
HS prognosis
- individual lesions heal 10-30 days
- can recur for years
complications of HS
- SCC
- lymphedema
- psychosocial issues
- anemia
- amyloidosis
- lumbosacral epidural abscess
- disseminated infection
- fistulas
what is the MC soft tissue tumor?
lipoma
what is a lipoma
- slow growing benign fatty tumor that form soft lobulated masses enclosed by a thin capsule
- often found in shoulders, back, neck, and head
what type of tumors are lipomas?
mesenchymal (they can develop in almost all organs)
lipomas in the GI tract
- submucosal fatty tumors
- MC location: esophagus, stomach, SI
- can cause luminal obstruction and bleeding
typical pt. presenting w/ a lipoma
- 40-60 yo group
- rare in children
- no clear gender predilection
- F: chondroid, myolipoma, adiposis dolorosa
- M: spindle cell, speomorphic, intramuscular, lipoblastoma, multiple symmetric lipomatosis
RF for lipoma
- obesity
- ETOH
- liver dz
- glucose intolerance
- soft tissue trauma
S/S of lipoma
- often asx
- slow growing (if fast, suspect other dx)
- sx will vary depending on location
PE of lipoma
- subQ, nontender, rubbery feel
- “slippage sign”
- overlying skin is nl
- commonly <5cm
what should you consider if a lipoma is over 5 cm?
-liposarcoma
but regular lipomas can be > 10 cm
indications for imaging a lipoma
- larger lesions w/ irregular shape
- suggestive of myofacial involvement
imaging modalities for lipoma
- start w/ US but MRI is most sensitive
- MRI helpful in differentiating lipoma from sarcoma
gold standard for histological dx of lipoma
- open surgical bx
- although core-needle bx is preferred
tx of lipoma
- observation is an option
- tx is usually surgical excision
- if it’s superficial, can try steroid injection or liposuction
- kybella injections have been successful
indications for removal of lipoma
- diagnostic uncertainty
- cosmetic concerns
- nerve impingement
- pain
- increase in size
- irregular characteristics
- > 5 cm
- core needle bx w/ atypical features
- features consistent w/ sarcoma
complications of a lipoma
- hematoma and seroma MC
- infections rare but possible
- high risk of recurrence
what kind of lipomas have the highest rate of recurrence?
- intramuscular
- lipomas w/ infiltrating tendencies
- bilobar lipomas
what is the MC cutaneous cyst?
-epidermoid cysts (EC)
epidermoid cysts are aka
- sebaceous cysts
- epidermoid inclusion cysts
what are ECs?
- benign cysts that can form anywhere on the body
- MC on face, scalp, neck and trunk
- very rarely can become malignant
patho of EC
- derived from epidermis or epithelium of hair follicle
- epithelium encloses w/i the dermis and becomes filled w/ keratin and lipid
- walls are thin and rupture is common
epidemiology of ECs
- no racial predilection
- M>F
- 3rd-4th decade of life
what are pilar cysts?
- appear identical to epidermal inclusion cysts but 90% are on the scalp
- usually have fam hx
S/S of ECs
- usually asx
- discharge of malodorous “cheeselike” material
- can get inflammed/infected
PE of EC
- dermal or SQ nodule
- firm and usually solitary
- 0.5-5 cm
- may have central pore or punctum
diagnostics of an EC
- labs typically unnecessary
- if recurrent infection, C&S indicated
- if in unusual location (breast, bone, intracranial), imaging indicated or FNA
general measures in tx of EC
- asx ECs need no tx
- oral abx if infected
surgical care of EC
- simple excision or incision w/ removal of cyst and cyst wall (or will recur)
- if inflamed, I&D
complications of EC
- rare; infection, scarring
- malignancy is rare
pilonidal dz
-spectrum of clinical presentations ranging from asx hair containing cysts and sinuses to large sx abscesses of the sacrococcygeal region w/ tendency to recur
synonym for pilonidal dz
jeep dz
epidemiology of pilonidal dz
- M>F
- late teens - early 20s
- decreases after 25
- rare > 45
- Caucasians > AA > Asians
patho of pilonidal dz
- hair in natal cleft draws into deeper tissues via movement of buttocks
- follicle is occluded from stretching and pore blocking from debris
- inflammation w/ secondary infection occurs
- polymicrobial d/t proximity to anorectal region
genetic component in pilonidal dz
- congenital dimple in natal cleft
- spina bifida occulta
- follicular occluding tetrad
what is the follicular occluding tetrad (there are actually 4)?
- ance conglobata
- dissecting cellulitis
- hidradenitis supperativa
- pilonidal dz
RFs for pilonidal dz
- sedentary/prolonged sitting
- excessive body hair
- obesity / increase sacrococcygeal fold thickness
- congenital natal dimple
- trauma to coccyx
asx presentation of pilonidal dz
-painless cyst or sinus at top of gluteal cleft
acute presentation of pilonidal dz
-acute abscess: severe pain, swelling, discharge from top of gluteal cleft that may or may not have drained spontaneously
chronic presentation of pilonidal dz
-chronic abscess w/ persistent drainage from a sinus tract at the top of the gluteal cleft
which presentation of pilonidal dz is MC?
acute abscess
PE in pilonidal dz
- pt is usually afebrible and nontoxic
- inflamed cystic mass at top of gluteal cleft w/ limited surrounding erythema
- +/- drainage or sinus tract
- less common presentation: significant cellulitis of surrounding tissue
diagnostic tests for pilonidal dz
- it’s a clinical diagnosis
- consider CBC and wound culture if severe infection
- consider MRI to differentiate perirectal abscess and pilonidal
tx of pilonidal dz
- I&D is primary tx for recurrent dz
- meds: abx not indicated unless significant cellulitis
if pilonidal dz needs abx (cellulitis suspected), what is used empirically?
-cefazolin + metronidazole
or
-amoxicillin-clavulanate
criteria for admission for pilonidal dz
- severe celluitis
- large area excision
F/u recommendations for pilonidal dz
- frequent dressing changes after I&D
- f/u wound checks
- monitor for fever, more extensive celluitits
pt education in pilonidal dz
- wash area briskly w/ washcloth daily
- remove hair from crypts weekly
- avoid prolonged sitting
- neg. pressure wound therapy
- laser epilation of hair in gluteal fold
prognosis of pilonidal dz
-simple I&D has 55% failure rate
-median time to healing is 5 weeks
more extensive surgical excisions involve hospital stays and longer healing time
complications of pilonidal dz
malignant degeneration is a rare complication if untreated
