Week 11: Derm Flashcards

Question

What is the best steroid of potency to use in the elderly?

Answer 1

Group 6 or 7 (low potency)

Answer 2

False. It is better to start treatment with amore potent corticosteroid rather than a mild, less effective one. As the disease becomes less severe, you may reduce the potency of the steroid molecule, The more acute and severe a disease, the more potent the drug should be.

Answer 3

yep but better make it a low potency (group 7) one! beware risk of glaucoma, cataracts

Answer 4

Yep! Again, group 6 or 7. Only slightly less absorptive than the eyelids.

Answer 5

Yes I.e. lupus discoid lesions won't resolve with oral steroid therapy and need topical steroid added

Answer 6

Reconsider your diagnosis. Both fungal and bacterial infections are made worse when treated with topical corticosteroids.

Answer 7

False STOP applying med when skin disease is cleared. Give pt specific parameters. Post inflammatory hyper/ hypopigmentation and residual erythema are expected, do not require treatment, and slowly resolve.

Answer 8

c (rx files)

Answer 9

c (rx files)

Answer 10

a (rx files)

Answer 11

b (rx files)

Answer 12

Chronic, inflammatory, immune mediated skin disorder with genetic base and environmental triggers

Answer 13

-peaks between 30-39 years and 50-69 years, but occurs in all ages -no clear sex predilection --2-3% of population, all races -commonly family history (90% of cases)- typically genetic -atopic people (highly allergic, ie asthma, allergies) -triggers include stress, skin injury, anything immunosuppressant, infections (bacterial or viral), drugs (lithium, BB, antimalarials, NSAIDs, tetracyclines), low vit D,

Answer 14

Psoriasis is linked with many comorbidities include obesity, diabetes, metabolic syndrome, HTN, DM, Chron’s disease, liver/ kidney disease, psychiatric disease, local trauma, smoking, drinking, lithium, allopurinol, antimalarials, beta blockers -Increases risk of malignancy 2 fold (lymphoma, non melanoma skin Ca, solid organ cancer)

Answer 15

Plaque Guttate Pustular Erythrodermic Inverse (intertriginous)

Answer 16

Pink to red papules and plaques with white/ silvery scale Pruritic Well- demarcated

Answer 17

Pin point bleeding when scale is removed, strongly indicates psoriasis Fun clinical story! I saw a pt in clinic with ? fungal infection, took skin scrapings for KOH prep, and noted pinpoint bleeding after scraping away the scale. I connected the dots and ID'd auspitz sign later when charting and researching on up to date. We started him on high potency steroids and it dramatically improved!

Answer 18

PITTING, nail whitening, friable nails, yellow spots, splinter hemorrhage, thickened nail beds, separation of distal end of nail plate from nail bed (onycholysis

Answer 19

* most common, 80-90% of cases * Lesions: well-demarcated, thick, silvery, scaly, erythematous plaque surrounded by normal skin. * Small erythematous papules enlarge and coalesce into larger lesions. * Typically on face, scalp, elbows, knees and sites of trauma. -often worse in winter due to lack of sun

Answer 20

* more common in young adults and children. * Small, discrete, scattered round oval salmon pink/ red scaling papules all over trunk/extremities -post strep pharyngitis infection. -Can resolve in 6-12 months.

Answer 21

-generalized erythema (>90% BAS) with fine desquamative scale on surface -associated with arthralgia, pruritus, dehydration, electrolyte imbalance -acute can be onset/ severe if drug induced (lithium, BB, NSAIDs, antimalarials or steroid withdrawal) -can be chronic if poorly controlled psoriasis ****Can be life threatening and requires immediate medical care****

Answer 22

Sudden onset erythematous macules and papules which evolve rapidly into pustules -Can be painful -Can be generalized or localized -patient usually has hx of psoriasis -may occur with suden with drawal from steroid therapy

Answer 23

Erythematous plaques on flexural surfaces like axillae, inframmary folds, gluteal folds, inguinal folds; may be macerated/ moist

Answer 24

Development of skin disease in sites of truama. Occurs in psoriasis (and other disease like lichen planus, vitiligo)

Answer 25

Joint pain, stiffness (morning), back pain Tends to affect distal joints, DIPs Asymmetric oligo arthritis in which <5 small joints/ large joints are affected Can also present as symmetric polyarthritis (similar to and sometimes indistinguishable from RA) Arthritis mutilans (destructive) Spondyloarthropathy including sacroiliitis and spondylitis Enthesitis Dactylitis

Answer 26

Usually clinically Skin biopsy for challenging cases (not usually necessary) No labs to confirm Genetic testing not used

Answer 27

Emollients- reduce fissure formation Topical corticosteroids- reduce scaling, thickness, redness Topical vitamin D analogues (calcipotriene)- reduce keratinocyte hyperproliferation Others- retinoids, calcineurin inhibitors

Answer 28

Generally, a higher potency Up To Date suggests Group 1 for short term control (except on face/ intertriginous regions)

Answer 29

Generally for moderate (3-10%) to severe (10% +) disease Phototherapy Systemic therapy- NSAIDs, methotrexate (severe disease), cyclosporin, acitretin (retinoid), DMARDs (TNF alpha inhibitors)

Answer 30

Seborrheic keratosis

Answer 31

Scalp, face, neck, trunk of older adult Usually on sun exposed regions of body Spares palms and soles

Answer 32

Yellow or brown greasy "stuck on" macules or papules "smashed smartie"

Answer 33

Very common 69-100% caucasian males over the age of 50 Prevalence increases with age M>F Unusual in age <30 Risk factors: aging skin, UV exposure

Answer 34

Clinical diagnosis Biopsy only if uncertain

Answer 35

malignant melanoma (lentigo, nodular) Melanocytic nevi Pigmented BCC Solar lentigo Spreading pigmented AK

Answer 36

Only if desired for cosmetic purposes Cryotherapy, electrodessication, shave excision Follow up not needed unless looking infected Management- sun protection

Answer 37

Sudden appearance of new SK's (multiple lesions >5-10) may indicate internal malignancy

Answer 38

autoimmune, subepidermal blistering disease

Answer 39

-mainly effecting older adults over the age of 60 -Often > 80 years of age, and mostly affects people over 50 -Rare in kids. Can occur in younger adults. -F:M -No racial preference -More prevalent in older people with neurologic disease (parkinsons, dementia) -Risk is greater in people with psoriasis, and it can be precipitated by treatment of psoriasis with phototherapy. -Occasionally induced by drugs like furosemide, captopril, NSAIDs

Answer 40

Autoimmune Results from attack on basement membrane of epidermis by IgG antibodies and activated T lymphocytes

Answer 41

prodrome of localized erythema or pruritic urticarial plaques that become more edematous and extensive (can be weeks to months) develops into pruritic tense bullae (1-3 cm) on erythematous, urticarial, or non inflammatory base. can affect mucous membranes often symmetric and generalized bullae rupture within 1 week leaving eroded base that heals without scarring

Answer 42

Often diagnosis is made clinically and confirmed with skin biopsy.

Answer 43

If severe and widespread, may need hospitalization. Risk of secondary skin infection. Potentially fatal disease. Localized- high potency topical corticosteroids Advanced/ generalized- oral corticosteroid (prednisone) plus dapsone or doxycycline Treat itching- i.e., with hydroxyzine. Takes about 6 weeks, and then steroids are tapered. Assess for drug induced disease (can happen months to 1+year after starting inciting medication) and discontinue drug of concern Referrals -opthalmology if ocular involvement (itching, burning sensation in eyes or visual change) -GI if esophageal involvement and dysphagia -ENT if laryngeal, pharyngeal, nasal mucosa involvement (hoarse voice, nasal obstruction)

Answer 44

A form of cutaneous dysesthesia where itch and/or changed sensation arise in the areas of skin on the medial aspect of the shoulder blade on either side of the back AKA thoracic cutaneous nerve entrapment syndrome

Answer 45

The nerves which supply sensation to the upper back emerge from the spinal cord (2nd to 6th thoracic segments) and run a long course up through the thick muscles of the back. They make a right-angled turn before reaching the skin. The nerves appear to be vulnerable to compression or traction. Partial compression, injury or nerve entrapment leads to the symptoms. Initial injury to the nerve may include: back injury, herniated disc, herpes zoster, sunburn, myelopathy, small fiber neuropathy

Answer 46

Localized pruritis, unilateral to the skin medial to the scapular border on the mid or upper back May have change in sensation to the area May have reduced or absent sweating to the area Cutaneous changes may occur but are secondary to scratching or rubbing the skin

Answer 47

Scratch marks Hyperpigmentation Hypopigmentation Lichen simplex chronicus Scarring

Answer 48

I'm assuming is mostly a clinical diagnosis... Radiology may demonstrate a degenerative vertebra or prolapsed disc in the area that corresponds to the nerve supply to the affected skin (the dermatome). In many cases, no abnormality is revealed. Skin biopsy would be normal unless there is superimposed dermatitis

Answer 49

fungal infection of the nail

Answer 50

Older age Other nail problems (psoriasis or trauma) Peripheral vascular insufficiency Hyperhidrosis Immunosuppressed states (e.g., diabetes, HIV infection, immunosuppressive therapy) Frequent public swimming pools occupations requiring occlusive footwear (causes trauma) 1/3 of cases have presence of tinea pedis

Answer 51

Dermatophytes, particularly Trichophyton rubrum, are the most common causes of onychomycosis Rarely yeast (eg, Candida albicans) and nondermatophyte molds

Answer 52

In patients with diabetes or immunosuppression, these infected areas can serve as a reservoir of fungi that may cause reinfection or serve as a portal of entry for bacteria, leading to secondary bacterial infections such as cellulitis

Answer 53

starts in 1-2 nails and spreads most patients develop lifelong infection (unless treated) yellow/ white nail plate elevated due to accumulation of hyperkeratotic debris within the plate brittle, thick nails Can be painful May disrupt surrounding skin and predispose to bacterial infection of surrounding area (paronychia --> cellulitis)

Answer 54

Up to Date & CPS recommends confirming presence of fungi prior to treatment because there are multiple conditions that can mimic OM According to CPS: The current standard for diagnosis is a combination of fungal culture and microscopy

Answer 55

No, don't need to treat in everyone History of repeated lower extremity cellulitis DM or other risk factors for cellulitis (d/t risk of secondary bacterial infections with onychomycosis) Immunosuppression nail pain or discomfort Patient desires treatment

Answer 56

True - ensure you tell your patients this before initiating treatment!

Answer 57

This is a curbsiders trick and not really included in other resources... If a patient is bothered by the thickness of the nail, you can prescribe urea 40% ointment or cream, applied to the nail plate until desired thinness. Highly effective for patients who seek to have nails of normal thickness that they can then paint over. Caution patient to keep off surrounding skin as can be irritating

Answer 58

Classic options: oral antifungals, topical antifungals, physical interventions (laser treatment, photodynamic therapy (PDT), and surgery Other nonpharm options that can be helpful if infection just starting: mentholated ointment (Vick’s VapoRub), vinegar soaks, compounded thymol in alcohol, antifungal nail lacquers **If severe, it seems like a lot of people just opt to get their nail removed!

Answer 59

Recommended for early/mild or limited cases, or if systemic tx contraindicated

Answer 60

negligible risk for serious adverse effects and drug interactions compared with systemic antifungal therapy

Answer 61

Often require long (many month) treatment, often not effective, recurrence common when stop tx

Answer 62

Filing the upper surface of the thickened nail (vigorous debridement) may increase the extent of penetration for a topical preparation and may increase the likelihood for successful topical therapy

Answer 63

Terbinafine ** Oral terbinafine is considered the drug of choice for OM caused by dermatophytes based on its higher efficacy, tolerability and lower risk of drug interactions Continuous dosing: Oral: 250 mg once daily for 6 weeks (fingernail) or 12 weeks (toenail).

Answer 64

can cause severe hepatotoxicity, severe cutaneous adverse reactions (such as SJS/TEN), thrombotic thrombocytopenic purpura and hemolytic-uremic syndrome. Can also cause prolonged taste & smell disturbances.

Answer 65

mild and transient headache, gastrointestinal symptoms (e.g., nausea, diarrhea, dyspepsia, abdominal pain), viral infections and skin rashes

Answer 66

Hypersensitivity to terbinafine or any component of the formulation; chronic or active hepatic disease. Use in caution if renal impairment!

Answer 67

Obtain baseline and mid-treatment serum aminotransferase level (and CBC seems to be sometimes recommended)

Answer 68

= a focal collection of mucin under the skin, and is commonly seen on the distal aspect of the fingers. a shiny papule found at the end of a finger or toe, close to the nail. It is called a pseudocyst because it is not surrounded by a capsule, unlike a true cyst. It is also called a myxoid cyst, a mucous cyst, a digital ganglion cyst, and a digital synovial cyst.

Answer 69

It is usually a solitary lesion that is skin coloured to translucent Jelly-like sticky fluid may be expressed from the pseudocyst (sometimes tinged with blood). The corresponding nail can show a groove or structural changes as a pressure effect of the pseudocyst. Osteoarthritis can accompany it, when it is regarded as a type of ganglion.

Answer 70

Treatments which may be successful for digital myxoid pseudocyst include: Repeatedly pressing firmly on the cyst Squeezing out its contents (make a hole with a sterile needle) Cryotherapy (freezing) Steroid injection Sclerosant injection Surgical removal. Unfortunately, digital myxoid pseudocysts often recur, whatever treatment is used.

Answer 71

= benign overgrowths of normal sebaceous oil glands that are usually found on the face A form of benign hair follicle tumor

Answer 72

They can be seen commonly on the face, vermilion lips and buccal mucosa (Fordyce spots), eyelids (meibomian glands), areola (Montgomery tubercles), and glans penis or clitoris (Tyson glands).

Answer 73

yellow to flesh-colored appearance Up to 3mm diameter often associated central umbilication Close inspection reveals a central hair follicle surrounded by yellowish lobules. There are often prominent blood vessels, best seen using dermoscopy

Answer 74

usually iodopathic cyclosporine has been reported to cause diffuse lesions Most often affects older people More common in immunocompromised

Answer 75

usually not required because they are typically asymptomatic removal options include electrodesiccation, serial topical LN, or topical retinoids When the lesions are severe, extensive or disfiguring, oral isotretinoin is effective in clearing lesions but these may recur when treatment is stopped. In females, antiandrogens may help improve the appearance.

Answer 76

Skin cancer of the basal layer of keratinocytes in the epidermis Mostly occurs on sun exposed areas of the body 70% on the face Sometimes on chest/arms

Answer 77

UV light -> mutation of tumor suppression genes and proto-oncogenes

Answer 78

Initial tumours are small and hard to detect Lesions grow slowly over months to years Metastasis is rare because tumors do not invade blood or lymph vessels

Answer 79

Nodular variant (most common): typically a pearly white, almost translucent, dome-shaped papule with overlying telangiectasias - Enlarges slowly, flattens centrally, or may develop raised rolled border - Often bleed, erode, become crusted, ulcerate at the centre Superficial BCC can resemble patch of eczema or psoriasis: circumscribed round or oval, red, scaling plaque. It can spreads peripherally, sometimes several centimeters. This is the least aggressive form. Most commonly on trunk or extremities Sclerosing BCC may just look like scar tissue. Pigmented BCC may look like melanoma.

Answer 80

It's key! Focus on prevention as there is approximately a 20-year delay between UV damage and BCC. Avoid chronic direct sun exposure and especially overexposure (sun burn)

Answer 81

Depends on location, size, tumor variant, patient's concerns. Completely remove the tumour to prevent reoccurrence at a later date. Electrodesiccation (cure rate 92-96%) Complete excision (preferred for non-facial, well-defined nodules; cure rate 90% at 5 years) cryosurgery Mohs surgery Topical imiquimoid 5% for superficial BCC

Answer 82

It is neither life-threatening or trivial. Needs to be dealt with but slow moving

Answer 83

Thinner The dermis thins, producing translucent, paper-thin quality that is more susceptible to tearing.

Answer 84

From the epidermal keratinocytes. Cutaneous invasive squamous cell carcinoma (SCC) generally arises within a actinic keratosis or within SCC in situ.

Answer 85

Head, neck, trunk, extremities, oral mucosa, periungual skin, and anogenital areas. Involvement of other areas, in particular the lower legs and anogenital region, is more common in people with darkly pigmented skin.

Answer 86

Tumors arising on the ear, preauricular surfaces, or at mucocutaneous interfaces (ie, lips, genitalia, and perianal area) tend to be more aggressive, with rates of metastasis estimated to range from 10 to 30 percent.

Answer 87

Unprotected exposure to ultraviolet (UV) radiation from the sun or tanning beds. Weakened immune system due to illness or certain immunosuppressive medications. History of skin cancer including basal cell carcinoma (BCC). Age over 50: Most SCCs appear in people over age 50. Fair skin: People with fair skin are at an increased risk for SCC. Gender: Men are more likely to develop SCC. Sun-sensitive conditions including xeroderma pigmentosum. Chronic infections and skin inflammation from burns, scars and other conditions. Skin precancers including actinic keratosis. History of human papilloma virus (HPV)

Answer 88

Bowen's disease or squamous cell carcinoma in situ usually presents as one or more slowly enlarging erythematous scaly plaques. Histologically, atypical keratinocytes are found throughout the epidermis without invasion through the basement membrane.

Answer 89

Lip cancer predominantly affects the lower lip. It particularly occurs in males chronically exposed to the sun and is more frequent in smokers.

Answer 90

SCC presents as an irregular keratinous nodule or a firm erythematous plaque, and frequently ulcerates. Histologically, atypical keratinocytes proliferate within the dermis.

Answer 91

Keratoacanthomas are keratocytic epithelial tumors that clinically and histologically resemble squamous cell carcinoma (SCC). It is controversial whether keratoacanthomas represent a subtype of well-differentiated cSCC or a separate entity. Keratoacanthomas are usually found on actinically damaged skin. Lesions typically exhibit rapid initial growth, manifesting as dome-shaped or crateriform nodules with a central keratotic core that develop within a few weeks.

Answer 92

Verrucous carcinoma is a rare variant of cSCC that presents with well-defined, exophytic, cauliflower-like growths that resemble large warts. Most common locations are in the penis, scrotum, perianal region, oral mucosa, plantar foot.

Answer 93

True! Oral SCC usually presents as an ulcer, nodule, or indurated plaque involving the oral cavity. The floor of the mouth and lateral or ventral tongue are the most common sites for these tumors. Lesions may arise in sites of erythroplakia (premalignant, persistent, red patches in the oral cavity) or leukoplakia (oral, persistent, white plaques. Oral SCC is often associated with a history of tobacco or heavy alcohol use.

Answer 94

Marjolin's ulcer" is a term used to describe a rare type of cSCC arising in sites of chronic wounds or scars [13-15]. The malignant transformation is usually slow, with an average latency time of approximately 30 years. initially present as an ulceration that fails to heal; nodules may develop as the lesion progresses. Other clinical signs include rolled or everted wound margins, excessive granulation tissue, rapid increase in size, and bleeding on touch. Has poor prognosis.

Answer 95

Squamous cell carcinoma in situ may be treated surgically. Other treatments include cryotherapy, 5-fluorouracil cream, imiquimod cream or photodynamic therapy (PDT).

Answer 96

A very rare, indolent, malignant skin tumor of epithelial origin, considered a variant of cSCC. As a flesh-colored, firm nodule or plaque, most often located in the head and neck region. Histopathologically, it shows islands of poorly differentiated epithelial cells with a dense lymphoid infiltrate, resembling undifferentiated nasopharyngeal carcinoma.

Answer 97

Invasive SCC is nearly always treated surgically. Wide margins are advisable for poorly differentiated or anaplastic tumours. Some tumours are treated by radiotherapy, particularly when surgery is difficult or incomplete.

Answer 98

A common, inflammatory dermatosis of the lower extremities occurring in patients with chronic venous insufficiency, often in association with varicose veins, dependent chronic edema, hyperpigmentation, lipodermatosclerosis, and ulcerations. A late manifestation of chronic venous disease

Answer 99

Age, family history of venous disease, female sex, standing occupation, obesity, and history of deep vein thrombosis. Heart failure and hypertension are aggravating factors.

Answer 100

Presents with erythematous, scaling, and eczematous patches or plaques on chronically edematous legs. The medial ankle is most frequently and severely involved, although the skin changes may extend up to the knee and down to the foot. Pruritus is variable but, when present, results in lichenification from chronic scratching or rubbing. Hyperpigmentation due to dermal hemosiderin deposition and scaling are predominant features in chronic forms.

Answer 101

-Higher frequency of contact dermatitis -Superinfection-Staphylococcus aureus and Streptococcus pyogenes are the most frequent causes of superficial (impetiginization) or deep (cellulitis and erysipelas) superinfection of stasis dermatitis. -Lipodermatosclerosis-The chronic phase is characterized by hyperpigmented and indurated skin that constricts the ankle region, giving the legs an appearance of an inverted champagne bottle. -Acroangiodermatitis- "pseudo-Kaposi sarcoma," is a rare, reactive, vasoproliferative disorder resembling Kaposi sarcoma that occurs on the lower limbs as a result of vascular hyperplasia secondary to hypostasis and elevated venous pressure

Answer 102

Pt can undertake lifestyle changes aimed at decreasing venous hypertension, reducing edema, and preventing venous ulcers. These include exercise, frequent walks, avoiding prolonged standing, leg elevation whenever possible, and weight loss. Gentle skin cleansing with mild, fragrance-free liquid cleansers and frequent use of bland emollients are indicated for the symptomatic treatment of skin dryness and pruritus associated with mild or chronic stasis dermatitis. Compression bandages or stockings

Answer 103

UptoDate suggests high or mid potency (group 3 and 4). Can be applied to the affected skin once or twice daily for one to two weeks.

Answer 104

Rosacea is a chronic inflammatory skin condition predominantly affecting the central face and most often starts between the age of 30–60 years, but can occur at any age. Rosacea is common and is characterised by persistent facial redness. It typically has a relapsing and remitting course, with symptoms controlled by lifestyle measures, general skin care, medications, and procedural interventions. Although rosacea can affect anyone, it is more common in with skin types most susceptible to sunburn (eg, individuals with lightly pigmented skin or skin phototypes I or II). Women>men, but some studies suggests equal predisposition between sexes. Adults males more predisposed to phymatous changes.

Answer 105

Annular - ringlike Dermatomal - confined to a dermatome and abruptly stops at the midline Grouped - clustered lesions (herpetiform) Linear - arranged in a line (suggestive of external cause) Reticular - netlike or meshlike (suggesting a process affecting the cutaneous vascular netowork)

Answer 106

Both macules and papules are <1cm in diameter. Papules are solid and raised, macules are flat (ie. just a color change). If you close your eyes and you cannot feel a <1cm lesion's presence then it is a macule

Answer 107

Plaque - Raised lesion > 1cm Patch - flat, > 1 cm (a color change)

Answer 108

Nodule - solid elevation of skin > 1 cm, usually extended into deeper skin layers (connective tissue/deep dermis/subcutis) (ex. cysts, lipomas, fibromas) Pustule - small circumscribed raised lesion that contains pus (ex. bacterial infections, folliculitis) Cyst - sac-like nodule that usually has an epithelial lining containing fluid or other debris

Answer 109

Drier Epidermal cells contain less moisture and change shape Atrophy of eccrine, apocrine, and sebaceous glands causes dry skin.

Answer 110

False - DNA repair of damaged skin decreases

Answer 111

The dermis becomes more permeable and less able to clear substances, so those substances accumulate and cause irritation. The barrier function of the stratum corneum is reduced, increasing risk for injury and infection. The significantly decreased number of Langerhans cells reduces the skin's immune response.

Answer 112

There are fewer melanocytes; pigmentation becomes irregular, giving decreased protection from ultraviolet radiation and leading to greying of hair.

Answer 113

Decreases Pressure and touch receptors and free nerve endings decrease in number, causing reduced sensory perception.

Answer 114

With compromised temperature regulation, loss of cutaneous vasomotion, and decreased eccrine sweat production, there is an increased risk for heat stroke and hypothermia

Answer 115

The nail plate thins, and nails are more brittle

Answer 116

Sun protection, sun protection, sun protection! Avoid the sun when ultraviolet light is strongest (e.g., 10 a.m. to 3 p.m.), avoid sun tanning beds, seek shade, use sunscreen preparations, especially those containing ingredients such as PABA (para-aminobenzoic acid), and wear protective clothing Do total body skin examinations routinely

Answer 117

Yes Up to 10% of AK, if left untreated, will develop into squamous cell carcinoma. Research has shown that people with AK have an increased risk of developing other types of skin cancer, including BCC and melanoma.

Answer 118

- Red, rough scaling lesions, that can sting or be pruritic. Located on sun-exposed areas such as the face, lips, ears, balding scalp, back of hand, forearm and leg, grouped/clustered. -Gritty texture on palpation is a helpful diagnostic clue.

Answer 119

Keratinocytes

Answer 120

False - Multiple lesions are common in males with fair skin.

Answer 121

uneven pigmentation, atrophy or thinning, and telangiectasias

Answer 122

Poorly defined area of redness or telangiectasia.

Answer 123

Over time, the lesion becomes more defined and develops a thin, adherent, yellowish, or transparent scale. -at this stage, easier to palpate than observe -discrete sandpaper-like change in skin texture associated with minimal erythema. -Presents most commonly as a 2- to 6-mm, erythematous, flat, rough, gritty or scaly, pink-purple papule. -With time, the adherent scale becomes progressively thicker and yellow in color. - Retained scale may form an elongated keratinous structure or a cutaneous horn.

Answer 124

squamous cell carcinoma - biopsy is required

Answer 125

describes AK with fine reticulated pigmentation and minimal scaling; they may mimic a solar lentigo or melanoma in situ. Lentigo maligna (melanoma in situ) appears as a pigmented patch and occurs most frequently on sun-damaged skin; it may be confused with a spreading pigmented AK, and thus a biopsy may be required to establish the correct diagnosis.

Answer 126

sun-induced keratinocyte atypia of the lower lip.

Answer 127

- There is focal crusting and scaling along with blurring of the vermilion border, which appears whitish or gray. - Actinic lesions in this location can be quite subtle clinically and behave aggressively. - Like its cutaneous counterpart, actinic cheilitis may progress to overt squamous cell carcinoma of the lip.

Answer 128

lesions that develop on the ear, the scalp, or at the vermilion border of the lip are more likely to metastasize to SCC, compared to other skin sites (monitor and treat aggressively).

Answer 129

AK are predominantly treated by cryotherapy. They may also be treated with the following: - Keratolytic creams containing 10% urea, 2 to 4% salicylic acid or 10 to 15% lactic acid to reduce scaliness - 2 to 4 weeks of 5-fluorouracil cream applied once or twice daily - 4 to 16 weeks of imiquimod cream applied two or three times weekly - Photodynamic therapy - Patients with significant diffuse photodamage or multiple and recurrent lesions present difficult treatment problems. - Ingenol mebutate gel applied for 2-3 days - 3 months of topical diclofenac in hyaluran gel applied twice daily - Adequate sun avoidance with sun-protective clothing and sunscreens should be encouraged to limit further damage.

Answer 130

The patient with multiple AK requires at least annual follow-up, if not more often for some patients who have more extensive sun damage. - Visible or detectable lesions represent a fraction of the total number of atypical keratinocytes actually present. - Most of the atypia are scattered within sun-damaged skin and below the level of clinical detection. Most certainly will develop more clinically apparent AK lesions over time. - It is well documented that patients with numerous AK have an increased risk for developing SCC over time.

Answer 131

Atopic Dermatitis (Eczema)

Answer 132

sensitivity to allergens such as environmental (extreme weather changes, dust, pollen etc), animals (dogs, cats), food (dairy, wheat, nuts, fish), irritants (detergents, soaps, creams etc), and stress

Answer 133

Acute eczema is characterized by intensely pruritic, erythematous papules and vesicles with exudation and crusting, whereas subacute or chronic lesions present as dry, scaly, or excoriated erythematous papules.

Answer 134

Skin thickening from chronic scratching (lichenification) and fissuring may develop over time

Answer 135

flexure folds (elbows, wrists, and knees), hands, feet, eyes, face *sparing groin and axillary

Answer 136

vitiligo and alopecia areata.

Answer 137

scaly, red, coin-shaped patches and plaques that often favors the lower extremities

Answer 138

True for atopic, not contact dermatitis. contact occurs following exposure to an external factor that triggers a reaction

Answer 139

False - common in adults

Answer 140

Scabies, seborrheic dematitis, cutaneous t-cell lymphoma, psoriasis

Answer 141

Moisturizers ■ Moisturizers work best when applied a few hours after topical steroids. ■ Application should continue for days or weeks after the inflammation has cleared. ■ Moisturizers are most effective when rubbed in well and applied directly after the skin is patted dry following a shower. Controlling pruritis: tepid baths and emollients, wet dressings to soothe, habit reversal training (scratching), CBT. - Stress management and helping the client get restful, restorative sleep are important.

Answer 142

Mild: low potency topical corticosteroid ointment (Hydrocortisone 2.5%) 1-2 times daily for up to 2 weeks. Moderate: Medium to high potency topical corticosteroid (Mometasone 0.1%) 1-2 times daily for up to 2 weeks. Topical calcineurin inhibitors (Tacrolimus 0.03%-0.1%) for moderate to severe eczema not controlled w/ topical steroid Severe: High potency topical corticosteroids (Clobetasol 0.025-0.05%) 1-2 times a day for up to 2 weeks. Consider biologic agents, phototherapy, allergen immunotherapy Topical anti-inflammatory therapy, oral antihistamines.

Answer 143

common inflammatory condition of the skin folds characterized by moist erythema, malodor, weeping, pruritis and tenderness

Answer 144

from moisture and friction associated with an absence of air circulation in deep skin folds. -Friction between adjacent skin surfaces leads to epidermal inflammation. - Moisture and sweat accumulation further macerate the skin layers. In addition, candidal or bacterial infection may initiate or aggravate intertrigo.

Answer 145

*affects people of all ages, from infancy to advanced age. *Most common in bedridden or debilitated older adults and infants because of immobility and minimal aeration of intertriginous areas

Answer 146

obesity, immunodeficiency (e.g., diabetes, HIV, prednisone), hot humid weather, poor hygiene, incontinence, tight-fitting clothing, hyperhidrosis (excessive sweating), frequent wet work involving hands (dishwashing), and use of topical steroids.

Answer 147

Candidal infection

Answer 148

moist, red or red-brown, beefy, homogenous patch within skin folds.

Answer 149

Groin is most comon site. Other sites: axilla, inframammary skin, umbilicus, neck folds in infants, under the pannus and finger/toe web spaces

Answer 150

Yes! Even though subtle onset, pts c/o pruritus, burning, tingling, and pain in the skin folds and flexural surfaces.

Answer 151

The erythematous patch can develop erosions, macerations, fissures, crust, and weeping from the site.

Answer 152

Bacterial intertrigo tends to weep and is an intensely erythematous and a potentially tender lesion.

Answer 153

satellite papules and pustules

Answer 154

Remove causative factors: - Minimize moisture and friction in skin folds - Treatment of hyperhidrosis - Weight loss if overweight - Treatment of diabetes - Daily cleansing of skin folds with a mild cleanser and dryer (use a hair dryer on a cool setting) - Aeration of area when feasible - Daily use of drying powders - Use of absorbent material or clothing such as cotton or merino wool to separate skin folds - Barrier cream in areas that may contact urine/stool

Answer 155

Intertrigo infected by bacteria should be treated with topical (eg, mupirocin) or oral antibiotics (eg, penicillin); fungal infection treat with antifungal; *1-2 times daily for 2-4wks Low-potency topical steroids only if pruritic. *Hydrocortisone 2.5% twice/day for one week, once/week for one week and then every second day for one week

Answer 156

Vesicle - small circumscribed elevation of epidermis containing serous fluid, <1cm (small blisters) (ex. herpes infections, acute allergic contact dermatitis) Bulla - circumscribed elevation of epidermis containing serous fluid, >1cm (large blister) (ex. autoimmune bullous disease such as pemphigus vulgaris, bullous pemphigoid

Answer 157

Solar Lentigo

Answer 158

Circumscribed, raised lesion of dermal edema (edematous papule or plaque) also known as hives or urticaria, typically last <24 hours

Answer 159

Common, benign, brown macules occurring on sun-exposed skin in whites and some Asians.

Answer 160

Petechiae- non-blanchable punctate foci of hemorrhage Purpura- non-blanchable, raised and palpable Ecchymoses - non-blanchable larger areas of purpura

Answer 161

No. Freckles appear in childhood and occur as an autosomal dominant trait. *They are usually confined to the face, arms, and upper trunk; numerous and darken in response to sun exposure. *red, tan, light brown macules (1–2 mm) with sharply defined borders. *Freckles appear in early summer and usually fade by early winter. Solar Lentigo increase in number and size with advancing age *indicates sun damage d/t UVR *2- to 20-mm oval macules, seen on a background of sun-damaged skin. *skin-coloured, tan to dark brown or black; sometimes with scales *persist year-round. *most common: face, neck, upper chest, arms, back of hands

Answer 162

Erosions - loss of epidermis Ulceration - loss of epidermis and part of the dermis

Answer 163

*2- to 20-mm oval macules, seen on a background of sun-damaged skin (years of sun exposure) *skin-coloured, tan to dark brown or black; sometimes with scales *persist year-round. *most common: face, neck, upper chest, arms, back of hands

Answer 164

Scale - excess accumulation of “dead skin”/fragments of the stratum corneum Crust - adherent, dried serum, exudate or blood on the skin (scab)

Answer 165

Both - occur in light and dark skin *more numerous in fair-skinned

Answer 166

Lichenification - thickening of the epidermis with accentuation of the normal skin lines (usually due to chronic rubbing/scratching) Excoriation - Loss of epidermal integrity due to scratching

Answer 167

melonocytes and accumulation of melanin within the skin cells (keratinocytes).

Answer 168

permanent fibrotic changes that result from damage extending into the dermis. Keloids extend beyond the borders of the original defect

Answer 169

*Flat seborrheic keratoses *Spreading pigmented actinic keratosis *Lentigo maligna - Lentigo maligna is an early form of melanoma in which the malignant cells are confined to the tissue of origin, the epidermis, hence it is often reported as [‘in situ’ melanoma]. It occurs in sun damaged skin so is generally found on the face or neck, particularly the nose and cheek. It grows slowly in diameter over 5 to 20 years or longer. [Dermnetz.org] *Junctional nevus *When numerous lentigines are present, consider the possibility of an associated syndrome, such as Peutz−Jeghers, LEOPARD, or NAME (LAMB)

Answer 170

indicates vascular dilation, blanchable red or pink hue in skin - not a color

Answer 171

Monitor for any change. Stable lesions do not require treatment Cosmetic reasons there are creams, peels, and light cryosurgery (may cause depigmentation) that can help reduce pigmentation Preventative measures include minimizing sun exposure and use of sunscreens, but this needs to start early in life.

Answer 172

Lichen Sclerosus

Answer 173

ABCDE: Asymmetry, borders, color, diameter, evolving Asymmetry - of one side of the mole compared to the other Border - irregularity - especially if ragged, notched or blurred Color- variations - more than 2 colors, especially blue-black, white (loss of pigment due to regression), or red (inflammatory reaction to abnormal cells) Diameter ≥ 6 mm (approx. the size of a pencil eraser) Evolving - changing rapidly in size, symptoms, or morphology

Answer 174

Lichen sclerosus can occur at any age but is more common in women older than 60 years and prepubertal girls between 8 and 13 years of age. Women: Men 5/10:1

Answer 175

A way to detect suspicious lesions in a person with multiple nevi. A skin lesion that looks different from those surrounding it may be an important finding.

Answer 176

*family history (in 12%) *associated with other autoimmune conditions such as thyroid disease, alopecia areata, pernicious anemia, vitiligo

Answer 177

Dermoscopy - should be performed on all suspicious pigmented lesions as a first-line diagnostic support modality

Answer 178

No. chronic, progressive, relapsing

Answer 179

Histopathological diagnosis. UptoDate recommends: A complete full-thickness excisional biopsy of suspicious lesions with 1 to 3 mm margin of normal skin and extending to a depth to encompass the thickest portion of the lesion should be performed whenever possible. Partial incisional biopsy may be acceptable for very large lesions or for certain sites, including the face, palm or sole, ear, distal digit, or subungual lesions

Answer 180

Yes, can evolve overtime into SCC - especiallly vulvar lichen sclerosus *risk for SCC (2.1% after 5 years, 3.3% after 10 years, 6.7% after 20 years)

Answer 181

A change in a long-standing mole; the development of a new, persistent skin lesion after puberty; a new, pigmented band in a nail; and any lesion growing under the nail

Answer 182

* ivory-white, flat topped, slightly raised papules with a faint-pink rim that coalesce into small oval plaques with a dull or glistening, smooth, white, atrophic, wrinkled surface. might read: “polygonal papules and porcelain-white plaques, erosions and various degrees of sclerosus”.

Answer 183

False - the majority of melanomas are initially detected by patients themselves, but the melanomas detected by clinicians are thinner than those identified by patients

Answer 184

Mostly common to labia minora and majora, but may extend over the perineum (encircles the vagina) and around the anus in a keyhole fashion or hourglass shape

Answer 185

Is multifactorial: Genetic susceptibility Altered microbiome of the skin and gut Dysregulation of the immune response may lead to excessive inflammation, vasodilation, lymphatic dilatation, and angiogenesis. Neurocutaneous mechanisms. Impaired skin barrier. Abnormalities of the innate immune system

Answer 186

Penile lesions (balanitis xerotica obliterans) favor the glans and coronal sulcus but may extend to the shaft.

Answer 187

Transient recurrent erythema, ie, flushing Persistent centrofacial erythema Telangiectasia Facial skin other than in the nasal alar region Lid margin telangiectases, conjunctival injection, and ocular irritation Together often termed erythematotelangiectatic rosacea Inflammatory papules and pustules (papulopustular) Phymatous changes Thickening of the skin due to hyperplasia/fibrosis of the sebaceous glands of the face. Most common area affected is the nose (termed rhinophyma) burning or stinging sensations cutaneous edema, and dryness Refer to opthalmolohy if ocular manifestations are indentified.

Answer 188

vulvar pruritus, burning, dyspareunia, and painful defecation (lead to constipation) which may have significantly detrimental effects on function and sexual health. - interfere with daily activities and sleep

Answer 189

Facial stinging or burning sensations, flushing, edema, dry-appearing skin, and papules and pustules, can aid with diagnosis of rosacea in patients with highly pigmented skin.

Answer 190

False - can occur anywhere on the skin surface. Can also occur torso (front/back)

Answer 191

Usually a clinical diagnosis. Skin biopsy may be used in uncertainty. **one diagnostic criterion or two major criteria to be fulfilled. Diagnostic criteria: -Persistent centrofacial erythema associated with periodic intensification by potential trigger factors -Phymatous changes. Major criteria -(must occur in centrofacial distribution) -Flushing/transient centrofacial erythema -Inflammatory papules and pustules -Telangiectasia — visible blood vessels (excluding nasal alar telangiectases, which are common in adults) -Ocular rosacea (lid margin telangiectasia, blepharitis, keratitis/conjunctivitis/sclerokeratitis/anterior uveitis). Minor features -Burning sensation of the skin -Stinging sensation of the skin -Oedema -Dry sensation of the skin

Answer 192

vulvar architecture is obliterated d/t longstanding erythema and edema; Mucocutaneous atrophy may lead to development of hemorrhagic bullae and erosions; Men: - Surface trauma leads to focal subepidermal hemorrhages and erosions. - Atrophy leads to phimosis of the foreskin with pain on retraction of the foreskin or erection. - The urethral meatus may become stenotic, and malignant degeneration may occur.

Answer 193

Encourage patients to record a symptom diary to aid the identification of triggers: Common triggers include: spicy food, hot/cold temperatures (hot baths), exercise, sun exposure, cosmetic products, medications (those that cause vasodilation), alcohol, fruits and vegetables, dairy, marinated meat products Avoid the triggers identified. General skincare advice: -Moisturise frequently -Use gentle over-the-counter cleansers -Mild, synthetic detergent-based cleansers rather than traditional soaps due to risk of irritation -Use physical sunscreens (ie, zinc oxide/titanium oxide) with SPF ≥ 30 -Avoid exfoliants -Avoid alcohol-based topical products -Avoid use of topical steroids as they may aggravate the condition -Cosmetics with a green tint are useful to minimise the appearance of redness.

Answer 194

Treatment depends on the individual's cutaneous features. *Transient erythema (flushing) -Alpha-adrenergic agonists (topical brimonidine, topical oxymetazoline) — they are often used infrequently for special occasions only, as persistent use may result in rebound flushing on discontinuation -Oral beta-blockers (carvedilol) -Oral clonidine may reduce flushing *Persistent erythema -Alpha-adrenergic agonists (topical brimonidine, topical oxymetazoline, as above) -Intense pulsed light therapy -Vascular laser *Inflammatory papules/pustules Topical azelaic acid (for mild/moderate only) Topical ivermectin Topical metronidazole (for mild/moderate only) Topical erythromycin Oral tetracyclines (oxytetracycline, lymecycline, doxycycline) Oral macrolides (erythromycin, azithromycin) Oral metronidazole Oral isotretinoin often at low dose (for refractory disease only) *Telangiectasia Electrodesiccation Intense pulsed light therapy Vascular laser Neurogenic rosacea Gabapentin Amitriptyline Oral beta-adrenergic blockers Consideration of endoscopic sympathectomy *Phyma If clinically inflamed: doxycycline, isotretinoin If clinically non-inflamed: physical modalities to remove excess tissue and reshape the structures (eg, ablative CO2 laser, erbium laser, radiofrequency, surgical debulking). *Ocular rosacea- General management Increase dietary intake of omega-3 fatty acids Warm compresses Gentle eyelash/eyelid cleansing to express sebum trapped in the meibomian glands First-line medical management (by opthalmology) If mild-moderate: topical azithromycin/topical calcineurin inhibitors If severe: azithromycin, doxycycline.

Answer 195

A cherry angioma.

Answer 196

It is a true capillary haemangioma. The angioma is composed of venules in a thickened papillary dermis. Collagen bundles may be prominent between the lobules. Commonly diagnosed clinically. Benign. Cherry angiomas markedly increase in number from about the age of 40, so it has been estimated that 75% of people over 75 years of age have them. But younger people can get them. No differences in sex or race. May be familial.

Answer 197

Cryotherapy, electrosurgery, vascular laser.

Answer 198

It should be biopsied if you believe it may be something else, such as a nodular melanoma or amelanotic melanoma.

Answer 199

dyspareunia, urinary obstruction, constipation, secondary infection related to ulceration, secondary infection (candidiasis) as a consequence of treatment, steroid use, squamous cell carcinoma.

Answer 200

punch biopsy

Answer 201

- Morphea and lichen sclerosus are similar on the skin (rarely both conditions may be present in some patients, although the presence of mucosal lesions favors a single diagnosis of lichen sclerosus) - Lichen planus and pemphigus vulgaris (especially for erosive mucosal lesions) - Lichen simplex chronicus (vulvar involvement from scratching) - Allergic contact dermatitis (typically fragrance allergy from personal hygiene products or steroid allergy from prior treatment) - Extramammary Paget's disease (should be considered for chronic anogenital itching with erosions) - Steroid-induced atrophy (can be confused with lichen sclerosus)

Answer 202

Lichen planus (LP) is an inflammatory disorder (T-cell mediated) of the skin and mucous membranes with no known cause. It appears as pruritic, violaceous papules and plaques most commonly found on the wrists, lower back, and ankles., but can be found anywhere. The prevailing theory is that exposure to an exogenous agent such as a virus, drug, or contact allergen causes alteration of epidermal self-antigens and activation of cytotoxic CD8+ T cells.

Answer 203

Clobetasol propionate 0.05% ointment is effective for vaginal and penile disease in adults 0.05% clobetasol 1-2 times daily until remission achieved (typically 2-3 months) or daily for 4 weeks, every second day for 4 weeks and then twice/week for 4 weeks

Answer 204

Women > men at ratio of 1.5:1 Most cases develop between the ages of 30 and 60. Maybe familial

Answer 205

Yes: topical corticosteroids 2-3 times/week even if asymptomatic (clobetasol or mometasone) adjust potency based on hyperkeratosis or presence of corticosteroid-induced atrophy

Answer 206

- Patients should used gentle cleansers such as Cetaphil and moisturize with a light moisturizer. - Women should avoid fragranced feminine hygiene products and scented toilet paper. - Ensure patients know which specific body surfaces to apply corticosteroids to - Teach monthly self-exam for signs of malignancy (hyperkeratotic plaques, erosions or ulcers that fail to improve with treatment within 2 weeks) Longterm Follow up

Answer 207

6 Ps: purple, polygonal, planar, pruritic papules, and plaques.

Answer 208

Lesions may have a shiny surface covered in fine white lines known as Wickham striae and are firm on palpation. They may be seen as a few individual lesions, found scattered widely, grouped in plaques, or arranged in annular, linear, or actinic (sun-exposed) patterns. Isomorphic response (i.e., Koebner phenomenon) can be seen in LP wherein new lesions arise in lines where scratching occurs, just as is seen in psoriasis. The most common areas of involvement include the flexor wrists, dorsal hands, lower back, ankles, and shins. Frequently a grayish-brown hyperpigmentation can be found after lesions resolve due to deposition of melanin in the superficial dermis Other less common features: Hypertrophic lichen planus can be a scaly and pruritic rash. Atrophic lichen planus is a rare annular variant with an atrophic centre. Reticular presents as asymptomatic white, lacy lines often seen on the bilateral buccal mucosa Annular lichen planus describes the development of violaceous plaques with central clearing often involving penis, scrotum, and intertriginous areas. Size ranges from pinpoint to larger than a centimetre.

Answer 209

- Chronic vulvar itching in the absence of infection should raise the suspicion of lichen sclerosus. - Consider lichen sclerosus to be a precancerous condition requiring regular follow-up and biopsy of areas suspicious for malignant change.

Answer 210

Contributing factors to lichen planus may include: Genetic predisposition Physical and emotional stress Injury to the skin; lichen planus often appears where the skin has been scratched or after surgery (koebnerisation) Localised skin disease such as herpes zoster Systemic viral infection, such as hepatitis C (which might modify self-antigens on the surface of basal keratinocytes) Contact allergy, such as to metal fillings in oral lichen planus (rare) and colour photographic developers Drugs; gold, quinine, quinidine, and others can cause a lichenoid rash. Vit D deficiency

Answer 211

LP that involves the mucosal surfaces and frequently is the presenting site. It is most commonly seen in the mouth but can be found on the lips, esophagus, glans penis, vulva, or vagina. Other subtypes of Lichen Planus are: Cutaneous lichen planus Mucosal lichen planus Lichen planopilaris Lichen planus of the nails Lichen planus pigmentosus Lichenoid drug eruption.

Answer 212

Longstanding erosive lichen planus can result in true squamous cell carcinoma, most often in the mouth, vulva, or penis. This should be suspected if there is an enlarging nodule or an ulcer with thickened edges. Oesophageal lichen planus can cause dysphagia, strictures, and possibly squamous cell carcinoma.

Answer 213

Is is diagnosed clinically, unless it is atypical or to look for cancer then you can do a biopsy.

Answer 214

Psoriasis, lichen simplex, pityarisis rosea, tinea, lichen sclerosis , leukoplakia, candidiasis, bullous pemphigoid, SCC, lupus, onychomycosis, subacute cutaneous lupus erythematosus, discoid lupus erythematosus, pityriasis rosea, secondary syphilis

Answer 215

Avoid soaps and shower gels that will exacerbate scaling. Use emollients regularly. Sedating antihistamines may help troublesome nocturnal itch (caution in older adults).

Answer 216

Lichen planus can have a chronic remitting and relapsing course. Cutaneous lichen planus tends to clear within a couple of years in most people, but post-inflammatory pigmentation may take years to subside. Other subtypes may take longer or cause permanent scarring.

Answer 217

Goals of care is to manage pruritis. Local treatments for the symptomatic cutaneous or mucosal disease are: Potent topical corticosteroids (including steroid impregnated tape) Topical calcineurin inhibitors, tacrolimus ointment, and pimecrolimus cream Topical retinoids Intralesional steroid injections. Systemic treatment for widespread lichen planus or severe local disease often includes a 1- to 3-month course of systemic steroids (eg, prednisone), while commencing another agent from the following list: Acitretin Hydroxychloroquine Methotrexate Azathioprine Mycophenolate mofetil Phototherapy. Antibiotics Adalimubab has been used for oral LP.

Answer 218

Total nevus count above 50 and/or presence of large (atypical/dysplastic) nevi Personal history of skin cancer Immunosuppression - particularly chronic use of immunosuppressive medications such as those used by organ transplant recipients. Sun-sensitive people and those with the red hair phenotype (light skin, red or blond hair, high-density freckling, light eye color) Family history of melanoma

Answer 219

Screening involves a full-body skin examination performed yearly by a clinician who has had appropriate training in the identification of melanoma (clinician examination) as well as education for patients about melanoma risk factors and advice to alert their clinician if self-examination detects changing moles or other suspicious skin lesions

Answer 220

1 - anatomic distribution 2 - configuration 3 - primary lesion and color 4 - secondary change if present

Answer 221

Chronic relapsing form of dermatitis occurring in areas rich in sebaceous glands

Answer 222

Areas rich in sebaceous glands (scalp, face, upper trunk, intertriginous areas)

Answer 223

Dandruff - diffuse fine scaliness of the scalp without underlying erythema

Answer 224

Severe forms present with inflamed, erythematous plaques covered with yellowish, greasy scales

Answer 225

Not fully understood. Possibility that is hormonally dependant, has a fungal component, is neurogenic, or may reflect a nutritional deficiency. Possible association with Malassezia spp (yeast) Currently considered an inflammatory disorder that probably results from dysfunction of sebaceous glands

Answer 226

Usually clinically based on appearance and location of the lesions. Can differentiate histologically if presentation is unclear.

Answer 227

True. This is a chronic condition that often requires repeated treatment or long-term maintenance therapy.

Answer 228

Topical antifungal 1-2 times daily for 4 weeks. If no improvement at 4 weeks, add a low potency topical steroid 1-2 times daily for up to 2 weeks. If improvement continue topical antifungal 1-2 times weekly to prevent relapse. If no improvement with above, switch to a topical calcineurin inhibitor (tacrolimus ointment)

Answer 229

Start with both low potency topical corticosteroid and topical antifungal 1-2 times daily for 2 weeks. Continue maintenance therapy with topical antifungal or calcineurin inhibitor 1-2 times/week to prevent relapse. Second line: topical calcineurin inhibitor Third line: systemic antifungal

Answer 230

Yes. Mild cases: antifungal shampoo 2-3 times weekly. If no improvement at 4 weeks add high-potency topical corticosteroids (foam, lotion, spray or shampoo) once daily for up to 4 weeks. Continue antifungal shampoo 1-2 times weekly to prevent relapse Moderate-severe cases: go straight to antifungal shampoo and corticosteroids. Second line after 4 weeks - systemic antifungal

Answer 231

Herpes zoster/shingles is caused by the reactivation of the varicella zoster virus (the chicken pox virus)

Answer 232

Immunosuppression (HIV, steroids, transplants), old age (most important risk factor, begins ~50yrs), autoimmune disorders (IBD, RA), F>M, occasionally associated with hematologic malignancy

Answer 233

Unilateral vesicular rash & neuritis. Dermatomal distribution, rash does not cross the midline.

Answer 234

- Dermatomal eruption occurs 3-5 d after pain and paresthesia of that dermatome - Within several days, grouped vesicles or bullae are the predominant manifestation - Within three to four days, the rash becomes pustular - In immunocompetent hosts, the lesions crust by 7 to 10 days and are no longer considered infectious - Painful, post herpetic neuralgia can last months

Answer 235

Shingles on the tip of the nose - signifies ocular involvement - shingles in this area involves the nasociliary branch of the ophthalmic branch of the trigeminal nerve (V1). Dangerous

Answer 236

True - kind of, people with shingles can spread VZV to people who have never had the virus or been vaccinated and this can cause chicken pox.

Answer 237

usually based on the clinical presentation (ie, unilateral, usually painful, vesicular eruption with a well-defined dermatomal distribution). Testing is available is diagnostic is uncertain - PCR, direct fluorescent antibody testing and viral culture

Answer 238

Antivirals recommended within 72 hours of rash starting. Can also be of benefit after 72 hours if all vesicles have not yet crusted

Answer 239

Valacyclovir 1000 mg TID for 7 days

Answer 240

Offer NSAIDs and/or acetaminophen. If pain is severe may require short acting opioid analgesics such as oxycodone. If pain is severe despite short acting opioid, can consider 10-14 day taper of oral prednisone. Last line - drugs like gabapentin. UTD suggests against the routine use of adjunctive therapies, such as gabapentin, tricyclic antidepressants, or glucocorticoids. The clinical benefit of these agents in reducing the risk of acute neuritis has not been clearly demonstrated and there are significant risks associated with these medications.

Answer 241

Adults 50 years old and up Second dose repeated 2-6 months after first.

Answer 242

Immobility – neuromuscular disorders, frailty, post-surgical immobility, ADL dependence, bed rest Impaired oxygenation status – COPD, HF, anemia Sensory loss – spinal cord injury, neuropathy, CVA Poor nutrition – inadequate intake of nutrients, dehydration, food insecurity, enteral/parenteral nutrition Medical devices – CPAP, splints/casts, tracheostomy devices, nasal cannulas Moisture/Incontinence – excess moisture on skin/skin folds Cognitive impairment – difficulty expressing pain/discomfort Comorbidity/Illness – edema, peripheral vascular disease, renal/liver disease, cancer, diabetes, autoimmune disease (increases risk of skin fragility) Advanced age – skin fragility and bony prominences Medications – NSAIDS, anti-neoplastics, systemic corticosteroids, anticoagulants, vasopressors can predispose to skin breakdown Palliative status Lifestyle – smoking, substance use

Answer 243

Pressure - pressure to tissue exceeds arteriolar pressure, delivery of oxygen and nutrients is compromised, resulting in tissue hypoxia Friction/Shear - deeper tissues (muscles and subcutaneous fat) are pulled one direction while the dermis and epidermis remain fixed due to contact with an external surface Moisture - Skin that is exposed to moisture (perspiration, feces, urine) has decreased mechanical strength and decreased stratum corneum stiffness

Answer 244

As little as two hours

Answer 245

Depending on the severity of injury, healing may take weeks to months. Wounds may also be classified as chronic, non-healable

Answer 246

Skin intact, non-blanchable erythema, remains after relief of pressure

Answer 247

Blister or other break in dermis with partial thickness skin loss, with or without infection, sc fat is not visible

Answer 248

Full-thickness skin loss, with or without infection, sc fat may be visible, undermining and tunneling may be present

Answer 249

Full-thickness skin and tissue loss. Exposed or directly palpable fascia, muscle, tendon, ligament, cartilage or bone. With or without infection. Often includes undermining and tunneling

Answer 250

Full thickness skin and tissue loss. Base of the ulcer is covered by slough or eschar

Answer 251

Localized persistent, non-blanchable, discolored, but intact skin or blood-filled blister. Potential for deep tissue damage.

Answer 252

Soft-tissue infection, sepsis, osteomyelitis

Answer 253

Initiate/maintain pressure injury prevention strategies based on Braden score Manage risk factors/comorbidities - Diabetes, PAD, venous insufficiency, neuropathy, incontinence - Encourage smoking cessation Nutrition Pain relief Consider patient concerns and goals of care Treat infection

Answer 254

- Monitor twice daily - Do not cover with a dressing

Answer 255

- Protective dry gauze for intact blister - Consider debridement of devitalized blister tissue - Non-adherent contact layer for open area or hydrophilic paste dressing (eg. Triad) - Protect from contamination (urine/feces)

Answer 256

- Debride soft/boggy slough or eschar using the most appropriate method (autolytic, mechanical, sharp, etc.) - Fill/pack dead spaces, tunneling, undermining - Protect from contamination

Answer 257

- Debride soft/boggy slough or eschar using the most appropriate method (autolytic, mechanical, sharp, etc.) - Contact layer for exposed fascia, muscle, tendon, bone, ligament, cartilage - Fill/pack dead spaces, tunneling, undermining - Protect from contamination

Answer 258

-Dry, stable eschar: keep it dry; paint with 10% povidone iodine daily or Q2days; protect from moisture; leave OTA or dry dressing - Soft, boggy eschar or slough: debride with appropriate method; fill/pack dead spaces, tunneling, undermining; protect with cover dressing; restage once wound bed exposed