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Dermatology-Clin Med

Dermatology unit of Clinical Medicine for PA students

READ FIRST Notecards about diseases will usually have 1) what they are 2) how to Dx 3) Tx including any prevention 4) anything else that distinguishes it/makes it special. When going through, try to answer each of these.
6 Characteristics to describe any lesion 1) color 2) surface characteristics 3) sharpness/margins 4) Distribution 5) pattern/shape 6) arrangment
Macule flat, circumscribed area of color change. Varies in size.
Patch a macule (flat circumscribed area of color change) greater than 1cm
Papule small, solid, raised lesion with distinct borders up to 5mm (some say 10mm). variety of shapes (domed, flat-topped, umbilicated)
Nodule larger, raised, solid lesion greater than 5mm (10mm)
Plaque solid, raised, flat-topped lesion greater than 1cm in diameter covering large areas. Can result from coalesced papules.
Pustule circumscribed elevation of skin containing purulent material (exudate). OFTEN infected (not w/pustular psoriasis)
Vesicle Blister; circumscribed, elevated, containing clear fluid usually less than 5mm in size
Bulla larger vesicle (blister) greater than 5 mm
Ointment thicker, more moisturizing, more occluding; best for chronic dry/thickened skin; greater penetration/higher potency
Creams more cosmetically accepted than ointments, versatile use
Solutions and Lotions useful for larger/hairy areas, contain powder in water +/- alcohol
Gels semisolid oil in water emulsion with alcohol base, dries easily, drying effect may be desired, irritating to open/dry/sensitive skin
Low potency topical steroids For: infants/small children/thin skin/intertriginous/occluded areas/face
Medium potency topical steroids adult, hairy skin
High potency topical steroids thick skins such as palms and soles (psoriasis)
Ultra-high potency last resort to prevent systemic therapy: VERY short periods of time
Melanocytic Nevi small benign mole w/ well defined border, symmetric, uniform color
Blue Nevi small, benign, elevated, blue-black mole
senile lentigines spot that has a small chance of turning into melanoma...occurs in the elderly
Dysplastic nevi syndrome multiple nevi on body (usually trunk): higher risk for melanoma
ABCDEs of skin lesions A: asymmetry B: border irregularity C: color (multiple / changing) D: diameter (greater than 6 mm) E: evolution –rapid change (eg enlargement- size or elevation)
Seborrheic keratoses common benign skin tumor; looks "stuck on"/warty/velvty; starts as macule ->plaque
Highest rate of skin cancer deaths Melanoma
Atopic Dermatitis Eczema; chronic, pruritic, inflammatory condition causing redness, swelling acutely and thickening, lichenification, hyperpigmentation chronically. Common in children.
xerosis dry skin; usually red, scaly with cracks
Keratosis pilaris tiny keratin bumps considered a normal skin variant
Nummular eczema large red papules and vesicles that merge into a red prutitic coin lesion 2-10cm
Lichen Simplex Chronicus Neurodermatitis: chronic dermatitis; thickening of skin due to repetitive scratching/rubbing; Tx Sx
Disease that are scaly with red, well marginated regions without epithelial disruption Papulosquamous
Psoriasis; Auspitz, Koebner's phenomenon well demarcated, red, thickened plaques with silvery-white scales. Nails pit/onycholysis. Auspitz: scraping causes underlying pinpoints of bleeding. Koebner's: injured areas greater effected. Tx: alternate 1)high potency cortico, 2)Vit D (calcipotriene)
Guttate psoriasis acute onset of small lesions associated w/ strep infx or meds
Pityriasis Rosea Herald patch: scaly, pink plaque followed by trunkal rash in Christmas tree pattern (follows lines of skin cleavage); self resolving
Lichen planus Planar (flat topped), purple, polygonal, pruritic, papules, plaques. Lesions coveredy by Wickham striae: lacy, reticular, white lines. Affecting flexor surfaces of wrists, forearms, legs. Bx for Dx, considered Hep C Ab testing.
Seborrrheic dermatitis Dandruff; chronic superficial inflammatory condtion affecting head/body where sebaceous glands are. Appear greasy, yellow, red w/scale. Infants: cradle cap. Ass. w/ yeast Malassezia. Tx: dandruff shampoos
Tinea capitus common childhood fungal infx; "black dot" alopecia (sheared off hair follicles). Tx: anti-fungal for a month. Can cause Kerion-inflammatory reaction (fungal cyst on head). Oral prednisone Tx.
Tinea corporis Ringworm; annular, scaly lesions w/ raised border and central clearing. Tx: topical antifungals (clotrimazole)
Tinea cruris Jock itch; well marginated, erythematous plaques in skin folds often pruritic. Tx: topical antifungals
Erythrasma superfical chronic bacterial infection in the intertriginous (skin folds) areas, usually corynebacterium minutissimum. Tx: Erythro or topical antifungal. (yes antifungals and ABX both work)
Intertrigo inflammation of skin folds induced by heat, moisture, maceration, friction. Worsened by infx. Tx infx, keep cool and dry. Satellite papules/pustules typical of candidal infection
Tinea pedis athlete's foot; erythema, scales, prutitis, possible vesicular or pustular lesions, between toes; worsened by poor foot hygiene. Tx: OTC or Rx antifungals, good foot hygiene, Domboro soaks 20 min bid
Tinea unguium onychomycosis; fungal infx of nails, thickened nails w/debris and discoloration; oral antifungals for months...LFT testing w/ chronic therapy, nail removal.
Tinea versicolor hypo or hyper pigmented macules and patches with fine scales, esp on back and chest. Overgrowth of Malassezia yeast. Noticeable in summer when lesions do not tan. "spaghetti & meatballs" under KOH prep. Oral antifungals or dandruff shampoo.
Actinic keratosis 1/1000 transition to squamous cell cancer. scaly, erythematous, often irregular, slightly raised, rough texture around sun-exposed areas. Tx: cryotherapy, Fluorouracil, Imiquimod (Aldara)
Bowen's Disease squamous cell carcinoma in situ; chronic, asymptomatic, non-healing, slowly enlarging, erythematous patch w/ sharp but irregular outline. Consider as possibility when dermatitis doesn't respond to topical steroid therapy.
Herpes Simplex single patch of grouped vesicles on an erythematous base; painful: itching or burning. Recurrent problem lying dormant for years. Tzanck test. Tx: antivirals, pt education.
Herpes labialis lips
Herpes gingivostomatitis – inside and outside mouth
Herpetic whitlow finger (dentists!!)
Herpes genitalis genitals
Herpes gladiatorum skin
Herpes keratoconjunctivitis eye
Herpes encephalitis brain
HSV Type 1 80% oral
HSV Type 2 80% genital
Varicella generalized vesicular rash due to herpes zoster; Tx: supportive: IB profen/acetaminophen (NO ASPIRIN: Reye's), oatmeal baths, cool compresses; Prevention: Varivax
Chickenpox common pruritic childhood illness, generalized vesicular rash that will crust over. Usually newly active and older healing lesions present at the same time***. Vesicle stage description: dew drop on rose petal"
Herpes Zoster Shingles; Painful, unilateral patches of grouped vesicles following dermatomal distribution of a reactivation of varicella zoster virus. Tx: antivirals w/in 72 hours, pain meds; prevent: Zostavax
Where is atopic dermatitis (eczema) typical on adults? Children? Adults: Flexor surfaces; Children: Extensor surfaces
Pompholyx Dyshidrotic eczema; vesicular "tapioca" lesions on hands, feet, fingers associated w/ stress, tinea, exposure; cause unknown but 50% comorbid w/ atopic dermatitis. Tx Sx: topical steroids, oral antihistamines
Impetigo Usually S.aureus starting as single red papulovesicle -> honey-colored lesions that weep. Tx: Bactroban ointment & oral ABX if widespread
Contact dermatitis suggested by patterns such a linear (plant) or circular (jewelry) as a immune-mediated allergy. Tx: removed offending agent and topic or systemic steroids if necessary.
Acne vulgaris types and etiologies Non-inflammatory/obstructive- Comedonal: blackheads and white heads. Inflammatory: pustules, nodules, erythematous papules.
Acne Tx keratolytic agents (retinoids (take 1-3 months to work)>benzoyl peroxide>salicylic acid): opens up comedones w/o physically popping w/ fingers. Topical ABX, oral ABX, Isotretinoin (accutane: teratogen drying everything out; contra: preg)
Acne rosacea facial flushing, erythema, inflammatory papulopustular eruptions like acne (Triggers: heat, cold, EtOh, hot beverages). Tx: avoid triggers, ABX
Rhinophyma bulbous lesions on the nose as a complication from acne rosacea.
Perioral dermatitis chronic papulopustular and eczematous lesions that burn. Tx: avoidance of precipitates: steroids, skin products, fluoride, sun, wind, heat. Topical/oral ABX; around mouth
Bacterial folliculitis hair follicle-based pustules. Tx: ABX- staph coverage
Miliaria Heat rash; burning, itching vesicles/papules/pustules. Tx: light clothing, menthol/camphor lotion, topical corticosteroids
Candidiasis superficial fungal infection causing erythema may have satellite vesicopustules; Tx: nystatin or clotrimazole. Seen in immunosuppressed and infants
Urticaria wheals/hives, challenging etiology (food, drugs, temps, autoimmune, infx, etc) Tx: H1 blockers (possible H2 as well), systemic corticos
Erythema multiforme herpes virus major trigger; self-limiting hypersensitivity rxn w/symmetric distribution of erythematous macules and small target lesions favoring palms, soles, extensor surfaces and face. Tx: light clothing, menthol/camphor lotion, corticosteroids
Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (TEN) hypersensitivty rxn causing macules, erosions, desquamation due to drugs usually. Tx: discontinue offending drugs, intensive/wound care
Lyme Disease bacterial infx due to tick bite w/ stage 1 presenting: erythema migrans- erythematous, large, expanding targetoid skin rash, fevers, chills, myalgias. Tx: oral ABX w/in 30 days prevents later stage disease
Erysipelas Subcu infx->cutaneous lymphatics; red, raised w/sharply demarcated borders->red, tense, painful, vesicular lesion on face/lower extremities; Tx: oral ABX (PCN). Asso. w/ strep pharyngitis
Cellulitis acute, spreading infx of dermix/sub-cu tissue, localized pain, swelling, erythema, warmth; comes from break in skin. Staph or strep. Tx: Abx w/ gram pos coverage, elevation, cool compress.
Pemphigus vulgaris chronic autoimmune, bullous disease w/potentially life-threatening infx due to sepsis. Bullae fragile and flacid (Nikolsky sign). Often starts at mouth. Tx: systemic steroids every day, methotrexate, azathiopine
Pemphigoid chronic autoimmune blistering disease in older patients with widespread tense bullae more pruritic than mucosal. Dx: Bx. Tx: topical/oral corticos, tetra, immunosuppressants. Less mortality than Pemphigus.
Common warts hyperkeratotic, may have black dots
Plantar warts often have calloused tissue, black capillary dots
Anogenital warts flat or cauliflower appearance (condyloma acuminata) are usually sexually transmitted
Verruca Warts; proliferations of skin caused by HPV; Tx: 75% regress w/o Tx. Can use salicylic acid, cryotherapy among others, duct tape occulusion, cimetidine, imiquimod for genital.
Molluscum Contagiosum lesions are firm, round, 3-5mm with CENTRAL UMBILICATION (indenting). Caused by pox virus, common in children, STD in adults. Tx: self-resolving or destructive therapies, tretinoin/imiquimod
Corns/Calluses of Feet/toes hyperkeratotic areas of skin due to pressure/friction. Tx: correction of foot deformities, shoes that fit, salicylic acid, lachydrin etc.
Acrochordons skin tags; soft, common, benign, pedunculated skin growths. Tx: Excise, if anything.
Basal cell carcinoma (BCC) most common malignancy, causes local destruction, 70% on face; pearly white/translucent papule w/telangiectasias with central depression and central depression Dx: Bx. Tx: excision, Mohs surgery, etc.
Mohs micrographic surgery appropriate or large or high-risk lesions or in locations where tissue conservation is important; thin layer by thin layer is removed and examined under the microscope until no more cancerous cells are found
Squamous cell carcinoma (SCC) 2nd most common skin Ca. Hx of sun exposure; raised, firm papules, scaly plaques; risk of metastates. Tx: Bx, excision, radiation if metastatic.
Scabies intensely pruritic and contagious papules found in "webbed" areas of body, wrists, penis, buttocks, breast, often w/ a delayed lesion rxn. Tx: Permethrin 5% cream neck down (leave on overnight) then again in a week.
Pediculosis Lice; mite infestation spread human to human or through clothing/linens etc. Head, body, pubic possible. Tx: Permethrin 1% first line. Use twice. Good hygiene.
Tarantula bite Found in desert areas/pets. Generally benign bites. Stinging/mild inflammation. No necrosis/systemic effects.
Black Widow bite minimal pain w/ initial bite-> neurologic/systemic effects. Tx: ABC monitoring and support. Anti-venom ONLY for severe Sx. Tetanus prophylaxis.
Brown Recluse bite mild stinging->redness & intense pain. Vesicle forms, sloughs off leaving ulcer. Venom cytoxic and hemolytic. Tx: wound management (cleansing, debridement, elevation, compresses, tetanus immunization. No anti-venom or way to stop progression.
Lipoma slow growing, benign tumor of fat tissue, rubbery, mobile, non-tender common in trunk, shoulders, neck, axillae. Tx: observe unless cosmetically unacceptable.
Erythema nodosum multiple bilateral inflammatory nodules w/ color change in brusing areas (commonly anterior shins). Drug-induced hypersensitivity or idiopathic. Tx: self-limiting; stop causative medication, Sx care (NSAIDs)
Furuncle deep hair follicle infx; red tender often pustular and fluctuant nodule (boil) abscess. Staph aureus. Tx: warm compresses, I & D, ABX.
Carbuncle nodule formed by group of furuncles.
Hidradenitis suppurativa comedone-like follicular occlusion, chronic relapsing inflammation/abscesses, mucopurulent discharge, progressive scarring involving apocrine glands. Tx: good hygiene, isotretinoin (accutane), I&D, wide surgical excision.
Epidermoid cyst common cutaneous cysts: proliferation of epidermal cells w/in circumscribed space of dermis. Contain soft, white, cheesy keratin material (not infx). Tx: ABX if infx, I&D
Stasis dermatitis chronic erythema, scaling, hyperpig of lower extremities ("brawny change"- brownish-red discoloration) caused by venous insufficiency. Tx: improve venous return, good skin care, topical steroids for redness, calcineurin inhibitor
Venous stasis ulcers irregular, shallow, over bony prominences; RISK: older, obesity, leg injury. Tx: aggressive wound care, compression wraps, ABX
Stage 1 Decubitus ulcer nonblanchable erythema
Stage 2 Decubitus ulcer blisters, ulceration, soft tissue loss of epidermis (Epithelial destruction)
Stage 3 Decubitus ulcer extends to subcutaneous fat
Stage 4 Decubitus ulcer extends deeper to muscle or bone
Decubitus ulcers impaired blood supply due to pressure ->ischemia/tissue necrosis. Tx: prevention (reposition/inspection/massage), reducing pressure, keep clean, debridement, ABX
Purpura/Petechiae bleeding into skin causes small, pinpoint petechiae or larger purpura. Non-blanching.
Cause of Postinflammatory hyper/hypo pigmentation any damage to the skin usually acne.
Melasma "mask of pregnancy"; acquired hyperpigmentation of sun-exposed areas. Commonly on face, in women and can occur with oral contraceptives/pregnancy. Tx: sunscreen, hydroquinone (has a bleaching quality), retinoids
Acanthosis nigracans hyperpigmented, velvety texture on neck, axillae, groin, folds associated with obesity, endocrine disease especially diabetes
Vitligo acquired disorder of depigmentation around 20-30 yo; associated w/autoimmune disorders (hypothyroidism, DM, alopecia areata). Noticable in darker skinned pts. Tx: steroids, UV light, Tacrolimus, depigmentation of normal skin, sun protection.
Tacrolimus (hint: it's a med) calcineurin inhibitor (immune modulator) used for vitiligo, atopic dermatitis, venous stasis dermatitis
Telogen effluvium physiologic alteration in follicular cycling causing early entry into telogen phase causing temporary diffuse hair loss. Occurs with stress, post-pregnancy. Resolves w/in 6 months.
Alopecia areata localized hair loss with distinct and well defined patches. Autoimmune. Self-limiting, but derm referral can give intralesional steroids or topical minoxidil
Androgenetic alopecia symmetric frontoparietal scalp recession due to genetic predisposition, hormones, age influences. Often androgen excess in women. Tx: Male only- oral finasteride (effects testosterone), topical minoxidil (Rogaine), Spirolactone (for androgen excess)
Subungual hematoma blood beneath nail caused by trauma exceptionally painful. Tx: drainage through nail w/in 24 hours UNLESS fracture suspected.
Paronychia soft tissue infection of nail border commonly caused by Staph (long term:Candida). Edema, erythema, pain, pus. Tx: warm soaks, oral ABX (Augmentin), I&D.
Morbilliform most common drug eruption rash. generalized, small, erythematous macules that can resemble measles.
Fixed drug eruption one or more annular or oval erythematous lesions that frequently resolve with hyperpigmentation and may recur at the same site with reexposure to the drug
Burns Tissue injury due to heat, chemicals, electricity or irradiation. Depth related to intensity and duration of exposure. Treatment based on depth and surface area involved
1st degree burn superficial (epidermis):Erythema, tender, blanches with pressure. Tx: cool compresses, Acetaminophen, Ibuprofen, topical corticosteroid
2nd degree burn superficial or deep partial thickness: Tender, red, blistered. Tx: wash and irrigate gently, sterile dressing, Silvadene (silver sulfadazine), tetanus prophylaxis, pain relief.
3rd degree burn full thickness: tough, leathery, nonpainful, Tx: often painless, referral to specialist/burn center.
6 C's of burn care Clothing, Cooling, Cleaning, Chemoprophylaxis, Covering, Comforting (i.e., pain relief)
Measles/rubeola fever, cough, coryza, conjunctivitis, maculopapular rash begins on the head and progresses down, lasts 4-6 days, Koplik spots “look ill”
Rubella rash similar to measles but has shorter duration and not as ill; lymphadenopathy (especially posterior auricular and suboccipital)- shorter duration
Roseola several days of high fever, rash appears as fever resolves, caused by herpes 6, generalized, more subtle pink rash for a couple of days
Erythema Infectiosum (Fifth disease) due to parvovirus, mild viral prodrome with fever, then slapped cheek rash, followed by generalized lacy, reticular erythematous rash over body- no longer infectious once rash occurs.
Rocky Mountain Spotted Fever acute, tick-borne disease caused y Rickettsia rickettsii. Sx: fever, headache, petechial rash (wrist, ankles, palms, soles), myalgias. Tx: Doxy (delay in Dx leads to increased mortality)
Syphilis "The Great Masquerader"; primary lesion: solitary papule ->nonpainful ulcer. secondary lesion: symmetric mucocutaneous lesions. Often on palms/soles. Dx: antibody testing: VDRL, RPR, Skin Bx. Tx: parenteral PCN.
Created by: crward88