Dermatology unit of Clinical Medicine for PA students
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| 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.
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| 6 Characteristics to describe any lesion | 1) color 2) surface characteristics 3) sharpness/margins 4) Distribution 5) pattern/shape 6) arrangment
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| Macule | flat, circumscribed area of color change. Varies in size.
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| Patch | a macule (flat circumscribed area of color change) greater than 1cm
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| Papule | small, solid, raised lesion with distinct borders up to 5mm (some say 10mm). variety of shapes (domed, flat-topped, umbilicated)
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| Nodule | larger, raised, solid lesion greater than 5mm (10mm)
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| Plaque | solid, raised, flat-topped lesion greater than 1cm in diameter covering large areas. Can result from coalesced papules.
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| Pustule | circumscribed elevation of skin containing purulent material (exudate). OFTEN infected (not w/pustular psoriasis)
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| Vesicle | Blister; circumscribed, elevated, containing clear fluid usually less than 5mm in size
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| Bulla | larger vesicle (blister) greater than 5 mm
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| Ointment | thicker, more moisturizing, more occluding; best for chronic dry/thickened skin; greater penetration/higher potency
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| Creams | more cosmetically accepted than ointments, versatile use
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| Solutions and Lotions | useful for larger/hairy areas, contain powder in water +/- alcohol
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| Gels | semisolid oil in water emulsion with alcohol base, dries easily, drying effect may be desired, irritating to open/dry/sensitive skin
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| Low potency topical steroids | For: infants/small children/thin skin/intertriginous/occluded areas/face
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| Medium potency topical steroids | adult, hairy skin
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| High potency topical steroids | thick skins such as palms and soles (psoriasis)
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| Ultra-high potency | last resort to prevent systemic therapy: VERY short periods of time
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| Melanocytic Nevi | small benign mole w/ well defined border, symmetric, uniform color
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| Blue Nevi | small, benign, elevated, blue-black mole
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| senile lentigines | spot that has a small chance of turning into melanoma...occurs in the elderly
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| Dysplastic nevi syndrome | multiple nevi on body (usually trunk): higher risk for melanoma
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| 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)
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| Seborrheic keratoses | common benign skin tumor; looks "stuck on"/warty/velvty; starts as macule ->plaque
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| Highest rate of skin cancer deaths | Melanoma
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| Atopic Dermatitis | Eczema; chronic, pruritic, inflammatory condition causing redness, swelling acutely and thickening, lichenification, hyperpigmentation chronically. Common in children.
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| xerosis | dry skin; usually red, scaly with cracks
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| Keratosis pilaris | tiny keratin bumps considered a normal skin variant
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| Nummular eczema | large red papules and vesicles that merge into a red prutitic coin lesion 2-10cm
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| Lichen Simplex Chronicus | Neurodermatitis: chronic dermatitis; thickening of skin due to repetitive scratching/rubbing; Tx Sx
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| Disease that are scaly with red, well marginated regions without epithelial disruption | Papulosquamous
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| 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)
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| Guttate psoriasis | acute onset of small lesions associated w/ strep infx or meds
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| Pityriasis Rosea | Herald patch: scaly, pink plaque followed by trunkal rash in Christmas tree pattern (follows lines of skin cleavage); self resolving
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| 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.
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| 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
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| 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.
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| Tinea corporis | Ringworm; annular, scaly lesions w/ raised border and central clearing. Tx: topical antifungals (clotrimazole)
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| Tinea cruris | Jock itch; well marginated, erythematous plaques in skin folds often pruritic. Tx: topical antifungals
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| 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)
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| 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
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| 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
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| Tinea unguium | onychomycosis; fungal infx of nails, thickened nails w/debris and discoloration; oral antifungals for months...LFT testing w/ chronic therapy, nail removal.
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| 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.
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| 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)
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| 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.
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| 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.
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| Herpes labialis | lips
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| Herpes gingivostomatitis | – inside and outside mouth
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| Herpetic whitlow | finger (dentists!!)
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| Herpes genitalis | genitals
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| Herpes gladiatorum | skin
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| Herpes keratoconjunctivitis | eye
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| Herpes encephalitis | brain
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| HSV Type 1 | 80% oral
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| HSV Type 2 | 80% genital
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| Varicella | generalized vesicular rash due to herpes zoster; Tx: supportive: IB profen/acetaminophen (NO ASPIRIN: Reye's), oatmeal baths, cool compresses; Prevention: Varivax
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| 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"
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| 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
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| Where is atopic dermatitis (eczema) typical on adults? Children? | Adults: Flexor surfaces; Children: Extensor surfaces
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| 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
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| Impetigo | Usually S.aureus starting as single red papulovesicle -> honey-colored lesions that weep. Tx: Bactroban ointment & oral ABX if widespread
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| 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.
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| Acne vulgaris types and etiologies | Non-inflammatory/obstructive- Comedonal: blackheads and white heads. Inflammatory: pustules, nodules, erythematous papules.
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| 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)
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| Acne rosacea | facial flushing, erythema, inflammatory papulopustular eruptions like acne (Triggers: heat, cold, EtOh, hot beverages). Tx: avoid triggers, ABX
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| Rhinophyma | bulbous lesions on the nose as a complication from acne rosacea.
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| 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
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| Bacterial folliculitis | hair follicle-based pustules. Tx: ABX- staph coverage
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| Miliaria | Heat rash; burning, itching vesicles/papules/pustules. Tx: light clothing, menthol/camphor lotion, topical corticosteroids
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| Candidiasis | superficial fungal infection causing erythema may have satellite vesicopustules; Tx: nystatin or clotrimazole. Seen in immunosuppressed and infants
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| Urticaria | wheals/hives, challenging etiology (food, drugs, temps, autoimmune, infx, etc) Tx: H1 blockers (possible H2 as well), systemic corticos
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| 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
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| Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis (TEN) | hypersensitivty rxn causing macules, erosions, desquamation due to drugs usually. Tx: discontinue offending drugs, intensive/wound care
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| 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
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| 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
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| 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.
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| 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
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| 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.
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| Common warts | hyperkeratotic, may have black dots
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| Plantar warts | often have calloused tissue, black capillary dots
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| Anogenital warts | flat or cauliflower appearance (condyloma acuminata) are usually sexually transmitted
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| 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.
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| 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
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| 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.
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| Acrochordons | skin tags; soft, common, benign, pedunculated skin growths. Tx: Excise, if anything.
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| 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.
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| 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
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| 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.
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| 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.
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| 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.
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| Tarantula bite | Found in desert areas/pets. Generally benign bites. Stinging/mild inflammation. No necrosis/systemic effects.
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| Black Widow bite | minimal pain w/ initial bite-> neurologic/systemic effects. Tx: ABC monitoring and support. Anti-venom ONLY for severe Sx. Tetanus prophylaxis.
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| 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.
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| Lipoma | slow growing, benign tumor of fat tissue, rubbery, mobile, non-tender common in trunk, shoulders, neck, axillae. Tx: observe unless cosmetically unacceptable.
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| 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)
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| Furuncle | deep hair follicle infx; red tender often pustular and fluctuant nodule (boil) abscess. Staph aureus. Tx: warm compresses, I & D, ABX.
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| Carbuncle | nodule formed by group of furuncles.
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| 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.
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| 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
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| 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
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| Venous stasis ulcers | irregular, shallow, over bony prominences; RISK: older, obesity, leg injury. Tx: aggressive wound care, compression wraps, ABX
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| Stage 1 Decubitus ulcer | nonblanchable erythema
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| Stage 2 Decubitus ulcer | blisters, ulceration, soft tissue loss of epidermis (Epithelial destruction)
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| Stage 3 Decubitus ulcer | extends to subcutaneous fat
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| Stage 4 Decubitus ulcer | extends deeper to muscle or bone
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| Decubitus ulcers | impaired blood supply due to pressure ->ischemia/tissue necrosis. Tx: prevention (reposition/inspection/massage), reducing pressure, keep clean, debridement, ABX
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| Purpura/Petechiae | bleeding into skin causes small, pinpoint petechiae or larger purpura. Non-blanching.
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| Cause of Postinflammatory hyper/hypo pigmentation | any damage to the skin usually acne.
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| 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
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| Acanthosis nigracans | hyperpigmented, velvety texture on neck, axillae, groin, folds associated with obesity, endocrine disease especially diabetes
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| 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.
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| Tacrolimus (hint: it's a med) | calcineurin inhibitor (immune modulator) used for vitiligo, atopic dermatitis, venous stasis dermatitis
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| 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.
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| Alopecia areata | localized hair loss with distinct and well defined patches. Autoimmune. Self-limiting, but derm referral can give intralesional steroids or topical minoxidil
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| 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)
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| Subungual hematoma | blood beneath nail caused by trauma exceptionally painful. Tx: drainage through nail w/in 24 hours UNLESS fracture suspected.
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| 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.
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| Morbilliform | most common drug eruption rash. generalized, small, erythematous macules that can resemble measles.
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| 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
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| 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
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| 1st degree burn | superficial (epidermis):Erythema, tender, blanches with pressure. Tx: cool compresses, Acetaminophen, Ibuprofen, topical corticosteroid
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| 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.
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| 3rd degree burn | full thickness: tough, leathery, nonpainful, Tx: often painless, referral to specialist/burn center.
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| 6 C's of burn care | Clothing, Cooling, Cleaning, Chemoprophylaxis, Covering, Comforting (i.e., pain relief)
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| Measles/rubeola | fever, cough, coryza, conjunctivitis, maculopapular rash begins on the head and progresses down, lasts 4-6 days, Koplik spots “look ill”
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| Rubella | rash similar to measles but has shorter duration and not as ill; lymphadenopathy (especially posterior auricular and suboccipital)- shorter duration
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| 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
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| 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.
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| 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)
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| 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.
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