Ch 3 MDT Flashcards by Chris Weber

Inflammation of a hair follicle that can occur anywhere on the body where hair is found

Folliculitis

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Most common infectious etiology of bacterial Folliculitis

Staph aureus

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Most common etiologies of non-infectious Folliculitis

Pseudo-folliculitis barbae (PFB)

Mechanical Folliculitis (Skinny Jean Syndrome)

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Folliculitis Risk Factors

Hair removal (shaving, plucking, waxing, epilating agents)

Other pruritic skin conditions: eczema, scabies

Occlusive dressing or clothing

Personal carrier or contact with MRSA-infected persons

Diabetes

Immunosuppression

Use of hot tubs or saunas

Chronic antibiotic use

Tattoos

Poor Hygiene

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Abrupt onset of follicular erythematous papules or pustules, with pruritus and pain in hairy areas

Rash occurs on hair-bearing skin, especially the face (beard, proximal limbs, scalp, and pubis

Folliculitis

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Pseudomonal folliculitis appears as a widespread rash, located mainly at:

Trunk and limbs

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Clinical hallmark of folliculitis

Hair emanating from the center of the pustule

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General treatment and prevention of Folliculitis

Antiseptic and supportive care is usually enough

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MRSA drugs

Bactrim

Clindamycin

Doxycycline

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Complications of Folliculitis

Recurrent Folliculitis (PRIMARY)

Progression to furunculosis or abscesses

Cellulitis

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Condition caused by ingrowing hairs, mostly in the beard area

Affects people with curly hair or those with hair follicles oriented at an oblique angle to the skin surface

Pseudofolliculitis Barbae

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PFB

What is often a problem in affected skin, especially in African-American people?

Keloid formation

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What may result from PFB?

Scarring and hyperpigmentation

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PFB affects ____% of black people

and ___% of white people

50-75%

3-5%

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Treatment for mild to moderate PFB

Medical treatment with grooming modifications

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Treatment for moderate to severe PFB

Laser hair reduction with grooming modifications

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PFB Laser Treatment

A series of at least ____ treatments is usually needed, with ____ days in between

Three

30-45 days

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A contagious, superficial, intra-epidermal infection occurring prominently on exposed areas of the face and extremities

Impetigo

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A deeper, ulcerated impetigo infection often with lymphadenitis

Ecthyma

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Most common form of impetigo.

Formation of vesiculopustular that rupture, leading to crusting with a characteristic golden appearance

Local lymphadenopathy may occur

Nonbullous impetigo

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Staphylococcal impetigo that progresses from small to large flaccid bullae

Ruptured bullae leaves brown crust

Less lymphadenopathy

Trunk more affected

Bullous impetigo

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Impetigo risk factors

Warm, humid environment

Tropical or subtropical climate

Summer or fall season

Minor trauma, insect bites, breaches in skin

Poor hygiene, poverty, crowding, epidemics, wartime

Familial spread

Complication of pediculosis, scabies, chickenpox, eczema /atopic dermatitis

Contact Dermatitis

Burns

Contact sports

Children in daycare

Carriage of group A streptococcus and Staph aureus

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Cutaneous pyoderma characterized by thickly crusted erosions or ulcerations.

Usually a consequence of neglected impetigo and classically evolves in impetigo occluded by footwear and clothing

Ecthyma

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What is the key to avoid infection of impetigo?

Avoidance of spreading

HAND WASHING

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Treatment for impetigo

Mupirocin ointment Remove crusts clean with gentle washing 2-3 times daily; clean with antibacterial soap, chlorhexidine, or betadine

Severe impetigo treatment may require:

Nafcillin or Cefazolin IV antibiotics

Complications of Impetigo

Ecthyma Cellulitis Resistance to treatment Lymphangitis Furunculosis

An acute bacterial infection of the dermis and subcutaneous tissue Typically caused by bacterial penetration through a break in the skin

Cellulitis

Most common etiologies of cellulitis

Hemolytic streptococci Staph aureus Gram-negative aerobic bacilli

Cellulitis is present with what four classic signs of inflammation?

Erythema Edema Tenderness Elevated skin temperature

Most common portal of entry for lower leg cellulitis

Toe web intertrigo with fissuring Secondary to interdigital tinea pedis

History - Previous trauma, surgery, animal/human bites, dermatitis, and fungal infection are portals of entry for bacterial pathogens - Pain, itching, and/or burning - Fever, chills, and malaise

Cellulitis

Physical Exam - Localized pain and tenderness with erythema, induration, swelling, and warmth - Regional lymphadenopathy - Purulent drainage from abscesses

Cellulitis

Labs considered for cellulitis when:

Signs of systemic disease (Fever, HR >100, SBP <90 mm Hg)

What needs to be ruled out in a patient with cellulitis?

DVT

Cellulitis treatment

Mark borders with a permanent marker Immobilize and elevate limb Pain relief Compression for edema Antibiotics

Antibiotics of choice for Human and Animal bites

Amoxicillin & clavulanic acid (Augmentin)

Complications of Cellulitis

Local abscess or bacteremia, sepsis Superinfection with gram-negative organisms Lymphangitis Gangrene

Medical Emergency Rare and rapidly progressing infection involving any layer of soft tissue including skin, subcutaneous fat, fascia, and/or muscle Extensive tissue destruction, systemic toxicity, limb loss and are potentially fatal

Necrotizing Fasciitis

Risk factors for necrotizing fasciitis

Major penetrating trauma Minor laceration or blunt trauma Skin breach Recent surgery Mucosal breach Immunosuppression Malignancy Obesity Alcoholism

Most frequently occurs in the extremities and may mimic DVT Pain, erythema, edema, cellulitis and high fever Pain is out of proportion to the severity of the physical findings

Necrotizing Fasciitis

Labs for Necrotizing Fasciitis

MRI: Edema along the fascial plane X-ray, CT or US are useful in demonstrating the air bubble in soft tissues Cultures: Group A strep and mixed aerobic and anaerobic bacteria

Treatment for Necrotizing Fasciitis

Prompt and wide surgical debridement is the cornerstone Broad-spectrum antibiotics MEDEVAC

Complications of Necrotizing Fasciitis

Toxic shock syndrome Amputation Septic Shock Death

A well-circumscribed, painful, inflammatory nodule at any site that contains a hair follicle. May extend into the dermis and subcutaneous tissues

Furuncle

A collection of pus within the dermis and deeper skin tissues. Manifests as painful, tender, fluctuant, and erythematous nodules Typically do not present with systemic symptoms

Abscess

A coalescence of several inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles Typically presents with systemic symptoms and fever

Carbuncle

Risk factors of abscesses (furuncle, abscess, carbuncle)

Carriage of pathogenic staphylococcus sp. in nares, skin, axilla, and perineum Diabetes mellitus, malnutrition, alcoholism, obesity, atopic dermatitis

Deep subcutaneous erythematous papules enlarge to deep-seated nodules that can be stable or become fluctuant within several days Multiple Hair Follicles. Most commonly occurs on the back of the neck, upper back and lateral thighs Tender, perifollicular swelling, terminating in discharge of pus and necrotic plug Malaise, chills, and fever may precede or occur during the height of inflammation

Carbuncle

Mainstay treatment for an abscess, furuncle, or carbuncle

Incision and Drainage

Carbuncles should be handled by dermatology or general surgery in all situations unless patient is:

Unable to be transferred

Most common benign cutaneous cysts

Sebaceous Cyst (epidermal)

The cyst wall consists of normal stratified squamous epithelium derived from:

Follicular infundibulum

Firm or fluctuant flesh-to-yellow colored solitary nodule (0.5-5 cm) which often connects with the surface by keratin-filled pores Grow slowly over time and may remain stable for months to years Commonly located on face, neck, upper back, chest; if due to trauma, on buttocks, palms, or plantar side of feet

Stable epidermal cyst

Warm, red and boggy and tender on palpation Sterile, purulent material and keratin debris often point towards and drain to the surface These lesions mimic and present very similarly to abscesses

Inflamed/Ruptured Epidermal Cyst

Biopsy of a cyst shows:

Encapsulated keratinocytes and cellular debris

Indications for removal of cysts

Inflamed/ruptured or infected epidermal cyst Produces functional deficit Cosmetic Pain secondary to location and duties

Cysts What must be removed to prevent further infection?

Capsule

The most common benign mesenchymal neoplasm in adults and are composed of mature white adipocytes

Lipoma

Lipomas can occur on any part of the body and usually develop superficially in the ______ tissue

Subcutaneous

Soft, painless subcutaneous nodule ranging in size from 1->10 cm Occur most frequently on the trunk and upper extremities and can be round, oval, or multilobulated Frequently patients have more than one

Lipoma

Transition of a preexisting lipoma to an atypical lipomatous tumor represents an exceeding rare phenomenon at ___%

<0.1%

Lipomas may be excised by dermatology for what reasons?

Cosmetic Pain Impedance of duties

Intramuscular lipoma recurrence rate is up to ___%

20%

Acute inflammatory process, with or without abscess formation, that involves the proximal and lateral nail folds and that has been present for less than 6 weeks

Paronychia

Paronychia is commonly caused by:

Manicuring, nail biting, thumb sucking, and picking at a hangnail

Acute paronychia of the toes is associated with:

Ingrown toenails

Most common infection of the hand, representing 35% of all hand infections in the U.S.

Paronychia

Paronychia treatment

Warm compresses or soaks Drainage using a scalpel blade inserted between the nail and nail fold Antibiotics if warranted

What is unnecessary in the treatment of paronychia?

Skin incision

Complications of paronychia

Further extension of infection with deeper involvement Nail distortion in chronic infections

Abscess of the distal phalanx fat pad Staph aureus is the most common pathogen Painful and swollen distal pulp space

Felon

The digital pulp, the fleshy mass at the fingertips, is divided into multiple compartments by _____ _____ that provide structural support

Fibrous septae

Pyogenic infection of the distal digital pulp space, with pus collecting in the spaces formed by the vertical septa anchoring the pad to the distal phalanx Nearly always follows minor finger injury (splinter or needle prick)

Felon

Felon treatment

Incision and drainage by a Dermatologist Antibiotics

Labs/Studies/Imaging for a Felon

Imaging to evaluate for retained foreign body and to rule out involvement of the distal phalanx

Complications of a Felon

Osteitis & osteomyelitis Ulcerative and tissue necrosis Flexor tenosynovitis Septic Arthritis

Grows best in warm, moist environments so infection is often confined to mucous membranes and intertriginous areas Opportunistic pathogen when allowed to overgrow and predisposing conditions permit

Candida (fungal)

What layers of the epithelium does yeast infect?

Outer Layers only

Fungal infection Risk Factors

Hormonal alterations -Pregnancy, oral contraceptives, diabetes Elimination of competing microorganisms -Antibiotics Physical environment changes -Skin maceration, increased humidity/temperature Direct/Indirect Immunosuppression -Corticosteroid therapy, immunosuppression

Candidiasis occurs most commonly in what type of areas?

Intertriginous areas (axillae, groin, digital web spaces, glans penis, beneath breasts, vulvovaginal)

Red, glistening surface with a long, cigarette paper-like, scaling and advancing border

Candidiasis

Treatment for Candidiasis

Skin kept dry and exposed to air as much as possible Antifungals

What is not recommended in the treatment for Candidiasis?

Topical Steroids

Diagnosis for Candidiasis is based on:

Clinical Appearance Location of Infection Presence of predisposing factors

Candidiasis Positive culture alone is usually meaningless because Candida is:

Omnipresent

Superficial fungal infections of the skin/scalp; various forms of dermatophytosis

Tinea

Infection of the crural fold and gluteal cleft

Tinea Cruris

Infection involving the face, trunk, and /or extremities often presents with ring-shaped lesions, hence the misnomer ringworm

Tinea corporis

Infection of the scalp and hair; affected areas of the scalp can show characteristic black dots resulting from broken hairs

Tinea capitis

Can subsist on protein, namely keratin and can cause disease in keratin-rich structures such as skin, nails, and hair

Dermatophytes

Infections acquired from animals

Zoophilic

Infections acquired from personal contact

Anthropophilic

Scaling, round or oval pruritic plaques characterized by a sharply defined annular pattern with peripheral activity and central clearing Papules and occasionally pustules/vesicles present at border and, less commonly in center

Tinea Corporis

Treatment for Tinea Corporis

Antifungal creams for at least 2 weeks Continue treatment 1 week after resolution of infection

Tinea corporis treatment that requires oral therapy

Extensive lesions or those with red papules

Tinea corporis What medication may be considered for highly inflamed lesions to minimize scarring?

Short course of prednisone

Labs/studies/imaging for Tinea Corporis

KOH Prep Woods lamp

Complications of Tinea Corporis

Extension of diease down to the hair follicles

Well-marginated, erythematous, halfmoon-shaped plaques in crural folds that spread to medial thighs; advancing border is well defined, often with fine scaling and sometimes vesicular eruptions Lesions are usually bilateral and do not include scrotum/penis (unlike candida infections)

Tinea Cruris

First line treatment for Tinea Cruris

Topical antifungal cream Absorbent powders

Treatment for refractory, inflammatory or widespread tinea cruris infections

Oral antifungals Resume topical antifungals/powders once resolved

Complications of Tinea Cruris

Secondary Bacteria infections

Superficial infection in the interdigital web and soles of the feet caused by dermatophytes Most common Dermatophyte infection

Tinea Pedis

Itching, burning, and stinging of interdigital webs and plantar surfaces Pain may indicate secondary infection Most present with asymptomatic scaling Woods lamp exam with not fluoresce

Tinea Pedis

Treatment for Tinea Pedis

Open-toed shoes Shower shoes Dry between toes after showering & frequent sock changing Cotten socks (absorbent, non-synthetic) Antifungal powders Wide shoes

Caused by Pityrosporum orbiculare Organism is nourished by sebum Very common in excess heat and humidity -Prevalence can reach 50% in tropical areas Not a dermatophyte infection

Tinea versicolor

Velvety tan, pink or white macules that do not tan Fine scales that are not visible but are seen by scraping the lesion Central upper back, chest, and proximal areas (highest concentration of sebum) Asymptomatic; Appearance is often the patient's main concern

Tinea Versicolor

Labs/Studies for Tinea Versicolor

Woods lamp will show hypo-pigmented areas of infections | -Faint yellow-green fluorescence

Complications of Tinea Versicolor

Relapses without any complications

Treatment for Tinea Versicolor

Selenium sulfide from neck to waist Ketoconazole shampoo to chest and back

Oral treatment for Tinea Versicolor is reserved for patients with:

Extensive disease who do not response to topical treatment

Acquired through direct contact of the nail with dermatophytes, yeast, or non-dermatophyte molds in the environment or through spread of fungal infection from affected skin

Onychomycosis

Predisposing factors for onychomycosis

Tinea pedis, psoriasis, hyperhidrosis, obesity, advancing age, contact with infected household members Trauma, poor nail grooming, sports and fitness activities, occlusive shoes

Most common onychomycosis presentation

Distal subungual onychomycosis | -Begins with white/yellow/brown discoloration of distal corner of the nail that gradually spreads moving proximally

Treatment for Onychomycosis

Confirm with KOH & fungal culture for potential liver toxicity LFT Oral antifungal (Gold Standard)

Required labs for onychomycosis

KOH and Fungal Culture to begin treatment

Disposition for onychomycosis

Consult to dermatology and/or podiatry

A contagious parasitic infection of the skin caused by the mite Sarcoptes scabiei

Scabies

Scabies is transmitted by:

Prolonged human to human direct skin contact

Scabies rash appears __ weeks after exposure

2-6 weeks

Cardinal feature of Scabies

Intense pruritus that worsens at night

Secondary lesions of Scabies

Impetigo Eczema

Labs/Studies/Imaging for Scabies

Ink test

Treatment for Scabies

Permethrin 5% or Lindane 1% applied to entire skin surface from the neck down to include fingernails/toenails and in the umbilicus After 12 hours, patient will bathe Treatment regimen should be repeated in 1 week

Scabies What may be used to control pruritus and inflammation after treatment with a scabicide?

Topical steroids

Obligate human parasites Direct contact is source of transmission Transmission via hats, brushes, or ear phones is common

Pediculus humanus capitis

Lice feed or suck blood every ___ hours (blood meal)

3-6 hours

Lice live for about _____

1 month

Female lice can lay __ eggs per day

7-10

Lice eggs (nits) are firm casts cemented to the hair shaft; hatch every __ days

8-10

Pediculosis pubis

Pubic louse

Pediculosis Corporis

Body louse

Pediculosis capitis

Head louse

Head lice are __ mm in length

3-4 mm

Pediculosis Capitis Easier to see than lice and are fluorescent

Nits

Sky-blue macules on the inner thighs or lower abdomen

Pubic louse infestation

Treatment for Lice

Permethrin / Lindane Remove nits Clothes and sheets washed and dried on high temperature

What can 'unglue' nits?

50% vinegar and 50% water Applied and removed in 15 minutes

Home remedies that can kill lice

Vaseline over scalp overnight (repeat for 3-4 weeks) Hair Clean 1-2-3 hairspray

Common, acute, self-limited papulosquamous skin rash that is most commonly seen in individuals 10-35 years old Viral etiology "Pink Scales" Sometimes preceded by a prodrome

Pityriasis Rosea

Pityriasis Rosea Prodromal symptoms are reported in ___% of patients -Malaise, mild fever, headache, sore throat, cough, or mild URI or GI symptoms

69%

Classic Pityriasis Rosea begins with a _____ ______ on the trunk or proximal limbs that precedes secondary eruption by 7-14 days

Herald Patch

2-5 cm round or oval, sharply delimited, pink or salmon-colored lesion on the chest, neck or back

Herald Patch (PR)

Lesions are distributed with long axes along cleavage - Christmas tree pattern on back - V-shaped pattern on upper chest Resolve in 45 days

Pityriasis Rosea

Medications for Pityriasis Rosea

Treat symptomatically | =Steroids/Antihistamines

Labs/Studies/Imaging for Pityriasis Rosea

KOH if atypical presentation Serologic Syphilis testing

Complications of PR

Long term skin pigmentary changes Abortion during pregnancy

Herpes Primary outbreaks manifest as:

Herpetic gingivostomatitis

Herpes Recurrent episodes usually affect the:

Vermillion border of lips of mucosa of the hard palate

HSV-1 can be transmitted via:

Mucous membranes/secretions Kissing/Sharing utensils or towels

HSV-1 __% infected by age 6

33%

__% of adults reported to have experienced oral herpes

60-90%

Herpes recurrences may be precipitated by:

Stress, sun, illness, fatigue, dental work, local trauma, menstruation, pregnancy, and immunodeficiency

Herpes Recurrent episodes occur in older children and adults, frequently with a prodrome of:

Perioral tingling, itching, numbness, pain, or burning Followed by papulovesicular lesions (cold sore) on the lip or vermilion border

Herpes Antiviral medications may reduce duration by about how many days?

1 day

Complications of Herpes Simplex

Pyoderma Eczema Herpeticum Herpetic Whitlow Ocular Keratitis

Diffuse pox-like eruption complicating atopic dermatitis; sudden appearance of lesions in typical atopic areas (upper trunk, neck, head); high fever, localized edema, adenopathy

Eczema herpeticum

Localized infection of affected finger with intense itching and pain, followed by vesicles that may coalesce with swelling and erythema Mimics pyogenic paronychia; neuralgia and axillary adenopathy are possible; heals in 2-3 weeks

Herpetic whitlow

Clinical syndrome associated with reactivation of latent varicella zoster virus Typically occurs years after primary Varicella Zoster Virus infection

Herpes Zoster (Shingles)

>__% of adults in United States are seropositive for varicella

95%

Herpes Zoster is most common at what age?

> 60 years old

What amount of people will contract herpes zoster in their lifetime?

One-third

Characteristic prodrome of Herpes Zoster that may precede rash by 1-5 days

Acute neuritis Paresthesias with allodynia or hyperesthesia described by patient as deep burning, throbbing, or stabbing sensation

Unilateral dermatomal rash without midline crossing that favors the thoracic, cranial, lumbar, and cervical dermatomes

Herpes Zoster

Begins with red macules and papules that progress to clear vesicles within 1-2 days with new vesicles forming over 3-5 days Vesicles evolve into pustules within 7 days; ulcerating and crusting of pustules by day 14

Herpes Zoster

Herpes Zoster Lesions usually heal within ___ weeks

2-4 weeks

Medications for Herpes Zoster

Antivirals <72 hours after onset or if new lesions are appearing Pain control

Occurrence of pain for months or years in the same dermatomal distribution as was affected by herpes zoster

Postherpetic Neuralgia

Acute herpetic neuralgia refers to pain preceding or accompanying the eruption of rash that persists up to __ days from its onset

30 days

Subacute herpetic neuralgia refers to pain that persists beyond healing of the rash but which resolves with ___ months of onset

4 months

Refers to pain persisting beyond four months from the initial onset of rash

Postherpetic Neuralgia

Reduces the incidence of Postherpetic Neuralgia by 50% when given within 72 hours of rash onset

Antivirals

Involves the Opthalmic division of the trigeminal nerve Presents with malaise, fever, headache, and periorbital burning/itching

Herpes Zoster Opthalmicus

___% of patients with HZO experience direct ocular involvement if antiviral therapy is not used

50%

Vesicles on the tip/side of nose precedes the development of HZO

Hutchinson's Sign

Disposition of patients with Herpes Zoster on the face

Medical officer for further evaluation

Warts is caused by what virus?

Human papillomavirus (HPV)

HPV ___ types ___ can infect humans

200 types 150 can infect humans

HPV Infection occurs by:

Direct skin contact

HPV Incubation period is approximately ___ months

2-6 months

Verruca vulgaris

Common warts

Verruca plantaris

Plantar warts

Verruca plana

Flat (plane) warts

Warts that are typically few in number Hands, periungual skin, elbows, knees and plantar surface Block dots are thrombosed capillaries May occur singly, in groups, or as coalescing warts forming plaques

Verrucae Vulgaris

Warts, slightly elevated and flat-topped Vary in size 0.1-0.3 cm May be few or numerous and often occur grouped or in a line as a result of spread from scratching Forehead, back of hands, chin, neck and legs Typically asymptomatic, however, cosmetically distressing

Flat (plane) warts

Caused by HPV infection on the plantar foot Occurs at points of maximal pressure, such as over the heads of the metatarsal bones Cluster many warts is called a "mosaic wart"

Plantar Warts

How to differentiate between plantar warts and corn/callus

Black dots are seen in warts Corns have a hard painful translucent central core

Treatment for warts

Salicylic acid Cryotherapy Duct tape

Complications of warts

Scarring and recurrence Some types of HPV have higher risks for Carcinoma

Non-immunologic reaction to substance or action producing direct damage to skin by chemical abrasion or physical irritation Causes: Chemical agents, alcohol, creams, powders, moisture, friction, and temperature extremes

Irritant Contact Dermatitis

Due to a delayed immunologic response to a cutaneous or systemic exposure to an allergen to which the patient has been previously sensitized

Allergic Contact Dermatitis

Most common cause of allergic contact dermatitis

Poison ivy Poison sumac Poison oak

Allergic contact Dermatitis Latency period of ____ hours

12-48 hours

Most common cause of metal dermatitis

Nickel

Hands are most often affected Erythema, dryness, painful cracking or fissuring and scaling are typically, Vesicles may be present Tenderness and burning are common and predominate the itching Open skin may burn on contact with topical products

Irritant Dermatitis

Irritant Dermatitis prevention

Avoidance of exposure PPE

Irritant Dermatitis Treatment

Steroid ointments Frequent application of a bland emollient is essential

Vesicles, edema, redness, and extreme pruritus Strong allergens such as poison ivy produce bullae Distribution first confined to the area of direct exposure May spread beyond areas of direct contact Itch and swelling are key components of the history

Allergic Contact Dermatitis

Most common sites of Allergic Contact Dermatitis

Hands, forearms and face

Allergic Contact Dermatitis treatment

Avoid allergic substance Topical steroids

Patch testing for allergic contact dermatitis should be delayed until the dermatitis has subsided for at least __ weeks

2 weeks

Seborrheic Dermatitis

Dandruff

Chronic, superficial, recurrent inflammatory rash affecting sebum-rich, hair regions of the body, especially the scalp, eyebrows, and face Prevalence: 3-5%

Seborrheic Dermatitis

Treatment for Seborrheic Dermatitis

Control rather than cure | -Shampoos: Zinc pyrithione, Selenium sulfide, Ketoconazole, Salicylic Acid, Coal tar

Chronic, inflammatory disorder most commonly characterized by cutaneous erythematous plaques with silvery scale Complex immune-mediated disorder associated with flares related to systemic, psychological, infectious, and environmental factors

Psoriasis

Most common variant of Psoriasis at 80% of cases

Plaque (vulgaris) Psoriasis

Psoriasis __% have psoriasis in a first-degree relative

40%

Well-demarcated salmon pink to red erythematous papules and plaques; silvery scale Scalp, auricular, postauricular area; extensor surfaces (knees elbows); umbilicus, lower back, intergluteal cleft, and nails

Plaque Psoriasis

Nail findings of plaque psoriasis

Pitting, oil spots, onycholysis

Pinpoint bleeding with removal of scale

Auspitz sign (plaque psoriasis)

New psoriatic lesions arising at sites of skin injury/trauma

Koebner phenomenon

Plaque psoriasis Genitals affected in up to ___% of patients

40%

Treatment for psoriasis

Topical corticosteroids/retinoids Systemic therapy if >20% of the body or very uncomfortable Phototherapy

Disposition for Psoriasis

Routine referral to dermatology for further evaluation and definitive treatment

Complications of Psoriasis

Psoriatic arthritis Exfoliative dermatitis

Disorder of the pilosebaceous units Notable for open/closed comedones, papules, pustules, nodules Early to late puberty, may persist in 20-40% of affected individuals into 4th decade

Acne vulgaris

Ance vulgaris ___% of adolescents affected

80-95%

Open comedones

Blackheads

Closed comedones

Whiteheads

Treatment for comedonal (non-inflammatory) acne

Topical retinoid

Treatment for mild comedonal + papulopustular acne

Topical antimicrobial Topical retinoid Antibiotics for those who cannot tolerate retinoids

Treatment for moderate papulopustular and mixed acne

Topical retinoid Oral antibiotics Topical benzoyl peroxide

Treatment for severe acne (nodulocystic acne)

Oral isotretinoin monotherapy

Acne medication Antibacterial properties and also comedolytic Visible improvement typically occurs within three weeks, with maximum results evident after 8-12 weeks

Benzoyl peroxide

Acne Medication Reduce the number of comedonal acnes in the sebaceous follicles and suppress inflammation. May cause skin irritation Use with benzoyl peroxide to decrease the occurrence of bacterial resistance

Topical Antibiotics (erythromycin & clindamycin)

Most common topical antibiotics used for the treatment of acne

Erythromycin and clindamycin

Most frequently used oral antibiotics for acne therapy

Doxycycline and minocycline

Treatment for severe recalcitrant nodular acne who is unresponsive to conventional therapy, including systemic antibiotics 20 week course Teratogenic Only prescribed by clinicians who participate in iPLEDGE

Isotretinoin

What can be beneficial in the treatment of acne for women older than 15?

Contraceptives

Complications of Acne

Cyst formation Pigmentary changes Severe scarring Psychological problems Gram-negative folliculitis

An abscess, or sinus tract, in the upper part of the natal (gluteal) cleft

Pilonidal abscess

Means "nest of hair"

Pilonidal

Physical exam reveals one or more primary pores (pits) in the midline of the natal cleft and/or a painless sinus opening No acute inflammation or infection

Asymptomatic pilonidal disease

Tender, swollen, and fluctuant nodule located along the superior gluteal fold

Acute pilonidal abscess

Treatment for an acute pilonidal abscess

Incision and drainage Antibiotics in the presence of cellulitis

Complications of pilonidal abscess

Systemic infection Recurrence

Active hair growth 80-85% of hairs are in this stage at a given time

Anagen (growth) Phase

Hair growth stops due to papilla detaching (removing blood supply) 1-3% of hairs are in this stage at a given time

Catagen (transitional) phase

Hair is resting phase for 1-4 months, up to 10-15% of hairs in a normal scalp. Hair is no longer connected to anything but the follicle

Telogen (resting) Phase

In late telogen phase, the follicle begins to grow again and hair base breaks free from the root and is shed 2 weeks, new hair shaft begins to emerge

Exogen (shedding) Phase

Anagen phase for shorter hairs (eyelashes, eyebrows, leg/arm hair)

1 month

Anagen duration for scalp hair

>6 years

= "hair loss"

Alopecia

Present follicular markings suggest a _______ alopecia

non-scarring

Absent follicular markings suggest a ______ alopecia

Scarring

Alopecia Occur secondary to something else in the body (systemic disease, endocrine disorders, vitamin deficiencies, malnutrition)

Non-scarring alopecia

Most common form of male hair loss affecting 30-50% of men by age 50 Occurs in highly reproducible pattern, affecting the temples, vertex and mid frontal scalp

Androgenetic alopecia

Androgenetic alopecia Familial tendency and racial variation and heredity account for __% of disposition

80%

Believed to be an immunologic process. Patches that are perfectly smooth and without scarring Involvement may extend to all of the scalp hair or to all scalp and body hair

Alopecia Areata

Alopecia of all the scalp hair

Alopecia totalis

Alopecia of all scalp and body hair

Alopecia universalis

Temporary hair loss that usually happens after stress, a shock, or a traumatic event. Usually occurs on the top of the scalp

Telogen effluvium

May occur following any type of trauma or inflammation that may scar hair follicles Chemical, physical trauma, bacterial or fungal infections, severe herpes zoster, chronic discoid lupus erythematosus, scleroderma, and excessive ionizing radiation

Cicatricial Alopecia

Treatment of alopecia

Most cases hair re-grows and no treatment is needed Consider treatment on how to deal with emotional stress Referral to dermatology for more intense treatment

Labs/Studies/Imaging for Alopecia

TSH CBC

Complications of Alopecia

Depression/Anxiety Mid-life crisis

Acute, delayed, and transient inflammatory response of the skin secondary to excessive exposure to ultraviolet radiation (UVR) Depending on frequency and exposure time, damage to melanocytes and keratinocytes

Sunburn

Susceptibility to sunburn =

Susceptibility to skin cancer; associated with an increased risk of melanoma at all ages

Risk factors of Sunburn

Near the equator More likely to occur at noon Altitude Reflection from snow (90%), Sand (15-30%), Water (5-20%) Fair skin, blue eyes, red & blond hair

Sunburn Erythema is first noted at ___ hours Peaks at ____ hours Subsides at ____ hours

3-5 hours 12-24 hours 72 hours

Sunburn Blisters heal without scarring in ____ days

7-10

Sunburn Scaling, desquamation, and tanning are noted ____ days after exposure

4-7

Occur quickly and appear as a sunburn

Drug-induced phototoxic reactions

Rare, IgE-mediated, photodermatosis characterized by pruritis, stinging, erythema, and wheal formation after exposure to sunlight

Solar urticarial

Complications of Sunburn

Melanoma Actinic Keratoses

The most important part of treatment for sunburn is:

Prevention - Protective clothing (SPF 50+) - Sunscreen (SPF 30+)

Measures the UV radiation required to produce sunburn on protected skin (with sunscreen) relative to UV radiation is required to produce sunburn on unprotected skin (no sunscreen)

SPF

SPF is related directly to:

Amount of Solar Exposure (not time)

Treatment for Sunburn

Cool compresses or soaks, calamine lotion, aloe vera NSAIDs

Contraindicated in the treatment of Sunburn

Topical Corticosteroids

Caused by lateral pressure of poorly fitting shoes, by improper or excessive trimming of the lateral nail plate or by trauma Pain, redness and swelling caused by the nail penetrating the surrounding nail tissue

Ingrown Nail

Virtually the only toe involved, with either the medial or lateral border of the nail may be affected

Great toe

Treatment of ingrown nail

Removing the penetrating nail with scissors and curetting the granulation tissue Small areas of granulation tissue can be simply treated with silver nitrate

Podiatrists treat chronic recurrent ingrown nails by destroying the lateral nail matrix with:

Phenol

Most common of all injuries to the upper extremities; typically results from a direct blow to the fingernail or a squeezing type injury to the distal finger Causes bleeding into the space between the nail bed and nail itself

Subungual hematoma

Separation of the nail from the nail bed

Onycholysis

Subungual hematoma What must be done prior to draining/trephination?

Rule out additional/more severe injuries

Subungual hematoma Drainage methods

Heated paperclip Cautery Pen Drill method Needle method

Most common acquired benign epithelial tumor of the skin Often mistaken for Melanoma Typically develop after age 50 Usually Asymptomatic

Seborrheic Keratoses

Usually multiple lesions, which can arise anywhere except the lips, palms, and soles Begin as circumscribed tan brown patches or thin plaques Over time, may become more papular or verrucous with a greasy scale and a stuck-on appearance

Seborrheic Keratoses

Treatment for Seborrheic Keratoses

Cryotherapy Curettage/shave excision Electrodessication

Result from the proliferation of atypical epidermal keratinocytes Represent early lesions on a continuum with squamous cell carcinoma Precancerous lesions Frequently occur in sun-exposed areas

Actinic Keratoses

Risk factors of Actinic Keratoses

Extensive sun exposure, history of sunburns, sunscreen usage Fair Skin, Male, >40 years old, geography

Commonly described as having a "rough, sandpaper-like" feeling

Actinic Keratoses

Patients with multiple Actinic Keratoses lesions require:

Annual Follow-up

Malignant tumor arising from melanocytic cells Most fatal form of skin cancer Increasing faster than any other potentially preventable cancer in the United States

Melanoma

Strongest association of Melanoma

Intermittent exposure and sunburn that occurred in adolescence or childhood

Nearly 50% of melanoma deaths in the U.S. occur in:

White males, age >50

Lesion will be the "ugly duckling", different than the other lesions - Asymmetrical - Irregular borders - Color Changes - Diameter >6 mm

Melanoma

Treatment for Melanoma

Dermatology: | -Biopsy, Complete excision of entire lesion into the subcutaneous fat

The goals of wound repair for lacerations and incisions are to:

Achieve Hemostasis Prevent Infection Preserve Function Restore Appearance Minimize patient discomfort

Wound Healing Day 0-5: no Gain in wound strength

Phase I: Initial Lag Phase

Wound Healing Days 5-14: Rapid increase in wound strength occurs.

Phase II: Fibroplasia Phase

Wound Healing Day 14 until healing is complete: Further connective tissue remodeling. Up to 80% of normal skin strength achieved.

Phase III: Final Maturation Phase

Indications for wound repair

Lacerations open for less than 12 hours Repair of sites where a lesion has been surgically removed

Contraindications for wound repair

Wounds open more than 12 hours Animal or human bites Puncture wounds

Four principles that should be incorporated in the process of closing any wound

1. Control all bleeding 2. Eliminate "dead space" 3. Accurately approximate tissue layers 4. Approximate the wound with minimal skin tension

Stitch should be wide as it is deep Equal distance from the wound margin and of equal depth No closer than 2 mm of other sutures Ideal for the scalp

Simple Interrupted Sutures

Quick and distributes tension evenly and provides excellent cosmetic results Less desirable in traumatic lacerations because of the increased risk of contamination

Simple running stitch

Promotes eversion of the skin edges. It is useful when the natural tendency of lose skin is to create inversion of the wound margins, which is to be avoided Appropriate when the skin is very thin and interrupted sutures have a tendency to pull through

Vertical Mattress Sutures

Suture technique is helpful in wounds under a moderate amount of tension; also promotes wound edge eversion Useful on palms of hands or soles of feet and in patients who are poor candidates for deep sutures because of susceptibility to wound infections

Horizontal Mattress Sutures

Provide a rapid and simple alternative to other methods of skin closure and wound repair Indicated for: - Wounds whose edges are easily approximated and not under undue tension - Long, Linear wounds of the scalp - Proximal extremities or the torso where cosmetic is not a concern

Skin Staples

Skin staples are contraindicated for:

Facial or neck tissue Areas where there is an inadequate subcutaneous base Over small mobile joints or wherever staples may interfere with normal function Wounds that are macerated/infected or over large tissue loss