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Flashcards in Derm 2 Deck (28):
1

Acute Skin Wounds: Referral 

  • Foreign matter post irrigation
  • Chronic wounds
  • Animal/human bites
  • Infected
  • Face, mm’s (mucous membrane), genitalia
  • Deep (closure needed)
  • Tetanus status(?)

Don't suture in wild, close in bacteria

 

2

What would you treat these wounds with and why?


1.H2O2, 3% - efferescent cleansing action, strong bactericidal effect
2.Neosporin ointment (Triple antibotic) – prevent wound infections
3.Iodine treated lake/creek water-irrigation removal of debris, antisepsis
4.Betadine solution-safe i.e., not absorbed systemically. 
 

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  • H202: weakly bactericidal, releases oxygen to have weak bactericidal effect, bubble and get gunk out
  • Neosporin: prevent infection, won’t treat infection, barrier (can use Vaseline), don’t like because resistance issues, out in the woods might be good
  • Irrigating to get the big chunk out. 1 tab per liter for clean water. 2 tab per liter of dirty water. Iodine very effective at cleaning water. Iodine not cause probably
  • Betadine: bactericidal, well tolerated, probably won’t be carrying when hiking 

3

Ferral Cat Wound

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  • Pasteurella multocida
  • The hot water most important part, but not Epsom salt
  • Refer for antibiotics
    • Cats have dirty mouths
    • P. multocida sensitive to augmentin
    • Little cut can streak up arm because of tendon sheath, infection all up arm, infection on hands really risky
  • Cut on leg not as risky, no “highway” tendon sheath

4

Acute Skin Wounds: Treatment

  • Cleanse with irrigation (saline)
    • saline better than water because less irritating
  • Antiseptics
    • hydrogen peroxide
      • enzymatic release of oxygen, effervscent cleansing action, short acting (O2 release), not in abcess, limited cidal effect, risk of tissue toxicity – little benefit over soapy water
    • ETOH
      • Good cidal activity in 20-70% range; tissue irritation; flammable; 
    • isopropyl alcohol
      • 70% stronger cidal; cytotoxic effects; drying; flammable
    • iodine
      • broad spectrum; oxidizes microbial protoplasm; Water base preferable to alcohol base – less irritating; stains, irritates tissue, allergic sensitization  (used with chlorhexidine allergy)
    • povidone-iodine
      • Better than iodine
      • AKA: Betadine
      • nonirritating; absorbed sysemically; 
  • Antibiotics
    • neomycin, Gm+/-
    • bacitracin, Gm-
    • polymyxin B, Gm-
    • tetracycline, DON'T USE
    • Use one Gm+ and -, don't need to double up,  so triple antibiotic ointment is bad, can cause sensitization

5

Insect Bites

  • Mosquito:  West Nile, malaria
    • Malaria: fever, malaise, swollen spleen, from typical area
    • West Nile: same sort of symptoms, horses
  • Fleas: annoying, bubonic plague, endemic typhus, itching problem
  • Scabies: “the itch”
    • Takes physical contact
    • Common reaction sites: interdigital spaces, flexor wrists, external male genitalia, buttocks, anterior axillary folds
    • Don’t jump across pharmacy counter
  • Spiders: black widow, brown recluse, hobo
  • Chiggers: (red bugs) brushy areas
  • DEET: Sunscreen first, then DEET
  • Bees, YJ’s, wasps: Local to allergy/anaphylaxis; infections 3-5 days, cold, prednisone, NSAID, H1RB, top steroids
    • Anaphylactic shock: red, swollen, lightheaded, dizziness have already developed antibodies
      • Benadryl too slow, only block reaction, but reaction still going. Need epinephrine.
    • Remove stinger immediately (if wait, already empty) get off with credit card
    • They have dirty mouths too, infection
      • Slower, 3-5 days, redness, swelling
  • How deal with local inflammatory reaction
    • 1 dose prednisone
    • Topical steroid
    • NSAID
    • H1RB
    • Cold compress 
       

6

Inset Bites: Treatment

  • LAs: Pramoxine less cross sensitivity;  temporary blockade of transmission of nerve impulses
  • Phenol conc >2% irritating, avoid in Pg, children  depresses sensory receptors
  • Topical antihistamines: use systemic
  • Camphor, menthol: Depresses cutaneous receptors; camphor – dangerous if ingested.
  • Hydrocortisone:
  • Spider Bites: big red blob, necrosis in the middle, normally don’t see spider that bit you
  • Local anesthetics: only last short time, sensitizer
  • Counterirritants:
    • Sarna lotion, camphor, menthol 
  • Systemic antihistamine, need to be sedating
    • cetirazine might be okay
       

7

Ticks

  • RM spotted fever
    • HA, fever, fatigue, palmar rash
  • Remove intact
    • tweezers at base
    • Not w/ mineral oil, vaseline – induces salivation
  • Lyme’s 
    • skin rash, flu
    • Untreated: neurological, HA, stiff neck, cardiac, rhem BAD
    • If treat quickly, okay
      • treatment effective, chronic if not treated
    • Target rash 2-3 weeks after bite
      • See picture

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8

Pediculosis

  • AKA: Lice (head, body, pubic)
  • Kids share hats, have sleepovers, put heads together, lay together
  • Nurses tend to go overkill and see it as the “black-mark”
    • Don’t keep kids out of school
  • Leads to overtreatment, leads to expense, resistance, toxicity
  • Only treat Sam, not the other kids
  • Seizure not caused by pyrethrins
    • Seizure caused by Quell, Lindane, neurotoxic to humans, keep away from children, tendency to overtreat
    • BE CAREFULL with refills
  • Side note: Febrile fits, fever, treat kid for fever because more serious
    • Mayo and dippity-doo to get the nits (“empty treehouses”) off hair shaft. Don’t comb obsessively
  • #4: Permethrin is a cream rinse, not a shampoo
    • Shampoo doesn’t stay on hair, let sit on hair for 10 minutes with cap.
    • Pass on instructions to patients ​

9

Pediculosis: Treatment

  • Physical (comb)
  • Pediculicides
    • Pyrethrins
      • Shampoo
    • Permethrin
      • Nix
      • cream rinse
    • Lindane
    • Malathion
    • Spinosad
    • Benzoyl alcohol
    • Ivermectin
      • Last chance drug
  • Tea tree oil
  • mayo, Dippity-Do, Vaseline
     

10

Fungal Skin Infections:


•Tinea pedis
•Tinea corporis
•Tinea cruris
•Tinea capitus
 

  • Common
  • Yeast fungal infections, under breast, vagina, mouth
  • Dermatophite causes majority of infection
  • Named by where it occurs ​
    • Pedis: Athletes foot
    • Corporis: Ringworm
    • Cruris: Jock's Itch
    • Capitus: Head

11

What is this?

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  • Tinea corporis
    • Vesicular on borders and clearing in middle
  • Hydrocortisone making fungi worse
    • Tinea incognito, when doesn’t look like “typical” ringworm
    • Steroids putting a mask on it 
       

12

Fungal Skin Infections: Treatments

  • Antifungals
    • Treat it long enough
    • Apply sparingly
    • Generous area
    • Put it on until done, and then a couple days longer
  • Clotrimazole
  • Turbinafine
  • Butenafine
  • Miconazole
    • Not as good against microsporin
    • Microsporin found in kids and hair
    • If kids and hair, think about using something different
  • Tolnaftate
    • Dermatophites ONLY
  • Undecylenic acid
    • Dermatophites ONLY
    • Very weak
    • Only good use as prophylactic in boots

13

Tinea unguium
onychomycosis

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  • Get after dose of athlete’s foot first
  • Get between toes 4 and 5 first
  • Big toes always get infected at nail base
  • 6-12 months to treat
  • Cannot treat nails topically
    • Lousy cure rates topically
  • Potential liver toxicity with systemic
  • Try to not get it in first place
  • Diabetes with fissures with athletes foot, entrance for bacteria
    • Not feel toes
    • Diabetic, careful to treat feet
    • Only if can’t feel feet, normal feet treat like everybody else
    • Soak in hot water, burn foot example 
       

14

Tinea Capitis

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  • Patch of hairloss
  • Patch, circumferential, spreading out, broken hair shafts
  • Cannot treat OTC
    • Cannot self treat because on head
  • Use turbenafine oral, flucanzol oral, grinesefol oral 
     

15

Don't treat hair and nails with topical products!

Only treat systemically

16

What is this?

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  • ID reaction
  • Looks like eczema of hands
  • New cosmetics, handling soaps, ask those questions
  • Rashes anywhere else, no
  • Athletes foot between 4-5
    • Treat it and hand rash go away
    • Id reaction means reacting to herself 
       

17

Acne: Grades

  • Grade I: comedones only
  • Grade II: papular acne
  • Grade III: pustular acne
  • Grade IV: Nodules/cysts, scarring

 

  • Grade 3 and 4 causes scarring
  • Grade 1: keep comedones open
  • Grade 2: Kill bacteria
  • Grade 3: Definitely need to kill bacteria 

18

Acne: Etiology

  • Rapid cell turnover
  • Increased sebum
  • P. acnes
  • Inflammation
  • Like rush hour, all plugged up
  • Closed comedone: expose to sunlight, blackhead
  • Papule: when explode under skin and causes irritation (zit)

19

Acne: Treatments

  • Cleansing
    • washes away the oils
    • Don’t use moisturizing soap, use sensitive soap, need to be squeaky clean with no oil
  • Benzoyl peroxide
    • (soln, cr)
    • Antibacterial drug, 30-40% efficacy is this reason
    • Mostly a ketorylytic, unplug comedone
      • Prevent papules from forming
    • Water base, cream, not as drying
    • Alcohol, more drying
    • Bigger dose more redness and peeling
      • Sensitive skin, use lower dose
      • Dripping in oil, alcohol base and higher dose
      • Good dose shows that after putting on skin a little dry and red, stiff face, DON'T COUNTERTREAT WITH LOTION
    • Takes 21 days 
  • Antibiotics
  • Retinoids
  • Diet is not a factor

20

Diagnose

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•Really bad, probably 3 or 4, needs to go to doctor
•Antibiotics 
 

21

(Acne) Rosacea

Adult Acne

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  • Disorder of blood vessels
    • Vascular, not sebaceous
  • No endocrine relationships
  • Differs from acne
    • Sensitive to touch
    • reddening of the face
    • enlarged blood vessels (telangiectasias)
    • solid papules
    • central face
    • no comedones
  • Worsened by alcohol, spicy foods, steroids
  • Treatment:
    • Oral antibiotics
    • Topical metronidazole, clindamycin (gels), mosturizing gels

 

22

Diagnose and Treat

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  • Planter Warts
  • Corn and calluses tell you that shoes don’t fit
    • Corn and calluses don’t lie
    • Retain footprint
    • Corn on top of foot and calluses on the bottom
  • He has way too many warts for salicylic acid
    • Apply patch directly to wart, eats away at wart until crater left
    • Can’t put on whole heel because will form a red ulcerated square on foot
  • Volatile, painted on salicylic acid
    • 4 drops on wart each night
    • Take a long time and the guy is already limping
  • Can freeze at home, but can only treat a little wart, this guy would need like 40 bottles
  • Referal needed because of extense/quantity

23

Warts


•Verruca vulgaris (common)
•Verruca planaus (flat, juvenile)
•Condyloma lata, acuminata (venereal)
•Verruca plantaris (plantar)**
Tender, disrupts the footprint pattern

24

Warts: Exclusions


•Face, toenails, fingernails, anus, genitalia
•Extensive – one site
•Painful plantar warts
•Chronic, debilitating disease (DM, PVD)
•Physical, mentally impaired
 

25

Warts: Rx

  • Salicylic acid
    • Liquid, plaster
  • Cryotherapy
    • Liquid nitrogen
    • Dimethyl ether (DMEP/propane)
  • Duct tape

26

What is this?

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  • Androgenetic Alopecia
    • male pattern baldness
    • finesteride
      • inhibits the 5-alpha-reductase type 2, inhibits conversion of testosterone to DHT
    • minoxidal
      •  5% vs 2%;  Foam – no propylene glycol irritant
    • have to do continious
    • take months to work 

27

What is this?

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  • Alopecia areata
  • treated with injectable steroids 
  • smooth, discrete
  • explanation point hairs at margins
  • nail involvement
  • thyroid, rheum, autoimmune
  • Rx: intralesional steroids

28

What is this?

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  • Telogen effluvium
  • diffuse, nonscarring, noninflammatory hair loss post trauma
  • Regrows, reassure patient
  • diffuse hair loss (all over), no spots, no broken hairs, usually emotional or medical problems