Derm

Question 1

What are the common types of dermatitis (eczema)?

Answer 1

—Allergic contact dermatitis

—Irritant contact dermatitis

—Atopic dermatitis

—Dyshidrotic dermatitis

—Lichen simplex chronicus

Question 2

What is this? How does it present?

Answer 2

Allergic contact dermatitis

Presentations: pruritis (common to all dermatites), vesicular/bullous formation, and commonly lichenification

Question 3

What mediates allergic contact dermatitis? Timeline?

Answer 3

type IV hypersensitivity that presents in two phases

1) sensitization (induction)- 10-14 days or 12-48 hrs upon re-exposure
2) elicitation (challenge)

Question 4

Common causes of ACD?

Answer 4

• Rhus dermatitis (poison ivy, poison oak- all contain urushiol)
• fragrances
• Nickel

Question 5

How does a Rhus allergy present?

Answer 5

initial episode occurs 7-10 days after exposure and within hours upon re-exposure and lastly 10-21 days depending on the severity with the initial exposure being the most severe and presents as:

linear erythema that can blister

Question 6

How is Rheu dermatitis treated?

Answer 6

Minor supportive care with topical steroids and anti-histamines

Question 7

What causes latex allergy?

Answer 7

Latex allergy may present as a delayed (on the dorsum of the hand) or immediate hypersensitivity

Question 8

Key points about acute dermatitis

Answer 8

-1 of 2 types of contact dermatitis that occurs primarily due to a type IV hypersensivity (except latex- I or IV) that can be diagnosed using a Patch test and generally requires supportive care, topical steroids, and antihistamines

Question 9

What is Irritant contact Dermatitis?

Answer 9

A non-immuologic, inflammatory rxn resulting from exposure to a toxic substance like bleach that can occur due to single exposure but is most commonly due to repeated exposure and is strongly associated with major risk factors that impair the barrier function of the skin like atopic dermatitis

Question 10

What are the most sensitive areas of the body for an ICD?

Answer 10

face, neck, scrotum, and dorsal hands

Question 11

How is ICD treated?

Answer 11

removal of the irritant, topical steroid therapy to reduce inflammation, emollients to improve barrier function, and prolonged caution is advice because the skin remains vulnerable to flares of dermatitis for prolonged periods

Question 12

What is Atopic Dermatits?

Answer 12

a very common chronic, pruritic, inflammatory disease that is characterized by periods of remission and exacerbations and xerosis BUT that can present differently based on the age group affected

Question 13

How does atopic dermatitis typically present in infants? What areas of the body?

Answer 13

erythematous plaques common on the face (cheeks, forehead, scalp), and extensor surfaces

Question 14

How does atopic dermatitis typically present in older children? What areas of the body?

Answer 14

—lichenified, eczematous plaques in flexural areas of the neck, elbows, wrists, and ankles

Question 15

How and where does atopic dermatitis tend to present in adults?

Answer 15

—Lichenification in flexural regions and involvement of the hands, wrists, ankles, feet and face (particularly the forehead and around the eyes)

Question 16

What mediates AD?

Answer 16

—AD is considered to be multifoactorial (skin function, genetics, etc.) and part of the inflammatory (type I) hypersensitivity triad that includes allergic rhinitis and bronchial asthma (a Hx of these illnesses is often present)

Question 17

What is a major pre-disposing factor for developing AD?

Answer 17

—Inherited reduction or loss of the epidermal barrier protein filaggrin is a major predisposing factor for AD

—Favors Th2-mediated immunity

Question 18

How is AD treated?

Answer 18

• avoidance of trigger factors
• anti-inflammatory therapy to control subclinical inflammation as well as overt flares (prednisone)
• in selected cases, adjunctive or complementary modalities such as —Topical tacrolimus or pimecrolimus

Question 19

—90% of atopic dermatitis skin lesions are colonized with microbes, usually _______

Answer 19

Staphylococcus aureus (—Presence of erosions, drainage with yellow crusting may indicate an infection)

Question 20

What is Eczema Herpeticum?

Answer 20

—A severe herpes simplex virus infection in an atopic patient that presents with multiple wide spread monomorphic, “punched-out” discrete erosions with hemorrhagic crusting

—Severe cases may require hospitalization and IV anti-viral medications

Question 21

What is this? Describe them. When do you see them?

Answer 21

Nummular Dermatitis/Discoid eczema- presents as —Coin-shaped, well-demarcated plaques with scale and possibly tiny vesicles, cracking or crusting that are very pruritic, —show, spongiotic dermatitis, and are more common in winter

Question 22

Describe Dyshidrotic Eczema/Pompholyx?

Answer 22

a chronic, relapsing palmoplantar eczematous dermatosis characterized by firm, pruritic vesicles and bullae. While the vesicles are due to spongiosis within the epidermis, their intact nature is explained by the thick tear-proof horny layer in these sites. Dyshidrotic eczema is not an independent disease entity because it is often a manifestation of other types of eczema, especially atopic dermatitis and irritant or allergic contact dermatitis.

Question 23

T or F. Dyshidrotic eczema causes —disturbance of sweat gland function

Answer 23

F.

Question 24

What is this?

Answer 24

Lichen Simplex Chronicus- Chronic, intensely pruritic skin condition triggered by repeated rubbing and scratching of the skin that typically presents with a solitary, well-defined, pink to tan, thick, and lichenified plaque

—Commonly on the lateral neck, scrotum/vulva, and dorsal foot

Question 25

What are the papulosquamous skin diseases?

Answer 25

—-Psoriasis —-Seborrheic dermatitis —-Pityriasis rosea —-Lichen planus

Question 26

What is Psoriasis?

Answer 26

**A chronic immune-mediated disease** with predominantly **skin and joint manifestations** that can present at any age, but occurs most commonly in two peaks: **ages 20-30 and ages 50-60** and has a **strong genetic component**

Question 27

What are the five main variants of psoriasis?

Answer 27

—plaque-type, guttate, pustular, inverse erythrodermic psoriasis

Question 28

What is this? Describe it. Where is it common?

Answer 28

Plaque psoriasis, the most common variant (90%) of psoriasis that is most prevalent on the scalp, extensor surfaces of the extremities, and the periumbilical and sacral trunk; they rarely occur on the face, or on intertriginous areas of the body (inverse psoriasis).

Question 29

What is the the Koebner phenomenon

Answer 29

**Plaque** psoriasis arising at sites of **trauma**

Question 30

What is this?

Answer 30

Ausptiz Sign

Question 31

How does the second most common variant of psoriasis, Guttate psoriasis, present?

Answer 31

It occurs more commonly in **young adults**, and it presents with **multiple small "drop-shaped"** erythematous scaly plaques diffusely on the body, most **frequently on the trunk** and is often preceded by **streptococcal infections, especially pharyngitis**.

Question 32

What is this?

Answer 32

Inverse/Flexural psoriasis- Erythematous plaques in the **axilla, groin, inframammary region** and skin folds that **may lack scale due to moistness of area** and are often **symmetric**

Question 33

Describe pustular psoriasis

Answer 33

Disease characterized by superficial pustules that may be localized on the **plams and soles** or they may be generalized and are often triggered by **corticosteroid withdrawal**

Question 34

Question 35

What are some other common manifestations of psoriasis?

Answer 35

- mucosal and nail changes. - The dorsal tongue may exhibit geographic, annular white patches. •Psoriatic nail changes include "oil spots," nail pitting, distal onycholysis, and accumulation of subungual debris. -arthritis

Question 36

How does psoriatic arthritis present?

Answer 36

The most common presentation is **asymmetric oligoarthritis** of the **small joints of the hands (sausage hands- below) and feet** * Psoriatic arthritis may also present as isolated monoarthritis, sacroiliitis, arthritis mutilans, or enthesitis. * In addition, psoriatic patients appear to be at an increased risk for developing obesity, diabetes mellitus, hyperlipidemia, hypertension, and cardiovascular disease

Question 37

What mediates psoriasis?

Answer 37

A **T-cell-mediated inflammatory disease** that may be **influenced by genetic factors** and that can be diminished by sunlight

Question 38

—Flares of psoriasis may be associated with \_\_\_\_\_\_

Answer 38

group A beta-hemolytic streptococcal infections, medications (eg, beta blockers, ACE – inhibitors, nonsteroidal anti-inflammatory drugs, lithium, interferon and antimalarials), and stress

Question 39

How is psoriasis treated?

Answer 39

-When localized, topical treatments including **topical steroids, topical retinoids, topical vitamin D analogs, topical keratolytics, and topical tar products** —-—**Systemic treatments** including phototherapy, oral retinoids (acitretin), methotrexate, and biologics (—TNF-alpha inhibitors, —IL12/23 blockers, and —IL-17 blockers) —

Question 40

T or F. —Systemic steroids should not be used for the treatment of psoriasis

Answer 40

T. because of the risk of disease flare upon discontinuation of the steroids

Question 41

Describe Seborrheic dermatitis

Answer 41

An **inflammatory** reaction to the **Malassezia (Pityrosporum ovale) yeast** that thrives on seborrheic (oil-producing) skin and presents as erythematous scaling patches In infants this presents with “**cradle cap”, pink to yellow macules** and patches with white greasy scales on the scalp, face, and diaper area

Question 42

Answer 42

Question 43

Answer 43

On the chest, it appears more central over the sternum

Question 44

Seborrheic dermatitis is often worse in patients with \_\_\_\_

Answer 44

HIV

Question 45

How is Seborrheic dermatitis treated?

Answer 45

- **Low-potency topical steroids** for flares on face - **Antidandruff shampoo** for scalp and chest

Question 46

What is Pityriasis Rosea?

Answer 46

—An acute papulosquamous eruption that mainly occurs in **young people** (most patients are between the ages of 10 and 35) with a suggested possible viral **(HHV-6/7) etiology**,

Question 47

How does Pityriasis Rosea present?

Answer 47

Usually an **asymptomatic** disease, but **flu-like symptoms** including malaise, nausea, loss of appetite, etc. and even fever and LAD can be seen AND classically starts with a **'herald' patch** and then a secondary phase with a **symmetric, salmon-colored 'Christmas tree" pattern rash**

Question 48

Pityriasis rosea

Answer 48

Question 49

How is Pityriasis Rosea treated?

Answer 49

**Self-limiting** (takes about 5-8 weeks) but **OTC anti-lotions and oral erythromycin can help with pruritis**

Question 50

Describe Lichen Planus

Answer 50

**Adult diopathic inflammatory disease** of the **skin, hair, nails, and mucous membranes** characterized by pruritic, purple, flat-topped papules with reticulated networks of white lines **(Wickham's striae)**

Question 51

—Some lichenoid drug eruptions have a photodistribution, while others are clinically and histologically indistinguishable from idiopathic lichen planus. What drugs commonly cause this? —

Answer 51

angiotensin-converting enzyme (ACE) inhibitors, thiazide diuretics, antimalarials, quinidine and gold

Question 52

Answer 52

Question 53

Lichen planus

Answer 53

Lichen planus

Question 54

What mediates Lichen Planus?

Answer 54

—Likely involves an **autoimmune reaction** against **antigens on lesional keratinocytes**

Question 55

Associations of Lichen planus?

Answer 55

—Hepatitis C — —

Question 56

Tx of Lichen Planus?

Answer 56

-topical steroids and topical calcineurin inhibitors

Question 57

How does scabies infection occur? Patient population?

Answer 57

Can affect anyone but more common in **women, children, immunocompromised individuals, and close groups of people** and occurs from **direct contact with an infected individual** or **fomites (below)**

Question 58

How does scabies present?

Answer 58

There is typically a **3-4 week incubation period** from infection **initially (or as fast as 1-2 days with re-infestation)** that results in papule formation throughout the body that are characteristically **more itchy at night and may show pathognomonic BURROWS**

Question 59

While most scabies papules occur on the body, the scalp and head are more frequently involved in \_\_\_\_\_\_\_

Answer 59

infants, elderly and immunosuppressed individuals.

Question 60

What are these?

Answer 60

**Burrows -** linear markings in the skin due to the movement of the mite. They are 1-10 mm in length and are most readily found in the interdigital spaces, wrists and elbows

Question 61

How should suspected scabies be addressed?

Answer 61

perform a mineral oil preparation on the patient. •You use a 15-blade scalpel and scrape a burrow on the skin. The scraped material is placed on a slide and a drop of mineral oil is added. A cover slip is placed on top and you see the image below when you look through the microscope.

Question 62

What are hyperkeratotic scabies, formerly called Norwegian scabies?

Answer 62

Immune suppressed or neurologically impaired individuals are at increased risk of developing crusted scabies that are **far more difficult to treat**

Question 63

How is scabies treated?

Answer 63

Scabies treatment includes a two-pronged approach. The patient and the environment must both be treated. •Two topical treatments separated one week apart with **a prescription 5% permerthin cream (if not pregnant)**. Apply topical medication from the neck down and leave on overnight; **for infants and the elderly, include the face and scalp.** Itch and lesions can persist for 2-4 weeks after successful treatment, referred to as “post-scabietic” pruritus or dermatitis.This is not a treatment failure, rather it represents the body’s response to dead mites.

Question 64

What is the 'environmental' treatment of scabies?

Answer 64

Includes **washing all clothing and linens used within the last week** in hot water and drying on high heat. For items that cannot be washed, seal items in bags for at least 3 days.

Question 65

T or F. Isolation from other people is necessary

Answer 65

F. As the causative organism cannot jump or fly, and can survive for only approximately 72 hours away from the skin.

Question 66

How are crusted scabies treated?

Answer 66

**Combination therapy** is typically used including **multiple doses** of **PO** **Ivermectin** and **Topical permethrin (if not pregnant)**. Given the high mite burden, **patients with crusted scabies need to be isolated**, and strict barrier nursing procedures instituted to avoid outbreaks in health care facilities.

Question 67

What are the types of Pediculosis (lice) that can infest humans?

Answer 67

* Head louse – Pediculus humanus var. capitis * Body louse – Pediculus humanus var. corporis * Pubic or crab louse – Phthirus pubis

Question 68

Lice affects all ethnic and socioeconomic groups, but is less common in \_\_\_\_

Answer 68

African-Americans

Question 69

Describe the pathogenesis of pediculosis

Answer 69

Female adult lice live 30 days and lay 5-10 eggs (nits) per day at the base of the hair where it meets the scalp. Live eggs remain close to the scalp to maintain warmth and moisture but as the hair grows, the nits move off the scalp with the hair. Because hair grows at a rate of ~ 1 cm per month, the duration of infestation can be estimated by the distance of the nit from the scalp.

Question 70

How does head lice present?

Answer 70

Frequently pruritic, associated with posterior cervical LAD, and dermatitis on the posterior neck

Question 71

What is the most common sites to find nits?

Answer 71

On the retroauricular and occipital scalp.

Question 72

How can nits be distinguished from hair casts?

Answer 72

Hair casts encircle the hair shaft and move freely in contrast to the nit which is cemented to the hair.

Question 73

How is Pediculosis treated?

Answer 73

It is prudent to re-treat with topical therapies 7-9 days after initial therapy to kill the newly hatched lice ## Footnote * Use OTC permethrin 1% or pyrethrins when resistance is not suspected. * Use malathion 0.5% when resistance to permethrin or pyrethrins is documented or when treatment with these products fails. Adjunctive nit combing can be performed. Occlusive methods have also been used to suffocate head lice using substances such as petroleum jelly and mayonnaise, but study results have been variable.

Question 74

Other parts of pediculosis treatment?

Answer 74

All persons living in the home should be examined to avoid re-infestation. * Those with live lice or nits within 1 cm of the scalp should be treated. * It is prudent to treat family members who share a bed with the person with infestation, even if no lice are found. * If it is not possible to examine household members, treat without an exam if the treatment is not contraindicated.

Question 75

Pediculosis: Patient Education

Answer 75

- Clothing and bedding should be washed and dried on the hot cycle of the dryer. - Brushes, combs and other hair care items can be placed in hot (\> 60°C) water for 10 minutes. - Non-washable items may be placed in the dryer or stored in a sealed plastic bag for 3 days.

Question 76

T or F. Children should not be restricted from attending school because of lice.

Answer 76

T.

Question 77

What causes Bed Bugs?

Answer 77

**Cimex lectularius (most common type)** affect people from all racial and socioeconomic groups

Question 78

Describe the transmission of bed bugs

Answer 78

Bed bugs may be spread during travel on clothing, bedding, mattresses, and laundry, etc and tend to **stay hidden during the day and feed at night** Bites may be multiple in a linear array; referred to as **“breakfast, lunch and dinner”**

Question 79

Question 80

How does a bed bug infestation present?

Answer 80

Usually presents as **pruritic**, erythematous and edematous papules with the appearance and duration of lesions vary depending on the **patient's degree of sensitization** **(Some individuals have little or no reaction to bedbug bites**) •Common for only one or a few family members (even among those sleeping in the same bed) to report lesions

Question 81

How are bed bugs treated?

Answer 81

Bites will typically **resolve within 1-2 weeks**. For symptomatic relief, treat with **potent topical steroids and antihistamines** Ultimate treatment requires detection and eradication of the household infestation. Bed linens need to be laundered and furniture vacuumed

Question 82

Key Points for Bed Bugs

Answer 82

Bedbugs typically **feed at night and infest all populations** Bedbug bites cause edematous papules which may be arranged in a **“breakfast, lunch and dinner”** pattern