open comodones
blackheads
closed comodones
whitehead
Impetigo etiology
S. aureus or strep
Impetigo tx
Topical mupirocin for small number of non-bullous lesions
Oral therapy for anything else: dicloxacillin, cephalexin, or clindamycin
Suspect MRSA→ clindamycin or linezolid
Lice tx
Permethrin 1% (shampoo & lotion), Ivermectin (Lindane restricted d/t neurotoxicity)
2nd tx in 7-10 days to kill any surviving nits
Can return to school after 1st tx
Mechanical wet combing is an alternative therapy for kids too young for medical therapy ( < 2 months)
Examine household & close contacts
Wash bedding & clothing in hot water w/ detergent, dry in hot drier x20min
Toys that can’t be washed should be placed in air-tight plastic bag x14days
Lichen Planus presentation
Develop on flexor surfaces of extremities, mucous
membranes of skin, mouth, scalp, genitals, nails
Purple popular pruritic polygonal planar
Oral white lacy patches = Wickam striae
Koebner phenomenon, fine scales
Lichen Planus tx
Typically resolves in 8-12mo
1st line = antihistamines, steroid ointment
2nd line = systemic steroids, UVB therapy
Scarlet Fever presentation
Pharyngitis
Strawberry tongue
Sandpapery rash that is worse in the groin and axilla with desquamation of palms and soles
Scarlet Fever tx
Penicillin VK or amoxicillin administered to prevent sequelae of rheumatic fever
Scarlet Fever etiology
GAS
Androgenetic alopecia
Male pattern baldness
Variable and unpredictable
Androgenetic alopecia tx
Minoxidil solutions = most effective in recent onset and smaller areas of hair loss
Finasteride may also be effective
SE = loss of libido and ED
Atopic derm presentation
Papules and plaques, with or without scales, are noted and may be associated with edema, erosion, and
crusts
MC on the flexural surfaces, neck, eyelids, forehead, face, and dorsum of the
hands and feet
pruritus and dry, scaly skin. Scratching leads to lichenification, fissures, and
worsening rash
Secondary infections caused by Staph aureus
Atopic derm etiology
Type I IgE mediated hypersensitivity rxn
Atopic derm tx
Antihistamines → ↓ itching
Topical corticosteroids = mainstay of the treatment; systemic corticosteroids should be
avoided
Tacrolimus and pimecrolimus are topical calcineurin inhibitors (immunomodulators) approved for moderate to severe atopic dermatitis
(less atrophy w/ prolonged use when compared to topical corticosteroids but may carry a potential to cause malignancy)
Hydration and topical emollients are key to management
Soaps, vigorous rubbing, frequent bathing, and irritant clothing such as wool should be avoided
UVB phototherapy is effective
Severe systemic cases may necessitate cyclosporine
Contact derm etiology
Type IV T-cell mediated rxn
Posion ivy tx
Tecnu, calamine lotion, oatmeal baths, astringents (witch hazel)
Allergic vs contact derm etiology
Type IV T-cell mediated rxn
Allrgic → metallic salts, plants (poison ivy), fragrances, nickel, preservatives, formaldehyde, propylene glycol, oxybenzone, bacitracin, neomycin, bleached rubber, chrome, sorbic acid
Irritant → water, soaps, detergents, wet work, solvents, greases, acids, alkalis, fiberglass, dusts, humidity, chrome, lip licking or other trauma
Allergic vs contact derm presentation
Eczematous (irritant), vesicular (allergic)
Allergic → Acute with macules, papules, vesicles, and bullae, chronic with lichenification, scaling, fissures, uncommon on scalp, palms, soles, or other thick-skinned areas that allergens can’t get through
Contact → Acute with bullae, erythema, and sharp borders, chronic with poorly-demarcated erythema, scales, and pruritus, fissured, thickened, dry skin, usually palmar
Diaper Dermatitis etiology
Candida
Diaper Dermatitis presentation
Red, well defined margins, pustules, vesicles, papules or scales
Satellite lesions
Common in dark, moist areas (axillae, under breast)
Diaper Dermatitis treatment
Topical antifungals such as nystatin
Perioral Dermatitis presentation
Papulopustules form on erythematous bases and may become confluent with plaques and scales
Vermilion border is spared, and satellite lesions are common
Perioral Dermatitis treatment
Avoid topical steroids bc will aggravate the lesions
Topical metronidazole or erythromycin or oral minocycline, doxycycline, or tetracycline
Untreated lesions will fluctuate over time, similar to rosacea
Type I drug rxn
IgE mediated, immediate
urticaria, angioedema
Type II drug rxn
Ab-mediated, cytotoxic (drugs in combo with cytotoxic antibodies)
Type III drug rxn
immune ab-antigen complex
drug mediated vasculitis and serum sickness
Type IV drug rxn
delayed cell-mediated
erythema multiforme
Exanthematous Drug Eruption presentation
> 2 d after drug
Limited to skin
Lesions initially appear on trunk and spread to extremities in symmetric fashion
Erythematous macules and infiltrated papules, pruritus and mild fever may be present
Exanthematous Drug Eruption tx
Resolves a few days - week after med stopped
Can continue med if not too severe and med cannot be subsuituted
Topical steroids, oral antihistamines and reassurance
Cold to help with itch
1st deg burn
epidermis only, ✚ pain and ✚ erythema
2nd deg burn
epi + dermis, ✚ pain, ✚ blisters ✚ erythema
3rd deg burn
through dermis, white and painless w/ surrounding 2nd deg burns
Parkland formula
LR @ 4ml x kg x BSA burn (half over 1st 8hrs, rest over next 16hrs)
Adult burn %
head →9 trunk→ 18 back→ 18 each arm→9 each leg→18 genitalia→ 1
Ped burn %
head→18 trunk→18 back→ 18 each arm→ 9 each leg→ 14 genitalia→1
Pityriasis Rosea presentation
Herald patch= initial salmon-colored macule on trunk → general examthem
Salmon colored oval/round papules with white circular scaling along clevage lines
Very pruritic, christmas tree pattern, confined to trunk and proximal extremities
May follow URI
Pityriasis Rosea tx
Self-limited→ resolves in 6-12 wk
For itch → topical steroids, PO anihistamines, moisturizeds, oatmeal baths
+/- UVB light if severe
Scabies presentation
Distribution is most common on the hands, wrists, genitalia, and axillary areas
Lesions often are seen in the web spaces btwn fingers and toes, around the belt line, or at the edges of socks.
Pruritic burrows, vesicles, or nodules with excoriations and crusting
Scabies tx
1% lindane or 5% permethrin in a lotion or cream
apply to the skin from the chin to the bottom of the feet and leave overnight (8 hr) then wash off in the AM
Repeat tx in 7 days
Antihistamines or topical steroids may help relieve the itching
Lindane is more toxic and should be avoided in children younger than 2 yo, people with extensive
dermatitis, and those who are pregnant or lactating.
All bedclothes and clothing of infected pts and household contacts should be washed
All close physical contacts should receive scabicide tx as well
Tinea Versicolor presentation
Hypo or hyperpigmented macular lesions
Esp on trunk
Fine rim of scale
Tinea Versicolor etiology
Malasezzia furfur (no really a tinea)
Tinea Versicolor w/u
KOH prep for spaghetti and meatballs
Tinea Versicolor tx
Topical selenium sulfide, pyrithione zinc, propylene glycol, ciclopirox, azole, or terbinafine
± UV light therapy
Systemic ketoconazole if recurrent or refractory
Tinea capitis tx
po griseofulvin, terbinafine, or itraconazole
Tinea Barbae, manuum, corporis, cruis, faciale, pedis tx
po griseofulvin, terbinafine, or itraconazole, air exposure
Topical terbinafine, naftifine, butenafine
± Soaks with aluminum acetate
2nd line: topical azole
Tinea Unguium (onocomycosis) tx
1st line is oral terbinafine
2nd line is oral azole or ciclopirox topical lacquer
3rd line is repeat therapy or nail removal
SJS vs TEN
SJS <10% TBSA and TEN >30%
SJS & TEN presentation
Mucocutaneous blistering rxns most often caused by drug rxn
Fever, photophobia, sore throat, mucosal inflammation, and sore mouth
Lesions tend to be concentrated more on the trunk at first
May be painful/sting
Progression occurs over 4 days → diffuse erythema, necrotic epidermis, wrinkled surfaces, sheetlike loss of epidermis, and raised, flaccid blisters (Nikolsky sign)
SJS and TEN w/u
✚ Nikolsky sign
Anemia, lymphopenia
Bx is diagnositc
SJS and TEN tx
Prompt withdrawal of offending agent
Transferto burn unit, gluid and electrolyte corrections
Regrowth of skin takes 3 weeks (more in pressure-point area)
Urticaria tx
Eliminate known cause
Acute → PO H1 antihistamine, such as diphenhydramine, hydroxyzine, fexofenadine, or
cetirizine
Chronic → H2 antihistamine, such as famotidine or ranitidine, may be added to the H1 regimen
EpiPen if concern for anaphylaxis
Verrucae presentation
Skin warts→ flat or superficial
Plantar warts→ deep
Rough surface, cauliflower like
Verrucae etiology
Caused by HPV
Replicates in cutaneous and mucosal epithelium
Common warts can occur on any surface of the skin while genital warts (condylomata) are spread through sexual contact
HPV 16 and 18 are RF for dysplasia
Verrucae tx
Spontaneous regression is typical over time
Salicylic Acid for common warts
Cryosurgery or E D&C (scar risk)
Imiquimod (Aldara)
Intralesional interferon if other tx fail
Anogenital→ trichloroacetic Acid or topical podophyllin
Surgical excision is successful but recurrence is common
Vaccination for 16, 18, 6 and 11