Flashcards in Derm I Deck (107):
Pruritis and erythema are typically located where in infants?
The most common chief complaint of atopic dermatitis is?
atopic dermatitis is associated with?
Asthma and/or exposure to allergens in pt hx
Atopic dermatitis description:
pruritic, chronic, relapsing
Most common location for atopic dermatitis?
Besides the most common location, where else is atopic dermatitis found?
face, trunk, hands, upper chest
atopic dermatitis lesions are characteristically?
erythematous, macular or papular, possible crusting, oozing, can develop lichenification with chronic scratching
diagnosis of atopic dermatitis?
no test is diagnostic. IgE may be elevated. eosinophils might be present
1st line treatment for atopic dermatitis:
frequent lubrication with thick emollient creams: infants-hydrocortisone, adults- triamcinolone
2nd line treatment for atopic dermatitis:
systemic steroids, plastic occlusive dressing with topicals, immunomodulators
contact dermatitis is?
a rxn to an external substance
two forms of contact dermatitis:
primary irritant dermatitis and allergic contact dermatitis
a pt w/ contact dermatitis will present with what hx?
pruritis with exposure to irritant
contact dermatitis PE will show?
acute: vesicles, macules, papules, and bullae with surrounding erythema. can also be erythematous with lichenification
tests for contact dermatitis?
tx for contact dermatitis?
avoid irritant, lotion w/ zinc oxide, talc, menthol, phenol (gold bond), higher potency topical steroid for short-term (fluocinonide), then transfer to med to low potency topical steroid (triamcinolone). hydroxizine or diphenhydramine for pruritis. systemic steroids in indicated. ABX if 2ndary bacterial infection
diaper dermatitis description:
occurs under the covered area of a diaper
a pt w/ diaper dermatitis will present with a hx of?
recent diarrhea or illness. irritation or agitation
diaper dermatitis PE:
mild= shiny erythema +/- scaling
moderate= papules, vesicles, erosions
prominent lesions on the buttocks, thighs, mons pubis, scrotum. skin folds are usually spared or affected last. satellite lesions.
diaper dermatitis with satellite lesions indicate an infection most likely caused by?
test for diaper dermatitis?
rarely needed if ever
tx for diaper dermatitis:
if purely contact dermatitis: low potency steroid (hydrocortisone)
if Candida is suspected: antifungal (miconazole)
nummular eczematous dermatitis is similar in sxs and tx to?
specific tx for nummular eczematous dermatitis:
avoid excessive use of soap. but, use super-fatted soaps like dove. lubricate the skin immediately after bath or shower.
perioral dermatitis description:
erythematous papules and pustules with possible scaling on chin, lips, and nasolabial folds.
a pt with perioral dermatitis will present with a hx of what?
cause unknown but some theories are formaldehyde in kleenex-type tissues, toothpastes, and clothes.
PE for a pt with perioral dermatitis?
erythematous papules and pustules with possible scaling on chin, lips, and nasolabial folds.
tests for perioral dermatitis?
tx for perioral dermatitis?
tetracycline ABX: typically doxycycline. Do NOT use topical steroids
seborrheic dermatitis description:
dandruff? erythema and greasy scaling lesions located especially on the eyebrows, scalp and face.
a pt w/ seborrheic dermatitis will present with a hx of?
burning, scaling, itching with periods of inactivity
PE for a pt with seborrheic dermatitis:
scalp can appear with mild scaling to widespread, thick crust
tests for seb derm?
biopsy with tx failure
tx for seb derm?
topical anitfungals, topical corticosteroids, coal tar, selenium sulfide
stasis dermatitis description:
chronic, eczematous erythema, scaling, and non-inflammatory edema of the lower extremities. typically accompanied by cycle of scratching, excoriations, weeping, crusting, and inflammation in patients with chronic venous insufficiency. Skin manifestations of chronic venous insufficiency usually appear later in the disease process.
a pt w/ stasis dermatitis will present with a hx of?
pt will usually be >50 years of age. sxs will usually present bilaterally with insidious onset, erythema, scaling and edema.
PE for a pt with stasis derm will show?
scaly, eczematous patches with violaceous (or brown) lesions, secondary ulcers occur as a result of weakened skin around the ankles, typically lower 3rd of the legs and medially
tests for stasis derm?
none specific tests for dermatitis but duplex US crucial in diagnosis for chronic venous insufficiency
1st line stasis derm treatment:
ABX if 2ndary infection. Burrow's solution: wet dressings and cooling paste if ulcerated. topical steroids
2nd line stasis derm treatment:
ABX based on culture and sensitivity. lubrication when dermatitis is quiescent.
Additional lines of treatment for stasis derm:
leg elevation, debride when needed
Dyshidrotic eczema description:
recurring vesicular papules on the palms, soles, or interdigital areas that are typically not erythematous. Possibly associated with excessive sweating
A pt with dyshidrotic eczema will present with a hx of?
burning, itching, and pain along with episodes that are sxs free. emotional stress. hx of atopy
PE for a pt with dyshidrotic eczema?
Early: clear vesicles, non-erythematous, typically bilateral and symmetric.
Later: vesicles become unroofed and inflamed with desquamation and peeling
tests for dyshidrotic eczema:
biopsy if uncertain
treatment for dyshidrotic eczema:
mild: low potency topical steroid
mod-severe: ultra-high potency steroids with occlusive dressing
recurrent: systemic steroids at onset of itching
can use more potent medications if necesssary (psoralens, botulinum toxin)
general: emollients, avoid prolonged immersion in water, use lukewarm water not hot.
lichen simplex chronicus description:
Chronic dermatitis that results from constant rubbing or scratching of the skin
a pt with lichen simplex chronicus will present with a hx of?
Gradual onset in easily reached areas
Pruritis is out of proportion to appearance of the lesion
PE for a pt with lichen simplex chronicus will show?
Lichenification and excoriated patches of skin
tests for lichen simplex chronicus?
Biopsy if no response to treatment
treatment for lichen simplex chronicus:
Topical anti-pruritic agents (doxepin, menthol preparations)
High potency topical steroids, transitioning to lower potency topical steroids as resolution allows
Can also use oral antihistamines for pruritis
dermatophyte infection description:
Superficial fungal infections associated with scaling, erythema, or change in skin pigmentation
a pt presenting with dermatophyte infection will have a hx of:
Tinea corporis: lesions anywhere on the body
Tinea capitis: ranges from round, very distinct lesions to generalized, diffuse, dry scalp
Tinea pedis: itchy rash on foot, possibly associated with onychomycosis
Tinea versicolor: typically asymptomatic macules more commonly found in summer with periodic recurrences
Gradual onset, usually with pruritis
Possible contacts, pets, showers
PE for dermatophyte infections:
Lesions are usually annular (ringworm); may be flesh colored, erythematous, or violet to brown in color
Lesions may occur anywhere on the body
Tinea capitis (various presentations):
Round to oval patches of alopecia with erythema
Seborrheic dermatitis-like pattern with minimal or no alopecia
Follicular pustules with crusting
Boggy, tender plaque with follicular pustules (kerion)
Diffusely dry scalp
Pruritic, erythematous lesions between the toes with fissures
Scaling, oval macular patches
Hypopigmented or hyperpigmented, depending on sunlight exposure and complexion
Distributed on upper trunk, neck, and proximal arms
tests for dermatophyte infections:
Tinea capitis: fungal culture, KOH prep
Tinea corporis: fungal culture, KOH prep
Tinea cruris: fungal culture, KOH prep
Tinea pedis: fungal culture, KOH prep
Tinea versicolor: fungal culture, KOH prep
treatment for dermatophyte infection:
Tinea corporis/cruris: topical azole antifungal, use for one week after resolution of symptoms; resort to oral meds if no resolution
Tinea capitis: oral griseofulvin, terbinafine, or itraconazole
Tinea pedis: antifungal cream BID until lesions have resolved for three days; resort to oral antifungals if no resolution
Tinea versicolor: ketoconazole or selenium sulfide shampoo (Selsun Blue; dandruff shampoo); oral antifungals for non-responders
drug eruptions description:
Adverse skin reaction response to administration of any medication
Urticarial response is most common, but can cause any morphological type of reaction
if a pt presents with suspected drug eruptions will need a hx of?
Complete medication history for the past month if suspected drug eruption
PE for drug eruptions will need?
Any new lesions of any morphology
tests for drug eruptions:
Routine lab tests are typically not helpful
treatment for drug eruptions:
Symptomatic treatment, but not always necessary
Treatment for anaphylaxis if indicated
Emergency treatment if indicated
Lichen planus description:
Cutaneous, inflammatory disorder of the skin and mucous membranes
a pt presenting with lichen planus will have a hx of?
Most common on flexor surfaces of the UE, extensor surfaces of the LE, the genitalia, and mucous membranes
Small flat, angular, red to violaceous, shiny, pruritic papules on the skin
Fine, white, lacy patches on oral mucosa
PE for lichen planus:
1 – 10 mm flat-topped (planar), shiny papules occurring in crops
Violaceous with white lace-like pattern (Wickham striae) on surface of papules. Wickham striae are best seen after topical application of mineral oil, and if present pathognomonic for lichen planus
polygonal or oval
grouped, linear, or scattered
Koebner phenomenon: new lesions may be noted at sites of minor injuries such as scratches or burns
Mucous membrane lesions are typically asymptomatic with a white lacy pattern
tests for lichen planus:
Biopsy, if indicated
treatment for lichen planus:
Superpotent topical steroids or intralesional corticosteroids
Soak and smear technique
Topical steroids in Orabase
Systemic steroids if no response
pityriasis rosea description:
Self-limiting skin eruption with multiple papulosquamous lesions
a pt with pityriasis rosea will present with a hx of?
Most common initial sign is a salmon-colored patch or plaque known as the herald patch
Widespread rash begins 7–14 days after the onset of the herald patch, although it may appear up to 3 months later.
Fever and malaise rare
PE for pityriasis rosea:
Salmon-colored to light-brown oval plaques with fine scales centrally and a collarette of loose scales along borders
tests for pityriasis rosea:
WBC normal, rule out syphilis if indicated, KOH prep to rule out tinea
treatment for pityriasis rosea:
Topical steroids or oral antihistamines for itching
Immunologic genetic skin disorder characterized by brick-red plaques with a silvery scale
Also characterized by flares and remissions
Plaque: Most common with patches on scalp, trunk, limbs (extensor surfaces); nails may be pitted and/or thickened
Guttate: Usually presents < 20 years of age; numerous small papules over wide area of skin, mostly on the trunk
Inverse or flexural: Affects intertriginous areas; lesions are moist with or without scaling
Pustular (von Zumbusch): True emergency: Severe form characterized by widespread erythema, scaling, pustule formation
Erythrodermic: Severe form, skin turns red; often presents with chronic disease and/or precipitated by high use of topical steroids
Nail disease: Can occur in all subtypes; fingernails involved in ~50% of cases and toenails in 35%
Psoriatic arthritis: Inflammatory arthropathy
a pt with psoriasis will present with a hx of?
PE for psoriasis?
Well-defined red papules coalescing to plaques; sharply demarcated silvery scales on red plaques
Auspitz sign: Underlying pinpoints of bleeding following scraping
Koebner phenomenon: response in traumatic area
Stippled nails and pitting
tests for psoriasis:
Clinical diagnosis, can order a RF with arthropathy – should be negative
treatment for psoriasis:
First line: emollients, topical corticosteroids, vitamin D analogues, topical retinoids, light therapy, also systemic methotrexate or cyclosporin, or biologics
Second line: topical immunosuppresants, salicylic acid or coal tar
steven's-johnson syndrome descritpion
Generalized hypersensitivity reaction, usually to a drug, in which skin and mucous membrane lesions are an early manifestation
Stevens-Johnson syndrome (SJS) exists on a continuum with toxic epidermal necrolysis (TEN).
Presents with characteristic targetoid cutaneous lesions on < 10% of the body surface area, targetoid cutaneous lesion involvement of 10–30% of BSA is considered an overlap between SJS and TEN, and involvement of >30% of BSA is TEN, which has up to 70% mortality
a pt with steven's-johnson syndrome will present with a hx of:
Usually a preceding illness for which the medication was given 1–3 weeks before initial cutaneous manifestations
Sudden onset with rapidly progressive rash that includes petechiae, vesicles, and/or bullae
Considered to be SJS if epidermal detachments affect < 10% of the skin
Burning sensation of the skin and sometimes of the mucous membranes, usually without pruritus
Fever 39–40°C (102–104°F), headache, malaise, arthralgias, and possibly cough productive of thick, purulent sputum
PE for steven's-johnson syndrome:
Recognized by the presence of several of the following features:
Vesicles and ulcers on the mucous membranes, especially of the mouth and throat
Erythematous macules with purpuric, necrotic centers and overlying blistering
Epidermal detachment with light lateral pressure (Nikolsky’s sign)
Fever 39–40°C (102–104°F)
Erosive vulvovaginitis or balanitis
Cough productive of thick, purulent sputum
Congestive heart failure (CHF)
Mental status changes
tests for steven's-johnson syndrome:
Culture and serology for source/type of infection
tx for steven's-johnson syndrome:
Corticosteroids are controversial
Multiple experimental treatments
Withdraw all medications
Meticulous care of skin
All patients should be admitted ASAP
toxic epidermal necrolysis:
Differences between SJS and TEN
Immediate transfer to a burn unit with avoidance of IV cath if possible and very gentle transport
ER treatment is to avoid the aggravating agent, and provide aggressive fluid replacement, warming measures, pain measures, but no established treatment regimens
erythema multiforme description:
Acute and self-limiting hypersensitivity reaction
Previously thought to be on spectrum of SJS and TEN
Mostly triggered by infectious agents, especially HSV
a pt with erythema multiforme will present with a hx of:
Possible mild prodromal symptoms
HSV infection in the last 10 – 15 days
Involves the skin and sometimes the mucous membranes (mouth most common)
PE for erythema multiforme:
Typical target lesions have three zones: raised and cyanotic center, edematous light intermediate ring and bright erythematous border
Flat or raised atypical target lesions have 2 zones: center and intermediate ring with a poorly defined border
Lesions may coalesce and become generalized.
Multiple papules or vesicles or painful ulcerations
tests for erythema multiforme:
No specific tests are indicated
treatment for erythema multiforme:
Medication for any underlying process
Topical corticosteroids or oral antihistamines for symptomatic relief
Possible antivirals with comorbid viral infection
bullous pemphigoid description:
Chronic autoimmune subepidermal blistering disease
Tense blisters on either normal-appearing or erythematous skin or mucous membranes
a pt with bullous pemphigoid will present with a hx of:
Pruritis is very common
PE for bullous pemphigoid:
Large, tense subepidermal blisters and urticarial plaques or bullae commonly occur in the flexural areas of the legs and arms, axillae, abdomen, and groin
Nikolsky sign should be negative
Asboe-Hansen sign should be negative
tests for bullous pemphigoid:
Biopsy is required for a diagnosis
tx for bullous pemphigoid:
High potency topical corticosteroids are considered first-line therapy
Possible oral steroids
acne vulgaris descritpion:
chronic inflammatory dermatosis notable for open/closed comedones and inflammmatory lesions, including papules, pustules, or nodules
a pt presenting with acne vulgaris will have a hx of:
Must ask duration, medications, cleansing products, stress, smoking, exposures, family history
Factors influencing symptomatology:
Males later onset, greater severity
Females may worsen prior to menses
PE for acne vulgaris:
Closed comedones (whiteheads)
Open comedones (blackheads)
Nodules or papules
Grading system (American Academy of Dermatology, 1990):
Mild: Few papules/pustules; no nodules
Moderate: Some papules/pustules; few nodules
Severe: Numerous papules/pustules; many nodules
Very severe: Acne conglobata, acne fulminans, acne inversa
Most common areas affected are: Face, chest, back, and upper arms (areas of greatest concentration of sebaceous glands)
tests for acne vulgaris:
Only indicated with symptoms of possible androgen excess
tx for acne vulgaris:
Chronic condition characterized by recurrent episodes of facial flushing, erythema (due to dilatation of small blood vessels in the face), papules, pustules, and telangiectasia (due to increased reactivity of capillaries) in a symmetrical, facial distribution
a pt presenting with rosacea with have a hx of:
Episodic flushing with increases in skin temperature in response to heat stimulus in mouth (hot liquids), spicy foods, alcohol, sun (solar elastosis).
Acne may precede the onset of rosacea by years
Typical stages of evolution:
The rosacea diathesis: episodic erythema, "flushing and blushing"
Stage I: Persistent erythema with telangiectases
Stage II: Persistent erythema, telangiectases, papules, tiny pustules
Stage III: Persistent deep erythema, dense telangiectases, papules, pustules, nodules; rarely persistent "solid" edema of the central part of the face (phymatous)
PE for rosacea:
Facial erythema typically on cheeks, nose, and chin
Prominent inflammatory papules with possible pustules and telangiectasia
test for rosacea:
Based on physical exam, lack of comedones
tx for rosacea:
Low-dose oral tetracyclines
Topical metronidazole, or other topical antibiotics
Topical sulfur-containing compounds
Inflammation of the hair follicle caused by infection, irritation, or injury
a pt presenting with folliculitis will have a hx of:
Pustular rash on hair-bearing skin, especially face, limbs and scalp
PE for folliculitis:
Multiple small papules and pustules
tests for folliculitis:
Culture and sensitivity