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Clin Med I > Derm II > Flashcards

Derm II Flashcards

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1
Q

Adolescent acne vs. Adult acne gender predilection

A

Adolescent - male

Adult - female

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2
Q

4 main factors of acne vulgaris

A
  1. Follicular hyperkeratinization
  2. Increased Sebum production
  3. Cutibacterium ances w/in follicle
  4. Inflammation

–> sebum is a growth medium for C. ances, Microcomedones are an anaerobic, lipid rich space for them, increased proliferation = increased inflammation

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3
Q

Closed comedone

A

Whitehead

-accumulation of sebum and keratinous material coverts a microcomedome into a closed comedome

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4
Q

Open comedome

A

Blackhead

  • the follicular oriface is opened w/ continued distension forming an open comedome
  • densely packed keratinocytes, oxidized lipids, and melanin all contribute to dark color
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5
Q

Acne vulgaris progression

A

Follicular rupture contributes to inflammatory lesions –> proinflammatory lipids and keratin are extruded into surrounding dermis –> worsened inflammation –> papules and nodules form

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6
Q

Most common endocrine disease associated w/ acne? What are some S/S

A

PCOS

-menstrual irregularity, insulin resistance, acne, hirsutism, ovarian cysts, acanthosis nigrans

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7
Q

What disease are androgens related to? How do they contribute?

A

Acne vulgaris

-stimulate the growth and secretory function of the sebaceous gland

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8
Q

Androgen production in adults vs. infants

A

adults - adrenal glands

infants - adrenal gland & testes in males, adrenal glands in females

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9
Q

A 6 mo. old presents with acne lesions, what is the cause? What should you advise the parents?

A
  • Elevated levels of androgens

- Androgen levels fall by age 1-2 and acne improves

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10
Q

A pts labs come back with elevated androgen levels, what conditions commonly present w/ Hyperandrogenism?

A
  • PCOS
  • Congenital adrenal hyperplasia
  • Adrenal or Ovarian tumors
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11
Q

How does insulin resistance affect acne

A
  • increases risk

- may increase androgen production and is associated w/ increased serum levels of insulin-like GF-1

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12
Q

Pt presents with acne lesions that are both closed and open, but not red or painful

-classify & stage

A

Comedonal acne –> non-inflammatory

Stage I (mild) - minor, no inflammation, black/whiteheads

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13
Q

Pt presents with acne lesions including papules & pustules that are red and inflammed

-classify & stage

A

Inflammatory acne

Stage II (moderate) - more blackheads, whiteheads, papules/pustules, slight inflammation, may progress from face

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14
Q

Extensive acne lesions that are highly inflammed and cause scarring

A

Nodular acne (cystic acne)

Stage III (Severe) - significant inflammation, severe papules/pustules, cystic nodules present, high risk for scarring and post-inflammatory hyperpigmentation

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15
Q

Female presents w/ persistent acne, irregular menstrual cycles & hirsutism

what test should you order?

A

PCOS –> endocrine testing for androgen levels

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16
Q

Treatments of acne vulgaris should target:

A

one of the 4 main contributors

  • follicular hyperkeratinization
  • increased sebum production
  • C. ances proliferation
  • Inflammation
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17
Q

Considerations for topical retinoids tx AV

A
  • once daily @ bedtime
  • local skin irritation, sun sesnitivity
  • Atralin - fish allergy
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18
Q

Considerations for topical combination products tx AV

A
  • once a day dosing
  • local skin irritation
  • may bleach hair/clothing
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19
Q

Considerations for oral abx tx AV

A
  • severe acne only, usually by specialist
  • avoid LT use
  • flare control
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20
Q

Pt presents w/ non-inflammatory open & closed comedones –> first line of tx after determining pt has a skin care routine

A
  • BP
    -Topical Retinoid
    or
    -Topical Combination Therapy (BP + abx, Retinoid + BP, or Retinoid + BP + abx)
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21
Q

Pt presents with slightly inflamed acne lesions with some papules and pustules –> 1st line of tx

A
  • Topical Combination Therapy (BP + abx, Retinoid + BP, or Retinoid + abx)
  • Oral abx + Topical Retinoid + BP
  • Oral abx + TR + BP + Topical abx
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22
Q

Pt presents with severely inflamed cystic acne lesions –> 1st line tx

A
  • Oral abx + Topical Combination Therapy (BP + abx, or Retinoid + BP + abx)
  • Oral Isotretinoin
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23
Q

For females w/ persistant inflammatory acne, what medications can we consider adding?

A

Oral contraceptives or Spironalactone

–> antiandrogenic

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24
Q

When prescribing a pt w/ acne vulgaris medication, what are important counceling points?

A
  • no cure –> improve outbreaks
  • may take 4 - 6 weeks to benefit
  • may get worse before it gets better
  • bleaching w/ BPO combo products
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25
Who is most likely to develop rosacea?
-fair skinned, >30 y/o, women (men for phymatous)
26
prevalence of rosacea
1 - 10%
27
36 y/o female presents w/ persistent central erythema that gets worse when she drinks alcohol, she reports a stinging/burning sensation on the associated lesion. PE shows spidered vessels and roughness. How can you explain to this pt the pathogenesis of her disease?
- Erythematotelangiectatic Rosacea - cause is unknown, related to: Immune dysfunction, Inflammatory responses to cutaneous microorganisms, UV damage, Vascular dysfunction
28
Erythema congestivum
- sxs of rosacea | - after exacerbation of facial redness, the return to baseline is slow
29
Pt presents w/ papules and pustules on her cheeks and central face. PE shows inflammation that extends past the follicle and no presence of comedones. What should you council this pt to avoid?
Papulopustular rosacea - extreme temps, sun, hot beverages, spicy foods, EtOH, exercise, irritation from topical products, drugs (nicotinic acid, vasodilators) - also exacerbated by emotions
30
54 year old male presents with thickened skin forming irregular contours on his nose & cheeks, what causes these contours to form?
- Phymatous rosacea | - Tissue hypertrophy
31
What is the risk for a patient with rosacea to develop ocular rosacea
> 50%
32
How do you dx rosacea?
- HPE | - no lab/serologic studies available
33
Management of Erythematotelangiectatic Rosacea
- 1st line: behavioral changes - 2nd line: laser and light based therapy - 3rd line: Alpha adrenergic agonists (topical --> Brimonidine gel, Oxymetazoline cream)
34
Management of Papulopustular Rosacea
- Topical Metronidazole cream/gel - Topical Azelaic acid cream/lotion/foam/gel - Topical Ivermectin cream - Oral Tetra, Doxy or Minocycline - Oral Isotretinoin
35
Management of Ocular rosacea
- lid scrubs, warm compress - Topical abx - Ilotycin ointment - Refer
36
Management of Phymatous rosacea
- Early dz: Oral Isotretinoin QD | - Late dz: Laser ablation or surgery
37
Prevalence of Psoriasis (adults & peds)? Gender/Age predilection?
- adults: 0.9 - 8.5% (55 - 79% = chronic plaque psoriasis) - peds: 0 - 2.1% - No gender predilection - peak onset: 30 - 39 yrs & 50 - 69 yrs
38
Increased distance from the equator is associated w/ inc. rates of what disease
Psoriasis
39
Psoriasis epidermis compared to normal epidermis shows:
- increased epidermal stem cells - increased number of cells undergoing DNA synthesis - shortened cell cycle time of keratinocytes - decreased turnover time of the epidermis
40
Pt presents w/ well demarcated, elevated erythematous plaques located symmetrically on her extensor elbows, knees and scalp. She reports the lesions are pruritic. Lesions have a silver scale appearance. What are two signs that are associated w/ this disease?
- Chronic plaque psoriasis - Koebner phenomenon: development of skin disease in sites of skin trauma - Auspitz signs : visualization of pinpoint bleeding after removal of a scale overlying a psoriatic plaque
41
22 y/o male presents w/ small papules and plaques (<1 cm) on his trunk and arms. Pt states these lesions appeared over the past 24 hours. Pt states he was last seen at his PCP 2 weeks ago for Streptococcal pharyngitis. Diagnosis? Who normally gets this?
Guttate Psoriasis -children & young adults w/ no history of psoriasis
42
Pt presents w/ acute onset of widespread erythema, scaling, and sheets of superficial pustules. What are you worried about? Causes?
- Pustular Psoriasis - Life-threatening complications --> malaise, fever, diarrhea, leukocytosis & hypocalcemia - caused by pregnancy, infection, & withdrawal of oral GCs
43
Erythrodermic Psoriasis presentation & consideration for management
- can be acute or chronic - generalized erythema & scaling from head to toe - usually managed inpatent d/t high risk for infection & electrolyte abnormalities
44
Pt presents w/ erythematous lesions w. no visible scaling distributed over her intertriginous areas --> why is this often misdiagnosed?
- Inverse Psoriasis | - because there is often no visible scaling it can be misdiagnosed as a fungal or bacterial infxn
45
Pt w/ Psoriatic arthritis comes in for an exam --> what manifestation are they at higher risk for ?
Nail Psoriasis --> most often Nail pitting
46
How do we diagnose Psoriasis?
- HPE: family hx (40% have 1st degree relative), characteristic plaques, Auspitz sign - Can do a 4mm punch biopsy to r/o other dz - No lab studies
47
When taking a pt hx, what are some risk factors to watch for when considering a diagnosis of Psoriasis?
- genetics (40% - 1st degree relative) - smoking - obesity (proinflammatory cytokines) - drugs (beta-blockers, Litium, antimalarials, NSAIDs, Tetracycline) - Strep pharangitis --> Guttate - HIV - Vitamin D deficiency (baseline lower levels) -Exacerbations d/t Infections, EtOH, Stress
48
Pathophysiology of Psoriasis
- Complex, immune mediated - Hyperproliferation and abnormal differentiation of the Epidermis --> Scaling, Induration, & Erythema --> no cure, manage sxs
49
Mild-Moderate Psoriasis Management
- Emollients - Topical Corticosteroids (Hydrocortisone, Triamcinolone, Flucinonide, Betamethasone diproprionate, Clobetasol) ALTERNATIVES: - Tar-T/Gel - Vitamin D Analogs (Calcipotriol cream/foam, Calcitrol ointment, Tacalocitol) - Topical Retinoids (Tazarotene cream) - Anthralin shampoo - Tacrolimus (immunomodulator, good for large areas)
50
Moderate-Severe Psoriasis Management (5 - 10% BSA affected)
- Phototherapy - Excimer laser (higher doses of UVB but <10 treatments needed for results) - Systemic (MTX + Folic acid - 2-25 mg weekly, Cyclosporine [T-cell suppressor] - 2.5 - 5 mg/kg/day BID, Apremilast [PDE-4 Inhibitor] - 10-30 mg daily or BID) - Biologics (TNF-alpha inhibitors, IL-17 inhibitors, IL-23 and related cytokine inhibitors)
51
Phototherapy in the Management of Moderate-Severe Psoriasis
- good for widespread disease (>5% BSA) - UVB: +/- topical therapy --> near-erythema inducing dose 3/week until remission - Narrow band UVB: suberythemogenic dose, usually more effective & fewer doses req. - Photochemotherapy (PUVA): tx w/ oral or bath Psoralen followed by 2 hrs. UVA radiation --> 3x/week until remission, then 1-2x/week maintenance
52
Hidradenitis Suppurativa is what kind of condition? AKA?
- Chronic follicular occlusive skin condition | - Acne Inversa
53
Prevalence of Hidradenitis Suppurativa? Who gets it? Distribution?
1 - 4% - African American Women - Onset ~ puberty - 40 y/o - Intertriginous areas (axilla, groin, perianal. inframammary)
54
32 y/o African American pt presents w/ a single, painful, deep seated nodule in her axilla, pt states the last time this happened there were more than one painful lesion --> What stage is this? Management for this stage?
- Hidradenitis Suppurativa - Hurley Stage I - Behavioral: avoid skin trauma, smoking cessation, weight management - Antiseptics: Chlorhexidine 1x/week - Emollients - Management of comorbidities
55
What are the Hurley Stages
- Hidradenitis Suppurativa - Stage I: abscess formation - Stage II: recurrent abscess formation w/ sinus tract formation & scarring - Stage III: diffuse involvement of multiple interconnected sinus tracts
56
What is the pathophysiology for Hidradenitis Suppurativa?
- Follicular occlusion --> rupture --> associated immune response - Ductal keratinocyte proliferation --> ductal plugging --> expansion --> rupture & release of contents --> immune response --> sinus tracts in skin
57
Management of a patent classified as Hurley Stage II
- Hidradenitis Suppurativa - Oral Tetracyclines for several months (Doxy - 100 mg BID, Tetra - 500 mg BID, Mino - 100 mg QD/BID) - Clindamycin 300 mg BID or Rifampin 600 mg QD - Oral Retinoids - Antiandronergic therapies (for females, BC, Spironolactone) - Punch biopsies of fresh lesions to prevent sinus tracts
58
Management of a patent classified as Hurley Stage III
- Hidradenitis Suppurativa - TNF-alpha Inhibitors (adalimumab, Infliximumab) - Systemic glucocorticoids (Prednisone) - Cyclosporine - Surgery
59
Prevalence of Alopecia? Age/Gender predilection?
- 1 in 1000, lifetime risk of 2% - 3rd decade of life, but can occur any time - No gender predilection
60
Alopecia pathogenesis?
- Autoimmune disease in which hair follicles in the growth phase (anagen) prematurely transitions to non-proliferative involution (catagen) and resting (telogen) phase - causes sudden hair shedding and inhibitor of regrowth + no permanent damage - T-cell mediated --> inappropriate trigger of immune response against follicular antigens
61
Risk factors for Alopecia
- Genetics (20% have first degree relative) - Severe stress - drugs and vaccinations - infections - vitamin D deficiency
62
Diseases associated w/ Alopecia
* **Thyroid Disease - Lupus - Vitiligo - Atopic dermatitis - Allergic rhinitis - Psoriasis - Down syndrome - Polyglandular autoimmune syndrome type I
63
Pt presents w/ smooth, circular, discrete patches of complete hair loss that developed over the past 2-3 weeks. Pt states that the patches are pruritic and burn. What do you expect to see on PE? What lab test would you order?
Alopecia areata - exclamation point hair at margins - thyroid testing - if biopsy done (rare) - peribulbar lymphatic inflammatory infiltrates surrounding follicles (swarm of bees)
64
Management of Alopecia
Limited hair loss (areara) -Topical or Intralesional corticosteroids (Triamcinolone, Betamethasone diproprionate) --> Caution: skin atrophy, hypopigmentation Extensive hair loss (totalis, universalis) -Topical Immunotherapy (DPCP, SADBE, DNCB) --> 2% solution applied to desensitize pt, 1-2 weeks later 0.01% solution applied to area 1/week, slowly titrate up to 2% --> DC if no improvement by 6 mo. 2nd line: Minoxidil, Anthralin cream, Phototheraphy (PUVA) Systemic Therapies: Oral GCs, Sulfasalazine, MTX, Cyclosporine, Biologics
65
Clinical Course of Alopecia?
- 50% w/ limited patchy hair loss recover spontaneously w/in a year - some progress to multiple episodes - 10% progress to alopecia totalis or univeralis
66
What manifestation would you expect to see in alopecia totalis/universalis that is less common in alopecia areata
- nail abnormalities --> Onyxhorrhexis (longitudinal nail fissuring) - 60% in severe disease - 10-20% in Areata

Clin Med I (4 decks)

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