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Flashcards in Derm Pictures Deck (61):
1

What is this?

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Ochronotic pigmentation of ear cartilage and sclera-

What is it? Bluish-gray auricular cartilage in a patient with alkaptonuria. B) Ocular ochronosis with scleral pigmentation.

What lab tests will show this? Increased homogentisic acid in the urine and the darkening of urine when adding sodium hydroxide

When does it occur? After age 40. Urine symptoms present at birth.

Why does it occur? Alkaponuria, an inherited biochemical error of metabolism. his deficiency results in accumulation and deposition of HGA in cartilage, causing the characteristic diffuse bluish black pigmentation. These affected connective tissue become weak and brittle with time, leading to chronic inflammation, degeneration, and osteoarthritis. Ochronosis can occasionally occur from exposure to various substances such as phenol, trinitrophenol, resorcinol, mercury, picric acid, benzene, hydroquinone, and antimalarials.

What is the treatment? No cure. A diet high in vitamin C may be helpful

2

What is this?

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What is it? Stasis dermatitis

What does it feel like? Slow onset of itching on both legs

What does it look like? Red brown discolration with ankle involvement and edema

Why does it occur? Chronic venous insufficiency with hypertension may lead to lipodermatosclerosis and venous leg ulcers. Backflow of blood from the deep to superficial venous syste

Who does this effect? Middle aged older than 50

How is it diagnosed? Dopple studies to determine deep vein circulation

How is it treated? Compression therapy, ligation therapy, light therapy for refractory stasis ulcers

3

What is this?

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Digital gangrene in Raynaud's- Multiple gangrenous lesions of the toes due to necrotizing arteriolitis in a patient with systemic lupus erythematosus and severe Raynaud's phenomenon.

What is it? Raynaud's disease causes some areas of your body — such as your fingers and toes — to feel numb and cold in response to cold temperatures or stress. In Raynaud's disease, smaller arteries that supply blood to your skin narrow, limiting blood circulation to affected areas – can lead to gangrene when artery is fully occluded

What does it look like? Skin turns white, then blue and cold and numb

What does it feel like? Cold fingers or toes, color changes in response to stress, numb and prickly feeling

How is it treated? Bp meds can help with circulation like CCB or alpha blockers. Staying warm will prevent attacks. Avoid smoking, avoid beta blockers, wear gloves

4

What is this?

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Annular sarcoidosis. Erythematous, indurated, ring-like plaques with central clearing are present on the back.

5

What is this?

•Description: Herpes zoster, known as "shingles," results from reactivation of the varicella virus.

•cutaneous infection characterized by vesicular lesions on an erythematous base.

•often preceded and accompanied by severe neuritic pain or itching.

•generally confined to a dermatomal distribution based on their dorsal root ganglion of origin, and should not cross the midline (if they do, consider Hodgkin's disease).

•Reactivation may be a consequence of aging, stress, or immune compromise.

•Zoster may reoccur, and patients may develop post-herpetic neuralgia (continued pain without cutaneous findings).

•Diagnosis:

•Primarily clinical.

•Tzanck smears may show multinucleated giant cells.

•Patients under 50 years of age should be given an HIV test and worked up for other causes of immunosuppression.

•Treatment: Causes of immunosuppression should be addressed. Pain control and wet dressings may alleviate symptoms.

•Antiviral therapy (such as acyclovir, valacyclovir, and famcyclovir) started within 72 hours diminishes duration of acute pain and lesion formation, and may decrease post-herpetic neuralgia.

•Other complications include encephalitis, spinal cord lesions, and secondary Group A streptococcus infection.

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6

What is this?

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•Description: Erythematous, non-pruritic papules on the back, torso, and palms consistent with secondary syphilis.

•normally appears around 6 weeks after the initial lesion, called a chancre (a painless, hard, indurated ulcer).

•often accompanied by a flu-like illness, hepatosplenomegaly, and lymphadenopathy.

•lesions vary widely, causing the axiom, "the great imitator."

usually erythematous or pink, papular, and occur diffusely, notably on the palms and soles

•Diagnosis:

•Screening for syphilis is achieved by the rapid plasma reagin (RPR) or the Venereal Disease Research Laboratory (VDRL) test.

•All positive tests should be confirmed with fluorescent treponemal antibody (FTA) absorption test.

•Rx: Treatment for early disease (Primary and secondary for less than 1 year) is one dose of IV benzathine Penicillin G. For late disease, PCN G is given once a week for three weeks. Follow-up includes RPR at 3, 6, and 12 months to assess response to treatment.

7

What is this?

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Chilblain lupus- Chilblain lupus characterized by reddish-blue nodules (in this case, on the fingers) occurring in cold weather. The lesions improved after the administration of nifedipine.

Chilblain Lupus Erythematosus (CHLE) is a rare form of cutaneous lupus erythematosus (LE), more frequently seen in middle aged females. It is characterized by erythematous to violaceous plaques over the acral areas induced by exposure to cold or drop in temperature unlike lesions of lupus erythematosus that worsen with sun exposure.

8

What is this?

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Myiasis – Nodule containing fly larva. Note the central punctum.

What is it? Infestation of the skin containing larvae of maggots

Where does it occur? People traveling to tropical country

What does it present as? Boil like lesion on exposed areas

What does it feel like? Painful, itchy, tender, feels like something is moving under the skin, may have fever

Treatment: put frigging bacon on it for a few hours until the larvae come up, then grab them with tweezers

9

What is this?

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Hidradenitis suppurative

  • What- tender inflammatory nodules; abscesses; and “double comedones” with seropurulent drainage are a common presentation; is a chronic, supporative disease
  • Why- blockage of the ducts by keratinous materials then secondary inflammation with chronic infection and draining abscess- bacterial pathogens include S. aureus, streptococci, E.Coli, and pseudomonas aerignosa. Predisposing factors are obesity and acne. Disease of terminal follicular apocrine glands
  • Where- typically involves axillae, anogenital region, and skin under the breasts
  • Diagnosis is clinical, based on characteristic features including typical lesions, location and chronicity. No biopsy required
  • Treatment- No cure; tx depends on severity. Therapies include topical and oral abx (1st line- tetracylcines), interlesional glucocorticoids, isotretinoin therapy and surgery (unroofing/ excisions or I&D) Psychosocial support important.

10

What is this?

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•Description:

•An erythematous tender papule evolving to a crusted ulcer with raised, sharply demarcated margins.

•Tularemia, or "rabbit fever," is an acute infection caused by the gram-negative Francisella tularensis.

• especially common in rabbit hunters, agricultural workers, campers, sheep herders, and laboratory technicians.

•organism is transmitted by a small abrasion or puncture wound, ingestion of infected meat, inhalation, or from the bites of infected insects.

•Tularemia presents as 6 different clinical syndromes--ulceroglandular (most cases), oculoglandular, glandular, oropharyngeal, typhoidal, and pulmonary.

•produces a prodrome of headache, malaise, myalgia, high fever, pruritic papules, and lymphadenopathy. wild animals.

•Diagnostic Workup:

•Diagnosis is usually made on clinical grounds, especially in a patient with a confirmed history of animal/insect exposure along with systemic manifestations.

•diagnosis can also be confirmed with serology, by demonstrating a fourfold rise in acute and convalescent antibody titers.

•Treatment: First-line therapy is Streptomycin, 1-2 grams/day for 7-10 afebrile days. Alternatives include Gentamycin, Tetracylcline, or Chloramphenicol but they have lower cure rates and higher relapse rates.

•Patients should also be advised to avoid drinking, bathing, swimming or working in untreated water where infection may be common among wild animals.

11

What is this?

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fly larvae protruding. same tx as Myiasis

12

What is this?

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Nodular sarcoidosis – rhinophymatous- Rhinophymatous nodular sarcoidosis. Diffuse enlargement of the nose with granulomatous infiltration resembling rhinophyma is present.

13

What is this?

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What is it? Sunburn

What does it look like? Blister formation on the skin, red

What does it feel like? Painful, hot to touch

When does it appear? hours after too much ultaviolet light from sunshine or artificial sources

How long does it last? Several days to fade

What can this cause? Increased sun exposure can lead to skin damage like wrinkles, rough spots, skin cancer

How is it treated? OTC pain relievers, like ibuprophen or naproxen. Corticosteroids help with itching. Moisturize peeling skin, do not break blisters as it will slow the healing process. Cover with gauze, if they break clean with soap and water and then an antibacterial cream. Aloe or hydrocortisone cream will also help.

14

What is this?

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Guttate Psoriasis

•Description: numerous erythematous lesions

•Guttate psoriasis is unstable, and occurs in sudden rash-like showers of discrete papules on the trunk, face, and scalp.

•Spares the palms and soles.

•may be associated with group A streptococcal pharyngitis, viral infection, impetigo, or steroid withdrawal.

•papules may or may not be covered with scales.

•Diagnosis: Based on clinical findings.

•Treatment: Confirm group A streptococcal infection via throat culture or increased antistreptolysin (ASO) titer.

•Determine HIV serostatus in high-risk patients, as sudden psoriasis episodes may be seen with HIV infection.

•Treatment: Treat the underlying streptococcal infection with antibiotics.

•In addition to ointments and emollients, preparations such as coal tar, calcipotriol, and topical steroids may be applied to lesions. UVB phototherapy may also be helpful.

•Scales may often be visualized after scraping the lesions. Guttate psoriasis

•much more likely to become chronic psoriasis that is stable and may go into remission.

15

What is this?

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Berloque dermatitis- This adolescent developed hyperpigmented streaks from a photosensitizer in his sunscreen. After several days of erythema, the red patches became dark brown.

What does it look like? The clinical presentation of berloque dermatitis may be classically divided into 2 phases. The initial acute inflammatory phase consists of erythema, edema, pain, pruritus, and increase in skin temperature around the area of contact with the phototoxic agent. The second stage is hyperpigmentation of the lesion.

Where does it occur? usually present with small areas of redness or pigmentation of the skin, usually on sun-exposed areas, such as the neck.

What does it feel like? Pain, itchiness. Hyperpigmentation main complaint.

What causes this? A careful history may reveal use of a perfume or fragrance-containing product on the skin prior to a period of sun exposure, such as sunbathing or a picnic.

How long does it last? If untreated, the natural history of the disease also is biphasic; the inflammatory lesions resolve in days to weeks, but the pigmentation may last months or even years.

What is the treatment? Limit sun exposure. Pain relief with analgesics. Topical corticosteroids. Discontinue offending perfume or substance, do not wear on sun exposed areas. Can use hydroquinone, skin bleaching, to treat.

16

Sarcoidosis

What is it? Sarcoidosis is a disease that leads to inflammation, usually in your lungs, skin, or lymph nodes. It starts as tiny, grain-like lumps, called granulomas. Sarcoidosis can affect any organ in your body.

What causes it?No one is sure what causes sarcoidosis. It affects men and women of all ages and races.

Who is affected? It occurs mostly in people ages 20 to 50, African Americans, especially women, and people of Northern European origin.

What are the symptoms? Cough, SOB, weight loss, night sweats, fatigue

How is it diagnosed? CXR, lung function test, biopsy

What is the treatment? Corticosteroids

17

What is this?

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ITP - Petechiae

•Description: This is an example of petechiae seen in the leg of a patient with a platelet count of two thousand.

•This finding is caused by Idiopathic Thombocytopenic Purpura, a disorder characterized by the autoimmune destruction of platelets.

•At platelet counts of less than ten thousand, small vessels hemorrhage, resulting in the diffuse petechiae seen here. Easy bruising is common in these patients but overt bleeding is rare.

•Diagnostic Work-Up: There is no gold standard test for ITP. Other causes of thrombocytopenia must be ruled out. A careful history along with a peripheral blood smear will direct additional testing, which may include autoantibody studies, imaging, HIV testing, and a bone marrow biopsy. Treatment: Treat the underlying cause if one can be identified. For true ITP, glucocorticoids (prednisone 1mg/kg daily) and intravenous immunoglobulins may help raise the platelet count to safe levels. Splenectomy may be indicated.

18

What is this?

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Subacute cutaneous lupus erythematosus

  • What- often presents with annular erythematous scaly plaques, scaling at the borders of the lesions is common
  • Where- neck, upper trunk, and arms are typical sites of involvement
  • Why- associated with discoid lupus erythematosus (DLE)
  • Tx: the elimination of exacerbating factors is an important component of long-term management. Strict photoprotection should be recommended, and photosensitizing medications should be discontinued if feasible. The possibility of drug-induced disease also needs to be considered in patients who present with SCLE, and should prompt discontinuation of any potential offending agents; topical corticosteroids for first line therapy
  • Erythematous, annular plaques with scale are present on this patient with subacute cutaneous lupus erythematosus:

19

What is this?

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Circinate balanitis

  • Rash on the head of the penis that is a clinical presentation of reactive arthritis/ Reiter syndrome.
  • serpiginous lesions on the glans penis that may take on an arcuate or annular appearance

Shallow erythematous erosions in a circinate distribution are present on the gland

20

What is this?

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••Actinic Keratoses

Dermatologist call them “AK’s”

•Red-tan scaly plaques

•May have silvery white scale

•On sun exposed areas, and directly related to sun exposure

•Premalignant and may develop into squamous cell

•Non-Infectious

21

What is this?

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Allergic Contact Dermatitis, Tea Tree Oil

•Description: Large erythematous, edematous plaques with clearly-defined borders that may cause stinging, itching, or pain.

•delayed, cell-mediated hypersensitivity reaction develops 48 hours to a few days after exposure to an allergen.

•The initial rash is confined to the area of exposure but may spread into the periphery, usually lasting 1-2 weeks unless exposure to the allergen is continued.

•In the acute stages, vesicles and papules may appear over the erythematous region.

•Later, plaques will fade in hue and dry, eventually lichenifying in the case of chronic exposures.

•Diagnosis: Based on history and physical exam. Location and history of products contacted are particularly useful in diagnosis. Allergen can be confirmed with the patch test; apply the suspected allergen to an area of skin previously unaffected by the dermatitis at least 2 weeks after the initial rash has subsided and look for a resulting skin reaction.

•Treatment: Identify and avoid the allergen. Use topical or systemic steroids if severe.

22

What is this?

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  • Rhinophyma in rosacea

  • What- complication of chronic active rosacea
  • Why- the result of chronic deep inflammation, an increase in connective tissue, sebaceous gland hyperplasia, and vascular ectasia that causes irreversible hypertrophy of the tissues in the nose
  • Where- phymatous changes may be seen in the chin, forehead, ears, eyelids and (most commonly) the nose
  • Benign but very cosmetically displeasing; severe cases may lead to airway obstruction
  • 4 types based on type of tissue hypertrophied- glandular,fibrous, fibroangiomatous, and actinic.
  • More common in men, (20:1 ratio)
  • Diagnosis- primarily clinical; biopsy only in unusual cases to r/o other causes
  • Treatment- usually surgical and requires referral to plastic/ dermatologic surgeons
  • Marked distortion of the nose is present in this patient with severe rhinophymatous rosacea:

23

What is this?

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Melasma

  • What- chronic disorder resulting in symmetrical, blotchy, brownish facial pigmentation;macules and large flat brown patches
  • Where- forehead, cheeks, nose, upper lips, jawline; more common in people who tan well or have naturally brown skin; genetic predisposition
  • Why- cause is complex; overproduction of melanin, by the pigment cells, melanocytes, which is taken up by the keratinocytes (epidermal melanosis) and/or deposited in the dermis (dermal melanosis, melanophages)
  • Triggers- sun exposure/ sun burn, pregnancy, hormone tx like birth control, certain meds (that tx cancer), and hypothyroidism
  • Diagnosis- clinical, could get biopsy to confirm
  • Treatment- d/c birth control, sunscreen SPF50+ / sun protection, use of mild cleanser;Tyrosinase inhibitors are the mainstay of treatment;
  • A mottled hyperpigmented patch is present on the cheek:

24

What is this?

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•Visualized directly superior and lateral to the tongue depressor underlying strands of this patients hair are louse eggs (aka nits).

•These nits are white and hard and attached to the hair shaft. Since the eggs require heat for incubation the eggs are laid usually 1 centimeter from the scalp surface.

•The eggs hatch in 7-10 days and the lice live for about 1 month with the ability to lay up to 10 eggs per day.

•This massive reproductive ability makes lice very contagious. Symptoms of infection range from asymptomatic patients to mild to moderate itching.

•WorkUp: Clinical diagnosis is usually adequate. On occasion repeated examinations will be necessary to discover lice. Nits flouresce with a Wood's lamp.

•Treatment: Over the counter permethrin rinse are usually the first line of treatment. More concentrated rinses can be used as second line agents along with pyrethrin and lindane shampoos.

•Agents should always be applied again 1 week later to eradicate lice that may have survived initial treatment. Special combs are available to help remove nits cemented to hair shafts.

•Treatment of family members and close contacts is recommended to stop spread of the infestation.

25

What is this?

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Livedo reticularis- A red-blue, reticulated vascular network is present on the legs.

What is it? Livedo reticularis is thought to be due to spasms of the blood vessels or an abnormality of the circulation near the skin surface. it may be a symptom of a serious underlying condition, such as vascular disease, an endocrine disorder or a rheumatologic disease, such as lupus.

What does it look like? It makes the skin, usually on the legs, look mottled and purplish, sort of a net-like pattern with distinct borders.

What is the treatment? Exercise and stay away from the cold

26

What is this?

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Fixed drug eruptions (A) typically resolve with postinflammatory hyperpigmentation (B).

What is it? Result of a drug allergy. Single, multiple round, sharply demarcated, dusky red patches Central bullae may appear in lesions of fixed drug eruptions, which present as single or multiple dusky erythematous to violaceous round plaques. The lesions tend to heal with significant postinflammatory hyperpigmentation and typically recur in the same sites with subsequent drug exposure.

What does it feel like? Itching and burning, may blister and turn brown.

Where does it occur? Will reoccur if the patient is exposed to the same agent in the same exact spot The lips, genitalia, face, and acral areas are common sites of involvement.

Diagnosis: Need a good history. Biopsy will show hydropic degeneration of the epidermal basal cells and pigmentary incontinence. 

Treatment: avoid the causative agent

27

What is this?

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Cutanous larva migrans:

What is this? Cutaneous larva migrans is the most common migratory skin infection in travelers 

Why does this occur? It develops when infective larvae of animal hookworms (usually Ancylostoma braziliense) penetrate the skin and migrate in superficial tissues, producing a characteristic serpiginous eruption How do humans become infected? direct skin contact with soil, sand, or other material contaminated with feces from hookworm-infected animals, usually dogs or cats.

When do lesions appear?  Lesions appear within several days of exposure

Where are the lesions found? feet, buttocks, and thighs

What do the lesions feel like? Lesions can be itchy or painful Tingling/prickling at the site of exposure within 30 minutes of penetration of larvae

What is the predisposing history? Often associated with a history of sunbathing, walking barefoot on the beach, or similar activity in a tropical location

What do the lesions look like? papular or vesiculobullous. The lesions can be complicated by secondary staphylococcal or streptococcal infection.

What is the treatment? Cutaneous larva migrans is typically self-limited, though medical treatment can shorten the clinical course of Thiabendazole

28

What is this?

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Pyoderma gangrenosum

  • What- presents as a rapidly enlarging, very painful ulcer. It is one of a group of auto-inflammatory disorders known as neutrophilic dermatoses; not infectious
  • Why- autoinflammatory d/t some form of neutrophil dysfunction, sometimes associated with RA, IBS, chronic active hepatitis, leukemia, PAPA syndrome, Wegener granulomatosis, or use of levamisole- adulterated cocaine; however 50% of those affected by it have none of those risk factors. Usually pts 50+ years.
  • It may start as a small pustule, red bump or blood-blister leading to an ulcer. The ulcer can deepen and widen rapidly. Characteristically, the edge of the ulcer is purple and undermined. Pyoderma gangrenosum is usually very painful. Several ulcers may develop at the same time
  • Diagnosis: clinical; biopsy could be done to r/o other causes
  • Treatment- topical steroids, tacrolimus ointment, intralesional steroid injection, compression bandaging to reduce swelling. If larger/ more severe ulcers- systemic oral or IV steroids or anti- TNFalpha inhibitor (infliximab, adalimumab). If secondary infection is detected also need ABX.
  • Multiple active and healing lesions of pyoderma gangrenosum with cribriform scarring in patient with inflammatory bowel disease:

29

What is this?

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•Description: Erythema, edema, pain, and warmth over chest of man with HIV.

•furuncle caused by MRSA.

•red, hot, and tender abscess.

•MRSA is a concern on any patient, but especially important in HIV, diabetic, or other immunocompromised states.

•In addition to the pain at the site, patients may have fever and general malaise.

•Diagnosis: Clinical + gram stain/culture. Tx: Incision and drainage + antibiotics. Antibiotics are required for immunocompromised patients.

30

What is this?

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Herpes Zoster C3 C4 Distribution

•Description: Clear vesicles on an erythematous, edematous base following the C3-C4 distribution on this patient's lateral neck and shoulder representing Herpes Zoster.

•Herpes Zoster is a reactivation of varicella zoster virus characterized by "stabbing" neuritic pain in a dermatomal distribution.

•constitutional symptoms precede the eruption by several days.

•Age, immunosuppressive drugs, lymphoma, fatigue, and emotional upset have all been implicated in reactivating the virus.

•Diagnosis:

•Consideration for HIV testing should be given for patients under 50 because decreased immune function triggers reactivation of VSV.

•Pain persisting more than 30 days after the eruption is called post herpetic neuralgia,

•Antivirals and amitryptiline have been shown to decrease the duration and intensity of post herpetic neuralgia.

•Treatment: Antiviral therapy started within 72 hours diminished the duration of acute pain and may decrease the duration of post-herpetic neuralgia. Oral corticosteroids are not indicated.

31

What is this?

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What is it? Schamberg's disease, a variant of pigmented purpuric dermatosis (PPD)

What does it look like? Schamberg's disease presents with discrete, nonblanchable, red-brown purpuric patches that are usually a few millimeters to several millimeters in diameter/ Brown macules and patches with red-brown (cayenne-pepper-like) pinpoint macules are present

When does it occur? Middle aged adults

Why does it occur? Can be from systemic diseases, medication reaction, venous hypertension, gravitational dependency, aerobic exercise, contact allergens, drugs

What does it feel like? Usually asymptomatic. May have mild itchiness.

Where does it occur? The most common site for involvement is the bilateral lower extremities (below the knees). The thighs and buttocks are also frequently involved.

Treatment: supportive stockings to help with vascular leaking, remove contributing factors like medication or contact allergen, topical steroids

32

What is this?

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Papular sarcoidosis- Multiple small papules are present on the nose and cheeks of this patient with cutaneous sarcoidosis.

33

What is this?

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New World cutaneous leishmaniasis due to L. (Viannia) panamensis- Circle shows a good location for skin punch biopsy.

What causes this? Leishmaniasis consists of a complex of vector-borne diseases caused by a heterogeneous group of protozoa belonging to the genus Leishmania; it is transmitted by sand fly vectors.

How is it treated? Many cutaneous leishmaniasis infections eventually resolve clinically without treatment, and not all patients who undergo treatment demonstrate elimination of parasitic infection. The benefits of treatment include accelerated healing of skin lesions, reduced likelihood of recurrence (especially in the setting of subsequent immune compromise), diminished severity of skin scarring and attendant emotional concerns, and reduced risk for metastatic infection. Treatment is with azoles.

Who gets this? Patients who served in the military in the Middle East can return with this infection

How is this diagnosed? Cutaneous scraping and microscopic analysis is the simplest and most common test

How is this treated? Pentavalent antimony

34

What is this?

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Skin Popping

•Description:

•Circular depressions and indentations due to subcutaneous injections of IV drugs. This technique is used by IV drug users when a peripheral vein cannot be found.

•lesions often lead to fat atrophy and scarring.

•Patients who have injected drugs into the veins on the dorsum of the hands often suffer phlebitis and lymphangitis secondary to foreign particles contaminating the injected products.

•Diagnosis:

•History and clinical features are sufficient for the diagnosis. It is also important to conduct serology tests to rule out Hepatitis B and C and HIV. Treatment:

•This is a physical finding that does not require treatment. Discourage IV drug use.

35

ABCDE

•Asymmetry

•Border

•Color

•Diameter

•Elevation and Enlargement

36

What is this?

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Botfly extraction from nodules- Top Left (A) Extraction of Dermatobia hominis larva from a nodule on the scalp. The lesion was anesthetized with lidocaine intralesionally and then gently extracted in toto. (B) An additional lesion from the same patient contained another larva.

What is it? Cutaneous furuncular myiasis Why causes this? Central and South American botfly enters through a pore

What are the symptoms? Locally painful, firm, furuncle lesion with a centrally located pore. Mimics an infectious sebaceous cyst.

How is this treated? Removal, try not to vomit while doing it

 

37

What is this?

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Telangiectasias

•Red, wiry

prominent dilated

cutaneous vessels

(linear

telangiectasis)

on the face.

Non-Infectious

Caveat – not just the elderly!

38

What is this?

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Lupus vasculitis- Palpable purpuric lesions on the shins in a patient with lupus and necrotizing vasculitis of the skin, kidney, and brain.

What is it? Cutaneous vasculitis is a term used for inflammation of the blood vessels in the skin that occurs in up to 70% of patients with lupus erythematosus (LE). The inflammation affects the smaller vessels of the skin such as the capillaries and the medium-size vessels that include venules and arterioles.

What does it look like? Palpable purpura in small vessel vasculitis that is caused by damage to the vessel wall and seepage of erythrocytes into the tissues.

What is the management? Managing CV includes general measures to keep the patient as comfortable as possible until lesions resolve spontaneously. These include resting, protecting fragile skin from injury, and using analgesics. Limiting exposure to sunlight and fluorescent lighting is also important for those patients who are very photosensitive due to circulating autoantibodies, which are underpinning the vasculitic syndrome.

39

What is this?

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  • What- chronic inflammatory disorder characterized by erythema, telangiectasias, papules, and pustules often affecting cheeks, forehead, and nose. More common in women.
  • As a chronic condition, rosacea is characterized by waxing and waning cylces. Chronic involvement of the nose can lead to irreversiblehypertrophy called rhinophyma (which is more common in men)
  • When- exacerbated by stress, hormonal fluctuations, ETOH, spicy foods, and sunlight. Usually presents in third decade of life and more often affects fair skinned pts
  • Why- etiology unknown. Demodex folliculorum is significantly increased in pts with roacea but true etiology unknown
  • Diagnosis- clinical dx is sufficient
  • Treatment- mild cases- topical metronidazole and topical azelaic acid have been found to be effective. Severe- oral tetracyclines or metronidazole. Refractory cases- vascular laser therapy or intense light therapy can be used

Inflammatory papules and pustules are present on the nose and cheeks on this patient

40

What is this?

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What is it? Bullous arthropod bite

What does it look like? Occasionally, vesicles or bullae occur at sites of arthropod bites. Multiple erythematous papules/intact fluid filled bulla.

Why does this happen?  Insect bite reactions are a response to irritating salivary secretions injected by the female mosquito to anticoagulate the blood. Males mosquitoes are harmelss as they do not have piercing mouthparts. The bite may appear urticarial, papular, vesicular, eczematoid or granulomatous.

What are some arthropods that can cause this? Lice, fleas, bedbugs, flies, mosquitos, bees, ants, wasps, beetles, moths, butterflies, sand flies, centipedes

How is it treated? Cleanse with soap and water and avoid secondary infection, use topical antihistamines

 

41

What is this?

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Telangiectasia, Cirrhosis

•Description: This patient with cirrhosis has multiple small, red arterioles with radiating capillary branches resembling a spider, hence the common name "spider angioma."

•will blanche completely with compression.

•characteristic of parenchymal liver disease, hyperestrogenic states (pregnancy and oral contraceptive therapy), and hereditary hemorrhagic telangiectasia (Osler-Weber-Rendu Syndrome).

•Diagnosis: History and clinical manifestations.

•Treatment: On elective basis for cosmetic reasons laser or electrosurgery may be used.

•Treatment should be directed at the underlying pathology.

42

What is this?

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Vesicles and bullae developed on the volar forearm after application of perfume.

  • What is it? Allergic contact dermatitis (ACD) is the classic presentation of a T-cell-mediated, delayed-type hypersensitivity response to exogenous agents. Large erythematous, edematous plaques with clearly-defined borders that may cause stinging, itching, or pain.
  • When does it occur? delayed, cell-mediated hypersensitivity reaction develops 48 hours to a few days after exposure to an allergen. The initial rash is confined to the area of exposure but may spread into the periphery, usually lasting 1-2 weeks unless exposure to the allergen is continued.
  • What does it look like? In the acute stages, vesicles and papules may appear over the erythematous region. Later, plaques will fade in hue and dry, eventually lichenifying in the case of chronic exposures.
  • Diagnosis: Based on history and physical exam. Location and history of products contacted are particularly useful in diagnosis. Allergen can be confirmed with the patch test; apply the suspected allergen to an area of skin previously unaffected by the dermatitis at least 2 weeks after the initial rash has subsided and look for a resulting skin reaction.
  • Treatment: Identify and avoid the allergen. Use topical or systemic steroids if severe.

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Well demarcated, red-brown, infiltrated plaques are scattered on the back and posterior arm. Hypopigmentation is present at the periphery of some lesions.

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•Crescent-shaped erythema, induration, edema of proximal nail folds of a woman with chronic paronychia; candidal onychomycois on fingernails.

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What is this?

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Erythema multiforme

  • What- acute inflammatory skin condition characterized by multiple, raised, annular, target- type lesions with central erythema
  • When- lesions appear suddenly as erythematous macules and papules that develop into the diagnostic target- type lesion within 24- 48 hours.
  • Where- frequently occur on the palms and soles, extensor surfaces, and face
  • Why- thought to be secondary to a cytotoxic immune response directed against keratinocytes expressing foreign antigens- common causes include infectious agents such as herpes simplex and mycoplasma, and drugs such as sulfonamides, phenytoin, barbiturates, penicillin and allopurinol. Most common cause of recurrent erythema multiforme is genital herpes. Rare causes include vaccines, connective tissue disease, and internal malignancies. But cause remains unknown in half of the cases.
  • Clinical dx with a history of recent viral illness or drug use is sufficient.
  • Tx- mild cases don’t require tx other than treating underlying cause or removing the offending agent if one is identified. Usually resolve within 1 to 2 weeks. If lesions are widespread may need systemic corticosteroids. If associated with herpes, prophylactic antivirals should be administered.

 

Multiple acrally distributed target lesions and mucosal erosions are present in this patient with erythema multiforme majus:

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  • Tinea Pedis. What- fungal infection causing scaling, erythema and maceration. Pts typically c/o intense pruritic areas between toes or on the plantar surface of the foot that are exacerbated by sweating.
  • Several different presentations- “athlete’s foot” refers to moist interdiggital inflammation that could lead to fissuring of the skin (most common between 4th and 5th digits). Acute vesicular tinea pedis- when blisters or pustules develop on the instep or sides of the feet from some infections. “Moccasin” tinea pedis refers to an infection that has caused hyperkeratosis over the entire sole of foot extending up the sides of the feet and over the heel.
  • Why- fungal infection caused by dermatophytes that include Trichophyton, Microsporum and Epidermophyton.
  • Where- toes/ plantar surface of foot
  • Diagnosis- clinical dx; potassium hydroxide (KOH) preparation of skin scrapings will reveal hyphae under microscopic examination- confirms dx
  • Treatment- topical or systemic antifungals agents are the treatment of choice. Keratolytic agents (salicyclic acid, lactid acid, hydroxyl acid) are useful in reducing hyperkeratosis. Any associated onchomycosis must also be treated
  • In this photo of acute tinea pedis the medial aspect of the left great toe demonstrates erythematous, papulovesicular lesions caused by Trichophyton mentagrophytes:

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Gynecomastia, Unilateral

•Description: Firm or rubbery glandular tissue beneath or symmetrically extending from the nipple of a male.

•physiologic, it is most commonly encountered in infants, adolescents, and men 50 to 80 years old.

•most commonly bilateral,

•may also be unilateral.

•older men, caused by decreased androgen production relative to estrogen.

•Other causes / differentials: medications, cirrhosis, malnutrition, hypogonadism, testicular tumors, hyperthyroidism, and chronic renal failure.

•Diagnosis: First, differentiate between gynecomastia, pseudogynecomastia, and carcinoma.

•Pseudogynecomastia is common in obese males; there is only soft adipose tissue, no palpable glandular tissue under the nipple.

•Carcinoma is typically unilateral, eccentric, firm, and associated with lymphadenopathy, nipple retraction or discharge, and dimpled skin.

•Other causes of gynecomastia. Start with a detailed medication history and consider examination of the testes, assessment of virilization, liver function studies, and measurement of testosterone, androstenedione, LH, and hCG.

•Treatment: True physiologic gynecomastia is a benign condition that has not yet been proven to increase a man’s risk for breast cancer

•Consider mammography for all males with unilateral gynecomastia.

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Tungiasis- Bottom Left - Papule containing a female sand flea (Tunga penetrans) on the distal toe.

What is it? Infestation of a burrowing sand flea

What patient education do I give? Don’t wear open toe sandals when walking in the sand

Where does this occur? Low income areas, poorer countries

What history is important? Travel to Central America, South America, India and tropical Africa

What does it feel like? Pain, itching

Where does it occur? Usually the feet

What does it look like? White patch with black dot in the middle

What is the treatment? Curate and excise the flea, cover with gauze and abx cream

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What is this?

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Solar/Senile Lentigines:

What are they? Commonly called liver spots, these are small, flat, discrete, brown macules.

What do they look like? Small, flat, brown macules 1-2cm irregular patches with variegated hyperpigmentation. Circumscribed.

What do they feel like? Not painful, not itchy. Benign.

When do they occur? In people over the age of 40, increase in prevalence and number with increasing age.

Where do they occur? Any sun exposed area like the face, arms, anda hands.

Why do they occur? Chronic sun exposure causes localized proliferation of melanocytes causing these visible brown macules.

Diagnosis: Clinical appearance, history of evolution, history of sun exposure. Take a biopsy if it is a single lentigo has thickening, irregular border or localized increased pigmentation.

Treatment: None but do perform skin cancer surveillance. If lesions are causing distress, use Q-switched ruby laser exposure to clear arm and hand lesions. Encourage sunscreen.

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Tinea Incognito

•Description: Tinea incognito is a tinea corporis infection that has been treated with topical corticosteroids for presumed eczema or psoriasis.

•altered appearance, and may contain atypical erythematous pustules or papules, brown hyperpigmentation, and diffuse erythema and scaling.

•marked scaly border of tinea is often absent.

•Tinea of the hands is frequently misdiagnosed as eczema and treated with topical corticosteroids.

•With initiation of topical corticosteroids, patients will often have reduced pruritus and erythema secondary to decreased inflammation, and the condition will seem to improve.

•However, soon the fungal infection will expand unimpeded, secondary to the local immunosuppression from the corticosteroids.

 

•Diagnosis: KOH preparation, which will reveal dermatophytic epidermal infection with superimposed fungal folliculitis.
•Treatment: Immediately discontinue the topical corticosteroids. Administer topical antifungals. Extensive lesions with deep involvement of the hair apparatus may require systemic antifungals such as lamisil, sporanox, diflucan, or griseofulvin.
•Treat secondary bacterial infection with antibiotics. Any rash that does not clear as expected with topical corticosteroid treatment deserves a KOH preparation, which should also be performed any time that tinea is part of the differential

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What is it? Phytophotodermatitis

What causes it? Contact with light sensitizing botanical substances and long wave ultraviolet radiation

When does this occur? 24 hours after exposure, peaks at 48-72 hours. Intensified by heat, sweating and wet skin

What does it look like? drip pattern blister formation Erythema, edema, and vesiculation occurring in a linear or odd configuration may develop after topical exposure to certain of plant-derived substances

What does it feel like? Burning hyperpigmentation

How long does it last? Lasting weeks to months, will turn into pigmentation changes

What is the treatment? Remove offending agent, cool compress for acute lesions, topical steroids if swelling is involved, if >30% of the body then need burn unit It is a self limited problem, just remove offending agent

What are some offending agents? Limes, celery, meadow grass, hogweed, certain plants in the spring, lemons, parsnip, parsley

 

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Actinic lichen planus

  • What/ where- A photodistributed variant of lichen planus that mot often occurs in individuals with dark complexions; sunlight is the triggering factor in most cases
  • Gray-brown plaques are present on the dorsal hand. Note the annular configuration of the largest lesion:

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Acrochordon (also known as skin tag or soft fibroma)

  • What- Pendunculated, soft papule, benign
  • Where- commonly occurs in skin folds, more common in 30+ years, obese pts, women more affected than men
  • Why- asymptomatic so no treatment required, can be removed for cosmetic reasons if the pt wants (with local anesthesia)

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What is this?

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Sucking Blister

What is it? Sucking blister

What does it look like? often it appears as a flat, scabbed, healing area

What causes this? While the blister created by the infant sucking on his extremity in the womb may still be intact at the time of delivery

Who gets this? Neonates

Where does it occur? Only areas accessible to the baby's mouth

Diagnose: based on observed sucking of the area

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What is this?

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Seborrheic Keratosis

•Raised

•Thickened pigmentation

•Looks “stuck on”

•DO NOT become cancerous

•Non-infectious

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What is this?

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Cherry  Senile Angiomas

•Small, smooth to slightly raised

•Can increase in size with age

•Commonly appear on the trunk in all adults over 30

•Non-Infectious

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•Description:

•Multiple violaceous papules and plaques in an HIV-infected patient.

•Kaposi's Sarcoma is a neoplasia of vascular endothelium, associated with human herpes virus 8.

•Diagnostic work-up:

•Skin biopsy is used to confirm the diagnosis. This would reveal intradermal nodules with vascular channels and atypical endothelial cells.

•Treatment: Local radiation is the treatment of choice. Liquid nitrogen cryotherapy and chemotherapy are other options

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•Description:

•Annular papulosquamous eruption with erythematous hyperkeratotic margins in a patient with HIV. Of note, skin lesions also commonly present as papules, 0.5 to 1.0 cm in diameter, and are virtually NEVER vesicular.

•lesions are widespread, loaded with spirochetes and are highly infectious.

•Secondary syphilis appears 2 to 6 months following primary infection.

•Diagnosis: The diagnosis is based primarily on clinical presentation and confirmed by dark-field examination and/or serology.

•Treatment: Treatment of choice is intramuscular benzathine penicillin G and doxycycline in those allergic to penicillin.

•Patients should be evaluated at 3 and 6 months after treatment.

•Nontreponemal tests should be negative or have decreased fourfold in titer

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Lichen planus

  • What- benign papulosquamous dx characterized by purple, pruritic, polygonal, planar papules (the 5 p’s). Pts will usually c/p pruritis and hyperpigmentation of the involved area
  • Where- most common areas of involvement are extensor surfaces of the wrist, ankle, buccal mucosa, vulva, and penis (lesions in the genital area may be painful)
  • When- about 25% of patients with lichen planus have chronic liver disease (association is highest in oral lichen planus)

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•Description: Scabies infestation by the mite Sarcoptes scabiei generally presents with intense pruritis in the interdigital webs and wrists.

•In this patient, papules and burrows are noted in a linear distribution under the skin.

•This is a hypersensitivity reaction to previous exposure to scabies and generally occurs within 24 hours of re-exposure.

•Mites are transmitted by skin-to-skin contact, often between children, sexual partners, and healthcare workers.

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Discoid Lupus, Sarcoid

•Description: Annular, brownish-purple, hyperpigmented maculopapular lesions and plaques with raised borders are found on the anterior chest, arms and neck of this patient with sarcoidosis.

•Skin involvement occurs approximately 30% of the time in this multisystem granulomatous disease which generally affects young adults.

has discoid lupus which presents with papules evolving to plaques and finally becoming depressed, atrophic, white scars with surrounding inflammation

•Diagnosis:  Biopsy of skin or lymph nodes generally reveals the classic noncaseating granulomas.
•Chest x-ray, pulmonary function tests, EKG, slit-lamp eye exam, liver function tests and a serum calcium test should be included in the evaluation of sarcoid.
•Treatment: Acute sarcoidosis with bilateral hilar adenopathy alone or accompanied by erythema nodosum, uveititis or arthritis is usually self-limited and requires no therapy.
•Chronic skin lesions such as the indurated plaques seen in the case of this patient rarely respond to topical steroids. Antimalarials such as hydroxychloroquine are sometime effective. Discoid lupus requires sun protection, topical steriods, and hydroxychloroquine or retinoids.