Derm- PP slides Flashcards
1
Q
what is the most frequent reason for malpractice in derm?
A
failure to diagnose
2
Q
notice characteristics of skin such as
A
color, moisture, temp, texture, mobility & turgor, lesions
3
Q
Red color of oxyhemoglobin best assessed at ?
A
fingertips, lips, and mucous membranes but in dark skinned people, palms and soles
4
Q
For central cyanosis, look in
A
lips, oral mucosa, and tongue
5
Q
For jaundice look in
A
sclera
6
Q
skin layers from the inside towards the outer most layer are ?
A
subcutaneous tissue, the dermis, the epidermis
7
Q
epidermal appendages
A
Hair Sebaceous glands Sweat glands (eccrine and apocrine) Nails
8
Q
epidermis characteristics
A
Thin but tough- has no blood cells Tightly bound cells – replaced every 4 weeks Stratified zones starting with the stratum germinativum - “basal cells” Blend of keratin and melanin
9
Q
dermis characteristics
A
inner supportive layer made of connective tissue AKA collagen Tough – helps to resist tearing Elastic / resilient capacity Placement of the nerves, sensory receptors, blood vessels, and lymphatics.
10
Q
characteristics of subcutaneous layer
A
Adipose tissue - AKA “fat” Stores fat for energy Provides insulation Soft cushioning effect
11
Q
hair
A
HAIR – is vestigial: no longer needed for protection from cold or trauma It is threads of keratin Held in place by the “arrector pili” that contract and elevate the hair – cause “goose bumps”
12
Q
2 types of hair
A
fine/faint = vellus course/thick = terminal
13
Q
sebaceous glands
A
Produce protective “lipid” substance – sebum – which is secreted through the hair follicle The sebum lubricates skin & hair Abundant in the scalp, face, forehead & chin
14
Q
2 types of sweat glands
A
eccrine and apocrine
15
Q
eccrine sweat gland
A
Coiled and open directly onto the skin surface Produce dilute saline – “sweat” As sweat evaporates, body temperature controlled Floods the skin surface with sweat for cooling Abundant on the body, and mature at 2 months age Everywhere on the skin – greatest concentration on the palms, soles, and forehead Controlled by the hypothalamic thermostat
16
Q
apocrine sweat gland
A
Thick & milky secretion that opens into the hair follicle Mainly in axillae, anogenital nipple & navel area Vestigial in humans Become active during puberty – increased by emotional stress and sexual stimulation Normal skin flora react with apocrine sweat to create body odor Represent scent glands Found chiefly in the axillae, eyelid, breast, and anogenital areas – but do not develop until puberty In humans – little purpose except the production of odor Any stress in emotion causes adrenergic sympathetic discharge from the apocrine glands The functioning of the gland decreases with the aging adult.
17
Q
nails
A
Hard plate of keratin Longitudinal ridges become prominent in aging Appear pink from the underlying highly vascular epithelial cells New keratinized cells start in the lunula
18
Q
(more) characteristics of subcutaneous tissue
A
Serves as a receptor for the formation and storage of fat Is a locus of highly dynamic lipid metabolism Insulates the body from extremes in temperature Supports the blood vessels and nerves The site of origin for sweat glands and hair follicles Cushions the body against injury The scaffolding for underlying body parts Provides boundaries for body fluid Protects underlying tissues from microorganisms, harmful substances, and radiation Modulates body temperature Synthesizes vitamin D Heaviest single organ in body (16% of body weight)
19
Q
Major function of skin is to keep the body in homeostasis so it.. (specifically functions of subq tissue)
A
Provides boundaries for body fluid Protects underlying tissues from microorganisms, harmful substances, and radiation Modulates body temperature Synthesizes vitamin D Heaviest single organ in body (16% of body weight)
20
Q
The mechanical properties of the skin depend mainly on
A
the dermis (the middle/ the “true” skin). This is achieved by the collagen and elastic fibers. -Initially, skin stretches easily, primarily as a result of reorientation of collagen fibers toward the load axis and a reduction in their convolution. -Elastic fibers maintain the tone of the skin and are responsible for restoring the extensibility of slack skin. -After the initial slack has been taken up, skin becomes much harder to extend. However, under continued stretch, further irreversible extension does occur through the process of viscous slip/extension. -This is mainly dependent on collagen fibrils and holds the epidermis in place
21
Q
the dermis contains
A
Contains blood, lymph, & peripheral nerves
22
Q
the layer of the epidermis
A
outer horny layer- the stratum corneum Underlying horny layer (stratum mucosum)
23
Q
what are the functions of the outer horny layer of the epidermis?
A
(aka stratum corneum) -Effective barrier against water and electrolyte loss -Effective barrier against the penetration of toxic agents and ultraviolet radiation -Intact it prevents invasion of normal bacterial to the bloodstream -Low water content, with a high electrical resistance and thus is the main component of the skin to offer some protection against damage from low-voltage electric current.
24
Q
what are the functions of the inner horny layer of the epidermis?
A
(aka stratum mucosum) -Contains Langerhan cells -Function as antigen-presenting cells that migrate to the lymph -Play an important role in allergic response
25
actual 5 layers to the epidermis are?
Basal, prickle, granular- the living epidermis Lucid, horny – the dead-end product
26
apocrine glands (of epidermis)
-produce sterile sweat -Represent scent glands -Found chiefly in the axillae, eyelid, breast, and anogenital areas – but do not develop until puberty -In humans – little purpose except the production of odor -Any stress in emotion causes adrenergic sympathetic discharge from the apocrine glands
27
eccrine glands (of epidermis)
-Also a sweat gland -Works alongside the cutaneous blood vessels in the maintenance of internal body temperatures -Floods the skin surface with sweat for cooling -Blood vessels dilate or constrict to dissipate or conserve body heat -Everywhere on the skin – greatest concentration on the palms, soles, and forehead -Controlled by the hypothalamic thermostat
28
understanding hair
-It grows at different rates in different regions of the body -It grows faster at scalp in women, faster on body in men -Assuming that the scalp contains about 100,000 hairs, it can reasonably be expected that 100 hairs will be shed daily.
29
The activity of hair follicles is intermittent: explain the different phases.
- Anagen is the active period, which may last for 3 or more years -Telogen is the resting phase, usually lasting about 3 months -Catagen is the transition or regression phase, usually approximately 3 weeks in duration (In the human scalp, at any one point in time, approximately 84% of hair is in anagen, 14% in telogen, and 21% in catagen.)
30
understanding wound healing: what are the 3 stages of it?
inflammation, proliferation and tissue formation, and tissue remodeling.
31
when does wound healing begin?
immediately after wounding- platelets dominate this early stage of wound healing: critical in hemostasis, activation of the coagulation cascade, chemotaxis of other inflammatory cells, and clot formation that serves as an early scaffolding for wound repair.
32
Primary lesions are defined as ?
lesions that arise de novo and are therefore most characteristic of the disease process
33
Included in primary lesions are ?
macule papule patch plaque nodule vesicle bulla pustule wheal abcess
34
description of a macule? Examples?
circumscribed flat, NOT palpable + color change up to 1 cm in size Examples- ash leaf macules, cafe-au-lait macules, capillary malformations
35
description of a patch? Examples?
circumscribed flat, NOT palpable +color change larger than 1 cm in size (same as macule except larger than 1 cm) Examples- Mongoloian spots, nevus deppigmentosus, nevus simplex
36
description of a papule? examples?
circumscribed elevated, PALPABLE solid lesion up to 1 cm in size Examples- wart, raised nevis, verrucae, milia, and juvenile xanthrogranuloma
37
description of plaque? Examples?
circumscribed elevated, PALPABLE plateau- like (raised but flat) solid lesion larger than 1 cm in size (from merging papules or nodules) Examples- mastocytoma, nevus sebaceous
38
description of a nodule? Examples?
circumscribed elevated, PALPABLE solid lesion with depth up to 2 cm in size (if larger- its a tumor) (larger than a papule- extends deeper in dermis)
39
description of a vesicle? Examples?
aka blister circumscribed elevated, PALPABLE fluid- filled lesion up to 1 cm in size Examples- herpes simplex, varicella, milaria crystallina
40
description of a bulla? Examples?
circumscribed elevated, PALPABLE fluid- filled lesion "balloon" more than 1 cm in size (same as vesicle except bigger) Examples- sucking blisters epidermolysis bullosa, bullous impetigo
41
description of a pustule? Examples?
circumscribed elevated lesion filled with purulent drainage up to 1 cm in size (if larger- boyle, abscess or furuncle) -Pustules can be primary skin lesions or can initially e a vesicle that then becomes filled with cells or debris. -There is no blood source- could be anywhere Examples: common acne, transient neonatal pustular melanosis
42
description of a wheal? Examples?
circumscribed elevated edematous often evanescent lesion caused by accumulation of fluid within the dermi often allergic rxn, tied to pruritis irregular in shape? Examples- hives, urticaria, bite reactions, drug eruptions
43
description of an abscess? Examples?
circumscribed elevated lesion filled with purulent fluid larger than 1 cm in size (bigger pustule) surrounded by inflammatory response -has a nutritional source aka its connected to the blood vasculature- so we would want to tx systemically Example- pyodermas- think MRSA
44
secondary lesions are ?
characteristically brought about by modification of primary lesions, either by the individual or through the natural evolution of the lesion in the environment. -It is simply the lesion that came second- after the original lesion
45
Included in secondary lesions are ?
crust scale erosion ulcer fissure lichenfication atrophy scar
46
description of crust? Examples?
Results from dried exudate overlying an impaired epidermis. Can be composed of serum, blood, or pus. Example- Epidermolysis bullosa, impetigo
47
description of a scale? Examples?
Results from increased shedding or accumulation of stratum corneum as a result of abnormal keratinization and exfoliation. Can be subdivided further into pityriasiform (branny, delicate), psoriasiform (thick, white, and adherent), and ichthyosiform (fish scale-like) Example- ichthyoses, postmaturity desquamation, seborrheic dermatitis
48
description of erosion? Examples?
Intraepithelial loss of epidermis. Heals without scarring . Examples- Herpes simplex, certain types of epidermolysis bullosa
49
description of an ulcer? Example?
Full-thickness loss of the epidermis, with damage into the dermis. Will heal with scarring Examples- Ulcerated hemangiomas, aplasia cutis congenita
50
description of a fissure?
Linear, often painful break within the skin surface, as a result of excessive xerosis.
51
description of lichenification? Example?
Thickening of the epidermis with exaggeration of normal skin markings caused by chronic scratching or rubbing. Example- atopic dermatitis
52
description of atrophy? example?
Localized diminution of skin. Epidermal atrophy results in a translucent epidermis with increased wrinkling, whereas dermal atrophy results in depression of the skin with retained skin markings. Use of topical steroids can result in epidermal atrophy, whereas intralesional steroids may result in dermal atrophy. Examples- Aplasia cutis congenita, intrauterine scarring, and focal dermal hypoplasia
53
description of a scar?
Permanent fibrotic skin changes that develop as a consequence of tissue injury.
54
The border of a cutaneous lesion may also help in ?
the differential diagnosis. Some lesions, such as acrodermatitis enteropathica, and erysipelas, have distinct borders
55
linear lesions
Several lesions follow a linear pattern. Linear lesions can be subdivided
56
Linear epidermal nevus-
These linear V- and S-shaped lines are believed to represent patterns of neuroectodermal migration, and skin lesions in this distribution indicate areas of cutaneous mosaicism. They do not follow any known vascular, nervous, or lymphatic pattern
57
KOEBNERIZATION (LINEAR)
Certain skin conditions tend to recapitulate at sites of skin injury, which may give them a linear configuration. Classic examples include: psoriasis, lichen planus, and lichen nitidus
58
Segmental infantile hemangioma
The configuration of segmental lesions is thought to be determined by the location of embryonic placodes or other embryonic territories, as can be seen in PHACE(S) syndrome
59
Sessile juvenile xanthogranuloma
Papules, nodules, or tumors having a **broad** base:Molluscum, dermatofibroma, dermal nevus, juvenile xanthogranulom
60
PEDUNCULATED (POLYPOID)
Papules, nodules, or tumors having a narrow, stalk-like base
61
ANNULAR
A round, ring-shaped lesion, where the periphery is distinct from the center
62
NUMMULAR
A coin-shaped lesion, with homogenous character throughout
63
GYRATE/POLYCYCLIC/ARCIFORM/SERPIGINOUS
Variations in the spectrum of annular lesions
64
TARGETOID/IRIS
Concentric ringed lesions, often with a dusky or bullous center. This is characteristic of erythema multiforme
65
HERPETIFORM
Clustered, similar to herpes simplex
66
CORYMBIFORM
Defined as a central cluster of lesions surrounded by scattered individual lesions
67
RETIFORM/RETICULATE
A net- like pattern of lesions
68
skin age related changes: childhood
Port wine stain and strawberry naevi, ichthyosis, erythropoietic protoporphyria, epidermolysis bullosa, atopic eczema, infantile seborrhoeic dermatitis, urticaria pigmentosa, viral exanthems, viral warts, molluscum contagiosum, impetigo
69
skin age related changes: adolesence
Melanocytic naevi, acne, psoriasis (notably guttate), seborrhoeic dermatitis, vitiligo, pityriasis rosea
70
skin age related changes: early adulthood
Psoriasis, seborrhoeic dermatitis, lichen planus, dermatitis herpetiformis, lupus erythematosus, vitiligo, tinea versicolor
71
age related skin changes: middle ages
Porphyria cutanea tarda, lichen planus, rosacea, pemphigus vulgaris, venous ulceration, malignant melanoma, basal cell carcinoma, mycosis fungoides
72
age related skin changes: old age
Asteatotic eczema, generalized pruritus, bullous pemphigoid, venous and arterial ulcers, seborrhoeic warts, solar keratosis, solar elastosis, Campbell-de-Morgan spots, basal cell carcinoma, squamous cell carcinoma, herpes zoster
73
vascular skin lesion: port wine stain
74
vascular skin lesions: strawberry mark
75
vascular skin lesions: Cavernous Hemagioma
Spongy mass
Will not involute on its own
May enlarge
76
vascular skin lesions- more examples of strawberry marks
77
vascular skin lesions- Petechiae
78
vascular skin lesions- Purpura
79
vascular skin lesions- hematoma
80
vascular skin lesions-
81
Measles (Rubeola)
82
Measles (Rubeola)
83
Measles (Rubeola)
84
German Measles (Rubella)
| (common childhood lesions)
85
common childhood lesions in childhood- chicken pox
86
common skin lesions- child and adult-
allergic reactions
Generalized
Pruritic
erythematous
87
common skin lesions in childhood and adult- Psoriasis
88
special skin considerations of the aging adult
Slow atrophy
Loss of elasticity: Thin, dry and wrinkled skin – **parchment thin!!**
Decrease in amount of and function of sweat and sebaceous glands – so that means what ????
Sun exposure accentuates changes.
Nails – longitudinal ridges and slow growth
Liver spots (senile lentigines)
Seborrheic keratoses
Actinic keratoses
Cherry angiomas
Senile purpura
Hair ↓ while graying -thin, fine.
89
aging skin
Advanced photoaging with atrophic skin,
irregular pigmentation,
telangiectasias,
skin sagging,
criss-crossed lines
and periorbital and perioral rhytides.
90
geriatric skin changes- Senile Lentigenes
Commonly called liver spots – small, flat
Follow sun exposure
Circumscribed
Not malignant – no treatment
**Non-infectious**
91
Seborrheic Keratosis
one type of keratosis
Raised
Thickened pigmentation
Looks “stuck on”
DO NOT become cancerous
**Non-infectious**
92
Actinic Keratoses
geriatric skin change
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**
93
Telangiectasias
Red, wiry
prominent dilated
cutaneous vessels
(linear
telangiectasis)
on the face.
**Non-Infectious
Caveat – not just the elderly!**
94
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**
95
infectious skin conditions
Often sexually transmitted Infections -
Often from traveling - and:
\*Suggestive of advanced other disease
\*Suggestive of infectivity
\*Patient often unaware
\* Scary – **Can be Highly Infectious**
96
head lice- how do they work/ replicate
- 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.
97
head lice- work up and treatment
* *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.
98
description of scabies, transmitted how?
Scabies infestation by the mite Sarcoptes scabiei generally presents with intense pruritis in the interdigital webs and wrists.
Mites are transmitted by skin-to-skin contact, often between children, sexual partners, and healthcare workers.
99
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.
100
more pictures of scabies
101
description of secondary syphilis
- 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.
102
diagnosis/ tx for secondary syphilis
- 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.
103
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.
104
herpes zoster c3 c4 distribution **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**.
105
**Description** of MRSA Furuncle
- 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.
106
**diagnosis** of MRSA furuncle
Clinical + gram stain/culture.
Tx: Incision and drainage + antibiotics. Antibiotics are required for immunocompromised patients.
107
herpes zoster- chest- description
- **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).
- Other complications include encephalitis, spinal cord lesions, and secondary Group A streptococcus infection.
108
Diagnosis of herpes zoster
* *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.
109
secondary Syphilis- description
**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.
110
diagnosis of secondary syphilis
* *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
111
general sore algorithm
112
Tinea infection
fungal infection
Active border (classic presentation). The border is red, scaly, and slightly raised. The central area is often lighter than the surrounding normal skin.
Sample this scale by scraping perpendicular to the border.
113
examples of basal cell carcinoma
114
examples of squamous cell carcinoma
115
Skin Cancer – Malignant Melanoma
Asymmetry
Border
Color
Diameter
Elevation and Enlargement
116
Facial - Oral Cancers
Be careful – they most likely develop under the tongue
117
examples of clubbing
118
Nail dystrophy caused by a subungual glomus tumor
119
Red flush of the nail bed induced by a subungual glomus tumor
120
Candidal onychomycosis
Crescent-shaped erythema, induration, edema of proximal nail folds of a woman with chronic paronychia; candidal onychomycois on fingernails.
121
photo
Description:
Well demarcated,
annular, targetoid,
regularly located
ecchymoses
122
Tinea Incognito description
* *- 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.
## Footnote
**However, soon the fungal infection will expand unimpeded, secondary to the local immunosuppression from the corticosteroids.**
123
tinea incognito dx and treament
- 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
124
Allergic Contact Dermatitis, Tea Tree Oil- description
* *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.
125
allergic contact dermatitis, tea tree oil dx & treamtment
* *- 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.
126
Vitiligo and B-12 Deficiency Smooth Tongue description
**Description**: Vitiligo is characterized by areas of depigmentation
- microscopically, are devoid of melanocytes.
- ultimately results from progressive destruction of melanocytes by cytotoxic T lymphocytes.
- an association with autoimmune diseases such as Hashimoto's Thyroiditis, Addison's Disease, Type 1 Diabetes and Pernicious Anemia.
This patient presented with vitiligo and a smooth tongue, and was found to have B12 deficiency.
127
Vitiligo and B-12 Deficiency Smooth Tongue Dx & Rx
* *Diagnosis:** Clinical diagnosis is usually adequate, but dermatopathologic exam may be used for confirmation.
- This would reveal normal skin with an absence of melanocytes.
- A Wood's lamp examination is useful to examine macules in light skinned patients.
- Rx: Treatment includes use of sunscreens, cosmetic cover-ups, and repigmentation procedures. Consider screening patients with vitiligo for other autoimmune disease.
128
Discoid Lupus, Sarcoid description
* *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.
129
Discoid Lupus, Sarcoid dx and treatment
* *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 sometimes effective. Discoid lupus requires sun protection, topical steriods, and hydroxychloroquine or retinoids.
130
Guttate Psoriasis description
* *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.
- 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.
131
Guttate Psoriasis dx & tx
**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.
132
Telangiectasia, Cirrhosis desription
* *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).
133
Telangiectasia, Cirrhosis dx and tx
* *- 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.
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Gynecomastia description (photo of 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.
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Gynecomastia
* *- 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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Hidradenitis Suppurativa
- The main disease of the terminal follicular apocrine glands
- Caused by blockage of the ducts by keritinous materials then secondary inflammation with chronic infection and draining abscess
- AKA: Verneuil's disease Pyoderma fistulans significa
- Hallmark of HS: axilla, inguinal folds, perineum, genitalia)
Etiology: exact cause not yet determined
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Hidradenitis Suppurativa- clincal manifestation/ physical exam/ Rx
- Clinical manifestation: firm painful nodule that may involute and discharge pus, often odiferous through the skin
- PE: lesions often bilateral, multifocal involvement, bridged scarring, double comedomes are classic
- Rx: first line – topic abx with oral tetracycline (several months)
Second line – surgical I&D
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Tularemia description
* *- 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
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Tularemia dx and tx
**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.
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Skin Popping description
* *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.
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skin popping dx
**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.
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ITP - Petechiae description
* *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.
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ITP - Petechiae work up
**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.
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Kaposi's Sarcoma description
**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.
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kaposi's sarcoma work up
**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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Paronychia (of Great Toe) description
**Description:** Paronychia is a bacterial infection of the nail fold.
- Chronic paronychia is usually due to chronic irritant exposure, and may be confused with the nail changes of psoriasis
can also occur secondary to allergic contact dermatitis, indinavir, lichen planus, candida, or a foreign body (i.e. a splinter).
- Chronic paronychia causes the cuticle to disappear, leaving the nail fold even more open to further infection. Many or all fingers are involved in chronic paronychia.
- Acute paronychia is normally caused by trauma or manipulation, although it can occur idiopathically.
- Both acute and chronic paronychia are painful and cause pus to build up underneath the cuticle.
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Paronychia dx and tx
**Diagnosis**: Insertion of an instrument between the nail and the nail fold will cause the pus to drain,
dramatically and immediately relieving the pain.
- Based on clinical findings.
**Treatment:** topical steroids, avoidance of irritants, and antistaphylococcal antibiotics for secondary infection.
- Treat acute paronychia with surgical drainage.
- Treat large erythematous abscesses with antistaphylococcal antibiotics.
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Onychomycosis description
**Description:** White, yellow, or brown discoloration and subsequent breakdown of the distal toenail down to the nailbed characterizes distal subungual onychomycosis,
most common form of fungal nail infection.
- Beginning distally with proximal progression towards the cuticle, the nail may become irregular, thickened, or eroded.
- great toe is usually the first affected, although several (but rarely all) nails on the foot may eventually be involved.
- Tinea pedis may coexist or precede nail involvement.
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Onychomycosis dx and tx
* *Diagnosis:** In order to rule out nail dystrophies that can mimic onchomycosis, confirmation of the presence of fungus should be performed prior to antifungal treatment.
- For distal subungual onychomycosis, KOH examination of nail scrapings is the first step.
- Visualization of dermatophytic hyphae and arthrospores confirms the diagnosis.
- Scrapings should be taken from the most proximal affected area.
- If negative, nail culture can be performed and may need to be repeated due to a high probability of false negatives.
* *Treatment:** Topical treatment is ineffective. Oral antifungal therapy (terbinafine) is preferred although high failure and recurrence rates still exist such that treatment is usually reserved for patients complaining of nail pain, patients desiring treatment for cosmetic reasons, and diabetics or others at high risk for cellulitis.
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Diabetic Foot Ulcer description
* *Description:** Peripheral neuropathy in this diabetic patient puts him at risk for the development of the necrotic ulcer on the lateral aspect of the great tow.
- Peripheral neuropathy decreases the patients' ability to sense ulcers, calluses or abrasions that occur on their feet and put them at risk for wounds and infection.
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diabetic foot ulcer dx and tx
* *Diagnostic workup:** Clinical recognition is diagnostic. Diabetic ulcers may be surrounded by a ring of callus, known as a "button abscess," that is fluctuant to the touch but may extend deep to the joint and bone causing osteomyelitis.
* *Treatment:** Prevention is the best treatment for diabetic neuropathy and this can be accomplished with strict glycemic control and annual diabetic foot exams.
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Tinea Pedis description
* *Description:** erythema, scaling, and bulla formation between the patient's toes indicates interdigital type
- Tinea Pedis. Tinea pedis is a dermatophytic infection that often provides breaks in the integrity of the epidermis
- breaks provide an avenue in which bacteria can invade causing localized or spreading infections such as cellulitis or lymphangitis.
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Tinea Pedis work up & tx
**Diagnositc work-up:** Clinical diagnosis is usually adequate.
Fungal hyphae may be present on KOH preparation, but are often difficult to isolate.
- Treatment: Burrow's wet dressings and Castellani's paint are indicated for acute type infection, while aluminum chloride hexahydrate 20% may be used for chronic type interdigital tinea pedis.
- The use of shower shoes while bathing and washing feet with benzoyl peroxide bar directly after showering can help prevent future outbreaks of infection.
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HIV Warts (of feet) description
* *Description:** HIV positive male patient presents with severe large verrucae vulgaris on the dorsum of the great toe.
- warts are extremely common, affecting 20% of school-aged childen, and also tend to occur in immunocompromised patients where they can be quite disfiguring.
- characterized by "black-dots" or thrombosed capillaries which are pathognomonic and uncovered by scraping the lesion with a scalpel.
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HIV warts work up & tx
**Diagnostic work-up:** Diagnosis is based on clinical findings.
Treatment: In this case these warts were recalcitrant to salicylic acid preparations and required liquid nitrogen (LN2) over several visits.
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Final Considerations - Review Genodermatoses
- The Importance of genetics should be obvious
- Many common dermatoses have a genetic component: e.g. psoriasis, atopic dermatitis,
- A number of inherited disorders are better understood through genetics e.g. white macules on an infants skin might be the first clue to tuberous sclerosis
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types of disorders- Keratinization Disorders
Most dramatic – ichtyosis
Only males are involved
Sex-linked recessive
Begin at birth and persist though life
AKA- fish skin
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