Derm Tx Flashcards
(196 cards)
1
Q
Atopic Dermatitis Tx
A
- Education: to avoid exacerbating factors and hydrate the skin
- vasline is best or other ltion -BID and after bathing - Topical Corticosteroid
-mild: low potency 1-2x per day x2-4 wks
-moderate: med-high pot
-acute: med-very high pot for up to 2wks then replaced with lower potency. - Topical Calcinereurin Inhibitors -
Pimecrolimus(Elidel) cream and Tacrolimus(protopic)
-steroid sparing and antiinflammatory because they imped production of proinflammatory cytokines.
-.1% for adults
-.03% for 2-15
-BID for mild eczema on face, eyelids, skin folds
-2-3x per week for maintanance
may have bruning or itching during the first week of use - Oral antihistamines prn pruitis, antibiotics for 2nd infection, oral steroids for severe or wide spread cases.
2
Q
Topical Corticosteroid warning
A
Face, groin, and skin folds have higher absoprtion so use caution when applying to those locations
-skin atropy, rosacea, striae, bruisng, telangiectasis, hypertrichosis
3
Q
Lichen Simplex Chronicus Tx
A
Want patient to stop the rubbing!
1. High Potency topical steroid
then:
2. Moisturizers
3. Antidepressants: Paroxetine(paxil) or Sertraline(zoloft)
4. for nocturnal pruritis: 1st gen antihistamine, hydroxyzine(Visatril) or Tricyclic antidepressent
4
Q
Dyshidrotic Eczema Tx
A
Primary:
1. Reassurance -usually resolve in 2-3wks
2. Topical Steroids (maybe at night with occlusion)
Secon:
3. Wet dressings (burow’s soaks)
5
Q
Keratosis Pilaris Tx
A
No really good treatment
pt. may try: exfoliating scrubs, topical retnoid, salicylic acid, alpha-hydroxy acids
6
Q
Contact Dermatitis Tx
A
Discontinue exposure or decrease hand washing
and wear protective clothing
- use a bland emollient like vasaline or aquaphor
*Topical corticosteroid 1-2 days x 7-14days
or oral corticosteroid if on face or more than 20% of the body
7
Q
Tx for common cutaneous drug reactions
A
Discontinue drug!!!
-sytemic corticosteroids to come the immune system
-topical steroids or antihistamines prn for pruitis
-cousel to avoid crossreactive drugs in the future
Typically resolved in 5-14 days
may be left with post inflammatory hyper-pigmentation
8
Q
SJS and TEN Tx:
A
Discontinue Medication!!!! Hospital admission if severe usually to ICU or Burn Unite Supportive care: -nutritional and fluid replacement( B/C mouth sores) -Temperature maintance -Pain relief -Occular managment -Wound care and sterile handling
9
Q
Tinea Capitis at risk populations
A
Children, african americans, homeless, poor hygeine, low SES, and overcrowding
10
Q
Tinea Capitus Cause/Presentation
A
Fingual infection (Trichophyton/Microsprorin)
From direct contact
-Scaly patches with alopecia
-black dots with alopecia
-widespread scaling with subtle hair loss
- Kerion
-Favus (multiple cup shaped yellow crusts): usually with immunocomp pt.
11
Q
Tinea Capitus Associated Signs
A
Cervical adenopathy, Dermatophydid reaction ( eczema like,in response to treatment), and rerely erythema nodosum (tender nodules)
12
Q
Tin Cap Dx
A
KOH prep, physical exam, culture, dermascope,woods lamp
13
Q
Tin Cap Tx
A
Systematic antifungal therapy
- Griseofulvin x 6-12wks for microsporin or empiric tx
- Terbinafine x2-4wks if tricophyton
14
Q
Tine Corporis Risk factors
A
Cargivers of children c tinea cap
athletes with skin contact (tinea corporis gladiatroum)
immunocomp
15
Q
Tinea Corporis Presentation
A
Pruritic, annular, erythematous plaque
with a central clearing , raised advancing border
16
Q
Tinea corp,cruris,pedis Dx
A
Physical exam. KOH prep, and culture
17
Q
Tinea Corp,Cruris,Pedis Pharm Tx
A
Topical antifungus
-Cotrimazole at least 2 wks (4wks if pedis)
Systemic only in special circum
-Intraconazole
18
Q
Improper treatment of Tinea infections can lead to what?
A
Usually if you accidentally use steroids
- Tinea Ingognito
- Mojpcchi’s granuloma
19
Q
Tinea Cruris Risk factors
A
Male, sweaty/humid, obese/skinfolds, athletes foot, and occulusive clothing
20
Q
Tinea Cruris Presentation
A
Begins at the inguina folds
well marginated, scaly, annular, with raised border
scrotum is typically spared
-Pruritis, pain
21
Q
Tinea Cruris tx non Pharm
A
Drying powder, avoid tight clothing, weightloss
22
Q
Tinea Pedis Risk Factors
A
occlusive footwear, communal baths or showers
23
Q
Acute Tinea Pedis presentation
A
self limited, intermittnet, recurrent infection
- itchy/pain vessicles following sweating
- secondary staph infections may occur*
24
Q
Chronic Tinea Pedis Presentation
A
slowly progressive that may persist indefinatly
- erosions between the toes (oft bw 3-4)
- interdigital fissures
- May progress to Mocassin Ringworm (along the whole bttom of the foot, with shapr demarcations of accumulated scale
- Tinea Manuum ( two feet one hand)
25
Tinea Pedis non pharm Tx
Burrows wet dressing 20min BID-TID
Treat secondary infections
Food powers, proper footwear
26
Onycomycosis Etiology
Nail infection caused by fungus, yeast, or non-dermatophyte molds
- typically yeast(candida albicans) with fingernails
27
Onycomycosis Risk factors
Old Age, Tinea Pedis, Genetics, Immunodeficiency, Household infection
28
Onycomycosis Presentation
Typically Cosmetic but may be painful
- brown/yellowing of the nail and nail thickening
1. Dista Sugungual: most common and starts from distal corner and moves proximal. Distal nail bed may break exposing nail bed
2. Proximal Subungual: near cutical and extends up usualy seen in immunocomprimised patients
3. White superficial: begins with dull white spots that will extend out. These spots are soft
29
Onycomycosis Dx
KOH prep, culutre, histopathology
30
Onycomycosis Tx
Not neccessary but considered if Hx of cellulitis, diabetic, desires cosmetic improv, or discomfort
- topical meds inefffective and high rate of failure
1. Dermatophye:Oral Terbinafine (6wks fingernails, 12wks toenails
2. Non-Dermatophyte: oral intraconazole (same duration as above)
31
What drugs treat both Onycomychosis and Tinea infections
Terbinafine- tinea capitus
| Intraconazole - other tinea inf
32
Candidial Interrigo etilogy and Risk Factors
infectious or noninfection skin condition of two closely opposed skin surfaces
-moisture, skin friction, immunocompromised
33
Candidal Interrigo Presentation
typically affects the groin,mammary/ab folds, web spaces, and axilla
- erythemous, maccerated(soggy) palques or errosions
- sattelite papules/pustules
- fine peripheral scaling
34
Candidal Intertrigo Dx
-Physical Exam, KOH prep, culutre
35
Candidal Intertrigo Tx
Prevent:
-drying agents, weight loss, address underlying med cond.
Pharm:
Topical x2-4 wks: Nystatin (for yeast)
Syestemic for resistant/severe: Fluconazole 2-5wks
36
Tinea Versicolor Cause/ Risk Factors
Caused by malassezia- normal skin flora of the skin that becomes pathologic
Seen in tropical climates, adolecents/ young adults, hyperhidrosis, genetics, immunosupression
*NOT contageous*
37
Tinea Versicolor Presentation
Macules, patches/plaques of the trunk and UE, can coalesce, often have fine scale, maybe erythemous
- often asymptomatic but may be mildly itchy
- often hypopigemented on dark skin and hyperpigmented on lighter skin
38
Tinea Versicolor Dx
Physical, KOH prep, Woods lamp (sometimes yellow/green flourescense)
39
Tinea Versicolor Tx
Topical
- Clotrimazole (2wk), Selenium sulfide( lotion, foam, shampoo x1wk), or Zinc Pyrinthione shampoos x2wk
Systemic
-oral intraconazole 5-7days
- only insevere cases and failed topical, not used in children
*note pigmentation can persist for months which makes it hard to nknow if the treatment has worked
40
Scabes etilogy/ risk factors
Parasitic infection- sarcoptes scabiei mite
- female mites and their eggs
- eggs hatch in 10 days
All groups affectes and it is transfered through direct contact
41
Scabes Presntation
Intial lesion and burrow (pathonomonic)
- locations: groin, rists, waist
severe pruritis which is often morse at night
In immunocomprimised people: Norwgian or crusted scabies
-will have severe fissures and requires oral medication
42
Scabies Dx
-Visualization of the burrow , microscopic identifcation of the mite, eggs, or fecal pellates with dermatoscope
43
Scabies Tx
Permethrin 5%- first treatment and then 2nd dose 10-14 days later
Oral Ivermectin- single dose repeated 2 weeks later
Edu: treat house and close contacts simulaneously, itching may persist for 2 wks( can treat with antihistamines and emoilliants), wash linens under high heat
44
Pubic Lice etilogy/ presentation
Parasites that are larger than Scabies
- crab louse (phthirus pubis)
- transmitted through sexual contact
- presents as itching in the groin or axilla
45
Pubic Lice Dx/Tx
Visualize the lice or nits with a microscope
Tx: Permithrin 1% cream and repeat in 10 days
and treat sexual partners
* often have another type of STI*
46
Important things to note when diagnosing acne vulgaris
- possible workup for hyperandrogenism for female patients with other sx
- rapid acne with other signs of virilication may be becuase of ovarian or adrenal tumor
- medication history may reveal acnes causing medications
47
Comedonal (non-inf) acne Tx
Topical retnoid
48
Mild papulopustuar and mixed acne Tx
Moderate
Sever
BP +/- topical antibiotic and topical retnoid
BP + topical retnoid+ oral abx (tetracycline class)
BP+ top ret+Oabx
OR oral isotrtinoin monotherapy
49
What acne meds are teratogenic ? What are okay?
Topical retnoid and not okay during pregnancy and BP is not really known
- oral erythromycin, topical clindamycin, and topical azelaic acid
50
Solar Lentigo
Age spot or freckles
- local proliferation of melanocytes and from UV damage
- well circumscribed
- brown macules
- often found in group
- no treatment required
51
Seborrheic Keratosis (SK)
-benign epidermal lesion proliferation of immature keratinocytes
- usually after age 50
warty, waxy, stuck on apperance
-well circumscribed
-back,head, neck
52
Irritated SK
caused by rubbing of friction of the SK
| - may have pruitis, pain, or bleeding
53
Leser-Trelat sign
sudden onset of multiple SK +skin tahs + acanthosis nigrican
- possible associated with GI and Lung cancer
54
SK eval and managment
Dx- clinical presentation and biopsy if necessry
| Tx: reassurance and possible removal for some ISKs. Shave off or use cryotherapy.
55
Keratoacanthoma Presetation
rapid growth- 6-8wks
- round, flesh colored nodule with central keratin plug
- same risk factors as skin cancer
- benign but some say it pseudo-malignancy
56
Karatonacanthoma Managment
Majority will resolve on their own in 6-9mo
Difficult Dx: requires biopsy and treatment
- typically excisional biopsy is typically preferred
57
Actinic Keratosis etiology andRisk Factors
AK
"pre cancer" may progress to SCC
M>F
light skin, history of UV exp, immonsuppression, ^age
58
AK presentation
- Erthematous, scaly/gritty macule or papule
- may be tender
- often felt easier than seen
59
AK dx
clinical
dermatoscope
Shave or punch biopsy if unable to differentiate from SCC (>1cm, rapid growth, ulcer)
*if >6mm then we just consider it SCC in situ
60
AK tx
may spont resolve but usually treat anyway
- Cryotherapy or surgical intervention
Field Treatment: if you have multiple lesions
-topical flourouracil cream (preferred)
-Photodynamic therapy (PDT)
-Imiquimod (Aldara)
61
Basal Cell Carcinoma Etiology
Most common type of skin cancer
| - arised from the basal layer of the epidermis
62
BCC presentation
nodular
- flesh colored
- pearly* papule
- has telangiectasia*
- may have central ulcer with *rolled boreder
- most common on the head and neck
* may be pink patch to AK or SCC in situ.
63
BCC tx
```
Surgical is preffered
-currettage or desiccation
-excision within 4mm margins
-Mohs for high risk or cosmetic
Nonsurgical
-radiation if poor surgical canidate
-Imiquimod cream
-5% fluoroiracil cream
-Photdynamic therapy
```
64
Squamous cell carcinoma etilogy
2nd most common
-originated from keeratinocytes and AK
M>F
- can arise from previous area of skin injuries like scars
65
SCC presentation
papule, plaque, nodule
- not as sandpapery as a AK
pink, red, skin colored
- get a scaly appearance, friable, indurated
-not as nice of a border
-often asymptomatic but van be very irritable
66
SCC tx
```
Surgical
- wide excision or mohs
Non surgical
- Radiationfor poor surgical canidate or residual tumor
-Curettahe and Desiccation or cryotherapy ( good for SCC in situ which is low risk)
-5-fluorouracil therapy
-Imiquimod
-PDT
```
67
Malignant Melanoma Etiology + Risk
high morbidity and Mortality
>5 atypical nevi or >25 nevi in gen
Risks: fair skin, blue eyes, red/blonde hair, freckling, immunosupression, family history
68
Melanoma presentaion
-usually asymptomatic and arise usually de novo but some can arise from pre-existing nevus
- pigmented papule, plaque, or nodule
ABCDE
69
Superfiial spreading melanoma
- most common
- confined to epidermis
- often in younger pop
- radial spread> verticle spread
70
Nodular Melanoma
Rapid verticle growth and minimal radial growth
- very agressive
- nodule is inflammed and friable
71
Lentigo Maligna
Elderly pt with chronic sun exposure
- slightly less common
- slowl progression and usually spead radially and remains superficial
72
Acrak Lentiginous
More in darker skin and AA pop
- M>F
- spreads superficial more than verticle
73
Breslow depth and Melanoma
How deep the lesion is related to the prognosis of the skin cancer
74
Melanoma Tx
```
Wide surgical clearing -2cm margins
- typically dont use Mohs
-regional lymph node dissection
If really large or advanced: radiation, chemo, immuno
3mo follow up
```
75
Erthymatotelangiectatic rosacea
Chronic redness of central face, flushing (wet or dry), skin sensitivity, dry appearance, telangiectasias
76
Papulopustular rosacea
papules and pustules
inflammation can be confluent
but there are no comedones
77
Phymatous rosacea
only rosacea that is more common in men than women
- tissue hypertrophy causing irregular contours
- mostly on nose and can involve cheeks, forehead, and chin
78
Occular rosacea
in addition to one of the other 3 types
- may preceded, coincide, or follow
- dry eyes, pain, itching, blurry vision, photosensitivity
79
Erythematotelangiectatic rosacea Tx
1. Modify behavior to avoid triggers, gentle skin care, and avoid sun exposure
2. Laser pulse light therapy or topical brimonodine (vasoconstrictor)
80
Papulopustular rosacea Tx
Mild:
- metronidazole
- Azelaic acid
- then: ivermiectin or sulfacetamide-sulfur
81
Phymatous rosacea Tx
Early- Isotretinoin( retinoid)
| Advnced- surgical debulking or laser ablation
82
Scorpion sting Grades 1-4
1: local pain c paresthesiaa at sting site
2. local symp + remot pain and parasthersias
3. Either cranial nerve or somatic skeletal neuromuscular disfunction
4. Both cranial and somatic skeletal dysfunction
83
Scorpion Sting Dx
-clinical
Tap Sign: local pain made worse by tapping near the stinging sight
cranial nerve disfunction: hypersalivation, abnormal eye move, blurred vision, slurred speech, tongue fascicilations
Skeletal dis: fasiculations, shaking or jerking, emprosthotonos (tetanic forward flx), fever
84
Scorpion tx
```
Pain managment
cleansing of sting site
tetanus prophylaxis
observe for 4hrs
Severe cases:
-treat for respiratory comprimise, MI, Hyperthermia, Rhabdomyolysis, multiple organ failure
-fentanyl for pain
-IV benzodiazepines
-Antivenom** cannot use with the benzos
```
85
Bee sting LLR
Rare
- exagerated erythema and swelling
-gradually elnarges over 5-10days
Tx; cold compress and prednisone, antihist, NSAID
86
Bee sting complications
1. Secondary bacterial infection- worsening after 3-5 days of it getting better
2. Anaphylaxis
- treat with epinephrine and refer to speciallist
87
Widow bites
-found near human habitats
- small local reaction (often no venom inj)
-blanched circular round patch with central punctum
- venom causes catacholamine relase> intermitant radiating pain, ab/chest/back spasm, sweating, HA/N/V
Tx: local wound care, antiemetics, narcotic analgesics, tentanus, muscle relaxers, maybe antivenom
88
Recluse spider bite
usually happen indoors
-painless initially> red plaque/papule c central pallor> possible vessiculation
- necrosis can occur +N/V/Ha>> rareley renal failur, rhabdo, anemia, hypotension
Tx: cleansing, cold compress, analgesics, antibiotics, surgical excision for necrosis only fter the wound has stabilized
89
Tx of vitiligo
- screen for other autoimmune disorders
Tx: topical and systemic corticosteroids, calcineurin inhibitors, narrow band UV B phototherapy, skin grafts
- edu on sunscreen
90
Hidradenitis Supprativa etiology/ risk factors
chronic inflammatory skin dis of the hair follicle
female>males usually around 23
genetics, mechanical stress, smoking obesity
from a cycle of occlusion and rupture
91
Hidradenitis Supprativa presentation
```
Nodules in the axilla and groin
more form as the disease progresses
may form abscess(collection of pus)
-sinus tracts can form
-comedomes
-scaring
```
92
Hidradenitis Supporativa Dx
Clinical based off lesion, location and history of relapse
93
hidradenitis supprativa Tx
1. Lifestyle Mod: avoid skin trauma, hygeine, no smoking, weight managment, diet
2. Pharm:
- Topical clindamycin
-intralesional corticosteroids
-anti-androgenic agents
-Surgery ( punch debredment or wide exicion)
Super sever> TNF inhibitors, oral retnoids
94
Complications asso. c Hidradenitis supprative
fistulae, contractures(melted skin appearance), Lymphatic obstruction, infection, SCC, depression
95
Measles Etiology
Rubeola
-Virus Paramyxovirus
highly contageous- maintain in an area for 2hrs
spread via cough sneezes, close breathing
96
Measles Clinical Stages
1. Incubation: 2-3 wks - typ asymptomatic
2. Promodone: anorexia, malaisw, fever 105+
followed by *3C's cough, coryza, conjunctivitis*
3. Enanthem: *Koplik spots
4. Exanthem: blanching and maculopapular
- starts on face head to toe and spares the hands and the feet
97
Measles Dx
Reportable disease!
- serum and throat swab for histologic analysis
* serology: measles specific IgM
98
Measles complications
Common:
-diarrhea > ottis media
Severe and less common:
-Pneumonia ( common in children), Encephalitis, subacute sclerosing panencephalitis (1-2 yrs later)
High risk: preg, immunocomp, young or old
99
Measles Tx
```
Symptomatic treatment nly
- vitamin A may lessen severity
Patient education
- avoid contact with pregnant women
*vaccination!!!!
```
100
Erythema Infectiosum Etiology
Fifths disease- parovirus B-19
- transmitted by respiratory secretions
- common in children
101
Erythema Infectiosum Presentation
can last from weeks to years
1. Incubation : 7-14 day
2. prodorome: no specific flu sx
- low grade fver, coryza, HA, Nauseae, diahreeha, malaise, sorethroat
3. Facial Rash***- Slapped Cheek***
4. Body Rash: 2-3 days later
- *lacey rash*- paink macular rash on extensor surfces
- may get polyarthropath (pain in joins)
102
Erthyema indectiosum Dx/ complications
- based on clinical presentation
Compl:
- transient aplastic crisis
- in preg: *hydrops fetalis
103
Erthyema Indectiosum managmentn
reassurance and tell them to avoid pregnant women
- will go away on its own
- a lot of people have already had it
104
Rubella
German Measles
Rubella virus
- large particles in the air
105
Rubella presentation
1. Incubation 12-23 days
2. Prodorone 1-5 days
- may have rash during
- low fever, *lymphadenopathy, cold symptoms
3. Rash appears
- erythemous papules and purpura- pin point pink
- can be contageous for 7 days
* * head to toe progresson**
106
Rubella Dx
clinical presentations - often resolve on its own
| - may do serology if you cant tell
107
Rubella Complications
Congenital rubella syndrome- in pregnant women and is lethal to bany
*blue berry muffin rash*
108
Rubella Managment
treat symptoms and avoid pregnant women
- rubella titer is drawn at first prenatal visit!
- prevention via immunization
109
Roseola Infantum etiology
Herpes virus 6 is most common
- infants and younger children
- transmission is not understood
110
Roseola Infantum present
- high fever that comes and then resolves abruptily
- then a rash comes out of nowhere
* this story is very classic
1incubation: 9-10 days
2. Prodrome: febrile maybe higher than >105 with abrupt end
3. Rash: *neck to trunk and then it will go toface*
- blanching, pink, maculopapular rash
- not itchy usually
111
Roseola Infantum Dx/ tx
Clinical presentation
- serology is the pt is immunocomprimised
Tx: suppotive treatment -antipyretucs
112
Hand, Foot, and Mouth Disease Etiology
Cozsackie A16 virus
- mostly children 1-5
- fecal oral or oral respiratory secretions
113
HFM disease presentation
1. incubation: 3-5 days
2. Prodorome 12-24 hrs
- no symptoms, fever, fussiness, abdominal pain, diarrhea
3. Oral enanthem/exanthem- oral more
- sore throat and vessicles on buccal mucose and toungue
- vessicles on hands* feet* and buttocks
114
HFM dx/Tx
Dx: clinical presentation
- usually by based on location
Tx: symptomatic maybe litocaine gel and prevent with good hygeine
115
Molluscum Contagiosum etiology/risk factors
Poxvirus
common in children/ immunocomp
-direct physical contact with fomites (towel, lines etc.) or skin
- can also autoinoculation via scratching or clothing or shaving
116
Molluscum Contagiosum Presentation
Lesions: flesh colored and *umbilicated*
located anywhere except palms and soles!
- usually no associated symptoms
- self limiting but super duper contagious
117
Molluscum Contagiosum Dx/Tx
Clinical presentation
Tx: you dont really need treatment
- home: podophyllotoxin cream ( not in preg)
-office: quick cyotherapy, currettage, canatharidin
118
HPV types
1. mucosal: condyloma acuminata
| 2. Cutaneous: common, plantar, and flat wart
119
HPV condyloma accuminata etiology/pres/Dx/tx
genital warts
- most commonanorectal infection in MSM
transmission- sexual contact
Present: *cauliflower like lesions*, perianal growth, mild pruritis
Dx; clinical presentation may need to evaluate for internal lesions (anoscopy or proctosigmoidoscopy)
Tx: Topical posophyllin, electrocautery, laser, cryother. excision
120
HPV verruca Vulgaris etiology
```
more common in kids and younger adults
Common Warts
-transmission skin to skin contact
- spont resolution 1-2 yrs
- reoccurance is common
Present: raised rough surfaced lesions wih tiny pigmented **thrombosed cappillaries** "seeds". Common on hands and feet.
```
121
HPV verruca vulgaris dx/tx
Dx: clinical presentation- may scrape of with 15 blade to visualize the thrombosed cappilaries
Tx: may spont resolve, salicylic acid, cryotherapy, electrodessication,
122
Varicella etiology/transmission
Chicken pox
Varicella Zoster virus- a herpes vaccine
- through aerosolized droplets and is highly contagious
- reoccurance can occur
123
Varicella Presentations/Dx
1. incubations 10-21 days
2. Prodorome 2-5
-fever, malaise, paryngitis, anorexia
3. Rash *vesicular rash*
-pruritic
rash occurs in stages paipule> blister> ulcer Dx: clinical typically but a Tzanck smear will show mononucleated giant cells
124
Varicella complications
- group A strep
- Encephalitis and reye syndrome (uncommon)
- most complications occur in immunocomp pt.
125
Varicella tx:
sypotomatic treatment
- contagious until all lesion have crusted over
- avoid pregnant females!!
- acyclovir in imminosup pts.
- vaccines
126
Herpes Zoster presentation
1. Prodrome:
- acute neuritic pain precedes eruption 3-5 days
- throbbing stabbing burning senstions
- itching fever, headade, allodynia
2. Rash Active
- development of grouped vessicles on a erythematous base
- follows dermatome and unilateral most often
- thoracis distribution most common
127
Herpes Zosters chronic complications
1. . post herpetic nerualgia: lanciating pain that lasts months after resoltution of lesions
2. Herpes Zosters Qphthlmicus- sight threatening linked to trigemial ganglion
- begins with sign on nose (hutchinsons sign)
3. Other retinal problems or nerve palsies
128
Herpes Zosters Tx
treat early -72hrs ( lower pain/severity)
Antiviral: Famciclovir 500mg TID 7days
Valacyclovir 1g TID x 7days
- hydration, keep skin clear, pain managment
- NSAIDs, narchotic, topical anesthetics for acute
- Chronic; tricyclic antidepressets, gabapentin, pregablin
* if ocular involvment send right away to an eye doctor (emergency)
129
Herpes Zosters Infectious precautions
- can transmit virus to give someone chickenpox but can not give shingles
- avoid pregnent women, infants, and immunocomp
- infectious until crusts have healed
Prevention: Zostavax or Shingrix** vaccines
- approved >50 yo and recommended for >60
130
Herpes Symplex Virus -1
| -location and transmis.
Most common oral- cold sores and transmitted by direct contact during viral shedding
- can have a very severe primary presentation ( Pharygitis, mouth pain, fever )
131
Herpes symplex Virus II
| -location and trans.
Most often genital
- sexually transmitted
- pt may be asymptomatic and still spread the disease
- genital herpes can also comes from HSV-1
132
HSV presentation
Prodrome: burining, tingling, or pruritis
Lesions appear: grouped vesicles on an erythematous base> may crust later
- can have lymphadenopathy
133
HSV dx
1. clinical presentation
2. Can do viral culture
3. Direct microscopy via Tzanck smear use wright stain> see giant mononucleated cells ( just pos for herpes)
134
HSV tx
Start early!!- 72 hours
Valcyclovir, Famciclovir, or Acyclovir
- can treat before outbreak or chronic suppression which decreases recurrences and asymptomatic sheading
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Epidermal Inclusion Cyst Presentation/ Tx
```
epidermpid cyst
- soft, mobile, often central punctum
- if infected> erythema and pain
Tx:
- may spontaneously go away but recur often
-kenalog injection, I&D, excision
- if infected then I&D, oral abx
```
136
Lipomas
Composed of adipose tissue and most common soft tissue tumor
Present: soft, mobile, non tender
Tx: surgical removal
- there is a concern of maligncancy with deeper tumors
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Sarcoma
Rare malignant tumor -usually of soft tissue
Presentation: enlarging, painless mass of extremities or trunk
Managment: imaging of primary lesion MRI, core needle biopsy, surgical resection, chest CT to rule out metastasis
138
Seborreheic Dermatitis risk factors
infants and then again as teenagers
M>F
in 3rd 4th decade
- cause is unknown but possibly a fungus malessezia furfur
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Seborrehic Dermatitis presentation
| Infants
Dandruff
common, chronic, relapsing dandruff or inflammation
- gets worse with stress and when it is cold and dry
Infants: yellow greecy scale "cradal cap" and you will see it in the diaper region and axilla
Adults: erythematous coalescing macules, patches or plaques areas where there is hair, scalp, eybrows
^ with HIV and parkinsons
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Seborrheic Blepharitis
dandruff around the eyelid
- have yellow crust with a greasy appearing flakes and edges are pink
Tx: warm compress and eyelid scrubs
141
Sebhorrheic Dermatitis Dx Tx
Clinical diagnosis
Tx: warm compress for cradal cap and baby shampoo. Can use olive oil to losen up
Scalp: antifungal shampoo and topical steroid
Ketoconazole (shampoo or cream)
Senlenium Sulfide or antidandruff shampoo
Face: low pot top steroid, topical antifungal, or combination
142
Pityriasis Rosea Etiology
Benign viral exanthems
| - common in teens and young adults in the spring or fall
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Pityriasis Rosea Present
Possible prodroms- fver or malaise
Herald patch (2-5cm) as primary lesion which is larger than the other ones on the trunk and secodnary lesion 1-2 wks later
-pink or slamon, fine scale (collarette scale), oval papulaes and plaques
-Christmas tree pattern
- usually asymptomatic possible itching
144
Pityriasis Rosea Dx/ Tx
Tx: self limiting and will go away on its own
- antihistamine for itching and possibly topical steroid ( just for itching)
- sun helps it go away faster
- can do a KOH prep to make sure its not funcgal
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Lichen Planus presentation
Prurutuc, purple, polygonal, papulaes (4 Ps)
-papulosquamous eruption
- skin (itchy) genitals nails, scalp, most common- wrist, ankles, shins back and MOUTH (painful)
Wickhams striae- tiny white lines running through papules
146
Lichen Planus cause
idiopathic: dont know why
- 30-60yr olds
- immune mediated response
- drugs can cause
association with hep C
Koebner phenomenon- development of lesions in site of trauma
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Lichen Planus Dx/Tx
Dx: punch or shave biopsy
Tx: self limiting disorder and resolved 1-2 yrs
- topical steroids (high pot)
- injection intralesional triamcinolone
then: oral steroids, phottherapy, oral retinoids
148
Psorisis Etiology/ Risks/
hyperproliferation inflammatory skin disorder
-overactive T cells to cause inflamation which shortens skin cell cycle so skin pile up.
M=F
20-30 and 50-60 yo
genetic- usually have 1st degree relative
Risks: genes, infections (strep), medications, stress/skin inj, weather(cold and dry), tobacco or heavy alch
149
Psorisis presentation
erythematous with silvery white scale
- itchy or burning
- can be local or generalized
may also have nail pitting and psoriatic arthritis
150
Psorisis Vulgaris
most common form
- plaques with scale and defined margins
- the plaques are symetrical on the body and smaller ones can clump together
Koebner phenomenon and auspitz sign
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Guttate Psorisis
Strep infection often preceded this onset
- will often resolve on its own but you may get plaque psorisis
- little droplets
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Pustular psorisis and palmplantar psorisis
Pustular- such wide spread inflamation may have fever> treated in hospital
Palm- debilitating becuase fissures will form so hard to walk and use hands and usually require more exstensive treatment
153
Psorisis Tx
sunshine, warm baths, emollients (reduce pruritus), occlusive dressing, rest,
***** do NOT use oral steroids*****
Topical:
1.Group 1 or II corticosteroids (high pot) 2-3wks [ good if small TBSA and not in genitals, hand, face]
2.steroid sparing agents [can be used in combination therapy]
- synthetic vIt D
- coal tar
- topical retinoids- tazarotene
-totcal caliceurin inhibitors (tacrolimus and pimecrolimus)
> use topicals after soaking
3. Phototherapy
Moderate to sever: >5% TBSA requires care by derm and wil need photo therp or systemic
154
Psoriatic Arthritis Etiology/ present
inflamatory arthritis
- 1/3 of pt with psorisis will have this
- pain and stiffness usually worse in the morning
- usually asymetric
- typically of the smaller joints (hands fingers) but also spine
- enthesitis and dactylitis (sausage digets)
155
Psoriatic arthritis Dx
```
lab findings non-specific - will have elavated sedimentation rate and leukocytosis
- usually negative for RF factor
lab tests are just to rule out other Dx
***usually just a history and physical
- possbile additional immaging
```
156
Inverse psorisis
Will often appear in the axilla, genitals
| - often not as scaly as other types
157
Folliculitis Cause/ presentation
itchy Inflammation of the hair follicle with pustules and papules
Infectious:
-s. aureus (most common)
-"hot tub folliculitis) - gram neg Pseudomonas
possibly from a drug interaction
158
If folliculitis gets worse what can happen?
can turn in a furnucle and then possibly a carbuncle abscess
159
Folliculitis Tx
- saphylococcal
- gram neg
```
Usually no tx (self limiting)
Staphylococcal folliculitls
- topical: mupirocin
- oral abx: cephalexin
If MRSA: clindamycin or doxycyclin
Gram Negative folliculitis
- Ciprofloxacin
```
160
Impetigo eitology and risks
Contagious superficial bacterial infection
Kids>adults
1.S. aureus- bullous and non bulllous
1. Ecthyma is usually strep
161
Impetigo types
Honey colored crusting- typically on face neck and extremities
1. Nonbullous: most common
papules. vessicles> pustules> hone colored ccrusting
2. Bullous- vesicles enlarged and forms bulla
3. Ecthyma- punched out ulcers with overlying crusts
- like cigarrette burns
162
Impetigo Dx/Tx
```
typically clinical possible culture
TX:
1. non bullous and bullous:
- - mild abs : mupirocin
- mod/sever: dicloxicillin cephalexin
2. Ecthema is always oral therapy (ones above)
```
163
Cellulitis etiology and risks
Risks: skin trauma, lymphedema, venous indufficency, obesity, immunosup
1. pus- strep
2. no pus- s. aureus
- caused by beta-hemolytic strep, staph
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Types of cellulitis
Expanding redness and not really well demarcated. Pain and swelling
1. Nonpurulent (non pus)- cellulitis or erysipelas
- erythema edema warmth
2. Purulent: absess or purulent cellulitis
painful fluctuant and erythematous nodule
165
Erysipelas
```
Type of non-purulent cellulitis
-streptocci bacteria
Well demarcated and perfect border of erythema
-usually on cheeks and lower extremities
- warm. with fever and chills
usually in the elderly
```
166
Abscess etiology
Type of purluent cellulitis
enclosed collection of pus
-painful fluctuant erythematoud nodule
167
abscess Dx/ Tx
clinical diagnosis- maybe U/S
| Tx: I and D - sometimes we test with culture and may need additional abs ( IC, very red
168
Cellulitis tx
Erysipelas
purulent
Cellulitis: oral cephalexin or IV cefazolin
Erysipelas: beta-hemolytic strep therapy
-cefazolin, ceftiaxone
Purulent infection:
1. abscess- I&D +/- abx
- trimethoprim-sulfamethoxazole, doxycycline, clindamycin
2. Purulent cellulitis- sim abx to above
169
MRSA prevention and control
Hand hyfeine, enviornmental cleaning, contact precautions
| - decolonization with chlorohexidine wash and mupirocin ointment intranasally
170
MRSA risk factor
Abx, invasive device, chronic wound, hospitalization, group settings, colonization of MRSA,
171
MRSA tx
Oral abx: trimethoprim-sulfamethoxazole, doxycycline, clindamycin
- tailored to culture results
IV abx may be necessary (vancomycin):
-if extensive involvement, toxicity, rapid progression, failure PO tx, immunocomp
172
Systemic Lupus Cutanious manifestations
1. Discoid lupus: scaly plaques, annular on sun exposed areas
2. Malar/butterfly rash
- erythema on cheeks and bridge of the nose
- nasolabial folds are spared !
173
Lupus Rash DX/Tx
Dx: autoimmune connective tissue disease workup
sun protection and smoking cessation
- topical or intralesional steroids
- Hydroxychloroquine
* some people are on medications that cause a lupus rash*
174
Erythema Multiforme
acute, immune mediated conditions distinct target like lesions
can be associated with viral, bacterial or functions
- herpes is most common
- can be associated with NSaIDS or abx
175
Erythema Multiforme Dx/Tx
Dx: clinical dx
may have labs will be non specific inflammatory markers, leukocytosis
Tx: symptomatic tratment
- usually self limiting
-topical steroids, oral antihistamines, anestetic mouthwash
- antiviral meds are not indicated
176
Dermatitis Herpetiformis etilogy
autoimmune skin condition associated with gluten sensitivity (possibly celiac disease)
Sx: pruruitic papules and vesicles
herpeticform pattern- forearm, knees, scalp, butt
Dx: markers for seriological, biopsies of the lesions (looking through direct immunoflourescence)***
Tx: gluten elimination and dapsone
177
Pemphigus Etioogy
life thretening blistering disorder on epidermis
- autoimmmune:antibodies can cause acantholysis
- genetic, idopathic, drug induced
178
Pemphigus presentation
Accantholysis: separation of the epidermis
Mucosal involvment
- flaccid bullae
Nikolsky sign: gentle pressure causes superficial layer to slough off
179
Pemphigous Dx/Tx
Physical: acantholysis and Nikolsky sign
-biopsy and **perilesional skin biopsy**
later can do IIF and ELISA
Tx: always indicated
**systemic corticosteroids and immunosupressive agents**
180
Pemphigoid etilogy
Chronic autoimmune subepithelial blistering condition
181
Pemphigoid Presentation
- begin with prurirtis eczematous or uticarial lesions
Classic: *tense bullae**urticarial erythematous plaque. on trunk and extremities
+/- mucosal involvment
182
Pemphigoid Dx/Tx
Dx: biospy *perilesional direct immunoflourensense**
Tx: *topical and/or systemic corticosteroids*
- immunosupressive agents
183
Melasma/Cholasma
aquired hyperpigmentation of the skin.
- often with hormones like the pill of pregnancy
- regresses within a year
Tx: skin lightener and sun protection
184
Acanthosis Nigricans
hyperpigmentation velvety plaques
| - associated with insulin resistance
185
Hirsutism
male pattern hair growth in women
| - caused by a variety of things
186
Adrenal excess on skin
Cushing syndrome
| - increase sebum, acne, androgenic alopecia, hirsutism, striae
187
Adrenal insufficency of skin
Addisons disease
| - hyperpigmentation of the gums, buccal mucosa, elbows, knees, palms, genitalia
188
Thyroid effects on skin
Hyperthyroidism: warm moist skin
-pretibial myxedema
- non pitting, scaly, orange peel skin
Hypothyroidism: dry cool skin
189
Porphyria Cutanea Tarda cause /Sx/ risks
deficiency of uroporphyrinogen decrarboxylase- suppose to break down porphyrins
Sx: painless sub-epidermal blistering on sun exposed areas
Risk: genetic, tobacco, etoh, estorgens, liver disease
190
Porphyria Cutanea Tarda Dx/TX
Dx; ^ serum/ urinar porphyrins, ^ liver tests irons stores
Tx: discontinue potential cause
phlebotomy for the the ^iron
wear sun protective clothing
191
Pressure injury stages
1: intact skin with localized erythema
2. partial thickness loss with exposed dermis
- no adipose visible and no eschar
3. full thickness
- adipose is visible with rolled edges but no facia or muscle visible
4. Full thickness skin and tissue loss with esposed muscle, tendon or bone
- eschar with rolled edges
192
Pressure injury tx:
- redistiribute pressure
- local wound care
1. transparent film for protection
2. dressings that maintain moisture
3. debridement of necrotic tissue with appropriate dressing +/-abx
193
Tick removal
- grasp tick as close to skin surface
- wash area
>36hrs ^ risk for lymes
RMSF can be after only 6 hrs
194
Erythema Migrans
Etiology: borrelia Burgdorferi
Pres: bulls eye rash
- fatigue, HA, arthralgia,fever
- later: cardiac, arthritis, beuro, bells palsy
Tx: doxycycline or amoxicillin
- can do 200mg dose of doxycycline for prophylaxis is >36hrs
195
Rocky Mountain Spotted Fever
Etiology: rickettsia rickettsia
1. non specific symptoms: Fever, HA, arthralgias, nausea 2-14 after tick bite
* do not wait for the rash becuase some people dont get it
Rash: petechial lesion on ankles wrists then trunk
196
Rocky Mountain spotted fever Dx and Tx
Dx: clinical because the serology is retrospective
Tx: doxycycline
