DERM1-Table 1 Flashcards
1
Q
What happens to the epidermis with age?
A
–Skin more fragile; prolonged turnover rate & ↓ DNA repair
–↓7-dehydrocholesterol + less outdoor activity = insufficient sun exposure = ↓ Vitamin D production
2
Q
What happens to the dermis with age?
A
–Loss thickness
–↓ Mast cells & histamine; ↓ vascular supply; ↓ collagen synthesis
3
Q
What happens to the SQ fat with age?
A
↓ volume (face & hands) & ↑ volume (abdomen & thighs)
this can lead to pressure ulcers
4
Q
What does the change in hair with age potentially lead to?
A
Thinning of hair can lead to baldness/alopecia
5
Q
What does the decrease in melanin production potentially lead to?
A
Graying of hair
6
Q
What does the flattening of the dermo-epidermal jxn lead to?
A
Skin fragility and propensity to injury
7
Q
What does capillary fragility lead to?
A
Actinic purpura
8
Q
What can atrophy of sweat glands lead to?
A
Difficult with temp regulation with advanced age
9
Q
A pt presents with rash…. What are the classification basics?
A
–Onset: acute vs. chronic –Distribution & pattern –Type of primary lesion & topography –Secondary features –Consistency w/palpation
10
Q
What are secondary features? What classifies them?
A
–Crusts: serous, hemorrhagic, purulent
–Scales: hyperkeratosis, accumulated stratum corneum
–Fissure: linear cleft in skin d/t marked dryness, thickening & loss elasticity
–Erosion: loss of epidermis, moist & oozing or crusted
–Ulceration: loss of epidermis & partial superficial dermis: note size, shape & depth along w/traits border, base & surrounding skin
–Excoriation: exogenous, all or part epidermis
-atrophy: epidermal thinning leads to shiny wrinkled appearance, dermal leads too depression
-lichenification” thickening and accentuation of natural skin lines
11
Q
What are 3 ROS you must ask if a pt presents with a rash?
A
Fever, pruritus, dysesthesia
12
Q
Acute fever+ rash = what?
A
Infectious
Inflammatory
Other
13
Q
What are the infectious causes of acute fever+ rash?
A
Bacterial: TSS, scarlet fever, meningococcal
Viral: exanthems, dissem zoster, immunocompromised
Fungal/ protazoal
14
Q
What are the inflammatory causes of acute fever+ rash?
A
SJS/TENS/erythema multiforme, pustular psoriasis, rheumatologic (SLE, vasculitis), drug rxn (serum sickness rxn), graft vs. host rxn
15
Q
What are the other causes of acute fever + rash?
A
Neoplastic- lymphoma
16
Q
What are the types of pruritus? What is the ddx for each?
A
- Primary (aka idiopathic)
- Secondary: derm disorder, allergy, systemic dz, malignancy, toxin d/t renal/hepatic failure, meds, neuro dz, behavioral dz
17
Q
What are the types of dysesthesia?
A
Neuropathic and psychocutaneous
18
Q
What is the DDX for neuropathic dysesthesia?
A
–Radiculopathy; small fiber polyneuropathies
–Orodynia (burning mouth syndrome); burning scalp syndrome
19
Q
What is the DDX for psychocutaneous dysesthesia?
A
Neurotic (psychogenic) excoriation: associated w/OCD, stress, anxiety, depression & bipolar disorder
20
Q
What can you use KOH prep on?
A
Scales, hair shafts, subungual and or nail plate
21
Q
What is dermoscopy?
A
noninvasive method: allow in vivo evaluation of colors & microstructures in epidermis, dermoepidermal junction & papillary dermis not visible to naked eye
22
Q
What is dermscopy used to ID?
A
specific diagnostic patterns related to distribution of colors & dermoscopy structures can better suggest a malignant or benign pigmented skin lesion
23
Q
When is biopsy indicated?
A
- Rash or vessels involving dermis: r/o drug rxn, deep tissue infection, vasculitis, E. multiforme
- Atypical moles – malignant suspicion (FHx/PMH – risk factor evaluation, advanced age, fair skin, multiple pigmented nevi)
24
Q
What are some criteria for atypical moles?
A
–ABCDE criteria
–Glasgow 7-point checklist: major vs minor features
–“Ugly duckling” sign
25
What are the types of biopsy?
Shave or punch and excisional
26
What is a saucerization?
Spoon shaped biopsy
27
What is an elliptical?
Excision where the entire lesion is removed
28
What is primary intention?
Wound healing where wound edges heal directly touching each other
–Results in linear scar tissue = goal whenever a wound is sutured closed
29
What is secondary intention?
wound is left open & filled with granulation tissue which subsequently turns into scar tissue
30
When is shave biopsy indicated?
predominantly epidermal lesions w/out dermal extension - warts, papillomas, skin tags, superficial BCC & SCC, seborrheic & actinic keratoses
31
When is shave biopsy not indicated?
When there is a suspicious pigmented lesion
32
How is a shave biopsy performed?
–Inject anesthetic & create wheal to elevate lesion
–45 angle to shave (#15 scalpel blade, dermablade, double edge razor blade, scissors)
•Remove thin disk of tissue:
33
What is the healing for a shave biopsy?
Can use silver nitrate or aluminm chloride for hemostasis, keep area clean and covered for one week
34
A punch biopsy can be both ???? OR ???
Excisional or incisional
35
When is punch biopsy indicated?
lesion requires dermal or subcutis (bullous lesion, dysplastic or complex nevi, scalp or hair follicle)
36
What is the limitation of punch biopsy?
narrow deep specimen – may not be wide enough sample because select thickest area of lesion
37
How is punch biopsy performed?
Punch perpendicular to surface of lesion & rotate through skin until no tension on tissue = full thickness sample; remove tissue w/forceps or needle to minimize crushing
38
What is the post procedure tx of punch biopsy?
Can do electrocautery or use an agent for hemostasis
| Close small site with 2nd intention and large site with steri-strip adhesives or suture
39
When is a saucerization biopsy indicated?
for pigmented or suspect skin lesions
lesions difficult to remove elliptically d/t cosmesis or anatomic location, vesicobullous disorders, seborrheic keratosis
40
How is a saucerization biopsy performed?
–45 angle to remove disk of tissue: 1- 4 mm deep combined epidermis & dermis + subcutis
•Nidus of pigment noted s/p biopsy - perform punch or elliptical biopsy
41
How do you tx a saucer biopsy?
Same as punch but keep area clean and dressed for healing by secondary intention
42
What is a wedge biopsy?
Incisional, for large lesions - need length, width & depth; stab incision (V or triangular shape) = remove a cone of tissue
43
What does an excisional biopsy do?
remove entire lesion down to the subcutis
44
When is an excisional biopsy indicated?
Neoplasms
45
How is an excisional biopsy tx?
–Hemostasis: electrocautery or agent
| –Close site w/sutures
46
When are powders used topically?
mix w/active agent & use for lesions in moist or intertriginous areas
47
When can foams be used?
alcohol or emollient based, aerosolized, hairy areas
48
When are solutions used?
mixed w/solvent, intertriginous & hairy areas
49
When are lotions used?
water based emulsion, cool & dry inflammatory/exudative lesions
50
When are creams used?
exudative conditions
51
When are ointments used?
allow drug penetration, less stinging w/ulcerations, lichenified lesions
52
What are non-occlusive dressings and how are they used?
* Gauze: allow air to reach wound
| * Soak w/saline solution: cleanse & debride crusted lesions when dressing has dried
53
What are the occlusive dressings and how are they used?
•Transparent films, hydrocolloid, zinc oxide gelatin
•Apply over steroids to increase absorption
Protect/heal burn wounds or pressure ulcers
54
What are the antipruritics and when are they used?
* Doxepin: atopy, lichen simplex chronicus, nummular dermatitis
* Diphenhydramine: can be sensitizing in topical preps
* Camphor: 0.5-3%; Menthol: 0.1-2%; Pramoxine HCl (Caladryl)- stains
55
What are the non steroid anti-inflammatory?what are the ADRS?
Tar preparations:
| ADR = photosensitization, stain clothes, irritation, folliculitis
56
What are antistringents?
Drying agents… these are used for exudative lesions, weeping pressure ulcers
57
What are the antistringents?
cornstarch, aluminum chloride, aluminum acetate (Burrow’s)- good on feet and btwn fingers and toes, aluminum sulfate & calcium acetate (Domeboro), witch hazel
58
What are the keratolytics?
Salicylic acid and retinoids
59
What does salicylic acid do?
dissolves intercellular cement substance, & produces desquamation of horny layer w/out affecting structure of viable epidermis
60
What do retinoids do?
Inhibits microcomedo formation & eliminates lesions, makes keratinocytes in sebaceous follicles less adherent & easier to remove
61
What are 1st line anti-inflammatory agents?
Steroids
62
Where are low potency steroids used? High potency?
–Low potency: thin lesions, body folds, face
| –High potency: lichenified plaques, hand, feet
63
What are the ADRs after 1 mo use of steroids?
localized skin atrophy, striae, fungal growth, contact dermatitis d/t additives/solvents
64
What topical abx are used for what skin conditions?
Clindamycin or erythromycin: acne vulgaris
Metronidazole: rosacea
Bacitracin/polymyxin: post op, superficial cuts/abrasions
65
What is the ADR of neomycin?
Contact dermatitis
66
What is the 1st line tx for scabies?
permethrin 5% cream leave on 8-14 H then wash off, can repeat in 1 wk if needed
67
What is 1st line tx for lice- capitis?
1st line: wet combing & permethrin; can repeat in 7-9 days if live nits observed
»Apply permethrin to wet hair, behind ears & nape, wash off in 10 minutes
68
What is 1st line for lice- corporis?
1st line: linen & clothes hygiene (149F), treat pruritus & 2ndary infection
69
What is 1st line for lice- pubic?
–1st line: wet combing & permethrin 1% cream; can repeat in 7-9 days if live nits observed
»Apply permethrin to wet hair, wash off in 10 minutes
70
What is the tx for lice in the eyebrows?
–Petrolatum TID-QID x 8-10 days
–Fluorescein drops 10-20%: apply to eyelids = immediate pediculicidal effect
Remove physically
71
What are the topial antifungals categories?
–Allylamines
–Benzylamine
–Imidazoles
–Miscellaneous
72
What are the allylamines and their indications?
Amorolfine 5% solution – T. unguium
•Naftifine 1% cream or gel – dermatophytoses, candidiasis
•Terbinafine 1% cream or solution, 250 mg tablet – dermatophytoses
73
What are the Benzylamine and their indications?
Butenafine 1% cream - dermatophytoses
74
What are the Imidazoles and their indications?
* Butoconazole 2% cream – vulvovaginal candida
* Clotrimazole 1% cream/lotion/solution, 10 mg lozenges – dermatophytoses, oropharyngeal candida
* Econazole 1% cream – dermatophytoses, T. versicolor
* Itraconazole 100 mg tabs, 10mg/ml solution – T. unguium, onychomycoses
* Oxiconazole 1% cream/lotion or sulconazole 1% cream/solution – T. versicolor, dermatophytoses
75
What are the miscellaneous antifungals and their indications?
* Carbolfuchsin solution – chronic dermatophytoses
* Ciclopirox 0 .77% gel, 8% lacquer solution – dermatophytoses, onychomycosis, T. versicolor
* Gentian violet 1-2% solution – T. pedis
* Tolnaftate 1% liquid, powder, aerosol, cream – T. versicolor, dermatophytoses
* Zinc 25% solution, 10% tincture – superficial dermatophytoses, T. pedis
76
What are the 2nd line anti-inflammatory agents?
topical immunomodulators
77
How do immunomodulators work?
Suppress immune system & inflammation by inhibition of enzyme (calcineurin) crucial for multiplication of T-cells required for activation of immune system (cytokines)
78
Can the immunomodulators be applied to delicate areas such as the face and eyelids?
Yes, they are not significantly absorbed into bloodstream & less likely than steroids to cause systemic side-effects
–Don't affect collagen in skin as topical steroids can so don't cause localized skin thinning
79
Why might systemic immunosuppressants be given to a pt?
Gives a break from high potency topicals, breaks the itch-scratch cycle & allow skin to heal w/out immune system input
80
Which immunosuppressant is usually given?
Cyclosporine
| use
81
What are the ADRs with using systemic immunosuppressants?
–↑ risk bacterial (including TB) & viral (shingles) infection
–GI upset & vomiting
–↑ risk skin/internal CA
–↑ BP (cyclosporine), kidney damage (cyclosporine & methotrexate), liver damage (methotrexate)
82
what is Fitzpatrick classification referring to?
–amount of melanin pigment in skin
| •Constitutional color (white, brown or black) + result of exposure to ultraviolet radiation (tanning)
83
What are the skin phototypes?
–I: pale white skin, blue/green eyes, blond/red hair – always burns, does not tan
–II: fair skin, blue eyes – burns easily, tans poorly
–III: darker white skin – tans after initial burn
–IV: light brown skin – burns minimally, tans easily
–V: brown skin – rarely burns, tans darkly easily
–VI : dark brown or black skin – never burns, always tans darkly
84
What is MED?
•minimal erythema dose
| –Lowest dose of UVR capable of inducing erythema in a person
85
What are the acute cutaneous effects of UVR?
sunburn (inflammation + erythema) & tanning (immediate vs. delayed)
86
What are chronuc effects of UVR?
»Photoaging: ephelides, dyspigmentation
| »Photocarcinogenesis
87
What are the categories of photodermatoses?
1) Polymorphic light eruption (PMLE)
2) Photoaggravated dermatoses
3) Drug induced photosensitivity & Phototoxicity
88
What is PMLE most likely caused by?
Idiopathic and autoimmune
89
What is the onset and duration of PMLE?
–1-3 H s/p sun exposure; usually spring/summer
| –Duration: lesions last days
90
What is the clinical presentation on PMLE typically?
extensor forearms, dorsa/hands, face & neck; pruritic, symmetric, flesh colored or red papules &/or papulovesicles that coalesce into plaques
91
How is PMLE tx?
Photoprotection: avoid sun, clothing/hat, zinc or titanium sunscreen & topical CS
92
What are examples of photoaggravated dermatoses?
atopic derm, seborrheic derm, SLE, rosacea
93
What is the onset and duration of photoaggravated dermatoses?
–Onset: w/in hours of exposure
| –Duration: days to months
94
What is the clinical picture for photoaggravated dermatoses?
exacerbation of underlying skin condition in sun-exposed & non-sun exposed areas
95
How are photoaggravated dermatoses tx?
Photoprotection
| Manage underlying condition
96
What is the onset and duration of drug induced photosensitivity/toxicity?
hours s/p exposure
97
What is the clinical presentation for drug induced photosensitivity/toxicity?
“exaggerated sunburn” reaction – burning/stinging, vesicles or bulla followed by desquamation & hyperpigmentation
98
What is the etiology of drug induced photosensitivity/toxicity?
photo-onycholysis (tetracyclines, psoralens), thiazides, slate gray hyperpigmentation (amiodarone, diltiazem, tricyclics)
99
How is drug induced photosensitivity/toxicity tx?
DC causative agent
100
What is photoallergy?
photoallergic contact dermatitis to topical med’n or chemical & UVR exposure
101
What is the onset of a photoallergy?
1st exposure – 7-10 days; recurrent – minutes to hours
102
What is the clinical presentation of photodermatoses?
Pruritic, eczematous eruption with/without vesicles/bulla
103
How is photoallergy tx?
discontinue agent, photoprotection, topical or oral CS
104
What is phytophotodermatitis?
phototoxic rxn to plant exposure
105
What is the distribution with phytophotodermatitis?
sites exposed to plant toxin + sun exposure
106
What is the clinical presentation of phytophotodermatitis?
–Inflammatory rxn: w/in 1 day, erythematous streaks, vesicles/bulla, non-pruritic but painful
–Delayed hyperpigmentation – lasts months to years
107
How is phytophotodermatitis tx?
Wash off the plant pollen/juice, supportive care, photoprotection, topical or oral CS, pt education
