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Flashcards in Dermatology 2 Deck (74):
1

Acne

disease of pilosebaceous unit, appears near puberty; more sever in males, more persistent in females, dismissed as minor

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Classification of acne

5 cysts, comedones >100, inflammatory> 50 or >125 total- severe

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Etiology of acne

sebum is the pathogenic factor in acne, it is irritating and comedogenic, begins when sebum production inc, propionibacterium acne proliferates in sebum, and the follicular epithelial lining becomes altered and forms plugs called comedones, testosterone is a factor

4

Pathogenesis of acne

inc sebum production, hyperkeratosis of sebaceous duct, propionibacterium acnes, blocked or plugged pilosebaceous follicles

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Treatment of mild acne

benzoyl peroxide, topical antibiotic or combo and retinoid applied on alternate evenings; oral antibiotics if no response in 6-8 weeks

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Treatment of moderate acne

topical antibiotic and benzoyl peroxide, oral antibiotics, topical retinoid can be introduced if inflammation subsides, oral abx should be continued until no new lesions develop and then taper gradually

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Treatment of severe acne

requires aggressive tx, reassuree about effectiveness, I&D for cysts w/ thin roofs, intra lesional injection of kenalog, oral antibiotics, oral prednisone to control inflammation, rapid introduction of accutane

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Hormonal acne

increased facial oiliness, premenstrual acne, inflammatory acne on mandibular line and neck, adult acne, worsening in adult, treatment failure w/ accutane, h/o irregular menses, hirsutism, alopecia

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Hormonal tx for acne

oral contraceptives, spironolactone, and prednisone/dexamethasone

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Steroid acne

uniform size and symmetric distribution

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neonatal acne

seb glands stimulated by maternal androgens

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acne conglobata

double comedones, papules, cysts and abcesses, mainly black, no systemic symptoms

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acne fulminans

ulcerative, necrotic acne w/ systemic sx, fever, wt loss, leucocytosis, arthralgia, muscle pain, elevated esr, treat w/ steroids followed by accutane, abx not effective

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other types of acne

occupational, acne cosmetica, excoriated acne

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Perioral dermatitis

occurs in young women, resembles acne, lesions confined to chin and nasolabial folds, pustules on cheek adjacent to nostril are characteristic, pathogenesis unknown (prolonged use of fluorinated steroids? cosmetics?)

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Treatment of perioral dermatitis

abx, 2-3 weeks or oral tetracycline and erythromycin are mainstay tx, doxy also effective, long term maintenance therapy w/ oral abx may be required, tacrolimus ointment, topical abx are not effective, avoid other topicals

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How long does treatment for perioral dermatitis take

2-3 months w/ proper treatment

18

Rosacea primary features

flushing, non-transient erythema, papules and pustules, telangiectasia

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Rosacea secondary features

burning or stinging, dry appearance, edema, ocular manifestations, peripheral location, phymatous changes

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Rosacea pearls

unknown etiology, EtOH may worsen, sun exposure, heat, hot drinks, a mite "demodex folliculorum", after age 30, celtic origin,

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Rosacea clinical features

erythema, edema, pappules, pustules and telangiectasia, eruptions on forehead, cheeks, nose and occasionally around the eyes, chronic deep inflammation around the nose --> irreversible hypertrophy

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Rhinophyma

whisky nose, common in rosacea

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Ocular rosacea

common, 58% w/ rosacea, mild conjunctivitis, soreness, foreign body sensation and lacrimation, maybe dry eyes, dec visual acuity may result from long standing disease

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Treatment of oral antibiotics

doxycycline, tetracycline, minocycline or metronidazole, severe refractory cases can be treated w/ accutane, first line is metronidazole cream, sulfa prep (Sulfacet-R), mirvaso controls erythema for 12 hrs

25

Hidradenitis Suppurativa

chronic suppurative and scaring disease of the skin and subcutaneous tissue in axilla, anogenital regions, under breasts and body folds, mild is misdiagnosed as recurrent furunculosis

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Pathogenesis of hidranenitis suppurtiva

now believed to be a disease of follicle instead of apocrine appartatus, bac infection prop a major cause of exacerbation, not appear until puberty

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Clinical presentationof hidrandenitis suppurtiva

double comedone, communicating under skin, progressive and self perpetuating, extensive, deep, dermal inflammation results in large, painful abcesses, healing process permanentlly alters the dermis, cordlike bands of scar tissue criss cross

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Management of hidradenitis suppurtiva

abx, long term oral, tetracycline, erythromycin, doxy, and minocycline, accutane in selected cases, large cyst should be incised and drained to intralesional injection of kenalog, get bac culture, wt loss and stop smoking

29

Psoriasis

1-3% pop, genetic, unknown origin, chronic, recurrent exacerbation and remission that are emotionally and physically debilitating

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Pathology of psoriasis

epidermis contains a large number of mitoses, epidermal hyperplasia and scale, dermis contains enlarged and tortuous capillaries that are very close to the skin surface and impart the characteristic erythematous hue, bleeding

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Auspitz's sign

bleeding when capillaries rupture as scale is removed, see pin point hemorrhages w/ scaly skin

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Variations of morphology of psoriasis

chronic plaque psoriasis, guttate psoriasis, pustular psoriasis, erythrodermic psoriasis, HIV induced psoriasis, light sensitive

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Variationin location of psoriasis

scalp, palms and soles, pustular psoriasis of palms and soles, psoriasis inversus, nail psoriasis, psoriatic arthritis

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Guttate and pustular psoriasis

destinctive lesions, begin as red scaling papules, coalesce to form round oval plaques, Auzpitz's sign, scale is adherent, silvery white reveals bleeding when removed, koebner's phenomenon, affects extensors

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Koebner's phenomenon

lesions develpp at site of trauma, scratching, sunburn, surgery

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Drugs that precipitate psoriasis

lithium, beta blockers, antimalarials, systemic steroids

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Chronic plaque psoriasis

most common, evolve into erythrodermic, chronic, well-defined plaques w/ silvery white scales, enlarge to certain size and remain stable for months, temporary brown, white or red macule remains when plaque subsides

38

Guttate psoriasis

strep pharangitis or viral URI may precede eruption by 1-2 weeks, scaling papule may appear on trunk and extremities, mm-1 cm, may resolve spontaneously in weeks to months, responds to abx

39

Generalized pustular psoriasis

rare form, sometimes fatal, erythema suddenlly appears into flexural areas and migrates to other surfaces, numerous tiny, sterile pustules from an erythemmatous base, lakes of pus, leukocytosis, febrile, relapse common

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Treatment of generalized pustular psoriasis

w/drawal both topical and systemic steroids (may precipitate flares), wet dressings and group V steroids, for severe cases systemic therapy w/ acitretin methotrexate and cyclosporine

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Erythrodermic psoriasis

severe, unstable, highly labile disease, mainly in pt w/ chronic disease, rarely initial presentation, precepitating factors: systemic steroids, topical steroids, phototherapy, stress, infection, other topical therapies

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Treatment of erthrodermic psoriasis

bed rest, avoid UV light, compresses, liberal use of emollients, inc protein and fluid intake, antihistamines and hospitalization; methotrexate, cyclosporine, acitretin, biologics

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Psoriasis of the scalp

may be only site affected, plaques similar to skin but scales are anchored by hair, extension of plaques onto the forehead is common, even in most severe cases the hair is not permanently lost, tx topical steroids

44

Psoriasis of nails

pitting best known abnormality, oil spot lesion, localized separation of the nail, cellular debris accumulates, brown yellow color; onycholysis- separation of nail from the nail bed in irregular manner, like fungal infection, fragmentation

45

Psoriatic arthritis

5-8% in psoriatic pts, higher among pt w/ more severe cutaneous disease, 53% suffer from arthralgia, RF neg, 80% nail involvement, progressive arthritis

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Diagnosis of psoriatic arthritis

to exclude other arthritis disease: ANA, ESR, WBC, uric acid, ESR is best lab to disease activity, RF levels typically normal

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Five presentations of psoriatic arthritis

asymmetric arthritis, symmetric, distal interphalangeal joint disease, arthritis mutilans, ankylosing spondylitis

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Asymmetric arthritis presentation

most common pattern involving one or more joints, sausage finger, continued inflammation promotes soft tissue swelling on either side of the joint

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Symmetric arthritis presentation

polyarthritis resembling RA occurs but the RA factor is neg

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Distal interphalangeal joint disease

Most characteristic presentation of arthritis w/ psoriasis is involvement of DIP, chronic but mild, 5% pts

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arthritis mutilans

most severe form, involves osteolysis of any of the small bones of hands and feet, leads to digital telescoping producing the opera glass deformity

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ankylosing spondylitis

may occur as an isolated phenomenon

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Treatment of psoriatic arthritis

NSAIDs 1st line, intralesional injections w/ corticosteroids, methotrexate- 2nd line, biologics- embrel, humira, remicade, antimalarials, cyclosporine, acitretin, photochemotherapy, steroid creams

54

When to stop treatment of psoriatic arthritis

when the plaque cannot be felt by drawing the finger over the skin surface

55

Seborrheic dermatitis

common, chronic inflammatory disease w/ characteristic pattern for different age groups, pityrosporum ovale is cause, genetic and environment influence, many pt have oily complexion, remission and exacerbation common

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Infants, cradle cap

infants develop greasy adherent scales on vertex of the scalp, scales may accumulate and become thick and adherent and can be removed w/ shampooing, secondary infection can occur

57

Treatment of cradle cap

serum and crust are treated w/ antistaph abx, erythema and scaling- group VI or VII steroid, dense scale removed w/ warm mineral oil or olive oil then wash detergent after sseveral hours, remission can be prolonged w/ salicylic acid and tar shampoos

58

Tinea amiantacea

1-several patches of dense scale anywhere on scalp, persist for months before parent notices area of some hair loss and yellow white plates of scales, 2-10 cm

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Treatment of tinea amiantacea

warm 10% liquor carbonis detergens in nivea oil, apply over night and shampoo in morning, can use tar shampoo for maintenance, topical steroid lotion too

60

Adult or classic SD

fine, dry, white scaling w/ minor itching, should wash hair everyday w/ antidandruff shampoo; scalp and margins, eyebrows etc, on ears could be eczema or fungus, varying degrees

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Treatment of adult SD

shampoos, zinc soaps, selenium, tar, salicylic acid, topical steroids, V-VII creams, anti yeast meds- ketoconazole or ciclopirox olamaine, also sulfacetamide, metrogel, protopic and elidel creams

62

Pityriasis rosea

common, binign, asymptomatic eruption, unknown etiology, `23 yo, 2% recur, 20% have h/o acute infection w/ fatigue, HA or sore throat

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Clinical features of pityriasis rosea

2-10 cm round lesions~17% pt, mainly on trunk or proximal extremities, d-w enters eruptive phase, smaller lesions appear and inc in num, long axis of oval plaques oriented along skin lines "christmas tree pattern", collarette scale

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Treatment of pityriasis rosea

spontaneously clears in 1-3 months, oral erythromycin, group V steroids for itching, UVB

65

Lichen planus

unique inflammatory cutaneous and mucous membrane rxn pattern of unknown etiology, 40 yom, 46yof, 10% have fam hx, associated w/ Hep-C!

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Primary lesions

pruriitic, planar, polygonal, purple papules, heal w/ pigmentation, 2-10 mm papule/plaque, close inspection of surface shows lacy reticular pattern, criss-cross, whitish lines "Wickham striae" accentuated by immersion oil, focal epidermal thickening, koebner's phenomenon

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Types of lichen planus

localized papules, hypertrophic lichen planus, LP of palms and soles, oral mucous membrane LP, Nail

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localized pupule LP

most commonly located on flexor surfaces of wrist/forearms, legs/above ankles, 20% do not itch, chronic, last >4 years

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hypertrophic LP

pretibial and ankles, reddish brown or violaceous plaques w/ rough or verrucose surface, heal w/ dark pigmentation, average 8 yrs, intalesional steroids

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LP of palms and soles

papules are larger and aggregate into semi translucent plaques w/ globular waxy surface

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Follicular LP

lichen planopilaris, may cause scarring alopecia

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Oral mucous membrane LP

asymptomatic dendritic, branching or lacy, shite network pattern seen on buccal mucosa, seen in >50% of the pts w/ cutaneous disease, twice more common in women

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Nails LP

proximal to distal linear grooves and depressions

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Treatment of LP

topical steroids I-II, intralesional steroids, systemic steroids, acitretin, azathioprine, cyclosporin, dapsone, antihistamines, steroids in orabase for mucous membranes