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Flashcards in Dermatology 3 Deck (51):
1

Infantile Hemangiomas

Propranolol (4)

  • Approved for use in IH March 2014
  • Must be started early‐reached 80% of size by 3‐5 months
  • Effective at reducing IH size as compared with placebo, observation and other treatment including steroids
  • THIS HAS TO BE STARTED EARLY
    • Proliferate between 4-5 months
    • Started early it will not progress

2

Infantile Hemangioma

  • Timolol (topical)

  • Greater effectiveness than observation (64%)
  • Timolol plus laser with varying response
  • 75% regress without regrowth

3

Pityriasis Alba

  • Mild, often asymptomatic, form of AD of the face
  • Presents as poorly marginated, hypopigmented, slightly scaly patches on the cheeks
  • Typically found in young children (with darker skin), often presenting in spring and summer when the normal skin begins to tan
  • Reassure patients and parents that it generally fades with time
  • Use of sunscreens will minimize tanning, thereby limiting the contrast between diseased and normal skin
  • If moisturization and sunscreen do not improve the skin lesions, consider low strength topical steroids
    • Dryness
    • Moisturizer

4

Take Home Points AD

  • AD is a chronic, pruritic, inflammatory skin disease with awide range of severity
  • AD is one of the most common skin disorders in developed countries, affecting ~ 20% of children and 1-3% of adults
  • Distribution and morphology of skin lesions varies by age
  • A large percentage of children with AD will develop asthma or allergic rhinitis
  • The pathogenesis of AD is multifactorial; genetics, skin barrier dysfunction, impaired immune response, and the environment play a role
  • Treatment for AD includes long-term use of emollients and gentle skin care as well as short-term treatment for acute flares
  • Acute inflammation is treated with topical steroids
  • Treat pruritus with antihistamines
  • Secondary skin infections should be treated with systemic antibiotics
  • Identification of true food allergies should be reserved for refractory AD in children in whom the suspicion for a food allergy is high
  • Pityriasis alba is a mild form of AD of the face in children
  • Sunscreen and emollients are the 1st-line treatments for patients with pityriasis alba
  • Reassure patients and parents that pityriasis alba will fade with time

5

Papulosquamous Disorders - Psoriasis Overview

  • Chronic Recurrent Inflammatory Disorder
  • Many Cases (37%) start in childhood or Adolescence
  • Plaques are Circumscribed, Erythematous, and Covered with Micaceous Scale
  • Most Common Sites: Elbow, Knee, Buttocks, Scalp, and Nails
  • Koebner Phenomenon is Common

 

  • Diaper rash that doesn’t get better
  • Onset of psoriasis around 10 years old

6

Psoriasis - Different Forms

  • Napkin Psoriasis
  • Guttate Psoriasis one or two Weeks after Strep
  • Scalp Psoriasis
    • Responds well to steroids
    • Liquid form
  • Erythrodermic Psoriasis
  • Pustular Psoriasis
  • Psoriatic Arthritis

7

Clinical Characteristics Psoriasis Guttata

  • Annular, localized erythematous to salmon colored plaques with hyperkeratosis
  • Commonly noted on trunk, abdomen, and back
  • Recent pharyngitis may precipate
  • Treat infection can clear it up
    • Teardrops** See them all over
    • Strep throat with family history of psoriasis and get teardrops
    • Herald of further psoriasis

8

Clinical Characteristics: Nail Psoriasis

  • Nail pitting, oil spots, subungual hyperkeratosis
  • Extensive pitting and subungal hyperkeratosis
  • Gets confused with fungal infection

9

Inverse Psoriasis

  • Founds in folds
  • Thick plaques in axillae and groin
  • Secondary infection with candida

10

New & Old Psoriasis Treatments

  • Topicals

  • Anthralin cream 1%
  • Topical steroids
  • Tar
  • Topical calcineurin inhibitors twice a day (off label)**

11

Psoriasis Tx

Phototherapy + Systemic

 

  • Phototherapy
  • Systemic agents
    • Cyclosporine
    • Oral antibiotics
    • Methotrexate
    • Retinoids (oral Accutane)

12

Psoriasis Tx

Biological Agents

  • Etanercept (subcut), adalimumab (subcut) and infliximab (IV)
  • Not approved for this use
    • Prone to infection

13

Psoriasis Tx

Alternative Therapies

  • Omega-3-fatty acids
    • Alternative choice
    • Not a lot of research
  • Indigo naturalis (a traditional Chinese medicine)

14

Scalp psoriasis – plaque-like lesions

Auspitz sign

Koebner

Bleed as you scratch its psoriasis

Linear pattern at the back of the elbows – big plaque, raised, thick, positive

15

Pityariasis Versicolor

 

Common months

  • Widespread, hypopigmented, minimally scaly plaque (Tinea pityriasis)
  • Superficial yeast infection resulting from Malassezia furfur
  • Superficial scaling hypopigmented or hyperpigmented macules or flat papules on the upper trunk, arms, neck and face
    • Common in Spring and Summer due to heat and humidity factors
    • May present as Folliculitis
  • Most commonly in high humidity and temperatures
    • Low grade yeast infection
    • Can be raised or flat

16

Pityariasis Rosea

  • Begins with a herald patch
  • Goes to generalized, non-pruritic eruption within 2 weeks
  • Characterized by oval, erythematous lesions with long axis in lines of skin cleavage
  • Clears spontaneously within 6 weeks

17

Pityariasis Rosea

  • Frequently confused with secondary syphilis and generalized tinea corporis

  • Patch that starts first and spreads over the body
    • Christmas tree distribution
    • Can be confused with secondary syphilis
    • NEVER ON THE PALMS!!!!
      • Only syphilis is on the palms
    • Trunchal rash
    • Syphilis is ALL OVER AND ON THE HANDS AND FEET
  • See this in clusters
    • See one or two cases in a week; see 10 by the end of the month
    • Might have some infectious – so clustered

18

Autoimmune: Vitiligo

  • Due to melanocyte destruction or damage
  • Reduced or absent pigmentation of the skin, hair and Mucous membranes.
  • .5 to 2% of the world population
  • Genetic propensity paired with environmental triggers melanocyte destruction
  • Autoimmune disease
  • Treatable
    • Genetic propensity toward autoimmunity
  • Associated with deficiencies of vitamins—lack of antioxidants, Lack of Vitamin D
  • Teens with vitiligo or a family history of vitiligo should avoid hair dyes
  • Tan and hazel/green eyes are associated with vitiligo

19

Vitiligo Co-Morbidity

  • Vitiligo is associated with other autoimmune illnesses such as alopecia areata, psoriasis, rheumatoid arthritis
    • Need to test thyroid with alopecia areata and vitiligo done
  • Non segmental vitiligo has a higher incidence of autoimmune thyroid disease

20

Vitiligo Diagnosis

  • Segmental vitiligo spread over month or years in the skin segment involved
  • Can be along lines of Blaschko
  • More common in children
  • Nonsegmental vitiligo spreads slow and steadily

21

Vitiligo Management

  • While young children may not want therapy early medical treatment is more likely to work in the first 2-5 years of the disease
  • Need thyroid screen and vitamin D level (25-hydroxyvitamin D)
  • Celiac disease screening should be done if there are symptoms of abdominal pain and bloating
  • Joint complaints screen for JIA
    • Sed-rate

22

Vitiligo Treatment (6)

  • All topicals used are off label
    • Using them in high class – class 2
  • Topical corticosteroids (class 2-mometosone)
  • Topical calcineurin inhibitors (pimecrolimus, tacrolimus (elidel and protopic)
  • Topical vitamin D analogues (Calcipotriene) use of topical for 3-4 month on face and 6-8 months on the body
  • Photochemotherapy with psoralens and UVA
  • Excimer laser for focal disease or poor response to topical agents
  • Grafting
  • REFER TO DERM

23

Vitiligo -- Prevent Worsening

  • Avoid food that are hydroquinone rich and phenol rich such as blueberries and pears and mushroom that contain melanin
  • Hair dyes
  • Take a B complex and antioxidant vitamin
  • Vitamin D supplement

24

Alopecia Areata

Overview

  • Sudden loss of hair
  • Hair comes out in clumps
  • May be reaction to stress
  • Patient may have thyroid disease
  • Patient may complain of tingling or burning
  • Well circumscribed annular patches of alopecia
  • May see exclamation point hairs
  • Sparing of white hairs
  • May affect non scalp hair
  • Nail pitting in 10%

25

Alopecia Areata

Treatment

  • Topical Class 1 steroids
  • Intralesional steroid
  • Topical irritant therapy
  • Immunotherapy

26

Alopecia Areata

Outcome

  • Hair regrowth: more common with single patches
  • Can be recurrent

27

Non-infectious Skin Lesions

 

Nevus of Johansson

28

Assessment for Active Hair Loss

  • Pull Test
    • Grab about 60 hairs and tug at them from proximal to distal end
    • Removal of more than six hairs indicates a positive pull test and active hair loss

 

29

Telogen Effluvium

Overview

  • Generalized hair loss
  • Abrupt onset with trigger factor—
    •  Blood loss, iron deficiency, thyroid imbalance, initiation of drugs
  • Hair thinning but no bare patches
  • Prominent shedding
  • Any age but not common in childhood
  • Positive pull test
  • Previous major illness or stress

30

Blisters

Prevention

  • If they are tense, they may need to be drained
  • Need to be covered once they are open to reduce friction
  • Prevention:
    • Petroleum jelly on a “hot spot” can decrease the incidence of these blisters

Tennis Player

31

Calluses and Corns

  • Very thickened stratum corneum
  • Can occur on feet or hands depending on activity
  • Response to friction so patient should avoid over trimming
  • Can use pumice stone or file but should not share tools.

 

Runners

32

Jogger’s Nipples

  • Occurs in endurance athletes
  • Cover nipples with Band-Aids

Vaseline with loose clothing help to prevent chaffing

 

Long distance runner

33

Abrasians

16 year old runner

  • Turf burn, mat burn, road rash are all names
  • Epidermis is scraped away
  • Clean with soap and water
  • Apply antibiotic ointment and cover

34

Black Nails

Cross country runner wants to know what is happening with his nails

  • Occurs in runners, cyclist and tennis players
  • Repeated trauma of the nail against the show
  • Subungal hematoma
  • May need drainage by HCP if painful
  • Prevention
    • Keep nails short cut and making sure the toe box is adequate.
      • Shoes must fit

35

Piezogenic Papules

Overview

  • Papules resolve when the patient is non-weight bearing
  • Papules can usually be compressed
  • They mostly occur over posterior and lateral border of the heels
  • They are often bilateral
  • No treatment is required.

 

Have patient STAND UP if they are presenting with heel pain to see the papules

36

  • Painful piezogenic papules

  • Restriction of weight-bearing exercise
  • Weight loss
  • Compression stockings
  • Foam rubber foot pads, or foam-fitting plastic heel cups
  • Consultation with orthopedist or podiatry

37

Acne Mechanica

 

A field hockey goalie presents with worsening acne around the chin

  • Cause
  • Occlusion and pressure for the padding and face equipment in football, ice hockey, and field hockey
  • Clean after work out with benzoyl peroxide wash or astringent
  • Will improve once the adolescent is not longer wearing the face equipment

38

Pitted Keratolysis

 

 

Tennis player complaining of foul smelling feet

  • Intense odor
  • Pits in the epidermis on the feet
  • Needs antibacterial soup
  • Topical benzoyl period is helpful
  • Topical antibiotic such as clindamycin
  • Or erythromycin.

39

Mastocytomas

  • Composed of Mast cells
  • Red or red-brown nodules
  • Multiple in urticarial pigmentosa
  • May urticate or form a blister
  • Avoid vigorous rubbing, hot baths, aspirin, alcohol, ibuprofen, and codeine
  • Cyproheptadine (Periactin) for treatment if needed

40

Dyshidrotic eczema (pompholyx)

  • Dyshidrotic eczema presents as very pruritic vesiculopapules on the palms, soles, and sides of the fingers.
    • The vesicle fluid has been compared to tapioca pudding.
    • After healing, they often leave behind a mark with a mahogany color, called post-inflammatory hyperpigmentation.
  • Many patients have a history of atopic dermatitis, and many have coexisting tinea pedis
  • The mainstay of treatment is potent topical steroids

41

Dyshidrotic eczema (pompholyx)

  • LOCATION CUES TO VESICLES ON FEET (4)

  • Dorsal foot: contact dermatitis, insect bites
  • Sides of feet and toes: dyshidrotic eczema
  • Soles: tinea pedis (often with scaling and interdigital maceration)
  • Balls, heels: friction blisters

42

Lichen striatus

  • Rare, idiopathic popular eruption of childhood characterized by the sudden onset of flat‐topped, skincolored or hyperpigmented papules arranged in a linear configuration along the lines of Blaschko
  • The eruption typically resolves spontaneously in a few months to four years. Histology reveals a lichenoid lymphocytic infiltrate with overlying acanthosis and dyskeratosis.

43

Herpes Simplex

  • Herpes simplex viruses 1 and 2 cause painful, grouped vesicles on an erythematous base
  • HSV 1 favors...
  • HSV 2 favors...

  • Vesicles may appear pustular (white to yellow)
  • Tends to recur in the same place
  • HSV 1 favors the mouth and nose
  • HSV 2 favors the genitalia, buttocks, thighs
  • Perianal erosions or ulcerations in immunosuppressed patients are usually HSV

44

Often dont see ___1___, just the ____2____

Herpes Simplex

  • 1. VESICLES
  • 2. EROSIONS
    • Look for bright red rim on erosion
    • Pain and recurrence suggests HSV

45

  • herpes VESICLES IN BATHING SUIT DISTRIBUTION

  • Recurrent vesicles on genitalia, buttocks, or thighs, are HSV until proven otherwise
  • HSV usually has bright red borders and may present as pustules, or erosions
  • Severe perianal HSV may occur in HIV or other immunosuppression
  • Single genital ulcers could be syphilis or chancroid as well

46

What Tests are used to confirm diagnosis of herpes simplex

  • Tzanck prep can be used to confirm herpes family viruses, but it does not differentiate them from one another. It requires scraping the base of an active vesicle or erosion. Results are immediate.
  • Viral culture can be performed when there is fluid present, but it is less helpful once crusts have formed. Results in 1-3 weeks. Not as helpful for VZV. The gold standard for HSV.
  • Direct fluorescent antibody (DFA) test can differentiate HSV 1 and 2, as well as VZV. Like Tzanck prep, scrape the base of a vesicle or erosion. Results in 48 hours.
  • The HerpSelect test is a blood test, which uses IgG antibodies to differentiate past exposures to HSV 1 and 2 but not VZV. Results in days to weeks.

47

HSV Treatment

  • Acyclovir is a safe, cheap, and reliable treatment for HSV
    • Should be started immediately at first sign of recurrence
    • Acyclovir can be used in pregnancy
    • Intravenous acyclovir is available for generalized HSV or VZV in the immunocompromised
  • Famciclovir and valacyclovir are more expensive but have easier dosing

48

HSV Treatment for Recurrent Episodes

  • Mounting evidence shows that patientinitiated, oral antiviral therapy works best
  • Patients start taking at earliest sign of outbreak (burning, pain, itching, etc.)
  • Short therapies work as well as longer ones
    • Acyclovir 800 mg TID x 2 days
    • Famciclovir 1 gram BID x 1 day (manufacture is pulling this drug off the market)
    • Valacyclovir 2 grams BID x 1 day

49

Tinea Pedis (Athlete's Foot)

  • Tinea pedis may have fine scales on the sole and between toes
  • Vesicles often appear on bottom of foot
  • Scrape the roof of a vesicle to improve sensitivity of KOH exam

50

Types of Tinea Pedis (4)

  • Moccasin
    • Diffuse erythema, scaling, and maceration on the plantar surface of the feet
  • Interdigital
    •  Most common and is erythema, scaling and maceration in web spaces
  • Inflammatory
    • Acquired from animals
    • Presents with vesicles, pustules, and blisters on feet
  • Ulcerative
    • Interdigital distribution but with more erosions and ulcers
  • Most common in adolescents and rare in prepubertal children
  • Warm moist environment promotes it
  • Transmitted on the floors of locker rooms, swimming pools and household contact

51

Tinea Pedis Tx

  • Counsel on foot care to prevent recurrence
    • Keep feet dry; change absorbent socks daily
    • Wear flip flops in locker rooms, pool decks, etc.
    • Use antifungal powders in shoes
  • Localized involvement
    • Azoles (miconazole, clotrimazole) are fungistatic and must be used twice daily
    • Allylamines (terbinafine, naftifine) and benzylamines (butenafine) are fungicidal
    • Cure rates are better with fungicidal antifungals, but generic azoles are usually cheaper