Dermatology Fungal, Bacterial, Viral

Question 1

Skin

• Skin =
• Functions as our?
• Regulates aspects of el____ and m_____

Answer 1

• Skin: Largest organ in the body
• First line of defense from infections and caustic exposure
• Regulates aspects of elimination and metabolism

Question 2

Skin Layers

(3)

Descriptions of each

Answer 2

Epidermis, Dermis, Subcutaneous fat

1. Epidermis- outermost layer; waterproof barrier. Contains melanocytes and melanosomes that determine skin color/pigment.
2. Dermis: 2 layers; primarily made of collagen the structural protein of the skin
3. Subq: known as the panniculus. Lobules of lipocytes.

Question 3

A small (usually less than 1cm in diameter), flat blemish or discoloration that can be brown, tan, red, or white and has same texture as surrounding skin

Answer 3

Macule

Question 4

A small (less than 0.5cm in diameter), thin-walled, raised blister containing clear, serous, purulent, or bloody fluid

Answer 4

Vesicle

Question 5

A solid, raised mass usually larger than 2cm in diameter with possible skin discoloration

Answer 5

Tumor

Question 6

A small, firm, circumscribed, elevated lesion 1-2 cm in diameter with possible skin discoloration

Answer 6

Nodule

Question 7

A circumscribed, pus or lymph filled, elevated lesion that varies in diameter and may be firm or soft and white or yellow

Answer 7

Pustule

Question 8

A slightly raised, firm lesion of variable size and shape, surrounded by edema, skin may be red or pale

Answer 8

Wheal

Question 9

A small, solid, raised lesion less than 1cm in diameter, with red to purple skin discoloration

Answer 9

Papule

Question 10

A raised, thin-walled blister greater than 0.5cm in diameter, containing clear or serous fluid

Answer 10

Bulla

Question 11

Derm Terms

• Essential to know the basic terms when _____ to colleagues and ____ what you see
• Always assess the (1) - pruritis, burning, pain and (1) signs - flat, raised, deep, superficial
• Primary lesions = (1) flat, nonpalpable <1cm ie lentigo VS. (1) >1cm ie vitiligo
• Secondary lesions = cr___, ex_____, sc_____, sc____, er_____, etc
  
  • Diagnostic details: Dis_____, Ev____, Co____, Con_____

Answer 11

• Essential to know the basic terms when communicating to colleagues and documenting what you see
• Always assess the subjective - pruritis, burning, pain and objective signs - flat, raised, deep, superficial
• Primary lesions = macule-flat, nonpalpable <1cm ie lentigo VS. patch >1cm ie vitiligo
• Secondary lesions = crusts, excoriations, scars, scales, erosions, etc
  
  • Diagnostic details: Distribution, Evolution (time period), Color, Consistency (blanch, texture, temperature)

Question 12

Vehicles for Topical Medication Administration

(3)

• (1) → (1) → (1) → (1) (more potent than lotions so don’t want to use like on the head)
• Lotions, Creams, Ointments- most common
• Foams, solutions, Gels
• Consider the ____ of the body you’re treating and how ____ of an area

Answer 12

• Lotions → Creams → Gels → Ointments (more potent than lotions so don’t want to use like on the head)
• Lotions, Creams, Ointments- most common
• Foams, solutions, Gels
• Consider the part of the body you’re treating and how large of an area

Question 13

Fungal Infections

(2)

Answer 13

Tinea (dermatophytes) - fungus

Interigo (candida) - yeast

Question 14

Tinea Overview

Tinea = Dermatophytes (used interchangeably)

• Tinea =
• Majority caused by (3) fungi/dermatophytes
• Dermatophyte is fungus that invades and proliferates in the nonviable keratinized layer of skin—(1)
  
  • Rarely ______ skin or hair follicle (Majocchi’s granuloma) → superficial

Answer 14

• Tinea means a superficial fungal infection of the hair, skin, or nails (does not go beyond epidermis)
• Epidermophyton, Trichophyton Rubrum (most common), Microsporum
• Dermatophyte is fungus that invades and proliferates in the nonviable keratinized layer of skin—stratum corneum
  
  • Rarely penetrate skin or hair follicle (Majocchi’s granuloma) → superficial

Question 15

Tinea Overview

1. Classified =
2. Predisposing factors
   
   1. Gender (1)
   2. Environment (1)
   3. G____, Sw_____
   4. Wr______
   5. Sm______
   6. Hx (1)
3. Transmitted =
4. Diagnosed =
   
   1. (1) is possible but takes up to 6 weeks for results
   2. (1) can also be used to confirm presence of dermatophyte
5. Avoid using (1) → may exacerbates sx and confuse dx (Tinea Incognito)

Answer 15

1. Classified according to Latin term for body location: capitis—head; pedis—foot; cruris—groin; corporis—body
2. Predisposing factors
   
   1. male
   2. humid environment
   3. gym, sweating
   4. wrestling
   5. smoking
   6. hx of diabetes/any immunosuppression
3. Transmitted via direct contact with infected person, animal, or environment
4. Diagnosed via KOH slide (scrape of skin)– Looking for hyphae
   
   1. culture is possible but takes up to 6 weeks for results
   2. DTM (dermatophyte test medium) can also be used to confirm presence of dermatophyte
5. Avoid using steroids → may exacerbates sx and confuse dx (Tinea Incognito)

If you suspect tinea but it could be eczema, treat the tinea first and if not improving then treat the inflammatory response bc if you use topical steroids first, won’t treat the tinea

Question 16

Tinea Capitus

=

1. Can be associated with scalp ____, chronically ____ hair (i.e. sweating), poor _____
2. Causes: sharing ____, _____ tools
3. More common in _____ children
4. Incubation period of __- __ days
5. Presence of (1) helps differentiate from alopecia (1) sign
6. May have (1): swollen, boggy, fever, pain, lymphadenopathy, pus

Answer 16

Fungal infection of scalp → bald spots (secondary alopecia)

1. Can be associated with scalp injury, chronically moist hair (i.e. sweating), poor hygiene
2. Causes: sharing hats, barber’s tools
3. More common in black children
4. Incubation period of 2-4 days
5. Presence of broken hair shafts helps differentiate from alopecia (black dot sign)
6. May have Kerion: swollen, boggy, fever, pain, lymphadenopathy, pus

Question 17

What do these pictures show?

1st pic =

2nd pic =

These are examples of what type of tinea capitus? Can we treat with topical antifungals?

Answer 17

1st pic: Alopecia- no hair shafts noted in bald spot

2nd pic: Tinea appears to have “black dots” d/t broken hair shafts within bald spot; Black Dot Tinea Capitus is one form

These are examples of non-inflammatory T. Capitus with scaling and well demarcated areas being affected. Note the broken hairs.

Cannot be treated with topical antifungal bc goes deeper into hair follicle

Question 18

What do these pictures show?

This type may require what type of treatment?

Answer 18

Tinea Capitus Inflammatory Type with Kerion

• Always evaluate for and consider possibility of a secondary bacterial infection
• (oozing, wheeping, treat tinea + secondary bacterial infection)
• Inflammatory Type- often very pruritic. May have secondary bacterial infection. Includes significant inflammation of the scalp.
• This type may require treatment with PO antifungals, PO steroids, and/or PO ABX

Question 19

Tinea Capitus Treatment

Rx (1)

1. Other options (3), however all these can be (1)
2. _____ Rx _____ as monotherapy, however use of (1) may discourage recurrence
3. Who else do you treat?
   
   1. Instructions =
   2. Prevention =
   3. Also have your (1) checked if suspected partner in crime

Answer 19

Griseofulvin (Microsize PO x 4-6 weeks vs 8-12 weeks with food)

1. Terbenifine (Lamisil), Itraconazole (Sporanox), Fluconazole (Diflucan) → Hepatotoxic
2. Topical Rx ineffective as monotherapy, however use of antifungal shampoo on a weekly basis (ketoconazole 2% 1-3/week) can discourage recurrence
3. Household members bc can be asymptomatic carriers
   
   1. Antifungal shampoo, leave on for 5min then rinse 3x/week
   2. Don’t share combs, towels, or hats
   3. Have pets checked by vet if suspected partner in crime

Question 20

Tinea Corporis

AKA (1)

• Typically begins as p_____, cir_____, er______, d___, sc____ patch that spread _______ → ______ clearing
  
  • Edges =
  • Borders =
• Most common differential (1)
• May be seen in (3)
• Most common cause (1)

Answer 20

Ringworm

• pruritic, circular, erythematous, dry, scaling patch that spreads centrifugally → central clearing
  
  • raised edges
  • well defined borders
• Nummular (coin shaped) eczema
• Adults caring for children with tinea capitus, athletes w/skin to skin sports (wrestling), immunosuppressed
• Trichophyon Rubrum (T Rubrum)
• DDX: nummular eczema, granuloma annulare, erythema anulare centrifugum (EAC), secondary syphillis. Depends on the body part that it presents with & hx of response to top roids or top antifungals*
• Consider differences in appearance in dark-skinned individuals*

Question 21

Tinea Corporis Treatment

=

(2)

If immunosuppressed?

Answer 21

Topical Antifungals 1st line

1. Imidazoles (econazole, ketoconazole, miconazole, etc)
2. Terbinafine (Lamisil) or Ciclopirox (Loprox)- Ciclo also safe in pregnancy and breastfeeding

Oral tx if immunosuppressed

Question 22

Tinea Cruris

AKA (1)

Effects (2) parts, (2) usually spared

• May be associated w sw_____ or ex_____
  
  • Often self inoculation via (1)
• Presentation =

Answer 22

Jock Itch

Groin or “crural fold” (upper, inner thighs), Scrotum and penis usually spared

• sweating, exertion
  
  • self inoculation via tinea pedis (spread via towels, hands)
• Begins as small erythematous patch w crust and scaling that spreads peripherally w curved (scalloped) well defined edges

Question 23

Tinea Cruris Treatment

=

• If severe or nonresponsive to topicals?
• Treat (1) if present to prevent reinfection
• Keep area (2), Rx (1), clothing should be?

Answer 23

Topicals usual recommendation continue Rx 1 week past sx clearing: Usually requires 2-4 weeks tx - prepare pt!

• Oral agents x2 wks
• Tinea Pedis
• Keep area dry and well vented as much as possible, Zeazorb powder; boxers, not briefs; loose-fitting, cotton clothes

Question 24

_{Tinea Pedis}

AKA (1)

Causes (4)

• May be accompanied by what other condition?
• Presents as mac_____, hyper_____ p_____ in the (1) spaces or as dull _____ with scaling and hyperkeratosis on plantar surfaces of feet

Answer 24

Athlete’s Foot

Moisture/hyperhidrosis, Poorly ventilated shoes, Immunosuppression, Prolonged oral steroids

• Onychomycosis (nail fungus)
• Macerated, hyperkeratotic plaques in the interdigital web spaces or as dull erythema with scaling and hyperkeratosis on plantar surfaces of feet

Question 25

Tinea Pedis Types (3) * Which type is most common? * Always examine between (2) digits * Assess for possible (1)

Answer 25

Interdigital, Moccasin, Vesiculobulous * Interdigital * 4th and 5th digits * 2ndary bacterial infection

Question 26

Tinea Pedis Treatment = * **\_\_\_ - ___ weeks** * Severe cases or if immunosuppressed? * Keep area ___ and well ____ as much as possible

Answer 26

**Topical antifungals** (Econazole, Nafitine, Ketoconazole, Terbinafine) * **2-4 weeks** * Oral tx for 2 weeks * Dry, Well ventilated

Question 27

Tinea/Pityriasis Versicolor = Caused by? Prevalent in what type of climate? Common in ___ adults, especially in the \_\_\_\_\_

Answer 27

**Chronic, asymptomatic, superficial infection** **Yeast** (*Malassazia furfur or P. Ovale)* Warm humid climates Young adults, Summer * *Very common for pt to report dyspigmentation in dark skinned individuals* * *History of the eruption is very important!* * *Used to be called tinea but is not from a dermatophyte, but yeast*

Question 28

Tinea Versicolor Presentation

Answer 28

* Fine scale, guttate (resembling drops) or nummular patches appear that are pink or brownish macules and patches in pale skin and hypopigmented macules in dark skin w/delicate scaling * Typically asymptomatic

Question 29

Tinea Versicolor Treatment = Rx (2) shampoos, must leave on skin how long? Rx (1) PO \_\_\_mg, advise pt to exercise \_\_\_min later (1) is ineffective for this condition

Answer 29

**Topical, oral, shampoo application to skin. Takes several weeks to work and it often recurs** **Selenium Sulfide or Ketoconazole Shampoos** – must leave on skin at least 10 minutes, then rinse. Can be applied overnight and rinsed in AM. **PO fluconazole 300mg,** advise pt to exercise 30 min later X Terbinafine X

Question 30

Tinea Versicolor Ddx

Answer 30

seborrheic dermatitis, pityriasis rosea, vitiligo, mycosis fungoides, confluent and reticulated papilomatosis

Question 31

What is this rash called?

Answer 31

Tinea/Pityriasis Versicolor

Question 32

Intertrigo =

Answer 32

Inflammation caused by *Candida Albicans* d/t moisture, heat, friction, most commonly occurs in mucosal surfaces or skin folds

Question 33

Intertrigo 1. Risk factors 2. Presentation (1)\*

Answer 33

1. **Obesity, diabetes**, recent ABX or steroid use, immunosuppression, chronic moisture or friction 2. **Erythematous patches**, erosions, fissures, itching, burning. May have **satellite lesions.**

Question 34

Intertrigo Treatment = Rx (2) * Eliminate pre\_\_\_\_\_ factors * Keep area dry via (3)

Answer 34

**Topical antifungals BID until 1 wk after sx resolve; cont 2x/wk after to prevent recurrence** Nystain or Imidazole ointment * Eliminate predisposing factors * Clothing, Zeazorb, or Nystatin powders

Question 35

Sample Case ## Footnote 48 yo overweight female with hx of HTN, GERD, and poorly controlled DM type II presents for eval of a rash that has been present in the bilateral inframammary creases for 2 months. She reports burning, itching, and states that fluid sometimes weeps from the area. She admits to sweating a lot and wearing tight bras. On physical exam, this is what you see, how would you document/describe the morphology of this rash? What diagnosis do you suspect?

Answer 35

Erythematous, not well defined, satellite papules, no oozing, is flat so not a plaque but a patch Large erythematous poorly defined patch **Intertrigo** (can be caused by candida but can simply be inflammatory from friction and moisture)

Question 36

Onychomycosis =

Answer 36

Nail infection typically caused by a dermatophyte, occasionally by mold or yeast

Question 37

Onychomycosis Diagnosis via (1) If cannot isolate via above? (2)

Answer 37

KOH Culture or nail clip *KOH exam is a simple skin test to check if an infection in the skin is caused by fungus. KOH stands for* *potassium* *(K), oxygen (O), and hydrogen (H), affected skin or nail is* *gently scraped with a small scalpel or the edge of a glass slide**. The scrapings from the skin are placed on a microscope slide and a few drops of a potassium hydroxide (KOH) solution are added*

Question 38

Onychomycosis Treatment **1st line =** * Can consider other oral antifungals but? * Duration for fingernails (1), toenails (1) * Consider (1) evaluation pre tx and 1-2w in * Advise pt that they may not (1) for 6-12m

Answer 38

**Oral terbinafine (Lamisil) considered 1^st line** * lower efficacy/safety concerns? * 6-8 weeks fingernails, **4 months toenails** * **Hepatic eval** * May not see improvement for 6-12 months

Question 39

Onychomycosis Notes * When can you treat with just topical laquer? * What should you absolutely do before starting an oral antifungal? * (1) soaks for 20-30min also help

Answer 39

* If nail matrix is not involved * CONFIRM DIAGNOSIS, must monitor for liver dx * Apple cider vinegar soaks

Question 40

Topical Antifungal Agents Chart

Answer 40

Question 41

What is your diagnosis?

Answer 41

A) Tinea Versicolor B) Onychomycosis C) Tinea Capitus with Kerion D) Tinea Corporis (facei) E) Pityriasis Alba (not fungal) - *tinea versicolor rarely presents on the face, so topical steroid may help better*

Question 42

Bacterial Infections (3)-(4)

Answer 42

* Impetigo – **superficial** bacterial infection * Usually a *Staph* or *Strep* infection * Cellulitis- **deeper** in the skin * Infection of dermis & subq * Follicular (involving the hair follicle) * Folliculitis * Furuncle * Carbuncle * Hydradenitis Suppurativa

Question 43

Impetigo = * Typically occurs where on the body? * Most common skin infection in (1) ages *\_ - \_* * Contagious? * **(1) → (1)**

Answer 43

**Superficial** bacterial skin infection usually by *Staph aureus,* occasionally Group A *Strep pyogenes* * **face,** hands, neck, extremities * children 2-5yo * highly contagious * **Papules → Vesicles golden crust**

Question 44

Non-Bullous vs. Bullous Impetigo = * Always (1) if any doubt of dx * Classic “\_\_\_\_ - \_\_\_\_” not seen in everyone * Risk factors * Climate (1) * Hygiene (1), \_\_\_care * Skin tr\_\_\_\_\_ * Hx of (1)

Answer 44

No blisters, localized 70% of cases VS. less common, starts as bullae, more widespread (typically does NOT scare-reassure pts and parents) * Bacterial culture if any doubt of dx * “golden-crust” not seen in everyone * Risk factors * Hot, humid climate * Poor hygiene, daycare * Skin trauma * History of itching an insect bite

Question 45

Impetigo Treatment = **Rx (1)** * Consider tx in ____ if hx of frequent, repeat infx

Answer 45

**Topical Antibiotics** **Mupirocin 2% ointment TID for 5-7 days** * nares if hx of frequent, repeat infx

Question 46

Impetigo Treatment for Severe, Bullous lesions widespread, and not responsive to topical tx, if fevers is present = Rx (4), duration

Answer 46

**Oral antibiotics** Dicloxacillin, Augmentin, Cephalexin, Clindamycin (if MRSA suspected), 10 days *Ask about hx of allergies, culture if not improving*

Question 47

Cellulitis = Causes (3) Risk factors (4)

Answer 47

**A bacterial infection involving the dermis, subcutaneous tissue, and fat** Typically ***staph and strep** (beta hemolytic strep, strep pyogenes, MRSA),* unless by an animal bite After trauma or wound, surgery, venous stasis, recent hospitalization

Question 48

Cellulitis Presentation Usually occurs on ___ limb/s, most often on ____ legs (4) symptoms

Answer 48

Usually occurs on one limb, most often on lower legs ## Footnote **Erythema, Edema, Tenderness, and Warmth**

Question 49

Cellulitis Treatment (1) for 5-7 days Rx (3) if MRSA is suspected (2) Nonpharm maneuvers (1) If S/S of systemic infection (fever, tachy, AMS), significant co-morbidities

Answer 49

Antibiotics *Bactrim, Clindamycin, Doxycycline* **Elevate, Hydrate** skin to prevent cracking if edema Eval in ED and/or admission for IV antibiotics

Question 50

Cellulitis Monitoring Uncommon complications (3) If hx very rapid progression, febrile, not responding to PO abx → consider (1) and do what? (1) border of erythema, recheck in ___ hours (sooner if greater concern), we don't expect to see a reduction within that time frame but want to ensure that (1)

Answer 50

Sepsis, Osteomyelitis, Necrotizing skin infection Necrotizing fasciitis, send to ER Outline border with a pen, recheck in 48h, just to ensure it's not increasing

Question 51

What does this picture show? Treatment requires?

Answer 51

Cellulitis w streaking (lymphagitis) Requires oral antibiotics

Question 52

Empiric Antimicrobial Therapy for Uncomplicated Cellulitis (excluding MRSA)

Answer 52

Question 53

Empiric Oral therapy for Cellulitis caused by MRSA and beta-hemolytic streptococci

Answer 53

Question 54

Superficial bacterial infection of hair follicle → Pus collects in epidermis, usually caused by *staph aureus* from nose or can be sterile

Answer 54

Folliculitis

Question 55

A cluster of furuncles (boils) A coalescence of several (2 or more) inflamed follicles into a single inflammatory mass with purulent drainage from multiple follicles

Answer 55

Carbuncle

Question 56

A "boil" infection of the hair follicle extending into Subq tissue → small **abscess** formation

Answer 56

Furuncle

Question 57

Inflammatory papules, pustules due to inflammation of follicles and perifollicular skin

Answer 57

Pseudofolliculitis Barbae (PFB)

Question 58

Pseudofolliculitis Barbae (PFB) * Most common in (1), but can occur in anyone, especially with c\_\_\_\_, c\_\_\_\_ hair * Typically occurs immediately after (1), advise to use (1) * Patient may report p\_\_\_ or pr\_\_\_\_\_ * Complications (2)

Answer 58

* black men, coarse, curly hair (*growth of tightly curled hairs within the follicle can cause an inflammatory reaction)* * Shaving, use electric clippers/razors * pain, pruritis * Post inflammatory hyperpigmentation (PIH), Keloids (less common)

Question 59

Folliculitis Treatment Treatment of choice Rx (1) * PO abx? * Discuss shaving techniques: not too ____ blades, no ___ blades, never ___ shave, use ____ water * If recurrent, consider (1)

Answer 59

**Topical Antibiotic Benzaclin gel combo** 1. Clindamycin phosphate 1% BID (lotion, foam, gel) 2. Benzoyl Peroxide 5% as a wash or topical gel 1-2x daily * rarely required, but may help if severely inflamed (doxy and minocycline) * not too many blades, no dull blades, never dry shave, use warm water * laser hair removal

Question 60

Carbuncle Notes A cluster of furuncles (boils) * These are fluctuant masses. You can palpate the ____ filled cavity * Often associated with (2) * Definitive treatment =

Answer 60

* These are fluctuant masses. You can palpate the fluid filled cavity * Poor hygiene, smoking * I&D, middle pic would need I&D + abx

Question 61

Furuncle Treatment Only definitive treatment (1) PO abx?

Answer 61

I&D if organized (fluctuant) - until organized, frequent warm compresses will either resolve or organize so can I&D NOT recommended *Per CDC: I&D is treatment of choice except when…immunosuppression, severe local symptoms, systemic symptoms, high suspicious of MRSA, difficulty with draining the lesion or failure to respond to I&D. Always culture the fluid.*

Question 62

Chronic, inflammatory follicular occlusive disorder that affects intertriginous skin (folds like axilla and groin)

Answer 62

Hidradenitis Suppurative

Question 63

Hidradenitis Suppurative * Course = * More prevalent in (1) * Often sc\_\_\_\_\_\_ * Inflammatory (3) that ____ and lead to permanent \_\_\_\_\_\_ * Tx = (1) then (1)

Answer 63

* Highly variable course * women * scarring * Inflammatory nodules, fistulas, abscesses that flare and lead to permanent scarring * PO abx then derm consult

Question 64

Viral Skin Infections (4)-(3)

Answer 64

**Herpesvirus (Varicella, Zoster, HSV types 1 and 2)** **Molluscum** **Warts/HPV** **Pityriasis Rosea** *Viruses- 2 types- DNA stranded or RNA stranded; Herpesvirus: A medium-sized virus that contain double-stranded DNA. Produce latent, but lifelong infection, which may be intermittently clinically apparent . Includes Fully developed by tense vesicles, herpes simplex consisting of grouped vesicles on an erythematous base, zoster being made up of vesicles, sometimes hemorrhagic ones, that course along a dermatome of an adult usually, and varicella being characterized by widespread discrete vesicles in children as a rule.*

Question 65

Epidemiology of Herpes Simplex **(1)** = children acquired, usually **orolabial** * Referred to as (2) * usually acquired around _____ age, 80-90% will test seropositive **(1) =** usually associated with **genital** * 22-25% of US population has it by age \_\_, 10-20% will test seropositive

Answer 65

**HSV Type 1** * “Cold Sore” “Fever blister” * preschool age **HSV Type 2** * 22-25% of US population has it by age 35

Question 66

Herpes Simplex Characteristics 1. Transmission = 2. Diagnosis\* = 3. Treatment = Rx (2) 4. Cure =

Answer 66

1. Virus enters via mucus membranes 2. **Viral culture** 3. Acyclovir 5x/day or Valacyclovir BID 4. No cure

Question 67

Herpes Simplex Virus Notes **One of the most prevalent infections worldwide** * T**est w (1)**, not serologic testing because blood tests indicate an infection, but cannot confirm that a lesion is caused by HSV infection. Tx goals are to ______ the course of a current infection and prevent \_\_\_\_\_\_ * May have prodrome of 24 hrs of (3) sensations preceding the outbreak. May have flulike symptoms of HA, fever, nasal congestion. * (1) is a common trigger and severity of outbreak may correlate w/severity of ____ exposure.

Answer 67

* T**est w/viral culture**, not serologic testing because blood tests indicate an infection, but cannot confirm that a lesion is caused by HSV infection. Tx goals are to shorten the course of a current infection and prevent recurrences * May have prodrome of 24 hrs of tingling, itching, or burning preceding the outbreak. May have flulike symptoms of HA, fever, nasal congestion. * UVB is a common trigger and severity of outbreak may correlate w/severity of sun exposure.

Question 68

Herpes Simplex and Zoster **Infection becomes (1) in the nerve ganglion → then one day (1)**

Answer 68

**Infection becomes dormant/latent in the nerve ganglion → then one day it reactivates** *The virus enters either through mouth or genitalia via mucous membranes or at a site of injury to the skin or via bodly fluids (saliva, semen, vaginal fluid..) . The virus enters vulnerable host cells and begins to multiply & can destroy the host cell causing and inflammatory reaction; otherwise it lays dormant/inactive (latent) & during this time the virus is not multiplying, and host cells remain healthy until something triggers the virus to begin multiplying again.*

Question 69

What is causing these lesions? * 2 most common sites * DDx (1) * Ask about recent ____ hx. Pt is usually infected __ *-* __ weeks prior to outbreak.

Answer 69

Lesions are usually Type 1 HSV but can also be 2 * Most common site is vermillion border of lip and 2^nd most common is near the nares, but can occur elsewhere on the body (ear, fingers, cheeks as in Eczema herpeticum). * Impetigo (hx very important) *sometimes treat for both, Hx of fluid filled bump = HSV* * Ask about recent sexual hx. Pt is usually infected 1-2 weeks prior to outbreak.

Question 70

HSV Stages (1) (no lesions) → (1) → (1) → (1) → (1) or * *All these stages happen usually over __ - __ days* * *Prodrome is usually worst during the ___ outbreak. May have prodrome of (3) preceding the outbreak.* * *When are you shedding the most virus?* * *Ask about triggers like?*

Answer 70

Prodrome (no lesions) → Papule → Vesicle cluster → Ulcer → Crusting or Faint Erythema * *5-7 days* * *Prodrome worst during 1st outbreak. May have tingling, burning, itching* * *Tingling phase is when you are shedding the most virus, so don't share drinks!* * *UV exposure (beach, skiing), stress, illness, etc*

Question 71

HSV Education **Patient education is key!** 1. (1) and early (1) stages are most contagious 1. Pt will often report tingling or itching prior to eruption 2. (1) stage less infective 3. The virus is _____ even when a person is asymptomatic 4. The ___ outbreak is the worst (fever, pain, malaise) and may last weeks 1. However, more than 10% of initial outbreaks are completely \_\_\_\_\_\_ 2. Subsequent outbreaks usually resolve within __ days 5. Tell patient to avoid?

Answer 71

1. Prodrome, early vesicular stages most contagious 2. Golden crust stage less infective 3. The virus is shedding when a person is asymptomatic 4. The 1st outbreak is the worst (fever, pain, malaise) 1. However, more than 10% initial outbreaks are completely asymptomatic 2. Subsequent outbreaks usually resolve within 5 days 5. Avoid close contact, kissing, sharing drinks or toothbrushes

Question 73

What is this condition? Caused more often by which HSV?

Answer 73

Herpetic Whitlow HSV Type 1 * Occurs when digits are exposed to HSV* * HSV infection may take the form of a felon or whitlow (an infection of the pulp of the fingertip). Tender, erythematous at the lateral nailfold. Deep-seated blisters develop 24-48 hrs after symptoms begin. Children may aquire d/t thumbsuckin or nail biting. Tends to occur in ppl w/hx of HSV. Children usually caused by HSV-1. 75% of cases in adults are HSV-2*

Question 74

Herpetic Whitlow 1. Common in peds due to? Common in adults who are? 2. Very ______ due to deep vesicles 3. Ddx (1) 4. Tx (1)

Answer 74

1. peds dt thumb or finger sucking, adult HCW 2. Very painful dt deep vesicles 3. Cellulitis 4. **Needs admission to hospital for IV antivirals**

Question 75

What is this condition? Usual symptoms? *Avg incubation period?*

Answer 75

Genital Herpes Simplex Mild or asymptomatic *Avg 5 day incubation period*

Question 76

Genital Herpes Simplex in Females Symptoms in women?

Answer 76

**In women the major complaint is vaginal pain & dysuria (herpetic vulvovaginitis)** *Active lesions contain live virus & are infectious. Persons w/recurrent genital herpes shed virus asymptomatically between outbreaks. Can occur through normal appearing skin. Most transmission of genital herpes occurs during subclinical or unrecognized outbreaks or while the infected person is **shedding asymptomatically. Risk is 10% for partners in monogmous relationships**). Symptoms can last up to 3 wks for initial outbreak. In recurrent outbreaks symptoms may last only a few days*

Question 77

35 y.o. female with 2 day onset or pruritic, painful rash that is worsening. Routine phlebotomy 4 days ago with application of Band-Aid to site. Afebrile and VS WNL. What is the most likely diagnosis? What would you treat with? 1. Contact dermatitis 2. Cellulitis 3. Tinea corporis 4. Hidradenitis suppurativa

Answer 77

1. Contact dermatitis 2. **Cellulitis, Tx = oral abx** 3. Tinea corporis 4. Hidradenitis suppurativa

Question 78

Herpes Zoster/Shingles 1. **Cause (1)** 2. **Initial Presentation (1)** 1. After 5-7 days, patient will exhibit \_\_\_\_\_\_ 3. **Pattern (1)** 4. **Symptoms (1)**

Answer 78

1. Reactivation of varicella zoster virus (VZV) 2. Papules, vesicles, pustules on an erythematous base 1. After 5-7 days, patients will exhibit crusting 3. Follows dermatome, unilateral, DOES NOT CROSS MIDLINE 4. Very painful (especially in elderly) * Caused by varicella zoster virus. Following natural infection or immunization, the virus remains latent in the sensory dorsal root ganglion cells. It begins to replicate at some later time, traveling down the sensory root into the skin. Other than immunosuppression & age, factors involved in reactivation are unknown. Elderly tend to have more pain. Lesions can develop on mucous membrane & genitalia. FOUR TIMES LESS LIKELY IN AFRICAN AMERICANS.* * Young pts, duration of 2-3 wks. Elderly may have duration \>6 wks.* * Anything neck up → refer to ophthalm/ear doctor to make sure no vision or hearing loss*

Question 79

Herpes Zoster/Shingles Dermatome Which dermatomes are most frequently effected?

Answer 79

Thoracic dermatomes most frequently affected (55%) *T3-L1 most common* *Thoracic dermatomes are most frequently affected (55%) the cranial (20%, most being the trigeminal nerve), lumbar (15%), sacral (5%).*

Question 80

Herpes Zoster/Shingles Diagnosis

Answer 80

Usually diagnosed with history and clinical presentation alone however, **best test is viral cx obtained from vesicular fluid**

Question 81

Herpes Zoster/Shingles Goals * **Goals**: _____ clinical course, provide an\_\_\_\_\_, prevent complications & decrease the incidence of **(1)** * Rx(2) may not be enough; consider (1) * Topical (1) patches may help

Answer 81

* **Goals**: shorten clinical course, provide analgesia, prevent complications & decrease the incidence of **postherpetic neuralgia** * NSAIDs and Acetaminophen may not be enough; consider tramadol * Topical lidocaine patches may help

Question 82

Herpes Zoster/Shingles Treatment **(1)** within **\_\_\_ hours of the onset of \_\_\_\_,** reduce the s\_\_\_\_ and d\_\_\_\_ of acute \_\_\_, and incidence of (1) **Rx (3)**

Answer 82

**Oral antiviral agents** started **within 72 hours** of the onset of rash, reduce the severity and duration of acute pain, and incidence of postherpetic neuralgia. 1. **Acyclovir/Zovirax**: 800 mg 5 times daily x 7-10 d. 2. **Famciclovir /Famvir**: 500 mg t.i.d. x 7 d. $$$ 3. **Valacyclovir/Valtrex**: 1000 mg t.i.d. x 7 d. $$$$

Question 83

Herpes Zoster/Shingles Prevention At what age?

Answer 83

**Zostavax Vaccine** **\>60** (whether or not they have had herpes zoster, reduces risk of shingles by 51%)

Question 84

Herpes Zoster/Shingles Ophthalmologic Involvement Requires? Can lead to (2)

Answer 84

Immediate ophthalmology consult Can lead to corneal scarring and blindness

Question 85

Is this Herpes simplex or zoster?

Answer 85

Likely Zoster. Doesn’t cross midline and is able to occur on mucous membranes.

Question 86

Is this HSV or Impetigo? What questions would you ask?

Answer 86

Taking a thorough history is key! * Have you had this before? * How long has it been there for? * Did you notice a tingling or burning sensation prior to the eruption? * Exposure/kissing someone? * Apply any home remedies?

Question 87

Smooth, skin-colored, **dome-shaped**, pearly papules with **umbilicated centers** (crateriform lesions)

Answer 87

**Molluscum Contagiosum (MC)**

Question 88

Molluscum Contagiosum (MC) 1. Cause (1) 2. Transmission (1) 3. Prevalence most commonly in (1) 4. In adults is considered an (1) 5. Can _____ and resolve (1) over several months

Answer 88

1. Poxvirus 2. Skin to skin contact with infected skin 3. Most common in children 4. Considered an STD in adults 5. Can involute and resolve on its own over several months

Question 89

Molluscum Contagiosum (MC) Treatment Options to speed resolution can cause scarring, which is permanent but not common * C\_\_\_\_\_\_ * Cr\_\_\_\_ * Manual removal with large bore \_\_\_\_\_ * Cantharidin (\_\_\_) * (1) /topicals * Im\_\_\_\_\_ topicals

Answer 89

* Curette * Cryo (liquid nitrogen) * Manual removal with large bore needle * Cantharidin (acid) * 5-FU/topicals * Imiquimod topicals *Topical treatments not as effective*

Question 90

Molluscum Contagiosum (MC) Differentials (2) * Note: Common for children to have lesions in _____ region, always be suspicious of (1) but many infections occur without any hx of it

Answer 90

**Folliculitis, Basal Cell Carcinoma (BCC)** * Note: Common for children to have lesions in genital region, always be suspicious of sexual abuse but many infections occur without any hx of it * BCC if only 1 or 2 lesions, but very rare in kids, more commonly diff dx of folliculitis - use magnifying glass, are they pustules or firm?*

Question 91

Human Papilloma Virus (HPV) Verruca Vulgaris AKA (1) * Represents an infection of the (1)* * What do the black dots represent?* * Most commonly caused by what type of HPV? What types cause genital warts?*

Answer 91

**Common Warts** * Represents infection of the keratinocytes* * Black dots represent hemorrhage d/t trauma to dilated tortuous capillaries within the dermis* * HPV 2 on body, HPV 6 and 11 in condyloma genital warts*

Question 92

What condition is shown in these pictures? * Caused by what type of HPV?* * Description?* * Ease of treatment?*

Answer 92

**Plantar Warts (Verruca Plantaris)** ***HPV 1*** * Hyperkeratotic papules that coalesce into plaques* * Very difficult to treat bc skin on the soles of the feet is thickets, so important to manage patient expectations*

Question 93

What condition is shown in these pictures? Caused by what type of HPV? Most common cause (1) (2) populations primarily affected Most common sites (4) Highest rate of (1)

Answer 93

**Verruca Planae (Flat Warts)** **HPV3** Shaving Children, young adults Forehead, cheeks, nose, perioral spontaneous remission * HPV type 3. Children & young adults primarily affected. 2-4mm flat-topped papules that are slightly erythematous or brown on pale skin & hyperpigmented on darker skin. Generally multiple and grouped on the face, neck, dorsa of hands, wrists, or knees. Shaving can cause flat warts d/t autoinoculation. Warts tend to form linear formation (koebnerize).* * Can be confused for lentigines or ephelides.*

Question 94

Condyloma Acuminata AKA (1) * Typically worse during (2) * *Caused by HPV type (2)* * *Educate on importance of safe \_\_\_\_* * *Tx = ______ (can cause scarring and discoloration)*

Answer 94

**Genital Warts** * Worse during pregnancy and immune suppression * *HPV 6 and 11* * *Educate on importance of safe sex* * *Tx = freezing (can cause scarring and discoloration)*

Question 95

Pink pearly penile papules (don't confuse with warts) Treatment?

Answer 95

Micropapillomatosis Labialis ## Footnote **Do NOT treat - normal anatomical finding (sebaceous glands of corona)**

Question 96

Condyloma DDx: skin \_\_\_\_\_, S\_\_\_\_ K\_\_\_\_\_, M \_ * Common in a\_\_\_\_, e\_\_\_\_, in\_\_\_\_ folds * **(1): Pedunculated, flesh or hyperpigmented color** * Benign and usually found in skin \_\_\_\_. Often a/w _____ gain * Vary _____ in size from person to person * Can differential by texture: warts are \_\_\_\_, MC are \_\_\_\_

Answer 96

* Common in axillae, eyelids, inguina folds * **Skin tags: Pedunculated, flesh or hyperpigmented color** * Benign and usually found in skin folds. Often a/w weight gain * Vary greatly in size from person to person * Can differential by texture: warts are rough, MC are smooth

Question 97

24 yo male with no significant PMH, presents with a rash that appeared 10 days ago. He first noted a large spot on his lower chest and several days later states he saw a ton more spots appear. He reports the rash is completely asymptomatic. His ROS is unremarkable. He denies taking a new medications or supplements. 1. Eczema 2. Psoriasis 3. Pitryasis Rosea 4. Tinea Corporis 5. Drug eruption

Answer 97

1. Eczema - *not itchy or symptomatic* 2. Psoriasis - *not symptomatic* 3. **Pitryasis Rosea** 4. Tinea Corporis - *maybe that middle spot but doesn’t usually have a big eruption* 5. Drug eruption - *no new meds*

Question 98

Pityriasis Rosea =

Answer 98

A **self-limiting viral exanthem** with unknown cause, sometimes a/w URIs most common in healthy children and young adults age 15-40 yo

Question 99

Pityriasis Rosea Characteristics Starts with a **“\_\_\_\_ \_\_\_\_”** on trunk * Few days to weeks later → crops of ____ lesions, ____ colored, ____ shaped, ____ in height, and ______ of scale develop * _____ face, hands, and feet * Lasts __ *-* __ weeks

Answer 99

Starts with **“Herald Patch"** on trunk * Few days to weeks later → crops of smaller lesions, salmon colored, ovoid shape (*egg shaped),* raised, colarette (*smaller/tighter collar)* of scale * Spares face, hands, and feet * Lasts 5-8 weeks * An inflammatory process. Oval patches usually from neck to knees* * Salmon-colored papular macular lesions that are first discrete & then may become confluent. Patches are oval and covered w/finely crinkles, dry epidermis which often desquamates leaving a collarette of scaling. Begins w/a herald patch usually larger than succeeding lesions. Herald patch may persist for 1 week before others appear.*

Question 100

Pityriasis Rosea Treatment Treatment is symptomatic, pruritis in 50% of cases 1. Z\_\_\_ oxide 2. C\_\_\_\_\_ lotion 3. Topical st\_\_\_\_\_ 4. Oral anti\_\_\_\_\_\_, PO antivirals? PO steroids?

Answer 100

1. Zinc oxide 2. Calamine lotion 3. Topical steroids 4. Oral antihistamines

Question 101

What form of Pityriasis Rosea is shown in these pictures?

Answer 101

**Inverse Form** Affects axillae, groin, limbs, but spares trunk (note-same applies to inverse psoriasis)