Dermatology Lecture 2 pt 2 Flashcards
(106 cards)
1
Q
What bacterial infections do we cover in this lecture?
A
- Cellulitis
- Vasculitis
- Erysipelas
- Erysipelothrix
- Impetigo/Ecthyma
- Leprosy
- Typhoid Fever
- Ehrlichiosis
- Necrotizing Fasciitis
2
Q
What is cellulitis and causative agents
A
3
Q
Clinical features of cellulitis and needed work-up?
A
4
Q
What is this condition?
A
Cellulitis
5
Q
Treatment of Cellulitis?
A
Treatment: Mild/early- Cephalosporins if allergic then Erythromycin
*Consider MRSA Coverage -Mark margins to monitor infection and response to treatment
- Choice of antibiotic varies – based on severity, patient’s co-morbid conditions,
community rates of drug-resistant pathogens.
-If poor response to treatment or necrosis of soft tissue occurs, surgical intervention is
mandatory
6
Q
Treatment for cellulitis caused by dog and cat bites
A
- DOG or Human bite – Amoxicillin-clavulanate (Augmentin), Doxycycline if PCN allergic
- CAT bite – typically covering for Bartonella spp– Augmentin + Clindamycin or Bactrim or
Doxy
7
Q
What is this condition?
A
Definition – extravasation of red blood cells into the skin or mucous membrane
Non-blanchable. Can’t displace the blood
8
Q
What are the 4 types of Purpura
A
4 types
– petechia – flat macules < or = to 4mm
-ecchymosis – flat, macules or patches, >5mm, fade in color
-palpable purpura – elevated, round/oval, red/purple
retiform – stellate or branching lesions, +/- palpable
9
Q
Vasculitis presentation
A
- May occur as an idiopathic, predominantly cutaneous vasculitis
- Palpable purpura (nonblanching, elevated lesions) is the cutaneous
hallmark of vasculitis - Other lesions include petechiae (esp. early lesions), necrosis with ulceration, bullae, and urticarial lesions
- Lesions most prominent on lower extremities
10
Q
What conditions is vasculitis associated with
A
- Infections
- Collagen-vascular disease
- Primary systemic vasculitides
- Malignancy
- Hepatitis B
- Drugs (esp. thiazides)
- Inflammatory bowel disease
- Exercise-induced (Disney rash)
11
Q
What condition is this?
A
- Palpable purpuric papules
on the lower legs are seen
in this patient with
cutaneous small vessel
vasculitis
12
Q
What is this condition?
A
Cutaneous Acute Vasculitis
- Characterized clinically
by palpable purpura,
especially of the legs - May be limited to the
skin or involve other
tissues as in Henoch-
Schönlein purpura
(HSP)
13
Q
What is this condition?
A
Henoch-Schonlein Purpura (HSP)
- It is immunoglobulin A (IgA)-mediated and mostcommonly occurs in children after a streptococcal or viral infection (type of severe vasculitis)
- Petechiae and purpura of necrotizing vasculitis are usually localized to the lower third of the extremities.
14
Q
What is the treatment for HSP
A
- Treatment: Antibiotics if indicated. Prednisone if moderate to severe. Cyclophosphamide or azathioprine have been used in conjunction with prednisone
15
Q
What is this condition?
A
Livedo Reticularis
- Reticulated (lace-like or Net-like)
blanching erythema
symmetrically distributed over
lower extremities. - Does blanche
- Frequently seen in autoimmune
vasculitis
16
Q
Generalized treatment of vasculitis?
A
- Will differ based on cause
- Pursue identification and treatment/elimination of an exogenous cause or underlying disease
- If part of a systemic vascultitis treat based on major organ-threatening features
- Immunosuppressive therapy should be avoided in idiopathic predominantly
cutaneous vasculitis as disease does not usually respond
17
Q
What is this condition?
A
- Systemic vasculitis characterized by
necrotizing inflammatory lesions
that affect medium-sized and small
muscular arteries, preferentially at
vessel bifurcations - Can lead to microaneurysm
formation, aneurysmal rupture
with hemorrhage, thrombosis, and,
consequently, organ ischemia or
infarction - Lungs are usually spared
18
Q
Sxs and dx for Polyarteritis Nodosa?
A
19
Q
Treatment of polyarteritis Nodosa?
A
Corticosteroids IV; if refractory,
may add biologics (Infliximab,
etanercept etc.) or methotrexate
20
Q
Condition? How is it defined?
A
- Sharply demarcated, painful, indurated,
erythematous “fiery red”, edematous
plaques
21
Q
Condition? what causes it?
A
22
Q
What are the clinical features of Erysipelas?
A
- Begins as a small erythematous patch (bigger than macule) that rapidly progresses to a fiery-red, hot, indurated, tense, and shiny plaque
- The lesion classically exhibits a sharply raised border with abrupt demarcation from healthy skin.
- This is the differentiation from cellulitis, which has less defined
border
23
Q
Laboratory and treatment of Erysipelas?
A
24
Q
What is this condition?
A
25
What is this condition?
Impetigo
26
What is this condition? Define
Ecthyma
* Deeper form of impetigo * Ulcerative pyoderma of the skin caused by group A beta-
hemolytic streptococci
* It is often referred to as a deeper
form of impetigo because it
extends into the dermis
27
Treatment of Impetigo/Ecthyma?
28
What is this condition? Describe
Ecthyma Gangrenosum
* Vesicular rash progressing to
hemorrhagic bullae, and later to
necrotic ulcers.
* Note the eschar
29
What cause ecthyma grangrenosum and what is dx/treatment?
EX ciprofloxacin
30
Case Study
31
What is this condition?
32
Treatment for Hanson's Disease (leprosy)
Dapsone+Rifampin+Clofazimine
for 6-12 months (extensive
treatment!)
33
What is this condition?
* Salmonella species
* Seen in Asia/Vietnam
* See salmon colored rash and non-
bloody diarrhea (enteric fever)
34
What is the dx and treatment of Typhoid Fever?
* Dx: Antibody Widal test
* Tx: Azithromycin or cephalosporin
or fluoroquinolone depending on
region resistance salmon-colore
35
What is this condition?
Ehrlichiosis
* Tick-borne bacterial infection * Rash is uncommon, but
accompanied by headache,
myalgia, lymphadenitis and
hepatomegaly
* Spares palms and soles
36
What is the dx and treatment for Ehrlichiosis
* Dx: PCR
* Tx: Doxycycline or Minocycline,
or Rifampin
37
What are the 3 types of necrotizing fasciitis
* Type 1: polymicrobial/ salt-water contamination with Vibrio species,
MRSA and others
* Type 2: Group A streptococcal
* Type 3: Clostridium infection, Clostridium myonecrosis (gas gangrene
38
What is this condition?
Widespread fascial necrosis
* Clostridial myonecrosis: gas (“air”) gangrene
* SQ emphysema or air seen on x-ray/ CT scan
* Usually direct inoculation from an open wound; uterine following C-section; some “spontaneous” cases; anaerobic organism
* Brawny edema, crepitance, brownish
discoloration, malodorous serosanguinous discharge; bullae; air gangrene
39
Treatment of necrotizing fasciitis?
* Update Tetanus
* IV ABX broad spectrum to cover MRSA
* Surgical debridement (fasciotomy, debridement, even amputation)
* Progressive, life-threatening situation
40
What are the main fungal infection we cover in this lectures?
* Candidiasis
* Rhinocerebral Mucormycosis
* Dermatophyte Infections
* Tinea Versicolor
* Tinea corporis/pedis
41
What is this condition?
Diaper Dermatitis from Candidiasis
Confluent erosions, marginal
scaling, and “satellite pustules” .
Often under folds of skins
42
What is this condition?
Candidiasis
Small erosions in the interdigital web space of the hand
Diabetics prone to this
43
Laboratory test for Candidiasis?
* Laboratory: Grams stain or KOH to visualize pseudohyphae (no true septae) and
elongated yeast forms
-Culture for fungus and bacteria
44
Treatment for candidiasis?
* Remove predisposing factors such as chronic wetness, antibiotics, or improving
glucose control in diabetics
* Nystatin or azole antifungals (ketoconazole, clotrimazole, miconazole, econazole)
* Add hydrocortisone cream to decrease the associated inflammatory response in
severe symptoms
45
What condition is this?
Rhinocerebral Mucormycosis (Zygomycosis)
* Necrotic lesions of palate and
mucosa due to fungi
* Clinically patients have depressed
sensorium and CN palsies
* Seen in immunocompromised
state
* Is a surgical emergency
46
Dx and treatment of Rhinocerebral Mucormycosis (Zygomycosis)
Dx: PCR
* DDx: Aspergillosis
* Tx: Amphotericin B (very strong),
surgical and ID consult
47
What is this condition?
Tinea versicolor
* Hypopigmented or
hyperpigmented round or oval
macules with fine scaling that do
not tan and can be pruritic
* Variation of presentation based
on skin tone.
48
How to diagnosis Tinea Versicolor?
* Laboratory: KOH show hyphae and spores (spaghetti and meatballs)
-Wood’s light exam shows Blue-green fluorescence
49
Treatment for Tinea Versicolor?
Topical Treatment:
-Selenium sulfide shampoo applied from neck to waist, leave on 15 min, once a
day for 7 days
-Ketoconazole 2% shampoo or cream – not first line due to liver SE
-Oral ketoconazole but patients shouldn’t shower for 18 hours as the medicine
works but being delivered through the patients sweat
---------Sweating must be induced
50
What is this condition?
Tinea Corporis (body)
* Erythematous, annular patch with
distinct borders and central clearing
usually with scaling
51
What condition is this?
Tinea Capitis
Scalp (Tinea Capitis)-broken hair
shafts are seen as black dots
* Kerion (indurated, boggy
inflammatory plaque studded with
pustules) can be present in any
location of tinea, but most commonly
seen on the scalp
52
What laboratory test is done for Tinea Corporis?
Potassium Hydroxide (KOH) to visualize hyphae
* Multiple septated, tubelike structures and spore (hyphae or mycelia) formations *
Wood’s Lamp
* Hairs will fluoresce greenish
* Intertriginous sites will fluoresce coral red
-Fungal cultures
53
Treatment for Tinea Corporis?
* Topical imidazoles, allylamines, or substituted pyridone used twice a day for 4-6 weeks
* Chronic or resistant: Oral griseofulvin, itraconazole, terbinafine, or ketoconazole
* Kerions: Oral fluconazole or griseofulvin
54
What condition is this?
Note: No hyphae with KOH. Thats how you know it is not candidiasis or tinea
55
What condition is this?
Serpiginous lesion
Denoting a cutaneous lesion that extends with a wavy/creeping or serpent-like border.
* Typically parasitic (hookworm) in nature
and occur in tropical locations
* Cutaneous Larva Migrans
* Presents as pruritic and painful rash
56
Diagnosis and treatment for serpiginous lesion/hook worm
Dx: Punch biopsy
* Tx: Albendazole 400mg QD x 3 days
* Alt: Thiabendazole TID until
resolved
* Alternatively ivermectin or
cryosurgery
* Triamcinolone can be given for
symptomatic relief
57
What condition is this?
Acanthosis Nigricans
Hyperpigmentation with thick,
velvety accentuation of the dermal
lines
* Most commonly on the axillae, neck
but can also be groin, anogenitalia,
antecubital fossae, knuckles,
submammary, and umbilicus.
* Common in insulin resistance
58
Lab and treatment for Acanthosis Nigricans?
* Laboratory: R/O Diabetes Mellitus, Carcinoma if clinically suspected
* Treatment: No proven treatment other than for underlying disorder if present
59
Definition of first degree burn?
First-degree-red, moist, swollen, and painful and blanches when lightly touched but does not develop blisters
60
Definition of second-degree burn?
Second-degree: red, swollen, and painful, and develops blisters
61
Definition of third degree burn?
Usually are not painful because the nerves have been destroyed.
The skin becomes leathery and may be white, black, or bright red.
The burned area does not blanch, and hairs can easily be pulled from their roots without pain.
No blisters develop
62
What is the rule of nines?
63
Burn treatments
Treatment:
* 1st and 2nd degree burns: cool compresses
* Silver sulfadiazine is no longer recommended
* Blisters should not be broken according to AAPA; however, rupturing the blister and using the top as a partial thickness skin grafts allows the wound to heal quicker and gives pain relief
64
Burn treatment continued
Larger 2nd degree and any 3rd degree burns:
Hospitalization and fluid replacement.
Escharotomy and fasciotomy are done when indicated
* Fluid replacement if >15% TBSA full thickness burn
* LR is most common (Parkland Formula) * Total fluid = 4mL x wt (kg) x TBSA (%)
* Early intubation if inhalation injury
* Assess tetanus vaccine status with any open wound
65
What are the first two stages of decubitus ulcers?
Stage I: Nonblanching erythema of intact skin
Stage II: Necrosis, superficial or partial-thickness involving the epidermis and/or
dermis; shallow ulcer
66
The last two stages of decubitus ulcers?
Stage III: Deep necrosis; crater ulcers with full thickness skin loss; damage or necrosis can extend down to, but not through the fascia
Stage IV: Full thickness ulceration with extensive damage and necrosis to muscle,
bone, or supporting structure
67
What causes Decubitus ulcers?
* Decubitus: due to impaired blood supply because of pressure. Studies show cell
damage occurs in as early as 30 minutes following constant pressure to the area.
Sacrum and hips are most common. Complications include osteomyelitis,
bacteremia, and sepsis
68
What is the treatment plan for decubitus ulcer?
Treatment: Repositioning at least Q2hrs, massaging prone areas, and frequent
monitoring and contamination avoidance are key
-Minimize friction, air mattress, meticulous hygiene and good nutrition
-Ulcer-moist sterile gauze (Gelfoam), DuoDerm, and/or surgical Debridement
-Topical and/or systemic antibiotics if indicated
69
Management of stage I and II decubitus ulcers?
Stage I and II
Topical antibiotics (not neomycin) – allergic reaction
If debridement is needed: wet to dry normal saline dressings
Consider hydrogels or hydrocolloid dressings if the ulcer does not heal by 30%
in 2 weeks.
70
Management of stage III and IV ulcers
Stage III and IV
Surgical management
Debridement of necrotic tissue
Bony prominence removal
Skin grafts
*Prolonged systemic antibiotics depending on sensitivities for any secondary bacterial
infection
71
What are the two types of leg ulcers? Define?
1) Diabetic-tend to be deep, punched out lesions over the malleoli, the plantar surface of the feet or toes and are usually painless
2)Arterial-Not preceded by dermatitis and are smaller than stasis ulcers. These are painful, pulses are diminished or absent, and
the distal areas are cold
72
What condition is this?
Stasis dermatitis-
preceded by dermatitis,
then wide but not deep ulcers
develop, with irregular,
undulating edges and clean
base. Elevation relieves pain
73
Treatment of diabetic and arterial ulcers?
* Diabetic and Arterial:
Smoking cessation and moderate exercise to enhance flow
* Debridement if necrotic
* Wet to dry dressing or hydrogel
74
Treatment of stasis dermatitis?
Stasis: Elevation and Compression
* affected limb should be whirlpooled, lesion painted with gentien violet and an
Unna boot applied weekly
* Compression should be applied first thing in the morning with leg elevated
75
What is this condition? Describe
Hidradenitis Suppurtiva
* Multiple comedones, some
paired (which is characteristic),
associated with several deep
exquisitely painful abscesses and
old scars
76
More symptoms of Hidradenitis suppurtiva
* Occurs in axillae, groin, anogenital, and/or breasts
* Purulent/seropurulent drainage often present from abscesses and/or
open sinus tracts
* Fibrosis, “bridge” scars, keloids and contractures are common
77
Treatment for hidradenitis suppurtiva
Treatment: Intralesional cortisone or triamcinolone, I&D and excision of
sinus tract
-Oral antibiotics (doxycycline or cephalexin)
-Oral prednisone tapered over 2 weeks if pain/inflammation are severe
-Oral Isotretinoin – may be useful in early disease when combined with
surgical excision
-Infliximab (Remicade);Adalimumab or Etanercept IV infusion. These are an
anti-tumor necrosis factor alpha, reducing inflammation and alters immune
response.
78
What is a lipoma and how do you treat?
79
What is this condition?
Epithelial Inclusion Cysts-Freely movable subcutaneous masses
80
Treatment of epithelial inclusion cysts?
81
What condition is this? Describe it?
Melasma
Hyperpigmented macules occurring on sun-exposed areas of the face
Most common on the forehead, cheeks, and upper lips
Often happens after pregnancy due to hormonal changes
82
What is treatment of Melasma?
* Prevention is key: SUNSCREEN containing titanium dioxide or zinc oxide
-3% hydroquinone solution in combination with topical .025% tretinoin gel
-Combination of 4% hydroquinone and glycolic acid in a cream base
May disappear spontaneously without treatment
when seen in pregnancy - often disappears after the patient delivers
when associated with oral contraceptive pills – often disappears after the medication is stoppe
83
What type of rash is this and what is it associated with?
Malar or butterfly rash
Condition of Systemic lupus erythematosus (SLE)
* Malar distribution = Cheeks and
Nose
* Showing prominent, scaly, malar
erythema
* Involvement of other sun-
exposed sites is also common
84
What is this condition?
Pilonidal cyst
85
What is pilonidal cyst ?
Pore, sinus and/or fistulas may be visualized alone or in the presence of nodule on the midline sacral region at the upper end of the cleft of the buttocks
* Lesions become inflamed due to rupture, or less commonly, infection
* Often occur with nodulocystic acne, dissecting cellulitis, and hidradenitis suppurativa
86
Laboratory and treatment for pilonidal cyst?
* Laboratory: Bacterial Culture if purulent discharge is present
* Treatment:
* I&D if abscess
* Referral to general surgeon for complete excision, as simple cystectomy and
marsupialization have a high rate of reoccurrenc3
87
What is this?
Urticaria
* Present as generalized pruritic
wheals
* A sign of more
systemic/generalized
involvement of allergic reaction
Showing characteristic discrete
and confluent, edematous,
erythematous papules and
plaques
88
Laboratory for urticaria?
89
Treatment for Urticaria?
90
What condition is ? Describe it
Vitiligo
* Chalk white macules, sharply
demarcated often occurring
around eyes, mouth, neck,
axillae, hands, wrists groin,
knees, feet
* Early lesions are off-white and
can have normal or hyperpigmented border
* Frequently are post-traumatic or
solar
* Koebner Phenomenon
91
What laboratory should be ordered for vitiligo?
Laboratory:T4, TSH(r/o thyroid disease); fasting blood glucose(r/o DM); CBC, c Diff(r/o pernicious anemia); ACTH stimulation test if
Addison’s disease is suspected
92
Treatment for vitiligo?
* Treatment: Sunscreen, cosmetic cover-up, or repigmentation therapies
* Ultrapotent topical steroids (if no response in 2 months unlikely to be effective – monitor for signs of early steroid atrophy and telangiectasia)
* Systemic phototherapy * Skin grafting.
93
What is this condition?
94
What condition is this?
95
What condition is this?
Sweet Syndrome
* Acute febrile neutrophilic dermatosis,
linked to HLA B54 * Autoimmune interleukin-1 and TNFα play a role in activation
* On skin see very painful papulovesicular
rash with annular erosions
* Expect conjunctivitis and oral mucosal
ulcerations
96
Dx and treatment of sweet syndrome?
* Dx: Clinical, but on biopsy see
neutrophilia without vasculitis, ESR is
elevated
* Tx: Corticosteroids, not antibiotic
97
What is this condition?
Still's disease
* Inflammatory arthritis with fever, rash and
joint pain
* Evanescent salmon-colored rash on trunk &
proximal extremities that coincides with
fever spikes
* Appears similar to juvenile RA *
Dx: Clinical
* Tx: Corticosteroids (prednisone) or IL-1 blockers (Anakinra) if steroids not sufficient
98
What is this condition?
* Noninfectious cause of fever and petechia
* What’s the difference from ITP?
* Triggered by various causes: Pregnancy, bacterial infections, autoimmune
* Genetically linked to ADAMTS13 dysfunction
(Upshaw-Schulman Syn.
99
What is the dx and treatment for TTP
* Dx: Fever, anemia, thrombocytopenia, AKI and mentation change
* Tx: Plasmapheresis and steroids, FFP can be
infused if pheresis not available. Do NOT
transfuse platelets
* Purpura Fulminans see in DIC
100
What is this condition? causes and treatments?
Erythema Multiforme
101
What condition is this?
Erythema Marginatum from scarlet fever
102
What condition?
Erythema Migrans
103
What condition?
Erythema Ab Igne
* Toasted Skin Syndrome * Secondary to long-term exposure to infrared radiation/heat.
* Develop reticulated erythema,
hyperpigmentation, teleangiectasia,
burning and pruritis.
* Discontinue heat exposur
104
What condition?
Erythema Induratum
* Previously known as Bazin
Disease, now just Panniculitis
* Commonly associated with
cutaneous TB
* Small superficial and painful
nodules are felt
* Work-up for TB
* Differentiate from early
Erythema Nodosum
105
What condition?
Erythema Nodosum
106
What condition?
Er ythema Infectiosum (5th Disease)
* Does not involve cheeks only, can
spread to trunk
* Caused by Parvovirus B19
* Rash appears after low-grade fever
drops and URI symptoms pass
* Can cause hepatitis
