Lecture 5- (Derm) exam 3 Flashcards
(248 cards)
1
Q
- What is epidemiology?
- What does epidemiological reseach help in?
A
- Epidemiology is the foundation of public health and is defined as the study of the “distribution and determinants” of diseases or disorders within groups of people and the development of knowledge on how to prevent and control them.
- Epidemiological research helps us understand who has a disorder or disease and why andhowit was brought to this individual or region.
2
Q
What is dermatology?
A
The branch of medicine concerned with the diagnosis and treatment of skin disorders.
3
Q
What are some basic questions for skin HPI?
A
- Initial and subsequent morphology of the lesions.
- Location of lesion(s).
- Symptoms (e.g., itch, pain, tenderness, burning).
- Date of onset/duration/time of day.
- Severity-current and in the past.
- Factors causing flares.
- Use of medications, including over-the-counter products.
- Response to prior treatment.
- History of previous similar outbreaks.
4
Q
What are some tumor/abnormal growth questions for HPI?
A
- What changes have occurred in size and appearance of the lesion?
- Is there a history of spontaneous or trauma-induced bleeding of the lesion?
- Is there a history of sunburns or tanning bed use?
- What is the history of use of sunscreens?
5
Q
What are the fitzpatrick skin type?
A
6
Q
What is the importance of fitzpatrick skin type?
A
It is also important to determine the patient’s Fitzpatrick skin type, as this helps to identify patients at risk for skin cancer. The patient should be asked if they burn easily or tan after initial exposure to approximately 45–60 minutes of sunlight in early summer.The patient’s response determines the Fitzpatrick skin type.
Typically, there is some correlation between a patient’s Fitzpatrick skin type and skin color. However, there are patients with darker skin tones who do experience sunburns and sun damage.
7
Q
What do you need about in PMH for adult/childhood, medications and allergies?
A
Adult/Childhood
* Past and current diseases, personal history of skin cancer, and other skin disorders.
Medications
* All systemic and topical medications, including over-the-counter medications and supplements.
Allergies and Medication Intolerances
* Medications, foods, pollens, chemicals.
8
Q
- What do you need ask about family history for skin issues?
- What do you need to ask about for social history?
A
Occupation(s), hobbies, travel history, marital status, housing status. SKINDEX QUESTIONNAIRE
9
Q
What do you need to ask for ROS for skin?
A
High-yield questions for cutaneous disorders include fever, chills, fatigue, weight changes, lymphadenopathy, joint pain/stiffness, wheezing, rhinitis, menstrual history, birth control history, photosensitivity, depression, and anxiety.
10
Q
General Examination of the Skin:
* Relies heavily on what?
* Should take place where?
* Differential diagnosis is generated on basis of what?
* What do you do for DX hypothesis?
A
- Relies heavily on inspection
- Should take place in a well-illuminated room with pt completely disrobed
- Differential diagnosis is generated on basis of a thorough exam with precise descriptions of the skin and narrowed with pertinent facts from the history
- Lab, diagnostic procedures, skin biopsy can be used, when appropriate to test DX hypothesis
11
Q
What areas are of high risk and need special attention too?
A
Any areas of chronic sun exposure, such as the scalp, face, ears, neck, extensor forearms, dorsal hands, and upper trunk
12
Q
- What are the mc sites of basal and squamos cell carcinomas?
- Where is 40% of melanomas in men?
- Where is 40% of melanomas in female?
A
- The head and neck, which are the most common sites of basal and squamous cell carcinomas.
- The back, which is the site of almost 40% of melanomas in men.
- The legs, which are the site of over 40% of melanomas in females
13
Q
What are the steps to diagnose any skin disorder?
A
- type of primary lesion
- secondary features
- color of lesion
- shape of the lesion
- arrangement and distribution of the lesions.
14
Q
A
15
Q
A
16
Q
Under notes
- The color of the lesion often correlates with what?
- Terms such as hyperpigmented and hypopigmented are often used to describe lesions that are what?
- Erythema or erythematous are terms used for what?
- It is important to note that in individuals with darker tones erythematous skin rashes may appear like what?
- Also postinflammatory hypopigmentation and postinflammatory hyperpigmentation of lesions may result in what?
A
- The color of the lesion often correlates with underlying pathophysiologic changes
- Terms such as hyperpigmented and hypopigmented are often used to describe lesions that are darker or lighter than the patient’s overall skin color.
- Erythema or erythematous are terms used for red hues of lesions that are due to dilated blood vessels in the dermis.
- It is important to note that in individuals with darker tones erythematous skin rashes may appear purple or hyperpigmented
- Also postinflammatory hypopigmentation and postinflammatory hyperpigmentation of lesions may result in color changes in lesions ranging from white to black.
17
Q
A
18
Q
A
19
Q
What are various terms for surface contour? (4)
A
- Flat-topped
- Pedunculated (on a stalk) – squamous cell carcinoma or skin tag
- Verrucous (wartlike)
- Umbilicated (containing a central depression) – basal cell carcinoma, molluscum contagiosum
20
Q
What is this conditions? What are the terms for the primary lesions?
A
Macules and patches. Vitiligo on dorsum of hand.
21
Q
- What is a macule? What are examples?
- What is a patch? What are examples?
A
Macule is a circumscribed area of change in normal skin color (<1cm in diameter) without elevation or depression
* i.e. freckles, flat moles, petechiae, measles
Patch is a large (>1 cm), flat lesion with a color different from the surrounding skin. Differs from a macule only in size
* i.e., vitiligo, port wine stains, Mongolian spots, café-au lait patch
22
Q
What are these?
A
- Top: Vitiligo
- Bottom left: Cafe au lait spots
- Bottom right:
A. Melanin in epidermis ex. Café-au-lait spots
B. Melanin in dermis ex. Mongolian spots
C. Transient capillary dilation (erythema)
D. Hemosiderin (purpura)
23
Q
Presence of 6 or more coffee colored patches should raise suspicion for what?
A
Neurofibromatosis type 1 or Albright Syndrome
24
Q
What does this show?
A
Nodule. Nodular amelanotic melanoma.
* secondary crusting
25
* What is a nodule? What is an example?
* How is a nodule different than a papule?
* What is a tumor? What are examples?
Solid, round or ellipsoidal lesion that may involve the epidermis, dermis, or subcutaneous tissue
* i.e. dermatofibroma
Depth of involvement and size (>1cm) differentiate a nodule from a papule
Tumor is a nodule >2cm in diameter
* i.e. neoplasm, lipoma
26
What are each one of these?
* Left: nodule-> possible BCC?
* Middle:
a. Infiltrates ex TB, metastatic, neoplasms
b. Benign (EIC) or malignant (SCC,BCC) proliferation of keratinocytes
* Right: Tumor
27
What do these show?
Vesicle and bulla. Pemphigus.
28
Vesicle, Bulla
* What is it? what are examples?
* What is a vesicle?
* What is a bulla?
* Often walls are so what?
* Circumscribed, elevated, superficial cavity containing fluid
* i.e. HSV, contact dermatitis
* Vesicle-less than 1 cm
* Bulla-greater than 1 cm
* Often walls are so thin that serum, lymph fluid, blood, or extracellular fluid can be seen
29
What is a cyst?
Cyst is a soft, raised encapsulated lesion with semisolid/liquid content. The cyst isn't as transparent as bulla and doesn’t unroof the skin if pressed upon it.
30
What is this?
Papules and a plaque. Chronic allergic contact dermatitis to metal button.
31
What is a papule? What are examples?
Superficial, solid lesion, usually less than 1cm in diameter.
* i.e., closed comedones, raised mole, or whitehead in acne
32
What are these pics?
Top: papule
Bottom:
* a. Metabolic, external, or locally produced deposits ex Acne pimples
* b. Localized cellular infiltrates ex Lichen Planus
* c. Hyperplasia of local cellular elements ex Lichen Simplex Chronicus
33
* What is a plaque?
* What is an example?
* frequently formed by what?
* Can gradually blend with what?
* A plateau-like elevation >1cm in diameter above the skin surface that occupies a larger surface area than height.
* Usually well-defined in psoriasis
* Frequently formed by a confluence of papules
* Can gradually blend with surrounding skin like in eczematous dermatitis
34
What is this? (Description)
Plaque
35
What is this?
Wheal. Urticaria.
36
* What is a wheal? What is an example?
* Can change in what?
* Rounded pale-red papule or plaque that is characteristically disappear in hours
* i.e. urticaria
* Can change rapidly in size and shape due to shifting edema in the dermis
37
What is this?
Pustules. Pustular psoriasis.
38
* What is a pustule?
* What are examples?
* Circumscribed, superficial cavity of the skin that contains a purulent exudate
* May vary in size and shape
* Acne, Folliculitis, Ant bites etc. ->Does not signify the existence of infection
39
What are these called?
Pustule
40
What is this?
Cyst. Staphylococcal boil.
41
42
What is this
Scale. Psoriasis.
43
Desquamation aka scaling
* What is this?
* What are examples?
* a. Psoriasis and Solar (Actinic) and b. Keratosis
* Scales are flakes of the stratum corneum
44
What is this?
a. In psoriasis, the proliferation of epidermal cells is increased, and the stratum corneum is not typically formed. Scales may be large or tiny, adherent or loose.
b. Densely adherent scales (feel like sandpaper) result from a localized increase in stratum corneum and are characteristic of an actinic keratosis
45
What is this?
Crust. Collapsed bullae of pemphigus.
46
Crust:
* What is it?
* What are examples?
* Develop when serum, blood, or purulent exudate dries on the skin surface
* a)Impetigo b) Ecthyma
47
What are these?
Left: A. Impetigo: crust may be thin, delicate, and friable or
Right: B. Ecthyma: when involves the entire epidermis, crusts may be thick and adherent. If it is accompanied by necrosis of deeper tissue, it is known as ecthyma
* Ecthyma Involves dermis
48
What is this?
Lichenification. Atopic dermatitis on dorsal hand is a common cause.
* thicker, too much itching->skin trauma
49
What is lichenification?
Thickening of skin with accentuation of normal skin surface markings most commonly due to chronic rubbing
50
What is this?
Fissure. Callous on heel
51
What is this? What is a cause?
Excoriations and erosions from straching (linear lines). Lichenoid drug rash.
52
What is this?
Ulcer. Venous ulcer on leg.
53
* What is an ulcer?
* What is an erosion?
* Skin defect in which there has been loss of epidermis and upper papillary dermis, may extend to subcutis
* An Erosion is a defect only involving the epidermis and heals without scar
54
What is this?
Macerated- white part
* dt wet socks/shoes
55
What is this?
Eschar. Heparin necrosis.
56
What is this?
Atrophy. Lichen sclerosis, extragenital.
* Genitals with females, very tight (unflexable), thin, white
57
What is this?
Depressed scar. Scar after herpes zoster
58
What is this?
Elevated scar. Hypertrophic scar after laceration
59
What does keloids result from?
Resulting from ear piercing, with firm exophytic flesh-colored to erythematous nodules of scar tissue.
60
What is darier sign?
Rubbing a lesion causes urticarial flare
61
What is auspitz sign?
pinpoint bleeding after scale is removed (psoriasis)
62
What is nikolsky sign?
Pushing a blister causes further separation of the dermis. TEN
63
What is a photopatch test?
documents photoallergy; PATCH TEST: demonstrates hypersenitivity
64
What is koebner phenomenon?
Minor trauma leads to new lesions at site of trauma. Psoriasis
65
What is shagreen skin?
An oval-shaped nevoid plaque. Skin is colored or pigmented on the trunk or back and is associated with tuberous sclerosis.
66
* What is spider hemangioma?
* What is telangiectasia?
Spider Hemangioma – common with liver disease
* central arteriole with radiating thin-walled vessels
Telangiectasia
* Dilated, superficial blood vessels
## Footnote
Things that do blanch when pressed upon by. (due to thin walled vessels). Petechia doesn’t blanch – microhemorrhage.
Rosacea.
67
Cherry hemangiomas:
* Known as what?
* What does it look like?
* What is it?
* What is the txt?
* Known worldwide as Campbell de Morgan spots
* Discrete papules that do not blanch
* Benign proliferation of endothelial cells.
* Generally, no treatment, but excisional biopsy may help to r/o malignant melanoma if hemangioma is darker in color.
* Alternatives include cryosurgery or laser therapy
68
What is this?
Cherry Hemangiomas
69
Melanocytic Nevi:
* Most are what?
* What is the cause?
* What does it depend on?
* What increases the number?
* What is the txt?
* Most are benign and congenital
* Melanocytes scatter to basal layer during embryo development
* Depending on layer of distribution, can be macular (café-au-lait spots) or nests of melanocytes (moles)
* Sun exposure increases number on moles/nevi
* Can be removed for diagnostic or cosmetic reasons.
* Always send tissue for pathology
70
What are these?
71
Telangiectasias:
* What is it?
* When do they appear?
* Small arborizations of superficial blood vessels.
* Such lesions can appear in older persons & have no major significance, other than their cosmetic problem.
72
What is this?
Telangiectasias-> Rosacea
73
Dermatographism
* What is this?
* Form of urticaria in which whealing occurs in the site and in the configuration of application of stroking (pressure, friction) of the skin
74
What is this? What is the txt?
Dermatographism-> Urticaria. Antihistamine treatment. H2 blockers
75
Lymphangitis:
* What is this?
The red streak extends from the ankle to the groin and follows lymphatic channels.
76
What is this?
lymphangitis
77
How would you documentation?
multiple round, pink plaques with scale on the elbow. Dark brown hyperpigmentation and white scarring are seen on the edge of the plaques
78
How do you documention
2 cm plaque with an irregular border and variations in color including black, brown, red, and blue. No ulcerations are seen.
79
What are the different eczematous eruptions?
* Atopic Dermatitis
* Contact Dermatitis
* Perioral Dermatitis
* Seborrheic Dermatitis
* Stasis Dermatitis
* Nummular Dermatitis
* Dyshidrosis
* Lichen Simplex Chronicus
80
What is this? how do you know?
atopic dermatitis-> it is in the anticubital fossa/folds of flexor surfaces
## Footnote
Remember, you can get lichenifation if strach too much
81
Atopic Dermatitis:
* What is it?
* Often complicated by what?
* Involves what?
* Poorly defined pruritic erythematous patches, papules, and plaques with or without scale. Edema with widespread involvement.
* Often complicated by erosions and excoriations and can become secondarily infected by Staph Aureus
* Involves flexor surfaces
82
Atopic Dermatitis
* where is it more common?
* Is it chronic or acute?
* itchy or not?
* Patients will have a history of what?
* Most commonly involves flexural surfaces, neck, eyelids, forehead, face, dorsum of hands and feet.
* Chronic relapsing skin disease that often begins in childhood
* PRURITIC
* Patients often have a History (personal and/or family) of Asthma or Allergic Rhinitis (especially eggs)
83
How do you diagnosis atopic dermatitis?
* Bacterial Culture if infected and/or recurrent infection/failure of outpatient therapy
* Viral Culture if suspecting eczema herpeticum
84
What is the txt for atopic dermatitis?
85
What is the lichenification?
thickening of skin with accentuation of skin markings
86
Lichen Simplex Chronicus
* What is it?
Well-defined lichenified plaques and/or papules occurring in areas chronically scratched in atopic dermatitis
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Lichen Simplex Chronicus (neurodermatitis)
* What are the lab tests?
* What is the txt?
Laboratory:
* KOH to R/O Fungus
Treatment:
* Topical Steroids (high potency or tar preparations-occlusion helps penetration
* Antihistamines for itching
* Avoidance
88
Contact Dermatitis:
* What is it?
* What is rhus dermatitis?
* Acute-Well-defined areas of erythema and plaques. Vesicles, erosions, crust and urticaria may be present
* Rhus Dermatitis - Urushiol-induced contact dermatitis (oils from poison ivy, poison oak, poison sumac, and the Chinese lacquer tree)
89
What is this?
Contact Dermatitis
90
Contact Dermatitis
* What can happen chronic?
* Patients complain of what?
* Contact with what?
* What is most common cause?
* Where and when is it more common?
* Chronic-Lichenification and excoriations usually present
* Patients complain of itching and/or burning
* Contact with cleaning supplies, solvents, oils, abrasives, oxidizing or reducing agents, dust, enzymes and plants are common offending agents
* Fake Jewelry/accessories distribution in Nickel allergies
* Hand eczema is the most common; 80% of occupational contact derm
91
What is this?
Contact Dermatitis-> vesicles
92
Contact Dermatitis
* Lab tests?
* What is the txt?
Laboratory: Patch testing, Cultures if infected
Treatment: Avoid/remove offending agent
* Burrow’s solution/Epsom salts cool compresses and topical steroids
* Systemic corticosteroids if Severe
* Antihistamines, soapless cleansers, oatmeal preparations for the itching
93
Nummular Dermatitis
* What is it?
* What may be present?
* Erythematous, coin-shaped plaque, with small vesicles that have coalesced.-> on Extremities
* Crusting and excoriations may be present
94
What is this?
Nummular Dermatitis
95
Nummular Dermatitis (discoid)
* What type of disorder?
* What labs need to be done?
* Pruritic, inflammatory disorder that typically affects young adults and the elderly and often occurs in the winter
* Laboratory: Cultures if infected
## Footnote
* Men > Women ; most over 50 yo
96
What is the txt of nummular dermatitis (discoid)
Emollients and topical steroid, bathe in lukewarm water, humidification
* Intralesional triamcinolone
* Crude Coal Tar 2-5% ointment (may be combined with glucocorticoid preparation)
* Systemic antibiotics if secondary infection (S aureus is common)
* PUVA or UVB 311nm Therapy (Phototherapy)
97
Perioral dematitis:
* What is it?
Erythematous, papulopustules in the area around the mouth that may become confluent with plaques and scale
98
What is this?
Perioral Dermatitis
99
Perioral dematitis:
* What may be present?
* What are the labs?
* What is the txt?
* What do you avoid?
100
Seborrheic Dermatitis:
* What is it?
* Common with what skin type?
* What thrives in the seborrheic dematitis?
* lights up under what?
* Yellowish red, often greasing, or white dry scaling macules and papules of varying size
* Oily skin
* The lipid-dependent Malassezia (formerly known as Pityrosporum ovale) is a saprophyte of normal skin that thrives at the sites of predilection for seborrheic dermatitis
* Lights up under the Wood’s Lamp
101
Seborrheic Dermatitis
* Occurs where?
* What is the treatment?
* Occurs in central areas of the body where sebaceous glands are most active-scalp, face, ears, chest, groin
* Treatment: Topical Steroids, Ketoconazole shampoo/cream, Topical Sulfa preparations
102
Stasis Dermatitis:
* What is it?
* What is present in ~30% of patients?
* Inflammatory papules, scales, crusting often occurring in the presence of edema and varicosities.
* Ulcers are present in ~30% of patients
103
What is this?
stasis dermatitis
104
Stasis Dermatitis
* What are the risk factors?
* Chronic venous insufficiency; Female > Male
* Age
* FHx
* Standing job
* Obesity
* Hx DVT
105
Stasis dematitis:
* What are the laboratory texts?
* What is the txt?
106
Dyshidrosis or Dyshidrotic Eczema
* What is another term?
* What is it like in the early phase?
* Dishwasher dermatitis
* Early in disease-Pruritic, small vesicles in clusters (tapioca appearance) most commonly on hands/feet. Occasionally, bullae form
107
What is this?
Dyshidrosis or Dyshidrotic Eczema
108
Dyshidrosis
* What is it late in the disease?
* What are the risks?
* What labs do you need to order?
* Late in disease-Papules, scaling, lichenification, and erosions from ruptured vesicles. Painful fissures may develop
* Risks: Similar to atopic/contact dermatitis
* Laboratory: KOH to R/O fungus and Culture to R/O bacteria
109
What is this?
dyshidrosis
110
Dyshidrosis:
* What is the txt? if severe?
111
What are the different Papulosquamous Disease?
* Acrochordons
* Drug Eruptions
* Lichen Planus
* Pityriasis Rosea
* Psoriasis
112
Skin tags - Acrochordons
* What are they
* Where are they present?
* most common in who?
* What is the txt?
113
Drug Eruptions :
* What is this?
* Severe drug eruptions may be accompanied by what?
* What is the treatment?
* Erythematous macular and/papular symmetric eruption that is very pruritic
* Severe drug eruptions may be accompanied by eosinophilia, lymphadenopathy, and liver function abnormalities.
* Treatment: Withdrawal offending drug
* Systemic Prednisone, Antihistamines and topical steroids, cool oatmeal baths
114
Drug Eruptions:
* Who commonly experience this reaction?
* What are DDXs?
* Mononucleosis patients taking amoxicillin or AIDS patients taking sulfa drugs frequently experience this reaction. (antibiotics, sulfonamides)
* Viral exanthem, secondary syphilis, atypical pityriasis rosea, and scarlet fever must all be considered in the differential diagnosis
115
Drug Eruptions:
* What can lead to exfoliative dermatitis?
* This symmetric, morbilliform (measles-like), blanching eruption may eventually become confluent or forming into unusual shapes, leading to an exfoliative dermatitis
## Footnote
Morbiliform – macular papillar type rash.
116
Drug Eruptions:
* What are fixed drug eruption?
* What will repeated exposure cause?
* What drug?
* This red to violaceous, pruritic, sharply demarcated patch is a cutaneous reaction to a drug
* Repeated exposure will cause a similar reaction in the same location
* Can be due to NSAIDs
117
What is this?
Drug Eruptions
118
Drug-Induced Photosensitivity (photodermatoses)
* What is this?
* What is the distribution like?
* What are common drugs?
* Linearly distributed, pruritic vesicles in a photodistribution make the diagnosis (actinic prurigo)
* The distribution of the rash is limited to sun-exposed areas.
* Common drugs causing drug-induced photosensitivity are **carbamazepine, amiodarone, doxycycline, furosemide, phenothiazines, and sulfonamides** (CAPS DF)
119
This man was in the sun, what is it?
Drug induced photosensitivity
* Erythematous reaction to ultraviolet radiation associated with carbamazepine use
120
Sun-exposed Distribution -> Porphyria Cutanea Tarda
* What is this?
* What can it be associated with?
* Blisters and erosions of porphyria cutanea tarda.
* Can be associated with Hep C (so is lichen planus).
121
Lichen Planus
* What is it?
Flat-topped, shiny, violaceous papules with surface white lines (Wickham striae) that appear to be grouped and can coalesce.
122
What is this?
Lichen Planus
123
What is this?
Lichen Planus
124
Lichen Planus
* Where are the mc areas?
* Mucosal lesions occur where?
* What are the labs?
* Can be what?
* Most commonly occur on the flexor aspects of the wrists, lumbar area, eyelids, shins, and scalp
* Mucosal lesions occur on the glans penis and in the mouth, and are usually painful and often ulcerate
* Laboratory: Biopsy and immunofluorescence to confirm diagnosis
* Can be drug-induced, assoc Hep C
| Ages 30-60 yo
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Lichen Planus
* What is the topical and systemic therapy?
126
Pityriasis Rosea
* What is this?
* What is it characterized by?
* Erythematous, dull pink to fawn colored, plaques with fine adherent scales that are oval (Circinate) or round that is symmetrical and follows the Langerhans lines giving a Christmas tree pattern.
* Characterized by a Herald Patch, which is the largest->Herald patch presents first
127
What is this?
Pityriasis Rosea
128
What is this?
Pityriasis Rosea
129
What is this?
Pityriasis Rosea
130
What is the txt for pityrisis rosea? What is the symptomatic tx for pruritus?
131
Pityriasis Alba:
* What are the characteristics?
* Worsen with what?
* Self limited when?
* What is the txt?
132
What is this?
Pityriasis Alba
133
Psoriasis:
* What is this?
* What happens to the nails?
* What may patients have?
* Commonly found on what?
* Well marginated, erythematous plaque or papules with silvery-white surface scale; removal of scale results in the appearance of small blood droplets (Auspitz Phenomenon)
* Pitting of the nails and thickening of nail beds is a common associated finding
* Pt may also have psoriatic arthritis in distal joints of hands and feet, typically asymmetric
* Commonly found on knees, elbows, and buttocks, scalp, and palms
## Footnote
Pitting, leukonychia, red spots lunula, nail plate crumbling, oil drop distribution, onycholysis, subungual hyperkeratosis
134
Psoriasis:
* What type of disorder?
* Who does this disorder affect?
* What is koebner's phenomenon?
* What surfaces do they affect?
135
What is this?
Psoriasis
* silver colored scale of plaque psoriasis is diagnostic
136
Psoriasis Variants:
* What is Psoriatic erythroderma
lesions involve entire skin and is an exfoliative and serious condition
137
What is this?
Psoriatic erythroderma
138
What is Psoriasis Guttate (drop-like)?
* acute eruption in disseminated pattern typically appearing after strep pharyngitis
* Abrupt appearance
139
What is this?
Psoriasis Guttate (drop like)
140
# Psorasis
What is Pustular (von Zumbusch’s syndrome)? What is seen with this?
is an abrupt life-threating condition characterized by widespread pustules that coalesce to form lakes of pus; fever, malaise, and leukocytosis are seen
141
What is this and what are the other s/s that come with it?
Pustular (von Zumbusch’s syndrome) is an abrupt life-threating condition characterized by widespread pustules that coalesce to form lakes of pus; fever, malaise, and leukocytosis are seen
142
What are the different severity of psoriasis?
* Mild psoriasis = < 2% of body surface area (BSA) affected
* Moderate psoriasis = 3% to 10% of BSA
* Severe psoriasis = > 10% of BSA
## Footnote
Most patients have a mild form of psoriasis
About a quarter of individuals have a moderate-to-severe form of skin disorder
143
What is the txt of psoriasis?
144
What is the difference in ointment, cream and lotion?
* Ointments have minimal water content compared to others, therefore will not “dry out”
* Ointments penetrate deeper skin better, moisturize better, stay on skin longer without drying out
145
* What is the txt for pustular psoriasis?
* What are other txt-> if other txt fail?
146
Psoriasis:
* What is it characterized by?
* Characterized by small and large erythematous plaques with adherent silvery scale.
* Moderate –severe
147
What is this?
Psoriasis
148
What are the different disorders that cause desquamation?
* Staph TSS and SSS
* Erythema Multiforme
* Stevens-Johnson Syndrome
* Toxic Epidermal Necrolysis
149
Staphylococcal Toxic Shock Syndrome (TSS):
* What is the orgnaism that causes this?
* When did the incidence rise?
* Where does this occur?
* What toxins are associated with this?
* What type of infection?
150
What are the five s/s involved with TSS (staph)
151
What are the sxs of:
* scarlet fever
* Staph scalded skin syndrome
* meningococcal
* RMSF
* Kawasaki disease
* Toxic epidermal necrolysis/ Stevens-Johnson syndrome
152
What is this?
153
What is this?
Erythroderma-> desquamates
* Sunburn type rash that blanches; fades in 3 days with full-thickness(death of entire layer of skin) desquamation especially palms and soles
154
What are the different labs that you need to do in staph toxic shock syndrome?
* CPK=Suggests necrotizing fasciitis or myositis
* Lactate an enzyme that helps with cellular respiration and is released by tissues when they are damaged or injured.
155
Diagnosis/Treatment of Staph TSS:
* Isolation of bacteria?
* explore what?
* Admit where and treat for what?
* Consult who?
* What is the txt?
156
What are the antibiotics given in staph TSS?
157
“Staph” Scalded Skin Syndrome
* Who and when do you see this more?
* Exists on what? what are the s/s?
* Children less than 5 years old
* Prevalence in Summer/Fall
* Exists on a continuum – they may have just a few bullous lesions or they can have generalized exfoliation of all their skin
* The earliest cutaneous signs of SSSS are macular erythema and skin pain. Initially, erythema is accentuated in the skin folds, such as the neck, axillae, inguinal folds, and gluteal cleft.
* The erythema may be subtle, can wax and wane, and may be especially difficult to appreciate in patients with highly pigmented skin.
158
Staph Scalded Skin Syndrome
* What is the txt?
* What do you need to do with the skin?
* What should you do if it is drug induced?
* Treat Staph with penicillinase-resistant penicillin.
* Skin is treated as though it is a burn->Skin care
* If this is "drug induced," the drug should be discontinued, and steroids may be helpful and antibiotics would not be given.
159
What is this?
Staph Scalded Skin Syndrome
160
Erythema Multiforme:
* What is this?
* often localized to where?
* Patients complain of what?
* What is it caused by?
* “Target Lesion” eruptions in which the lesions are slightly raised circular and more erythematous peripherally. Vesicles or bullae may be present centrally
* Typical target lesions consist of three components: a dusky, central area or blister, a dark red inflammatory zone surrounded by a pale ring of edema, and an erythematous halo on the extreme periphery of the lesion
* Often localized to the hands and feet, but can be generalized.
* Patients complain of fever, malaise, and weakness. the lungs and eyes may be affected in M. pneumoniae infection.
* EM secondary to HSV infection is thought to involve a cell-mediated immune process directed against viral antigens deposited in lesional skin
161
Erythema Multiforme
* what are the causes?
* Three most common causes are drug reaction (particularly penicillin's and sulfonamides) or concurrent HSV or Mycoplasma infection
* Other drugs: phenytoin, barbiturates, phenylbutazone, or allopurinol (BAPP)
162
What is this?
Erythema Multiforme-Desquamation
163
What is this?
Erythema Multiforme
164
Erythema Multiforme
* What is the txt?
165
What may be detected in sereve erythema multiforme?
In severe cases, elevations of the erythrocyte sedimentation rate, white blood cell count, and liver enzymes may be detected
166
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
* What is it?
* What classifies each?
* Generalized eruption of lesions that can initially have a target-like appearance but then become confluent, brightly erythematous, and bullous and leads to epidermal loss. 90% of patients have mucocutaneous erosions (mouth, lips, conjunctiva, genital and anal skin)
* Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are rare, severe mucocutaneous reactions triggered, in most cases, by medications and characterized by extensive necrosis and detachment of the epidermis.
* SJS and TEN exist as a continuum and are classified based on the percentage of skin body surface area (BSA) detached: severe cutaneous adverse reactions characterized by extensive necrosis and detachment of the epidermis.
167
What is this? what areas are involved (percentage)?
Stevens-Johnson Syndrome
* Oral cavity involvement is the most common (90 percent of patients), followed by nasal (50 percent), ear (50 percent), and laryngeal involvement (30 percent)
168
Stevens-Johnson Syndrome
* Patients present with what?
* What is the body surface affected in SJS and TEN?
* What does this the picture show?
* Patients present with fever, photophobia, sore throat
* By definition involves less than 10% BSA in SJS, 10-30% in overlap cases, and greater than 30% BSA in TEN
* Note the target lesions on the hands of this patient, as well as the mucosal involvement on the lips
169
Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis
* What are the associated drugs?
* How do you diagnosis?
* Sulfonamides, Aminopenicillins, quinolones, cephalosporins, tetracyclines, phenobarbital, carbamazepine, phenytoin, valproic acid, oxicam, allopurinol and corticosteroids.
* Clinical diagnosis and Could also perform skin biopsy
170
What is this?
SJS:
* complete corneal epithelial defect
* Oral mucosal involvement may take the form of erosions, blisters, and hemorrhagic cheilitis
171
* What is this?
* What can happen in the genital area?
Stevens-Johnson Syndrome
* Genital involvement can be seen in up to 60 to 70 percent of patients and commonly presents as erosions and blisters.
* Extensive pain and dysuria may lead to acute urinary retention.
* In females, vulvovaginal involvement may present with erosive and ulcerative vaginitis, vulvar bullae, vaginal synechiae, and may lead to long-term anatomic sequelae.
172
TEN:
* What is it?
* What does it look like?
Generalized, macular eruption with some target-like lesions which rapidly developed epidermal necrosis, positive Nikolsky's sign, bulla formation, and denuded erosive areas
173
What is this?
Ten
* Upper right: The initial bullae have coalesced, leading to extensive exfoliation of the epidermis
* Lower right: Seen here is a necrotic epidermis lifting off the dermis to form a subepidermal bulla
174
During the active phase of ten, what is the patient at risk?
During the active phase of the disease, the patient is at risk of fluid and electrolyte imbalances, increased metabolic demands, sepsis, hypothermia, organ decompensation, and death due to the extensive skin detachment ("skin failure")
175
What is the txt of SJS and TEN? What is some controversy?
176
Bullous Pemphigoid
* What is it?
* Few bullae can be what?
* May be preceded by what?
* What are the symptoms?
* Bullous pemphigoid is an autoimmune cutaneous blistering disease characterized by autoantibody deposition at the epithelial basement membrane zone
* Localized or generalized tense vesicles and/or bullae formation on normal skin or an erythematous base
* Few bullae can be hemorrhagic
* May be preceded by an urticarial or eczematous rash
* Symptoms: moderate/severe pruritis progresses to tenderness over the eroded lesions
177
What is this?
Bullous Pemphigoid
178
Bullous Pemphigoid
* What are the most common areas?
* Who does this affect?
* What causes the bullous formation?
* May have an association with what?
* Axillae, thighs, groin are commonly affected. Mucous membrane lesions are less severe and less painful than seen in Pemphigus vulgaris
* This is an autoimmune disorder that occurs in elderly patients (typically >80yo)
* Autoantibodies, complement fixation, neutrophil, and eosinophils cause bullous formation
* May have an association with malignancy
179
What the major goals for the treatment of bullous pemphigoid (3)?
●Decrease blister formation and pruritus
●Promote healing of blisters and erosions
●Improve quality of life
180
Bullous Pemphigoid:
* What are the lab txts? What sign is not there?
* What is the txt?
181
Pemphigus Vulgaris
* What is this?
* What is the 1st sign?
* Skin lesions occur when?
* The term "pemphigus" describes a group of autoimmune, mucocutaneous, blistering disorders characterized by acantholysis (loss of keratinocyte-to-keratinocyte adhesion) in the epithelium of mucous membranes or skin.
* Vesicles or bullae that rupture and leave erosions and crust.
* Oral lesion usually 1st sign of disease.
* Skin lesion occur 6-12 months later
182
What is this?
Pemphigus Vulgaris
183
Pemphigus Vulgaris
* What sign can be elicted?
* What may be present?
* May or may not have what?
* Why is it a serious autimmune disease?
* Occurs when?
* What are the lab txt?
* Nikolsky's sign can be elicited, disappears when repsonding to tx
* Weakness, malaise, pain or burning sensation may be present
* May or may not have pruritis
* Serious autoimmune disease where the IgG antibodies induce acantholysis, resulting in a loss of cell-to-cell adhesions
* Occurs in middle-aged adults (30-60yo)
* Laboratory: Immunofluorescense and Bx
184
What is hailey-hailey disease?
When it affects primarily neck, armpits, skin folds, and genitals
* Hailey-Hailey disease is not an autoimmune disorder and there are no autoantibodies.
185
What is this?
HHD is a chronic condition with multiple recurrences and limited therapeutic options.
186
Pemphigus Vulgaris
* what is the txt?
187
Acne Vulgaris
* What is it?
* What is the pathogenesis?
* What is a big population affected?
* _ component
* Considered what?
188
What is this?
Acne vulgaris
189
Acne Vulgaris :
* What are the lab txts?
* What is the txt?
190
What do you need to monitor with isotretinoin?
191
Acne Vulgaris
* What are some other txt?
* Oral antibiotics are added to topical therapy if patient has significant amount of inflammatory lesions and/or cysts-TCN, Minocycline (can cause blue-black pigmentation), Doxycycline, Bactrim
* Oral contraceptives in female patients
192
What is the txt for severe scaring cystic acne? What are the side effects?
Isotretinoin can be prescribed by providers who are registered with the government-regulated I-pledge program
* Inhibits sebaceous gland functioning and keratinization
Side effects: Dry eyes, nose, lips, joint pain, mood swings, and suicidal thoughts. Premature closure of long bones, visual changes, headache with blurred vision, hepatic enzyme elevation, leukopenia, triglyceridemia and teratogenicity
193
Rosacea
* What is it?
* What does it present with?
* Chronic inflammatory skin disease, MOA poorly understood
* Scattered small inflammatory papulopustules and sometimes nodules occurring cheeks, chin, forehead, glabella and nose. Face usually appears red or flushed. Telangiectasia are often present
194
What is this?
Rosacea
195
Rosacea:
* What is a common complication?
* What is txt?
Rhinophyma-enlarged nose-is a common complication
Treatment: Avoid triggers-heat, sun, spicy food, alcohol
* Topical metronidazole gel or cream, sodium sulfacetamide, azelaic acid
* Oral antibiotics TCN, minocycline, or doxycycline if topical treatment fails
* Systemic isotretinoin only for severe disease not responding to antibiotics or topical treatments (teratogenic-all females must be screened for pregnancy prior to initiation and maintain effective contraception during treatment course)
196
Folliculitis
* What is it?
* How does it present?
* Folliculitis refers to inflammation of the superficial or deep portion of the hair follicle. The classic clinical findings of superficial folliculitis are folliculocentric, inflamed papules and/or pustules on hair-bearing skin
* Erythematous papules or pustules at hair follicles
197
What does this show?
Folliculitis
198
Folliculitis-> list the organsism:
* Bacterial
* Fungal
* Viral
* Parasitic
Bacterial:
* Staphylococcal folliculitis
* Pseudomonal folliculitis
* Gram-negative folliculitis
Fungal:
* Malassezia (Pityrosporum) folliculitis
* Dermatophytic folliculitis
* Candida (candidal) folliculitis
Viral:
* Herpetic folliculitis
* Molluscum folliculitis (rare)
Parasitic:
* Demodex (demodectic) folliculitis
199
Folliculitis
* What is the txt?
* Hot tube folliculitis is due to what? What are other orgnaisms?
Treatment: Gentle cleansing and topical clindamycin, erythromycin, or Mupirocin
* Oral antibiotics for more extensive cases
Hot tub folliculitis is due to Pseudomonas and can be treated with fluoroquinolones
* Other possible organisms include Staphylococcus aureus and Streptococcus pyogenes. Bacterial culture may be taken. Antibiotic treatment is then tailored to the specific organismX
200
Tricky Pseudofolliculitis Barbae
* Irritation from what?
* looks similar to what?
* More common in who?
* What happens to the hair?
* _ response
* Cured with what?
* Advice what?
* Irritation from shaving
* Looks very similar to a folliculitis
* Much more common in dark skin and curly hair
* Hair actually curves back into follicle
* Inflammatory response
* Cured by beard growth
* Advice lubricating shave gel, less frequent shaving.
201
What is this?
Pseudofolliculitis Barbae
202
What does this show?
Seborrheic Keratosis
203
Seborrheic Keratosis
* What is it?
* Bengin or mal?
* What is txt?
* could be a sign of what?
* Verrucated, velvety, stuck on beige to brown or black plaque
* These are benign
* Treatment: Reassurance
* Could be a sign of gastric cancer
* Leser-Trelat sign: when this rash is rapidly developing in size and number
204
What is this?
Seborrheic Keratosis
205
What is this?
Actinic/Solar Keratosis
206
Actinic/Solar Keratosis
* What is it?
* More common in who?
* These are what?
* Scaly, erythematous, plaques/papules that occur on sun exposed skin, sometimes painful
* More common in fair skinned individuals
* These are pre-cancerous and given enough time they progress to squamous cell carcinomas
207
Actinic Keratosis
* What is the topical and systemic therapy?
208
Basal Cell Carcinoma (BCC)
* What does it look like?
* Patients complain of what?
* Pearly papule with telangiectasias on sun-damaged skin (ie. face, scalp, ears, chest, back, and legs).
* Patients commonly complain of bleeding.
209
What is this?
Basal cell carcinoma
210
What is this?
Basal Cell Carcinoma (BCC)
211
Basal Cell Carcinoma (BCC)
* Mos common what?
* What does BCC usually not do?
* Most Common Skin Cancer
* Basal cell cancer does not usually metastasize; rather it infiltrates the surrounding area destroying tissue
212
Basal Cell Carcinoma (BCC)
* What are the different types?
* **Noduloulcerative** (most common)
* Superficial (**mimics eczema**)
* Pigmented (may be mistaken for melanoma)
* Morpheaform (plaque-like lesion with telangiectasia)
* Keratotic (basosquamous carcinoma)
213
Basal Cell Carcinoma (BCC)
* Shows what?
Showing central ulceration and a pearly, rolled, telangiectatic tumor border.
214
Basal Cell Carcinoma (BCC)
* What is the txt?
* Electrodesiccation and Curettage
* Simple surgical excision
* Mohs micrographically controlled surgery
* Other treatment methods, such as cryosurgery, radiation therapy, and laser surgery, may be used in specific circumstances.
215
Squamous Cell Carcinoma (SCC)
* What does it look like?
* Common?
* Does it meatasizes?
* Indurated and keratotic papules or nodules often showing ulceration and/or crusting
* Second most common skin cancer
* Uncommonly metastasizes, but it can, especially in immunocompromised patients
216
What is this?
Squamous cell carcinoma
* Hyperkeratotic crusted and somewhat eroded plaque on the lower lip.
217
Squamous Cell Carcinoma (SCC)
* What is the txt?
218
Kaposi Sarcoma
* What do they look like?
Oval, purple papule with faint yellow-greenish halo
219
What is this?
Kaposi Sarcoma
* Violaceous confluent papules and nodules with edema
220
What is this?
Kaposi Sarcoma
221
What is this?
Kaposi Sarcoma
* Violaceous nodules on the upper gingiva, covering the teeth
222
Kaposi Sarcoma
* What is it?
* What is linked to several variants of KS?
* What are the subtypes?
223
Classic KS
* Who does it affect?
* Lesions appear what?
* Where are the locations?
* Indolent disease that occurs in middle-aged men of Southern and Eastern European origin
* Lesions appear reddish, violaceous, or bluish-black macules and patches that spread and coalesce to for nodules or plaques
* Predominately arises on the legs; but also may occur in lymph nodes and abdominal viscera
224
What is this?
Classic KS
225
African Cutaneous KS
* What is it?
* Endemic where?
* _ aggressive but systemically _
* Nodular, infiltrating, vascular masses occur on the extremities, mostly men between the ages of 20-50
* Endemic in tropical Africa
* Locally aggressive, but systemically indolent
226
What is this?
African Cutaneous KS
227
African Lymphadenopathic KS
* What is it?
* May occur in who?
* Fetal?
* Lymph node involvement, with or without skin lesions
* May occur in children under 10 years old
* Aggressive, often fatal within 2 years of onset
228
AIDS-Associated KS
* What is is?
* Predilection for what?
* What is expected?
* May be the presenting manifestation of what?
* Cutaneous lesions begin as one or several red to purple-red macules, that rapidly progress to papules, nodules, and plaques
* Predilection for the head, neck, trunk, and mucous membranes
* Fulminant, progressive course with nodal and systemic involvement is expected
* May be the presenting manifestation of HIV
229
What is this?
AIDS-Associated KS
230
Immunosuppression-Associated KS
* What is it?
* Tends to occur in who?
* Lesions resemble those seen in Classic KS; however, site presentation is more variable
* Tends to occur in recipients of renal transplants and cancer patients being treated with cytotoxic chemotherapy
231
What is this?
Immunosuppression-Associated KS
232
Kaposi Sarcoma
* What are the labs?
* What is the txt?
233
Melanoma
1. What is this?
2. What sign is present?
* Black, brown, pink, blue, and/or flesh colored macule, papule, nodule or plaque that is > 5 mm in diameter, asymmetric, has an irregular surface (elevated) or border, or has variation in color
* Ugly Duckling Sign: Suspected mole looks different/Sticks-out from other moles on the body
234
What is this?
Melanoma
235
Melanoma:
* Can arise from what?
* Prognosis is most dependent on what?
* Only 20-25% of melanomas arise from existing moles. That means that 75-80% of melanomas arise from “normal” skin
* Prognosis is most dependent on the depth of invasion, therefore, early detection and treatment are essential.
236
What is the ABCDE acronym?
* **Asymmetry** – One half doesn't match the other half.
* **Border irregularity** - The edges are ragged, notched or blurred
* **Color** - The pigmentation is not uniform. Shades of tan, brown, and black are present. Dashes of red, white, and blue add to the mottled appearance.
* **Diameter** - The width is greater than 5 millimeters (about the size of a pencil eraser). Any growth of a mole should be of concern.
* **Evolution** – Rapid changing in size, color, or other traits
237
What are the types of melanoma (4)
1. Superficial Spreading Melanoma
2. Lentigo Maligna Melanoma
3. Acral Lentiginous
4. Nodular
238
Superficial Spreading Melanoma
* What is it?
Most common type of malignant melanoma & demonstrates color variation (black, blue, brown, pink, and white) and irregular borders.
239
What is this?
Superficial Spreading Melanoma
240
Lentigo Maligna Melanoma
* Characterized by what?
* What phase before invasion?
* What is a presursor lesion?
* Most common in who?
* Often confused with what?
* Characterized by a single, flat, freckle-like macule with an irregular border, usually on the face.
* Very long radial growth phase before invasion
* Lentigo Maligna (Hutchinson’s melanotic freckle) is precursor lesion
* Most common in elderly and in sun-exposed areas (esp. face)
* Often confused with a solar lentigo or a seborrheic keratosis.
241
* What is this?
* Where does it occur?
Lentigo Maligna Melanoma
* Occurs on sun-exposed skin as a large, hyperpigmented macule or plaque with irregular borders and variable pigmentation
242
Acral Lentiginous
* Occurs where?
* Similar to what?
* Metastasize or not?
* Occurs on palms and soles, mucosal surfaces, in nail beds and mucocutaneous junctions
* Similar to lentigo maligna melanoma but with more aggressive biologic behavior
* Metastasize easily, are often mistaken for plantar warts or subungual hematomas
243
Nodular
* What does it start as? What does it become?
* What is the prognosis?
* Must be differentiated from what?
* Starts as a papule which becomes an elevated nodule with irregular borders and variegation in color.
* Generally poor prognosis because of invasive growth from onset
* Must be differentiated from a hemangioma, angiokeratoma, or pigmented basal cell carcinoma.
244
* What is this?
* Most commonly manifests itself as what?
Nodular Melanoma
* Most commonly manifests itself as a rapidly growing, often ulcerated or crusted black nodule.
245
Melanoma Labs & Imaging
* What plays a small role in the dx of melanoma
* What in increased in melanoma?
* What imaging?
* Tumor markers play a small role in the diagnosis of melanoma
* They are used to monitor after treatment.
* Lactate dehydrogenase (LDH) – increased in serum of melanoma patients. S100B is used as an additional marker to detect progression
* Ultrasound employed to eval suspicious lymph nodes
* CT, MRI, PET not recommended
246
Melanoma
* What is the txt?
Shave biopsy for a clinically evident melanoma should not be performed. Shave biopsy maybe utilized in questionable nevi lesions to decide whether excisional biopsy is indicated
247
Staging/Prognosis
* What is the Sentinel Lymph Node Biopsy (SLNB)?
Sentinel Lymph Node Biopsy (SLNB) – the first draining lymph node in the lymphatic draining system of the primary tumor.
* Is the best baseline staging test for detection of occult nodal metastasis
* Far more sensitive and accurate at detecting microscopic metastases than PET, CT or ultrasound combined with fine-needle aspiration.
248
What is the prognosis of different stages?
