Module 11: Dermatology (a) Flashcards
(44 cards)
1
Q
Common Growths
-Actinic Keratosis
A
- Gritty or sand-paper-like rough macule or thin pápula
- Sun-exposed skin
- Actinic keratosis very rarely becomes squamous cell carcinoma — 1:100 to 1:1000 risk
- Treatment
- Liquid nitrogen application
- 5-fluoruracil cream
- Imiquimod cream
2
Q
Common Growths
-Seborrheic Keratosis
A
- “Stuck-on” usually brown to black thin pápulas to plaques
- Trunk and head & neck > extremities
- Benign
- Treatment
- NOT Necessary
- If irritated — Liquid nitrogen application
3
Q
Acne Vulgaris & Rosacea
A
- Chronic papulopustular eruption affecting the pilosebaceious units of the face and trunk
- Acne Vulgaris Types — Comedonal, papulopustular, nodulocystic (Conglobata), Fulminans
- Acne Rosacea Types — Classic, Granulomatous, pyoderma faciale — Flushing more common
- Primary Lesions — Red pápula/nodule, pustule, comedones (white and black heads)
4
Q
Acne Vulgaris
-Grades 1-4
A
- Mature closed comedo - “White head”
- Open comedo - “black head” — oxidized lipids
- Grade 2 — Papular: Red inflamed pápulas
- Grade 3 — Papulopustular: Pustules
- Grade 4 — Nodulocystic: Furuncles that have nodulear/cystic appearance
5
Q
Acne Vulgaris Therapeutic Agents
A
- Topicals
- Retinoids (tretinoin, adapalene) — comedolytic & shrink sebaceous glands — NOT for pregnant women - Spironolactone — Okay for women — NOT given to men d/t risk of gynecomastia — Anti-androgen activities — NOT for kidney dz
- Oral contraceptives — Yasmin — only for adjunctive therapy
6
Q
Acne Vulgaris Therapeutic Agents
-Oral Antibiotics
A
- Tetracycline — 500 mg BID -TID — Photosensitivity, GI upset - empty stomach
- **Doxycycline — 100 mg QD - BID — Photosensitivity, $$
- **Minocycline — 100 mg QD — Dizziness, BLUE skin pigmentation
- Erythromycin — 500 mg bid-TID — GI upset
**Doxycycline and minocycline are most commonly prescribed
Above antibiotics have anti-inflammatory properties
7
Q
Acne Vulgaris Therapeutic Agents
-Oral Isotretinoin
A
- Nodulocystic acne or refractory acne — 120-150 mg/kg per course W/ FOOD
- A/Es TERATOGENICITY, EXTREME xerosis, increased LFTs & triglycerides
- ALL women of child-bearing potential must list 2 forms of contraception to register
- Mixed evidence of risk of colitis — U.C.»_space;> Crohn’s) 2x
For Topical and oral retinoids, ACNE may become worse prior to getting better
8
Q
Acne Vulgaris Therapy
-Grade 1 Comedonal Acne
A
- Tx w/ topical tretinoin cream or gel at bedtime
- Apply a small amount (pea-sized) to affected regions of the face
- Apply to Dry face, NOT wet
- Try applying every other night if irritating - Consider adding topical antibiotic or topical benzoyl peroxide in the morning
9
Q
Acne Vulgaris Therapy
-Grade 2: Papular Acne
A
- Add oral antibiotic if moderately severe or if chest and back are involved
- Continue oral antibiotic for at least 6-8 wks then slowly decreased daily dose to avoid flare-ups - DO NOT abandon a given therapy until a 6 wk trial has been completed
TEST 6-8 weeks
10
Q
Acne Vulgaris Therapy
-Grades 3-4: Papulopustular/Nodulocystic Acne
A
- If severe, consider ISOTRETINOIN
- REFER to Dermatology
- STOP all other Acne Treatment - Contraceptive Counseling is IMPORTANT — Oral contraceptives are safe w/ isotretinoin
11
Q
Pitfalls of Therapy for Acne Vulgaris
A
- NOT waiting 6-8 weeks to establish a response to starting therapy
- Ignoring impact of cosmetics, skin cleansers, hair lubricants, picking, OCPs, occupational exposures, stress, and hormones on a patients acne
- Poor patient education on how to counteract the drying effects of topical therapy
12
Q
Acne Rosacea Therapeutic Considerations
A
- No Comedones — NO place for topical comedolytics (Tretinoin, benzoyl peroxide)
- C. Acnes bacteria NOT important — Topical erythromycin and clindamycin NOT helpful
- Vascular instability leads to “FLUSHING”
Acne Rosacea has “BACKGROUND ERYTHEMA” Papules, pustules are on top of the redness
13
Q
Therapy for Acne Rosacea
A
- Metronidazole cream or gel BID
- Azelaic acid cream or gel BID
- Ivermectin 1% cream BID
- If moderately severe ADD oral antibiotics
- Doxycycline, minocycline
- Erythromycin
14
Q
Pitfalls of Acne Rosacea Therapy
A
- NOT waiting 6-8 weeks to establish a response to starting therapy
- Ignoring impact of cosmetics, skin cleansers, skin care products, topical steroids, stress
- Triggers for Flushing
- SUN Exposure, ETOH, Chocolate,
15
Q
Psoriasis
-Info
A
- Chronic eruption of “scaly plaques” on the extensor surfaces that may involve the scalp and nails
- Primary lesion — WELL-DEFINED PLAQUE — Thick silvery scale — pitting of nails is diagnostic
- Usually develops in 40’s to 50’s years olds
16
Q
Psoriasis Types More Common in HIV?
A
- Inverse & Erythrodermic psoriasis
- Severe Psoriasis can occur after RAPID PREDNISONE TAPER**TEST
- If a patient has a hx of Moderate Psoriasis and has been on steroids recently, think of that as the cause for SEVERE Psoriasis
17
Q
Psoriasis
-Therapeutic Modalities Topicals
A
- Topical steroid creams & ointments
- Topical Calcipotriene cream & ointment
- Topical tazarotene (Retinoid) gel
- Phototherapy (UVB & PUVA)
- Oral methotrexate, acitretin (retinoid), or cyclosporine, apremilast
18
Q
Psoriasis
-Therapeutic Modalities Injectables
A
- Humara
- TNF
- IL 12/23
- IL-17A
- IL-23
19
Q
Psoriasis
-Topical Steroids and Potency
A
- NEVER use class 1 or 2 topical steroids on face or skin folds
- Can PERMANENTLY Thin the skin
20
Q
Limited Plaque Psoriasis Therapy
A
- Topical Steroids
- Class 1 or 2 for short 14 day control
- Class 3-4 for daily maintenance therapy
- Topical calcipotreine .005% cream DOVONEX — Apply BID +/- topical steroids
- Topical tazarotene .1%, .05% gel TAZORAC — QD +/- topical steroids — NEVER for pregnant women
21
Q
Eczema
-Info
A
- Inflamed, pruritic skin (dermatitis) not due, exclusively, to external factors (allergens, sunlight, cold, heat, fungus, etc)
- Types:
- Atopic (most common starting as a child)
- Asteatotic - only in winter
- Hand & Nummular - Primary lesion is ILL-DEFINED scaly red patch
- Diagnostic — R/O external factors as the sole cause of eruption
22
Q
Atopic Eczema
-Pathophysiology
A
- Genetic and environmental factors play a strong role
- Histology — Spongiosis = intercellular edema w/in the epidermis — Acute and chronic inflammatory cells
- T cell mediated cytokine release — TH2 type
- More likely to be seen in urban settings not rural settings
- Psoriasis = TH1 cells — Eczema is TH2 cells
23
Q
Therapy of Mild to Moderate Eczema
A
- Correct Diagnosis — R/O allergic or irritant contact dermatitis, dermatophyte infections, & drug reactions
- Good skin care
- Mild super fated skin cleanser — Lukewarm not hot showers, lubricate skin frequently w/ unscented or fragrance free lotions/creams - Topical Steroids — Only for flares
- Class 1 or 2 for short term (14 days) — For Children, use class 3 or 4 d/t to thin skin (mometasone cream) - Consider topical or oral antibiotics if crusted
- Topical tacrolimus or pimecrolimus $$$ for refractory disease
- both meds are calcineurin inhibitors that inhibit T cell proliferation
- NO skin atrophy
- FDA concerned about long-term use — Dermatologists are NOT concerned
24
Q
Therapy for Severe and Widespread Eczema
A
- Dermatology REFERRAL
- Oral or intramuscular steroids
- Phototherapy
- Oral methotrexate — cyclosporine — NOT for children
- Dupilumab injections — Anti-IL-4 — Look for A/E conjunctivitis
25
Urticaria
| -Info
1. Pruritic transient plaques caused by local release of histamine in the skin
2. Types - Acute and chronic (Chronic >6 wks)
- Physical (Cholinergic, pressure, heat
3. Primary lesion — wheals
4. Key diagnostic — TRANSIENT lesions — <12-24 hrs
26
Urticaria
| -Pathophysiology
1. Exposure of allergen to lungs, gut or skin
2. Type 1 hypersensitivity reaction:
- IgE mediated mast cell degranulation
- Release of histamine and other chemical mediators
- Increased capillary permeability and tissue edema
27
Urticaria Therapy
1. ID allergen and avoidance — drugs, pollen, chemicals, food, bacteria, preservatives, malignant tumor
2. Antihistamines (Avoid systemic steroids) — Loratadine, cetirizine, fexofenadine, atarax
3. If Chronic >6 wks — Consider adding cimetidine (Tagamet) 400 mg bid-TID
4. If severe and chronic consider omalizumab (Once monthly injection* — blocks binding of IgE to IgE receptor in mast cells
28
Dermatophyte Infections
| -Info
1. Superficial fungus infection of the skin caused by dermatophyte fungi
2. Types — Tinea corporais, capitais, cruéis, Mannum (hand), Pedis, unguium (nail)
3. Primary Lesion is WELL-DEFINED red PATCH. Or yellowish nail w/ Subungual crumbling
4. Diagnostic Keys — ID of hyphae on KOH exam or fungus culture
29
Therapy of Dermatophyte skin infections
| -Localized skin involvement
1. Topical Antifungals cream
- Miconazole 2% BID
- Clotrimazole 1%
- Ketoconazole 2% QD bid
2. Nystatin has NO EFFECT on dermatophyte fungi — Only works for Candida
3. AVOID combination products w/ steroids — Can cause permanent skin atrophy
30
Therapy of Dermatophyte skin infections
| -Widespread skin involvement
1. Terbinafine 250 mg daily x2-3 wks
| 2. A/E — Abnormal taste, GI upset, increase LFTs
31
Tinea Capitis
1. You lose hair with Tinea capitis, NOT with Eczema
2. Topical agents are INEFFECTIVE
3. For Children — Oral Griseofulvin 8 weeks
4. For Adults — Terbinafine 2-8 weeks
5. Selenium sulfide or Ketoconazole shampoo daily — Reduces infectivity
32
Therapy of Dermatophyte Nail Infection?
1. TERBINAFINE 250 mg daily for 6 wks (fingers) or 12 wks (toes) DRUG OF CHOICE
2. VICKS VAPOR RUB helps w/ nail fungus ** Once daily for 1 year until nail grows out
33
Tinea Versicolor
1. “Spaghetti and meatball” appearance or “grapes & vines”
2. Caused by malassezia fungi
3. Treatment — Ketoconazole 1% or 2% shampoo (as a body wash and leave on for 5 minutes
- RARELY oral antifungals
34
Scabies Infestation
| Info
1. Infestation of the skin d/t to the ectoparasita sarcoplasma scabei
2. Primary lesion: Linear burrow, excoriated pápulas
3. Diagnostic Keys — Scabies prep, others itching, head and neck spared
—Involves HANDS and WAISTLINE
-Scabies is larger in children
Types of scabies — Classic & Crusted
35
Scabies
| -Diagnostics
1. Mineral oil prep — Scrape any place where pt is itching and put it on the prep
36
Classic Scabies s/Sx’s
1. 1st infestation to time of itching can be 2 to 6 weeks
| 2. Treat entire household when one person is infected
37
Classic Scabies Therapy
1. Permethrin 5% cream (Elimite) — Applied to all skin sparing face for 8-12 hours as a single application — May repeat in 1 week
OR
2. Oral Ivermectin 200 mcg/kg/dose x1 dose — repeat in 2 weeks **Must repeat to kill eggs**
-All personal contacts should be treated
-Topical steroids - Class 3-4
-Oral antihistamines — It may take 3-4 wks for itching to completely resolve — Pt’s need to shed dead mites, feces and eggs so itching will stop
38
Crusted Scabies
1. SEVERE form of scabies with 1000’s of mites
2. Markedly thickened scaly crusted skin
3. Color is creamy grey to yellow
4. Erythema to erythroderma present in background
5. RISK factors
- Immunocompromised, elderly, disabled, debilitated
6. May have little to no itching — delayed and difficult diagnosis — HIGHLY Infectious
Appearance of DRY CRACKED SAND ***TEST
39
Treatment of Crusted Scabies
1. Combined treatment ivermectin + permethrin cream
| 2. Very complicated treatment
40
Pyoderma
1. Bacterial infections of the skin, usually d/t staph/strep
41
Pyoderma
| -Impetigo?
1. Honey-colored crusted “erosions” lesions
| 2. Primary lesion is a pustule — appearance of herpes simplex 2 but less clustered
42
Pyoderma
| -Folliculitis
1. Follicular pustules or papule’s
43
Pyoderma
| -Furuncle
1. Boils.. Multiple furuncles are called furunculosis
44
Pyoderma
| -Therapy?
1. Obtain a swab culture for bacterial ID and antimicrobial sensitivities
2. Empiric Tx before culture results
- Clindamycin 300 mg TID -QID x 7-14 days **
- Trimethoprim-sulfa DS bid x 7-14 days
3. Topical mupirocin (Bactroban) ointment has excellent Staph/Strep action
