Rash

Question 1

What is a rash?

Answer 1

Inflammatory skin erruption

Question 2

Differential diagnosis of a rash os primarily based on morphology of the lesion:

Answer 2

1) First identify the primary lesion, this is the lesion that is the typical element of the eruption.

2) Determine the global reaction patern.

3) Distribution of the lesions (diffuse, isolate, localized, regional, universal)

Question 3

Primary lesion:

Answer 3

initial lesion that has not been altered by trauma or manipulation, and has not regressed.

Question 4

Secondary lesion:

Answer 4

Develops as the disease evolves or as the patient damages the lesion. ex) rubbing, scratching, infections.

Question 5

Primary lesions:

Answer 5

Bulla
Macule
Nodule
Papule
Patch
Petechiae
Plaque
Pustule
Vesicle
Wheal

Question 6

Bulla:

Answer 6

A circumscribed, elevated lesion that measures ≥ 1cm and contains serous or hemorrhagic fluid (ex: larger blister)

Question 7

Macule:

Answer 7

circumscribed, nonpalpable discoloration of the skin that measure < 1cm in diameter.

Question 8

Nodule:

Answer 8

A palpable, solid, round ellipsoid lesion measuring ≥1cm; it differs from a plaque in that it is more substantive in its vertical dimension compared with its breadth.

Question 9

Papule:

Answer 9

An elevated, solid lesion that measures <1cm in diameter

Question 10

Patch:

Answer 10

A circumscribed, nonpalpable discoloration of the skin that measures ≥1cm.

Question 11

Petechiae:

Answer 11

Nonblanching reddish macules representing extravascular deposits of blood, measuring ≤ 0.3cm (less than the size of a pencil eraser).

Question 12

Plaque:

Answer 12

A palpable, solid lesion that measures ≥1cm

Question 13

Purpura:

Answer 13

Nonblanching reddish macules or papules representing extravascular deposits of blood, measuring > 0.3cm.

Question 14

Pustule:

Answer 14

A lesion that contains pus; may be follicular (centered around the hair follicle) or nonfollicular.

Question 15

Vesicle:

Answer 15

A circumscribed, elevated lesion that measures <1cm & contains serous or hemorrhagic fluid (ex:small blister)

Question 16

Wheal:

Answer 16

A round or annular (ring-like), edematous papule or plaque that is characteristically evanescent, disappearing within hours; may be surrounded by a flare or erythema. (ex: hive)

Question 17

Secondary lesion:

Answer 17

Atrophy
Crust
Erosion
Lichenification
Scale
Scar
Ulcer

Question 18

Atrophy:

Answer 18

A depression in the skin resulting from thinning of epidermis, dermis and/or subcutaneous fat.

Question 19

Crust:

Answer 19

A collection of dried blood, serum, and/or cellular depris.

Question 20

Erosion:

Answer 20

A focal loss of epidermis does not penetrate below the dermal-epidermal junction and, therefore, can heal without scarring.

Question 21

Lichenification:

Answer 21

Thickening of the epidermis resulting from repeated rubbing, appearing as accentuation of the skin markings.

Question 22

Scale:

Answer 22

Excess dead epidermal cells; scale may be fine, silvery, greasy, desquamative, or adherent.

Question 23

Scar:

Answer 23

Abnormal formation of connective tissue, implying dermal damage.

Question 24

Ulcer:

Answer 24

A focal loss of full-thickness epidermis and partial to fill thickness dermis, which often heals with scarring.

Question 25

Papulosquamous eruptions (papules and plaques w/scales):

Answer 25

Question 26

Folliculopapular eruptions: (perifollicular papules)

Answer 26

Question 27

Dermal reaction patterns:

Answer 27

Question 28

Purpura and petichiae:

Answer 28

Question 29

Nonpalpable purpura:

Answer 29

Question 30

Blistering disorders (vesicles, pustules, and bullae):

Answer 30

Question 31

History in dermatology:

Answer 31

Include your standard HPI, past medical history, family medical history, social history, sexual history and the following questions: When? (onset) Where? (site of onset) Does it itch or hurt? (symptoms) How has it spread (pattern of spreading)? (Evolution) How have the individual lesions changed? (evolution) Provocative factors? heat, cold, sun, exercise travel history, drugs, pregnancy, seasonal changes -Exposures at the site? changes to routine (laundry detergent, cosmetics, cleaning products?) Previous treatment and response to treatment? (Topical systemic) Constitutional symptoms? headache, fever, chills, weakness, malaise arthralgias, etc. -More chronic ones: weight loss, weakness, malaise

Question 32

Physical exam:

Answer 32

Genral shape: round, oval, polygonal, polycystic, annular (ring-shaped), iris, serpiginous (snakelike), umbilicated. Size Color Margination: well defined, Ill defined Palpation: -Consistency (soft, firm, harm, fluctuant, board-like) -Deviation in temp (hot, cold) -Mobility -Tenderness? -Estimate the depth of the lesion (ex: dermal or subcutaneous) Number: single or multiple lesions Arrangement: Multiple lesions may be: -Grouped: herpetiform, arciform, annular, reticulated (net-shaped), linear, serpiginous -Disseminated: scattered discrete lesions Confluence: yes or no Distribution: -Isolated? -Localized vs. regional vs. generalized -Pattern: symmetric, exposed areas, sites of pressure, intertriginous area, follicular localization, random, following dermatimes or blashko lines

Question 33

Ruling out melanoma and dysplastic nevi:

Answer 33

1) Asymmetry 2) Irregular borders 3) Variegated color 4) Diameter: a lesion larger than 6mm is at higher risk for malignancy 5) Evolution/Enlargement: a lesion that changes over time is at higher risk for malignancy

Question 34

Magnification with hand lens:

Answer 34

Hand lens (7 x magnification) Binocular microscope (5x to 40x magnification)

Question 35

Oblique lighting:

Answer 35

Used to view degrees of elevation or depression in a lesion. Done in a darkened room.

Question 36

Subdued lighting:

Answer 36

Used to enhance the contrast between circumscribed hypopigmented or hyperpigmented lesions and normal skin.

Question 37

Wood lamp:

Answer 37

356 nm ultraviolet long-wave light, "black light): -Can pick up florescent pigments and subtle color -Causes some superficial lesions to fluoresce. -Vitiligo presents as amelanotic -Tinea capitis and tinea versicolor can sometimes be visualized with wood lamp but not likely tinea corporis, as many references would suggest: depends on species of fungus: porphyrias, erythrasma, some bacterial infections (pseudomonas) -Deep(raticular dermal) lesions typically do not flouresce under wood lamp -Typically used by dermatologists, not necessary in naturopathic medicine

Question 38

Diascopy:

Answer 38

Firmly pressing a microscopic slide or glass spatula over a lesion Can assess if the red color of a macule is due to capillary dilation or extraversion of blood that does not blanch.

Question 39

Dermoscopy:

Answer 39

Hand lens with built in lighting and magnification. Inspection of deeper layers of the dermis. Helpful to distinguish between benign and malignant lesions.

Question 40

Patch testing:

Answer 40

Used to confirm a diagnosis of allergic contact sensitization and identify the agent that caused the allergic reaction. Substances to be tested are applied to the skin in shallow cups (finn chambers), taped onto the skin and left in place for 24-48 hours. Contact hypersensitivity will show as a papular vesicular reaction that will develop within 48 to 72 hours when the test is read.

Question 41

Prick testing:

Answer 41

Used to determine type I allergies. A drop of a solution containing a small amount of allergen is placed on the skin and the skin is pierced through this drop with a needle. A positive result would be a wheal appearing within 20 minutes. Caution: the patient needs to be under constant supervision due to possibility of anaphylaxis.

Question 42

Skin scraping:

Answer 42

Dermatophyte/KOH collection -Microscopic examination for mycelia should be made of the roofs of the vesicles or of scales or in the hair in dermatophytosis. The tissue os cleared with 10 to 30% KOH and warmed gently. Hyphae and spores can then be viewed. Microbiology (culture & sensitivity) and specimen handling biopsy *Note most of these clinical tests are performed by allergists or dermatologist, some ND's offer prick testing and skin scraping, but a patient can be referred out for further evaluation

Question 43

Biopsy:

Answer 43

Different tools can be used for different types of lesions. Punch biopsy: -Useful in the workup of cutaneous neoplasms, pigmented lesions, inflammatory lesions and chronic skin disorders. -3 to 4 mm punch, a small tubular knife cuts through the epidermis, and subcutaneous tissue by rotating the tool. Excisional biopsy (wide local excision): -Surgical removal of a tumor and some normal tissue around it.

Question 44

Atopic dermatitis:

Answer 44

Question 45

Contact dermatitis:

Answer 45

Question 46

Seborrheic dermatitis:

Answer 46

Question 47

Dyshidrosis (Acute palmoplantar eczema):

Answer 47

Question 48

Nummular dermatitis:

Answer 48

Pathophysiology: The natural aging process, chronic venous stasis, bacterial colonization, certain drugs, and sensitization to contact allergens, most commonly metals (nickel sulfate, potassium dichromate, cobalt chloride), may compromise the cutaneous lipid barrier.[1] The release of cytokines (i.e., IFN-g and IL-17) results in increased recruitment of T cells, dendritic cells, and Langerhan's cells, eventually leading to epidermal hyperplasia and the development of characteristic lesions.[6] Epidemiology: affecting predominantly females 15 to 25 years of age and males 50 to 65 years of age. Prevalence ranges from 0.1% to 9.1% Time course: Patches can last for weeks to months, and flare-ups or episodes can repeatedly happen over a long period of time. Symptoms & signs: Coin shaped lesions on the skin on the trunk, hands, and legs The lesions are brown, pink or red Itching and burning of the lesions Lesions often appear like a skin injury, such as a burn, abrasion (from friction), or insect bite Oozing of fluid from the lesions and crusting Diagnostics: Diagnosis involves review of medical history and visual skin inspection. -Allergy skin test: To determine the substances causing allergies. -Patch test: To determine a specific substance which causes allergic inflammation. -Skin biopsy: To rule out other possible causes e.g. infection.