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Flashcards in Rashes Deck (99):
1

Which dietary substance can exacerbate atopic derm?

What else can exacerbate it?

Nickel in diet

Also stress and weather changes
As well as dry skin

2

Rash on right arm antecubital fossa
12 yo male
With excoriations and fissures

1) Do you have a history of Asthma or allegirs like runny nose, itchy eyes, sneezing? No
2) Do your parents have any asthma or allergiesNo
3) does this ever happen in the back of the knees?
4) What is the name of the soap you use in the shower :
- with atopic dermatitis, harsh soaps can trigger itchiness so use gentle soaps like Cerave Cetaphil or unscented dove
- only lukewarm water and thick cream within 3 min of shower - also Cerave Cetaphil (dry skin aggravates itchiness)
- gentle laundry detergent like ALL FREE AND CLEAR and no dryer sheets
5) Tx: 1. Triamcinolone 0.1% cream BID-TID 2 days on, 2 days off until rash clears (keep it in the fridge)
2. MUPIROCIN OINT for 2ndary IMPETIGO (fissures in skin)
3. Zertec 1 tab in AM
4. HYDROXYZINE 10 mg 1-4 tabs HS (grogginess subsides after 4 days)

List of dx

3

Which supplement needs to be added in seborrheic dermatitis

Zinc
(Nuts like cashews, beef, lamb)

4

SE of systemic corticosteroids

Glaucoma
OSTEOPOROSIS (add vit D and calcium, DEXA scan by pcp)
HTN/ DM
Obesity
Straie
Adrenal suppression

Depression

5

Which labs to order when new rash?

ASO
IgE (allergies and atopic derm)
CBC (anemia can cause itch)
CMP (kidney fx)
TSH (hypothyroid causes skin dryness=itch)
Vit D (correlation with high IgE)

6

Which retinoids is ok to combine with BP wash

Differin (adapalene)

7

Which stage of hair growth is attacked in alopecia areata?

Anagen stage - growth stage

(A in Alopecia, A in Anagen)

It’s not an autoimmune disorder but immune system attacks follicles in anagen stage, inflammatory T cell attack hair follicles and follicular melanocytes which breaks off anagen hairs, leaving a tail that grows out (“exclamation hairs”)

Rx: kenalog injections (IntraLesional Kenalog)
And fluocinonide solution to spots

8

Stages of hair growth

Anagen - growth

Catagen- intermediate

Telogen - rest/shedding

9

What to do when labs come back with high ASO (did I mean to say IgE?)

What Med do you start a patient on?

Antihistamines for underlying allergies

- zertec Q AM

- montelukast Q HS (because IgE is above 600)

- HYDROXYZINE 10 or 25 Q HS (1-4 tabs)


For rash, start TAC 0.1%

10

Acanthtosis

Epidermal hyperplasia (thickening) of basal and Spinosal layers

11

In Alopecia Areata, ask pt about history of which Illnesses?

Thyroid disorder %1
Autoimmune disorders (vitiligo #1)

12

Ophiasis is

Form of Alopecia Areata:
- loss of hair along temporal area

Very hard to tx
Will need wig

13

1) What percent of Alopecia Areata has family history?

2) Which onset of AA has the worst prognosis

1) 25% have FH

2) childhood onset is worse prognosis
(adult onset is better prognosis - adult with 1 patch: probably will go away on its own )
Ophiasis is bad prognosis - hard to tx

14

Name an extracutaneous finding in Alopecia Areata

10% have nail pits (which are evenly spaced compared to psoriasis pits)

15

1) What type of Hair loss is Alopecia Areata? Permanent or not

2) AA is associated with which antigens?

1) Not permanent - non scarring hair loss

2) Human Leukocyte Antigens (HLA - no HLA in milder forms)

16

Treatment for Alopecia Areata

- can regrow on its own within 2 years

- IL kenalog 2.5-5 (gets rid of lymphocytes)

- Squaratic acid tx - poison ivy like solution applied to scalp and lymphocytes go after it. 50-60% develop contact sensitization (contact derm allergy?)

- methotrexate

- topical steroids (clobetasol soln) not as effective
- oral steroids for widespread loss (totale and universale)

17

Which drugs can induce Telogen Effluvium?

ACE #1
BB, blood thinners (Coumadin is big), lithium, levodopa

18

When does Telogen Effluvium usually start?

2 months after a stressful event like divorce, surgery, child birth, Illness/fever

Must remove stressor or
Becomes chronic

19

Which labs to order with Telogen Effluvium?

THYROID (TSH)
CBC iron panel (B12 to rule out pernicious anemia (body can’t absorb B12)
+/- ANA but can have false positives

20

How many hairs lost per day in Telogen Effluvium?

150-400 or more (normal daily shedding is 100-150)

21

What type of test do you have to perform during physical exam in or with hair loss

Hair pull test:

4-5 Hair come out with ROOT (with ball WITHOUT sheath) of 40 pulled (in Telogen Effluvium)

22

Tx for Telogen Effluvium

Resolves spontaneously within few months but must stop stressor

Minoxidil 5% (rogaine) - avoid touching other areas as SE is unwanted hair growth

Also punch bx

23

Etiology of Telogen Effluvium

Stressful event causes Premature conversation if anagen (growth) hairs into Telogen (rest) hairs which end up shedding 2 months later

24

Max dose of lido 1% per day is

Without Epi- 300 mg per day or 30 ml
With Epi - 500mg per day or 50 ml

1 % lido is 10 mg/ml

25

Digital mucous cyst

Around cuticle
Due to arthritis - Synovial fluid comes out when lance it
If firm - could be cancer but lance it first to see what comes out

26

SE of Accutane

H/O CROHNS Disease (makes CROHNS worse)
Liver/pancreas
Cholesterol
Muscle joint paint
Depression
CI in PREGS (2 forms of birth control)

Changes in night vision
Abd pain and nausea
Dry skin: mouth

Can’t donate blood
Can’t get pregs

27

Paronychia

Inflammation of skin around nail (can be fungal or bacterial)

28

Trachyonychia

Washboard nails/sandpaper

29

Which drugs can cause LPP (Lichen Planopilaris)?

Lisinopril, BB, HCTZ, Planoquil
Foxy, NSAIDs

30

What does LPP look like?

Porcelain scar like areas on scalp with adherent scale around follicles (area around follicles can also be red, inflamed)

Can be itchy, with perifollicular crusts and inflammation (Use Doxy for that)

31

20% of patients with LPP have which disorders?

Hypothyroidism and 20% have wickem straie in mouth

32

What is the cause of LPP

Cause unknown - imm system attacks hair follicles leading to permanent hair loss (could get sued bc permanent hair loss could be prevented)

No cure - only prevention


Vs AA - is reversible hair loss and autoimmune

33

When is Valcyclovir contra-indicated?

Kidney problems

34

What patient population is LPP prevalent in?

Post menopausal women

35

Tx for LPP

Betamethasone lotion BID for itching - 2 weeks on, 2 weeks off, 2 weeks on. Etc
Nizeral (ketoconazole) shampoo OTC QOD for inflammation

If no improvement on Above, oral Doxy (SE: abdominal and sunburn)
Then IL Ken?

LPP Eventually goes away - meaning the progression goes away but scarring is permanent??? Unless area is already scarred

36

How to describe LP (Lichen Planus) to patients?

Common pruritic inflammatory condition of skin

37

What are the most common extra-cutaneous presentations of LP

Mouth witchem straie and nail (split, ridges, onycholysis) in 5-10% (always check)

38

Most common areas for LP

Flexor writs, dorsal hands, low back, legs

Shins (rare risk of SCC), medial things, ankles

Axialla

Trunk low back

Anus, Glans penis, vulva (dispareunia) ddx:lichen sclerosis

Maybe face, palms, soles

39

Which type of LP has a risk of SCC

3% risk in vulvovaginal and ORAL LP

Hypertrophic LP on shin looks like LP (path can’t tell the difference?) so do IL kenalog and if it goes away - it’s LP

40

Which drugs can trigger LP?

LISINOPRIL
BBs
Furosemide
Metformin
Also for LPP: doxy NSAIDs plaquinile

Takes weeks before improvement after stopping the offending med

41

Which diseases are associated with LP?

Hepatitis C virus
Hep B vaccines
Primary biliary cirrhosis

42

Which skin rash on the shin looks like SCC and can’t be differentiate on path?

Hypertrophic LP looks like SCC on shin (and path can’t tell apart)

GIve IL Kenalog and it is goes away - it’s LP

43

Tx for LP

1) Class 1 Topical steroids
2) Protopic (elidel) for groin, axila - also great for Lichen sclerosis)
3) SUNLIGHT - go outside
4) Oral steroids OR
5) Flagyl (metronidazole) 500 mg BID x2-3 weeks
NO ALCOHOL but if comes back
6) plaquinil and methotrexate

44

Thyroid is associated with which skin diseases?

Lichen Planopilaris LPP
Apolicia Areata (associated with higher incidence of autoimmune disease)
Telogen Effluvium (which is caused by stressful event - stress lowers thyroid which causes hair to fall out)
Rarely granuloma Annulare??

45

What is Squaric Acid used to treat?

Alopecia Areata (immune cell stack the squaric acid which is like applying poison ivy on scalp)

46

Patient presents with pruritic papules or plaques on frost, dorsal hand or anckle or lower back - what else to check during exam?

Mouth for wickem straie (in pt presenting with Lichen Planus)

And NAILS (10% have splitting, Ruffin, chycholysis)

47

Check nail in what skin diseases?

Alopecia Areata (evenly spaced compared to psoriasis )

Lichen Planus (rudging, splitting)

Psoriasis

48

QUESTIONS:

Nail involvement in LPP like LP?
THyroid also in LP or only in LPP?

49

Most common areas for Lichen Planus?

Wrists, dorsal hands, ankles and lower back

Shins can be affected (with gut rate papules)

50

What is the characteristic finding of a LP papule or plaque

Whickem straie (fine white lines cross the plaques)

51

Cause of Lichen Planus (according to derm tens)

Prevalence/frequency of LP

Autoimmune disorder where T cells attacks an unknown protein in skin cells and mucosal keratinocytes

Affects 1 % of people (either mouth or skin)

52

Oral LP

Wickem straie can be painful with ulcers (risk of SCC with mouth LP - must do dental exam Qyr
Often around tooth filling/crown - gold or mercury. TOgether with contact derm

Difficult to tx oral LP:
1) Topical lass 1 ointment or gel in mouth
2) Kenalog in orabase dental paste
3) NO PROTOPIC - affects kidney (bu ok on lip)
4) oral steroids
5) IL Kenalog
6) Is flagyl also used if all above fails like in regular LP?

53

Which skin disorder is Flagyl used for 3-4 weeks?

Lichen Planus

54

Can LP clear on its own?

Yes, within 8-10 months

55

Can mouth LP be related to drugs?

No

56

Which hair loss disease is often mistaken with androgenic alopecia but it’s a subtype of LPP?

Frontal Fibrosing Alopecia - affects anterior scalp, forehead and brows with sparse lonely hairs

57

What to ask a patient before starting on oral contraceptives?

Any h/o blood clots, breast or ovarian cancer, SMOKER, >35 yo

58

SE of spironolactone

Breast tenderness. CI in PREGS
Irregular menses
Increase in urination (poss dizziness)
(In men: gynecomastia)

CI in PREGS

Check K if >40 yo (must have good kidney function)

59

Peri oral dermatitis

Form of rosacea
Can have cracked lip corner
Sometime nose and eyes

Tx:
Metro gel 0.75 Bid
Cetaphil
Doxy 20 mg BID WITHOUT food (NO PREGS) to speed up metro gel
(Of pt on OCP - any time given abx- can interfere with OCP so use condoms)

Use arm and hammer toothpaste
No gum or mouthwashes
Fluoride makes worse
Can take multivitamin

NO CORTISONE - makes it worse (after making better at worse)

60

Dyshydrotic Eczema

How many time do you wash ur hands
TAC pint Bid
No hand sanitizer

61

3most common causes of neck irritant contact dermatitis

Necklaces (have nickel or cobalt)
Perfumes (even if apply else where end up on neck)
NAIL POLISH (even clear has microacralades)

TX: memetazone BID

Skin on neck is very thin

Use hypo allergenic products - means without preservatives and fragrance. Some fragrance free products use fragrance to mask odor) so we recommend vanicream soap and moisturizer

Liquid soaps have preservatives so use bar soap

62

Leg edema is a SE of which Med

Gabapentin

63

Best Med for kidney or liver related itch

Gabapentin

SE
Leg edema
Sedation

64

Tx for itch if nothing works

UVB light TIW
lay outside 20-30 min TIW

65

What other drug works for kidney or liver itch?

Cholesteramine

66

Which antimalerial medication is contraindicated in psoriasis but works great for Tumid Lupus

Plaquinile

67

First 2 questions when pt presents with itchy rash

And which test to do on pt who presents with itch

Any new meds

What products do you use


Do pen test for dermatographism

68

CREST is part of which disease

Scleroderma (limited cutaneous)

Calcinosis
Reynaulds
Esophagial dysmotility
Scrodactaly
Telangectasias

69

Morpheus is

Localized scleroderma

70

Systemic sclerosis is

Systemic scleroderma

71

LP is

Common pruritic inflammatory condition

72

What other 2 body areas can LP affect

Mouth - wickham straie

Nails

73

#1 tx for Hydradenitis supparativa

Doxy x12 weeks

Women- spironolactone with OCP bc no pregs

74

Granuloma annulara is associated with which 2 diseases

DM and thyroid
H/o lupus or RA or TB or cocci?
Chron joint pains?
Feeling well otherwise?

Tx:
IL Kenalog
Or cortisone cream
Do labs for cocci



Harmless rash- comes and goes and disappears in 8 years
Reason unknown
Check valley fever

75

Dyshidrotic eczema

Comes and goes, in ppl predisposed to sweating , worse with SMOKING, stress and water

Worse by nickel (avoid food beans choc asparagus)
Worse with smoking
Decrease washing

Vani soap and cream
Hypoallergenic
No hand sanitizer
No neosporin
No hot water


Avoid touching nickel, detergents, solvents, water - use gloves

Worse with sweating - OTC CertainDry antiperspirant for hyperhydrosis- apply hs with gloves and wash off in am (could cause shaffing but could help)

TX
BETAMETH cream Bid 2 was on/off
Protopic in weeks off
ZERTEC or Allegra day and hudroxyzone 25 HS (don’t drive after taking it)

76

Perioral dermatitis is a subtype of?

Rosacea

77

Perioral (Perineal?) derm tx

Clindamycin gel bid together with minocyclin 50 qHS to kick start medication

Improving so changed to Clindamycin in am and elidel pm (stopped abx)

Also on sulfacetomide wash 10%/ (what’s 4.5%about?)

Elidel qd or Bid (fda approves for eczema)

78

What to tell scalp psoriasis patients to make sure

Make sure they are not abrasive when washing hair and when combing hair cause will make psoriasis worse

79

Dyshydrotic eczema is caused by

Palmoplantar hyperhidrosis (related to sweating)
Ho of atopic derm
Genetics
Contact with irritants like water detergent
Friction
Contact allergy to nickel
Tinea
Rxn to drugs

80

If LP without oral involvement, it’s most likely cause by what?

Drug induced:
Lisinopril #1
Atorvastatin
HCTZ
METFORMIN (guy started 6 months ago and 2 months later rash)
CCB is rare

Drug induced LP distribution is more on legs (can be small hypertrophic guttate plaques or large plaques (with white film over if moisturized)

81

GRANULOMA annulare can be caused by which diseases?

And is associated with which 2 disorders

Order which labs

Cocci, TB, RA (chronic joint pains) and lupus ??? Not true

DM, thyroid (and RA)

Order CXR ?
Order cocci Serology and quantiferon Gold (for TB)

82

Which is not to use in perioral dermatitis?

CORTISONE - will make better then worse

Use arm and hammer toothpaste
No gum
No mouthwashes
Fluoride makes worse

83

How to tx dyshydrotic eczema

Betamethasone cream BID 2 was on/off (not on face or groin)
Protopic on weeks off

For itch - Allegra 180 day and hydroxizone HS

Smoking makes worse

Do not touch nickel
Decrease hand washing - wear gloves
No hot water
No neosporin
No hand sanitizer
Only hypoallergenic soap and moisturizer

84

What makes dyshydrotic eczema worse

Mix of contact derm (water, detergents) and adult eczema

Triggered by stress and sweaty palms

Smoking (must stop)

Weather changes?
Irritants like water, detergents, solvents
Nickel (try low nickel diet?)

85

What warning to give a patient on OCP

Anytime take antibiotics, there is a chance it will interfere with your birth control so use condoms while on abx

86

Tx for LP

- Topical class 1 betameth oint BID
- PROTOPIC (never mouth) or Elidel (both calcineurin inhibitors):
IS THIS FOR WEEKS OFF STEROID?
- Sun light outside 20-30 min TIW
- Oral steroids OR
- Flagyl 500 BID x 2-4 weeks (no alcohol)

87

Never use Protopic where?

Mouth (affects kidneys)
But ok to use on lips

88

Make sure not to use what with perioral dermatitis?

Steroid cream (makes it initially better then worse)

89

Which labs to order when putting pt on plaquenil

CBC
CMP

90

Lichenoid keratosis

Vs bcc: no skin lines in bcc when stretch it

91

Which blood labs to order in AA

TSH

92

Which organism causes seb derm

Pitirosporum (Malassezia) yeast (non pathogenic yeast) was

93

What often causes scalp folliculitis

Pitirosporum (Malassezia) yeast

Micro pustules which are not too inflamed

94

Tx for for LPP (oral Med)

Doxy 100 with dinner or 20 bid without food
Plus betameth lotion bid
Plus ILken 5 mg (mix IL Ken 10 50-50

95

What other disorder does Rosacea commonly coexist with?

Seb derm

96

Oral med for LPP and FFA

Doxy
Betameth lotion BID
Plus IL Ken 5 mg

97

Circinate

Circular in appearance

98

Sx of LPP and FFA and tx for them

Itchy, scaly

For itch. Betameth lotion BID
For perfollicular crusting and inflammation - DOxy 100 with food or 20 BID without food

99

NP presenting with hair loss, what to ask, what to examine, what to do and how to tx

Ask:
-thyroid issues (Telogen and AA), autoimmune, feeling ok? (AA)
- irregular menses (evidence of androgen excess - hirsutism, acne, menses, deep voice)
-Last PE (CBC, anemia, B12)
-new meds?
-what meds on (BB.AC, Lithium, BLOOD thinners, levodopa - Telogen loss; LPP: ACE/BB/HCTZ, doxy, NSAID, plaquinil)
- any stressful events in last 2-4 months
-SMOKER??? (RF in female with adrogenetic loss)
-Anyone else in family

Check:
NAILS (10% of AA, even spaces as opposed to Psoriasis)