Skin Flashcards
Rocky Mountain Spotted Fever
presents with abrupt onset of high fever, chills, severe headache, nausea/vomiting, photophobia, myalgia, and arthralgia followed by a rash that erupts 2 to 5 days after onset of fever.
The rash consists of small red spots (petechiae) that start to erupt on the wrist, forearms, and ankles (sometimes the palms and soles). It rapidly progresses toward the trunk until it becomes generalized (Figure 1).
Brown Recluse Spider Bites
found mostly in the midwestern and southeastern United States.
Systemic symptoms include fever, chills, nausea, and vomiting.
- Any child with systemic signs should be hospitalized (the condition may cause hemolysis).
Most spider bites are located on the arms, upper legs, or trunk (underneath clothing).
Bite may feel like a pinprick (or be painless). The bitten area becomes swollen, red, and tender, and blisters appear within 24 to 48 hours.
Central area of bite becomes necrotic (purple-black eschar). When the eschar sloughs off, it leaves an ulcer, which takes several weeks to heal.
Erythema Migrans
(Early Lyme Disease)
The classic lesion is an expanding red rash with central clearing that resembles a target.
The “bull’s-eye” or target rash usually appears within 7 to 14 days after a deer tick bite (range: 3–30 days).
The rash feels hot to the touch and has a rough texture. Common locations are the belt line, axillary area, behind the knees, and groin area.
It is accompanied by flu-like symptoms. The lesion spontaneously resolves within a few weeks. It is most common in the northeastern regions of the United States.
Use of DEET-containing repellent on skin and permethrin on clothing and gear can repel deer ticks.
Meningococcemia (Meningitis)
Meningococcemia is a systemic infection caused by Neisseria meningitidis (gram-negative bacterium) that can progress very rapidly and cause death within several hours.
Symptoms include sudden onset of sore throat, cough, fever, headache, stiff neck, photophobia, and changes in level of consciousness
-The risk is higher for those who live in close quarters, such as first-year college students residing in dormitories, nursery or day care, and military barracks; individuals with asplenia (no spleen), defective spleen (sickle cell anemia), HIV infection, or complement immune-system deficiencies; and infants (3 months to 1 year).
-Prophylaxis should be given as soon as possible after exposure.
–Rifampin (twice a day for 2 days) and ceftriaxone 250 mg intramuscularly (one dose) are recommended for close contacts.
Shingles Infection of the Trigeminal Nerve (Herpes Zoster Ophthalmicus)
This is a sight-threatening condition caused by reactivation of the herpes zoster virus that is located on the ophthalmic branch of the trigeminal nerve (cranial nerve [CN] V; Figure 2).
Patients report sudden eruption of multiple vesicular lesions (which rupture into shallow ulcers with crusts) that are located on one side on the scalp and forehead and the sides and tip of the nose.
If herpetic rash is seen on the tip of the nose, assume it is shingles until proved otherwise.
The eyelid on the same side is swollen and red.
Patients complain of photophobia, eye pain, and blurred vision.
This is more common in elderly patients. Refer to an ophthalmologist or the ED as soon as possible
Melanoma
Dark-colored moles with uneven texture, variegated colors, and irregular borders with a diameter of 6 mm or larger are observed (Figure 3).
They may be pruritic. If melanoma is in the nail beds (subungual melanoma), it may be very aggressive.
Lesions can be located anywhere on the body, including the retina.
Risk factors include family history of melanoma (10% of cases), extensive/intense sunlight exposure, blistering sunburn in childhood, tanning beds, high nevus count/atypical nevus, and light skin/eyes.
Acral Lentiginous Melanoma
This is the most common type of melanoma in African Americans and Asians, and it is a subtype of melanoma (<5%).
These dark brown-to-black lesions are located on the nail beds (subungual), palmar and plantar (sole of foot) surfaces, and rarely the mucous membranes.
Subungual melanomas look like longitudinal brown-to-black bands on the nail bed (Figure 4).
Basal Cell Carcinoma
The most common type of skin cancer in the United States. Superficial form (30%) of basal cell carcinoma (BCC) looks like a pearly or waxy skin lesion with an atrophic or ulcerated center that does not heal.
The lesion could be white, light pink, brown, or flesh colored (Figure 5).
It may bleed easily with mild trauma. This is more common in fair-skinned individuals with long-term daily sun exposure.
An important risk factor is severe sunburns as a child.
Subungual Hematoma
Direct trauma to the nail bed results in pain and bleeding that is trapped between the nail bed and the fingernail/toenail.
If the hematoma involves >25% of the area of the nail, there is a high risk of permanent ischemic damage to the nail matrix if the blood is not drained.
One method of draining (trephination) a subungual hematoma is to straighten one end of a steel paperclip or use an 18-gauge needle and heat it with a flame until it is very hot.
The hot end is pushed down gently (90-degree angle) until a 3- to 4-mm hole is burned on the nail. The nail is pressed down gently until most or all of the blood is drained or suctioned with a smaller needle.
Blood may continue draining for 24 to 36 hours.
Screening for Melanoma
The “A, B, C, D, E” of melanoma:
A: Asymmetry
B: Border irregular
C: Color varies in the same region
D: Diameter >6 mm
E: Enlargement or change in size
Also watch for include intermittent bleeding with mild trauma and new onset of itching.
Scarlet fever
“Sandpaper” rash with sore throat (strep throat)
Tinea versicolor
Hypopigmented round-to-oval macular rashes, most lesions on upper shoulders/back, not pruritic
Pityriasis rosacea
“Christmas tree” pattern rash (rash on cleavage lines); “herald patch” largest lesion, appears initially
- “Herald patch”: This is the first lesion to appear and is largest in size; appears 2 weeks before full breakout. It is a single round-to-oval shape and about 2 to 5 cm in diameter (Figure 1).
Treatment Plan - Advise patient that lesions will take about 4 weeks to resolve.
- If high risk of sexually transmitted disease (STD), check rapid plasma reagent (RPR) to rule out secondary syphilis.
Molluscum contagiosum
Smooth papules 2–5 mm in size that are dome shaped with central umbilication with a white “plug”
Erythema migrans
Red target-like lesions that grow in size, some central clearing, early stage of Lyme disease
Meningococcemia*
Purple to dark-red painful skin lesions all over body, acute-onset high fever, headache, level of consciousness changes, rifampin prophylaxis for close contacts
Rocky Mountain spotted fever*
(Rickettsia rickettsii from tick bite) Red spot–like rashes that first break out on the hand/palm/wrist and foot/sole/ankle, acute-onset high fever, severe headache, myalgias
Brown recluse spider bite
Bite area becomes swollen, tender, and red; blister appears within 24 hours; center of lesion may form a purple-to-black eschar (10%), which becomes an ulcer when it is sloughed off
Urticaria (Hives)
Erythematous and raised skin lesions with discrete borders that are irregular, oval, or round (Figure 1).
Lesions become more numerous and enlarge over minutes to hours, and then they disappear.
They may occur as one episode or recurrent (usually daily) episodes that resolve in 24 hours and then recur. Skin that is compressed (e.g., with tight bra straps) may have lesions that assume a shape (such as linear-shaped lesions under bra strap).
Urticaria is considered chronic if it lasts longer than 6 weeks. Most cases are self-limited.
Urticaria has multiple etiologies (e.g., medications, viral/bacterial infections, insect bites, latex allergies); if the cause is eliminated, the urticaria will resolve. If associated with angioedema or progresses to anaphylaxis, it can be life-threatening
Xanthelasma
Raised and yellow-colored soft plaques that are usually located under the brow or upper and/or lower lids of the eyes on the nasal side (Figure 2).
If the patient is younger than 40 years of age, rule out hyperlipidemia.
Approximately 50% of patients with xanthelasma have hyperlipidemia. If the xanthomas are located on the fingers, it is pathognomonic for familial hypercholesterolemia.
Order a fasting (8–12 hours) lipid profile. The condition is also known as plane xanthomas.
Melasma (Mask of Pregnancy)
Bilateral brown- to tan-colored stains located on the upper cheeks, malar area (cheeks and nose), forehead, and chin in some women who have been or are pregnant or on oral contraceptive pills (estrogen).
The condition is more common in dark-skinned women. Stains are usually permanent but can lighten over time
Cherry Angioma
Benign small and smooth round papules that are a bright cherry-red color (Figure 3).
Sizes range from 1 to 4 mm. Lesions are due to a nest of malformed arterioles in the skin.
They always blanch with pressure and are more common in middle-aged to older patients.
No treatment is necessary, since the condition is benign.
Acanthosis Nigricans
Diffuse velvety thickening of the skin that is usually located behind the neck and on the axilla (Figure 4).
It is associated with diabetes, metabolic syndrome, obesity, and cancer of the gastrointestinal (GI) tract
Acrochordon
(Skin Tags)
Painless and pedunculated outgrowths of skin that are the same color as the patient’s skin (Figure 5).
Common locations are the neck and axillary area. When twisted or traumatized (e.g., gets caught on a necklace), the outgrowth can become necrotic and drop off the skin.
Up to 50% of adults have skin tags. More common in diabetics and the obese.
Hidradenitis suppurativa is a recurrent, chronic, infection of the apocrine glands, commonly found in the
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the armpit or groin area.
Hidradenitis suppurativa is bacterial in nature, and is thought to have a genetic link.
-It is not related to hygiene, so showering more would not help the lesions.
Treatment includes:
-warm soaks
-avoiding certain foods like dairy
-antibiotics such as clindamycin.
Erysipelas
A subtype of cellulitis involving the upper dermis and superficial lymphatics that is usually caused by group A Streptococcus. For facial erysipelas, assume it is infected with MRSA and choose an antibiotic that is effective against MRSA.
Classic Case
Sudden onset of one large hot and indurated red skin lesion that has clear demarcated margins. It is usually located on the lower legs (the shins) or the cheeks (Figure 1). It is accompanied by fever and chills. Hospitalization is recommended, since patient may be bacteremic.
Herpetic Whitlow
Herpetic whitlow is a viral skin infection of the finger(s) caused by herpes simplex (type 1 or type 2) virus infection and results from direct contact with either a cold sore or genital herpes lesion.
Classic Case
Patient complains of an acute onset of extremely painful red bumps and small blisters on the sides of the finger, the cuticle area, or on the terminal phalanx of one or more fingers (Figure 1); may have recurrent outbreaks. Ask patient about coexisting symptoms of oral herpes or genital herpes.
Treatment Plan
Usually the symptoms are treated.
* Self-limited infection: Analgesics or NSAIDs for pain as needed
* Severe infections: Treat with acyclovir (Zovirax)
Patient Education
* Avoid sharing personal items, gloves, and towels.
* Cover skin lesions completely with large adhesive bandage until they heal.
Paronychia
Acute local bacterial skin infection of the proximal or lateral nail folds (cuticle) that resolves after the abscess drains.
Paronychia
Acute local bacterial skin infection of the proximal or lateral nail folds (cuticle) that resolves after the abscess drains. Causative bacteria are S. aureus, streptococci, or Pseudomonas (gram negative). Chronic cases are associated with coexisting onychomycosis (fungal infection of nails; Figure 1).
Classic Case
Patient complains of acute onset of a painful and red swollen area around the nail on a finger that eventually becomes abscessed. The most common locations are index finger and thumb. Reports a history of picking a hangnail, biting off hangnail, or trimming of the cuticle during a manicure.
Treatment Plan
* Soak affected finger or toe in warm water for 20 minutes three times a day.
* Apply topical antibiotic, such as triple antibiotic or mupirocin, to the affected finger after soaking.
* Abscess: Incision and drainage (use no. 11 scalpel) or use the beveled edge of a large-gauge needle to gently separate the cuticle margin from the nail bed to drain the abscess
Scabies
Classic Case
Patient complains of pruritic rashes located in the interdigital webs of the hands, axillae, breasts, buttock folds, waist, scrotum, and penis. Severe itching that is worse at nighttime and interferes with sleep. Other family members may also have the same symptoms.
Objective Findings
The rash appears as serpiginous (snakelike) or linear burrows.
Treatment Plan
* Permethrin 5% (Elimite): Apply cream from the neck to the sole of the feet after bathing or showering. Wash off after 8 to 14 hours. Repeat treatment in 7 days.
* Treat everyone in the same household at the same time. Any clothes/bedding used 3 days before and during treatment should be washed and dried using the hot settings. Another option is to place the items in a plastic bag that is sealed for at least 72 hours.
Tinea Infections (Dermatophytoses)
infection of superficial keratinized tissue (skin, hair, nails) by tinea organisms (Figure 1). Tinea trichophyton, microsporum, and epidermophyton are classified as dermatophytes. Tinea infection is classified by location. Most cases of tinea can be treated with topical antifungal medication except for tinea capitis and moderate-to-severe onychomycosis or tinea unguium (toenails).
Labs
* Fungal culture of scales/hair/nails or skin lesions
* KOH slide microscopy (low–medium power) reveals pseudohyphae and spores
Medications
* OTC topicals (creams, gels, sprays, solutions, powders)
* OTC azoles/imidazoles: Clotrimazole (Lotrimin Ultra), naftifine (Naftin) once a day or twice a day, miconazole (Monistat) twice a day, ketoconazole (Nizoral) shampoo/cream once a day
* Prescription topical azole: Terconazole (Terazol) twice a day
Molluscum Contagiosum
Dome-shaped papules (2- to 5-mm diameter) with central umbilication (white plug; Figure 1).
- Caused by skin infection with the poxvirus.
- Spread by skin-to-skin direct contact.
- More common in children.
- In immunocompetent host, it usually clears up in 6 to 12 months. T
- he CDC considers it an STD if lesions are located on the genitals in sexually active adolescents and adults.
