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Flashcards in skin Deck (135):
1

common causes of rash

allergens, infections, collagen vascular disease, toxic, drugs, metabolic

2

life threatening rashes

anaphylaxis, angioedema, bacterial endocarditis, meningococcal meningitis, severe thrombocytopenia, Kawasaki syndrome, TSS, toxic epidermal necrolysis (TEN)

3

flat, non-palpable skin lesion

macule-->patch(>1cm)

4

elevated, firm circumscribed skin lesion

papule-->nodule(1-2cm)

5

elevated firm rough skin lesion (>1cm) flat top

plaque

6

elevated, irreg. shaped cutaneous edema

wheal

7

elevated, circumscribed, superficial, not into dermis, filled with serous fluid

vesicle-->bulla (>1cm)

8

like vesicle but pus

pustule

9

superficial dilated blood vessels

telangiectasia
1 cause: chronic etOH

10

allergic skin reaction

urticaria, hives

11

suspect bacterial endocarditis

Oslar nodes and Janeway lesions

12

if wet purpura in mouth worry about

severe thrombocytopenia (as low as 2000)
infectious etiology

13

peds

Kawasaki

14

skin sloughs off, typ. medication related, tachy

toxic epidermal necrolysis (TEN)
also SJS w/ sulfa drugs

15

present w. purpura, fever, altered, neck stiffness

meningitis

16

K-OH prep

highlights fungal infection

17

basal cell carcinoma

-caucasians
-pearly white lesion, pt may scratch-->bleed
-slow growing tumor
-30% lifetime risk M>F

18

BCC risk factors

-UV sunlight, tanning, chronic arsenic exposure, radiation, long term immunosuppr. tx (transplants)

19

BCC dx

-pearly/waxy translucent in light papule
-best obs. w/ stretched skin
-erythematous patch >6mm or non-healing ulcer in sun exposed areas
-shave or punch biopsy: bests of basaloid cells in dermis, sep. from adj stroma by thin clefts

20

BCC tx

-electrodessication and curettage: not able to histologically confirm complete removal
-surgical excision
-Mohs surgery: take out one slide at a time til histologically confirm no more BCC (imp. on face, lips, nose, etc)

21

BCC topical/non-surg tx

-5-fluorouracil: pyrimidine antimetabolite, interferes w. DNA synthesis
-Imiquimod (Aldara): unknown mechanism, TLR7 agonist, induces cytokines (INF-a)

22

radiation therapy for BCC

typically avoided
used in pt. who are nonsurgical candidates
-admin. in 4+ fractions, limits side effects, gives normal skin time to heal while cancerous cells cannot repair themselves as quickly

23

benefits of radiation tx

-cosmetically sparing, noninvasive, painless, nonsurg. candidates

24

BCC follow up

monitor pt annually

25

metastatic basal cell

deeply invasive/large lesions >10cm2
-missed w. poor examination, altered elderly pts
-reg. lymph nodes, lungs, bones, skin, liver
*Vismodegib (Erivedge): Hedgehog pathway inhibitor

26

squamous cell carcinoma

non-healing ulcer/wart nodule
recurring, bleeding lesion, dry, scaly
dorsum of hand, arm, nose
-sun damage, fair skinned ind., transplant recipients

27

SCC risks

2nd most common
UV radiation, tanning, arsenic exposure, smoking, high fat/meat diet, immunesuppr (transplant >5 yrs, HIV, long term glucocorticoid use)

28

genetic risk factors for SCC

xeroderma pigmentosum, v. rare
epidermolysis bullosa
albinism
Fanconi's anemia

29

other SCC risk factors

Chronic lymphocytic leukemia (CLL)
meds:
Voriconazole(longterm anti fungal)
BRAF inhibitors (Vemurafenib and Dabrafenib) used to tx metastatic melanoma, but do not stop, cut out SCC

30

Actinic Keratosis

-develops into SCC
-chronic sunlight exposure-->excess keratin buildup
-

31

SCC dx

complete skin and regional exam
-lymph node exam
biopsy

32

SCC tx

surgical excision
Mohs
electrodesiccation and curettage
radiation therapy: for non surg candidates, if extensive perineural or large nerve involvement, LN involvement

33

SCC follow up

every 3 mos w/ LN exam for 1 year, then every 6 mos thereafter

34

malignant melanoma

UV radiation exposure
cutaneous
acral: palms, soles
mucosal
ocular/uveal

35

inc. risk for malignant melanoma

-Irish/European, fair
-more freckles
-Fam Hx

36

ABCDE of malig mel

Asymmetric
Borders-irregular
Color-variations
Diameter->pencil eraser
Evolution-take pic to monitor changes

37

staging of malig mel

>4 mm deep: systemic chemo (T4, metastatic)
-thickness, ulcerated or not
-regional LN

38

stage 1A-1B

wide excision

39

stage 1B (0.76-1mm)

wide excision +/- INF

40

stage III

LN dissection and INF

41

stage IV

systemic therapy (chemo)

42

wider margins do not have added benefit with tumor thickness

>4mm (grow deeper)

43

sentinel LN biopsy if..

>1mm depth
-less if high risk features: ulceration, elevated MR, regression signs, BT>=0.75 mm

44

complete LN dissection

radiation after

45

stereotactic radiosurgery

for brain metastases: hottest around lesions to spare rest of brain tissue

46

chemotherapy meds

Ipilimumab
Dabrafenib + trametinib
Pembrolizumab
Nivolumab

47

other chemo meds

Vemurafenib
Dabrafenib
Trametinib
Imatinib
Dacarbazine
Temozolomide
Alb-bound palitaxel
IL-2
Dacarbazine or temozolomide-based combo
Pacliltaxel
Pacliltaxel/carboplatin

48

BRAF inhibitors

Vemurafenib, dabrafenib
-MAP kinase pathway inhib. (inhib. *BRAF V600E*)
SE: edema, HA, rash **SCC of skin! arthralgia

49

MEK inhibitors

Trametinib
-rev. and sel. inhib. mitogen-act EC kinase (MEK) downstream from BRAF (combine with BRAF inhibs.)
SE: *cardiomyopathy, rash, anemia, hemorrahge, liver inflamm.

50

CTLA-4 inhibitors

Ipilimumab
blocks CTLA-4, allows for enhanced T-cell activation and prolif
SE: (hyperactivates Imm. sys) colitis, dermatitis, hepatitis, hypophysitis, thyroiditis

51

Anti-PD-1 Monoclonal Ab

Nivolumab
Pembrolizumab
inhib. PD-1 activity by binding PD-1 rec. to block ligands PD-L1/2, releases PD-1 pathway med inhib of IR (anti tumor response)
SE: e-lyte abnormalities, cytopenia, rash

52

Ipilimumab

enables prolif of T cells thru CD28 or CTLA-4-->inc. signalling-->T-cell activation
-works in 10-15% pts
-takes 1-4 mos (diff. to monitor)
-may look worse on CAT scan after tx before gets better

53

50% BRAF mutations in

skin lesions, not as common in others

54

BRAF inhibitors (vemurafenib)

shuts down cascade of DNA replication

55

combine BRAF and MEK

to inc. survival

56

largest challenge w/ BRAF/MEK combo w/ PD1 inhibitors

poor side effects w/ PD1 inhibs.

57

PD1 inhibitors

releases shut down of CTL, allows immune response

58

scaly

psoriasis, xerosis, pityriasis

59

vesicular

shingles, herpes simplex

60

weepy/crusted

impetigo

61

pustular

acne, folliculitis

62

figurate

erythema mulitform

63

bullous

bullous pemphigoid, pemphigus vulgaris

64

nodular

erythema nodosum

65

morbilliform

drug rash, viral exanthema

66

erosive (umbilicated)

vesicular dermatitis

67

ulcerative

decubiti, herpes simplex, cancers

68

biliform rash

chest and neck (drug reaction)

69

honeycombing rash

face and chin-impetigo rash

70

impetigo

chin, crusty, weepy lesion

71

melanocytic nevi (normal moles)

72

atypical/dysplastic nevi

>6mm, irreg borders, irreg. pigment
-5-10% adults

73

separated keratosis

"stuck on" lesion, waxy
not worrisome
could transition into something worse

74

malig mel

flat or raised, suspected in any lesion w/ appear. change, varying colors
ABCDE

75

most common malig mel etiology

"superficial spreading" comes from dysplastic nevi
-acral lentinginous in all skin types (palms/soles)

76

malig. mel tx

excision and re-excision (Mohs)
margins depend on size/thickness
LN biopsy for high risk/thick lesions (sys. chemo)

77

atopic dermatitis

pruritis, exudative eruptions on face, neck, wrists, hands, skin folds
-hx of allergies, rhinitis
-tendency to recur
-typ. childhood (

78

atopic dermatitis

wet: dry it
dry: moisten
acute weeping: oatmeal astringent soaks, high pot. corticosteroids

79

tx for subacute or scaly lesions

(dry, red and pruritic)
mid-high pot. steroids, wean to emollients

80

tx for chronic dry lichenified lesions

nightly occlusion to hold in moisture (silvadene, vaseline)
high pot corticosteroids
aquaphor

81

atopic dermatitis maintenance tx

constant appl. of moisturizers, sparing used of corticosteroids

82

lichen simplex chronicus

itching, scratching, dry, leathery lesions
-trauma, exposure
*exaggerated skin creases
-well circum. scaly plaque
neck, wrists, forearms, lower legs, scrotum, vulva (vulva: biopsy)
-often appear psoriatic
-risk of invasive superinfection

83

lichen simplex chronicus tx

high dose topical corticosteroid +/- occlusion
antihistamins to prevent itching
(dis. may remit to other sites)

84

psoriasis

-AI, may have no sympts or itching
-scalp, elbows, knees, palms, soles, nails
-"silver scales" on erythematous plaque, occurs in creases
limited (10% BSA)-->moderate-->generalized (>30%) disease
continuum w/ rheumatoid arthritis

85

psoriasis tx

numerous sm. plaques (mild-mod disease): phototherapy, home UV lights
lg plaques: v. high pot steroids 2-3 wks BID then pulse
-vit. D analogs
-scalp: tar shampoo, salicylic acid gel
*never use SYSTEMIC (ORAL) corticosteroids (lead to severe rebound)

86

severe psoriasis tx

UVB tx 3x week
psoralen plus UVA (PUVA)
methotrexate
acitretin (pustular)
cyclosporin
anti-TNF agents, DMARDs

87

pityriasis rosea

oval scaly eruption on trunk
Herald path-->then eruptions
"christmas tree" distribution
occasional pruritus
resolves in 6 wks

88

seborrheic dermatitis and dandruff

dry scales w/ underly. erythema
-face, scalp, eyelids, ears, presternal inter scapular areas
acute or chronic
-pruritis is inconsistent mild-->severe

89

tx for seborrhea

scalp: shampoos w. zinc pyrithione, selenium, ketoconazole
tar shampoo
facial: mild c.steroids, ketoconazole cream 2x daily
intertrig. : low pot. c.steroids 5-7 days
eyelids: baby shampoo

90

fungal inf. of skin

tinea corporis (body)
tinea circinata (body)
tinea cruris (groin)
tinea manuum (foot)
tinea pedis (foot)
tinea versicolor (pityriasis versicolor) (cent. up. trunk)
-dx with 10% KOH prep, Cx, skin biopsy

91

tinea corporis/circinata

ring-shaped, exposed areas, +/- itching (often) can be severe in HIV pts
tx: topical antifungals (PO griseofulvin if severe)

92

tinea cruris ("jock itch")

-groin, sparing scrotum
peri. spread, sharply demarcated, central clearing
-assoc. pedis, onychomycosis
-reoccurs after tx
tx: antifungal powder, top. antifung. cream, oral griseofulvin/itraconazole if severe

93

lyme disease should not..

ITCH
-think fungal- tinea
ringworm

94

tinea manuum/pedis

scaling, itching btw toes along foot
-can prog. to moist macerated areas
-common in LE cellulitis pts
tx: macerated: aluminum subacetate soaks, br.spec antifungal creams
dry/scaly: OTC topical anti fungal

95

tinea versicolor (pityriasis versicolor)

velvety pink, tan macules (also white, tanning resist.)
fine scales
upp trunk/chest
yeast on microscopic exam (Malassezia-"spaghetti and meatballs")
tx: selenium sulfide lotion, Ketoconazole PO if severe

96

cutaneous lupus

chronic cut. lupus and discoid lupus
-scaling, atrophy, dyspigmentation, telangiectasia, photosensitive
-head, scalp, face, ears
tx: avoid sun, photosens. drugs, radiation therapy
-high pot. steroid creams

97

cutaneous T-cell lymphoma (Mycosis fungoides)

loc/gen erythematous patches/plaques >5 cm
-trunk
severe pruritis
tx: diff. PUVA, retinoids, other skin. dir tx

98

vesicular dermatoses

HSV 1 & 2
herpes zoster (shingles)
vesiculobullous eczema
porphyria cutanea tarda

99

HSV

recurrent sm. vesicles on an erythematous base (orolabial/genital distribution)
-post-stress, trauma, sun
-viral cx, abx test +
-1st episodes may present as gingivostomatitis or sev. genital outbreak w/ flu sumps and lymphadenopathy
(ppl test + for HSV)
-shingles should not typ. recur

100

herpes zoster

pain along dermatome distribution-->grouped vesicular lesions
(occ. fall outside if >20 lesions), typ. not dissem unless pt. is IC
-face, trunk
varicella zoster virus
tx: zostavax >50yo

101

Hutchinson's sign

shingles on nose
must consider optic nerve is involved

102

Ramsay-Hunt syndrome

shingles in ear, must consider ear drum is involved, Bell's palsy
can lead to systemic infection

103

Herpetic whitlow

lesion on finger/thumb (HC workers, sexual activity(autoinoculatoin) finger/thumb suckers)
HSV 1* or 2

104

herpes/shingles tx

oral antiviral: acyclovier, valacyclovir w/in 72 hours
-abx if secondary cellulitis
tx only shortens duration by 1-2 days BUT **dec. risk of post-herpetic neuralgia!!* (esp. elderly)

105

vesiculobullous eczema

"tapioca" vesicles on palms, soles, sides of fingers
multiloculated large blisters
recurs over lifetime
tx: topical & systemic steroids, chronic prob--> steroids abort the flares

106

porphyria cutanea tarda

non-inf./inflamm. blisters on sun-exp. sites
-assoc. liver disease
dx: PE, abn. LFTs, elev. ur porphyrins
tx: phlebotomy, eliminate etOH,

107

impetigo

superficial blisters w. some opaque/purulent material
-rupture easily, weep-->crusted superfic. erosions
dx: Gs often + for GPC in clusters/pairs (staph or strep, MRSA)
tx: top. bacitracin or mupirocin(bactroban) chlorhexidine/bleach baths, occasional oral coverage

108

contact dermatitis poison ivy

erythema, intense pruritus-->dev. of blisters: weeping, crusting
autoinoculation, spread by scratching, look for exposure hx
tx: was oil w/ dish soap
severe: mid-pot steroid creams
m. severe: tapering prednisone

109

acne vulgaris

onset of puberty
op/closed comedones (white/black heads)
most common
severe: papular, pustular, cysts, nodules, scarring
-face, upper trunk

110

tx of acne vulgarism: comedones

face wash, topical retinoids, benzoly peroxide, top. abx

111

tx of acne: mild papular/cystic

top. clindamycin/eryth w/ benz peroxide, poss. tretinoin cream

112

tx of acne: mod pap/cystic

oral tetra, doxy, minocycline, OCTs, topical

113

tx of sev. acne

isotrentinoin, intralesional injection, laser dermabrasion, oral and topical agents

114

rosacea

chronic, neurovasc. component, telangiectasias, flush
glandular as well
exacerb. by hot foods, etOH, emotions, sun
tx: avoid triggers, also tetra/doxy/mino

115

folliculitis

hairy areas typ.
itching, burning, pustular formation
staph, strep, MRSA
"hot tub": diffuse pruitis, rash in exposed areas, pseudomonas, clears spontaneous (no abx)

116

candida tx

topical: miconazol, nystatin powders
clotrimazole, ketoconazole creams/lotions
oral: flucanazole, voriconazole
nystatin swish and swallow

117

MRSA

v. indurated w/ min. purulence
may req. drainage, some spont. drain
tx: trimethoprim/sulfa, doxy, clindamycin
-->rarely causes sys. inf.

118

steven johnson syndrome

dry, cracked bleeding lips,
red rash, stinging sensation, skin peeling
**stop offending medication!!**

119

erythema multiforme

sudden onset of syst. erythematous skin rxn
target lesions having clear centers
mild, self-lim post-viral inf. or med rxn OR
major, life threatening: SJS, TEN

120

erythema multiform tx:

stop offending agent!
TEN: burn unit for massive skin exfoliation
steroids, IVIG

121

erythema migrans

bullseye, *with Lyme disease*

122

bullous pemphigoid

tense blisters in flexural areas, subepiderm. blisters, gen >60 yo

123

pemphigus vulgaris

flaccid blisters, crusts, erosions, acantholysis
any age

124

BCC

pearly papule >6mm, non healing, sunexp. area, "rat bite" lesion, bleeding
tx: Mohs, removal

125

SCC

nonhealing ulcer, long term sun exposure, often begins as actinic keratosis
tx: Mohs, excisional, top. retinoid acid

126

Kaposi's sarcoma

brown/black flecks, classically on chest
*HIV+, males* (anal sex)
can be in bowels-->bleed to death

127

Pediculosis

(lice!)
pruritus w/ excoriations, nits(eggs) on hair shafts, lice on skin, clothing
direct contact needed (can't jump)
tx: permethrin cream rinse (Nix), high temp laundering

128

erythema nodosum

painful, erythematous nodules on ant. aspects of shins, below knees
mostly women (10:1)
-recent viral proc., drug rxn, underly. IBD
-lasts about 6 wks, can reflare

129

erythema nodosum tx

NSAIDS, time

130

cellulitis

may come in w. flu-like symptoms: fever, chills, body aches, nausea
typically GAS (redness, blisters) (staph causes pus, boils, abscesses)

131

cellulitis tx

cephalosporins: cefalexin, (4x day, low compliance), cephadroxil, cefuroxine
clindamycin
not her favs: bactim, amoxicillin
vs IV: ancef (ceph) or vancomycin

132

cellulitis vs decubitis ulcer

the latter needs wound care, typ. IV abx, doppler to ensure perfusion

133

scabies

*extremely itchy*
ask about bugs
extremely contagious
chest, classically on fingers
topical permetherin
oral ivermectin

134

what can cause low grade fever/fatigue for weeks

CMV
Coxsackie
Parvovirus
Mono
(*viruses*!)
or smoldering diverticulitis, abscess

135

non infectious causes of low grade fever/fatigh for weeks

malignance (>50)
joint pains: rheumatoid arthritis
AI diseases
LPE