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Flashcards in Skin Disorders Deck (226):
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Skin's 4 main functions

protection, sensation, thermoregulation, metabolic function

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Skin and subcutaneous tissue provides a major source for vitamin ___

Vitamin D

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Primary Lesion - Macule

Flat lesions observed due to change in color.

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Primary Lesion - Patch

Flat lesions > 1 centimeter

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Primary Lesion - Papule

Lesions raised above the skin; increase in consistency.;

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Primary Lesion - Plaque

Raised lesion > 1 cm

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Primary Lesion - Nodule

Raised dome shaped lesion > 1.0 cm

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Primary Lesion - Tumor

Large lesion, greater than nodule

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Primary Lesion - Wheal

Increased fluid in tissue (edema/swollen); blanchable

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Primary Lesion - Vesicle

Sharply marginated elevated lesion with fluid-filled lesion,

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Primary Lesion - Bullae

Sharply marginated elevated lesion with fluid-filled lesion, > 1 cm

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Primary Lesion - Pustule

Focal epidermal accumulation of inflammatory cells, serum, sometimes microorganisms; discolored (i.e., yellow/green) entrapped fluid pocket within epidermis

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Freckles, drug rash, birthmark, vitiligo, malignant melanomas, these are examples of

Macules

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Neurofibroma, breast carcinoma, keratoacanthoma are examples of

Tumors

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Hives, dermatographism are examples of

Wheals

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Bullous pemphigoid; Pemphigus are examples of

Bullae

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Pustular psoriasis, impetigo are examples of

Pustules

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Secondary Lesion - Crust

Oozing from vesicles or drying up of vesicles

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Secondary Lesion - Scale

Excess of surface keratin material

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Secondary Lesion - Fissure

Linear Break in epidermis

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Secondary Lesion - Erosion

Shallow scooped out break in epidermis

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Secondary Lesion - Ulcer

Complete removal of epidermis with discrete margins, and may extend into dermis and /or fat

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Secondary Lesion - Scar

Repair of skin with fibrous tissue

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Secondary Lesion - Atrophy

Loss of tissue with little or no replacement

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Examples of Scars

Acne ice-pick scar, Hypertrophy, Keloid

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Examples of Scales

Psoriasis, ichthyoses, desquamation

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Examples of Atrophy

Striae

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Special Lesions - Alopecia

Loss of hair

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Special Lesions - Comedo

Involves a hair follicle and the duct or opening of the sebaceous gland

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Special Lesions - Sebaceous cyst

Large encapsulated cavity filled with sebaceous material

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Special Lesions - Folliculitis

Superficial pustules or inflammation in hair follicles only

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Special Lesions - Furuncle

Deeper larger infection of hair follicle

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Special Lesions - Abscess

Cavity filled with pus

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Special Lesions - Telangiectasia

Dilatation of small blood vessels that are permanently enlarged

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Special Lesions - Ecchymoses

Large area of bleeding into skin

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Special Lesions - Lichenification

Thickening of the skin

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Epidermis consists of a 4-layered keratinized squamous epithelium, the layers are:

• Stratum corneum • Stratum granulosum • Stratum spinulosa • Basal cell layer

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Dermis

fibroelastic vascularized tissue

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Subcutaneous tissue (hypodermis)

contains various amounts of adipose tissue dependent on location, gender, etc.

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Epidermal appendages are developed from

developed embryologically from the downward growth of epidermal epithelium

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Epidermal appendages include

• Hair follicles • Sweat glands • Sebaceous glands • Nails

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Atypical lymphocytic epidermotropism on biopsy indicates

Mycosis Fungoides (MF) or Cutaneous T cell Lymphoma (CTCL)

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Red, scaly lesions that worsen in dry, cold climate

seborrheic dermatitis

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Child w/ food allergies and asthma + rash would likely indicate

atopic dermatitis

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Oil spots and nail pitting are associated with

Psoriasis

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+ Auspitz =

Psoriasis

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Histology shows munro micro abscesses

Psoriasis

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Histology shows Pautrier’s microabscess

Mycosis Fungoides (MF) or Cutaneous T cell Lymphoma (CTCL)

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pruritic psoriaform rash on buttocks, non-responsive to steroids

Mycosis Fungoides (MF) or Cutaneous T cell Lymphoma (CTCL)

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Pruritic lesions + gluten sensitivity

Dermatitis Herpetiformis

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IF shows IgA deposition w/in dermal papillae

Dermatitis Herpetiformis

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Child nose/mouth vesicular lesions + previous Strep or Staph infection

Bullous impetigo

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"Honey-crusted" lesions

Bullous impetigo

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Oral ulcers and flaccid blisters that easily rupture

Pemphigus (Vulgaris Variant)

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IgG and C3 around each keratinocyte (fish net appearance)

Pemphigus (Vulgaris Variant)

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“Nikolsky Sign”

Pemphigus (Vulgaris Variant)

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Histology: bullae just above the basal cell layer (suprabasal).

Pemphigus (Vulgaris Variant)

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Tense bullae on flexor aspects, primarily of legs

Bullous Pemphigoid

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Subepidermal bullae (clefting b/w D-E) associated with eosinophils

Bullous Pemphigoid

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IF shows Linear deposits of IgG along basement membrane

Bullous Pemphigoid

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IF shows a granular band of Ig and complement along the D-E junction

Chronic Discoid Lupus Erythematosus (CDLE)

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pruritic polygonal, purple papules on wrist

Lichen Planus

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Band like lymphocyte infiltrate at D-E junction with basal cell degeneration

Lichen Planus

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(scattered “Colloid or Civatte bodies”): wedge shaped thickening of granular cell layer

Lichen Planus

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“saw toothing”

Lichen Planus

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fibrotic thickening of fat septa, giant cells

Erythema nodosum

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Painful tender nodules on lower legs

Erythema nodosum

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Pearly papule on nose

Basal Cell Carcinoma (BCC)

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Most common skin malignancy

Basal Cell Carcinoma (BCC)

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Lymphoplasmacytic infiltrate at periphery

Medullary Carcinoma

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High grade features with low-grade behavior

Medullary Carcinoma

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Blue Dome Cysts

Pure Fibrocystic Change w/ no increased risk for breast cancer

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Mucin lakes with malignant cell islands

Colloid Carcinoma

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nests of uniform tumor cells suspended in mucin lakes

Colloid Carcinoma

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Seborrheic Keratosis Clinical Presentation

middle age, elderly - face & trunk "stuck-on" raised pigmented papule

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Seborrheic Keratosis Histological Presentation

horn cyst formation, sharply demarcated

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Dermatosis Papulosa Nigra

smaller Seborrheic Keratoses on face of black ppl

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Lesser-tralet sign

sudden onset of many papules due to paraneoplastic syndrome (Hormone excreting tumor)

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Seborrheic Keratosis is from

keratinocytes

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Ancanthosis Nigricans Clinical Presentation

Thick, hyperpigmented velvety skin in flexural areas ie. axilla, groin, neck, anogenital

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Ancanthosis Nigricans Histological Presentation

papillated hyperkeratosis, rete ridges

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Ancanthosis Nigricans typically seen in

Obese, Endocrine Disorders (diabetics)

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Fibroepithelial polyp Clinical Presentation

soft, flesh colored "skin tag"/acrochordon on neck, trunk, face, intertriginous/skin folds

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Fibroepithelial polyp Histological Presentation

slender, fibrovascular stalk

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Keratoacanthoma Clinical Presentation

flesh colored dome-like nodule w. central keratin-filled crater , on face, hand in sun-exposed Caucasians > 50

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Keratoacanthoma Histological Presentation

cup-shaped epithel prolif w. central keratin plug, may have atypical keratinocytes

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Keratoacanthoma possibly is due to

HPV

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Keratoacanthoma treatment

r/o SCC, self-limited

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Epithelial Inclusion Cyst/Epidermoid cyst Clinical Presentation

firm dermal or subcutaneous nodule with down-growth and cystic expansion of epidermis

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Epithelial Inclusion Cyst/Epidermoid cyst Histological Presentation

well circumscribed

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Milium

small Epithelial Inclusion Cyst

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Tricholemmal cyst

Hair follicular epithelium-derived on scalp

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Trichilemomma Clinical Presentation

flesh colored papules, on central face, perioral areas from hair follicle origin

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Cowden’s Disease

Trichilemomma may be internal marker for malignancy assoc w. breast CA and thyroid CA

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Cylindroma Clinical Presentation

single or multiple coalescing nodules on forehead & scalp sweat gland origin

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turban tumor

multiple coalescing cylindromas on forehead & scalp

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Cylindroma Histological Presentation

"jig-saw puzzle" islands of basaloid cells in dermis

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Syringoma Clinical Presentation

Multiple small tan papules Near lower eyelid; women - sweat gland origin

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Syringoma Histological Presentation

“Tadpole” shaped islands of basaloid

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Syringoma can mimic

Microcystic Adnexal Carcinoma

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Muir Torre Syndrome (HNPCC)

Sebaceous Adenoma: Microsatellite Instability - a variant of Lynch Syndrome!!!!

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Sebaceous Adenoma

May be associated with Muir Torre syndrome; microsatellite instability

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Actinic Keratosis Clinical Presentation

Premalignant, dysplastic lesion Typically

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Actinic Keratosis Histological Presentation

atypia in lower epidermis, basal cell hyperplasia & dyskeratosis, damaged collagen ->blue-grey elastic fibers

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Actinic Keratosis is seen commonly in

elderly, light-skinned, sun-exposed

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SCC Clinical Presentation

non-healing ulcerated nodule in sun-exposed ind, xeroderma pigmentosum, etc

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SCC may show what orally?

white thickened plaques on mucosa (leukoplakia)

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SCC Histological Presentation

In situ SCC has full thickness epidermal atypia; Invasive SCC breaks thru D-E junction into underlying dermis (more advanced)

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Bowen’s Disease

demarcated red scaling plaques = In situ SCC

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BCC Clinical Presentation

pearly papules, surrounded by telangectasias, due to sun exposure

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BCC Histological Presentation

basal cell prolix into dermis + "peripheral palisading" (basaloid islands; NOT cylindroma or syringoma)

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most common type of skin CA malignancy?

BCC

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Nevoid Basal Cell Syndrome/Gorlin syndrome

rare, AD, many BCCs throughout life

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BCC is associated w/ what gene

activated SHH - loss of PTCH + p53 gene function

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Lentigo Clinical Presentation

hyperpigmented macules 5-10mm on skin & MM, do not darken in sun, common from infancy

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Cutaneous Horns may be present in

Actinic Keratosis --> SCC

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Lower Lip skin nodule/ulcer think

SCC

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Upper Lip skin nodule/ulcer think

BCC

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Lentigo Histological Presentation

"lentiginous growth" or hyper pigmented, linear hyperplasia of melanocytes (elongated, thin rete ridges)

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Lentigo vs Freckle

Lentigo do not darken in sun, larger, darker, skin or mucous membrane

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Melanocytic Nevus - 6 types

Common, may present in childhood or adulthood: Junctional, Compound, Intradermal, Blue, Halo, Dysplastic

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Middle aged + pimple on nose that won't go away; you should think =

BCC

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Junctional Nevus Clinical Presentation

flat, smooth, uniformly pigmented (brown to black)

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Junctional Nevus Histological Presentation

symmetric nest of melanocytes at DE junction (young)

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Compound Nevus Clinical Presentation

raised, smooth border, uniform pigment

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Compound Nevus Histological Presentation

nests of melanocytes in BOTH D & DE junction (aging nevus proceeds from junction into D)

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Intradermal Nevus Clinical Presentation

raised, smooth border, uniform pigment (or flesh-colored)

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Intradermal Nevus Histological Presentation

nests of melanocytes in dermis entirely (not at DE Jct)

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Blue Nevus Clinical Presentation

small, blue-black nodules

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Blue Nevus Histological Presentation

heavily pigmented dendritic melanocytes

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Halo Nevus Clinical Presentation

white zone around mole

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Halo Nevus Clinical Presentation

lymphocytic infiltrates surrounding compound or intradermal melanocytes

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Dysplastic Nevus (BK or Clarks mole) Clinical Presentation

irregular borders/pigment, sun exposed or non-exposed

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Dysplastic Nevus Syndrome or Familial Melanoma Syndrome

Numerous dysplastic nevi (genetic)

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Dysplastic nevus presence increases risk for

Melanoma

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Dysplastic Nevus (BK or Clarks mole) Histological Presentation

Cytologic and architectural atypia → Shows features of pre-melanoma

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Dysplastic Nevus gene involvement

p161NK4A, BRAF, CDK4

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Which malignancy has the highest increase in incidence?

Malignant melanoma - 90% increase over 30yrs

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Most common malignancy in young adults?

Malignant melanoma

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Malignant melanoma risk factors:

FHx, red/blonde hair, freckling, 3+ blistering sunburns, 3+ outdoor jobs, presence of actinic keratosis, dysplastic nevi syndrome, tanning-UVA

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1-2 risk factors for Malignant melanoma increases your risk by

3.5X

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3+ risk factors for Malignant melanoma increases your risk by

20X

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ABCDE of Malignant Melanoma

Asymmetric shape, Border irregularity, Color - nonuniform, Diameter >5mm, Elevated

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Melanoma can be found on whack body parts

skin, oral, conjunctiva, orbit, nail bed, esophagus

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Melanoma prognosis is dependent on

Depth of invasion and clinical stage

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Types of Melanoma

Superficial spreading melanoma Nodular melanoma: (vertical growth) Lentigo maligna melanoma (Hutchinson’s freckle): early phase radial growth Acral lentiginous melanoma: adial growth

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Breslow Depth measures

Depth of invasion of melanoma below the stratum granulosum

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Melanoma Histological Presentation

atypical melanocytes w. nuclear hyperchromasia, mitosis, prominent nucleoli, individual necrosis, lack maturation amelanotic = melanin absent from cells

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Clarks Level I - Melanoma

(In situ) Intra-epidermal - 100% survival rate of 5 years

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Clarks Level II - Melanoma

Invades papillary dermis - 90% survival rate of 5 years

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Clarks Level III - Melanoma

Fills papillary dermis - 70% survival rate of 5 years

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Clarks Level IV - Melanoma

Invades reticular dermis - 40% survival rate of 5 years

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Clarks Level V - Melanoma

invades SubC fat - 25% survival rate of 5 years

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Clinical Stage of Melanoma

Lymph node involvement, distant metastases - 5 year survival

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Benign Fibrous Histiocytoma (Dermatofibroma) Clinical Presentation

Typically on legs of adults (trauma), tan-brown, firm papule "dimple in center” w/ lateral compression

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Benign Fibrous Histiocytoma (Dermatofibroma) Histological Presentation

non encapsulated prolif of spindle shaped fibroblasts

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Dermatofibrosarcoma protoberans DFSP Clinical Presentation

On trunk - firm, indurated solid nodules; may ulcerate

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Dermatofibrosarcoma protoberans DFSP Histological Presentation

slow growing fibrosarcoma, locally aggressive, rare metastasis; radially oriented (storiform pattern) fibroblasts, mitosis

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Dermatofibrosarcoma protoberans DFSP gene involvement

translocation of COLIAI and PDGFb

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Mastocytosis Clinical Presentation

pruritus, flushing, rinorrhea, dermal edema & erythema (wheal), dermatographism

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Mastocytosis Histological Presentation

high # mast cells, purple cytoplasmic granules

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Darier's Sign indicates

Mastocytosis or Urticaria Pigmentosum

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Urticaria Pigmentosum Clinical Presentation

Mastocytosis that is localized to the skin with round to oval red-brown papules and plaques

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Urticaria Pigmentosum Histological Presentation

high # mast cells, eosinophils, edema (metachromatic stain: giemsa, toludine)

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Mycosis Fungoides or Cutaneous T cell Lymphoma Clinical Presentation

> 40y/o, scaling patch (like psoriasis), indurated plaque, re-brown nodule, disseminated

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Mycosis Fungoides or Cutaneous T cell Lymphoma Histological Presentation

Pautrier’s microabscess, bandlike atypical lymphocyte infiltration in dermia, mycosis cells w/ cerebriform-like nuclei

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Patch stage of Mycosis Fungoides Histological Presentation

lymphocytic epidermatropism

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Tumor stage of Mycosis Fungoides Histological Presentation

Pautrier’s microabscess (cluster of infiltrative atypical CD4+ lymphocytes in epidermis), mycosis cells with cerebriform nuclei

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Sezary Syndrome

systemic mycois fungoides - white scaly hands/palms

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Urticaria Clinical Presentation

Hives, wheals: Type I Hypersensitive (IgE) response to an Ag + histamine (mast cells)

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Urticaria Histological Presentation

dermal edema, sparse dermal inflammation

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Eczema Clinical Presentation

Allergic Contact Dermatitis, Atopic Dermatitis, Seborrheic Dermatitis

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Eczema Histological Presentation

intraepidermal vesicles; dermal edema w. possible eosinophils/lymphocytes; w/ overlying parakeratosis

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Allergic Contact Dermatitis

Type IV HSN - poison ivy, jewelry, etc

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Atopic Dermatitis Clinical Presentation

Type I HSN; Infant/Child w/ +FHx of eczema, asthma, allergies w/ pruritic rash, erythema, excoriation, lichenfiation of skin (FLEXURAL areas, not nasolabial)

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Seborrheic Dermatitis Clinical Presentation

NASOLABIAL FOLDS, ears, eyebrows, scalp (oil distribution); red, scaly, itchy, dry flakes; ‘comes and goes’; SEASONAL

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Erythema Multiforme Clinical Presentation

bull’s eye target lesion; limited hypersensitivity to drugs (sulfamide, dilantin, barbituate, penicillin)

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Erythema Multiforme Complications

EM Major/SJS: mucous membrane involvement TEN: epithelial necrosis and sloughing

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Erythema Nodosum Clinical Presentation

15-30y/o lower legs/shins, red painful nodules

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Erythema Multiforme etiology

HSV, mycoplasma, idiopathic

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Erythema Multiforme drugs

sulfamide, dilantin, barbituate, penicillin

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Erythema Nodosum Histological Presentation

fibrosis thickening of fat septa, giant cells

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Erythema Nodosum etiology

beta hemolytic strep, herpes, fungal; BCP, sulfonamides; UC, sarcoidosis, Behcet’s syndrome

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Erythema Induratum clinical presentation

adolescents & menopausal women, back of legs

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Erythema Induratum Histological Presentation

granulomatous inflam of fat lobules & necrosis

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Psoriasis Clinical Presentation

salmon-colored papules + silver scales on EXTENSOR surfaces; Usually assoc w/ RA, AIDS, etc

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Koebner’s phenomenon

psoriasis lesions develop at site of trauma

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Auspitz sign

psoriasis removal of scale induces miniscule blood droplets from dilated vessels in dermal papillae

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Psoriasis nails

oil spot, pitting, onycholysis

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Psoriasis Histological Presentation

Munro Microabscesses: neutrophils w/in the epidermis, Periodic thinning of epidermis where it overlies dermal papillae + acanthosis + parakeratotic hyperkeratotsis w/ nuclei retained in corneum

192

Von Zumbush Syndrome

acute onset pustular psoriasis with fever & arthritis = life threatening

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Lichen Planus Clinical Presentation

polygonal purple papules, pruritic, may coalesce into plaques, highlighted by white lines (Wickham striae) found on wrist, shin, scalp alopecia, lumbar, buccal mucosa; drug-induced possibly

194

Lichen Planus Histological Presentation

Colloid/Civatte bodies (basal cell degeneration), saw-tooth rete + acanthosis

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Lupus Erythematosus Clinical Presentation

AID of CT; worsens in sun, macular butterfly rash with acute SLE

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Chronic Discoid LE Clinical Presentation

sharp margins, scaly, atrophic red plaques on sun-exposed areas (anti-DNA, RF) – basal cell degeneration (vacuolization): epidermal atrophy with keratin plugging

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Chronic Discoid LE Histological Presentation

Lymphocytic infiltrates along D-E junction,

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IF for Chronic Discoid LE

granular band of Ig along D-E Jct "Lupus Band"

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Acne Vulgaris Clinical Presentation

Adolescents, comedones (w- and b-heads), acne

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Rosacea Clinical Presentation

middle-ages women, flushing -> red/telangiesctasia -> pustules -> rhiniophyma

201

Bullous Impetigo Clinical Presentation

"honey crust" subcorneal blister, on face, hands, trunk due to Staph or Strep; typically in children/infants

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Bullous Impetigo Histological Presentation

subcorneal pustules with neutrophils & gram pos agents

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Pemphigus (Vulgaris variant) Clinical Presentation

flaccid vesicles & bullae (rupture easily; oral mucosa, scalp, trunk; AI disorder of desmosomes protein; 40-60y/o

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Nikolsky Sign

pressure on flaccid bullae --> lateral extension of blister = Pemphigus (Vulgaris variant)

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Pemphigus (Vulgaris variant) Histological Presentation

Tombstone row of basal cells - suprabasilar, thin bulllae covering

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IF for Pemphigus (Vulgaris variant)

Fish-net, IgG around every keratinocyte

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Bullous Pemphigoid Clinical Presentation

Tense bulla, do not rupture easy, skin, mucosa, lower legs; AI disorder of hemidesmosomes (lamina lucida); elderly

208

Bullous Pemphigoid Histological Presentation

subepidermal bulla, + eosinophils, few lymphocytes & neutrophils

209

IF for Bullous Pemphigoid

linear deposits IgG along BM

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Dermatitis Herpetiformis Clinical Presentation

Recurrent pruritic, tiny, grouped vesicles; Associated w/ Celiac; IgA to gluten Xreacts w/ fibrils of BM

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Dermatitis Herpetiformis Histological Presentation

tips of dermal papillae filled w. neutrophils (microabscesses)

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IF for Dermatitis Herpetiformis

granular IgA deposits at dermal papillae tips

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Verruca Clinical Presentation

benign epithelial hyperplasia due to HPV

214

Verruca Types

vulgaris (most common, anywhere esp hands); plana (flat); plantaris; palmaris; acuminatum (cauliflower-like venereal wart on genitalia/perianal/rectal)

215

Verruca Histological Presentation

papillated epidermis, koilocytotic (viral) changes = irregular nuclei surrounded by cytoplasmic halo

216

Molluscum Contagiosum Clinical Presentation

discrete, umbilicated, pearly-white papules of the neck, trunk, eyelids; POX virus

217

Molluscum Contagiosum Histological Presentation

cup-like epidermal hyperplasia, bright pink glassy cytoplasmic inclusions (molluscum bodies)

218

Tinea capitus

fungal - scalp w. painful boggy nodules, hair loss, detect with Wood’s lamp

219

Tinea barbae

fungal - beard area in men

220

Tinea cruris

fungal - inguinal

221

Tinea pedis

fungal - athlete foot (webs)

222

Onchomycosis

fungal - nails, discolored & thickened

223

Tinea Corporis

ring-worm - body surface, expanding, round, slightly red annular plaque

224

Scabies

sarcoptes scabei burrows in stratum corneum - interdigital skin, genital skin (homeless)

225

Lyme

spirochete infection (Borrelia burgdorferi) - annular lesions, erythema migrans

226

Lice

Pediculosis capititis and pediculosis pubis