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Flashcards in Skin Disorders Deck (284):
1

How many different skin phototypes are there and what is this classification called? (TN)

  • Fitzpatrick
    • Phototype I (lightest) to VI (darkest)

2

How should a skin lesions be described? (TN)

  • SCALDA
    • Size and surface area
    • Colour – hyperpigmented, hypopigmented, erythematous
    • Arrangement – solitary, linear, reticulated, grouped, herpetiform
    • Lesion morphology – macule, patch, papule, plaque, nodule, tumour, vesicle, bulla
    • Distribution – dermatomal, intertriginous, symmetrical/asymmetrical, follicular
    • Always check hair, nails, mucous membranes and intertriginous areas

3

What are 8 different morphologies of lesions and differentiate based on size. (TN)

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4

Differentiate between a cyst and pustule and an erosion and ulcer. (TN)

  • Cyst: epithelial-lined collection containing semi-solid or fluid material
  • Pustule: elevated lesion containing purulent fluid (white, grey, yellow, green)
  • Erosion: disruption of the skin involving the epidermis alone; heals without scarring
  • Ulcer: disruption of the skin that extends into the dermis or deeper; heals with scarring

5

What are 7 secondary morphological lesions? (TN)

  • Crust: dried fluid (serum, blood, or purulent exudate) originating from a lesion (e.g. impetigo)
  • Scale: excess keratin (e.g. seborrheic dermatitis)
  • Lichenification: thickening of the skin and accentuation of normal skin markings (e.g. chronic atopic dermatitis)
  • Fissure: linear slit-like cleavage of the skin
  • Excoriation: a scratch mark
  • Xerosis: pathologic dryness of skin (xeroderma), conjunctiva (xerophthalmia), or mucous membranes
  • Atrophy: histological decrease in size and number of cells or tissues, resulting in thinning or depression of the skin

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6

What is purpura and the three different types? (TN)

  • Purpura: extravasation of blood into dermis resulting in hemorrhagic lesions; non-blanchable, 3mm-1cm in size
    • Petechiae: small pinpoint purpura, <3mm in size
    • Ecchymoses: larger flat purpura, >1 cm in size, aka a “bruise”

7

What are 10 different patterns and distribution of skin lesions? (TN)

  • Acral: relating to the hands and feet (e.g. hand, foot and mouth disease)
  • Annular: ring-shaped
  • Follicular: involving hair follicles (e.g. folliculitis)
  • Guttate: lesions following a “drop-like” pattern (e.g. guttate psoriasis)
  • Morbilliform: a maculopapular rash resembling measles
  • Reticular: lesions following a net-like pattern (e.g. livedo reticularis)
  • Satellite: lesions scattered outside of primary lesions (e.g. candida diaper dermatitis)
  • Serpiginous: lesions following a snake-like pattern (e.g. cutaneous larva migrans)
  • Target/Targetoid: concentric ring lesions, like a dartboard (e.g. EM)

8

Provide possible diagnoses for each type of skin lesion: brown macule, discrete red papule, red scales, vesicle, bulla, pustule, oral ulcer and skin ulcer. (TN)

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9

What should be considered in the differential diagnosis for eczema?

  • Atopic dermatitis (Eczema)
  • Contact dermatitis
  • Seborrheic dermatitis
  • Impetigo
  • Psoriasis
  • Candidiasis

10

What is the atopic triad? (DFCM)

  • Asthma
  • Allergic rhinitis
  • Atopic dermatitis

11

How does atopic dermatitis look like on the skin? (DFCM)

  • Erythematous papules, patches and plaques with poorly defined borders
  • Dry skin and pruritus – leads to Itch Cycle – can lead to lichenification and inflammation

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12

What should be considered in patients with atopic dermatitis as a potential complication? (DFCM)

  • Secondary Impetigo

13

Where do atopic dermatitis typically affect infants and children? (DFCM)

  • Infants: cheeks, scalp, extensor surfaces
    • Spares diaper area
  • Children: face, neck, flexural surfaces
    • Increased lichenification

14

In patients with suspected atopic dermatitis that have crusted or vesicular lesions, what test could be performed? (DFCM)

  • Viral cultures to rule out HSV infection

15

What are 4 important points to educate to patients and parents about the management of atopic dermatitis?

  • Emollients – Cetaphil or Vaseline
    • Ceramide containing – CeraVe or Restoraderm
    • Shower with warm (not hot) water, use emulsifier oil or Oatmeal in baths and use emollient after
  • Keep house cool and humidified
  • Clothing
    • 100% cotton
    • Mild detergents – i.e. Ivory Snow
    • Rinse laundry twice if possible
    • No fabric softener or bleach
  • Children
    • Don’t play in grass or leaves
    • Apply moisturizer to face before feeding

16

What is first-line treatment for atopic dermatitis?

  • Topical steroids

17

How should the dose of topical steroids for atopic dermatitis be determined?

  • Tailor potency to disease and degree of lichenification
    • BID to QID for low and mid potency
    • OD to BID for high and ultra high potency (max 2-4 weeks)
  • Mild potency: face, groin and any joints
    • Hydrocortisone (Hyderm or Emo-Cort) 1% or 2.5%
  • Moderate potency for <2 weeks is okay
    • Betamethasone valerate (Betaderm) 0.05% or 0.1%
  • High potency – consult with Derm
    • Betamethasone dipropionate (Diprosone) 0.05%
  • Ultra-high potency
    • Clobetasol propionate (Dermovate) 0.05%
  • Ointment > Cream > Lotion in terms of potency
    • Avoid ointment for open lesions and intertriginous folds

18

What are 5 potential adverse effects of topical steroids for atopic dermatitis? (TN)

  • Atrophy
  • Striae
  • Telangectasia
  • Corticosteroid acne
  • Tachyphylaxis
  • ***No adrenal suppression or growth changes until regular use of high-potency steroids

19

What is second-line therapy for atopic dermatitis?

  • Topical Calcineurin Inhibitors
    • Pimecrolimus 1% (Elidel)
    • Tacrolimus 0.03%, 0.1% (Protopic)

20

How would topical calcineurin inhibitors be prescribed for atopic dermatitis?

  • Used for short-term (BID therapy) or long-term intermittent therapy (2x/week) for Mod-Severe
  • Pimecrolimus currently not approved for maintenance therapy
  • For use in patient >2 years of age

21

What is the benefit of topical calcineurin inhibitors over topical steroids and what are the potential risks?

  • No skin atrophy – may be better for face, neck and skin folds
  • No tachyphylaxis
  • Black-box warning: ?link to lymphoma or immunosuppression
  • Side effects: transient skin irritation or burning, pruritus

22

What can be used to treat atopic dermatitis refractory to topical treatments or with widespread disease?

  • Phototherapy

23

What would be a Mild Approach and Moderate-Severe Approach long-term for atopic dermatitis?

  • Mild
    • Steroids are first-line for flares once daily
    • Return to emollient-only treatment after flares
  • Moderate-Severe
    • 2x/week steroids with emollient use for maintenance
      • Get control with higher potency, then taper strength
    • Or Calcineurin Inhibitors BID
    • Consider phototherapy

24

What is seborrheic dermatitis called in infants? (TN)

  • Cradle Cap

25

What is the uninflamed form of seborrheic dermatitis called? (TN)

  • Pityriasis capitis (Dandruff)

26

How does seborrheic dermatitis typically appear? (TN)

  • Greasy, erythematous, yellow, scaling, minimally elevated papules and plaques in areas rich in sebaceous glands, can look moist and superficially eroded in flexural regions

27

What is the suspected pathophysiology of seborrheic dermatitis? (TN)

  • Malassezia spp. (YEAST)

28

What can be used to treat seborrheic dermatitis on the face? (TN)

  • Ketoconazole (Nizoral) cream daily or BID + mild steroid cream daily or BID

29

What can be used to treat seborrheic dermatitis on the scalp? (TN)

  • Salicylic acid in olive oil or Derma-Smoothe FS lotion (peanut oil, mineal oil, fluocinolone acetonide 0.01%) to remove dense scales
  • 2% ketoconazole shampoo (Nizoral)
    • Shampoos used twice weekly for at least 1 month
  • Ciclopirox (Stieprox) shampoo
    • Shampoos used twice weekly for at least 1 month
  • Selenium sulfide (Selsun Blue) or Zinc pyrithione (Head and Shoulders) shampoo
    • Shampoos used twice weekly for at least 1 month
  • Steroid lotion (betamethasone valerate 0.1% lotion BID)

30

What are the two mechanisms of contact dermatitis? (TN)

  • Irritant
  • Allergic

31

What are the top ten allergens identified in contact dermatitis? (TN)

  • Nickel sulfate – jewelry, belt buckles
  • Neomycin sulfate – topical antibiotic in Polysporin
  • Balsam of Peru – fragrance material
  • Fragrance mix – fragrance components for allergen testing in cosmetics
  • Thimerosal – preservative used in vaccines, contact lens solution, cosmetics
  • Sodium gold – jewelry, dentistry, electronics
  • Formaldehyde – colourless gas
  • Quaternium-15 – component in shampoos, moisturizers, conditioners, soaps
  • Cobalt chloride – cosmetics, jewelry, buttons, tools
  • Bacitracin – topical antibiotic in Polysporin

32

How does irritant and allergic contact dermatitis present clinically?

  • Irritant (Right)
    • Usually the hands (palmar surface)
    • Burning and pruritus
    • Erythema, dry and fissured skin
    • Less distinct borders
  • Allergic (Left)
    • Exposed skin areas, often the hands (dorsal surface)
    • Pruritus is the dominant symptoms
    • Erythema, vesicles and bullae
    • Distinct angles, lines and borders

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33

What is the evidence for steroid use for contact dermatitis?

  • Irritant – No evidence
  • Allergic – Good evidence

34

What should management be for contact dermatitis?

  • Irritant
    • Avoidance of irritants
    • Wet compresses with Burow’s solution
    • Trial cool compresses, calamine lotion and colloidal oatmeal baths
    • Topical/oral steroids
  • Allergic
    • Consider patch testing if persistent
    • Avoid allergen and its cross-reactants
    • Wet compresses soaked in Burow’s solution (drying agent)
    • Steroid cream (e.g. HC 1%, betamethasone valerate 0.05%, betamethasone valerate 0.1% cream; BID)
    • Systemic steroids prn (prednisone 1 mg/kg, taper over 2 week)
    • Antihistamines not effective, sedation probably helps the most

35

What is the prevalence of psoriasis in Canada? (DFCM)

  • 1.7%

36

At what ages does psoriasis incidence peak? (DFCM)

  • 20-30 and 50-60

37

What type of disease is psoriasis classified as? (PBSG)

  • Autoimmune with a genetic predisposition

38

How does psoriasis typically appear on the body? (DFCM)

  • Erythematous papules coalescing into plaques with silver-white scales, and well-defined borders

39

What areas of the body are classically affected by psoriasis? (DFCM)

  • Elbows
  • Knees
  • Sacral-gluteal region
  • Scalp
  • Lower back
  • Palms and Soles

40

What are 7 possible triggers of psoriasis? (DFCM/PBSG)

  • Physical trauma (e.g. vaccinations, tattoos, sunburn)
  • Stress
  • Infections (e.g. HIV)
  • Medications (e.g. systemic glucocorticoids, oral lithium, interferon, beta-blockers)
  • Alcohol
  • Cigarette smoking
  • Cold weather with low humidity

41

What is important to determine on clinical history in a patient presenting with psoriasis?

  • Family history (1/3 of patients)
  • No or mild pruritus, sometimes painful
  • Localization of lesions: scalp, elbows, knees, and lower back
  • Arthritis

42

What areas should be examined specifically in patients with psoriasis as they are often missed? (PBSG)

  • Scalp
  • Ears
  • Nails
  • Natal cleft
  • Genitalia

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43

How does the majority of psoriasis appear? (PBSG)

  • 80-90% is Plaque Psoriasis
    • Sharply demarcate erythematous papules and plaques with a silver scale
    • Bathing can remove the scale
    • Often symmetrical

44

What is inverse psoriasis and what are 2 diagnoses to also consider in the differential? (PBSG)

  • Inverse psoriasis: plaque psoriasis with minimal scaling in the intertriginous areas (axillae, groin, natal cleft, under breasts)
  • Intertrigo: moist, erythematous lesions in intertriginous areas
  • Cutaneous T-cell lymphoma: erythematous patches/plaques in intertriginous areas, diagnosis confirmed with skin biopsy

45

What is guttate psoriasis, in what patients is it more common, what areas of the body does it affect, and what is a common precipitant? (PBSG)

  • Guttate Psoriasis: small papules of short duration (weeks to months)
    • Usually in those <30
    • Evidence on trunk, proximal limbs or face (does NOT affect palms/soles)
    • Commonly precipitated by URTI (streptococcal)

46

What are 2 diagnoses to also consider for guttate psoriasis? (PBSG)

  • Secondary syphilis
  • Pityriasis rosea: 1-2 weeks after vague viral episode, a single patch appears on trunk (Herald patch) and similar smaller lesions along skin cleavage lines (associated with human herpes virus type 6)

47

What are 2 signs on history associated with psoriasis? (DFCM)

  • Koebner phenomenon: new psoriatic lesions appearing at site of injury or trauma
  • Auspitz’s sign: bleeding after removal of psoriatic scales

48

What % of psoriasis patients have scalp involvement? (DFCM)

  • 86% - pruritus and scaling

49

What % of psoriasis patients have nail involvement and what are they? (DFCM)

  • 25% - pitting, leukonychia, red spots in lunula, nail plate crumbling, subungual hyperkeratosis, onycholysis, splinter hemorrhage, oil spot

50

What should be considered in the differential diagnosis for psoriasis?

  • Seborrheic dermatitis
  • Lichen simplex chronicus
  • Atopic dermatitis
  • Tinea corporis
  • Secondary Syphilis
  • Mycosis fungoides
    • Often are sharply demarcated and red, but limited scale and can itch

51

What potential comorbidities of psoriasis need to be investigated for?

  • Psoriatic arthritis
  • Depression
  • IBD (Crohn’s)
  • Lymphoma
  • Metabolic syndrome
  • CAD

52

What % of patients with psoriasis are affected by psoriatic arthritis? (DFCM)

  • 30%

53

How is psoriasis severity defined? (PBSG)

  • Extent of body surface area (BSA) involvement
    • Mild: <5%
    • Moderate: 5 to <10%
    • Severe: ≥10%
      • Involvement of hands, feet, facial or genital regions
  • Estimated using the palm (subject’s flat hand and thumb together, includes fingers) which ~1% of the total BSA

54

What topical treatment should all patients with psoriasis do?

  • Emollients (moisturizers) daily applied to entire body after shower/bath
    • Helps to minimize skin irritation and decrease likelihood of new lesions at the sites of minor trauma

55

What are 4 different types topical therapies for psoriasis?

  • Steroids
  • Vitamin D Analogues
  • Calcineurin Inhibitors
  • Retinoids

56

What are 6 different forms of vehicles for topical therapies for psoriasis? (PBSG)

  • Ointments
  • Creams
  • Solutions
  • Oils
  • Lotions
  • Foams

57

What is an advantage of using foam formulations as a topical therapy for psoriasis? (PBSG)

  • Quick drying
  • Ease of application
  • Lack of fragrance

58

How much topical agent is typical required to cover the whole body? In a patient with a 10% BSA involvement, how much would be required? (PBSG)

  • 30 g required to cover the whole body
  • 10% BSA = 3 g BID or 6 g daily
    • i.e. 60 g tube of ointment should last the patient 10 days

59

What are the different topical steroid doses that can be used for psoriasis?

  • Moderate: Betamethasone valerate (Betaderm): 0.05% or 0.1%
    • Only for the most mild cases or as foam for the scalp
    • Higher potency has longer disease free intervals
  • High: Betamethasone dipropionate (Diprosone): 0.05%
    • Comes in lotion for use on scalp
  • Ultra-High: Clobetasol propionate (Dermovate): 0.05%

60

For which areas of the body are low potency corticosteroids recommended to be used? (PBSG)

  • Thin-skinned areas: face, body folds, genitals

61

How frequently can topical steroids be applied per day for psoriasis? (PBSG)

  • Daily to TID (depending on type)

62

What are examples of mild, moderate and high potency topical steroids for scalp psoriasis? (PBSG)

  • Mild: Hydrocortisone 2.5% BID-TID
  • Moderate: Betamethasone valerate 0.1% lotion BID-TID
  • High: Betamethasone dipropionate 0.05% OD-BID
  • Ultra-High: Clobetasol propionate 0.05% shampoo OD, spray BID

63

What are known adverse effects associated with topical steroids? (PBSG)

  • Burning
  • Irritation
  • Pruritus
  • Dryness
  • Atrophy
  • Contact dermatitis
  • Rosacea
  • Striae
  • Purpura
  • HPA axis suppression

64

What topical treatment for psoriasis is considered “steroid sparing”? (DFCM)

  • Topical Vitamin D3 analogues

65

What other topical treatment can be used on its own or with steroids for psoriasis?

  • Vitamin D Analogues – better effect when combined with steroids
  • Dovonex (Calcipotriene) and Vectical (Calctriol)
    • Dovobet – Betamethasone dipropionate + Calcipotriol
      • Comes in ointment or lotion
      • Scalp gel can be applied once daily at bedtime, washout in morning
    • Slower onset of action, but longer disease-free intervals

66

What are known adverse effects associated with topical vitamin D analogues? (PBSG)

  • Burning
  • Pruritus
  • Edema
  • Peeling
  • Dryness
  • Erythema – mitigated with ongoing use

67

What is the maximum amount of topical Vitamin D analogues that should be used? (DFCM)

  • <40% BSAS or <100 g/week

68

In what patients should there be caution in the use of Vitamin D analogues for psoriasis?

  • Renal failure – can cause Hypercalcemia and PTH suppression

69

What are 2 examples of topical calcineurin inhibitors for psoriasis and their indications?

  • Pimecrolimus (Elidel) or Tacrolimus (Protopic)
    • For use in patients >2 years of age
    • Less effective for plaque psoriasis
    • First-line for facial or intertriginous psoriasis
    • Important as steroid sparing agents if need to use continual therapy

70

What is an example of a topical retinoid that can be used for psoriasis and its indications and side effects?

  • Tazarotene (Tazorac) – 0.05% or 0.1%
    • Side effects (often peri-lesion) – itch and burning
      • Use every-other-day or with steroid/moisturizer to decrease SE
    • As good as steroids, but longer disease free interval

71

Which topical therapy for psoriasis has the most ADEs? (DFCM)

  • Topical retinoids

72

What is a good topical therapy for scalp psoriasis? (DFCM)

  • Mid to high potency topical corticosteroids (e.g. Betamethasone dipropionate) and calcipotriol
  • Available shampoo formulations: clobetasol propionate solution or shampoo

73

Does scalp psoriasis cause hair loss?

  • No

74

What is a good topical therapy for psoriasis on the palms and soles?

  • Clobetasol with occlusive dressing

75

When should systemic treatment be considered for psoriasis?

  • >5% of body surface area (BSA) involved
  • Genitals, hands, feet or face involved

76

What are options for systemic treatment in psoriasis?

  • Phototherapy + Systemic (Methotrexate, Biologics)

77

What are 2 systemic immunosuppressives that can be used for psoriasis? (PBSG)

  • Methotrexate
  • Cyclosporine

78

What are 3 severe toxicities that are associated with methotrexate use? (PBSG)

  • Liver
  • Renal
  • Bone marrow

79

What is prescribed with methotrexate to protect against adverse reactions such as stomatitis? (PBSG)

  • Folic acid

80

What are 4 biologic agents that can be used for psoriasis? (PBSG)

  • Adalimumab (Humira)
  • Etanercept (Enbrel)
  • Infliximab (Remicade)
  • Ustekinumab (Stelara)

81

How often should phototherapy be used for psoriasis and what type of wavelength is required? (PBSG)

  • Phototherapy 1-4x per week
  • UVB – higher success rates and low risk of malignancy
    • UVA used in tanning beds – risk of skin cancer and carcinogenesis

82

What is the prevalence of acne among those aged 12 to 24 years? (CMAJ/PBSG)

  • 85%

83

What is the medical term for common acne? (CMAJ)

  • Acne vulgaris

84

Describe the pathobiology of acne.

  • Follicular hyperproliferation and abnormal desquamation – the normal dead cells are blocked from leaving the follicle by hyperkeratinization
  • Increased sebum production – an androgenic effect
  • Propionibacterium acnes proliferation
  • Inflammation

85

What are 4 diagnoses to consider in the differential diagnosis of acne. (DFCM/PBSG)

  • Rosacea – telangiectasia and no comedones
  • Perioral dermatitis – erythematous papules on chin and nasolabial folds, with a thin rim sparing around the vermilion border
    • May occur spontaneously or with topical steroid use
  • Pseudofolliculitis barbae – ingrown hairs in the beard area of individuals with curly hair who shave closely
  • Milaria – heat rash with nonfollicular papules, pustules and vesicles
  • Bacterial Folliculitis – variable distribution that spreads with shaving or scratching
  • Hidradenitis suppurativa – painful boils and sinus tracts
  • Sebaceous hyperplasia – no erythema

86

What should women with acne be asked about specifically? (DFCM)

  • Signs of hyperandrogenism (PCOS)
    • Hirsutism
    • Acanthosis nigricans
    • Menstrual irregularity

87

What complications of acne are more common in individuals with darker skin? (PBSG)

  • PIH
  • Keloid scarring

88

What is first line therapy for patients with acne in skin of colour to reduce PIH? (PBSG)

  • Topical retinoids
    • Azelaic acid (Finacea) – indicated for acne rosacea

89

What are the 3 categories of acne based on severity? (CMAJ)

  • Comedonal acne (NONinflammatory)
    • Small white papules (closed comedones) – white heads
    • Grey-white papules (open comedones) – black heads
  • Mild-to-moderate Papulopustular acne
    • Inflammatory lesions that are mostly superficial
  • Severe acne
    • Deep pustules and/or nodules, which may be painful, may extend over large areas and can lead to tissue destruction

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90

What is a rare subtype of severe acne? (CMAJ)

  • Conglobate acne: extensive inflammatory papules, nodules and cysts
    • Can lead to disfiguring scars

91

What was considered superior efficacy in the CMAJ guidelines on acne? (CMAJ)

  • Statistical significant (p < 0.05)
  • Clinical relevance (minimum 10% difference in lesion counts)

92

What is first-line treatment for comedonal acne and mild papulopustular acne? (CMAJ)

  • Topical therapies
    • Retinoids OR
    • Benzoyl peroxide OR
    • Fixed-dose combinations of retinoids with benzoyl peroxide or Clindamycin
      • BPO/clinda
      • BPO/adapalene

93

What topical therapy can be tried if the initial first-line options fail for comedonal acne or mild papulopustular acne? (CMAJ)

  • Clindamycin/Tretinoin fixed-dose combination

94

What is a second-line option for comedonal acne or mild papulopustular acne if topical therapies fail? (CMAJ)

  • Combined oral contraceptives + Topical
  • Systemic antibiotics + Topical (only for Mild papulopustular)

95

What is the first-line option for moderate papulopustular acne? (CMAJ)

  • COC or Systemic antibiotics + Topical

96

What is the first-line treatment option for severe papulopustular/nodular acne? (CMAJ)

  • Oral isoretinoin

97

If a patient with severe acne is unwilling, unable or intolerant to oral isoretinoin, what treatment can then be tried? (CMAJ)

  • Systemic antibiotics with topical BPO +/- topical retinoid OR COC

98

Summarize the clinical treatment algorithm for acne. (CMAJ)

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99

What type of topical formulation is better for dry or sensitive skin and what type for oily skin? (CMAJ)

  • Cream/Lotion for Dry/Sensitive
  • Gel for Oily

100

What are 4 points to educate patients about with acne?

  • Acne is NOT a hygiene problem
  • There is NO relationship to diet
  • Acne causes stress, NOT vice versa
  • Acne usually worsens the week before menses

101

What should patients be advised to do to help with acne that does not involve pharmacotherapies?

  • Limit face washing to 1-2x daily with mild soap (or soapless cleanser)
    • Neutrogena Oil Free Acne wash or Cetaphil or CeraVe
    • Dove bar soap or body wash
  • Consistency with washing/treatment is key
  • Gently wash face (men)
  • Use water-based or non-comedogenic makeup, sunscreen and lotions rather than oil-based

102

What are common adverse effects related to all topical acne therapies? (CMAJ)

  • Dryness
  • Redness
  • Burning
  • Irritation
  • Peeling

103

What doses can benzoyl peroxide be prescribed in? (CMAJ)

  • Benzoyl Peroxide 2.5%, 5% 10% gel, cream or lotion
    • 10% not for comedonal

104

What is the primary active ingredient in Proactiv? (PBSG)

  • BPO

105

What are 3 types of topical retinoids and which seems to be inferior? (CMAJ)

  • Tretinoin 0.025%, 0.04%, 0.05% gel or cream (Retin A, Stieva A)
    • Inferior
  • Adapalene 0.1% and 0.3% gel or cream (Differin)
  • Tazarotene 0.1% gel (Tazorac)

106

What is the fixed-dose combination of adapalene-BPO? (CMAJ)

  • Adapalene 0.1% and BPO 2.5% gel (TactuPump)
  • Adapalene 0.3% and BPO 2.5% gel (TactuPump Forte)

107

What is the fixed-dose combination of clindamycin-BPO? (CMAJ)

  • Clindamycin 1% and BPO 5% gel (BenzaClin, Clindoxyl)

108

What is the fixed-dose combination of clindamycin and tretinoin? (CMAJ)

  • Clindamycin 1.2% and tretinoin 0.025% (Biacna)

109

What topical acne treatment can be effective for hormone acne (premenstrual) that occurs near the jawline?

  • Dapsone (Aczone)

110

What is the use of systemic (oral) antibiotics for acne on their own not recommended? (CMAJ)

  • Selection of antibiotic resistant bacteria
  • Addition of BPO recommended to limit the emergence of antibiotic resistant bacteria

111

What are the preferred systemic (oral) antibiotics for acne and why? (CMAJ)

  • Tetracycline or Doxycycline
  • Minocycline associated with an increased risk of drug-induced lupus and hepatitis

112

Which COC combinations have been shown to be effective for the treatment of acne? (CMAJ)

  • Ethinyl estradiol 20 ug and levonorgestrel 100 ug (Alesse)
  • Ethinyl estradiol 20 ug and drospirenone 3 mg (Yasmin)
  • Ethinyl estradiol 35 ug and norgestimate 180, 215 or 250 ug (Tri-cyclin 21)
  • Ethinyl estradiol 35 ug and cyproterone acetate 2 mg (Diane-35)

113

What are potential adverse effects associated with topical retinoids for acne?

  • Erythema
  • Scaling
  • Dryness
  • Pruritus
  • Burning
  • Photosensitivity
  • Potential exacerbation of acne within the first few weeks

114

What is a contraindication to use of topical retinoids and what ages are they recommended in? (CMAJ)

  • Pregnancy
    • Tazarotene category X
    • Adapalene and Tretinoin category C
  • Adapalene and Tazarotene for patients ≥12 years of age
    • No age limitation for Tretinoin

115

What should patients using topical retinoids be counselled about?

  • Avoid prolonged exposure to the sun and wear sunscreen
  • Avoid waxing or laser hair removal due to skin fragility

116

What are potential adverse effects associated with topical BPO for acne?

  • Contact dermatitis (1-2%)
    • Can cause severe reaction
    • Health Canada recommends spot trial on 1 or 2 small affected areas for 3 days to ensure no hypersensitivity symptoms develop
  • Erythema
  • Peeling
  • Dryness
  • Can bleach clothing, bedding, and hair (use old sheets and wear old t-shirt in bed)

117

What are potential adverse effects associated with topical dapsone for acne?

  • Dryness
  • Erythema
  • Sunburn
  • Contact dermatitis
  • Methemoglobinemia and hemolytic anemia
  • Contraindicated in pregnancy and breastfeeding

118

How long should systemic antibiotics be prescribed for acne?

  • 3 months – then stop and maintain with topical treatment

119

How is Accutane (Isotretinoin) prescribed for acne?

  • Initial 0.5 mg/kg divided BID for 1 month, then increase to 1 mg/kg
  • Total dose is 120-150 mg/kg (often takes 4-5 months)

120

What do females need to do before starting Accutane (Isotretinoin)?

  • 2 contraceptive methods 1 month pre-treatment to 1 month post-treatment

121

What are potential adverse effects associated with Accutane (Isotretinoin) for acne?

  • Cheilitis
  • Conjunctivitis
  • Dry mucous membranes of the nose and mouth
  • Xerosis
  • Photosensitivity
  • Less common:
    • Arthalgias
    • Myalgias
    • CNS – headache, nyctalopia (inability to see in dim light or at night), pseudotumor cerebri

122

What do patients treated with Accutane (Isotretinoin) need to be monitored for?

  • Hypertriglyceridemia
  • Elevated total cholesterol
  • Reduced HDLs
  • LFT and Platelets

123

What bloodwork should be performed in patients on Accutane (Isotretinoin)?

  • Initial and at 2 weeks
    • CBC, ESR, beta-HCG (2 tests before beginning), glucose, lipids, AST/ALT, INR, Bilirubin and Albumin
  • Monthly
    • Beta-HCG, Lipids, AST/ALT, INR, Bilirubin and Albumin

124

How can rosacea be differentiated from acne? (TN)

  • Rosacea has NO comedones
  • Rosacea distributed more along central face and has symptoms of flushing

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125

How does rosacea typically appear? (TN)

  • Dome-shaped papules +/- pustules
  • Flushing, non-transient erythema and telangiectasia
  • Central face: forehead, nose, cheeks and chin
  • Remissions and exacerbations

126

What is rosacea on the nose called? (TN)

  • Rhinophyma: distinct swelling caused by lymphedema and hypertrophy of subcutaneous tissue

127

What can be exacerbating factors for rosacea? (TN)

  • Heat
  • Cold
  • Wind
  • Sun
  • Stress
  • Drinking hot liquids
  • Alcohol
  • Caffeine
  • Spices (triggers of vasodilation)

128

How is rosacea diagnosed? (TN)

  • Presence of 1 or more of the following primary features:
    • Flushing (transient erythema)
    • Nontransient erythema
    • Papules and pustules
    • Telangiectasia
  • May include one or more of the following secondary features:
    • Burning or stinging
    • Dry appearance
    • Edema
    • Phymatous changes
    • Ocular manifestations (blepharoconjunctivitis, keratitis, iritis)
    • Peripheral location

129

What are 3 general recommendations to manage rosacea? (TN)

  • Trigger avoidance
  • Avoid topical corticosteroids
  • Make-up to mask erythema

130

What are specific 1st line rosacea treatment? (TN)

  • Oral tetracyclines (250-500 mg PO BID)
  • Topical metronidazole
  • Oral erythromycin (250-500 mg PO BID)
  • Topical azelaic acid

131

What is being promoted a new topical option for rosacea? (CMA POEM / Cochrane)

  • Doxycycline and Tetracycline are effective
  • Doxycycline 40 mg dose may be as effective as 100 mg dose (less side effects)
  • Oral tetracycline similar to Topical Metronidazole in effectives for papulopustular rosacea
  • Topical Brimonidine 0.33% gel (alpha agonist) reduces redness for up to 12 hours after use
  • Topical Ivermectin effective, similar to topical metronidazole
  • Oral isotretinoin more effective than doxycycline 100 mg

132

What are the 3 stages of hair growth? (TN)

  • Anagen = growth stage
  • Catagen = transitional stage
  • Telogen = resting stage

133

When a patient presents with alopecia, what is important to determine initially and how can this be determined? (TN)

  • Scarring (Cicatricial) vs Non-Scarring (Non-Cicatricial) Alopecia
    • Non-scarring: intact hair follicles on exam
    • Scarring: absent hair follicles on exam

134

What acronym can help remember the important causes of alopecia? (TN)

  • TOP HAT
    • Telogen effluvium, tinea capitis
    • Out of Fe, Zn
    • Physical: trichotillomania, “corn-row” braiding
    • Hormonal: hypothyroidism, androgenic
    • Autoimmune: SLE, alopecia areata
    • Toxins: heavy metals, anticoagulants, chemotherapy, vitamin A, SSRIs

135

What are 5 types of non-scarring (non-cicatricial) alopecia? (TN)

  • Androgenetic alopecia
  • Physical
    • Trichotillomania
    • Traumatic: ‘corn-row’ braiding
  • Telogen effluvium
  • Anagen effluvium
  • Alopecia areata

136

What is the differential for non-scarring alopecia? (TN)

  • Autoimmune
    • Alopecia areata
  • Endocrine
    • Hypothyroidism
    • Androgens
  • Micronutrient deficiencies
    • Iron
    • Zinc
  • Toxins
    • Heavy metals
    • Anticoagulants
    • Chemotherapy
    • Vitamin A
  • Trauma to the hair follicle
    • Trichotillomania – causes scarring on DermNet
    • ‘Corn-row’ braiding – causes scarring on DermNet
  • Other
    • Syphilis
    • Severe illness
    • Childbirth

137

How does androgenetic alopecia appear for men and women? (TN)

  • Males: fronto-temporal areas progressing to vertex, entire scalp may be bald
  • Females: widening of central part, “Christmas tree” pattern

138

What are 5 treatment options for androgenetic alopecia? (TN)

  • Minoxidil (Rogaine) solution or foam
  • Spironolactone in women
  • Cyproterone acetate (Diane-35) in women
  • Finasteride (Propecia) in men
  • Hair transplant

139

What are potential precipitants of telogen effluvium? (TN)

  • SEND hair follicles out of anagen and into telogen
    • Stress and Scalp disease (seborrheic dermatitis, allergic contact dermatitis)
    • Endocrine (hypothyroidism, post-partum)
    • Nutritional (iron and protein deficiency)
    • Drugs (acitretin, heparin, lithium, interferon, beta-blockers, valproic acid, SSRIs)

140

How long after exposure to the precipitant does hair loss occur with telogen effluvium and how long for it to regrow? (TN)

  • 2-4 months after exposure
  • Regrowth within a few months

141

What are potential precipitants of anogen effluvium? (TN)

  • Chemotherapeutic agents, other medications (e.g. Levodopa, Colchicine, Cyclosporine), exposure to chemicals (thallium, arsenic)

142

How long after exposure to the precipitant does hair loss occur with anogen effluvium and how long for it to regrow? (TN)

  • Hair loss 7-14 days after single pulse of chemotherapy
    • Most clinically apparent after 1-2 months
  • Reversible, follicles resume normal growth few weeks after agent stopped

143

What is the pathophysiology of alopecia areata? (TN)

  • Autoimmune

144

What are 2 subtypes of alopecia areata? (TN)

  • Alopecia totalis: loss of all scalp hair and eyebrows
  • Alopecia universalis: loss of all body hair

145

What sign can be found on clinical exam in alopecia areata? (TN)

  • “Exclamation Mark” pattern: hairs fractured and have tapered shafts)

146

What are 4 diseases that can be associated with alopecia areata? (TN)

  • Pernicious anemia
  • Vitiligo
  • Thyroid disease
  • Addison’s disease

147

What are management options for alopecia areata? (TN)

  • Intralesional triamcinolone (corticosteroids)
  • UV or PUVA therapy

148

In a patient with suspected scarring (Cicatricial) alopecia, what should be done? (TN)

  • Biopsy

149

What are 2 types of lesions seen in pityriasis rosea? (TN)

  • “Herald patch” – precedes other lesions by 1-2 weeks
  • “Christmas Tree” pattern – lesions follow skin tension lines (Langer’s Lines) parallel to ribs on back

150

How do lesions in pityriasis rosea appear? (TN)

  • Red, oval plaques/patches with central scale that does NOT extend to edge of lesion (collaret)
    • Some plaques may be annular (ring-shaped)
  • Sites: trunk, proximal aspects of arms and legs
  • Varied degree of pruritus

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151

What is believed to be the cause of pityriasis rosea? (TN)

  • HHV6/7
  • May follow a few days after a URTI

152

What treatment options are available for pityriasis rosea? (TN)

  • None required as will clear spontaneously in 6-12 weeks
  • Topical corticosteroids when PIH is a concern or if uncomfortable
  • Oral erythromycin for 2 weeks
    • May clear up faster
  • Oral acyclovir for 7 days
    • May clear up faster

153

What are the 3 most common genera of dermatophytes infecting humans? (DFCM)

  • Trichophyton
  • Microsporum
  • Epidermophyton

154

How can the diagnosis of a fungal (dermatophyte) skin infection be confirmed? (DFCM)

  • Potassium bromide (KOH) microscopy of a skin scraping
    • Shows hyphae or Mycelia or with Fungal Culture

155

What tool can be useful for the diagnosis of a fungal skin infection? (DFCM)

  • Wood’s lamp (UV-A light) – Tinea Versicolor

156

What is in the differential diagnosis for a fungal skin infection? (DFCM)

  • Eczema
  • Contact dermatitis
  • Acne
  • Folliculitis
  • Psoriasis
  • Lichen planus
  • Trauma/irritation

157

What are 8 types of fungal skin infections? (DFCM)

  • Tinea Capitis
  • Tinea Corporis (Ringworm)
  • Tinea Barbae
    • Tinea Faciei – non-bearded areas
  • Tinea Cruris (Jock Itch)
  • Tinea Pedis (Athlete’s Foot)
    • Tinea Mannum - hands
  • Tinea Unguum (Onychomycosis)
  • Tinea Versicolor (Pityriasis Versicolor)
  • Candida intertrigo

158

How does Tinea Capitis appear, where is it located and what can it be associated with? (DFCM)

  • Scaling, itching and erythema of the scalp, eyelashes and eyebrows
  • Can also present as patchy alopecia, black-dot alopecia, occipital adenopathy, or a kerion (sterile inflammatory scalp mass)
  • More common in children, mainly black
  • Very contagious, may be transmitted from barber, hats, theatre seats, pets

159

How does Tinea Corporis appear and where is it located? (DFCM)

  • Annular lesions, with scaly, well demarcated border and central clearing
  • Trunk, limbs, face
  • May be hyperpigmented in darker-skinned persons

160

How does Tinea Barbae appear, where is it located and whom it is more common in? (DFCM)

  • Inflamed pustules, erythema and scaling on neck and beard area
  • More common in farm workers

161

How does Tinea Cruris appear and where is it located? (DFCM)

  • Sharply demarcated areas of redness, scaling and pruritus on the medial thigh
  • Central clearing
  • Pruritic, erythematous, dry/macerated
  • No satellite lesions

162

How does Tinea Pedis appear, where is it located and what is a potential complication? (DFCM)

  • Interdigital scaling, erythema, itching and sometimes blisters seen on the foot
  • Can also present as scaly, erythematous and hyperkeratotic lesions on the sole and sides of foot (refererd to as Moccasin Ringworm)
  • Strep cellulitis is a potential complication

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163

How does Tinea Unguum (Onychomycosis) appear, where is it located and what can it be associated with? (DFCM)

  • Thickened, raised, discolored, and cracked nails
  • More common in elderly, diabetic, and immunocompromised patients
  • Can be seen on the hand or foot

164

What are the best predictors of onychomycosis on clinical exam? (CMA Infopoem)

  • Plantar desquamation
  • Interdigital tinea pedis
  • Previous diagnosis of fungal disease in the feet and subungual hyperkeratosis

165

What are 2 topical option for the treatment of onychomycosis and their effectiveness? (TN/UTD)

  • Jublia (Efinaconazole) 10% solution
    • Applied directly to the nails once daily for 48 weeks
      • 1 drop per nail (2 drops for great toenail)
    • 4 weeks after 48-week treatment, complete cure achieved by 15-18% vs 3-6%
  • Penlac (Ciclopirox) 8% nail lacquer
    • Applied directly to the nails once daily for 48 weeks
    • After 48-week treatment, complete cured achieved by 7% vs 0.4%

166

What is the recommended length of treatment for tinea unguum (onychomycosis)? (TN/UTD)

  • Terbinafine (Lamisil) 6 weeks for fingernail or 12 weeks for toenails
    • 76% cure rate after 3-4 months (UTD)

167

What would a green discolouration of the nails suggest and what would be the treatment?

  • Pseudomonas nail infection
  • Vinegar soaks x15 min TID for 1 month

168

How does Tinea Versicolor appear and where is it located? (DFCM)

  • Hypo or hyperpigmented circular macules on the trunk and extremities

169

How does Candida intertrigo appear and where is it located? (DFCM)

  • Erythematous, macerated and pruritic plaques with peripheral scaling and satellite lesions
  • Typically occurs in moist area of friction such as groin, buttock, axillae and skin folds

170

How should topical antifungals be applied and how long should their treatment be continued for? (DFCM)

  • Applied to the affected and surrounding area (1-2 inches beyond rash)
  • Treatment continued for 1 week after the symptoms are gone

171

In which fungal skin infections is systemic antifungal therapy recommended? (DFCM)

  • Tinea capitis
  • Tinea barbae
  • Onychomycosis
  • Patients that have failed topical therapy

172

What are 3 classes of topical antifungal agents and examples of each and their indications? (DFCM)

  • Azoles – clotrimazole (Canesten), ketoconazole (Nizoral)
    • Dermatophytes, tinea versicolor, candida
  • Allylamine – terbinafine (Lamisil)
    • Dermatophytes and tinea versicolor
  • Polyene – Nystatin
    • Candida

173

What is the toxicity concern associated with terbinafine? (TN)

  • Liver toxicity
  • CYP 2D6 inhibitor

174

What is the recommended management for Tinea Capitis? (TN)

  • Terbinafine (Lamisil) x 4 weeks
    • Oral agents required to penetrate the hair root where dermatophyte resides
  • Adjunctive antifungal shampoos or lotions for patient and HOUSEHOLD CONTACTS
    • Selenium sulfide shampoo 2.5% 3x per week

175

What is the recommended management options for Tinea Corporis, Tinea Cruris, Tinea Pedis and Tinea Manuum? (TN)

  • Topical:
    • 1% clotrimazole
    • 2% ketoconazole
    • 2% miconazole
    • 1% Terbinafine (Lamisil)
    • Lotriderm (Clotrimazole & Betamethasone) BID for up to 2 weeks
  • Oral:
    • Terbinafine
    • Itraconazole
    • Fluconazole
    • Ketoconazole (if extensive)

176

What are 5 types of bacterial skin infections? (DFCM)

  • Erysipelas – bacterial infection of the superficial dermis and superficial lymphatics
  • Cellulitis – bacterial infection of the deeper dermis and subcutaneous fat
  • Folliculitis – bacterial infection of the hair follicles with purulence in the epidermis
  • Furuncle (Boil) – bacterial infection of a hair follicle with purulence extending beyond the dermis into the subcutaneous tissue
  • Impetigo – contagious bacterial infection of the superficial skin commonly seen in the pediatric population

177

How can erysipelas and cellulitis be differentiated on exam? (DFCM)

  • Erysipelas – RAISED lesions with WELL DEMARCATED borders, exhibit intense erythema, warmth and edema
    • ACUTE onset of symptoms
    • RAPID PROGRESSION to systemic symptoms of fever/chills
  • Cellulitis – NOT RAISED, SOMEWHAT demarcated, exhibit erythema, warmth and edema
    • SLOW onset of symptoms
    • May develop purulence or an underlying abscess requiring incision and drainage

178

What are the 3 types of impetigo? (DFCM)

  • Non-bullous – mix of vesicles and pustules, form thick, characteristically GOLDEN-crusted exudates
  • Bullous – vesicles form yellow-brown bullae that can burst to form a BROWN crust
  • Ecythma – ulcerative lesions extend through the epidermis deep into the dermis, “PUNCHED-OUT” appearance

179

Where is impetigo commonly seen? (DFCM)

  • Children aged 2-5
  • Common on face and extremities

180

What would be the treatment for early folliculitis, mild folliculitis or mild impetigo, and moderate/severe folliculitis or impetigo? (DFCM)

  • Early Folliculitis = hot compresses and anti-septic cleansers daily
  • Mild = mupirocin 2% or fusidic 2% cream applied topical TID
  • Moderate/Severe = Keflex or Cloxacillin or Clindamycin or Erythromycin (all PO)

181

What are 3 types of oral antibiotics that can treat community acquired (CA)-MRSA? (DFCM)

  • TMP/SMX PO
  • Doxycycline
  • Clindamycin

182

What are 2 types of IV antibiotics that can treat CA-MRSA? (DFCM)

  • Vancomycin IV
  • Linezolid PO/IV

183

What are 3 types of parasitic skin infections? (TN)

  • Scabies
  • Lice (Pediculosis)
  • Bed bugs (Hemiptera)

184

What is scabies characterized by? (TN)

  • Skin infection due to Sarcoptes scabiei (MITE)
  • Superficial burrows
  • Intense pruritus (especially nocturnal)
  • Secondary infection

185

How does the primary scabies lesion appear? (TN)

  • Superficial linear burrows
  • Inflammatory papules and nodules in the axilla and groin

186

Where does scabies typically affect? (TN)

  • Axillae
  • Groin
  • Buttocks
  • Hands/Feet (especially WEB SPACES)
  • Sparing of head and neck (except in infants)

187

How long do scabies mite remain alive on clothing/sheet? (TN)

  • 2-3 days

188

How long is the incubation period for scabies? (TN)

  • 1 month then pruritus begins

189

How should scabies be managed? (TN)

  • Bathe, then apply permethrin 5% cream (i.e. Nix) from neck down to soles of feet (must be left on for 8-14 hours) and requires 2nd treatment 7 days after first
  • Change underwear and linens – wash with detergent in hot water cycle then machine dry
  • Treat family and close contacts
  • Mild potency topical steroids and antihistamines for symptoms management

190

How does lice typically present? (TN)

  • Intensely pruritic red excoriations, morbilliform rash, caused by louse (a parasite)

191

What are the 3 locations that lice can present? (TN)

  • Scalp lice: nits (i.e. louse eggs) on hairs
    • Red excoriated skin
  • Pubic lice: nits on hairs
    • Excoriations
  • Body lice: nits and lice in seams of clothing
    • Excoriations (mainly shoulders, belt-line, buttocks)

192

How should lice be managed? (TN)

  • Permethrin 1% (Nix cream rinse) (Ovicidal) or Permethrin 1% shampoo
  • Comb hair with fine-toothed comb using dilute vinegar solution to remove nits
  • Repeat in 7 days after first treatment
  • Shave hair if feasible
  • Change clothing and linens
  • Wash clothes and linens used 2 days prior with detergent in hot water cycle then machine dry
  • Put un-washable items in a sealed bag for 2 weeks

193

What is an expensive option to treat head lice? (CMA Infopoem / NEJM)

  • Topical Ivermectin 0.5% ($260 per 4 oz bottle)
  • Applied once to scalp

194

What treatment has been shown to be better than Permethrin for the treatment of lice? (TFP)

  • Dimeticone (NYDA) (silicone based product that suffocates lice and is applied to dry hair, left 8 hours, then repeated after 1 week)
  • 4% or 9.2% concentrations
  • NNT = 3-4 compared to permethrin for lice

195

What causes bed bugs? (TN)

  • Cimex lectularius – small insect that feeds mainly at night
    • During day bedbugs hide in crevices in walls and furniture

196

How does bed bugs typically present? (TN)

  • Burning wheals, turning to firm papules, often in groups of three – “breakfast, lunch and dinner” in areas with easy access (face, neck, arms, legs, hands)

197

How should bed bugs be managed? (TN)

  • Professional fumigation of home
  • Topical steroids and oral H1-antagonists for symptomatic relief
  • Definitive treatment is removal of clutter in home and application of insecticides to walls and furniture

198

What are most lower-limb ulcers? (PBSG)

  • Venous stasis ulcers

199

Differentiate between venous stasis ulcers and arterial ulcers. (PBSG)

  • Venous Stasis Ulcers: caused by skin injury in patients with impaired venous circulation
  • Arterial Ulcers: caused by lack of blood flow distal to an area of vessel occlusion

200

What is the definition of a pressure ulcer (decubitus ulcer)? (PBSG)

  • Localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction

201

What are 5 risk factors for venous stasis ulcers? (PBSG)

  • Pregnancy, obesity, immobility, prolonged standing/sitting, leg trauma
  • Venous impairment (post-phlebitic syndrome, DVT, varicose veins, previous vein surgery, valve incompetence in perforator veins)
  • History of venous insufficiency ulcers
  • CHF
  • Nephrotic syndrome

202

What are 4 risk factors for pressure ulcers? (PBSG)

  • Pressure on skin greater than arteriolar pressure (leads to hypoxia and compressive forces)
  • Friction, pressure and shearing forces from sitting or lying or from transfer/rolling methods
  • Moisture (sweat, feces, urine)
  • Immobility, Incontinence, Dietary Inadequacy

203

How do venous stasis, arterial and pressure ulcers appear clinically? (PBSG)

Type of Ulcer

Clinical Clues

Venous stasis

  • May be large, relatively superficial and with RED/YELLOW base
  • Signs of venous pressure – EDEMA
  • “Champagne glass” ankle may be present
  • Often significant drainage
  • Peripheral pulses palpable

Arterial

  • Commonly distal with well-defined borders, a “PUNCHED-OUT” appearance
  • Often over the MEDIAL-MALLEOLAR region
  • DRIER and DEEPER than venous ulcers, with minimal granulation tissue
  • Typically covered with pale pink, yellow or black eschar
  • Often PAINFUL

Pressure

  • Located over areas of pressure (e.g. HEELS, TROCHANTERS, SACRUM)
  • Initially NON-BLANCHABLE erythema, increasing to open areas

204

What should be assessed in all patients presenting with lower-extremity ulcers? (PBSG)

  • Clinical assessment
  • Palpable pedal pulses
  • Capillary refill
  • ABPI (Ankle Brachial Pressure Index)

205

How are pressure ulcers staged? (PBSG)

  • NPUAP staging
    • Stage 1 – intact skin, non-blanchable redness, localized (usually over bony prominence)
    • Stage 2 – partial-thickness loss of dermis, shallow and open
    • Stage 3 – full-thickness tissue loss, subcutaneous fat may be visible (no tendons, muscles or bones), may be undermined or tunnelled
    • Stage 4 – full-thickness tissue loss, bone exposed, tendon or muscle visible or palpable, slough or eschar may be present
    • Unstageable – full-thickness tissue loss, base of ulcer bed covered by slough or eschar

206

What are signs of a spreading wound infection? (PBSG)

  • Wound breakdown
  • Spreading erythema
  • Induration
  • Discolouration
  • Warmth
  • Crepitus
  • Lymphangitis
  • Pain
  • Malaise

207

What are 3 indications to swab a wound for cultures? (PBSG)

  • Signs of spreading or systemic infection
  • Lack of response to appropriate antibiotic treatment
  • Protocol requirements for antibiotic-resistant organisms

208

How should a wound be swabbed? (PBSG)

  • Clean the ulcer with warm tap water or saline first
  • Remove unhealthy tissue
  • Place the swab onto “clean” viable tissue, rotate and press firmly to obtain fluid from beneath the surface of the wound

209

What are 4 practices to prevent pressure ulcers? (PBSG)

  • Education patients and caregivers about ischemic pain as a response to pressure
  • Move or reposition the patient to take pressure off
  • Maintain skin integrity through regular cleansing, moistening and inspection
  • Ensure adequate nutrition, ideally including a daily protein intake of 1.2-1.5 k/kg body weight

210

What is recommended for all patients at risk of pressure ulcers? (PBSG)

  • High density foam mattress/seating
  • Sheepskin may be used over top of regular mattresses where high density foam mattresses are unavailable

211

What is recommended for prevention of venous leg ulcers in patients with venous hypertension, leg edema or postphlebitic syndrome? (PBSG)

  • Continuous and indefinite awake-time use of compression stockings

212

What are 4 principles of managing wound infections? (PBSG)

  • Appropriate dressing and dressing changes
  • Wound drainage and cleansing
  • Debridement as necessary
  • Antimicrobial therapy

213

How much should a wound improve to indicate appropriate wound healing? (PBSG)

  • 30% reduction in wound measurement (length x width x depth) at 3-4 weeks
    • Most pressure ulcers show signs of healing within 2 weeks

214

What are factors that can impair wound healing? (PBSG)

  • Nutritional status
  • Ischemia
  • Hepatic/Renal/Cardiac disease
  • Medications
    • Systemic steroids
    • NSAIDs (topical Voltaren)
    • Anti-neoplastics
  • Age
  • Smoking
  • Psychosocial status

215

What should be considered when ulcers do not heal despite standard care? (PBSG)

  • Biopsy – to rule out malignancy

216

What are 6 ways to treat venous leg ulcers? (PBSG)

  • Elevate legs
  • Calf pump exercises
  • Regular or range-of-motion exercise
  • Weight management
  • Skin care
  • Compression therapy

217

What is required prior to initiating compression therapy in patients with venous leg ulcers? (PBSG)

  • ABPI

218

At what ABPI can compression therapy be used and how much? (PBSG)

  • ABPI ≥0.8 mmHg
  • 40 mmHg compression stockings

219

What is the benefit of keeping wounds moist? (PBSG)

  • Level 1 evidence
    • Decrease healing time
    • Less pain
    • Less risk of infection
    • Require fewer dressing changes
    • Cost-effective

220

What is the benefit of debriding necrotic tissue in a skin ulcer? (PBSG)

  • Inhibit bacterial growth
  • Promote wound healing

221

What are 5 ways to debride a wound or skin ulcer? (PBSG)

  • Sharp (scalpel or scissors)
  • Mechanical – superficial loose or necrotic exudate
  • Enzymatic
  • Autolytic (hydrocolloid or hydrogel dressings)
  • Biosurgery or Maggot Larvae

222

What characteristics are associated with dermatofibromas? (TN)

  • Button-like, firm dermal papule or nodule, skin-coloured to red-brown colouring
  • Majority asymptomatic but may be PRURITIC and/or TENDER
  • Legs > Arms > Trunk
  • Dimple Sign: lateral compression causes dimpling of the lesion

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What should be done to treat bothersome dermatofibromas? (TN)

  • Excision
  • Cryosurgery

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Differentiate between corns vs warts vs calluses. (TN)

  • Corns: whitish yellow central translucent keratinous core
  • Warts: bleed with pairing, black speckled central appearance due to thrombosed capillaries
  • Calluses: layers of yellowish keratin revealed with paring

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Where are corns commonly found? (TN)

  • Dorsolateral 5th toe and dorsal aspects of other toes

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How can corns be treated? (TN)

  • Relieve pressure with padding or alternate footwear, orthotics
  • Paring, curettage

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Differentiate between keloids and hypertrophic scars. (TN)

  • Keloids – extended BEYOND margins of original injury with claw-like extensions
  • Hypertrophic scar – confined to original margins of injury

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What are risk factors for melanoma? (DFCM)

  • Intermittent intense sun exposure (like BCC, unlike SCC)
  • Immunosuppressive therapy
  • Family history of MM
  • Family history of pancreatic cancer
  • High number of common nevi
  • 1 or more atypical/dysplastic nevi
    • Should screen more often if have dysplastic nevi
    • Prophylactic excision is not recommended as most melanoma develop de novo, but having dysplastic nevi increases that risk
  • Light skin phenotype (Fitzpatrick 1/2)

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What are the screening recommendations for melanoma? (DFCM)

  • General Population – routine TBSE and counseling on SSE NOT recommended
    • No risk factors
  • High risk (5-10x) – screen by PCP annually for skin cancer, counsel about SSE (self-skin exam) and SCP (skin cancer prevention) by PCP
    • 2 or more of the following:
      • 1st degree relative with MM
      • 1 or more atypical nevi
      • Many (50-100) nevi
      • Naturally red or blonde hair
      • Tendency to freckle
      • Skin that burns easily and tans poorly or not at all
      • Outdoor occupation
      • Childhood in lower altitudes
      • Tanning bed use in teens and 20s
      • Radiation therapy as adult
  • Very high risk (>10x) – TBSE by dermatologist or trained PCP on yearly basis, counsel about SSE and SCP
    • Immunosuppressive therapy
    • Personal history of skin cancer
    • 2+ 1st degree relatives with MM
    • >100 nevi total or 5+ atypical nevi
    • >250 PUVA treatments for psoriasis
    • Radiation therapy for cancer as a child

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What is in the differential diagnosis for melanoma?

  • Dysplastic nevus
  • Traumatized nevus
  • Pigmented basal cell
  • Dermatofibroma
  • Seborrheic keratosis

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What are 4 types of NMSC? (DFCM)

  • BCC
  • SCC
  • Bowen disease (SCC in situ)
  • AK (solar keratosis, senile keratosis)

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What is the most common human cancer? (DFCM)

  • BCC

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Where are BCC commonly found? (DFCM)

  • Nose

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Which of BCC or SCC poses a greater metastasis risk? (DFCM)

  • SCC

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What is the risk of cancer associated with AKs? (DFCM)

  • Develop into SCC (1/1000)

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What are biopsy options for NMSC (except AKs)? (DFCM)

  • Shave biopsy
  • Punch biopsy
  • Deep shave (SCC and Bowen’s)

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What are options for field therapy in patients with a history of Bowen’s disease or AKs? (DFCM)

 

  • 5-FU (2-3 weeks)
  • 5% Imiquimod (8-10 weeks)
  • 3% Diclofenac gel (AKs)

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What should be asked on history for suspicious skin lesions?

  • A – Asymmetry
  • B – Borders irregular
  • C – Colour changing or multiple
  • D – Diameter >6 mm
  • E – Evolving
  • ABCDE Rule
    • 97% sensitivity if use on criteria, but only 43% specificity
    • Can consider biopsy if 1 criteria present
    • Consider referral if evolving +1 other criteria

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What are the 4 types of melanoma? (DFCM)

  • Superficial spreading
  • Nodular
  • Invasive lentigo maligna melanoma
  • Acral lentiginous melanoma

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How do most melanomas present?

  • Superficial spreading (70% of all melanomas)
    • Asymmetry and color variegation are characteristic
    • Majority arise de novo, only ¼ from dysplastic nevi
  • Nodular also possible
    • Discrete nodular, usually with dark pigmentation (although may be amelanotic as well)

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What are two specific types of melanoma that can appear on specific locations of the body?

  • Lentigo Maligna
  • Acral Lentiginous

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How does lentigo maligna appear typically?

  • Usually arises in areas of sun-damaged skin, particularly on the head and neck
  • Freckle-like, tan-brown macule and gradually enlarges and develops darker or lighter asymmetric foci and raised areas, which signify dermal invasion

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How does acral lentiginous appear typically?

  • Shows the asymmetry and color variegation of typical melanomas
  • They are distinguished clinically by their locations on the palms, soles or nails

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How should all suspicious skin lesions be investigated?

  • Biopsy all suspicious lesions
    • Excisional biopsy with 2mm of regular skin surrounding is best
    • Can do punch biopsy if lesion is large
  • Any concerning brown lesion should be biopsied – Don’t Watch and Wait

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How should melanomas be excised/treated? (DFCM)

  • Leave it to plastics
  • In situ melanomas can have margins of 0.5-1 cm
  • <1mm thick can have 1cm margins
  • >1mm thick can have 2cm margins

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What is pemphigus vulgaris?

  • Autoimmune blistering disease of the skin and mucous membranes

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What is in the differential diagnosis for pemphigus vulgaris?

  • Mouth ulcers
    • HSV
    • Aphthous ulcers
    • Erythema multiforme
  • Wide-spread erosions
    • Bullous pemphigoid
    • Bullous drug eruptions
    • Pyoderma gangrenosum
    • Impetigo

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How does pemphigus vulgaris appear?

  • Flaccid, non-pruritic, painful epidermal bullae/erosions
  • Typically begin in oropharynx, then spread to skin
  • Nikolsky’s Sign – pressure around a lesion leads to an erosion

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What is pemphigus vulgaris associated with?

  • Thymoma
  • Myasthenia gravis
  • Malignancy

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What is the treatment for pemphigus vulgaris?

  • High dose steroid – prednisone 1mg/kg
    • May require long-term or other immunomodulator
  • Refer immediately

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What is bullous pemphigoid?

  • Autoimmune bullous eruption

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How does bullous pemphigoid typically appear?

  • Pruritic, tense, subepidermal bullae on an erythematous or normal base
  • Prodromal urticarial for weeks to months that evolve into bullae
  • Locations – lower legs, medial thighs, groins, flexor forearm, axillae

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What is the treatment for bullous pemphigoid?

  • High dose steroid – prednisone 1mg/kg
    • May require long-term or other immunomodulator
  • Refer immediately

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How does cutaneous T-cell lymphoma appear?

  • Progressive patches/plaques with telangiectasia
  • May wax and wane
  • May be pruritic
  • May have scale

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How is cutaneous T-cell lymphoma diagnosed?

  • May need repeated skin biopsy
  • Keep a high degree of suspicion when presumed Psoriasis or Dermatitis does NOT respond to appropriate treatment

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What is the treatment for cutaneous T-cell lymphoma?

  • Topical alkylating agents for localized disease
  • Chemotherapy for extensive disease

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How does Stevens-Johnson syndrome present?

  • Prodrome of flu-like symptoms for 1-3 days
  • Vesicles and bullae develop over a few days

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What are potential triggers of SJS?

  • Medications – 50-80%
    • Allopurinol, Antibiotics, Antipsychotics, Antiepileptics, NSAIDs
    • Septra has a 20x risk compared to any other drug
  • Infections – 15%

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How should patients with burns be managed?

 

  • Fluid resuscitation
  • Tetanus prophylaxis
  • Early intubation if suspect inhalation injury
    • Closed space, unconscious, noxious chemical
  • Escharotomy – in circumferential full thickness burns

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How should fluid be replaced in burn patients?

  • Parkland Formula = 4cc/kg/%TBSA with RL in first 24h
    • ½ in first 8 hours, ½ in remaining 16h
    • 0 hour = time of burn (therefore if present 3h after burn, give ½ in 5h)
    • Add normal fluid maintenance to this formula
  • Urine output 50cc/hr (Adult) or 1cc/kg/hr (Children)

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What are specific things to look for with chemical and electrical burns?

  • Chemical – high volume irrigation before other treatment
  • Electrical – look for entrance and exit

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When can a patient presenting with a burn be discharged?

  • Asymptomatic
  • No significant cutaneous injury
  • No urine heme
  • Normal ECG
  • Observed 4-8h

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When should a patient presenting with a burn be admitted?

  • Partial thickness 15-20% (>10% if <5y or >60y)
  • Full thickness 2-5%
  • Smoke inhalation, high voltage electrical, circumferential

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What can be prescribed for patients topically for burns?

  • Flamazine 1% (Silver Sulfadiazine)
    • Apply to a thickness of 1/16 inch once or twice daily
    • Contraindicated in newborns, pregnancy, and lactation
  • Chlorhexidine
  • Bismuth-impregnated petroleum based gauze (e.g. Xeroform)

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What can be given to patients for post-burn pruritus?

  • H1 and H2 antihistamines (diphenhydramine, cetirizine, cimetidine)
  • Aloe vera, Vaseline based products, cocoa butter

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What is Wegener’s Granulomatosis?

  • Systemic vasculitis of small blood vessels

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What diagnostic triad is used to diagnose Wegener’s?

  • Necrotizing granulomatous vasculitis of respiratory tract
  • Glomerulonephritis
  • C-ANCA positive

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How does Wegener’s present clinically?

  • Chronic rhinosinusitis, nasal ulcerations, bloody discharge
  • Cough, SOB, hemoptysis, chest pain, CXR nodules
  • Renal failure
  • Skin lesions – irregular ulcers and erythematous plaques/papules and subcutaneous nodules

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What is the treatment for Wegener’s?

  • Steroids and Cyclophosphamide
  • Dialysis if needed

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What is systemic lupus erythematosus (SLE)?

  • Chronic inflammatory multi-system disease of unknown etiology

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What patients are at increased risk of SLE?

  • 10% have family history
  • F:M = 10:1, with onset during reproductive years (13-40)
  • More common in blacks and Asians
  • Can be secondary to drugs

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What is the criteria to diagnose SLE?

  • 4 or more of 11 must be present serially or simultaneously
    • “4, 7, 11 rule” à 4 out of 11 criteria (4 lab, 7 clinical)
  • 4 RASHES
    • 4 rashes: Malar rash, Discoid rash, Oral Ulcers, Photosensitivity
    • Renal – proteinuria (>0.5 g/day or >3+ dip) or Cellular Casts (RBC, Hb, granular, tubular, mixed)
    • Arthritis - ≥2 joints, symmetric, large or small, non-erosive
    • Serositis – Pleuritis, Pericarditis
    • Hematologic – Hemolytic anemia, Leukopenia, Lymphopenia, Thrombocytopenia
    • Excitation – seizures or psychosis
    • Serology
      • ANA (98% SN, not SP)
      • Anti-dsDNA and Anti-Sm (not SN, but >95% SP), anti-phospholipids or false positive VDRL
  • SOAP BRAIN MD
    • Serositis
    • Oral ulcers
    • ANA
    • Photosensitivity
    • Blood
    • Renal
    • Arthritis
    • Immune
    • Neurology
    • Malar rash
    • Discoid rash

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What investigations should be performed in patients suspected of having SLE?

  • CBC, GBCL, ESR, CRP
  • ANA (sensitive), anti-dsDNA (specific), C3, C4
    • ANA should be ordered when a patient has 2 organ systems of potential SLE origin that are otherwise unexplained
    • ENA panel ordered when ANA positive
    • Anti-dsDNA increases and Complement decreases with increasing disease severity
  • Urinalysis, ACR
  • Consider arthrocentesis for Cells, Culture and Crystals

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What are treatment options for the different complications of SLE?

  • Rituximab to treat underlying SLE pathology
  • Cutaneous lupus – sunscreen and hydroxychloroquine
  • Arthritis – NSAIDs, hydroxychloroquine, steroids, methotrexate
  • Nephritis and Neuritis – steroids, cyclophosphamide
  • Serositis – NSAIDs, steroids
  • Thrombocytopenia – steroids, IVID, splenectomy
  • Avoid exogenous estrogen – no OCP or HRT

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What are potential causes of drug induced lupus?

  • Anticonvulsants (phenytoin)
  • Antihypertensives (hydralazine)
  • Antiarrhythmics (procainamide)
  • Isoniazid (INH)
  • OCP can exacerbate

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How does drug-induced lupus differ from SLE?

  • Relative to SLE has:
    • Abrupt onset
    • Middle aged presentation
    • No gender preference
    • No racial discrimination
    • Less cutaneous, renal, neurologic and hematologic involvement
    • Similar joint, hepatic and constitutional symptoms

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What laboratory findings are expected in patients with drug-induced lupus?

  • Anti-histone positive
  • Anti-Smith/dsDNA negative
  • Complement normal

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What is the treatment for drug-induced lupus?

  • Discontinue offending agent

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What are two well-known types of drug reactions?

  • Erythema multiform
  • Serum sickness

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What is the etiology of erythema multiform?

  • Infection: HSV, Mycoplasma
  • Drugs: Sulfa, Penicillin, NSAIDs, anticonvulsants, allopurinol

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How does erythema multiform typically appear?

  • Classic “Bull’s Eye” pattern +/- bullae or erosions
  • Bilateral and Symmetric – usually asymptomatic rash
  • Can have mucosal involvement
  • Fever, Malaise, Weakness

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What is the treatment for Erythema multiform?

  • Stop Drug
  • Topical steroids, oral antihistamines
  • Acyclovir if HSV

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How does serum sickness present?

  • Symmetric drug eruptions with fever, arthralgia, LAD and rash
  • 5-10 days after the drug

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How should serum sickness be managed?

  • Symptomatic treatment with NSAIDs, Antihistamines
  • Oral steroids for more severe reactions
    • Temp >38.5
    • Extensive arthritis
    • Extensive rash