Acute Dermatologic Conditions

Acute Dermatologic Conditions

• Impetigo is a contagious infection, prominent on exposed face and extremities
• Impetigo is most common in children; those infected should be kept out of school for 48 hours.
• Risks: Sports, daycare, and warm/humid environments.
• It appears as small superficial vesicles that are "honey crusted".
• Treat with topical mupirocin (Bactroban) TID and wash with antibacterial soap or chlorhexidine (Hibiclens).
• Fifth disease is a common viral infection (Parvovirus B 19) that presents with an eruptive rash and other symptoms like sore throat, mild fever, runny nose, nausea, headache, and itching.
• The infection is not contagious once the rash develops, and the patient can return to school.
• Phase 1 involves "slapped cheek" syndrome with circumoral pallor for 2-4 days.
• Phase 2 presents with erythematous maculopapular rash on extremities and trunk, fading into a centrally clear, lacy pattern that lasts 1-6 weeks.
• Phase 3 is a persistent, variable rash that worsens during heat, stress, and sunlight and lasts 1-3 weeks.
• Pregnant women can pass the virus to the fetus, so urgent referral to a specialist is needed.
• Treatment is supportive.
• Hand-foot-and-mouth disease is a highly contagious viral illness (Group A coxsackievirus) with lesions on the buccal mucosa, palate, palms, soles, feet, and buttocks
• It is common in children but can still affect adults.
• This illness is self-limiting, usually resolving in 7-10 days.
• Symptoms include fever, URI symptoms, sore throat, and painful mouth lesions preceding skin lesions and rash
• Symptomatic care is the treatment, avoid aspirin in children with febrile illnesses to prevent Reye's syndrome (swelling in the liver and brain).
• Erysipelas is a distinct form of cellulitis marked by acute, well-demarcated, superficial bacterial skin infection, typically on the face, scalp, and extremities.
• The most common pathogen is Streptococcus pyogenes.
• Symptoms include fever, headache, vomiting, chills, and arthralgia.
• Treated with penicillin, Bactrim, or cefazolin, chronic form exists.
• Staph infections typically present with erythema, warmth, tenderness, swelling, an indurated center, and possible abscesses.
• Other symptoms include tenderness, heat, pain, oozing, swelling, and redness.
• Risk factors: "spider bite", HX of MRSA, athlete.
• Wound cultures are recommended for purulent lesions with systemic signs of illness.
• Treat with Trimethoprim-sulfamethoxazole (Bactrim), Doxycycline, or Clindamycin.
• Cat Scratch Disease presents as subacute tender lymphadenitis after contact with a cat, the scratch being most common.
• At the contact site, a red macule emerges and develops into fluid-filled vesicles and crusts, along with unilateral lymphadenopathy.
• It lasts 1-2 weeks and may persist for 2 to 8 weeks.
• Typically self-limiting, resolving in 2 to 6 months.
• Treatment includes analgesics and antibiotics for immunocompromised individuals.
• Pityriasis Rosea is an idiopathic, self-limited skin eruption, mostly on the face trunk and distal extremities
• Hallmark sign: 2-10cm salmon-colored oval patches or plaque known as herald patch that precedes the generalized rash 1-2 weeks later. Oval lesions appear parallel to each other "Christmas tree rash".
• Treat mild pruritus with oral or topical antihistamines and topical steroids or oral steroids if itching is severe
• Resolves in 6-12 weeks

Herpangina

• Herpangina is a viral infection that causes fever and multiple vesicles, followed by painful mouth ulcerations involving the soft palate, uvula, and tonsils transmitted by fecal-oral route or resp droplet.
• Acute symptoms: fever, sore throat, yellowish/grey/white vesicles surrounded by red halo
• Symptomatic treatment: analgesics and topical anesthetics
• Resolves in 7-10 days but viral shedding lasts 4 to 6 weeks

Oral Candidiasis

• Oral Candidiasis is a fungal infection of the mouth membranes that may affect the throat, esophagus, and trachea
• It is identified via white oral plaques present on an erythematous base
• Risk factors include immunocompromised individuals, use of inhaled corticosteroids, antibiotics, dentures, and infants under 6 months
• Treatment: oral antifungal agents such as Nystatin oral suspension, and fluconazole (Diflucan)
• It resolves within 2 weeks

Diaper Dermatitis

• Diaper Dermatitis is an acute inflammation of the skin in the region of the perineum, buttocks, lower abdomen, and inner thighs
• Occurs in pediatric patients and adults with urinary or fecal incontinence due to prolonged contact with wet/soiled diapers
• Treat: leave open to air if possible, skin barrier ointment (zinc oxide), topical antifungal, topical low-potency corticosteroid (combo products on market)

Tinea Infections

• Tinea versicolor is a fungal infection with well-marginated lesions of varying color (white, red, brown)
• Common locations are the shoulders, chest, back, and axilla.
• Risk factors: hot, humid climates, wet clothes
• Tinea pedis is a fungal infection of the feet with itching, odor, burning, maceration in toe webs, scaling, or blistering on soles of feet
• Risk factors: athletes, immunocompromised
• Onychomycosis is a fungal infection of the fingernails/toenails
• Risk factors: immunocompromised, tinea pedis, PVD, older adults, and communal swimming pools
• Treatment includes oral antifungals.
• Tinea capitis is a fungal infection of the scalp
• Appears as round, patchy scales on the scalp with or without alopecia
• Requires Griseofulvin orally for 4 to 6 weeks, taken with a high-fat diet wear sunscreen due to
• Intertrigo is a superficial fungal skin infection in intertriginous areas with increased warmth, humidity, or friction
• Classic case is an obese patient complaining of bright-red and shiny

Paronychia

• It's a localized superficial infection of the perionychium, which is the skin bordering the nails.
• Staphylococcus aureus is most common pathogen that causes this
• Risks: nail-biting and ingrown nails

Pediculosis

• Pediculosis is an infestation of the body, head, or pubic area by lice, with an incubation period of 1 month.
• Head and body lice are common in children.
• Risks include prolonged proximity to infected people and sharing hats/combs

Acne

• Skin type is important when treating acne
• For dry skin, use creams and lotions
• For oily skin, use gels and solutions
• For hairy areas use lotions and foams
• Treatment selection should be based on acne severity, present and past treatments
• Systemic treatment is indicated for moderate to severe inflammatory acne resistant to topical therapy
• Systemic therapy should always be used with retinoid or benzoyl peroxide.
• Topical antimicrobials include Benzoyl peroxide, Dapsone, Clindamycin or Erythromycin
• Benzoyl peroxide is pregnancy category C and may bleach hair or clothing, and can cause dryness, redness, and peeling
• Dapsone is pregnancy category C and may cause temporary yellow or orange skin and hair
• Clindamycin or Erythromycin is pregnancy category B, and should not be used alone due to antibiotic resistance, so always use benzoyl peroxide or retinoid
• Topical Retinoids- include Tretinoin or Adapalene, PC C
• Each binds to a different set of retinoic acid with slight differences in efficacy, tolerability, and activity so will likely cause skin irritation, start 2-4 times per week an advance to nightly use as tolerated.
• Use Tretinoin cautiously in people with fish allergies
• Common side effects are dry skin, peeling, scaling, burning sensation, erythema, pruritus, sunburn, and change in pigmentation
• Combination Topicals
• Use Benzoyl peroxide + retinoid
• Or Benzoyl peroxide + antibiotic
• Or Retinoid + antibiotic
• Systemic Acne Treatment
• Tetracyclines- NEVER give to children under 8 years of age or pregnant due to risk of permanent bone/teeth discoloration
• Do not use as monotherapy; use in conjunction with topical benzoyl peroxide to prevent antibiotic resistance or topical retinoid to improve results and remember that treatment may take 2 to 4 months
• Macrolide
• Erythromycin is a 2nd line option if cannot tolerate tetracycline
• Use with topical retinoid to improve results but not with topical antibiotic and remember that resistance up due to overuse
• Combined Oral Contraceptives
• Are only approved for acne in women who also desire contraception
• Not to be used as first line therapy

Shingles

• Shingles are treated with the following
• Antiviral like Valacyclovir, or Acyclovir which needs more frequent dosing but less expensive
• Pain control with NSAID and Capsaicin Cream
• Avoid use of topical antibiotics
• May take up to 3 weeks for rash to resolve
• Pain may last for 3 months or more

Dermatitis and Corticosteroids

• Don't use oral steroids if a patient has diabetes or a suspected infection.
• Topical corticosteroids are the most common therapy
• The medication should be used for the shortest duration to prevent cutaneous atrophy
• Choose optimal vehicle (ointment, cream, lotion, solution, gel, foam).
• Treatment options include cortisone, Triamcinolone, Betamethasone
• Use only mild potency for the face, neck, groin, or axilla, and avoid using fluorinated topical steroids on the face
• Prescribe an appropriate amount; whole body coverage takes 30 gms, estimate amount to prescribe by calculating whole body x % needing medication using Rule of 9’s

Infestations

• Scabies or lice
• Permethrin
• Ivermectin
• Malathion
• Bedbug or flea bites
• Corticosteroid topicals
• Repeat treatment in one week to kill eggs
• Treat all household members/sexual partners
• Caution: Malathion is highly flammable and a poison

Common Derm Terms

• Lesion: any single area of altered skin which may be solitary or multiple.
• Rash: widespread eruption of lesions.
• Dermatosis: a skin disease.
• Nummular lesion: round (coin-shaped) lesions also known as discoid.
• Linear-shape lesion: often occurs for some external reason such as scratching, also striate.
• Concentric rings: like a dartboard, also known as iris lesion.
• Gyrate rash: rash appears to be whirling in a circle.
• Annular: lesions grouped in a circle.
• Erythroderma: affects the whole body or most of the body, which is red all over.
• Telangiectasia: name given to prominent cutaneous blood vessels.
• Purpura: bleeding into the skin which may appear as petechiae (small red, purple or brown spots) or ecchymoses (bruises), purpura does not blanch with pressure (diascopy).
• Macule: an area of color change less than 1.5 cm diameter with a smooth surface.
• Patch: a large area of color change with a smooth surface.
• Papule: small palpable lesions that are less than 0.5 cm diameter, raised above the skin surface, and may be solitary or multiple. Some authors allow up to 1.5 cm.
• Vesicle: small fluid-filled blisters less than 0.5cm diameter which may be single or multiple.
• Pustule: purulent vesicle that is filled with neutrophils and may be white, or yellow, and may be infected.
• Bulla: a large fluid-filled blister that may be a single compartment or multiloculated.
• Abscess: localized collection of pus.
• Weal: oedematous papule or plaque caused by swelling in the dermis which often indicates urticaria.
• Distribution: skin lesions are scattered or spread out, may be isolated (solitary or single) or multiple, localization of multiple lesions in certain regions helps diagnosis as skin diseases tend to have characteristic distributions.
• Acral: affects distal portions of limbs (hand, foot) and head (ears, nose).
• Blaschko lines: roughly linear, segmental pattern thought to be indicative of somatic mosaicism.
• Dermatomal: corresponding with nerve root distribution.
• Extensor: involving extensor surfaces of limbs, in contrast with flexor surfaces.
• Flexural: involving skin flexures (body folds); also known as intertriginous.
• Follicular: individual lesions arise from hair follicles which may be grouped into confluent plaques.
• Generalised: universal distribution that may be mild or severe, scattered or diffuse.
• Herpetiform: Grouped umbilicated vesicles, as arise in Herpes simplex and Herpes zoster infections.
• Koebnerised: Arising in a wound or scar. The Koebner phenomenon refers to the tendency of several skin conditions to affect areas subjected to injury.