CAM Master List 7 PDF

Overview Dermis: hair follicles, nerve endings, sweat glands and connective tissue Skin Cell Formation: Diagnosis Criteria (CLAMPS TN): 1.​ Cell division: keratinocytes divide in the 1.​ Color deepest (basal) layer 2....

Overview Dermis: hair follicles, nerve endings, sweat glands and connective tissue Skin Cell Formation: Diagnosis Criteria (CLAMPS TN): 1.​ Cell division: keratinocytes divide in the 1.​ Color deepest (basal) layer 2.​ Location/distribution (extent, pattern) 2.​ Cell differentiation: as cells move up in the 3.​ Arrangement (grouped vs disseminated & dermis, they change shape and composition confluence (yes or no)) 3.​ Keratinization: cells secrete keratin 4.​ Margination (well or ill-defined) proteins and lipids to form a matrix that 5.​ Palpation (consistency, temp, mobility, protects the skin and gives it strength tenderness, depth) 4.​ Desquamation: the outermost layer of skin 6.​ Shape cells die and shed off from the skin 7.​ Type (papule, macule, pustule) 8.​ Number: single vs multiple (# of lesions) Papulo-Squamous Diseases ❖​Eczema/Dermatitis ❖​Dyshidrotic Eczema ❖​Lichen Simplex Chronicus ❖​Nummular Eczema ❖​Contact Dermatitis ❖​Stasis Dermatitis ❖​Atopic Dermatitis ❖​Seborrheic Dermatitis ❖​Perioral Dermatitis ❖​Fixed Drug Eruption ❖​Lichen Planus ❖​Pityriasis Rosea ❖​Psoriasis Eczema/Dermatitis Overview What? ❖​ Inflammatory reaction of epidermis & dermis ❖​ “The itch that rashes” Etiology ❖​ Multiple etiologies ❖​ Wide range of clinical findings Symptoms ❖​ Hyperkeratosis ❖​ Scaling ❖​ +/- fissuring Acute ❖​ Pruritus ❖​ Erythema ❖​ Vesiculation Chronic ❖​ Pruritus ❖​ Xerosis ❖​ Lichenification Eczema/Dermatitis Dyshidrotic Eczema Lichen Simplex Chronicus What Clinical Features ❖​ Localized lichenification in circumscribes ❖​ Acute, chronic, and recurrent plaques ❖​ Fingers, palms, soles ❖​ Thickened skin, excoriations ​ Lateral fingers and toes ❖​ Usually >20 y/o ❖​ F>M ❖​ Chronic - usually relapsing Symptoms ❖​ Sudden, deep-seated pruritic, clear “tapioca-like” vesicles Cause ❖​ Repetitive rubbing and scratching Complications ❖​ Painful when erosive Common Sites: ❖​ May develop bullae ❖​ Scalp, neck, extensor forearms, scrotum, and lower legs Treatment ❖​ Strong steroids Treatment ❖​ IL steroids ❖​ D/c scratching! ❖​ Severe cases: PO prednisone ❖​ Occlusive bandages ❖​ Topical steroids ❖​ Tar preps ❖​ IL steroids (small lesions) ❖​ PO hydroxyzine Eczema/Dermatitis Nummular Eczema Contact Dermatitis What? What? ❖​ Acute or chronic ❖​ Chronic Inflammatory ❖​ Etiology unknown ❖​ Most > 50 y/o Causes ❖​ M>F ❖​ Irritant: chemical (ex. hands) ​ Soaps, detergents, solvents Symptoms ❖​ Allergic: ​ nickel/jewelry, plants ❖​ Coin-shaped plaques of grouped small ❖​ **plastics, chemical residues on clothes, papules and vesicles on erythematous plants base ❖​ Working in the yard? Plant exposure? ❖​ Highly pruritic ❖​ Most common in legs and upper extremities Symptoms ❖​ Stinging, itching, burning, pain with Treatment fissures, weeps, crusting ❖​ Moisturizer ❖​ Topical steroid Presentation ❖​ PUVA or UVB (sunlight) ❖​ Well-demarcated erythema and edema, non umbilicated vesicles or papules Treatment ❖​ Remove etiologic agent ❖​ Wet dressings (Burrow’s solution - OTC) ❖​ Topical glucocorticoids ❖​ PO prednisone (if severe) Eczema/Dermatitis Stasis Dermatitis Atopic Dermatitis What? What? ❖​ Related to venous insufficiency ❖​ **not cellulitis** ❖​ Acute, subacute, chronic relapsing ❖​ Common in infancy, itch-scratch cycle ❖​ Frequent w/ personal or FHx AD, *Physical Exam* allergic rhinitis, & asthma ❖​ Skin barrier dysfunction, IgE reactivity ❖​ Inflammatory papules ❖​ Infantile, child, & adults types ❖​ Hyperpigmentation ❖​ Scaly and crusted erosions in lower legs and ankles Eliciting/Exacerbating Factors ❖​ Inhalants, microbials, aeroallergens, Treatment foods, season (winter), and emotional stress ❖​ Avoid scratching ❖​ Emollients throughout the day ❖​ Topical corticosteroids Symptoms ❖​ Wrap legs/compression stockings ❖​ Dry skin, pruritus ❖​ “The itch that rashes” ​ Itch > scratch > rash > itch > scratch > rash ❖​ Poorly defined erythematous patches, papules, & plaques with or without scaling *Treatment* ❖​ Avoid scratching ❖​ Wet dressings ❖​ Topical steroids ❖​ Topical or PO antibiotics ❖​ Hydration ❖​ Emollients ❖​ Topical calcineurin inhibitors ❖​ PO H1 antihistamines ❖​ PO steroids only for severe intractable cases Eczema/Dermatitis Seborrheic Dermatitis Perioral Dermatitis Risk Factors Risk Factors ❖​ Female 20-45 ❖​ Ages: infancy, puberty, 20-50 y/o ❖​ Fluoridated toothpaste ❖​ M>F ❖​ Topical corticosteroids ❖​ Worse in fall/winter (dry environment and stress) ❖​ Summer: worse in some, better in others Distribution ❖​ Common in immunosuppressed - HIV, Parkinson’s, nutritional deficiencies ❖​ Periorbital skin (zinc) ❖​ Spares the vermillion border Distribution Physical Exam ❖​ Scalp, face, genitalia, and body folds ❖​ Erythematous grouped papulopustules ❖​ “Cradle cap” - yellow greasy scales on that may become plaques with scales scalp ❖​ Can have satellite lesions ❖​ Often seen in hair bearing regions ❖​ May include perinasal and periorbital skin (eyebrows, central face, scalp) - looks like dandruff Treatment Physical Exam ❖​ Eliminate steroids and irritants ​ Cosmetics, skin care products ❖​ Pruritus ❖​ Topical metronidazole, erythromycin, or ❖​ Red plaques pimecrolimus ❖​ Greasy looking ❖​ Yellowish scales may be present on areas w/ plethora of sebaceous glands Treatment ❖​ Selenium sulfide (Selsen BLUE, Head and Shoulders) ❖​ Topical antifungals ❖​ Tar shampoo (neutrogena T-gel) ❖​ Mild topical steroids Eczema/Dermatitis Seborrheic Dermatitis Lichen Planus What? What? ❖​ Acute or chronic inflammation involving ❖​ Adverse cutaneous reaction to ingested skin or mucous membranes drug ❖​ 30-60 y/o ❖​ Resolves in a few weeks after d/c ❖​ F>M offending agent ❖​ Idiopathic Distribution Distribution ❖​ Solitary (or multiple) erythematous patch ❖​ Flexor creases of arm and legs or plaque ❖​ Usually asymptomatic ​ May have some pruritus, pain, or Symptoms burning ❖​ Sharpy demarcated macule, round or oval ❖​ 4 P’s: ​ Initially red, then dusky red ​ Papule to violaceous ​ Purple ​ May evolve to bulla, then erosion ​ Polygonal ​ Pruritic Causes *Treatment* ❖​ TCN ❖​ Sulfa ❖​ Topical or PO steroids ❖​ NSAIDs ❖​ Cyclosporine ❖​ OCPs ❖​ Others such as barbiturates, quinine, yellow food coloring *Treatment* ❖​ D/c drug ❖​ Topical steroids (non-eroded) ❖​ Antibiotic ointment (eroded) ❖​ PO steroids for severe mucosal lesions Pityriasis Rosea What? ❖​ Resolves spontaneously in 6-12 weeks ❖​ Acute rash, self-limited course ❖​ More common in the fall Etiology ❖​ Reactivation of HSV-7 & HSV-6 Symptoms ❖​ Initial: ​ Single, primary herald patch usually on trunk (80% of pts) ❖​ Secondary: ​ Eruption 1-2 weeks later ​ Fine scaling papules and patches in “christmas tree” pattern (lines of cleavage) on back ❖​ Herald patch: oval, salmon-red plaque or patch 2-5 cm with fine collarette peripheral scale Treatment ❖​ PO or topical antihistamines ❖​ Topical steroids ❖​ UVB phototherapy or natural sunlight ❖​ PO steroids Psoriasis Guttate Psoriasis History Taking What? ❖​ Usually a + FHx ❖​ All ages ❖​ Drop-like scattered (scaly) red to pink ❖​ M=F lesions - diffuse ❖​ Worse with stress, obesity ❖​ Often preceded by strep infection ❖​ +/- joint pain - psoriatic arthritis ❖​ Usually in children or young adults 10 days ❖​ Macule >papule > vesicles and bullae ❖​ Hands , feet, palms, soles, elbows, knees, mouth, torso, face, genitals Stevens-Johnson Syndrome / Toxic Epidermal Necrolysis What? Management ❖​ Acute life-threatening ❖​ Admit to ICU or burn center + d/c mucocutaneous reaction offending agent/drug ❖​ Necrosis and detachment of epidermis ❖​ IV fluids and electrolytes (treat as burn ❖​ Differ by % of body surface involved pt) ❖​ SJS < 10 % epidermal detachment ❖​ Narcotics for pain ❖​ TEN > 30 % epidermal detachment ❖​ Systemic glucocorticoids controversial (overlap 10-30%) ❖​ IVIG (if started early) ❖​ 90% of the time, mucous membranes ❖​ Surgical debridement not recommended affected - ocular, oral, and genital ❖​ Lasts approx 8-12 days ​ Rarely present on palms/soles Risk Factors ❖​ Higher incidence in HIV and active cancer ❖​ F>M ❖​ Often idiopathic or drug induced: anti-seizure meds, sulfa, allopurinol, NSAIDs Presentation ❖​ Usually 4 days to 4 wks after drug exposure ❖​ Fever, malaise, and arthralgias (flu like sx) for 1-3 days then… ❖​ Skin is sloughing off and painful - burning, paresthesia, etc - conjunctival burning/itching, and painful mouth lesions ❖​ Lesions: ill-defined, coalescing, Nikolsky Sign erythematous macules w/ purpuric centers or diffuse erythema ❖​ The ability to extend the area of ​ Pain out of proportion superficial sloughing by applying gentle ❖​ Lesions usually start on face and thorax lateral pressure on the surface of the skin and symmetric at an apparently uninvolved site ❖​ Pathognomonic for pemphigus - TEN Vesicular Bullae ❖​Bullous Pemphigoid ❖​Pemphigus Bullous Pemphigoid What? ❖​ Autoimmune disease of elderly pts (60-80 years) Symptom ❖​ Pruritic, large, tense, bullae scattered but also in groups ❖​ Often started with urticarial eruption ❖​ Don't rupture as easily as pemphigus Distribution ❖​ Axillae ❖​ Medial thigh ❖​ Groin ❖​ Flexor UE ❖​ Lower LE ❖​ Can be in the mouth Treatment ❖​ PO or topical steroids 50 - 100 mg OD ❖​ Immunosuppressives Pemphigus What? ❖​ Chronic or acute ❖​ Bullous autoimmune disease ❖​ Adults 40-60 Symptoms ❖​ Usually starts in mouth ❖​ No pruritus ❖​ Burning and painful Distribution ❖​ Scalp ❖​ Face ❖​ Chest ❖​ Axillae ❖​ Groin ❖​ umbilicus Physical Exam ❖​ Vesicles and bullae ❖​ Easily rupture ❖​ Flaccid and weeping ❖​ + Nikolsky sign Treatment ❖​ Dermatologist ❖​ High dose steroids and immunosuppression Acneiform Lesions ❖​Acne Vulgaris ❖​Rosacea ❖​Folliculitis ❖​Hidradenitis Suppurativa Acne Vulgaris Comedones What ❖​ Open = blackheads ❖​ Closed = white heads ❖​ Inflammation of pilosebaceous units Course Risk Factors ❖​ Often clears by early 20’s ❖​ Primarily young people (on face, trunk, ❖​ Flares in winter and with onset of menses upper arms, and sometimes buttocks) ❖​ More severe in males than females ❖​ Less often in Asians and African Treatment Americans ❖​ Cystic acne can be familial ❖​ Long term goal is scar prevention ❖​ Worse in fall and winter ❖​ Remove plugging, treat bacteria ❖​ Mild: ​ Topical antibiotics (clindamycin Pathogenesis and erythromycin 3%, 5%, BID) ​ Benzoyl peroxide gels 2%, 5%, 10% ❖​ Follicular keratinization, androgens, ​ Bleaches fabrics propionibacterium acnes ​ Can get in combo ​ Topical retinoids: ​ Gradual inc in strength Follicular Plugging from 0.01%, 0.025%, 0.05% cream, gel, liquid, ❖​ (comedone) traps sebum → androgens or ointment produce more sebum → bacteria produce ​ Retinoic acid, Adapalene, inflammatory response tazarotene ​ Can't use if pregnant ❖​ Moderate: same regimen for minor Contributing Factors PLUS ​ PO antibiotics (minocycline ❖​ Meds (lithium, isoniazid, steroids, OCP, 50-100 mg or doxycycline 50-100 androgens) mg BID tapered to 50mg as acne ❖​ Stress lessens) ❖​ occlusion/pressure (hand on face) ​ Spironolactone 25-50 mg QD ❖​ Cosmetics, pomade, sweat ❖​ Severe: same as above w/ PO isotretinoin for cystic or refractory acne ❖​ PO isotretinoin - complete remission Presentation for months to years - inhibits sebaceous gland function and keratinization ❖​ Seen with comedones (must have for ​ Extremely teratogenic diagnosis) cysts, pustules, and/or ​ NEED effective contraception + 2 nodules negative preg test prior ❖​ Can result in pits, depressions, scars, or ​ Pseudotumor cerebri when used in hyperpigmentation combo w/ tetracycline ❖​ Nodulo-cystic type can be painful ​ Can cause elevated triglycerides & mild - mod elevations of transaminases ​ Dry skin & mucosa ​ Can cause depression Rosacea What Treatment ❖​ Chronic inflammation of facial ❖​ Reduce of eliminate alcohol & caffeine pilosebaceous units ❖​ Metronidazole gel or cream, ivermectin ❖​ Recurrences common; usually lifetime cream ❖​ 30-50 y/o ❖​ Topical antibiotics ❖​ F>M ❖​ PO antibiotics better than topical (minocycline, doxycycline, TCN) - papulopustular rosacea Physical Exam ❖​ PO isotretinoin for severe disease ❖​ Surgery for rhinophyma ❖​ Episodic erythema ❖​ Telangiectasia (lasers) ​ “Flushing and blushing” ❖​ Stages I, II, III: ​ Persistent erythema, telangiectasis, papules, tiny pustules, nodules ❖​ No comedones Triggers ❖​ Hit liquids, spicy foods, alcohol/wine, aged cheese, exposure to sun & heat, stress Duration ❖​ Days, weeks, months Late Stage ❖​ Rhinophyma ❖​ Metophyma ❖​ Blepharophyma ❖​ Otophyma ❖​ Gnatophyma Distribution ❖​ Symmetric on face ❖​ Rarely on neck, chest, back and scalp Folliculitis What? ❖​ Inflammation or infection of superficial hair follicles ❖​ More common males Etiology ❖​ Most common staph aureus ❖​ Hot tub → pseudomonas aeruginosa Risk Factors ❖​ Prolonged antibiotic use ❖​ Topical corticosteroids ❖​ Hot tubs Presentation ❖​ Perifollicular papules and /or pustules w/ surrounding erythema ❖​ Hair bearing skin ❖​ Often pruritic Treatment ❖​ Benzoyl peroxide wash (bleaches) ❖​ Topical mupirocin, clindamycin, erythromycin ❖​ If no improvement → PO cephalexin Hidradenitis Suppurativa What? Pathogenesis ❖​ Chronic, suppurative ❖​ Follicle plugging > dilated follicle & ❖​ Apocrine gland skin apocrine ducts > inflammation > bacterial growth > extension of suppuration/tissue destruction > ulceration, fibrosis, sinus Etiology tracts > scarring ❖​ No known etiology Treatment Distribution ❖​ Usual spontaneous remission at > 35 y/o ❖​ Intralesional steroids then I&D abscess ❖​ Axillae, inguinocrural, anogenital, ❖​ Prednisone for severe pain and inframammary, rarely scalp inflammation ❖​ F (axillae) > M (anogenital) ❖​ Surgery (excision, skin grafting) ❖​ Isotretinoin for early disease ❖​ Adalimumab (Humira) Risk Factors ❖​ Psychological ❖​ Obesity, smoking, genetic predisposition to acne ❖​ FHx: NC acne & NS Presentation ❖​ Lesions: ​ Tender open & double comedones ​ Red nodules/abscesses ​ Sinus tracts ​ “Bridge” scars ​ Hypertrophic & keloidal scars ​ Contractures