Dermatology Notes PDF

# **Module 9: Urticaria, Erythemas, Drug Reactions** ## **Urticaria** - Erythematous wheals - Types: spontaneous, cold, solar, delayed pressure, dermographism - Acute < 6 weeks - Chronic > 6 weeks - 50% is idiopathic so they do not require work-up - 40-50% autoimmune -...

# **Module 9: Urticaria, Erythemas, Drug Reactions** ## **Urticaria** - Erythematous wheals - Types: spontaneous, cold, solar, delayed pressure, dermographism - Acute < 6 weeks - Chronic > 6 weeks - 50% is idiopathic so they do not require work-up - 40-50% autoimmune - thyroid - Can be associated with H. pylori - Treatment: - First - antihistamine daily - Second - antihistamine 4x daily - Third - Dupixent, doxy, cyclosporine - Do labs - Fourth - Allergist = Zolair +- cetirizine - Keep in mind: - If you know the trigger take it away - If only angioedema is present do a work up - Normally no constitutional symptoms but if present do a work up ## **Common Drug Reactions** - Most common is Penicillin - Most severe - Bactrim ## **Morbilliform rash/exanthematous** - normally generalized on the trunk - Normally appear 7-14 days - Most common drug reaction and present with penicillin and bactrim ## **Red Man syndrome - Vancomycin** - macular erythema on back of neck, spreads to trunk, face, and arms - Pruritus - Tx: - Sometimes hypotension - Antihistamines, topical steroids and slow-down infusion ## **Fixed Drug Eruption** - round/oval patches that are fixed to one spot - 1-2 weeks after first exposure to drug - More lesions if continued exposure - Most common cause- NSAIDs (naproxen) - Rule out cupping ## **Photosensitivity - UVA exposure** - Phototoxic - no sensitization - Looks like a really bad sunburn - Caused by NSAID, Doxy/tetracycline, Hydrochloro - Photoallergic - prior sensitization required - Can resemble lichen planus - Caused by sulfa medications ## **Erythema Multiforme** - Minor - Associated with HSV - No systemic sx’s - No/Mild mucosal involvement - Major - Associated with Mycoplasma but can also be HSV - Systemic sx’s - Significant mucosal involvement - Treatment: - Valacyclovir - antiviral - Topical steroid for itching - Oral steroid if severe ## **Stevens-Johnson Syndrome & Toxic Epidermal Necrolysis (TEN)** - Due to a drug eruption 7-21 days after taking the drug - Mucosal involvement, organ damage, peeling skin - Common drugs: allopurinol, sulfa, anticonvulsants - Body surface area: - <10% Steven Johnson - 10-30% Both - >30% TEN - Prognosis: heavily dependent on how quickly you discontinue the drug - 30% drop in death per day - SCORTEN - prediction of mortality (day 1 and 3) - 5% Steven Johnson - 30% TEN - Treatment: - Death mainly due to staph and pseudo - If survive - burn unit, gynecology, ophthalmology # **Module 10: Vesiculobullous Diseases** ## **Pemphigus Vulgaris** - Autoimmune epidermal blistering disease in the spinosum - Blood work to test for desmoglein 1 + 3 - +Nikolsky, Asboe-Hansen signs indicate the blister can move/tear - Do not allow someone with this to go through surgery - Treatment: - Oral steroid - Rituximab if worsening ## **Bullous Pemphigoid** - Autoimmune subdermal blistering disease at the DEJ - Most common subepidermal autoimmune - The blister is tense and cannot move/tear - Associated with neurological disorders (MS, Stroke, Bipolar, Dementia, Parkinson’s etc.) - Treatment: - Mild - topical steroid then doxy - Moderate + severe - topical steroid, oral steroid then rituximab ## **Dermatitis Herpetiformis** - Cutaneous manifestation of Celiac Disease and HLADQ2 - Anyone who comes in with GI sx’s - Strong association with thyroid disease - Grouped vesicular papules that are ITCHY - Treatment: - Cut out gluten - If they do not want to cut it out then dapsone - Test for G6PD deficiency - **Testing for all of the above:** - 1. Intralesional - HE - formalin - 2. Perilesional - DIF - Michael # **Module 11: Malignancies of the Skin** ## **Actinic Keratosis** - Small, dry, rough, erythematous and flaky - Can feel it before seeing it - Precancerous from sun exposure - 10% will become SCC - Treatment: - Couple lesions - Cryotherapy (LN) - Multiple lesions - 5 FU BID for 2-4 weeks ## **Basal Cell Carcinoma** - most common and rare to metastasize. Increased risk with sun exposure and a genetic component - Superficial BCC: affects epidermis - Treatment: - ED&C, 5FU, surgery - Nodular: red, raised, scaly, telangiectasias - Bleed easily with pearly shiny appearance - Treatment: - Excision - MOHS - Biopsy: shave ## **Squamous Cell Carcinoma** - Red, scaly papule, nodule, or plaque - The second most common skin cancer - Most Dangerous form of skin cancer - most likely to metastasize (lip higher metastasis) - RF: - Sun exposure, HPV, smoking, immunocompromised, Lichen sclerosis/planus, chemical exposure - Treatment: - In situ - epidermis - ED & C + topical 5FU - Invasive - dermis - Excision + MOHS - Biopsy: shave ## **Melanoma** - The most common type is superficial - F/U with derm every 3 months for the first 2 years - Dysplastic nevi: - Mild/moderate - reassurance - Severe - MIS - Most important factor is depth - MIS (melanoma in situ) excision with 1 cm margins - < .8mm you do a wide excision - > .8mm refer to general surgery - How to identify: - Asymmetry - Border - Color - Diameter - Evolving - Biopsy: Deep Shave ## **Merkel Cell Carcinoma** - Very aggressive and rare form - Large nodule that arises out of nowhere - Biopsy: Punch or shave - Referral - oncology ## **Kaposi Sarcoma** - Rare cancer from the cells lining the blood vessels or the lymph - Association with HHV8 - History of immunocompromised or organ transplant # **Module 12: Pigmentary Disorders** ## **Melasma** - Symmetric (BL) hyperpigmented macular patches - On regions of the body that is sun exposed like on the face - cheeks, forehead, neck - Can be light brown or dark brown colored - RF: - Female - Pregnancy - Oral contraceptives - Fitz scale 3-4 - Treatment: - Will take long to respond - Hydroquinone can lighten the spots - Always wear sunscreen AND reduce UV exposure ## **Post Inflammatory Hyperpigmentation** - Hyperpigmented macular patch/plaque - Following an injury or a trauma - Common in FITZ 4 - 6 - Treatment: - Resolves within 6-12 months - Sunscreen - Hydroquinone can speed up the process if pt is bothered by it ## **Acanthosis Nigricans** - Hyperpigmented velvety patches or plaques - Dark hyperkeratosis - On the neck, axilla, groin, mammary - Linked to: - Insulin Resistant - Obesity - Metabolic disorder - Treatment: - Topical retinoid - Keratolytics (lactic acid, salicylic, glycolic acid) - Microdermabrasion ## **Vitiligo** - Depigmented macules and patches with demarcations - Destruction of melanocytes leading to depigmentation - RF: - Thyroid - Family history - Treatment: - Sunscreen always and avoid the sun - First line: - Topical steroid - Tacrolimus ointment (calc inhibitor) - Topical Vitamin D - Second line: - Opzelura cream - Jak 1/2 (this is the best treatment but insurance will not cover until the first line is tried) ## **Lichen sclerosus** - Ivory white itchy atrophic papule with a pink rim - Risk Factors: - Autoimmune dysfunction - Skin disease prior - Family history - Thyroid history, anemia, areata - Presentation: - Labia minora - genitals - causing a lot of inflammation and scarring - Often on women (10:1 ratio with men) - Diagnosis: - Biopsy any unhealing scar that could be SCC - Treatment: - First line - medium/high potency steroid - Second line - systemic steroid, oral retinoid, methotrexate or cyclosporine - Laser/PRP/Surgery can help # **Module 13: Wounds, Burns, Ulcers** ## **Pressure wounds** - Bed sores due to compression from bony prominent to the extensor surface with an increase in friction, moisture and pressure - Common on: - Heels, sacrum, malleolus, greater trochanter - Risk factors: - Sensory deficits, increase in age, poor nutrition, prolonged immobility - Stages: - First - intact skin - Second - shallow ulcer with the skin open - Third - less to the fascia - Fourth - bone and muscle involvement - Treatment: - Prevention - Manage the moisture and friction - If stage 4 then go to operating room - Sepsis may occur ## **Arterial LE ulceration** - Punched out appearance - Severe pain (esp with movement) - Dependent rubor - Pallor on elevation - Shiny atrophic skin - Alopecia in the area - Diagnose with ankle-brachial index - No compression socks - will construct blood flow ## **Venous Stasis** - Most common vascular disease in the world - Main cause of ulcers (70%) - Commonly found on lower leg, Medial Malleolus - RF - Tabacco use - Diabetes - Prior DVT, VTE, thrombophlebitis - Obesity, immobility, FH - Associated findings: - Irregular boarders - Absent or minimal pain - Hemosiderin staining - Reverse champagne bottle - Heaviness/achiness in feet - Tx: - Compression socks - Diagnose with Venous Duplex Ultrasonography ## **Stasis Dermatitis** - Dry pruritic scaly hyperpigmented rash on the LE due to venous insufficiency - Asymptomatic at first then will notice skin changes - Class 4 on the spectrum - Hyperpigmentation = hemosiderin = RBC breakdown - Lipodermatosclerosis = woody texture - Atrophie blanche = white scarred tissue (advanced) - Always get a venous US duplex doppler - Treatment: - Compression stockings for 3 months - Steroid to help with the itchy if it is not an open wound - Oral antibiotics if cellulitis is present and a referral to vascular - Elevation above heart level - Wound care - Walking + PT + Weight reduction # **Module 15: Derm Clinical Skills Workshop** ## **Shave Biopsy** - for lesions above the skin surface - Skin tag - Intradermal nevus - Cutaneous horn - Epidermis/dermis 1-4mm deep for skin cancer concern ## **Punch Biopsy** - Goes deeper than a shave biopsy. Ideal for those on blood thinners (they can be sutured but need to come back to get them removed) or a cosmetically sensitive region. 3-4 mm tool - Rashes - Blistering eruption - Autoimmune disease - Vasculitis - Erythema Nodosum ## **Cryotherapy** - non invasive technique using cryogen to remove benign and premalignant lesions (LN) - must do TWO freeze thaw cycles to help destroy the tissue - Vascular ischemia - Cell membrane destruction ## **Safety Pause** - Most important step - Have specimen bottle ready with labels - Verify pt’s name and DOB, and that the location marked matches - Do not rely on anyone else to do this for you.