Dermatology Midterm Study guide.docx

1. Identify and describe skin anatomy and the embryonic sources of the skin structures. a. [3 layers:] i. **Epidermis** ii. **Dermis** iii. **Subcutaneous tissue** b. Important Layers of the Epidermis: iv. **Stratum Corneum:...

1. Identify and describe skin anatomy and the embryonic sources of the skin structures. a. [3 layers:] i. **Epidermis** ii. **Dermis** iii. **Subcutaneous tissue** b. Important Layers of the Epidermis: iv. **Stratum Corneum: Dead Keratinocytes, thickest layer, waterproof barrier of the skin** v. **Stratum Basale: Living Keratinocytes, creates all other keratinocytes, produces all layers of the epidermis, contain melanocytes and other living skin cells** c. Embryology of the Skin: vi. Ectoderm 1. Epidermis 2. Associated glands vii. Mesoderm 3. Dermis 4. Hypodermis viii. Neural Crest 5. Pigment cells 6. Specialized sensory organs ix. Interactions between mesoderm and ectoderm important in formation of hair follicles d. **[Glabrous Skin]** e. No hair follicles or sebaceous glands x. Occurs on palms and soles xi. Distinct ridges - dermatoglyphics xii. Thick epidermis xiii. Encapsulated nerve endings f. **[Hairy Skin/Nonglabrous]** xiv. Hair follicles and sebaceous glands present xv. Occurs on most body surfaces xvi. Varies greatly from area to area (thickness of epidermis, dermis, types of hair -- vellus or terminal, type of sweat glands) xvii. Unencapsulated nerve endings 2. Describe skin pigmentation. g. **Pheo-Melanin=Red Colored skin** h. **Eu-Melanin=Black, Brown and Tan Colored Skin** i. **Both are produced by Tyrosine** 3. Identify the accessory structures of the integument and understand structure and function of these structures (sweat glands, hair follicles, nerve endings). j. **Eccrine Sweat Glands=Most of body, clear sweat, no smell, open onto body/not hair follicle** k. **Apocrine Sweat Glands=Armpits and Groin, milky Sweat, smelly, open into hair follicles** l. **Hair Follicles= Harbor Vasculature and Nerves for the skin for sensory sensation, also serves to grow hair** m. **Tactile Corpuscle= Nerve ending in the dermis which sense pressure and vibration, primary sensory nerves of the skin, accommodate with nerves in the hair for soft fine touch** 4. Discuss the various functions of the integument and how they are accomplished. n. **Barrier:** xviii. o. **Temp Regulation:** xix. Resists water evaporation, maintaining heat xx. Retains heat by shunting blood flow from cooler superficial vessels in dermis to deeper tissues xxi. Subcutaneous fat insulates xxii. Eccrine glands produce sweat which evaporates, dissipating excess heat p. **Sunscreen:** xxiii. Melanin (produced by melanocytes) packaged into melanosomes and distributed into keratinocytes xxiv. Melanin shields nuclei (DNA) from UV exposure 7. Excessive UV B results in sunburn 8. Excessive UV A results in wrinkles 9. Mutations accumulate through lifetime of exposure q. **Immune Barrier:** xxv. Antimicrobial peptides produced by keratinocytes xxvi. Immune cells (derived from bone marrow (B and T lymphocytes, plasma cells, monocytes and Langerhans cells) surveillance for infection, malignancy, toxins xxvii. UV decreases immune cell effectiveness r. **Critter Habitat:** xxviii. Commensal bacterial and yeast colonization xxix. Protect against colonization by potentially harmful bugs xxx. Normal flora recovers from reasonable washing xxxi. Antibacterial soaps may cause more harm than good 5. Describe skin lesions in medically appropriate language: **Study Lesion Flashcards on Quizlet** 6. Apply simple therapeutic measures such as drying therapies, emollients, and topical corticosteroids. s. **"If it's wet, dry it; if it's dry, wet it."** xxxii. Oozing wet lesions benefit from drying xxxiii. Dry scaly lesions benefit from emollients and often from topical steroids t. **Benefits of Topical corticosteroids:** u. Anti-inflammatory v. Decrease mitosis in epidermal cells w. Constrict blood vessels x. **Work for many conditions (but not for all!)** 7. Discuss the adverse effects of topical corticosteroids and how to minimize these AEs. y. **Adverse Effects:** xxxiv. Atrophy xxxv. Striae -- "stretch marks" xxxvi. Masking of underlying condition (e.g. tinea incognito) z. **Solutions for these AE's** xxxvii. Possible suppression of adrenal cortical function (large areas, occlusion, thinner skin) xxxviii. Use the proper potency for the lesion, for the shortest effective time. Alternate with non-steroid therapy when appropriate. 8. Describe the differences between acute eczematous inflammation (caatitis), eczema (atopic dermatitis), and urticaria in causation and pathophysiology. a. **Acute Eczematous Dermatitis (Contact Dermatitis):** xxxix. This is NOT Eczema-dermatitis does not mean eczema xl. **Delayed hypersensitivity reactions (Type IV)** xli. **We see erythema, edema and vesicles** xlii. Often weeping and pruritis, sometimes severe xliii. **Secondary to contact with an allergen** 10. *Plants (Poison Ivy, oak and sumac {rhus dermatitis})* 11. *Topical meds (Neomycin, benzocaine)* 12. *Nickel (Costume jewelry)* 13. *Personal care products(preservatives, perfume)* 14. *Latex/Rubber* b. **Eczema (Atopic Dermatitis):** xliv. **Eczema (especially in young children) often occurs with asthma, allergic rhinitis, IGE mediated allergic disease and is often familial** xlv. Irritants, including chemicals, water exposure, friction may contribute to sub-acute and chronic inflammation xlvi. **[Criteria to be Eczema (Atopic not Acute Contact dermatitis)]** 15. **Pruritus** 16. **Young age at diagnosis** 17. Typical morphology and distribution 18. **Flexural lichenification and linearity in adults** 19. **Facial and extensor involvement in children** 20. **Sparing of the groin and axillary regions** 21. Chronic, or chronic and relapsing course 22. **Personal or family history of atopy (asthma, allergic rhinoconjunctivitis or atopic dermatitis)** xlvii. Eczema can be irritated further by: 23. Low humidity 24. Contact irritants (personal care products, scents, etc.) 25. Rough fibers (wool) 26. Frequent washing with drying soaps/detergents 27. Emotional stress 28. Possibly inhaled and ingested allergens xlviii.  c. **Urticaria (Hives):** xlix. **May be acute (less than 6 weeks) or chronic** l. **Usually intensely itchy** li. **Transient erythematous plaques -- each individual lesion lasts less than 24 hours** lii. Variable sized lesions, round to oval, when confluent polycyclic liii. Often (but not always) allergic liv. **Immediate hypersensitivity (Type I)** 9. Be able to recognize common skin manifestations of allergic disease. d. **Acute Eczematous Dermatitis Presentations** lv. Blister (Bollus) lvi.  Vesicles Nickel Related (See Belt below) lvii. Vesicles Neomycin Allergy lviii. Response to PPD in hair dye/Henna lix. **Subacute ED** lx. More Scales, less intense than above lxi. **Chronic ED** lxii. Lichenification/Excoriation e. **Atopic Dermatitis (Eczema/Non Contact dermatitis)** lxiii. "Hand Eczema" Adult lxiv. "Foot Eczema" Adult Lichenification lxv. Nummular Eczema, Plaques on Extremities lxvi. Hyperkeratotic Eczema, Lichenification lxvii. Scales/Erosion of fingers lxviii. Pompholyx, Vesicles, Puritic lxix. Thick Scales on Lower extremities lxx. Keratosis Pilaris, no treatment needed lxxi. Autosomal Dominant Ichthyosis Vulgaris, flares up strongly in winter, dry scaling f. **Urticaria** lxxii. Standard Presentation is transient Plaques and wheals that disappear usually after 24 hours, comorbid urticaria below: lxxiii. Pruritic Urticarial Papules Plaques of Pregnancy, benign but very itchy lxxiv. Dermatographism, Pressure induced urticaria lxxv. **Angioedema**, not urticaria but usually occurs with it, swelling of **subcutaneous tissue** 10. Be able to propose treatment for common skin manifestations of allergic disease. g. **Treatment of Acute Contact dermatitis** lxxvi. **Cool, wet compresses**, oatmeal bath (Aveeno) lxxvii. **+/- calamine**, helps itching, may be too drying lxxviii. **PO and/or IM steroids, topical steroids no occlusion** lxxix. **Antihistamines** (Benadryl, Vistaril, Atarax), +/- ABX (BE SELECTIVE) h. **Subacute Contact Dermatitis** lxxx. **Topical steroids with occlusion, intralesional steroids** lxxxi. **Antihistamines (Hydroxyzine)**, +/- ABX lxxxii. **Moisturizers** lxxxiii. Tar ointments i. **Chronic Contact Dermatitis** lxxxiv. **Topical steroids with occlusion, intralesional steroids** lxxxv. **Antihistamines (Hydroxyzine)**, +/- ABX lxxxvi. **Moisturizer** j. **Treatment of Atopic Dermatitis/Eczema** lxxxvii. **Eliminate irritants, triggers** lxxxviii. **Emollients (Vaseline, Aquaphor, Eucerin) especially for dry lesions** lxxxix. **Topical corticosteroids (use lower groups for lower severity)** xc. **Topical Immune Modulators (tacrolimus - Protopic , protacrolimus -- Elidel)** xci. **Antibiotics for secondary infection (topical or anti-staph oral)** xcii. Wet dressings for severe flares (Rare) xciii. **Avoid harsh soaps (Ivory = bad, Dove/Aveeno = good)** k. **Treatment for Urticaria** xciv. Avoid suspected triggers xcv. **Antihistamines (H1 blockers, especially sedating ones like diphenhydramine - Benadryl and hydroxyzine -- Vistaril, Atarax, can add H2 antagonist for resistant cases --famotidine/Pepcid)** xcvi. **Prednisone tapers when needed** xcvii. **Epi when severe while beginning other therapies-Angioedema** xcviii. Topical steroids not helpful xcix. **Can consider IM/IV steroids, Severe cases** c. **Consider 5 I's being the Cause:** 29. **Ingestants** 30. **Inhalants** 31. **Injectants** 32. **Infections** 33. **Internal Disease (Autoimmune)** 11. Discuss the causes of acne vulgaris. l. Follicular hyperkeratinization -- plugging m. Increased sebum production n. ***Propionibacterium acnes* within the follicle** o. **Inflammation** 12. Describe the types of acne lesions. p. **Non-Inflammatory lesions** ci. Open or Closed Comedone "Blackhead", no redness/inflammation q. **Inflammatory Lesions** cii. 13. Distinguish between inflammatory and noninflammatory lesions. r. Noninflammatory open comedone s. Noninflammatory Closed Comedone t. Inflammatory Cyst u. Inflammatory papule v. Inflammatory Pustule w. Inflammatory nodule 14. Explain acne treatment. x. **If Infection is suspected**: ciii. **Propensity to scar should be determined** civ. **Scarring = Oral antibiotics x 2 months** cv. Program established in **3 visits** cvi. **Topicals take AT LEAST 8 WEEKS to have full effect** y. **For Oily Skin**: cvii. **Wash with warm water & mild cleanser** cviii. **Oil-Free** & Non-comedogenic products cix. Counsel - **NO PICKING, SQUEEZING, POPPING, RUBBING, OR MANIPULATING OF LESIONS** z. **For noninflamed blocked pores**: cx. **Retinoid comedolytic agents**: Tretinion (Retin-A), Adapalene (Differin), Tazarotene (Tazorac) cxi. **Non- retinoid Comedolytics**: Azelaic Acid (Finacea), Benzoyl Peroxide, Sulfur, Salicylic Acid, Glycolic Acid a. **For inflamed blocked pores**: cxii. **Comedolytic Agents** cxiii. **Topical antibiotics like clindamycin or erythromycin** cxiv. **Benzoyl peroxide** cxv. Sulfacetamide or sulfur products cxvi. **Oral antibiotics-If Severe** b. **Inflamed Pore treatment to consider**: cxvii. **Isotretinoin (Accutane)**- **[GET A PREGNANCY TEST-Teratogen]** cxviii. **Oral contraceptives for female** patients cxix. Spironolactone (75 to 150 mg qd) cxx. Steroid injection of individual cyst 34. TAC 3 mg/mL can dilute with saline cxxi. **Oral prednisone** 15. Distinguish the four types of rosacea. c.  16. Discuss treatment of rosacea. d. **Avoid triggers** e. **Physical blockers like sunscreen** f. **Topical and/or systemic treatment** cxxii. **Topical:** 35. Metronidazole (Metrogel or Noritate) 36. Azelaic acid 37. Ivermectin 38. Sulfacetamide plus sulfur lotion cxxiii. **Systemic:** 39. **Antibiotics if infection suspected** a. Tetracycline 500 mg bid b. Erythromycin 500 mg bid c. Doxycycline 100 mg bid (Oracea 40 mg) d. Minocycline 100 mg bid e. Bactrim DS BID f. Isotretinoin if severe and unresponsive-Get Pregnancy test 17. Define psoriasis and describe its clinical features, typical history, and physical exam findings. g. **Psoriasis:Chronic**, **inflammatory**, papulosquamous disease of **unknown etiology** due to abnormal T lymphocyte function/communication h. **Clinical Findings:** **Many different forms** but Common findings are **scaly, erythematous plaques on the elbows, knees and scalp, and can also be found on nails**. Effects joints causing pain and swelling (psoriatic arthritis) i. **History:** 2-3% of the population has it, equally affects men and women, **is genetically inherited**, **exacerbated by external factors**, earlier age of onset=more severe, usually occurs in ones 20's-30's and 50's-60's, **can induce psoriatic arthritis in 5-8% of population (negative Rh blood factor)**, can be pruritic j. **Exam Findings:** cxxiv. Scaly Plaques cxxv. Erythema around plaque cxxvi. Tends to Spare Palms and Soles, Mainly on scalp, sacral back and extremities cxxvii. **Auspitz Sign: Bleeding on the edge of plaque where it has been picked at** 18. Discuss the variations in psoriatic lesions, and the different presentations of psoriasis. k. Common **Scaly Plaque** Presentation l. **Gluttate**: Spread out plaques on trunk and extremities, associated with **Strep A infection, Viral infection to Steroid withdrawal** m. **Palmoplantar pustulosis**: **tobacco related flareup**, forms **sterile pustules on palms and soles**, painful, pustules harden/become brown n. **Inverse**: **Smooth, defined, red plaques on groin and under breast**, uncommon, **response to candida infection (yeast) or steroid withdrawal** o. **Generalized Pustular:** uncommon, **pustules form all over the body**, can also have **fever**/tenderness, **requires IMMEDIATE medical attention**, can be an ADR to certain drugs p. **Erythrodermic**: uncommon, **erythematous scales all over body**, severe, **Immediate medical attention needed**, **ADR related** q. **Psoriasis induced nail disease**: **nails begin pitting and dystrophy**, nails retract, **helpful for Psoriasis ddx** r. **Psoriatic Arthritis**: **fingers or distal finger joints change positioning and length**, **Rh factor negative on blood exam**, **starts between ages 20-40**, can be mutilating in 5% of cases s. **Perform Punch bx in severe cases**, **biopsy result if positive will show high levels of neutrophils** 19. Describe various treatments for psoriasis, including topicals, systemic therapies, and the role of UV. t. **Topicals:** cxxviii. **Topical coal tar solution**: Can be smelly and staining, cheap cxxix. **Vitamin D3 analogue**: Dovonex and Vectical cxxx. **Topical Steroids**: Group 1-4 steroids, group 1 for most severity cxxxi. **Intralesional Steroid**: Kenalog 10 mg/mL cxxxii. **Anthralin**-Apply for 20 minutes and wash off cxxxiii. **Tazorac Gel 0.1%** cxxxiv. Usually many of these are used combined, EX: Dovonex and Triamcinolone u. **UV Therapy 2 methods:** cxxxv. **UVB:** 40. **May be used in combo with topicals-**Very effective 41. Tar or lubricants enhance effectiveness 42. Steroid use diminishes length of remission 43. Side effects:burning, premature aging, & skin cancer cxxxvi. **PUVA:** 44. **Given 3 x weekly until clear then tapered off** 45. Photosensitizing psoralen taken 1.5 to 2 hours prior to treatment 46. GI intolerance, sunburn (photosensitivity), photodamaged skin, cataracts, increased skin cancer risk v. **Systemics:** cxxxvii. **Methotrexate**-Good for unstable and Erythrodermic Psoriasis, monitor for liver toxicity cxxxviii. **Cyclosporine (Neoral)**-Good for severe psoriasis, don't give live vaccines cxxxix. **Soriatane (Acitretin)-** Pustular and Erythrodermic, teratogenic-get pregnancy test cxl. **Biologicals**-Best for severe psoriasis, \$\$\$, also can't have live vaccines 20. Identify other papulosquamous disorders by their clinical features including seborrheic dermatitis, pityriasis rosea, and lichen planus. w. **Seborrheic Dermatitis** cxli. **Chronic** cxlii. **Likely caused by a yeast** cxliii. In infants = Cradle cap cxliv. **Moist papules** cxlv. **Transparent to yellow greasy scale** cxlvi. **Red patches or plaques** cxlvii. **Maybe diffuse but typically favors areas where the sebaceous glands are concentrated (scalp margins, central face, and pre-sternal area)** cxlviii. Stress, fatigue, and seasonal climate change x. **Pityriasis rosea** cxlix. Common, self-limited, usually asymptomatic, clinically distinctive papulosquamous eruption cl. The **first lesion or herald patch appears, most often on the trunk.** cli. Lesions are **salmon colored on Caucasian skin and dark brown on African-American skin**. clii. Lesions are **usually confined to the trunk and proximal extremities, often concentrated on the lower abdomen** cliii. **Plaques develop 1 to 2 weeks after herald patch**, maximum outbreak in 2 weeks cliv. **Plaques Clears spontaneously in 4 to 12 weeks** y. **Lichen Planus** clv. Uncommon, inflammatory papulosquamous disorder of unknown etiology clvi. Primary lesion- **2-10mm flat-topped papule with an irregular angulated border** clvii. **New lesion- pink to white** clviii. **Mature lesion-purple and sharply defined** clix. **Koebner phenomenon-Response to physical trauma** clx. **Wickham's stria** 47. 21. Generate a differential diagnosis for papulosquamous disorders. z. **Seborrheic Dermatitis** clxi. **Tinea of face** (annular plaques do KOH) clxii. **Cutaneous lupus** (flares with sun exposure, do ANA or skin biopsy) clxiii. **Rosacea** (can overlap and flares with topical steroid use) clxiv. **Psoriasis** (can also overlap, especially in scalp) clxv. **Pemphigus foliaceous** (can confirm with biopsy with immunofluorescence) a. **Pityriasis rosea** clxvi. **Tinea Corporis**-Rule out with KOH clxvii. **Secondary syphilis**-Perform Test clxviii. **Tinea Versicolor**-Rule out with KOH clxix. Drug Eruption clxx. **Guttate Psoriasis-Crossover** b. **Lichen Planus** clxxi. **Scarring alopecia vs. discoid lupus**-bx and immunofluorescence clxxii. **Papular form can be confused with psoriasis** and papular eczema clxxiii. **Hypertrophic lichen planus vs. psoriasis vs. lichen simplex chronicus** clxxiv. **Mucosal non erosive lesions vs leukoplakia vs. candidiasis** 22. Describe the treatment of the above-mentioned papulosquamous skin disorders. c. **Seborrheic Dermatitis** clxxv. **Topical antifungals** (ketoconazole or ciclopirox)-For Tinea clxxvi. **Antidandruff shampoo or soaps with zinc** (ZNP) or selenium sulfide (Selsun) or sulfacetamide/sulfur clxxvii. **Topical steroids group V-VII** (desonide BID) clxxviii. **Oral antifungal** (nizoral 200mg qd or Diflucan 150 mg qd x 1 to 2 weeks) clxxix. **Oral corticosteroids** clxxx. **Antistaphylococcal antibiotics** for secondary infection d. **Pityriasis rosea** clxxxi. **Treat pruritus with antihistamines** clxxxii. **Some folks use topical steroids, minimal evidence** (Group V) clxxxiii. **PO Steroids** 20 mg **BID-RARELY needed** clxxxiv. **Maybe erythromycin stearate** 250 mg QID x 2 weeks-**If bacterial** clxxxv. **Maybe acyclovir** 400-800mg 5x a day for 1 week-**If Viral** e. **Lichen Planus** clxxxvi. **Sedating antihistamine**-For Pruritus clxxxvii. **Group I-II topical steroids** BID clxxxviii. **Intralesional triamcinolone** (IL-TAC) hypertrophic 5-10mg/mL clxxxix. **Prednisone** 20mg BID for 2-4 weeks cxc. **Cutaneous LP is usually self-limited, resolves in a couple of years** cxci. **Mucosal LP does not resolve** 23. Describe the skin manifestations of infections caused by the gram-positive organisms Staphylococcus aureus and Streptococcus pyogenes including clinical features, labs, and treatment, along with other bacterial skin infections. f. **Impetigo (Staph Aureus Specific)** cxcii. Clinical Features:Most common on the face, perioral, **perinasal think honey crusted lesions**, **common in kids** cxciii. Labs:**Culture can be helpful if not responding or if MRSA** is suspected cxciv. Treatment: 48. **Mupirocin (Bactroban) TID x 10 days** 49. When extensive or not responding give oral anti-staph antibiotics 50. Dicloxacillin or cephalexin 250mg QID x 10 days, peds 25-50mg/kg/day divided 3-4 x 10 51. **Azithromycin or clarithromycin** 52. **Consider MRSA and alternate antibiotics when indicated** g. **Ecthyma** cxcv. Clinical Features:Notice **deeper ulceration and surrounding redness** **Lesion extends into dermis**, unlike impetigo cxcvi. Labs: **Culture to determine MRSA** cxcvii. Treatment: Topical/systemic antibiotics from above, occlusion of wound h. **Cellulitis** cxcviii. Clinical Findings: **Infection of dermis and Sub-Q tissues** characterized by **fever, erythema, edema and pain**, Usually occurs at site of a wound cxcix. Labs: Culture if open wound, CBC, ESR cc. Treatment: 53. Rest and elevate 54. Empiric antibiotic treatment pending culture results 55. Anti-staph/strep 56. 10-14 days of antibiotics. Monitor improvement. 57. Hospitalization and IV abx for sicker patients i. **Anaerobic Cellulitis (Clostridium Perfingens)** cci. Clinical Findings: **Edema, erythema, crepitus** over the affected area may be present ccii. Labs: CBC, lactic acid, blood cultures, wound culture, ESR, CRP, Procalcitonin cciii. Treatment: 58. Prompt **surgical debridement** 59. High dose **penicillin** 60. IV **Fluids** 61. Admission to hospital 62. j. **Gas Gangrene (Clostridium spp)** cciv. Clinical Findings:**Purple bullae, skin sloughing, edema** ccv. Labs: CBC, Blood cultures, wound culture if there is a wound, ESR, CRP, CMP, Procalcitonin ccvi. Treatment: 63. PO Clindamycin and penicillin 64. If mixed infection suspected then using Ampicillin-sulbactam (Unasyn) or Piperacillin-tazobactam (Zosyn) **AND** clindamycin **AND** Ciprofloxacin k. **Erysipelas** ccvii. Clinical Findings: **lower legs, face and in babies the periumbilical area**. When on face, classical butterfly distribution, cheeks and nose, **Deep. Dark red and vesicles may appear at the advancing border, may c/o itching, burning and tenderness, may see streaking of lymphangitis** ccviii. Labs: N/A ccix. Treatment: **Penicillin in hgh dose** l. **Folliculitis** ccx. Clinical Findings: **Dome shaped pustules with small erythematous halos that arise in the follicle**, often tender ccxi. Labs: Cx is not usually needed, KOH can be done to exclude fungal case ccxii. Treatment: 65. Avoid heat, friction 66. Antibacterial soap and warm moist dressings 67. Disposable razors 68. NO LOOFAHS-EVER 69. Mupirocin (Bactroban) TID x 5 days 70. PO Anti-staph ABX m. **Pseudomonas Folliculitis (Hot tub folliculitis)** ccxiii. Clinical Findings: **plaques are 0.5-3mm, erythematous and round with a central papule or pustule, primarily on the trunk and lower extremities that come in contact with dirty hot tub** ccxiv. Labs: N/A ccxv. Treatment: 71. Stay out of dirty hot tubs! 72. Rinse off when you get out of the hot tub 73. Can consider using a wet to dry dressing with acetic acid 5%, yes white vinegar, 20 minutes BID-QID 74. PO quinolones (Cipro or Levaquin) n. **Pseudofolliculitis barbae (Hair Bumps)** ccxvi. Clinical Findings:**sharp, shaved tapered hair reenters the skin as it grows from below which leads to a micro-abscess**, this is **painful** and/or **pruritic**, leads to scarring and keloids ccxvii. Labs: N/A unless there is abcess ccxviii. Treatment: 75. Stop shaving 76. Imbedded hair must be dislodged 77. PO Doxycycline OR Cephalosporins 78. If moderate to severe may need PO Prednisone 40-60 mg/day for 5-10 days 79. Intralesional triamcinolone injections 2.5-10mg/mL 80. For long term solution-laser hair removal o. **Furuncles and Carbuncles** ccxix. Clinical Findings: **Boil/Furuncle (Singular)**: deep dermal or Sub-Q, erythematous, edematous, and painful mass later points towards the surface and drains via multiple openings. **Carbuncle (Multiple)** is deep, tender, firm Sub-Q erythematous papules enlarge to deep seated nodules that can be stable or become fluctuant over a few days ccxx. Labs: Gram Stain and Culture ccxxi. Treatment: 81. Warm compresses 15-30 min several times a day 82. Incision and drainage is definitive therapy-fluctuant lesions, 11 blade, with Local anesthesia 83. Packing with iodoform gauze 84. Follow-up 85. Antibiotics= 10-14 days 24. Discuss syphilis including its skin findings, bacteriology, diagnosis, clinical features, and treatment. p. **Bacteriology**: **Spirochete Bacteria *Treponema pallidum*** q. **Skin/Clinical Findings Primary Infection**: **Cutaneous ulcer,Clean, erythematous base, raised, smooth edges, that are sharply defined appears at the site of initial contact**, May have a scant yellow/serous discharge ccxxii. Begins as a **papule and undergoes ischemic changes and erodes**. ccxxiii. Lesions may be **asymptomatic and undetected on the cervix** r. **Treatment Primary Infection**: **Penicillin** s. **Skin/Clinical Findings Secondary Infection**:**Symmetric hyperpigmented papules with collarette scale appear on torso, palms or soles in most patients**, Anal condyloma lata lesions are highly infectious t. **Treatment Secondary Infection**:**Penicillin** u. **Skin/Clinical Findings tertiary Infection**:Gumma or granulomatous **lesions develop subcutaneously expand and ulcerate the skin, lesions on liver, bones and other organs** ccxxiv. **Non lesion marks**: ccxxv. *Personality* ccxxvi. *Affect* ccxxvii. *Reflexes* (eg, hyperactive) ccxxviii. *E*ye (eg, Argyll Robertson pupils) ccxxix. *Sensorium* (eg, illusions, delusions, hallucinations) ccxxx. *Intellect* (eg, decreased recent memory, orientation, judgment, insight) ccxxxi. *Speech* abnormalities v. **Treatment Tertiary infection**:**Penicillin** 25. Identify and describe other STIs that cause skin ulcers and other skin lesions. w. **Chancroid (Haemophilus ducreyi)** ccxxxii. Skin Findings:**Painful erythematous papule first appears at site of inoculation, followed by pustule, then ulcer forms with a bright erythematous base, Painful, ragged edged ulcer with erythematous halo** ccxxxiii. Treatment: 86. **Azithromycin** 1 Gram x1 OR 87. **Ceftriaxone** 250 mg IM x1 OR 88. **Ciprofloxacin** 500 mg PO BID x 3 days OR 89. Erythromycin base 500 mg PO TID x 7 days x. **Pthirus Pubis (Pubic Lice)** ccxxxiv. Skin Findings: **Nits are firmly cemented to hair shaft, pubic hair is most common site but can spread to hair around anus and on people with a lot of hair can even spread to thighs and abdomen**, **very contagious** ccxxxv. Treatment: 90. **OTC permethrin or pyrethrin**-- Rid, Nix 91. **Prescribed 1% permethrin** -- applied and leave on for 10 minutes, wash off, repeat in 9-10 days 92. **Malathion lotion (Ovide)**, applied and shampooed 8-12 hours later, can repeat in 7-9 days 93. **Shave nits** and/or repeat treatment in 1 week 94. Oral ivermectin repeated in 10 days 26. Discuss the clinical features of the skin disorders caused by human papilloma virus (HPV) and their treatment. y. **Genital Warts (Condyloma Acuminata):** ccxxxvi. **Skin/Clinical Findings**:**Lesions tend to be pale pink to white and rough barely raised papules, some lesions will have projections on a broad base, surface may be smooth, velvety and moist and it lacks hyperkeratosis of other warts**, lesions may coalesce to form a large cauliflower type mass 95. 42.5% of adults 18-59 have it, some strains have high risk for cancer ccxxxvii. **Treatment**: 96. **Liquid nitrogen cryotherapy** 97. **Electrocautery and curettage** 98. Condylox (Podofilox) bid for 3 days, off for 4 up to 4 cycles 99. Imiquimod cream 5% every other night, washed after 8-12 hours until better (usually 2-3 months) 100. **Imiquimod is the best, safest primary care option** 27. Identify Molluscum Contagiosum and discuss its epidemiology and treatment. z. **Epidemiology**: Poxvirus infection, use KOH on umbilicated lesion to rule out Fungal a. **Skin Findings**: **Discrete, white, dome shaped lesions with central umbilication typical, in adults genital and pubic areas** are most commonly involved, **can appear anywhere except palms and soles** b. **Treatment**: ccxxxviii. Small lesions can be removed with a curette ccxxxix. Cryosurgery is the treatment of choice-liquid nitrogen, is a bit painful but it works ccxl. Cantharidin a small drop applied to lesion, causes temporary burning and erythema ccxli. Laser therapy works well but can get \$\$ 28. Describe the assorted skin manifestations of Herpes Simplex Virus (HSV) and their treatment. c. **Skin/Clinical Findings**: **Usually caused by HSV-2**, **Rash usually starts with red painful papules or plaque, then thin walled vesicles which may become pustules or rupture and form shallow ulcers**, Rash often more widespread during initial outbreak, more lesions, wider area ccxlii. Perform **Tzanck Prep by deroofing lesion for culture to confirm** d. **Treatment**: ccxliii. Acyclovir 400 mg ccxliv. How many times and length of treatment depends on if we are treating primary, recurrent, or providing suppressive therapy 29. Discuss the range of skin diseases caused by both candida organisms and by the dermatophyte fungal pathogens, their clinical manifestations, and their treatment. e. **Candida Induced Infections (caused by *Candida Albicans* and *Candida spp*)** ccxlv. **Candida Balanitis (Foreskin and Penis)** 101. Etiology: **Acute Candida spp infection of penis/foreskin**, seen **more in uncircumcised**, **KOH to specify** 102. Presentation: **Pinpoint red papules evolve into umbilicated pustules on the glans and coronal sulcus** with pasty **macerated debris under the foreskin**, **pustules will rupture and leave erosions, ulcerations and fissures follow, edema and pain** so intense that **patient may not be able to retract the foreskin** 103. Treatment: g. Topical tx usually works h. **Antifungal** BID x 10 days (books says 7) i. Antifungal examples = **miconazole, clotrimazole, ketoconazole** ii. Be careful if topicals contain steroids- will help with inflammation but will get a rebound affect i. **Diflucan** (fluconazole) 150 mg PO x1 ccxlvi. **Candida Intertrigo (Large Skin Folds)** 104. Etiology: **Yeast growth in warm, moist folds of large tissue areas like breasts and excess skin**, **KOH to specify**, **more prevalent in older women, patients with obesity, and patients with large breast tissue** 105. Presentation: **Pustules become macerated and develop into red papules with a fringe moist scale at the border**, may see **intact pustules outside the opposing skin surface**, **red**, **moist glistening plaques extend to or just beyond the limits of opposing skin folds**, advancing **border is long**, **sharply defined and has an ocean wave shaped fringe** of macerated scale, **satellite papules common**, painful fissuring in crease 106. Treatment: j. **KEEP IT DRY** k. **Cool moist dressing x20 minutes to dry** the wet areas l. **Antifungal creams** until rash clears m. **Diflucan** (Fluconazole) 100 mg QD x 7 days for resistant cases n. **Absorbent powder** (Z-sorb) f. **Tinea/Dermatophyte Infections** ccxlvii. **Diaper Dermatitis (Diaper Rash)** 107. Etiology: **Encompasses areas in close consistent contact with a diaper**, **diapers create warm moist area with occlusion allowing for fungal/bacterial growth** 108. Presentation:**Erythematous**, **scaling**, **eroded**, **painful plaques occur on the convex surfaces**, **creases are spared** 109. Treatment: o. **Change diapers frequently** p. **Diaper free tim**e q. **Barrier ointments-zinc oxide** r. Avoid cleaning too aggressively with irritating baby wipes s. **Antifungal creams BID until cleared up** \~ 10 days t. **Can alternate with hydrocortisone**, still apply both BID u. If **infection is present consider Bactroban** ccxlviii. **Tinea Versicolor** 110. Etiology:**Caused by yeast** ***Pityrosporum orbiculare***, **Part of normal skin Flora, more active in warm/humid climate** 111. Presentation: **Numerous small circular, white scaling papules on the upper trunk**, **may involve the upper arms, neck and abdomen**, **lesions are hypopigmented in tanned skin and pink or fawn colored in untanned skin**, **wood's light exam shows hypopigmented areas** of infection, **Perform KOH which will show short broken up rods "Spaghetti and meatball" presentation** 112. Treatment: v. **Selenium sulfide lotion 2.5%** from back of neck to upper thighs, wash off after 10 min, repeat Q7 days w. **Ketoconazole 2% shampoo**, apply to dampened skin, lather, rinse off after 5 minutes, apply daily x 3 days x. **Fluconazole (Diflucan)** 300 mg x1, repeat in 2 weeks y. **Itraconazole** 200 mg daily x 1 week ccxlix. **Pityrosporum Folliculitis** 113. Etiology: **Caused by yeast** ***Pityrosporum orbiculare***, **Part of normal skin Flora, infect hair follicle changing presentation** 114. Presentation: **asymptomatic or slightly itchy dome shaped follicular papules and pustules 2-4 mm in diameter**, **May occur on forehead, acne like** 115. Treatment: z. **Best treated with topicals AND systemics** a. **Selenium sulfide lotion 2.5%** from back of neck to upper thighs, wash off after 10 min, repeat Q7 days b. **Ketoconazole 2% shampoo**, apply to dampened skin, lather, rinse off after 5 minutes, apply daily x 3 days c. **Fluconazole (Diflucan)** 300 mg x1, repeat in 2 weeks d. **Itraconazole** 200 mg daily x 1 week ccl. **Tinea of the Nail (Onychomycosis)** 116. Etiology: **General fungal infection of the nail**, **increased frequency with age** 117. Presentation: e. **Distal subungual (Most common)**: **Distal nail turns yellow** f. **White superficial**: **nail is soft, dry and powdery** g. Proximal subungual: h. Candida (rare): 118. Treatment: i. **Topical antifungal are less effective than systemic** j. **Diflucan (Fluconazole)** 150mg Q weekly X 9 months k. **Itraconazole** 200 mg QD x 6 weeks for fingernails x 12 weeks for toenails l. **Lamisil** 250 mg QD x 6 weeks for fingernails x 12 weeks for toenails m. **Nail debridement needs to be done at each office visit,** removing infected nail plate provides higher cure rates ccli. **Angular Cheilitis** 119. Etiology: **Chronic inflammation in corners of the mouth**, **more common in the elderly and those with increased salivary secretion, often bacterial AND yeast** 120. Presentation: **Papules and pustules surrounding a fissure**. **Edema**, **erythema** with scaling develop with **persistent inflammation**, then **erosion and ulceration** 121. Treatment: n. **Antifungal cream BID and steroid** (group V-VI) BID. Until the area is dry and free of inflammation o. Use **thick protective lip balm at bed** ie. Chapstick, Aquaphor, zinc, petroleum p. If **secondary bacterial infection will need Bactroban or systemic ABX** q. **DON\'T use steroid/antifungal mixed creams, reduced effectiveness** cclii. **[Cutaneous Fungal infection]** (All below are diagnosed through clinical signs, KOH plates OR Woods light exam explained below) 122. **Woods Light Exam:** Use **Blue/Green Light** to diagnose infections with **Microsporum fungal infections** and use **Pale Yellow light** to diagnose infections with **Pityrosporum Fungal** infections (EX: Pityrosporum Folliculitis or Tinea Versicolor) ccliii. **Tinea Pedis (Tinea of the foot/athletes foot)** 123. Etiology: **More prevalent in men than women, varies in presentation due to various fungal variants, KOH can confirm the fungal variant if needed** 124. Presentation: r. **Interdigital**: **Macerated**, may result in bacterial superinfection s. **Chronic scaly plantar**: **Resistant to tx** t. **Acute vesicular**: **Inflammatory reaction**, **secondary infection is common**, **vesicles may fuse into bullae** 125. Treatment: u. **Terbinafine 1%** BID x week v. **Can use orals if needed** w. **Prevention is key-powder** applied to the feet x. **Dry well after showering** ccliv. **Tinea Cruris (Tinea of the groin and anal areas/"Jock itch")** 126. Etiology: **Prevalent in post pubescent men, increased risk if groin is occluded and sweating/moist and warm** 127. Presentation: **Sharp border**, unilateral but can be bilateral, **scaling or advancing vesicles**, **Scrotum rarely involved (differentiates from intertrigo)**, May have **ringworm pattern, skin within the border turns red-brown and is less scaly** 128. Treatment: y. **Antifungal** BID z. **Steroid BID** (Group V-VII) a. May need **systemic treatment if resistant to topicals** cclv. **Tinea Corporis (Tinea of the torso and limbs)** 129. Etiology: **More risk in warm/wet climate, wrestlers predisposed, mainly torso with some limb effect** 130. Presentation: b. 2 clinical patterns: c. **Annular (classic)**:**Flat scaly papules that develop a raised border** that extends at variable rates, border **may have erythematous raised papules OR vesicles**, **Central area may be brown OR hypopigmented**, **Itchy OR asymptomatic** d. **Deep inflammatory**: **round, inflamed lesion, has a uniformly elevated, erythematous boggy pustular surface**. **Pustules are follicular** and this means fungus has penetrated deep into the hair follicle 131. Treatment: e. **Antifungals** BID x 2 weeks, **continue treatment for at least 1 week after resolution of infection** f. **Griseofulvin** can be used but it is **hepatotoxic, need to check liver function before, during and after** cclvi. **Tinea Manuum (Tinea of the hands and feet (not pedis))** 132. Etiology: **Only affects hands and feet, more rare, rarely impacts children** 133. Presentation: **tinea involves the dorsal hand and has all the features of classic tinea corporis**, Lesions on **palms may be assumed to be callous, especially in laborers**, **usual pattern = 1 hand 2 feet OR 2 hands and 1 foot** 134. Treatment: g. **Antifungals** BID x 2 weeks, **continue treatment for at least 1 week after resolution of infection** h. **Griseofulvin** can be used but it is **hepatotoxic, need to check liver function before, during and after** cclvii. **Tinea Incognito** 135. Etiology: **Occurs when cutaneous fungal infection has been altered via topical steroids,** 136. Presentation: **Groin, face and dorsal aspect of the hand are most commonly affected**, diffuse **erythema**, diffuse **scale and scattered pustules** 137. Treatment: i. **Stop steroid cream** j. **Start antifungal BID** k. **Continue antifungal x 1 week after resolution** l. **May need oral antifungals if resistant** cclviii. **Tinea Capitis (Fungal infection of the head)** 138. Etiology: **Fungus invades Stratum corneum of the hair shaft, often spread via children, Trichophyton tonsurans is most common fungus, culture to confirm diagnosis using brush on a culture media** 139. Presentation: m. 4 clinical patterns: n. **Seborrheic Dermatitis type (most common)**: **diffuse or patchy fine white adherent scale** o. **Inflammatory (Kerion)** : inflamed boggy, **tender areas of alopecia with pustules** p. **Black Dot (uncommon)**: **large areas of alopecia without inflammation**, mild to moderate scalp scale q. **Pustular**: **pustules and scabbed areas** **without scaling or hair loss** 140. Treatment: r. **Terbinafine**, dose based on weight s. **Griseofulvin**, dose based on weight-Treatment of choice, **Check liver enzymes until stopped** t. **Itraconazole**, dose based on weight u. **Fluconazole**, dose based on weight cclix. **Tinea Barbae (Fungal infection of the beard)** 141. Etiology: **Fungal infection of skin around beard hair OR within the beard hair follicle** 142. Presentation: v. **[2 patterns:]** w. **Ringworm:** superficial, **resembles plaques of tinea corporis** x. **Follicular:** deep follicular infection resembles bacterial folliculitis, **may see pustules and draining nodules** y. **[Non Skin Findings:]** may see **regional lymphadenopathy when secondary bacterial infection is present** 143. Treatment: z. Topicals are not usually effective-don't penetrate the follicle well, **IE Use oral antifungals** a. **Terbinafine** 250 mg QD x2-4 weeks b. **Itraconazole** 200 mg QD x 2-4 weeks c. **Fluconazole** 150 mg once weekly x 3-4 weeks 30. Distinguish between common viral and non-viral exanthems, and discuss their etiology, their clinical features, and their treatment. g. **Herpes Simplex (Non genital)** cclx. Etiology: **Generally caused by Type 1 HSV but can be caused by HSV 2 via oral sex**, **highly contagious**, **Spreads via direct contact with lesion and secretions**, **recurrent infections are common**, starts 3-7 days after contact, **Tzank Prep to DX** cclxi. Clinical Features: **grouped vesicles on an erythematous base appear**, then **erode-they will umbilicate** at this point. In **primary the vesicles are more numerous and scattered than in recurrent infections** cclxii. Treatment: 144. **Acyclovir, Valacyclovir, Famciclovir** 145. Topical agents: (Shorten healing time by about 2 days) d. **Tetracaine cream 1.8%** e. **Abreva: OTC** 146. **Make sure to protect the lips from sun exposure-physical barrier** h. **Varicella (Chicken Pox)** cclxiii. Etiology: **Induced by Varicella Zoster Virus (VZV)**, **very contagious**, **transmits through air droplets and Physical contact**, **Long incubation time** cclxiv. Clinical Features: **vesicles, pustules and crusts all present at the same time**, **Rash starts on trunk and spreads to face and extremities**. Starts as a **firm red papule → thin walled clear vesicle** appears on the surface. **This will umbilicate then break after 8-12 hours and a crust forms** cclxv. Treatment: cclxvi. **Anti --itch lotions OTC** cclxvii. **Cool, wet compresses** cclxviii. Oatmeal baths cclxix. **Tylenol/Ibuprofen** (No ASA d/t Reyes) i. **Herpes Zoster (Varicella Induced Shingles)** cclxx. Etiology: **Reactivation of Varicella virus in root ganglion**, **effects skin of particular dermatome** cclxxi. Clinical Features: **Pain**, **burning prior to eruption**, usually 4-5 days, **eruptions begin as erythematous**, edematous plaques, **vesicles arise in clusters** cclxxii. Treatment: 147. **Acyclovir** 800 mg 5 times/day x 7 days OR 148. **Famciclovir** 500 mg Q8H x 7 days OR 149. **\*Valacyclovir** 1 g TID x 7 days 150. **Cool compresses** 151. **Prednisone taper** 152. **\*Gabapentin** 153. Tricyclic antidepressants (amitriptyline) 154. NSAIDS, Tylenol or Opioids 155. Lidocaine patches j. **Hand, Foot and Mouth (Coxsackie-virus)** cclxxiii. Etiology: **Very contagious**, spreads through **direct contact or air droplets, most common in children, breakouts in summer and autumn** cclxxiv. Clinical Features: **Oral ulcers**, varies from a **few to ten or more**, very **painful**, cutaneous lesions appear after the oral lesions and **start as red macules that become pale white oval vesicles with erythematous halo** cclxxv. Treatment: 156. Usually resolves within 10 days 157. **Treat the sx** 158. **Tylenol/Ibuprofen** k. **Nongenital Warts (HPV)** cclxxvi. Etiology: **HPV induced at nongenital regions of the body**, **transmits through** **contact with lesion** cclxxvii. Clinical Features:**Flesh colored papules evolve into dome shaped**, **gray to brown**, **hyperkeratotic**, **discreet and rough papules**, with **black spots** (**thrombosed capillaries**), If **filiform then these warts grow with finger like projections on a narrow OR broad base** cclxxviii. Treatment: 159. Spontaneously resolve with time 160. Duct tape 161. Salicylic acid, QD (8-12 weeks) 162. Cryotherapy 163. Filiform warts are usually removed after local anesthesia and then either snip it or use dermal curette l. **Flat Warts (HPV)** cclxxix. Etiology: **Treatment resistant, HPV induced, spreads through mild trauma such as shaving** cclxxx. Clinical Features: **Pink, light brown or yellow papules** are **slightly elevated and flat topped**, may be a **few or numerous** or occur in a line as a result of **spread from scratching** cclxxxi. Treatment: 164. **Imiquimod 5% cream** QD, can be QOD if irritation occurs 165. Cryotherapy 166. **5-Flourouracil (5-FU)** cream QD-BID x3-5 weeks m. **Plantar Warts (HPV)** cclxxxii. Etiology: **Caused by HPV**, occurs at points of maximum pressure of the foot ("Ball" or Plantar surface of the foot, heels or toes), cluster is called **Mosaic wart** cclxxxiii. Clinical Features: **round**, **single or multiple**, coalescing **flesh colored**, **rough keratotic papules**, often looked depressed, **punctate black dots**, **If the lesion removes skin lines/ridges it\'s a wart, not a corn** cclxxxiv. Treatment: 167. If **painless then no tx needed** 168. **Debridement** 169. **Salicylic acid** 170. **5-FU cream** 171. Imiquimod 5% cream (But must debride the thick part off first) 172. Cryosurgery 173. Blunt dissection