Dermatology PDF - Module 9-13

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

Module 9: Urticaria, Erythemas, Drug Reactions ​ Urticaria ○​ Erythematous wheals ○​ Types: spontaneous, cold, solar, delayed pressure, dermographism ○​ Acute 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 - ​ macular erythema on back of neck, spreads to trunk, face, and arms ​ Pruritus ​ Sometimes hypotension ​ Tx: ​ 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 Fixed drug reaction​ ​ ​ ​ Red Man Syndrome ​ 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: ​ 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 ​ Death mainly due to staph and pseudo ○​ Treatment: ​ 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 ½ (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.