Dermatology Exam 4 Mod 11 PDF

Dermatology • Anatomy of the Skin, Nails, and Hair • A Methodical Approach o History o Distribution o Primary Lesion o Differential Diagnosis o Test History o Duration o Rate of Onset o Location o Symptoms o Family Hx o Allergies o Occupation o Previous Tx Configuration and Distribution o Localiz...

Dermatology • Anatomy of the Skin, Nails, and Hair • A Methodical Approach o History o Distribution o Primary Lesion o Differential Diagnosis o Test History o Duration o Rate of Onset o Location o Symptoms o Family Hx o Allergies o Occupation o Previous Tx Configuration and Distribution o Localized § Pattern • Scattered • Diffuse • Confluent § Variation • Size • Color • Texture • • • Primary Lesion § Key to accurate interpretation and description of cutaneous disease § Allows formulation of a differential diagnosis • Macule vs Patch o Macule § Less than 1 cm § Circumscribed § Flat § Brown, blue, red, or hypopigmented • Brown: Café au Lait • • • • • • • Blue: Mongolian Red: Rheum Fever Hypopigmented: Tinea Versicolor o Patch § Macule greater than 1 cm § Circumdcribed § Flat § Brown, blue, red, and hypopigmented Papule vs Plaque o Papule § Up to 0.5cm in diameter § Elevated § Solid § Variation in color § May become confluent and forms plaque • EX: Warts, molluscum, skin tag o Plaque § Greater than 0.5cm in diameter § Circumcribed § Elevated § Superficial § Solid • EX: Psoriasis Plaque Nodule o Greater than 0.5cm in diameter o Circumscribed o Elevated o Solid o Large nodules are referred to as tumors o EXO à grow outward o ENDO à grow inward § EX’ –oma, SCC, BCC Pustules o Circumscribed collection of leukocytes and free fluid o Varies in size § EX: Acne, Folliculitis, and Impetigo Vesicle vs Bulla o Vesicle § Up to 0.5cm in diameter § Circumscribed collection of free fluid • EX: Chicken Pox, Varicella o Bulla § § • • Greater than 0.5cm in diameter Circumscribed collection of free fluid • EX: Fixed Drug Eruption, Phiphgos?? Wheals (Hives) o Firm o Edematous plaque o Results from infiltration of fluid in dermis o Transient o May only last a few hours o Pruritic § EX: Urticaria, Angioedema Secondary Lesions o Developed through the evolution of skin disease OR o Created through scrating or infection § EX: • Scales, Crust, Erosions, Ulcersm Fissures, Athrophy, Scars o Scales: § Excess dead epidermal cell § Produced by abnormal keratinization and shedding § Varied Presentation • Fine to stratified • Desquamation o Crusts: § Collection of DRIED serum and cellular debris § Scab o Fissure: § Sharply defined § Linear loss of epidermis and dermis § Scarring o Erosion § Focal loss of dermis § Does not extend beyond dermoepidermal junction § Heal without scarring o Ulcer § Focal loss of epidermis and dermis § Heal without scarring o Atrophy § Depression in the skin from thinning of epidermis or dermis o Scars § Abnormal formation of connective tissue § Implies dermal damage § • • Color of scar often indicates stage of healing Tests: o Biopsy § Most common o Potassium Hydroxide § Identify fungal o Skin Scrappings § Mites à Rosacea, Scabies o Gram Staining o Fungal and bacterial cultures o Tzanack Test § Varicella o Wood’s light § Vitiligo o Patch test § Contact Derm o Dark field/ Blood Test § ASO blood test à strep rash Neoplasms of Uncertain Behavior o Mole Assessment § A à Asymmetry § B à Border § C à Color § D à Diameter § E à ***Evolution • Can track lesions with pictures o BASAL CELL CARCINOMA – most common § Originates in basal cells of the epidermis § Appears in areas of chronic sun exposure • 90% of non-melanoma came from UV § Slow growing § Locally invasive tumor/nodular § Pearly or waxy presentation § Central ulceration seen in later stages § Nodular and round o SQUAMOUS CELL CARCINOMA § Second most common form of skin cancer § Malignant tumor originating from keratinocytes § Appears in areas of chronic sun exposure • SPF of 15 or higher can decrease risk by 40% § Actinic keratosis (AK) is the precursor to most SCC. • Treat with Liquid Nitrogen § Has a tendency to metastasize • TREATMENT BASICS o Maintain Skin Barrier § Fluid homeostasis § Protection from infection § Temperature regulation § Prevent toxin absorption § Minimize ultraviolet radiation § Goal of treatment: Restore or maintain a normal skin barrier. o Skin Cleansing § Mild soaps and cleansers § Limit exfoliating brushes § Avoid scented soaps o Skin Moisturization § Occurs immediately after cleansing § Thicker oil based ointments for excessively dry or damaged skin § Lotion to maintain healthy skin o Topical Formulations § Drug and vehicle determine effectiveness • Vehicle Examples o Powders, Ointments, Creams, Pastes, Solutions and lotions, Gels and foams o Topical Application and Dosing § Rate of absorption varies by anatomical locations. • Ex. Least to greatest: palms and soles extremities torso face eyelids scrotum mucous membranes o Wet Dressings § Useful to dry exudate/wet skin § Debride infected wounds • ECZEMATOUS CONDITIONS o Progression § Inflammation à Papules à Scratch = Eczematous infection/Excorations o ACUTE Eczematous Inflammation § Characterized by: • Erythema • Edema • Vesculation • Weeping and/or oozing • Severe pruritus • Possible excoriations § Differentials/Possible Etiologies • Allergic contact hypersensitivity • Irritant exposure • Id reaction • Stasis dermatitis • Scabies • Dyshidrosis (Hand Eczema) • Atopic Dermatitis § Treatment • Cool and wet dressings with topical steroid creams • Oral antihistamines • Culture if you suspect secondary infection • Discontinue use of all other topicals • Patch testing • Behavior modification à stop itching § Examples: • Poision Ivy, Irritant Exposure • Water submerged occupation o CHRONIC Eczematous Inflammation § Characterized by: • Inflamed • Red • Scaling • Moderate to intense prolonged itching • Lichenified (thickened) • Habitual scratching § Differentials/Possible Etiologies • Atopic dermatitis • Chronic or irritant contact dermatitis • Lichen Simplex Chronicus • Nummular Eczema • Hyperkeratotic Eczema § Treatment • Ointments penetrate lichenified skin well • Protopic ointment • Break the “itch–scratch cycle” • Group I or II creams applied twice daily (avoid face) • • • • Group II-V steroids with plastic occlusion Intralesional injections Steroid impregnated tape FUNGAL INFECTIONS o TINEA (DERMATOPHYTE) § Means “fungus infection” § Dermatophyte infection classified by body region § Examples: • Tinea of the foot (athlete’s foot) • Tinea of the groin (jock itch) • Tinea corporis (ring worm of the body) • Tinea of the face • Tinea of the hand • Tinea cognito • Tinea capitis • Tinea versicolor (hypopig) o Can treat with OTC Selsum Blue § Topical Preparations • Major Classes o Allylamine/benzylamine o Imidazole § Systemic Agents • Griseofulvin • Ketoconazole • Fluconazole • Itraconazole • Terbinafine o CANDIDA INFECTION § Yeast like fungus Candida albicans: • Lives within normal flora of: o Mouth o Vaginal tract o Gut § Exacerbating conditions: • Pregnancy • Oral contraceptives • Antibiotic therapy • Diabetes • Skin maceration • Topical steroid therapy • Depression of cell mediated immunity § Examples: • • Oral Candidiasis • Vulvovaginitis • Candidal balanitis • Candidal intertrigo • Diaper candidiasis • Angular cheilitis (corner of the mouth infection) § Treatment of C. Albicans: • Dependent of location, duration, and severity o Topical antifungals o Systemic preparations VIRAL INFECTIONS o Verucca Vulgaris (Warts) § Benign epidermal growth caused by human papillomavirus (HPV) § Transmitted by contact with small breaks in skin, abrasions, or other trauma § Variable onset (1-6 months) § Variable duration § Spontaneous resolution § Physical Findings: • Flesh colored papules • Evolve to gray/brown dome shaped lesions • Hyperkeratotic • Discrete • Rough • Often surface black dots § Frequently located on hands, periungual skin, elbows, § Treatment: • No treatment consistently highly effective • Duct tape • OTC Salicylic acid 15-40% • Cryosurgery • Imiquimod 5% • Interlesional Candida antigen • Laser surgery o Molluscum Contagiosum § Poxvirus infection of the skin § Very common in children, considered a STI in adults § Spread by direct contact § Physical Findings: • Discrete • 2 to 5 mm § § § § • • Umbilicated • Dome shaped papules • Flesh colored • Grouped lesions • Inflammation, erythema, scaling, at periphery Pubic and genitals commonly involved • Camouflaged by pubic hair Lesions can appear anywhere except palms and soles Often confused with verucca vulgaris Treatment: • Avoid spread • Cryosurgery • Canthardin 0.7% • Imiquimod 5% cream PSORIASIS o Affects 1 to 3% of population o Transmitted genetically § Environmental factors needed to precipitate o Frequently begins in childhood (s/t strep) o Extent and severity varies o Clinical Presentations: main sites knees & elbows § Chronic plaque § Guttate § Pustular § Erythrodermic § Light-sensitive § HIV induced § NAIL DENTING o Topical Treatment § Not predictably effective § High patient dissatisfaction and nonadherence § Topical steroids § Intralesional injections § Topical calcineurin inhibitors § Vitamin D analougues § Tazarotene § Coal Tar § UV light therapy § Photochemotherapy § Tape or occlusive dressings o Systemic Therapy § Methotrexate § § § • • Acitretin Cyclosporin Biologics ACNE VULGARIS o Type/Presentation § Comedonal • Open • Closed § Pustular § Cystic o Treatment § Treatment varies by type and presentation • Benzoyl peroxide • Topical antibiotics • Retinoids • Oral antibiotics • Isotretinoin (Accutane) • Intralesional injections • Oral contraception • Spironolactone ROSACEA o Presentation § Acne-like eruption on face § No comedones or scarring present § Ocular disease and flushing are common § Common in people or Celtic origin § Physical Findings: • Primarily on forehead, cheeks, and nose • Erythema • Telangietasias (not constant) • Pustules o Pustules à Mites § Exacerbated by: • Spicy foods • ETOH • Stress • Sunlight § Treatment • Topical Med • Oral ABX • Isotretinoin (Accutane) • • • • Prednisone SCABIES o Infestation of Sarcoptes scabiei var. hominis mite o Physical Findings: § Intense pruritus § Linear burrow § Inflamed 1-2 mm vesicles and papules § Can be scattered and excoriated § Typically found on wrists, web spaces, sides of hands and feet, genitals, & abdomen. § Present on scalp, palms, and soles in infants. § Often misdiagnosed as: • Insect bites • Eczema • Impetigo o *Mites, eggs, and feces can be identified with microscopic exam. o Treatment § Topical • Permethrin à cover body head to toe • Lindane • Steroid § Oral • Ivermectin § Environmental • Wash clothing and bedding HUMAN & ANIMAL BITES o Common pathogens § Fusobacterium § Bacteroides § Porphyromonas § Prevotella o Most wounds heal with conservative treatment o Management o Examination § Irrigation § Debridement § Tetanus and rabies immunization o When to suture? § Punctures left open unless on face § Suture facial lacerations § Antibiotics not routinely given • May be necessary for deep puncture wounds HEAT INJURES o Thermal and Electrical Burns § Caused by excessive heat on skin o Classified in four degree § First-degree § Second-degree • PCP can only treat 1st and 2nd o Irigation and silvadine o Don’t pop à leads to secondary infection § Third-degree § Fourth-degree o Treatment § Prompt cold application § Irrigation with normal saline and apply Silvadene cream BID § Do not puncture vesicles or blebs § Refer to burn specialty care for • Third- and fourth-degree burns • Facial/ear burns, electrical burns, and digits.