Transcript Dermatology Review

Dermatology Review
QUICK Definitions:

Macule: flat circumscribed area distinguished from surrounding skin by color. i.e. freckles

Patch: same as macule but larger > 1cm in diameter.

Vesicle- fluid filled. Raised 5mm or less in diameter Example: blister – up to 1cm

Bulla- fluid filled same as vesicle but >5mm in diameter – greater than 1cm

Nodule- Elevated solid area 5mm or less across – btwn 0.5cm to 2cm in diameter [deeper into
the skin than a papule]

Papule- nodule elevated solid area >5mm across, usually dome shaped – up to 1cm in diameter

Plaque- elevated flat topped area usually >5mm across – greater than 1cm long

Wheal- transient. Pink or red raised area with central pallor. Shape and size vary. [i.e. hives or
mosquito's]

Additional defintions look at Intro to Derm ppt
In
Some Signs
the presence of lesions, the clinician induces a mild
trauma and more lesions form
Koebner Phenomenon
Pinpoint
bleeding following removal of a scale
Auspitz Sign
Slight rubbing causes seperation of the
skin layers [desqumation]
Nikolsky Sign
 Rub the lesion and it will lead to wheal
Darier Sign

Putting a glass slide against the skin – blanching indicates that capillaries are intact [skin will
return to its normal color], nonblanching indicates that capillaries are broken [skin will
reappear red i.e. petechia or purpura]
Diascopy
This pathology is…
Characterized
by increased epidermal cell
proliferation.
Erythematous or salmon colored plaques
with distinct borders covered with silvery
white scales.
Affects extensor surfaces more than flexor
surfaces.
May have nail changes such as pitting,
thickening, or onycholysis.
Psoriasis


Etiology?
Triggers?
Genetic T-cell problem or environmental
Autoimmune disease
Remissions and exacerbations
T-cell mediated  alternation in cellular kinetics of
keratinocyes  short cell cycle  leading to hyperkeratosis
Stress, Koebner
Phenomenon, and class I
topical steroids
There are two types of Psoriasis.
Two types of Psoriasis

Pustular Psoriasis
 Painful,
deep, sterile yellow
pustules evolving into red macules

Guttate Psoriasis
 Drop-like
lesions on trunk and limbs of
adolescents after strep throat
Treatment of Psoriasis
Hydrating creams
 Mid-potency topical steroids
 Tazarotene (Retinoid Creams)
 Systemic Immunosuppressants
 Coal Tar
 Phototherapy

Complication???
Arthritis
Genetic
link to family and personal history
Aggravated
by sweat, food, wool, and
other stressors.
Erythematous
excoriated scaling
plaques and patches
It
is known as “the itch that
rashes”…

Chronic recurrent inflammatory
skin disease
IgE
mediated
Aka
Eczema
Infants
have weeping inflammatory patches
and crusted plaques on extensor surfaces
and the face mostly
Adults have dry, lichenified pruritic
rashes on the flexor surfaces
Well, did you get it yet?
Atopic Dermatitis
Oh yeah…

Treatment:
 Eliminate
precipitating irritant
 Topical steroids
 Oral Antihistamines
 Emollients
May
have secondary infection.
Cell
mediated reaction involving
sensitized T lymphocytes
Clear
vesicles on erythematous base
that follows exposure to chemicals
previously sensitized to
Pruritis,
scaling, papulovesicular
lesions present in area of exposure
Can be treated with topical
corticosteroids and wet dressings
soaked in Burrow’s solution changed
every 2-3 hours
Dx: Contact Dermatitis
Skin
rash that occurs in areas of high
sebaceous gland concentration such as
face, eyebrows, and nasolabial fold
Responsible
for thick yellow brown
greasy scaling on infants
Caused
by an immunologic response to
endogenous yeast Pityrosporum
•Adults with this experience burning,
pruritis, erythematous plaques with scaling
Treated with ketoconazole shampoo and
cream, salicylic acid, and corticosteroids
 Dx: Seborrheic Dermatitis
Pruritic,
polygonal, purple, flat topped
papules covered with fine scales 4 P’s
Found
on flexor areas, shins, and mucous
membranes
Buccal
mucosa contain wickham striae
Lesions
resolve with hyperpigmentation
Treated
with corticosteroids, retinoid, oral
antihistamines and immunosuppressant

Dx: Lichen Planus
Etiology
suspected herpes virus
infection HHV7
Eruption
of many smaller scaling oval plaques
Herald
patch- single lesion 2-5 cm
precedes rash
Fades spontaneously 4-8 weeks
Treated
with antihistamines

Dx: Pityriasis Rosasia
Chronic
often asymptomatic superficial
fungal infection
Etiology:
M/C:
Round
malassezia furfur, pityrosporum
in hot humid environments
to oval macules patches on the trunk
Don’t
tan in sun exposed areas
Variable color white orange brown
Treated

with topical antifungals
Dx: Pityriasis Versicolor
•Risk Factors: Moisture, obesity, DM,
Immunosupressionn, Hx of antibiotic use
•Pruritic, painful, vulvovaginitis with adherent
white plaques to genitalia
•Oral thrush- white plaques adhere to
erythematous buccal mucosa tongue
•Tx: Topical or oral antifungals
Diagnosis: Candidia
•Wingless 6 legged insect spread by direct fomites
•
Can occur on the head, body or pubic area
Dx: Lice
Tx: pyrethrin, permethrin or
lindane (only for unresponsive)
•Infestation spread by direct sexual contact
•Major distribution: papules and pruritis
with burrows in finger webs wrists
elbows buttocks genitalia ankles
Tx: Permetherin
Dx: Scabies
•Chronic recurrent inflammatory conditions
wherein hair follicles and apocrine gland ducts
are occluded and become secondarily infected
Risk
Factors: Obesity, DM, Smoking,
Genetic and Hormonal associations
Pain, odor & drainage of the axilla & groin
•Double open comedones: papules and pustules
Abscesses and sinus tract formation
Dx: Hidrandenitis Suppurativa
 Tx: Topical and systemic antibiotics
(clindamycin tetracyclin) intralesional
steroids isotretinoin surgery

 IgG produced against proteins in the skin & mucu
membranes:
**leads to acantholysis & intraepidermal bulla***
•Presents with recurrent painful and oral mucosa:
***Flaccid blisters or bulla - residual erosions***
Hyperpigmentation
Positive nikolsky's sign
Dx biopsy of tissue with immunofluoresence
•TX may be treated in burn unit or ICU
***Iv fluids, electrolyte balance,
wound care***
Pemphigus Vulagaris
IgG produced against antigens in the dermal
epidermal basement membrane:
***leading to subepidermal tense bulla***
•Lesions begin as pruritic hives
Dx biopsy of tissue with immunofluoresence
Bullous Pemphigoid
Self limited viral infections of the skin affecting
children and sexually active adults
Etiology: pox virus (MCV)
•Dome shaped umbilicated pearly papules
TX: resolve spontaneously in 9-12 months
cryotherapy curettage
Molluscum Contagiousum
Etiology: abnormal follicular keratinization
increased sebum
Affects face neck chest and back
Tx topical salicylic acid retinoids benzoyl peroxide
-Topical antibiotic (clindamycin)
Acne
•Etiology: suspected fungal or mite component
Easy and recurrent flushing
Tx: avoid triggers, topical antibiotics
Rosacea
•Skin disorder resulting from an allergic reaction
•Associated with HSV, mycoplasma, drugs
•Multiple confluent target-like papules &
vesicles on the center
•Classic iris or target shaped lesions symmetrically
distributed on Palms and soles
Dx: Eryhtema Multiforme
•Involves mucous membranes especially manifested
by erosive lip lesions and conjunctivitis
Dx: Erythema Multiforme Major
•Doesn’t involve mucous membranes
Dx: Erythema Multiforme Minor
Tx: Antipyretics, antihistamines, analgesics, topical steroids
•Usually preceded by a prodrome of a
respiratory illness
•Spectrum of mucocutaneous drug induced or
idiopathic rxn involving @ least 2 mucosal surfaces
•Varied extent of skin involvement b/w 10-30%
•Starts with red macules
 bulla
necrosis
 desquamation
Dx: Stevens-Johnson Syndrome (SJS)
•Extensive keratinocyte death with separation of la
•Erythematous, dusky or purpuric macules of
irregular shape and size
Coalescence
full thickness necrosis w/ gray hue
epidermis detaches
Easily broken blisters
desquamation reveals raw bleeding dermis
•Involves greater than 30% skin surfaces
•Positive Nikolsky sign
Dx: Toxic Epidermal Necrolysys (TEN)
Tx for SJS/TEN: remove offending drug, supportiv
opthalmic consultBurn unit wound care
•Arises in skin exposed areas,
associated with chronic UV damage
•Metastasis and death is rare
•Pearly papule rolled border with
fine telangiectasia
•Rodent Ulcers
•Most common form of
skin cancer
Dx: Basal Cell Carcinoma
Tx: Excision, cryosurgery
•Findings typical over sun-exposed areas such as t
ears, cheeks and bottom lip
•Associatied with chronic UV damage
immunosuppression
•Metastatic potential
•Predecessor lesion is actinic keratosis
•2nd Most common form of skin cancer
Dx: Squamous Cell Carcinoma
Tx: Excision and Cryotherapy
•Melanocyte derived skin caner
•Hyper-pigmented macule or plaque with ABCDE
characteristics (asymmetry, borders, color,
diameter, enlargement/elevation)
•Superficial Spreading – most common
malignant manifestation (60-70%)
•Precedent lesion – dysplastic nevi
•Dx: Melanoma
Tx: Excision, Radiation and Chemotherapy
SHOW US WHAT YOU GOT…
A 28 year old body builder presents to the emergency room with
clustered lesions surrounded by an erythematous base on his
chest and neck. Patient complains of pruritis and burning pain
which is made worse when he sweats and when he wears tight
clothing. Patient denies going into the hot tub.
Diagnosis?
Folliculitis
Most common etiology?
Staph. Aureus
If the patient did use the hot tub then what would the etiology be?
Pseudomonas
How would you treat?
Gentle
cleansing of the areas involved
Topical antibiotic (mupirocin)
WHAT ABOUT THIS?!



This is an acute, deep-seated, red, hot, tender nodule,
which evolves from a staphylococcal folliculitis
Commonly found on butt, thighs, axilla, face and neck
You see follicular pustules in hair bearing areas


Diagnosis?
Furuncle
Now if this weren’t treated and were to become a deeper
infection comprised of interconnecting abscesses usually arising
from several contiguous hair follicles.

Diagnosis?

Carbuncle
Etiology?
Staph
A.
TX:
Incision and drainage
Systemic antibiotics – Nafcillin, Oxacillin, Cloxacillin, Dicloxacillin


A 35 year old woman with a PMHx of DM presents with
fever, chills and, malaise with pain and redness on her
medial thigh which is warm to the touch, after falling off
her motorcycle.

Diagnosis?
Cellulitis

Etiology?
Polymicrobal

TX:
•Unasyn
•Local wound care
•Oral cephalosporin
•Cloxacillin

Flesh colored hyperkeratotic firm papules
which disrupt the normal fingerprint lines
mainly found on the hands and feet.
Diagnosis?
Verruca
Etiology?
Human Papilloma Virus (HPV)
TX:
•Cryotherapy
•Pare down the warts

A 7 year old girl presents with multiple isolated
lesions on her face. On physical exam you note
honey colored crusts around her nose and mouth.

Diagnosis?
Impetigo

Staph

Etiology?
A or Streptococci
TX of choice?
•Topical antibiotic (Mupirocin)
•Remove crusts with saline soaks
Cutaneous
intraepidermal viral infx
•Oncogenic
•Sexually Transmitted
•Cauliflower-like lesions
DX???
CONDYLOMA ACUMINATUM
ETIOLOGY?
HPV- HPV 16, 18, 31 (oncogenic)
Vaccine: gardisel
TX: cryotherapy** podophyllin

Common recurrent and self limiting
Sexually transmitted
 Facial, non genital or genital presentation
 Vesicular eruption
 DX?
Herpes


Type 1 – primary infx, gingivostomatitis, fever,
malaise, local LAD lasts about 2 weeks
 HSV-2: primary infections, vulvaginitis, penile or
perennial lesions, fever, local LAD lasts about 2
weeks
TX: acyclovir topical or oral prophylaxis
•
Acute self limiting dermatomal vesicular eruption
•Usually unilateral may involve adjacent dermatomes
•Erythema grouped vesicles pustules and crusts
Previous Hx of chicken pox
•Complications include: post-herpetic neuralgia,
ophthalmic disease, Ramsey-hunt syndrome
•Etiology: Varicella Zoster
oDX: Shingles
TX: oral acylovir,
prophylaxis
•Transmission human to human animal or soil contact
Risks: heat, humidity, sweating, occlusion, DM **occlusive
footwear
•annular lesions asymptomatic or pruritic
•Dermatophytes digest keratin- skin hair and nails
DX: Tinea…..tx: topical antifungals for tinea corporis cruris pedis
Systemic antifungals for tinea capitis= griseofulvin
•dermatophytes (microsporum, trichophyton, epidermphyon) or yeasts
Tinea capitis: alopecia with scale and inflammation
Tinea corporis: single or mutlti[le plaques scaling erythema
active borders central clearing
Tinea cruris: inner thighs and inguinal folds
Tinea pedis: interdigital dry or macerated 'moccasin'
Tinea manum: dryneess hyperkaratosis of palms 'one hand
two feet disease'
Tinea unguim: change of color in nail brittleness subungual
debris
DX: KOH prep, wood's lamp, fungal culture biopsy
ALMOST FINISHED…

This patient presents with velvety
hyperpigmented thickening in areas such as the
neck, axilla, and groin.
Acanthosis Nigracans

This patient presents with light hair, light eyes,
has to wear tinted glasses and can’t be in the
sunlight.
•Albinism

Closed spaced infection which usually occurs on
the fingertip and is associated with redness and
pain.
•Felon
•A large, single bulla with erythema and edema on the thumb of a
child; the bulla has ruptured only in the center and clear serum
exudes from it.
Bullous Impetigo
•Group A streptococcus
•Painful, shiny, erythematous, edematous plaques involving
eyelids, cheeks, and the nose of an elderly febrile male.
ERYSIPELAS
•On palpation the skin is hot and tender. Portal of entry was
conjunctivitis.
WHAT IS IT???
NECROTIZING FASCIITIS
•Multiple, pruritic, erythematous papules, vesicles
•"dewdrops on a rose petal"
VARICELLA VIRUS
Angioedema
HYMENOPTERA
Multiple, pruritic, urticaria-like
papules at sites
FLEAS
Lyme’s disease
Borrelia burgdorferi
Erythema migrans
ONE more to go!

This is characterized by “exclamation point hair”
Alopecia

Areata
In androgenic alopecia how is the presentation of male
hair loss differ from that of females?
 Males:
•frontal and temporal hair loss

Females:
Central

hair loss
How can this be treated?
Finasteride
and Minoxidil
You thought that was hard?! TRY THESE!!!

Which spider has the red hour glass?

Which spider has the violin-shape on its back?

where do we see the “caufe-au-lait” spots and the “button-hole
sign”?
Black
Widow
Brown-Recluse
•Neurofibromatosis

This is an autoimmune disease where there are no melanocytes
present.
•Vitiligo

This is an edematous plaque that erodes the nipple and areola.
Paget’s Disease
 This patient has to undergo frequent endoscopy procedures because
of multiple polyps in his intestine. Patient also presents with dark
pigmentation around his lips. Diagnosis?
Peutz-Jeghers
Syndrome.
Too easy?! I guess, you are all just THAT smart… GOOD LUCK =)
REFERENCES
www.krugersalmightynotes.com
Compiled by: rachelle =)