Dermatology 1: Papules, Plaques, and Pustules – Flashcards
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Skin Anatomy
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Color Shape Configuration Texture Size Location Palpable
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Descriptive Factors of Rashes/Lesions
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When/where did it start? Is this the first episode? Itchy, burning, painful? Spreading? Pattern? Change in size, shape, color, location of lesions? Bleeding? Provoking, alleviating, exacerbating factors? PMHx: asthma, allergies, sensitivities Medications Travel history Environmental exposures Family history
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Derm History
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assessment of respiratory and cardiac stress (anaphylaxis)
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ROS must include!
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straight line i.e. contact dermatitis, lichen striatus (poison ivy)
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Linear lesions (configuration)
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rings with central clearing i.e. ring worm (tinea)
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Annular lesions (configuration)
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circular or coin-shape i.e. nummular eczema
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Nummular lesions (configuration)
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rings with central duskiness i.e. erythema multiforme, lyme disease
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Target (bull's eye) lesions (configuration)
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lacy or networked pattern (fishnets) i.e. livedo reticularis
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Reticulated lesions (configuration)
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grouped papules or vesicles arranged like a herpes simplex infection i.e. shingles
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Herpetiform (configuration)
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clustered in a dermatomal distribution like herpes zoster
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Zosteriform (configuration)
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irregular, pebbly, or rough surface i.e. warts and seborrheic keratoses
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Verrucous lesions (texture)
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thickening of the skin with accentuation of normal skin markings, results from repeated scratching or rubbing i.e. psoriasis
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Lichenification (texture)
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deep thickening of the skin, hard/resistant feel i.e. cellulitis
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Induration (texture)
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yellowish, waxy lesions, usually benign, idiopathic i.e. lipid disorders, commonly on eyelids
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Xanthomas (texture)
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central indentation, usually viral i.e. molluscum contagiosum
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Umbilicated (texture)
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epidermal exfoliation that occurs with gentle lateral pressure on seemingly uninvolved skin, seen in TEN (toxicepidermal necrosis) and pemphigus vulgaris i.e. touch skin with pressure, epidermis peels
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Nikolsky sign
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pinpoint bleeding after a scale is removed from plaques in psoriasis
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Auspitz sign
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development of lesions within areas of trauma, psoriasis, lichen planus i.e. think vitiligo occurs at areas of trauma
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Koebner phenomenon
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flat, non-palpable usually ;1cm in diameter i.e. freckles, port-wine stains
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Macule
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large macule, flat greater than 1cm
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Patch
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elevated or raised usually ;1cm rounded, flat-topped, umbilicated caused by hyper-proliferation of cells in the epidermis or superficial dermis i.e. warts, insect bites, mole
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Papule
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palpable, elevated ;1cm in diameter caused by proliferation of epidermal and superficial dermal cells i.e. psoriasis
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Plaques
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firm papules that extend into the epidermis, dermis, or subcutaneous tissue pigmented caused by proliferation of the mid to deep dermal cells i.e. lipomas, cysts
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Nodules
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small, fluid-filled papules, aka blisters ;1cm in diameter i.e. herpes
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Vesicles
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large, fluid-filled vesicles or blisters ;1cm in diameter i.e. burns, allergic contact dermatitis, bullous impetigo
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Bullae
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vesicles that contain pus usually infected i.e. folliculitis, acne
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Pustules
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aka wheals or hives elevated pruritic and erythematous lesions caused by local edema i.e. drug, hypersensitivity reactions
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Urticaria
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accumulation of horny epithelium i.e. psoriasis, seborrheic dermatitis
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Scale
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aka scabs dried serum, blood, or pus i.e. impetigo
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Crust
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loss of part of epidermis (usually from scratching) -open areas heal without scarring *excoriations- linear
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Erosions
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complete loss of epidermis and part of dermis due to venous stasis, trauma *heal with scarring i.e. decubitis ulcers, infections
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Ulcers
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non-blanching punctate foci of hemorrhage can be wet or dry i.e. indicative of systemic or hematologic disorders -platelet abnormalities, vasculitis, RMSF
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Petechiae
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large area of hemorrhage, can be called ecchymosis or bruising maybe palpable -hallmark of leukocytoclastic vasculitis -localized hemorrhage under the skin may indicate co-agulopathy
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Purpura
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thinning of skin caused by sun exposure, age, long term steroids
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Atrophy
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areas of fibrosis that replace normal skin after trauma can lead to keloids (hypertrophic scars that extend beyond the wound margin)
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Scars
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small foci of permanently dilated blood vessels usually occur in areas of sun damage found in numerous systemic diseases
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Telangiectasis
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inflammation of the superficial dermis/epidermis
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Dermatitis
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contact dermatitis: papular and itchy rash *can be caused by soaps, detergents, cleaners (localized) Dx: no specific test, arrive by history Tx: identify etiology, topical cortisone cream for pain/itching, PO diphenhydramine (Claritin)
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Irritant Dermatitis
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contact dermatitis: more itchy than painful, can have blisters/vesicles on an erythematous base *caused by contact to an allergen (nickel, soaps, perfumes, cosmetics, poison ivy/oak) Dx: KOH to r/o tinea, patch testing to identify chemicals, skin biopsy to exclude tinea, psoriasis or cutaneous lymphoma Tx: identification and removal of allergen, corticosteroids (PO and topical), and anti-histamines
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Allergic Dermatitis
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xerosis, scaly, patchy, cracked skin leading to lichenification unexplained intense pruritis morphology changes depending on age hereditary aggravated by what the person is wearing, stress, anxiety, or dryness worse in winter months
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Atopic Dermatitis (Eczema)
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dry, scaly, itchy skin scalp and face (*cheeks) rubbing against bedding, carpeting, and other things in order to scratch the itch, trouble sleeping want to prevent secondary infections
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Infant Eczema
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itchy rash beginning at the creases of the elbows or knees, neck, wrists, ankles, and/or crease between the buttocks and legs
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Child Eczema
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creases of the elbows, knees, and nape of neck especially noticeable on the neck and face and hands causes scaly skin, more scaly then in children or infants
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Adult Eczema
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5 minute luke warm baths followed by liberal application of moisturizer (petroleum or aquaphor) adding emulsifying oils to baths helps (prepares skin for moisturizer) topical steroids in ointment formulation-start with hydrocortisone 1% bid to lesions, can increase strength -typically increase FREQUENCY and then DOSE, then a whole new drug anti-histamines: atarax or diphenhydramine (benadryl) immunomodulators: tacrolimus (black-box warning) soft-clothing, avoid wool products, sleeping in cool temps, humidifier, wash clothing in mild detergents, avoidance of trigger foods (peanuts, eggs, seafood, soy, cow milk, tomatoes, oranges)
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Atopic Dermatitis Treatment
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type of eczema pruritic vesicular eruptions on the fingers, palms, and soles "tapioca-like" appearance without surrounding erythema Tx: high dose topical steroids and cold compresses
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Dyshidrosis
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chronic, itchy, inflamed skin caused by a cycle of scratching/rubbing causing more scratching "one or more slightly erythematous, scaly, well-demarcated, lichenified, firm, rough plaques with exaggerated skin lines are noted" Tx: avoid scratching, topical steroids, anti-histamines
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Lichen Simplex Chronicus
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urticaria appear as blanching, pruritic, palpable wheals with erythema and edema involving the dermis and epidermis allergic reaction resulting in histamine release extremely itchy and may result in angioedema Tx: anti-histamines (diphenhydramine or hydroxyzine); check ABC's --> listen to heart and lungs
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Hives
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acute, self-limiting (possibly viral) mildly inflammatory, oval, papulosquamous lesions on the trunk and proximal extremities starts with a "herald patch" which is single, oval/round, sharply demarcated, pink or salmon in color on the chest, back, or neck characteristic rash follows in a centrifugal or top down pattern a few days later in a classic "christmas tree" pattern Tx: reassurance, can try anti-histamines if itching is severe but usually not necessary, goes away on its own but can take up to 3 weeks
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Pityriasis Rosea
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inherited skin disorder (family history) of increased epidermal cell turnover and thickening of the epidermis erythematous papules and plaques with thick silvery scales common on the elbows, knees, and feet four types
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Psoriasis
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symmetrically distributed plaques involving the scalp, extensor elbows, knees, and back
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Plaque psoriasis
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abrupt appearance of multiple small psoriatic lesions
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Guttate psoriasis
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most sever form of psoriasis characterized by erythema, scaling, and sheets of superficial pustule with erosions
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Pustular psoriasis
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refers to a presentation involving the intertriginous (under breasts, groin) areas
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Inverse psoriasis
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pitting with color changes and crumbling of the nail
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Nail psoriasis
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diagnosis is made clinically and occasionally with a skin biopsy UV light (dec. the cell turnover) or high potency corticosteroids hospitalized in severe cases for a tar ointment or methotrexate
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Psoriasis Treatment
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skin test: RAST (radio-allergosorbant test) skin biopsy d/c offending drug/food if anaphylaxis: H1 antagonists- (anti-histamines, diphenhydramine, cetrizine) H2 antagonists- (ranitidine and cimetidine) steroid burst- (short and intense) tapering- (wean off to prevent adrenal insufficiency)
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Hives treatment
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cell-mediated immune response; unknown etiology found with other co-diseases of altered immunity (UC, vitiligo, myasthenia gravis, hep c) hypertrophic, pruritic lichen type lesions on flexor surfaces (wrists) of extremities which spread over the course of weeks involve mucous membranes (painful) actinic, annular, atrophic, linear, etc. Tx: resolve within 8-12 months but can try topical steroids
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Lichen Planus
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obstruction of sebaceous follicles (oil glands) self limiting, often found in teenagers and young adults manifests as open/closed comedones usually on the face, chest, back causes: stressful events (hormone changes), friction acne, oil based cosmetics retention hyperkeratosis, increased sebum production, inflammation, propionbacterium acne within the follicle Tx: mild cleansers, non-comedogenic moisturizers, diet, topical anti-inflammatory agents +/- topical oral antibiotics
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Acne Vulgaris
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retinoids: comedolytic and anti-inflammatory, help normalize hyperproliferation and hyperkeratinization thus decreasing comedomes -cause sun-sensitivity, qd, taken with oral contraceptive antibiotics: anti-microbial, may have anti-inflammatory properties -clindamycin (topical) -benzoyl peroxide cleansers -minocycline (oral)
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Acne vulgaris (topicals)
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Isotretinoin (accutane): can't get pregnant antibiotics: doxycycline and minocycline hormones: estrogen, oral contraceptives, spironolactone (washes out K+ causing hercitism)
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Acne Vulgaris (systemic)
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acneiform disorder of middle aged and older adults chronic vascular dilation of central face (nose, cheeks, eyelids, and forehead) susceptible to spicy foods, alcohol, temperature extremes, and emotional reactions Dx: flushing, non-transient erythema, papules and postules, telangiectasia) Tx: topical antibiotics or benzoyl peroxide are the initial treatments of choice -tretinoin cream (papular and pustular lesions unresponsive to other treatments) comes and goes
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Rosacea
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most common benign tumor in older adults over proliferation of epidermal cells (getting old) painless, thickened, acanthotic lesions with an irregular verrucous surface, brown to black in color, with greasy appearance ***Leser-Trelat sign: characterized by the abrupt appearance of multiple tumors that increase their size and number could be malignant if rapid especially GI tract
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Seborrheic Keratosis
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usually none needed ammonium lactate (lac hydrin) and alpha hydroxy acids reduce height of lesion, freezing with liquid nitrogen, curettage Work up and refer stat if Leser-Trelat sign present
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Seborrheic keratosis (treatment)
