question

Eczema dx/dermatitis

answer

Pompholyx (dyshidrosis) Nummular Dermatitis Lichen simplex chronicus Stasis Dermatitis Id reaction

question

Pompholyx (Dyshidrosis)

answer

compromise 20% hand derm cases

question

Dyshidrotic eczema

answer

pompholyx -not proved evidence with sweat glands

question

presentation of pompholyx

answer

1. clear, deep seated, tapioca like vesicles on PALMS AND SOLES 2. Erythema usally absent

question

Hands and soles, tiny little bliter, no inflammation

answer

pompholyx

question

resolves _____ in 1-3 weeks. pompholyx

answer

spontaneously

question

Tx for pompholyx

answer

1. emollients, Burow's solution, drain large blisters 2. Oral Abx prn 3. Oral or IM steroid 4. Aluminum chloride solution

question

Nummular dermatitis

answer

- 'coin like'- pts see tiny papules and vesicles that form erythematous coin shaped plaques - Pin point vesicles and erosion on dry skin - extensor surfaces of legs, B/L, symetrical - men and women 55-65, in winter

question

Extnesor surfaces of leg, B/L, symmetrical

answer

nummular dermatitis

question

correlation to alcohol abuse to nummular?

answer

possible

question

can nummular be cured?

answer

NO but can be controlled

question

how to treat nummular

answer

1. same as Atopic, but some Rx 2-3 weeks of ABX (keflex) therapy 2. Oral steroids only if severe

question

can nummular reslove spontaneously?

answer

YES

question

Juvenile Plantar Dermatosis(JPD)

answer

aka 1. Atopic winter feet 2. Sweaty sock dermatitis 3. forefoot dermatitis

question

Where in the body effected in JPD?

answer

Balls of feet and toes are erythematous, tender, dry and shiny, painful cracks and fissures. -- Dorsum and interdigitals are SPARED

question

is JPD self limiting?

answer

Yes, but supportive therapy helpful(emollients, keratolytics0

question

Asteatotic Eczema (AE) aka?

answer

Eczema craquele Winter eczema Winter itch Dessication dermatitis (aka without a fat)

question

presentation of AE?

answer

Dry, rough, scaly, inflammed skin with superficial crackling that looks like a 'dried river bed' Anterior tibia

question

what is assoc with AE?

answer

age, xerosis, low humidity, FREQUENT BATHING

question

decrease of ________ in s. corneum in AE

answer

intercellular lipids

question

can you give oral steroids to AE?

answer

NOPE give topical steroids, emollients, bath oils

question

Linchen Simplex chronicus (LSC) aka

answer

Neurodermatitis from rubbing

question

is it a disease or reaction patter?

answer

its a reaction pattern

question

what age group for LSC?

answer

over 60

question

presentation of LSC?

answer

Hyperpigmented, lichenified, leathery plaques, well demarcated

question

most common location for LSC?

answer

lower leg

question

treatment for LSC?

answer

its a BREAK ITCH-SCRATCH CYCLE - antipruitics - moisturize, - topical steroids - SSRI (OCD) - Oral doxepin(topical verions is Zonalon)

question

Does it spare face??

answer

Yes, and it happens a lot in areas where domiant hand can reach and scratch

question

is LSC related to OCD?

answer

yes

question

Prurigo Nodularis (PN) aka?

answer

Picker's nodules

question

PN seen in atopics?

answer

yes

question

prentation of PN?

answer

Hard keratotic nodules with scale in easy to reach places and extensor surfaces of extremities

question

Treatment for PN?

answer

- treat with anti-OCD, anti-depressant - topical steroids, pramosone, zonalon, moisturize

question

Nerve pain might be perceived as itch Tiny, SOLITARY LESIONS that look DARK and THINKEND!

answer

pruigo nodularis

question

Stasis Dermatitis

answer

typically presents with erythema, scale, pruritus, erosions, exudate, and crust

question

location of Stasis dermatitis?

answer

usually on the lower 1/3 of leg, superior to medial malleolus, unilateral or B/L

question

Stasis dermatitis can develop?

answer

Lichenification

question

what are other things that are present with SD?

answer

Edema Varicose veins Hemosiderin deposits (pinpoint copper colored macules)

question

summary of SD

answer

Leg vein not functioning--> blood leakage into skin aka copper penny discoloration aka hyperpigmentation in skin--> body sees this as foreign and thus cause irritation

question

Stasis Dermatitis is cutanous marker of

answer

venous insufficiency - venous blood should return from superficial into deep via perforating veins - when the valves become incompetent, there is reflux into superfical system

question

Venous hypertension->slow blood flow->cap permeable->edema and RBC extravasation (purpura and hemosiderin deposit)—leads to microangiopathy...then...

answer

Free Iron from hemosiderin deposits causes inflamm rxn, as does free radicals inflammatory molecules from surrounding neutrophils

question

where is microangiopathy is greatest and cause SD?

answer

medial supramalleolar area

question

where does statis dermatitis occur other than medial suramalleolar area?

answer

general over dilated varicose veins

question

progression of disease SD?

answer

Dry skin--> eczematous skin--> blisters--> open wounds

question

dry skin, asteatic eczema, pruritis before discoloration seen also found in pts with

answer

chronic venous insufficiency

question

Chronic venous insuff: stasis dermatitis

answer

1: First sign of CVI: Cushion-like pitting edema medial leg, stasis purpura leads to hemosiderin deposits, skin dry and itchy 2. Eventually, edema extends up leg and cellulitis appearing inflammation occurs. 3. Stasis dermatitis occurs when the skin, fat, and deep fascia becomes indurated and firm (process is lipodermatosclerosis) - oozing, crusting, pruritis, lichenification, erythema, scale.

question

Pitting edema

answer

Valvular insufficiency

question

When long standing stasis dermatitis and leg ulcer, the tissue becomes so inflammed that it loses barriers b/w ____, ____, ____. This becomes ___________

answer

- Epi, Derm and Subq - Lipodermatosclerosis

question

Risk factors for venous insufficiency

answer

heredity, age, female, pregnancy, obesity, prolonged standing, greater height

question

Early signs of venous insufficiency

answer

tenderness, edema, hyperpigmentation, telangiectasis, varicose veins

question

late signs of venous insufficinecu

answer

Lipodermatosclerosis, Ulcer, Atrophie blanche

question

Atrophie Blanche

answer

very specific to stasis dermatitis; will look like they have white scars aka Stellate or star-shaped.

question

______ can lead to fat necrosis with the end stage being permanent sclerosis with "inverted champagne bottle" legs --lipodermatosclerosis--

answer

Stasis Dermatitis

question

Lipodermatosclerosis - pts with this may also have acute inflammatory episodes that present with pain and erythema which are mistaken for________

answer

cellulitis.

question

Elephantiasis Verrucosa Nostra (ENV)

answer

inflammation of draining lymphatics (as occurs with cellulitis) results in damage to the vessels resulting in lymphatic insufficiency

question

EVN presents with

answer

overlying skin becomes pebble-like, hyperkeratotic, rough Ulceration in this setting is much harder to TREAT!!

question

what are complications of Venous insufficeincy?

answer

1. recurrent ulcer 2. Cellulitis 3. contact dermatitis -- subject to sensitization to the preservatives and active ingredients in wound healing products 4. Venous thrombosis

question

can neosporin cause contact dermatitis?

answer

YES Also, too much of it will cause yeast overgrowth

question

Tx for stasis derm

answer

treat both dermatitis and the underlying venous insufficiency!

question

what is used to tx stasis derm

answer

- compression stocking, compression therapy - exercise, elevation - ligation/stripping of vein - topical steroids - moisture - treat ulcer if present most important is to get swelling down!!

question

ID reaction

answer

aka: autosensitization dermatitis, disseminated eczema

question

what is ID reaction?

answer

It is a secondary, acute, papulovesicular derm DISTANT to the primary site of dermatitis - Coalesce into small plaques

question

where and distribution of ID reaction

answer

symmetric and on HANDS usually

question

infectious causes of Id reaction

answer

DERMATOPHYTES, leprosy, TB, candidiasis, bacterial

question

True id reaction is exacerbation of a pre-existing dermatitis such as...?

answer

Stasis, burns, contact

question

A true ID reaction is not due to external contact or infection (but we will call those an id rxn anyway). T/F?

answer

True

question

Is sensitized T-cells though to be the cause of Id rxn?

answer

yes

question

Treating the ID rxn

answer

Treat the primary site topical steroids topical antipruitics

question

Venous insufficiency ulcer characteristics

answer

tender, shallow, IRREGULAR ulcer with Fibrotic base below the knee

question

location of venous insufficiency

answer

located on medial ankle or along line of long or short saphenous - leg edema, hemosiderin, dermatitis!!

question

Pt with this will have aching or pain, and may be relieved by elevation

answer

venous insuff. ulcer

question

_____ aka livedoid vasculitis surroudns 38% of patients with venous insuff. ulcer

answer

ATROPHIE BLANCHE

question

if patient with long term venous insuff. do a _______? can progress to ________ carcinoma

answer

Biopsy Squamous cell carcinoma

question

Biopsy at 3-4 spots why??

answer

because skin is heterogenous not homogenous

question

why do ABI?

answer

do rule out arterial occlusive disease

question

is compression therapy contraindicated in patient with significant arterial dx

answer

YESSSSS

question

do you compress pat with DVT?

answer

NOOOOO

question

venous ulcer tx

answer

elevate legs above heart!!!

question

compression therapy for venous ulcer

answer

- contraind. ABI <.5 - multi-layer (profore_ - unna boot - stocking post-healing

question

other treatment for venous ulcer

answer

- promogran, silver dressing (acticoat) - topical steroid AROUND ulcer for stasis dermatitis if needed to get skin less inflamed - grafts - oral/iv antibiotics if infectd

question

malignant complication from venous stasis ulcer??

answer

rare but development of SQUAMOUS CELL CARCINOMA especially in female patients!!

question

type of ulcer that occurs over a boney prominence(toe or ankle) or after minor trauma (think ill-fitting shoes)

answer

Arterial ulcers

question

Arterial ulcer characteristics

answer

- Round, sharply demarcated borders - Shiny skin, atrophy surrounds - painful - Dry necrotic base, not very granular -

question

what other cause of arterial ulcer?

answer

cholesterol emboli, raynaud's, hypothermia (frostbite)

question

#1 tx for arterial ulcer

answer

Revascularize aka get them to a vascular surgen stat!!

question

Tx for arterial ulcer

answer

- local wound management - pain control - keep limbs warm and comfortable - eventually appropriate shoegear - encourage to stop smoking if indicated - Get BP and hyperlipidemia under control if indicated

question

Diabetic/neuropathic ulcer aka?

answer

MAL PERFORANS

question

Mal perforans

answer

check for sensation and pre-ulcerative lesions and off-load at check ups

question

Chacteristicss of mal perforans

answer

- punched out with hyperkeratotic rim - granular/fibrotic

question

what is most common cause of mal perforans??

answer

repetitive trauma #1 cause - callus formation(pre-ulcerative lesion) ==neuropathic pation do not feel and does not modify why they work so skin will break down due to repetitive trauma.

question

look at ulcer and get baseline xray to rule out?

answer

osteo

question

best treatment for diabetic ulcer??

answer

DEBRIDE, DEBRIDE, OFFLOAD!!!!

question

tx of diabetic ulcer?

answer

appropriate wound dressing application - glycemic control! smoking control!! - bypass/revascualrize if needed - treat infection if needed -- best cultures are intra-op b/c not contaminated by skin flora

question

Pressure Ulcer aka

answer

Bed sore, decubitus ulcer - unfortunate complication of long standing dx and hospital stays

question

Pressure ulcer characteristics

answer

Heels, Sacrum -pressure, shear force, friction, moisture - area of tissue necrosis

question

Tx of pressure ulcer

answer

relieve pressure!!!! - use two pillows w/heel off the edge - space boot or cradle boots= have cut outs where heel is - position changes - air/fluid mattresses - local care - make sure no oste- if suspected cliniclly

question

what are three differential dx of lower extremity ulcers?

answer

1. acroangiodermatitis (of Mali) 2. Cryofibrinogenemia 3. Buerger's Dx

question

Acroangiodermatitis (of mali)

answer

- violaceous patches dorsal feet in chronic venous dx - looks like kaposi's sarcoma

question

cryofibrinogenemia

answer

" when it gets cold I get these weird things all over me" - cold causes protein to precipitate - purpura, bruise, ulcer - stanozolol treatment

question

buerger's dx= in smokers

answer

- small-mediam arterial and veins - smoke, <50 yrs old, asymmetric cold lmib

question

Most common cutaneous manifestation is leg ulcer for____??

answer

sickle cell

question

Sickle cells

answer

history of leg ulcer prediposed to developing another one

question

where for sickle cell related ulcer?

answer

- medial or lateral mal, dorsum foot, achillies -- number 1 is Lateral mal

question

Malignancies as wounds and wounds that become malignant

answer

1. BCC 2. SCC 3. Melanoma 4. Kaposi's

question

what ; for malignant degneration of wounds??

answer

1.7%

question

most common scenario for malignant degeneration of wounds

answer

chronic wound on lower extremity with chronic osteo; usually squamous cell carcinoma(SCC) - wounds 2-50 years in duration - males, 40-70 yrs old

question

technical term for malignant degernation of wounds? (that develop SCC)

answer

MARJOLIN'S ULCER

question

SCC and Venous Stasis Ulcer

answer

risk of dveloping malignancy: 21%

question

SCC and Venous Stasis Ulcer charactristics?

answer

Exophytic growth in ulcer or irregularity in ulcer base

question

SCC and Venous Stasis Ulcer treatment

answer

excision and grafting

question

Chronic osteo and SCC

answer

may arise in assoication with chronic osteomyelitis and in draining sinus tracts - high of 30% metastatic rate

question

chronic osteo and SCC chacteristic?

answer

Exuberant granulation tissue

question

ronic osteo and SCC Tx?

answer

Amputation or Moh's goal: total excision of tumor

question

areas that bleed, drain, and don't heel?

answer

think of SCC

question

Verrucous Carcinoma

answer

- variant of SCC aka low grade variant which doesnt metastasize often - happens a lot in DM who have had amputations. - Will start warty and then will get weired with milky drainage!!

question

Malignancies that present as wounds?

answer

Rare, often misdiagnosed - consider if ulcer has short duration , unusual symptoms - BCC (60%) - SCC(15%) - Kaposi's - melanoma, - lymphoma, CTCL

question

inflammatory causes of wounds?

answer

Allergic contact dermatitis/Eczema pyoderma Gangrenosum Calciphylaxis Buerger's Dx

question

Pyoderma Gangrenosum

answer

ulcer with violaceous undermined borders

question

wound that is assoicated with IBD, crohn's disease and RA

answer

pyoderma gangrenosum!!!!

question

characteristics of pyoderma gangrenosum

answer

PUSTULES on red base scars!!

question

name is misleading

answer

pyoderma- pus gangrenosum- green its actually red base with pus

question

if you have leg ulcer that is NOT MEDIAL ANKLE considered ______________ until proven otherwise

answer

pyoderma gangrenosum

question

Pathergy?

answer

where you irritate the wound and make it worse

question

treatment of Pyoderma gangrenosum?

answer

1. prednisone 2. doxycycline 3. cyclosporine 4. infliximab***/etanercept/adalimumab 5. topicals/injections

question

when using injection go from wound into peri not from perio to wound

answer

it will create little ulcer: pethergy

question

Calciphylaxis

answer

red plaques in livedo pattern, become black gangernous plaques blitareal and symmetrical

question

this is typically assoicated with end stage renal diseae aka ESRD and 2nd to hyperparathyroidism

answer

calciphylaxis

question

livedo

answer

red/pink doiley pattern

question

treatment for calciphylaxis?

answer

page 87

question

when do biopsy???

answer

1. if not healed within 3 month or 2. older than 4 month and has not responted to treatement

question

biopsy method to consider?

answer

1. base and margin down to subQ tissue 2. mulitple sites 3. excisional if small enough and possible

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