Dermatology Lectures 1 & 2 – Flashcards
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Annular
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ring shaped
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Circulate
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circular
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Guttate
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Drop like Ex. guttate psoriasis
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Iris/Targetoid
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Circle within a circle Ex.Erthema Multiforme
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Zosteriform
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Linear along nerve (Herpes Zoster like)
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Arciform
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Shape of an arc Ex. Intertrigo
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Gyrate
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Twister Spiral Ex. Erythema Gyratum repens (paraneoplastic syndrome)
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Serpiginous
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skin lesion having a wavy margin Ex. Cutaneous larva migrans
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Epidermis
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Protection, melanocytes, langerhans cells
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Dermis
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Collagen, elastic tissue, and reticlar fibers THIN UPPER LAYER: Papillary dermis THICK LOWER LAYER: Extends toward the SQ
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Subcutaneous Layer
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contains fat, nerves, artery, veins
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What parts of the skin are used in temperature regulation?
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Hair and the Sweat glands
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Hair
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Source of heat insulation an cooling
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What is the purpose of Arector pili muscles, and where do they attach?
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The Arector pili muscles attach to the hair, they constrict causing them to stand erect and trap the heat
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Sebaceous glands
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Lubricate hair follicles
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Nails
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Fingernails: 0.5cm- 2mm per week 5.5 months for fingernail to grow from MATRIX to the FREE EDGE Toenails: take approximately 12-18 months
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What are examples of primary lesions?
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Macule, Patch, Papule, Plaque, Nodules, Pustules, Vesicles, Bullae, Wheals
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Macule
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Flat, discoloration, circumscribed example: freckle (<1cm)
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Patch
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(0.5-1.0cm) flat Ex. lentigo, Vitiligo, cafe au lait spots
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Papule
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solid raised lesion (< 1cm) Ex. nevus, acne, warts, measles
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Plaque
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(0.5-1.0cm) Elevated and superficial Ex. psoriasis, wart
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Nodules
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Solid, raised, (>0.5-1.0cm) longer than papule Ex. Hemangioma
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Pustules/ Vesicles
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Collection of leukocytes or free fluid, size varies (different colors) Ex. HSV, chicken pox, scabies, Impetigo
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Bullae
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free fluid (>0.5cm-1.0cm)
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Wheals
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Firm, plaque, (>0.5cm-1.0cm) Transient lasting only a few hours
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Secondary lesions
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Scales, Crust, Erosions, Ulcers, Atrophy, Scars
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Scales
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Excess dead skin
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Crust
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dried sputum and cellular debris
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Erosions
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Loss of EPIDERMIS (no scar) Linear loss of EPIDERMIS (fissure)
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Ulcer
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Loss of EPIDERMIS OR DERMIS will lead to scarring
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Atrophy
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depression, thinning epidermis
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Petechia
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Typically blanching indication superficial vascular dilation
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Lichenification
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Increased skin markings, thickened skin
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Cyst
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Well circumscribed, has a wall and lumen may contain fluid or solid matter
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Shave
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Suspect superficial lesion only (epidermis) Ex. Wart, Skin Neoplasm
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Gradle Cautery
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Good for pedunculated skin lesions Ex. Skin Tag
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Incision
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Obtain clear margins, removal of entire lesion for diagnosis, treatment Ex. Dysplatic nevus
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Punch
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To give pathologist full thickness of skin, leave small scars, can do with a stitch Average: 2-6mm in size, typically do a stitch if >4mm Ex. MM for depth, drug rash, lupus, Erythema Nodosum
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Pruritus
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Itch scratch cycle (Common)
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Acute lesions
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Erythematous, at times edematous papules/plaques, scaling, occasionally oozing secondary to scratching, excoriations
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Chronic lesions: lichenification, PIH
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Morgan Fold: Accentuated lower eyelid fold, Allergic Shiners Pale nasal mucosa
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Immune response of the Skine
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Increased T cell activations Abnormal cell-mediated immunity Overproduction of IgE
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Impetigo
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Honey colored crust (yellow)
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Type 1 hypersensitivity
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IgE mediated Occurs in minutes-hours Usually occurs after second insult
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Type 2 hypersensitivity
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Cytotoxic reactions IgG or IgM mediated
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Type 3 hypersensitivity
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Drug induced serum sickness/drug induced vasculitis IgG or IgM mediated
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Type 4 hypersensitivity
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Morbiliform reactions Mediated by T cells monocytes & macrophages rather than by antibodies Delayed hypersensitivity reactions (poision ivy)
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Scratch testing
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Pinprick to skin with deposition of a small amount of specific allergen placed Results within 15-20 minutes Food, mold, pollen, animal dander
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Patch testing
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-Best way to diagnose is by allergic contact dermatitis -Readings are taken 48 to 72 hours after placement. Can patch test with prepared sheets or to specific items of concern -Positive reaction: erythema (mild), papules (moderate), or vesicles and bullae (extremely positive reaction)
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RAST testing
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limited value in management, simply for diagnosis Allergen specific IgE antibody test
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Class I- VII (strongest to weakest)
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-Control inflammation, stronger potency for more dense plaques -Compromise barrier function so short contact recommended -Ointments penetrate skin better, creams have more chemicals -Topicals should always be applied to damp skin avoid high potency on face & occlusive areas (acne and atrophy)
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Tacrolimus (Protopic) & Pimercrolimus (Eidel)
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Non steriodals, decrease risk of steroid side effects, risk of malignancy including skin/lymphoma, avoid long term use -use for areas of the face or skin folder areas 0.03% for 2-15 y/o 0.1% >15y/o
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Oral steroids, Intralesional Kenalog, Intramuscular Kenalog
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-weight dependent for short term only AVOID INITIAL MEDROL DOSE PACK= inadequate amount of medicine and can cause recurrence after initial amelioration of symptoms. (better to taper ex. 60kg male may do 60mg x 3-4 d, 40 mvx 3-4 days) -good for poor adherence to PO treatment -can have high relapse rate of offending agent not ID or removed
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Cool compress
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For acute inflammation, suppress formation of vesicles and decrease inflammmtion
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Lipid rich moisturizer
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Help barrier function to help mimic lipid layer in skin
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OTC anti itch creams
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Can be allergic to cause over drying *the key is the apply the moisturizer on damp skin for prevention
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Topical Coal and Sal Acid preps
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Help maintain to soften thickened skin and suppress itch
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Immunosuppressives
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Indicated in patients that are not responding to oral and topical therapy and with severe AD Ex. Azathioprine, MTX, cyclosporine, mycophenolate mofeti Short term term basis of treatment
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Phototherapy
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Combines UVA-UVB or alone shown to be effective
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Topical or PO antibiotics
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-Bactroban, Hibiclens, Domeboros -Coverage of common pathogens Staph. aureus and Stepto. Pyogenes -Culture for bacteria from crust/weepings for proper coverage -if tines: curette and send out. Do not prescribe steroid
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Uticaria (exam, cause, dx.)
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Exam-blanch, pink, papules/plaques, commonly oval/linear, may coalesce. usually last <24hr Causes: foods, medications, insects, physical, temperature, hepatitis, (may be associated with SLE, Sjoren's -40% idiopathic Diagnosis: clinical
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Uticaria (Tx)
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tx. if persistent w/o known cause check bloods, PCP eval Antihistamines (IgE mediated) , zyrtec for itch Topicals: minimal relief gives the patient something to prevent from scratching
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Angioedema
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Usually painless, can be tender Causes: Hereditary: autosomal dominant disorder, may follow trauma -deeper (dermis and SQ) form of uticaria with larger ill defined areas of edematous involvement Exam: eyelids, lips, tongue, hands, feet, genitals m/c involved -Anaphylaxis can occur Treatment removal of agent, Prednisone PO or IV
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Angioedema-Uticaria-Eosionophilia Syndrome
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Face, neck, extremities, trunk 7-10 days duration Fever, increased body weight from fluid retention Increase in leukocytes and eosinophils No FH, rare, good prognosis
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Allergic Vasculitis (Cause and Exam)
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Cause: extreme reaction to foreign substance/drug Exam: Most patients> 15 years old -violacious patches usually on legs, buttocks or trunk; PALPABLE PURPURA, scattered or discrete lesions, m/c on legs can spree to buttocks/ arms -Patients ℅ burning pain & pruritus or no symptoms at all -systemic involvement if fever, malaise, abdo. pain -+/- check CBC -vesicles or Bullae
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Allergic Vasculitis (Dx. and Tx.)
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Diagnosis: exam +/- biopsy Tx. removal of the offending agent -possible ASA or coriticosterioids -consult with PCP -r/o recent cardiac procedures such as cath** -Antibiotics if suspect bacterial infection as cause -PO prednisone
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Stasis Dermatitis (Causes and Risk factors)
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Causes: chronic vascular insufficiency, edema, hyperpigmentation, dermatitis, fibrosis, ulceration Risk Factors: varicose veins, superficial phlebitis, venous thrombosis, pregnancy, as it worsens the previously mentioned
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Stasis Dermatitis (Exam, Dx)
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-℅ heaviness/aching/itch in legs; edema -inflammatory plaques, scales of the lower legs/ ankles, +/- dermal sclerosis *ulcers in 30% of patients *lipodermatosclerosis: lower 1/3 of the leg with pigmentation, induration and pigmentation (edema above and below the sclerotic area) Dx. clinical
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Stasis Dermatitis (Testing, Tx)
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Testing: refer patients for vascular eval. for possible dopplers, sono, ext Tx: avoid trauma, compression stockings, topical steroids, elevation of legs, vascular surgery, eval/ tx. of ulcers
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Erythema Multiforme
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*Third most common cutaneous drug rash -50% of cases no cause -can follow a URI, HSV, Mycoplasm pneumoniae** Common, acute often current inflammatory disease
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Erythema Multiforme (Exam)
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-Discrete erythematous macules becoming papulse -70% of cases have lesions on lips/buccal mucosa -Distal extremities/face are common sites (seeing symmetric pattern on backs of hands and feet and extensor aspect of forearms/legs) -Individual lesions heal in 1-2 weeks without scarring, new lesions appear in crops and entire episode can las about a month -m/c meds: **sulfonamides, PCN, phenobarbitals
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Erythema Multiforme (Dx, Tx, DDX)
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Diagnosis: Clinical Tx. d/c causative agent, PO antihistamines, possible systemic steroids DDX: Steves Johnson Syndrome
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Steven Johnson Syndrome & Toxic Erythema Necrolysis (TEN) :(
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aka: Erythema Multiform Major -Immune system reaction caused by medications with high morbidity and POOR prognosis offending agents: sulfonamides, PCN, Quinolones, cephalosporins SJS- sever variant of EM, TEN= sever variant of SJS= BAD NO specific age or gender at risk
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SJS and TEN (Exam)
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-Fever, photophobia, pharyngitis, mucosal inflammation* -Lesions on the trunk> morbilliform lesions > necrotic epidermis> flaccid blisters that break from bottom to top (NIKOSKYS SIGN:**take pencil with an erase and twist and skin comes off) -Anemia and lympopenia
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SJS and TEN (TX)
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-remove the offending patient -possible transfer to burn unit -supportive -fluids, fluids, fluids
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Drug reactions (causes and exam)
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Always get an accurate med list and length on meds, changes in dose/brand/generic, ect -Causes: m/c antibiotic, NSAIDS, Allopurinol, thiazide diuretics, opiates,(common also for pruritus), contrast dye Exam: ***exanthematous, morbullform rash are m/c skin eruption, can see uticaria, rash typically beings 2-3rd onset of offending agent
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Drug reactions (treatment)
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Tx. Topical steroids, antihistamines, PO steroids, IMK -REMOVE THE OFFENDING AGENT) -Always have patient c/w prescribing MD before instantly d/c meds. Don't tell the patient to stop their blood pressure medication or their new brand of insulin for a skin rash
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Erythema Nodosum (causes)
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Causes: 55% idiopathic, 55% streptoccocal infection** -coccidioiodmycosis- fungal infection (west/southwestern U.S0 -Fatigue, Malaise, poss. URI 2-8w prior -can last weeks to years
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Erythema Nodosum (Exam)
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-Nodular, erythematous eruption, tender, disappears -arthalgia in patients >50% -extensor aspects of extremities m/c site knee -F>M 18-34 y/o
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Erythema Nodosum (Dx and Tx)
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Diagnosis: clinical, throat culture, ASO titer, ESR level Treatmet: Self limiting, NSAIDS (Indomethacin 250mg TID or Naproxen 250mg BID more effective than ASA) -rest
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Contact, Irritant, Allergic Dermatitis
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Contact: prolonged contact with offending agents like diaper rash, clothes, soap Irritant: chemical use, think cleaners, solvents Allergic: type IV sensitivity reaction -may correspond exactly to con act (ie. watchband) common triggers are nickel, fragrances, latex, temp, stress, food, poison ivy
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Atopic Dermatitis (big 3)
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ASTHMA, ECZEMA, HEY FEVER
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Atopic Dermatitis (Exam)
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Type I hypersensitivity reaction -typically begins in childhood -chronic, relapsing, hereditary M>F Exam: m/c scaling pink papules or plaques of flexural surfaces, neck, eyelids, dorsum of hands; dematographism
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Atopic Dermatitis (Tx)
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-As previous mentioned, UVA/B can be considered as UV light can prevent exaggerated immune response that causes the inflammation -$, time constraints, (2-3x/week), non-affected skin with UV exposure-risk factor
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Nummular Eczema
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Pruritic inflammatory disorder Common in young adults/ elderly Round papules and plaques resembling eczema, coin shaped Worse in cooler months Treatments as previously mentioned
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Dyshidrotic Eczema
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Small vesicles on hands and feet that can progress to form fissures/erosions -commonly found on lateral aspects of fingers F>M, <40 y/o -Induced by stress, hot/humid weather -can cause intense itching that leads to breakage of vesicles, can cause pain -KOH to rule out dermatophytosis Tx. drain bullae
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Lichen Simplex Chronicus
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Causes: Long hx. of atopic dermatitis/ repetitive scratching/rubbing Exam: -solid, firm, thick plaques -little or no scratching -single or multiple lesions -m/c: scalp, angles, lower legs, upper thighs, exterior forearms, genitals dx.: based one exam , R/O TINEA!!!! before giving steroids Biopsy if unsure- hyperplasia, hyperkeratosis
