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freckles (ephilides)

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tan macules, similar to lentigo which occur in older adults but these occur more often in young children increased mealnin at basal layer occurs in *sun-exposed* areas at *young age*, more common in fair skin more noticeable during summer months no tx necessary

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benign melanocytic nevi

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avg 40-50 per adult more common in *fair skin* patients triggered by sunlight begin in infancy, continue into adulthood (*30s*) natural progression: junctional -> compound -> intradermal 2-6mm oval or round, *even color and margin*

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junctional nevus

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nests of melanocytes in epidermis

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compond nevus

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pigmented papule (raised) sharp margin, may be lighter in color than junctional nevus nests of melanocytes in epidermis and dermis

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intradermal nevus

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flesh colored papule hx important to distinguish from basal cell nests of melanocytes in dermis

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dysplastic nevi

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2 shades of brown *"fried egg"* appearance often > 6mm mahogany, red-brown color doubly covered areas increased risk of melanoma if > 50

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melanoma

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1000 fold increase in incidence since 1950 76,000 cases in US in 2012 9,000 deaths in 2012 1 in 35 americans will develop melanoma risks: fair, blonde or red hair, freckles and tend to sunburn *7-fold* increase in teenage girls using tanning bed 1 time per month concern if *new pigmented lesions > 35yo*

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*melanoma clinical features*

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A- asymmetry B- border irregularity C- color variation D- diameter greater than 6mm E- evolution

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melanoma subtypes

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superficial spreading is the most *common* type lentigo maligna melanoma nodular melanoma acral-lentiginous melanoma is most common in *dark skinned races* and occurs and palms of hand or soles of feet amelanotic melanoma

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diagnosis of melanoma

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prognosis most dependent on *tumor thickness (Breslow depth)* tumors 1-4mm- sentinel lymph node biopsy recommended

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prognosis of melanoma

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minimum risk: depth 4.0mm has 5yr survival < 50%

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melanoma pathology

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single melanocytes with *pagetoid spread* up into epidermis nests of *atypical* melanocytes in dermis mitotic figures and ulceration can affect prognosis *depth* is most important factor for prognosis measured from granular layer to deepest melanocyte (Breslow's depth) *S100* positive

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vitiligo

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*depigmented* patches commonly on elbows, knees, around mouth and eyes can occur in areas of trauma possible family hx rare association with other autoimmune diseases (thyroid) pathology: *loss of melanocytes* in basal layer

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ash leaf macule

answer

> 2 is concerning for tuberous sclerosis, may be first sign of it hypopigmented macule usually present during early childhood healthy children may have 1-2

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benign epithelial tumors

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seborrheic keratoses, aad.org - education - basic dermatology curriculum - learning modules: benign skin lesions

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acanthosis nigricans

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velvety hyperpigmented plaques neck, knees, ankles, occasionally on hands/tongue associated with obestiy, *DM* (insulin resistance), rarely internal malignancy tx: treat underlying cause (weight loss, control DM), keratolytics (lac-hydrin, salicylic acid), topical retinoids

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pathology of acanthosis nigricans

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acanthosis: thickening of stratum spinosum papillomatosis: undulating epidermis hyperkeratosis: thickening of stratum corneum

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actinic keratosis

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occurs on *chronically* sun-damaged areas: face, arms, upper chest and back discrete scaly (hyperkeratotic) papules can be red, flesh-colored or tan/brown often easier to feel than see ~5% risk of transforming to SCC tx: liquid nitrogen, topical retinoids, 5-FU topical cream can remove it

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squamous cell carcinoma

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occurs in areas of *chronic* sun exposure arms, hands, head and neck *hyperkeratotic*, firm papule or plaque, more crusty than BCC +/- firable *increased risk:* immunosuppressed (HIV, transplant), HPV infection, old burn scars, chronic ulcer, h/o radiation, tobacco exposure (lips), arsenic exposure tx: excision, Mohs, radiation, 5% risk of mets

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SCC pathology

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arises from *keratinocytes* within the epidermis downward growth into dermis with finger-like projections *keratin pearls* or squamous eddies may have areas of atypia, mitotic figures

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basal cell carcinoma

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*most common type of malignancy* occurs in areas of *chronic* sun exposure such as head and neck, arms, upper chest and back *pearly* papule with telangiectasias friable, slowly growing, new lesion in adults

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4 types of BCC

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superficial: epidermis only, usually not on face nodular: most *common* subtype, pearly papule sclerosing: most *aggressive subtype*, can appear scar-like pigmented: tan/brown/gray/black papule more common in dark skinned races

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BCC pathology

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arises from *basal* layer proliferation of basaloid cells *peripheral palisading* clefting rarely significant atypia +/- surrounding inflammation

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BCC treatments

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electrodessication and curretage, surgical excision, mohs, radiation extremely rare risk of metastasis- .1%

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dermatofibrosarcoma protuberans (DFSP)

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malignant larger than dermatofibroma (DF), multi-lobulated, usually > 1cm shoulder is most common location rare risk of metastasis high risk of local recurrence

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neurofibroma

answer

soft, fleshy, well-demarcated exophytic papule *"button hole"* sign flesh colored and usually occurs on the trunk may occur *without* neurofibromatosis increased fibrous tissue in dermis nerve nuclei are "wavy" S100 positive

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disorders of epidermal maturation

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ichthyosis: congenital or acquired "fish-like" severe sacling, flaking plate-like scales tx: emolliants, dry skin care, keratolytics (lactic acid), topical retinoids

question

urticaria

answer

wheals migrating with each lesion lasting *less than 24 hours* and is extremely pruritic acute *(6 weeks)*- idiopathic (50%), underlying autoimmune disorder, chronic infection, malignancy- need to send these to derm edematous, erythematous, migrating, pruritic *50% of cases are idiopathic*

question

urticaria treatment

answer

acute: *avoidance*- fragrance free, preservative free soaps, lotion, detergents; oral *antihistamines* chronic: high dose oral antihistamines, immunosuppression

question

contact dermatitis

answer

skin condition created by reaction to externally applied substance *2 types:* irritant contact dermatitis, allergic contact dermatitis

question

allergic contact dermatitis (ACD)

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ACD occurs when contact with particular substance elicits a *delayed hypersensitivity reaction type IV* the sensitization process requires 10-14 days, upon re-exposure the dermatitis appears within 12-48h most common cause is Rhus dermatitis from poison ivy, posion oak or poison sumac (all contain the resin urushiol) other common causes include fragrances, formaldehyde, preservatives, topical abx, bezocaine, vitamin E, rubber compounds, nickel

question

posion oak and posion ivy

answer

poison oak: 3-7cm in length, lobulated notched edges, groups of 3,5 or 7, grows on bush-like plants, turns colors in autumn posion ivy: 3-15cm in length, notches edges, groups of 3, grows on hairy-stemmed vines or low shrubs, turn colors in autumn

question

rhus allergy prevention

answer

avoid the plants apply barrier: clothing, PTC products which bind resin more than skin wash clothing, shoes and objects after exposure (within 10 minutes if possible)

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erythema multiforme

answer

*targetoid* papules almost always palms and soles often related to *HSV* outbreak less likely a medication

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steven johnson syndrome

answer

*medical emergency* usually caused by *medications*, most often bactrim (TMP-SMX) or dilantin (phenytoin) targetoid lesions + *mucosal involvement* crusting of lips conjunctival injection/pain- get ophthalmology sloughing, crusting, pain of vagina/urethra/penis tx: discontinue offending agent and *supportive care* with fluids and pain management

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toxic epidermal necrolysis

answer

*even worse medical emergency* similar causes as SJS- medications *>30%* body surface area involvement with skin sloughing off in *sheets* significant mortality, risk of death depends on age and other co-morbidities transfer to *burn unit* needs supportive care: electrolyte imbalance, heat loss, intubation, tube feeding, catheter monitor for infection

question

psoriasis

answer

well-demarcated erythematous *silvery* plaques extensor surfaces, may involve scalp can be *inherited*- ex CwC6 auspitz sign: pinpoint bleeding when scale is pealed off nail involvement more often with psoriatic arthritis, *fingernails* may have pitting, oil drops, onycholysis inverse psoriasis more rare associated with obesity, hypercholesterolemia, hypertension, DMII, depression, alcohol, smoking, psoriatic arthtritis pencil-in-cup deformity in destructive psoriatic arthritis

question

psoraisis treatment

answer

topical steroids, vitamin D analogs (calcipotriene), phototherapy (narrowband UVB), methotrexate, cyclosporine, acitretin biologics: TNF-alpha inhibitors, blocks IL-12 and IL-23, *risk of infection* *do not give prednisone*- can cause rebound with even worse symptoms

question

psoriasis and metabolic syndrome

answer

chronic inflammatory skin condition *pro-inflammatory cytokines* DM type II, arterial htn, hyperlipidemia, coronary heart disease

question

seborrheic dermatitis

answer

greasy scale with background erythema scalp: erythema with overlying snowy scale mid face involvement: glabella, eyebrows, nasal alar grooves can affect conchal bowls behind ears, mid chest and back worse with *HIV and parkinsons*

question

lichen planus

answer

will see picture of this- located around wrist purple, polygonal, pruritic, papules may have association with *hepatitis C*

question

when to refer blister to dermatology

answer

with exception of varicella most generalized vesicles and bullae represent *severe and potentially fatal* disese *refer urgently* to dermatologist

question

pemphigus vulgaris

answer

*superficial* bullae and erosions *pathology shows acantholysis (rolled up keratinocytes without attachments)* dx with direct immunofluoresence- netlike within stratum spinosum consult derm flacid blisters mucosal involvement common and dangerous occurs more commonly in 40s-50s splits at stratum spinosum due to antibodies (dx with IF)

question

bullous pemphigoid

answer

*deep, tense* bullae pathology: subepidermal split with *eosinophils* usually in *elderly* dx with direct immunofluoresence: linear at basement membrane consult derm thicker skin over blister, lower down and no mucosal involvement

question

dermatitis herpetiforms

answer

clusters of vesicles on *elbows and knees* confirm diagnosis with direct immunofluorescence- granular IgA deposits in dermal papilla associated with celiac disease and *gluten* sensitivity

question

porphyria cutanea tarda

answer

vesicles or erosions on *dorsal hands* occasionally itchy worsened by sun can be associated with *hepatitis C* treat with sun-protection and phlebotomy pauci-inflammatory, sub-epidermal split

question

acne

answer

contributing factors: hormones, bacteria (propionibacterium acnes), sebum production open comedone = blackhead closed comedone = whitehead debris and bacteria collect in cloegged pores, leads to inflammation, papules and pustules with erythema and edema these pressurized follicles can rupture in dermis resulting in tender, deep nodules comedonal acne tx with topical retinoid inflammatory acne needs accutane

question

acne treatment

answer

acne scarring is difficult to treat, therefore *aggressive prevention* is important topical retinoids (tretinon, adapalene) is main tx for *comedonal* acne, also needed for inflammatory hormonal treatments: OCPs, spironolactone

question

antibiotics for acne

answer

topical needs to used with *benzoyl peroxide* to decrease bacterial resistance oral for *3 months* continuously- minocycline, doxycycline, clindamycin, azithromycin, bactrim

question

isoretinoin (accutane) side effects

answer

elevated liver enzymes, hypercholesterolemia, hypertriglyceridemia, *teratogenicity*, epistaxis, chelitis, xerosis, mood swings, depression, IBD

question

acne rosacea

answer

chronic inflammatory condition located at "flush" areas of face (nose, cheeks > brow, chin) papules and pustules on background of telangiectasias and general erythema more common in women age of onset 30-50s (later than acne vulgaris) affected persons flush easily and report very sensitive skin no comedones

question

rosacea triggers

answer

alcohol, sunlight, hot bevarages, hot and spicy foods if it makes you *flush* it can flare rosacea, including emotional stress unlike acne vulgaris, rosacea is not related to androgens

question

papulopustular rosacea

answer

erythema, papules and pustules on nose and chin erythematous patches on cheeks bilaterally

question

rosacea treatment

answer

therapy is often long-term rosacea is chronic and controllable *sun protection* topical abx- metrondiazole oral abx laser therapy for erythema/telangiectasias

question

keratosis pilaris

answer

folliculocentric scaly papules occur most frequently on extensor upper arms, face and thighs may itch often associated with atopic dermatitis and ichthyosis vulgaris often referred as "acne" incorrectly rx: emollients, topical retinoids

question

panniculitis

answer

*inflammation of the fat* examples: erythema induratum, lupus profundus, pancreatic panniculitus, traumatic panniculitis *erythema nodosum*- one specific type, covered in more detail

question

erythema nodosum (EN)

answer

*painful, erythematous, non-ulcerative nodules* often symmetric, below the knees (mainly on the anterior *tibial* surface) lesions evolve from bright red to brown-yellow, resembling old ecchymoses patients may also present with fever, fatigue, and arthralgias morphology of the lesion, a *deep nodule*, identifies EN as an inflammatory disease of the fat (called a panniculitis) more common in women

question

conditions associated with EN

answer

OCPs and streptococcal infections many many others but >50% are idiopathic

question

alopecia areata

answer

*smooth, non-scarring* patches abrupt onset possible immunologically mediated, check TSH, glucose and ANA nails can be involves- trachyonychia

question

telogen effluvium

answer

increased *shedding* may not be noticeable to clinician no bald patches 1-6mo (avg 3) after stressful event- *hair cycle disrupted* stress can include weight loss, illness, pregnancy, severe injury, divorce, death, new medication, stopping OCPs

question

thermal injuries

answer

*first degree burn:* epidermis only, red, swelling, pain *second degree burn:* down to dermis, blisters form, severe pain, intense erythema *third degree burn:* most serious, all layers of skin, permanent tissue damage, may include fat, muscle and even bone, may be numb because of nerve damage

question

lupus erythematosus

answer

other organ sx: seizures, depression, psychosis, mouth ulcers, pericarditis, pleuritis, renal dysfunction, blood count abnormalities skin manifestations: *acute cutaneous lupus* is most common (butterfly rash), discoid lupus, subacute cutaneous lupus

question

treatment of acute cutaneous lupus

answer

topical steroids, *sun protection*, oral steroids, oral plaquenil (hydroxychloroquin)

question

dermatomyositis

answer

auto-immune disorder that affects the skin and *muscles* and may be a sign of internal malignancy in adults heliotrope rash often across eyelids, photosensitivity, Gottron's papules on joint dx- punch out bx of skin, blood work for aldolase, creatinine kinase and ANA, muscle bx, MRI of proximal muscles other organ sx: pulmonary, cardiac, GI 30% risk of *malignancy*- ovarian is most common in women

question

scleroderma- systemic sclerosis

answer

excessive fibrosis throughout body widespread skin involvement *rapid progression* early visceral involvement

question

scleroderma- CREST

answer

C- calcinosis R- raynaud's phenomenon E- esophageal dysmotility S- sclerodactyly T- telangiectasias skin sclerosis often limited to fingers and face less severe clinical course

question

scabies

answer

intense itching: nocturnal, itching may be without rash typical distribution: *finger webs*, nipples/areolas, waist bands, under bracelets/watches, *wrists*, folds "incubation period" may be month or more transmitted by close contact (not necessarily sexual) such as college, dorms, military, nursing homes and hospitals may have apparently unaffected family members but must treat all close contact to prevent re-infection

question

norwegian or crusted scabies

answer

common in *immunosuppressed* patients such as AIDS, transplants, chemotherapy, nursing home may need to treat with oral ivermectin

question

treatment of scabies

answer

elimite (permethrin 5%) cream is drug of choice approved for infants aged 2 months and older apply to entire body at bedtime wash off after 8-10 hours launder bed linens and pajamas in hot water repeat in one week treat all family members/close contacts regardless of symptoms

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