question

Pathophys of abscess

answer

localized infection of the dermis, may come from punctures and trauma, large cellular inflammatory response created (primarily neutrophils), aggregate of inflammatory cells replace necrotic dermis- creating pus, sterile abscess if possible hidradenitis suppurativa- apocrine duct obstruction with bact infxn, sinus tracts form and may drain purulent material furuncles- bacteria enter through the hair follicle

question

types of abscesses

answer

furuncle- localized at one hair follicle carbuncle- conglomeerate of multiple hair follicles hidradenitis suppuratica- apocrine gland pilonidal disease- gluteal cleft

question

prevalance and cause of abscess

answer

prevalence: common demo: hidradenitis- puberty, menopause pathologic cause: staph aureus most common, MRSA becoming more common

question

comorbidities, family and social history of abscess

answer

comor: hidradenitis- acne, obesity; diabetes, immunocompromised family hx: common with hidradenitis social: IV drug use (dirty needles)

question

PE of abscess

answer

lesion- adematous, erythematous, tender, fluctuant (indicates pus), indurated (early phlegmon) common locations: axilla, buttocks, perirectal, head and neck Hidradenitis: axilla--> scars and tracts pilonidal cyst: gluteal cleft

question

diagnostic studies for abscess

answer

clinical wound culture (if complicated or chronic)- oftern multipl epathogens, MRSSA more common now

question

complications of abscess

answer

fibrosis, scarring, progressive infeciton

question

Plan/Tx for abscess

answer

patient education: hot soaks or warm compresses for 20 minutes- QID procedure- incision and drainage is STANDARD for care- needs to be fluctuant with pus if complicated with fever or cellulitis- use ATB

question

essentials of diagnosis and pearls for abscess

answer

edamatous, tender, fluctuant, incision and drainage, abx if complication Pearls: staph aurerus is the most common pathogen

question

pathophys of cellulitis

answer

bacteria enters dermis ( external or hematogenous acute spreading inflammation of the dermis and subcutaneous tissue most common are Gram + staph, strep, haemophilus

question

Hx of cellulitis

answer

possible trauma history, pailful, erythematous if complicated: fever, chills, sweats

question

PE of cellulitis

answer

leasion- spreading indurated area of skin, erythematous warm, tender, if complicated: lymphadenopahty, phlebitis, fever erysipelas- sharply demarcated boarder, orangle peel surface

question

what are the four cardinal signs of inflammation

answer

calor- warmth rubor- redness tumor- edema dolor- pain

question

diagnostic studies and criteria of cellulitis

answer

diagnosis is clinical may perform- blood culture- if bacteremia, skin culture- often no yield, CBC- leukocytosis criteria: erythematous, warm, tender

question

complications of cellulitis

answer

phlebitis, bacteremia, gas gangrene, necrotizing fasciitis

question

plan/ Tx for cellulitis

answer

patient education: mark the skin at the cellulitis periphery to determine spreading Oral Abx: 1) first gen cephalosporins (Ceohalexin 500 mg QID 7d) 2) macrolides (Erythromycin 7d) 3) PCNase resistance PCN (Dicloxcillin) If not responding to oral abx: IV cephalosprorins if complicated by has gangrene or nerotizing fasciitis: surgical debridement

question

epidemiology of folliculitis

answer

prevalence commo demo: yound adults pathologic cause: staph aureus most common, psudomonas hot tub exposure social: hot tub

question

types of folliculitis

answer

pseudofolliculitis- infrown hairs of the beard area

question

differential diagnosis of folliculitis

answer

acne vulgaris, pseudofolliculitis barbae

question

diagnostic studies of folliculitis diagnostic criteria

answer

clinical diagnosis, Criteria: erythematous papule or pustules, hair follicle seen at pustule

question

epidemiology of impetigo

answer

prevalence: common demo: children pathologic cause: staph aureus comorbidites: atopic dermatitis more likely social hx: contagious, watch other family members

question

diagnostic studies and criteria of impetigo

answer

diagnosis is clinical criteria: honey colored crutst, psutules that have ruptures, erythematous glistening base, most common found perioral

question

differential diagnosis of impetigo

answer

acne vulgaris, folliculitis, ecthyma, herpes simplex

question

essential of diagnosis and pearls of impetigo

answer

honey colored crust, pustules that have ruptures, erythematous glistening base, most common found perioral, topical abx pearls: staph aureus most common bacteria

question

epidemiology of anthrax

answer

prevalence rare- social hx: farmers and vets at higher risk risk of bioterrorism

question

essentials of diagnosis for anthrax

answer

exposure, eschar, gram stain + rods encapsulated chains, cultures, PCR confirmation, fluoroquinolone abx

question

epidemiology of cat-scratch disease

answer

demo: adults and children affected pathologic cause: cats and bartonella

question

Hx and PE of cat-scratch disease

answer

Hx: bump at site, fever, malaise, anorexia PE: painless papule, painful lymphadenopathy most common in axilla

question

differential diagnosis of cat-scratch disease

answer

skin cancer, pyogenic lymphadenitits, mycobacterial infection, syphilis, tularemia, plague, toxophasmosis

question

essentials of diagnosis and pearls for cat-scratch disease

answer

essentials: exposure to car, painless papules/nodules, painful regiaonal lymphadenopathy, PCr +, Bx- lymphoid hyperplasia Pears: Bartonella

question

Prognosis and complications of cat-scratch disease

answer

prognosis- usually benign complications: retinitis

question

epidemiology of gas gangrene

answer

prevalence- rare pathologic cause: clostridium perfringens most common pathogen

question

Hx of gas gangrene

answer

possible skin injury, fever, tachycardia, painful skin

question

PE of gas gangrene

answer

fever (sight), tachycardia skin: wound becomes swollen, surrounding skin is pale ---> pale --->dusky ---> deeply discolored with coalescent red fluid filled vesicles fould smelling browl blood tinged serous discharge skin crepitus

question

prognosis and complications of gas gangrene

answer

prognosis: high risk mortality complications: severe prostration, stuporm delirium, and coma

question

comorbidities and social hx of necrotizing fasciitis

answer

comor: biabetes more common (20-30% of all cases) social: IV drug users more common

question

Hx of necrotizing fasciitis

answer

sweling, heat, erythema, and pain spread proximally and sitally skin darkens, blisters and bullae with clear yellow fluid form development of gangrene and necrosis is associated with mental staus changes and delirium

question

prognosis of necrotizing fasciitis

answer

high mortality (25-75%)

question

plan/ tx for necrotizing fasciitis

answer

emergency! surgical debridement broad spectrum ATB TV supportive therapy- IV fluids

question

Diagnostic criteria for necrotizing fasciitis

answer

fever, tachycardia, hyptension, progressive tender skin darkening and bullae, possible crepitus, imaging may confirm

question

pathophys of alopecia areata

answer

unknown pathogenesis believed to be autoimmune process hair matricies become arrested-loss can be patchy "swarm of bees"

question

prevalence, demo, and pathologic cause of alopecia areata

answer

1.7% of americans over 50 demo: equal pathologic cause: may be from drugs: thallium , vit A, retinoids, antimitoric agents, anticoagulants, oral contraceptives

question

Hx and PE of alopecia areata

answer

Hx: hair loss, acute onset PE: hair loss, oval patches, exclamation point hairs at edge, no scarring, skin may slightly depress, may have diffuse hair loss

question

differential diagnosis of alopecia areata

answer

tinea, syphilis

question

prognosis of alopecia areata

answer

5% may spontaeously resolve resolution unlikely if: if not in 1 year and the larger the area

question

prevalence, demo, and genetics of androgenic alopecia

answer

prevanence: very common demo: 100% of male caucasions ahve some degree, 40% of femailes over 40 family hx +

question

differential diagnosis of androgenic alopecia

answer

hypothyroidism

question

Essentials of diagnosis for androgenic alopecia

answer

Thinning of hair, gradual dark terminal hair replaced with minatureized hairs topical minoxidil OR 5a reducatse inhibitors

question

prognosis of androgenic alopecia

answer

majority of process occurs 30-50 yo variable

question

dx of androgenic alopecia

answer

diagnosis is clinical

question

Paronychia pathophysiology

answer

inflammation of the nail fold- may extend into proximal nail fold and eponychium

question

prevalence and social hx of Paronychia

answer

prev: common Social hx: nail biting, manicures, thumb sucking, occupational

question

differential diagnosis of Paronychia

answer

herpetic witlow onychomycosis

question

diagnostic studies of Paronychia

answer

clinical dx needle "slow motion" to drain consider: KOH and culture

question

essentials of diagnosis for Paronychia

answer

edema of nail fold tender I/D gram + abx

question

pathophys of Felon

answer

infection of distal finger subcutaneous pulp staph aureus most common often from injury or paronychia

question

prevalence, pathologic cause and comorbidities of Felon

answer

prevalence- not as common pathologic cause- staph aureus comorbidities: paronychia

question

Hx and PE of Felon

answer

hx: pain and swelling of finger PE: edema of distal finger at volar aspect, tender

question

differential diagnosis of Felon

answer

paronychia osteromyelitis flexor tenosynovitis

question

diagnostic studies of Felon

answer

consider: X ray- evaluate for soteromyelitis- raised periosteium

question

complications of Felon

answer

osteomyelitis

question

plan/tx of Felon

answer

procedures: incision and drainage Pharm: Initial: oral abx-->cephalosporin If severe: IV antibotics

question

essentials of diagnosis and pearls of Felon

answer

Essentials of diagnosis: edema of distal finger at colar aspect, tender Pearls: small lincision of area of most fluctuance

question

Hx of abscess

answer

pain, swelling, may develop at injection sites

question

differential diagnosis of abscess

answer

acne vulargis epithelial inclusion cyst

question

Plan for abscess: patient education and procedure

answer

Ed: hot soaks or warm compresses for 20 minutes QID Procedure: I/D is standard of care- needs to be fluctuant with pus

question

plan for abscess if complicated with fever or cellulitis

answer

Antibiotics --> MRSA coverage: sulfonamides (TMP-SXM, BID 7-10 days), clindamycin (300 mg QID 7d) tetracyclines (Doxycycline 100 mg BID 7d) ---> MSSA coverage: cephalosporins (Cephalexin 500 mg QID 7d), macrolides (erythromycin 250 mg QID 7d)

question

plan for abscess if associated with Hidradenitis and Pilonidal cyst

answer

Hidradenitis: excision of sinus tract after elimination of infection ---- may add intralesional steroids (triamcinolone) ---- OR oral steroids (prednisone taper 2 week) pilonidal cysts: marsupialization- avoids future infxn ---- I/D ---- sew edges of fibrous tract to wound edge creating a pouch

question

referrals for abscess

answer

general surgeon if complicated --- Pilonidal --- Hidradedenitis

question

Prevalence, comorbidities and types of cellulitis

answer

prevalence: common comorbidities: diabetes and immunocompromise Types: erysipelas- streptococcus

question

Differential diagnosis for cellulitis

answer

contact dermatitis stasis dermatitis superficial thrombophlebitis erythema infectiosum

question

essentials of diagnosis for cellulitis

answer

erythematous, warm tender oral abx

question

pathyphys of folliculitis

answer

inflammation of hair follicles --occusion, perspiration or tight clothing may irritate the follicles --bacteria enter follicle orifice: commonly caused by staphy aureus , create subcorneal pustule at opening of hair follicle --Pseudodomal folliculitis common in hot tubs --non-infectious folliculities may occur in hot oily environments (ships)

question

Hx and PE of folliculitis

answer

Hx: lesions at hairs that may burn, may be chronic or recurrent PE: erythematous papules or pustules, hair follicle seen at pustule most common locations: thigh, buttocks, scalp, beard

question

complications of folliculitis

answer

sycosis- deep seated folliculitis that frequently recurs abscesses may form

question

Plan/Tx for folliculitis: Patient education and mild folliculitis

answer

Ed: avoid offending environments warm compresses gentle cleansing mild: antiseptic cleansers daily of every other day for several weeks --- proidone-iodine (Betadine) --- chlorhexidine (hibiclens) --- benzoyla peroxide used Topical abx --- clindamycin --- macrolides (erythromycin) --- mupirocin

question

Plan for severe or hot tub folliculitis

answer

Severe: oral abx: cephalosporins, clindamycin, macrolides hot tub folliculitis: oral fluoroquinolones (Ciprofloxacin)

question

Essentials of Diagnosis and pearls of folliculitis

answer

Essentials: erythematous papules or pustules hair follical seen at pustule antiseptic cleansers or topical abx Pearls: most common--> staphy aureus Hot tub--> pseudomonas aeruginosa

question

Pathophys of Impetigo

answer

gram + skin infection bacteria infiltrate skin (minor trauma) staph aureus most common creates subcorneal pustules (below statum corneum) --inflammatory cells primarily neutrophils response and pus created --pustules easily burst--> crusts --with dermal inflammation

question

Hx and PE of impetigo

answer

Hx: start with single lesion, multiple other lesions develop, may itch or burn PE: lesions- honey colored crutst, pustules--> ruptured, erythematous glistening base, perioral--> most common

question

Plan/ Tx for Impetigo

answer

Patient education: change washcloth daily, resolves in 2 weeks Pharm: Initial: antibacterial soap, topical abx (mupirocin (Bactroban) 7-10d) Extensive lesions: oral abx: cephalosporins (Keflex) 7-10d

question

pathophys for anthrax

answer

Bacillus anthracis: gram + spore, rods in chains found in cheep, cattle, horses, coats, swine transmitted via broken skin, mucous membrance or inhalation warfare organism creates derm, pulm, and GI manifestiations derm: after 2 weeks creates necrotic tissue that sloughs off, spread hematogenously pulm: pneumonia or mediastinitis GI: bowel irritation, GI tract ulcers

question

Hx of anthrax

answer

possible exposure cutaneous: painless skin lesion Inhaled: viral symptoms: fever, malaise, headache, cough, congestions GI: fever, abdominal pain, vomiting, GI bleeding progress severely to sepsis or meningitis

question

PE of anthrax

answer

curaneous: erythematous papule initially, then vesiculates and creates necrosis, develops into black eschar, +lymph nodes Inhalation: wheezing crackles, fever GI: Diffuse abdominal tenderness, +/- rebound tenderness

question

diagnostic studies of anthrax

answer

skin gram + encapsulated box, rods in chains cultures or area + B. anthracis ---sputum, blood, CSF, Skin CXR: mediastinal widening from hemorrhagic lymphadenitis PCR to confirm

question

Prognosis for anthrax

answer

cutaneous prognosis good inhalational and GI anthrax mortality 85%

question

complications of anthrax

answer

sepsis, hemorrahic meningitis, hemorrhagic lymphadenitis, pneumonia, bowel perforation

question

Plan/Tx for anthrax

answer

patient educaiton: vaccination available, but only for indivudals with high risk Pharm: ATB- fluoroquinolone(ciprofloxacin), tetracycline (doxycycline)

question

cat-scratch disease pathophys

answer

bartonella henselae Gram - bacteria inoculation from cat teeth or claws cats transmit infection through flea feces- higher # fleas= higher likelihood of passing to other cate

question

Diagnostic studies for car-scratch disease

answer

Bx: lymphoid hyperplasia- later stellate granulomata with necrosis, coalescing micro abscessed and occational multinucleated giant cells serolgic testing (immunofluorescence or enzyme immunoassay)--most common with variable sensitivity and specificity, may take a few weeks other tests are of close sensitivity ( culture, Warthin-Starry sliver staining)

question

Plan for cat scratch disease

answer

if abscess-- I/D Pharm: 1st line: Macrolide abx (azithromycin x 5d) alternative (or if eye involement): tetracycline (doxycycline)

question

Gas gangrene pathophys

answer

AKA clostridial myonecrosis produced by any one of several clostridia- clostridium perfrigens, ramosum, biermentans, histolyticum, novyi cause: trauma, injection use toxins produces into devitalized tissues--> anaerobic--> shock, hemolysis, myonecrosis

question

Diagnostic studies for gas gangrene

answer

clinical dx, start treatment! radiography- show gas in soft tissue smear- absence of neutrophils, presence of gram+ rods anaerobic culture- confirms dx

question

Plan for gas gangrene

answer

initial: 1) IV ATB--> PCN G q3 hr, Clindamycin q8hr (decreased production of bacterial toxin) 2) surgical debridement Optional: hyperbaric oxygen

question

essentials of diagnosis and pearls for gas gangrene

answer

sudden onset of pain and adema in the area of owund contamination prostration and systemic toxicity brown to blood tinged watery exudate with skin discoloration of surrounding areagas in tissue by palpation or radiograph gram + rods in culutre or smear of exudate Pearls: clostridium infeciton typically

question

pathophys of necrotizing fasciitis

answer

flesh eating bacteria infnx often polymicrobial common pathogens--> group A strep, clostridium, Vibrio sp (saltwater) deep subcut infnx that results in destruction of fascia and fat

question

PE of necrotizing fasciitis

answer

skin: edema, heat, erythema, tenderness, spread proximally to distally, skin darkens and blisters w/ bullae with clear yellow fluid, tissue crepitus possible high fever as it progresses: sepsis- tachycardia, hypotension, altered mental status

question

Diagnostic studies of necrotizing fasciitis

answer

triad: CBC--> WBC high >14k BUN- high >15 Sodium low <135 should prompt a heighted index of suspicion imaging may confirm: CT, MRI

question

Comorbidities and genetics of alopecia areata

answer

comor: thyroiditis, pernicious anemia, addison's disease, celiac disease, RA, diabetes genetic: 25% have positive family history

question

types of alopecia

answer

alopecia totalis- only the scalp alopecial universalis- entire body

question

Diagnostic studies for alopecia areata

answer

Bx: dystrophic hair, lymphoctic infiltrate surround early anagen hair bulb--> swarm of bees

question

Plan for alopecia areata

answer

pharm: may respond to oral steroids patient education: relapse common

question

Essentials of diagnosis for alopecia areata

answer

hair loos oval patches exclamation point hairs at edge no scarring Bx: dytrophic hair with lymphocyte swarm of bees steroids may help

question

Androgenic alopecia pathophys

answer

genetic loss of hair androgen dependent lower levels of 5a-reductase actually increases dihyrotestosterone which shorens hair cycle and minaturizes hair unpredictibale and variable

question

Hx and PE for androgenic alopecia

answer

Hx: thinning of hair, beginning after puberty and noticable 20-30 yo, gradual, family history PE: thinning of hair, gradual, dark teminal hair replaces with miniaturized hairs (yellus) --> # of follicles stays the same patterns: men--> typically bitemportal women--> top of scalp

question

Plan for androgenetic alopecia

answer

pharm: type 2 alpha reductase inhibitor (Finateride) --90% maintain hair, 66% have regrowth, typically for males only, teratogenic topical minoxidil--> more effective with recent onset (20-40% effective), may be better choice for younger females

question

Hx and PE for paronychia

answer

Hx: pain and swelling at nail, may have recent manicure or admits to bitting nails PE: edematous at nail fold- pus may be seen, tender

question

Plan for paronychia

answer

patient education: avoid wet enviro, stap habits like nail biting or thumb sucking procedure: I/D (if flucutant) pharm: acute: cephalexin, erythomycin, dicloxacillin Chronic: avoid trauma, water, and irritants, Lotrisons (note: did not include dosages)

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