DERM test

Disorders of hypopigmentation

-

Varicella virus

- chikenpox

Lentigo

- linear melanocytic hyperplasia

First degree

-involves only the qpidermis - redness w/o blistering

Xanthelasma

; occur on the inner and outer canthus

Acquired disorders of hypo-pigmentation

- Tinea versicolor - Vitrilgo - Pituriasis alba - Postinflammatory Hypopigmentation

topical retinoids

- Tretinoin -Adapaine -tazarotene

Skin is also direct target for

behavioral problems can be impacted by psychological issues

Long standing skin diseases

--Potential for suicide must be considered when evaluating --Anxiety and depression: Antidepressants often recommended

Disorders of Acquired Hyperpigmentation

Freckles = Ephelis *Freckles are a benign condition consisting of clusters of concentrated melanin and appear most often on people with a fair complexion. *They are small macules, ranging from red to light brown in color. *They are stimulated by exposure to the sun. *Freckles are usually found on the arms, face and back. *The amount of freckles found on a individual varies. *Sunscreen helps to prevent the appearance of new freckles and with the darkening of existing ones.

pooling of blood in the deep vein system

causes venous hypertension and dilation of superficial veins

Contact dermatitis diagnosis

character and distribution should raise the index suspition -rash that is persistant - even the exposure to an allergen is uniform - eczematous manifestation are very often pathy -1st step is a very careful medical and environemntal exposure history - review any past history skin diseases, atopy, general health -personal care products, occupation, hobbies

Perioral Dermatitis

characterized by small, grouped erythematous papules in a perioral distribution.

modified Sabouraud medium

chloramphenicol, cycloheximide, and gentamicin addition - facilitiates growth of dermatophytes and inhibits growth of non- candida albicans/ cryptococcus/ prototheca species P. werneckli, scytalidium species/ ochroconis gallopava

TCS2 gene

chromosome 16 and involves the production of a protein called tuberin

not stage I

classify based on the highest stage of injury

Deep vein thrombosis -DVT

clot formation in a deep vein

enzymatic

collagenase, papain, fibrinolysin, deoxyribonuclease actually break down thin necrotic areas and allow for their removal but are ineffective against hard eschar or large areas of necrosis. Do not use in ulcers with exposed tendons

Type III: Immune complex disease-

combination of antigen and IgG or IgM antibodies in the blood are deposited in the walls of small vessels, often those of the skin -Complement activation, platelet aggregation and the release of lysosomal enzymes from polymorphs cause vascular damage.

Folliculitis:

comedos are absent and lesions are monomorphous

Tinea pedis:

common dermatophytes are Trichophyton rubrum, Trichophyton mentagrophytes, and Epidermophyton floccosum

Rosacea:

common features include erythema, telangectasias, papules and pustules on the central face. Acne vulgaris has comedos but no telangestasias and is generally not central face CENTRAL FACE

Postherpetic neuralgia (PHN)

common in eldergy pt with Herpes zooster viral treatment persists for weeks to years after skin lesions resolve -duration and severity of PHN are related to age -prodromal pain or acute pain during the first few days of vesicular eruptions PHN managment: Topical analgesic topical anesthetic EMLA oral analgesics; tricyclic antidepressants gabapentin nerve blocks useful in managing PHN immunization with VZV vaccine is suggested for the elderly with diminishing VZV-specific immunity

Junctional NMN Lesions

completely flat (A, B) or minimally elevated as in (C) and (D). They are symmetric with a regular border and, depending on the skin type of the individuals, have different shades of brown to black (D).

Albinism

complications result from abnormal nerve and retinal development. Due to the lack of coloration of the iris, these individuals eyes can appear pinkish-red in color. suffer from challenges due to their appearance both socially and emotionally. Children can especially be effected by social isolation and low self esteem.

Treatment

comprehensive assessment of the patient IS NEEDED * Treatment of acne is aimed at counteracting follicular hyperproliferation -increased sebum production -Propionibacterium acnes proliferation -inflammation

Surgical Treatments

considering treatment for older adults, comorbidities should always be evaluated -cardiac condition may reduce tolerance to surgery -Anticoagulation, diabetes, vascular, and immune-compromising conditions may alter healing -Arthritis may impair the ability to apply treatments or do dressing changes

Rubeola symptoms

coryza and hacky, bark-like cough, photophobia, malaise, fever, conjunctivitis

Dermatitis Artefacts

factitious disorder: Self-inflicted cutaneous lesions, deliberate and conscious, satisfies an unconscious psychological or emotional need Induce lesions by scratching, rubbing, picking, cutting, punching, sucking, biting, applying heat or caustics, usually more elaborate method of picking than neurotic excoriations Some patients inject substances like feces and blood Co-morbidity: OCD, BPD, depression, psychosis and mental retardation Look for physical and sexual abuse and other psychosocial stressors

Inflammatory papule:

follicle ruptures causing proinflammatory lipids and keratin are extruded into the surrounding dermis causing the development of an inflammatory lesion.

Sebaceous Gland

found everywhere on the body except palms, soles, dorsa of the feet and the lower lip. Sebum: light yellow oily fluid produced in the sebaceous gland. under the influence of dihydrotestosterone (converted from testosterone) which causes them to increase in size, metabolic rate and production of sebum. Sebum produced by the sebaceous gland will combine with the cells being sloughed off within the hair follicle.

septicemia is the most severe complication

from pressure ulcers -transient bacteremia occurs after pressure ulcer debridement in approximately 50% of patients

Onychomycosis

fungal infection of the nail caused by dermatophytes, nondermatophyte molds, or yeasts -Tinea unguium refers strictly to dermatophyte infection of the nail. -most prevalent nail disease and accounts for approximately 50% of all causes of onychodystrophy -14% of the population with both an increasing prevalence among older individuals -nail trauma, communal locker rooms, and wearing of tight shoes. -40% of patients with toenail onychomycosis show concomitant skin infections, most commonly tinea pedis

SCC

generally appear pink, scaly, and thicker than BCC, with fleshy or irregular borders. -erythematous or ulcerated and bleed easily -venous or diabetic ulcer and therefore should be part of the differential for a non-healing ulcer.

Vitiligo cause

genetic link as an inherited disorder with more than 30% of individuals having a family member effected by the disease.

Bacillary Angiomatosis

gram (-) cat exposure: Bortonella henselae but in immunocompromised patients -cutaneous manifestations including angiomatous lesions with differing appearances - small red to purple papules but expands into pedunculated lesions or nodules that are very friable and can bleed profusely DX: clincial presentation and serology TX: Azithromycin Think HIV!!!!

Hand/ foot and mouth Disease Oral Lesions

hard palate, tongue, buccal mucosa. Thin-walled vesicles progress rapidly to yellow gray ulcerations with a red halo

Massag

help relieve muscle tension, reduce stress, and promote relaxation. It can also be used to relieve and manage chronic and acute pain

Herpetiform blisters

herpes

Herpes on the nose

herpes virus infection multi nucleated cells

Pyodermas: Non-bullous impetigo DX

history and clinical appearance

Pyodermas: Folliculitis DX

history and clinical appearance. To culture, scrape off the entire pustule with #15 scalpel and deposit on cotton swab into medium

Ecthyma DX

history and clinical finding culture group A Beta-hemolytic strep and staph

Pyoderma: Bullous Impetigo DX

history and clinical finding of flaccid, fluid filled bullae that rupture and leave a brown crust. Gram stain and C and S. (S. aureus or beta-hemolytic Strep)

intertrigio dx

history and clinical presentation

Pitted keratolysis Dx

history and clinicla presentation (very characteristic)

Cellulitis Dx

history and physical C and S!!!!!!

Anthropophilic

human-associated=direct contact often epidemic in nature

physical

hydrotherapy (whirlpool, pulsed irrigation) surgical debridement wet-to-dry dressings (controversial)

Skin can be used as an expression of

hypochondriacal features and self-destructive tendencies

TSC1 gene

located on chromosome 9 and involves the production of a protein called hamartin

Plantar warts

look like a callus or corn -capillaries within the wart help differentiate these Mosaic warts are large hyperkeratotic plaques that result from the coalescence of multiple smaller warts -These warts grow "inward" due to the pressure of walking on them and can be quite painful

pneumatic compression devices work by

lower extremity edema enhancing diffusion of oxygen and nutrients to skin and subcutaneous tissues

Type IV: Cell mediated or delayed-

lymphocytes sensitized by cutaneous dendritic cells in the draining lymph node proliferate and undertake immunosurveillance of the tissues. On re-encounter with their cognate antigen-MHC complex, they become activated and induce inflammation and/or cell killing.

LTT

lymphocytes, which have been sensitized by a certain antigen, transform into blasts and proliferate when they are exposed to the same antigen for a second time. It has been used mainly to investigate contact sensitization to metals such as nickel, gold, chromium, and cobalt. Yet, it is often argued that LTT reproducibility is low, that it is difficult to standardize, and that it does not have sufficient specificity and sensitivity

Biosurgical

maggots

Pediculus humanus capitis tx

malathion (Ovide) in children > 6 month old -lindane -Nix -RID -ivermectin malathion and ivermectin = prescription -head shaving

Purulent Cellulitis

managed with empiric therapy for infection due to MRSA, pending culture results

Osteomyelitis

may complicate ulcers -often gram-negative source diagnosed by MRI or technetium-labeled bone scan

True central venous pressure

measured from a zero point in the right atrium - cant do clinically= use sterling angle as a landmark - its 5cm above RA

Seborrheic Keratosis- Treatment

not indicated, unless the lesions are symptomatic If treatment is needed: Cryotherapy: most common method Curettage/shave excision- use a scalpel and anesthesia Electrodesiccation, with anesthesia Hypo-pigmented or hyper-pigmented scarring may occur with healing

Psoriasis

number of stressors= onset -Early onset (before 40) may be more easily triggered by stress than late onset -Most common psychiatric symptoms: body image disturbance and disturbance in social and occupational functioning

Lichen planus

numerous colloid bodies are formed

Autolytic debridement

occlusive dressing hold serous exudation next to the wound and allow re-epithelialization while providing a barrier to bacterial contamination

Plane xanthomas:

occur palms, eyelids, face, neck and chest

Postherpetic neuralgia

occurs in 10-15% of patients older than 60. Pain may persist for 6 mo after rash has disappeared. complication in zooster

allergic contact dermatitis

often requires potent topical corticosteroids, oral antihistamines, or corticosteroids according to its severity less responsive to treatment and tends to run a more chronic course in elderly patients than in younger patients

Cutaneous candidiasis Dx

on clinical findings and confirmed by direct microscopy or culture. KOH preparation shows sausage-like pseudohyphe and yeast forms meat balls

Non-inflammatory:

open or closed comedones

Exanthema subitum mode of transmission

oropharyngeal secretions mainly in children from 6-24 months

Stage II

partial thickness skin loss involving the epidermis or dermis or both - the ulcer is superficial and manifests clinically as an abrasion, blister or shallow crater

swab is useless in determining waht

pathology - a biopsy of affected tissue is necessary to obtain a truly representative sample.

Risk factor: moisture

perineal area - under the abdominal and breast tissue - sleeping wounds

Large, coarse wrinkles due primarily to

photoaging

Never lay a patient directly on the trochanter

place at a 45 angle instead, using foam pillows or wedges to prop. - dont exceed 30 elevation of the head of the bed

the most common infectious complication among hospitalized burn patients

pneumonia - septic pulmonary emboli - suppurative thrombophlebitis of catherter sites - endocarditis - UTIs -acute renal failure

Delusions of prasitosis

prasitosis—believe body is infested with some type of organism, mate , move around the skin—often bring in specimens to prove the infestation —-antipsychotic meds—Pimozide similar to Haladol in chemical structure and potency. also used in Tourette's

Vitiligo treatment

prescription topical medications which include: Corticosteroids : the first treatment of choice for patients with limited disease and there is no involvement of the face. Immunomodulators Topical vitamin D analogs are second-line agents

PUSH

pressure ulcer scale for healing -incorporates surface area measurments - exudate - surface appearance with 5 point scoring system

Managment

prevention- key is education of the patients and caregivers - daily skin inspection= bony prominences - skin should be kept dry to prevent maceration * catheters * frequent chnages of incontinence products - repositioning of all physically impaired patients at 2 hour intervals -pressure relieving mattresses and overlays should be on all beds -Do NOT use doughnut cushions in the sacral region since they may cause impaired circulation

Dermatophytes

primary source of dermatophytic infection that can spread to the nails (tinea unguium), groin (tinea cruris), trunk (tinea corporis), and hands (tinea manuum

Pediculus pubis

pubic lice, "crabs sexual or close contact as well as via fomites (contaminated clothing, towels, and bedding). -mistaken for scabs or moles, or can blend in with skin color making them difficult to detect -Pruritus most common symptom followed by excoriations and possible inguinal lymphadenopathy -same regimen as for head lice -Ivermectin orally, is preferred for this infestation -closely crop off pubic hair to remove dead nits

Podophyllotoxin (Condylox)

purified derivative of podophyllin - applied for 3 consecutive days - 2/3 female and 1/3 men completely resolve

plaque

raised flat surface lesion >1cm

Neurotic excoriation

self-inflict, fingernails

uncertain lesions can be biopsied or excised

sent to pathology to confirm the diagnosis

Linear IgA bullous dermatosis

seperation along the basement membrane

Pemphigus Foliaceous

seperation just benieth the starus cornium

Rubella during preg

serious fetal malformations

risk assessment for developing of pressure ulcers

should be performed upon administration to health care setting -periodic intervals thereafter

Tinea versicolor

skin contains the right combination of oil, moisture and warmth, it starts to grow into small colonies on the surface of the skin. I n these colonies the yeast starts to increase its growth, during which they produces an acidic substance which is caused by an enzymatic oxidation. This reaction has a toxic effect on the melanocytes, leading to the hypopigmented color of the skin.

Skin disorders of the elderly

skin diseases are more common in the geriatric population than in the general population -Patients older than 74 years are even more likely to develop significant skin diseases.

Xenograft

skin form another species(porcine) until autografting can be done

Nummular dermatitis tx

skin lubricated. May use topical corticosteroids, topical calcineurin inhibitors, and emollients -responds slowly to treatment and runs a chronic course, which is often difficult to control even with potent topical corticosteroid preparations -UV light treatments help -Lesions are susceptible to staph infections so consider antibiotics

Group III Nonchromogens

slow growing and do not produce any pigment -Mycobacterium ulcerans -Mycobacterium avium-intracellulare complex

Group I Photochromogens:

slow growing with little to no pigment when grown in the dark but produce a yellow orange pigment when exposed to light -Mycobacterium marinum -Mycobacterium kansasii

Macule

small flat area of altered color <1cm

Periungual fibromas

small fleshy tumors that grow around and under the toenails or fingernails

papule

small raised, rounded lesion <1cm

Exanthema skin lesions

small, blanchable pink macules and papules (1-5 mm) that may remain discrete or become confluent.

Tendinous xanthoma

smooth nodules attached to tendons or ligaments. (Achilles)

Dermatosis papulosa nigra (DPN) treatment

snip excision, curettage, electrodesiccation (on low setting) Treatment can be difficult due to the high risk of pigment alterations after treatment. Avoid cryotherapy due to a very high risk of hypopigmentation. Application of petroleum-based ointments can promote healing.

Daily wound cleansing

soaking in a tub, showering or whirlpool for large areas. All old antimicrobial products and tissue debris must be removed to prevent harbors for bacteria.

Retin A

some use it to treat flat warts

Zooster

sort of dermatome pattern - stops at midline

burns

statistics - 70K ppl per year hospitalized - 1/3 to specialized burn units

Bullous impetigo

subcorneal blister containin neutrophils are present inside

Genetal herpes treatment

suppressible not curative primary outbreak * Acyclovir * Famciclovir * Valacyclovir Recurrent outbreaks are - start at the first sign of tingling for treatment

Malignant melanoma requires

surgery to ensure complete removal and decrease recurrence. The prognosis is determined by lesion thickness and any spread to lymph nodes -melanoma is limited to the epidermis, surgical excision is appropriate -has spread to the dermis, an oncologist should manage surgical and adjuvant treatment

Lipoma Treatment:

surgical removal of the lipoma (including the capsule) is needed for pain, cosmesis, or if the diagnosis is uncertain. Recurrence is not common.

Acne Conglobata tx

systemic antibiotics, intralesional glucocorticoid steroids, systemic glucocorticosteroids. Start isotretinoin after few weeks of steroids

Primary function of skin

tactile receptivity Skin is responsive to emotional stimuli and can express emotion (e.g., anger, fear, shame and frustration)

Blackhead:

the follicular orifice is opened with continuous distention forming an open comedo. Densely packed keratinocytes, oxidized lipids and melanin contribute to the dark color

pressure ulcer healing is accelerated during

the initial 3 months after development -reducting in size after 1 to 2 weeks of therapy has been predictive of healing outcomes.

Elaborations of toxins by S. aureus causes

the lesions of bullous impetigo and staphylococcal scalded skin syndrome.

The more superficial the speration of skin layers

the more flaccid the lesion

Hypomelanosis of Ito gene mutations --> cause

the specific genes involved have not yet been identified. Females tend to be affected more often than males. It estimated to occur in 1 - 8000 people. The skin findings associated with the disorder include small patches of pale to white areas that merge from larger asymmetric patches and are arranged in a whorled or linear pattern.

"nevi of special site"

these can have overlapping features with DN

Shagreen patch

thickened patch of skin with an orange peel texture called shagreen patch

ulceration is inevitable once the skin

thickens and circulation is compromised

Flare up can be unpredictable

which leads to feelings of out of control, uncertainty

Hypomelanic macules

white or lighter patches of skin that may appear anywhere on the body. These are sometimes called "ash leaf spots" because they resemble the leaf of an ash tree.

Infantile Acne

~3 months to 3 years of age -Similar to true acne histologically -Presents with open and closed comedones, occasionally inflammatory papules, rarely nodules -Hormonal studies are indicated in severe cases to r/o androgen excess -Treatment - topical agents, systemic agents if needed, to reduce scarring

Papule

Elevated, well-circumscribed lesion (<1 cm)

Subcutaneous:

Fat cells get smaller causing wrinkles and sagging to become more prominent

two types of vitiligo

Generalized vitiligo - segmental vitiligo

Acute lymphangitis dx

H and P. Can culture from the portal of entry

Treatment principles

- Follicular hyperproliferation and abnormal desquamation - Increased sebum production - Proprionibacterium acnes proliferation -inflammation

Intertrigio cause

- Group A and B streptococcus - C. minitissimum - Pseudomonas aeruginosa - Fungal

Periorbital cellulitis Dx

- H and P - CT of the orbits and sinuses - blood culture

Sebaceous adenoma

- MSI testing: no evidence of microsatellite instability

Hemorrhoids

Internal External Thrombosed

Tx for Erysipelas

- Oral: panicilin Amoxicillin Erythromycin Parenteral: - Ceftriaxone - Cefazolin

Orbital cellulitis most common organism

- S. Aureus (adults) - H influenza (children) 3 months - 4 years

treatment topical therapy

- Salicyclic or lactic acid - Podophyllin

Periorbital cellulitis infectious organisms

- Staphylococcus - Streptococcus (adults) - H. Influenza (children)

Acrokeratosis paraneoplastica (Bazex syndrome)

Paraneoplastic: Papulosquamous Disorders

Methods

Sharp: Autolytic:

Primary Psychiatric disorders

Skin disorder in which the primary problem is psychological. Skin manifestations are self-induced.

Blisters

Vesicles Bulla

Topical agents

Tretinoin adapalene

Viral culture can differentiate between

VZV, HSV-1 and HSV-2

Von Recklinghausen's Disease

Von Recklinghausen's Disease Autosomal Dominant Affects 1:3000 people

Types of Acne Lesions

Whitehead Blackhead: Inflammatory papule

Kawasaki diseases associated with

--associated with human coronavirus infection -superantigens related to those of bacterial toxin-mediated diseases such as toxic shock syndrome or scarlet fever

Neurofibromatosis 2:

affects hearing (acoustic neuroma). Minimal skin involvement

Inflammatory tinea barbae

most common clinical presentation.

BCC

-1/3 of all cancers in US, 20x more common than melanoma -5X more common than Sq.C. Ca -Incidence rising at 3-10% annually -Metastatic rate 0.03%

Gangrenous cellulitis cause

- Streptococcal Gangrene (mono-microbic) -Necrotizing fasciitis other than Grp. A Streptococcus (polymicrobic): anaerobes like Bacteroides, Clostridium, Peptostreptococcus and Enterobacteraceae

Small venule vasculitis

urticarial lesions, palpable purpura

Intralesional therapy

- Bleomycin - interferon alpha

Optimize nutrition

- glutamine - zinc - vitamin C

Skin appendage neoplasms

-Eccrine -Hair follicle(pilar) -Apocrine -sebaceous

Cephalexin (Keflex)

-Not as effective as others -Cephalosporins are hydrophilic which prevents penetration into the pilosebacious unit

Systemic Agents: Antibiotics

-Tetracycline, Erythromycin -Azithromycin

topic treatment of genital herpes

-Zovirax ointment -Penciclovir (Denavir)

common warts presentation

-solitary or grouped; some may be filiform -young adults and children mostly

Erythrasma tx

-wash with benzoyl peroxide 2.5% gel + erythromycin topical = 7 days

Vesicels

<0.5cm

Kawasaki key diagnossis

Nonpurulent bilateral conjunctivitis is a key diagnostic feature

Bite wounds

Animals Dog, Cat, snake, exotic animals (monkeys serious!) Humans

Vesicle

Blister with transparent fluid

Acne

Categories -Neonatal - not true acne -Infantile -Adolescent

Pemphigus vulgaris auto immune

Desmoglein 1 and 3 are being attacked - mainly desmoglein 1

Varicose veins

Dilation of veins secondary to incompetent valves permitting reflux of blood backwards into veins, increasing hydrostatic pressure

DVT signs

Edema of calf and foot of affected leg, calf tenderness; occasionally no signs/symptoms

Tsanck smear cannot distinguish between

HSV VZV infections

opportunistic infections of the skin of HIV

- histoplasmosis - cryptococcosis - H. Zoster - Mycobacterium tuberculosis - candida infections - molluscum contagiosum - pitysporum folliculitis

toxic shock

- sandpaper rash

Wickham's striae

Lichen planus associated

Nodule

Mass located in dermis or subcutaneous fat (may be solid or soft

Tuberous Sclerosis

Neurocutaneous Disorders

Compound Nevi

Pigmented papules Smooth and dome-shaped Tan to dark brown

Transient pustular melanosis

Transient pustular melanosis - vesicles that rupture easily with a collarette of scale, filled with Neutrophils

pyoderma: Streptococcus

is a secondary invader of traumatic skin lesions and causes impetigo, erysipelas, cellulitis and lymphadenitis

non genital outbreaks Orofacial

"cold sores" or "fever blisters" -1/3 of humans have this -May be brought on by stress, menses, sunlight -Itching/tingling are the usual prodrome followed by eruption of red papules that form vesicles

Genetal herpes symptomatic lesions

"potent" as transmitters since the viral load is much higher -outbreak occurs 2-14 days post exposure

Giant cell arteritis

"temporal" arteritis - can involve other branches of the carotid. Characterized by fever, anemia, high sedimentation rate, headaches, and occasional sudden loss of vision

three major clinical types

(1) interdigital, (2) moccasin, and (3) inflammatory vesiculo-bullous.

Dermal melanocytic NMN

(A) Two dome-shaped, sharply defined relatively soft tan nodules on the left cheek and right lateral mandibular region in a 60-year-old male. These lesions were previously much darker and less elevated. (B) A larger magnification of a dermal NMN. This lesion is sharply defined, has a reddish color with a central regular pigmented spot where the nevus obviously is still compound in nature. (C) Old dermal nevus on the upper lip of a 65-year-old woman. This lesion is relatively hard, has a smooth surface, and a pinkish color. This lesion is fibrosing.

Type I: Immediate-

(Ig) E bound to the surface of mast cells causes degranulation on antigen exposure. Can cause urticaria and even anaphylaxis. Response occurs within minutes

Pediculus humanus corporis

(body louse) -only 30% larger then head lice -homeless, refugees, and victims of war and natural disasters Dx= nits in lining of clothing, particularly the seams. excoriations, often linear and primarily on the back, neck, shoulders, and waist. Pruitis is usually present. DDX may include scabies, atopic dermatitis, contact dermatitis, drug reaction, or viral exanthema. body lice is disinfestation of all clothing and bedding. GOOD HYGEINE! -treated from head to toe with a topical insecticide or given oral ivermectin.

Pediculus humanus capitis

(head lice) -affecting hairs of the scalp most commonly in children between the ages of 3 and 12 -incidence is low among African-Americans in the United States -Diagnose by discovery of live adult lice or nits with viable louse inside; most commonly at hairline of temple, post-auricular areas and occiput -Spread by close physical contact and sharing of headgear, combs, brushes, and pillows.

Acquired Melanocytic Nevi

(moles) -Melanocytic nevi are benign proliferations of nevus cells -Named for the location of the nests of melanocytes Junctional nevi- located at the dermal-epidermal junction Compound nevi- located at the dermal-epidermal junction AND dermis Intradermal nevi- located in the dermis

Geophilic fungus

(soil-associated) cause sporadic human infection upon direct contact with the soil -intense inflammatory response

Tinea corporis

(trunk and limbs) -T. rubrum in hot and humid areas. -Also T. verrucosum and M. canis. -Single or multiple plaques, with scaling and erythema especially at the edges, characterize this presentation. -lesions enlarge slowly, with central clearing, leaving a ring pattern, hence 'ringworm -Pustules or vesicles may be seen. -Diabetics are more susceptible

Tinea versicolor treatment

*Selenium sulfide- 2.5% shampoo applied to the affected area daily for one week. The shampoo is rinsed off after 10 minutes. *Terbinafine - Topical terbinafine 1% solution applied twice daily for one week. *Ciclopirox - Topical ciclopirox olamine 1% cream applied twice daily for 14 days. *Itraconazole oral- adults is usually given as 200 mg per day for five days. *Fluconazole oral typically given as a 300 mg dose once weekly for two weeks.

Lentigo maligna melanoma

- 5%-10% of melanoma cases, but most of these are older adults. -It appears as a large, brown or irregularly pigmented macule with indistinct margins. -It commonly forms on the sun-exposed face, torso, and legs. -About 25% of lentigo maligna develops from benign moles. It rarely metastasizes, but its slow growth and similarity to seborrheic keratosis make it difficult to identify a change in ABCD

genital herpes recurrent infections

- 80-90% with first episode HSV-2 will ahve a recurrent episode within 12 months -50-60% with those taht have HSV-1

Congenital disorders of Hypopgmentation

- Albinism - Tuberous sclerosis - Nevus anemicus - Hypomelansis of Ito - Piebaldism

topical antimicrobials

- Benzyl peroxide -Common, useful antibacterial agent, also comedolytic Available in both OTC and prescription forms Gels, creams, lotions and washes range from 2.5 to 10% in concentration -Usually applied BID -Skin irritation is common -Do not apply simultaneously with tretinoin (oxidizes tretinoin) -Patients with excessively oily skin may benefit from those agents that are extremely drying (example - Desquam-X) -Available mixed with erythromycin (Benzamycin) -Potent bleaching agent - warn patients about damage to towels, clothing, washcloths, sheets, HAIR etc.

Lyme's Disease

- Borrelia burgdorferi -most common vector borne infection in the US - transmitted by infected nymphal tick/ genus lxodes (deer ticks) / white footed mouse == immature larval and nymph - white tailed deer preferred host fora dult ticks -incubation period 3-32 days after a tick bite - Erythema migrans erythemous macule or papule which enlarges to form an annular lesion with a distinct red border with a partially clearing middle --> TARGET LESION Tx: >12 y.o DOXYCYCLINE <12 y.o AMOXICILLLIN

Periorbital cellulitis tx

- Clindamycin - TMP-SMX - Amoxicillin -cefpodoxime - cefdinir

Surgical therapy

- Cryosurgery - Electrodessication

pathogenesis: of atopic dermatitis

- Downregulation of cornified envelope genes (filaggrin and loricrin) -reduced ceramide levels -increased levels of endogenous proteolytic enzymes - enhanced transepidermal water loss contribute to the decreased skin barrier function. -Skin pH is elevated with soaps and detergents, which leads to increased activity of endogenous proteases causing more loss of skin barrier function. -This can then contribute to increased allergen absorption into the skin and microbial colonization. -changes include intercellular edema of the epidermis, influx of T cells with occasional macrophages -Atopic skin inflammation is orchestrated by the local expression of proinflammatory cytokines and chemokines -Cytokines such as tumor necrosis factor-α (TNF-α) and interleukin 1 (IL-1) from resident cells [keratinocytes, mast cells, dendritic cells (DCs)] bind to receptors on the vascular endothelium, activating cellular signaling pathways, which leads to the induction of vascular endothelial cell adhesion molecules -antigen-presenting cells (dendrite cells), skin homing T cells, and keratinocytes -Genetics also plays a role in familial transmission with a strong maternal influence. -Genome-wide linkage studies of families with AD have implicated chromosomal regions that overlap with other inflammatory skin diseases such as psoriasis. -involves interactions between multiple gene products requiring environmental factors and the immune response to result in the final clinical phenotype -pruritus being a major component, numerous molecules including T-cell-derived cytokines, stress-induced neuropeptides, eicosanoids, and eosinophil-derived proteins play a role

Orbital cellulitis

- Emergency diagnosis -proptosis -orbital pain -fever - restricted mvt of teh eye -chemosis -visual disturbance

Periorbital cellulitis treatmetn

- Empiric treatment more difficult with MRSA

Intertrigio presentation

- Erythema - pruiritis - painful longitudinal fissures

Kaposi's sarcoma

- Erythematous macules / papules - develop into violaceous plaques + nodules -oval in shape - lesions are found on the trunk/ legs/ arms/ face/ oral cavity and lack symmetry

when reporting melanoma -accepted as essential worldwide to record and comment on the following variables

- Tumor thickness - Level of invasion - growth phase - mitotic rate - ulceration - lymphovascualr invasion - perineural infiltration -regression -microsatellitosis - tumor infiltrating lymphocytes

inflammatory lesions you will typically need

- a topical antibiotic

orbital cellulitis complications

- absecess formation - persistent blindness - limitation of eye mvt -diplopia

Chronic suppressive therapy of genital herpes

- acyclovir 400mg - valacyclovir 1g - famiciclovir 250mg adequate suppression has been established patients should be tapered to the minimal effective dose

Rubeola transmission

- aerosolized respiratory droplets

fluids

- all patients with burns of more than 20% (TBSA) + children + elderly= need IV fluids to replace fluids lost to externally and into the extravascular spaces - burns are associated with a capillary leak of electrolytes and protein in proportion to burn size

Acute lymphangitis tx

- antibiotics

orbital cellulitis tx

- antibiotics vancomycin: -ceftiaxone -cefotazime - ampicillin- sulbactam -piperacillin- tazobactum

cleaning the ulcer with these is not indicated

- antiseptic - antimicrobial solution

Imiquimoid (aldara)

- antiviral therapy stimualte the host immune system to eradicate the virus. - topical administration 3 time weekly for 1-3 months - works better on "mucous membrane" warts more so than "dry" warts side effects burning/ stinging/ pain

Cutaneous larva migrans

- any cutaneous lesion caused by migration of various nematode parasites -Ancyclostoma braziliense-larvae of dog/cat hook worms!!!!! -syndrome in which the larvae of any animal nematode infect humans AND in which the infected human is a dead-end host. -creeping eruption=migratory serpiginous lesion but does not denote the etiology of the lesion -raised, tunnel-like line of erythema outlining the path of migration -1-5 days after exposure: typical skin lesions Ova of hookworms are deposited in sand and soil in warm, shady areas, hatching into larvae that penetrate human skin -Larvae migrate up to several centimeters a day between the stratum germinativum and stratum corneum -Larvae die anywhere from days to months later. -feet and buttocks

Bullous pemphigoid immuno staining

- basement membrane is stained -dermal epidermal junctin stained

topical antimicrobials

- benzoyl peroxide - clindamycin - erythromycin - dapsone

secondary pyodermas

- bite wounds - infections of burns/ wounds - diabetic wound infection - decubitus ulcers - surgical wound

Debridement

- burn excision is begun as soon as pt is medically stable to determine the need for grafting -treatment of choice is to excise to viable tissue and immediate autografting; otherwise porcine heterografting or biobrane is used -small blisters or those on the palms of the hands and soles of the feet in children are left intact

gangrenous cellulitis

- categorized by anatomical location -causative organisms and predisposing conditins

DX for furunculosis

- clinical presentation - C and S not routine unless concern is new finding of MRSA

Pityriasis alba

- common in chuildren and goes away by adulthood -by dry, fine-scaled, pale patches, that may be round, oval or irregular in shape -easy to see the lesion on an adult -loss of pigment associated with pityriasis alba is not permanent - pityris alba is usually self- liming and doesnt require treatment

treatment of venous ulcers

- compression therapy elastic compression stockings (TED hose/ jobst stocking) - paste gauze boots (unna boots) - multilayer elastic wraps or dressings -pneumatic compression devices

Nevus Anemicus

- congenital dissorder -a solitary patch which is paler than the surrounding skin. It can have surrounding macules of varying size and shape -It cannot be made red by trauma, cold, or heat -paler area is due to the blood vessels within the nevus being more sensitive to the body's own vasoconstricting chemicals -benign patch and surrounding macules appears on the skin at birth or very early in childhood. -people a nevus anemicus is found on an area that is normally covered by clothing and as such its appearance is so light that no treatment is required. -people these are less than 10cm in size. If there is doubt about the diagnosis, rubbing the area causes the skin around the lesion to become red while the lesion itself will not be effected.

estimation of extent of injury

- count only 2nd and 3rd degree burns - rule of 9s: divide the body surface into areas that are multiples of 9% of the total - anterior trunk- 18% - Posterior trunk- 18% - Each leg- 18% - head neck- 9% - Eacharm- 9%

Onychomycosis

- cutaneous fungal infection often (90%) caused by dermatophytes, so called tinea unguium. Prevalence increases with age -Nail thickening, crumbling, discoloration, onycholysis, or subungual hyperkeratosis. It often involves the great toenails.

Interferon alpha

- cytokine injected only into refractory warts - very costly -influenza like side effects - frequent re-injection

Human fungal infections primarily due to

- dermatophytes= multicellular filaments or hyphae - Yeasts= unicellular forms that replicate by budding

Biopsy the lesion

- edge of blister is where the money is - 3-4 mm punch in buffered formalin for rutine pathology - 3 to 4 mm punch biopsy (perilesional) for direct immunoflurescence (DIF) in Michelles holding media= held for a week or two.. see if DIF is necessary

Herpes Simplex Virus

- enveloped dsDNA -Type I being "oral" cold sores -Type II being of genital origin both can be found in multiple areas

mafenide acetate ( Sulfomylon)

- excellent penetration - antibacterial spectrum - agent of choice for deep burns with thick eschar, those with gram- negative infection (pseudomonas) - and burns of the war where chondritis is a major complication Mafenide acetate complication - pain = 10% allergic rate/ systemic absorption with development of metabolic acidosis

Leprosy

- face and ears - sumemtrical - not as hypo pigmented in the center as tuberculous leprosy

Sarcoptes scabiei dx

- find the burrow within a thin/ thread like/ linear structure/ - place a drop of minerla oil over the burrow = the area is scraped off and inspected with microscope -Permethrin treatment - Lindane topical is popular and oral ivermectin is effective = all family members and close contacts should be treated simultaneously

Azaleic acid (Azalex)

- for topic treatment -Naturally occurring antibacterial, comedolytic, anti-inflammatory and anti-keratinization effects -Treatment of mild to moderate inflammatory acne vulgaris -Topical cream 20% topical gel 15%: thin film applied to the affected area BID -May cause hypopigmentation - useful in patients having post-inflammatory hyperpigmentation -$$$$$$ no generic available ($365/30gm tube)

miscellaneous benign pigmented lesions

- freckle/ ephelide -lentigo - melanotic macule - cafe au lait

Stage III

- full thickness skin loss and damage or necrosis of subcutaneous tissue that may extend to but not through the underlying fascia - ulcer manifests clinically as a deep crater with or without undermining of adjacent tissue

gangrenous cellulitis Dx

- high suspicion of lesion followed by surgical exploration

Clinical presentation of urticaria and angioedema

- hive or wheal is circumscribed - erythematous or white -nonpitting - edematous - usually pruritic plaque edematous central area(wheal) can be pale in comparison to the erythematous surrounding area(flare) -Lesions of angioedema are less well demarcated -vary in color, size, and areas of involvement -can be involved in the lips, larynx, and the mucosa of the GI tract. -Bullae or purpura may appear in areas of intense swelling

Scalded Skin Syndrome tx

- hospitalization - IV antibiotics penicillinase- resistant penicillin and supportive care

Melanoma

- inc incidence 76K new cases in 2014 and 9.7K deaths -new biological treatment are showing some promise== before the only hope was early detection - risk is 1 in 40 for whites - 1 : 1000 for blacks - 1:200 hispanics most common in pale skin/ blue eyes/ red or blonde hair/ freckle easily

Acute lymphangitis

- inflammatory process involving the subcutaneous lymphatic channels -starts by a wound (bite / blister) - can become bacteremia so always treat as if it has the potential to become serious

Erysipelas

- its a form of cellulitis - Group A strep - Lymphatic involvment (streaking) - demarcation bw involved and uninvolved skin - Bright red/ painful/ edematous/ sharply defined borders -legs and face -virulent soft tissue infection can be common - systemic signs

Bleomycin

- larger dermatology centers - pain and tissue necrosis can result

most common types of melanoma

- lentigo maligna melanoma (melanoma arising within a pre -existing lentigo maligna) - superficial spreading melanoma - acral lentiginous melanoma -nodular melanoma

Subcutaneous fat tumors

- lipoma - angiolipoma

cryosurgery

- liquid nitrogen applied to lesions for two 30 sec freeze-thaw cycles - may permanently depigment the skin - may survive in the periphery and the "ring wart" will appera surrounding the treated area

Herpes simplex and herpes zoster

- look the same microscopically

Pathogenesis of urticaria and angioedema

- mast cells is the major effector in most forms - histamine/ leucotriences/ cytokines/ chemokines = leads to alteration in vasopermeability - upregulation of adhesion molecules on endothelial cells - rolling and attachment of blood leukocytes -chemotaxis - transendothelial cell migration

Debridement

- necrotic tissue must be removed to facilitate wound healing -adequate cleansing - reduction of necrotic tissue -promoting of blood borne growth factor production -accurately stage the wound

Meningococcemia

- neisseria meningitides = encapsulated gram (-) diplococci - acute septicemia from this organism can kill faster then an other infectious disease - Invades small blood vessel endothelial cells and release bacterial endotoxin -Endotoxins cause the release of cytokines which cause severe hypotension, lowered cardiac output, and endothelial permeability -Organ anoxia and massive disseminated intravascular coagulation can result in organ failure, shock and death -decreased permeability and thrombosis lead to infarction producing areas of purpura with an irregular pattern. Clinical Presentation: fever, headache, N/V, and rash Lesions of acute infection are easily identified and virtually pathognomonic with a mixed petechial and maculo-papular rash most prevalent on the extremities and extensor surfaces.!!!! -The rash starts as erythematous macules that are of a brownish-stained appearance - then becomes purpuric (Purpura fulminans) with an irregular edge -petechiae may also be seen in the conjunctiva -lesions can undergo necrosis causing peripheral gangrene - DO NOT BLANCH WITH PRESSURE Dx: clinical presentation/ LP/ blood culture Tx: antibiotics treat the lesion with appropriate wound care products

Stage I ulcer

- non blanchable erythema of intact skin

Cimetidine (tagamet)

- not better then placebo -apply to childrens warts until it spontaneously resolvs - can be give orraly as well 30-40 mg/kg/day in 3 divided doses

tenia pedis source of reinfection

- onchychomycosis

Atopic dermatitis features

- pruritus - eczema -chronic or relapsing features - typical morphology and age specific patterns - patterns include: * facial/ neck/ extensor involvment in infants and children - flexural or previous flexural lesions in any age group - sparing of the groin and axillary regions

Immunotherapeutic agents

- pt form antibody to an allergen - then the allergen is applied to the warts once a week or every other week -hosts own immunity destroys

Toxic shock syndrome

- rare - potentailly fatal multisystem illness associated with Staphylococcus aureus infection -early cases were associated with tampon usage -now case mainly occur postoperatively but has been associated with postpartum states/ IV drug usage/ HIV and cellulitis - caused by EXOTOXINS produced by STAPHYLOCOCCUS AUREUS -massive release of cytokines produce fever, rash, hypotension, tissue injury and shock SAND PAPER RASH!!!!!

Tuberous Sclerosis

- rare autosomal dominant genetic disorder - effects multi-systems causing benign tumors to grow on the skin, kidneys, heart, and brain. Two gene mutations: TSC1 and TSC2

Erythrasma presentation

- red or brownish red -sharp border of demarcation -pruritis or burning sensation

Herpes zoster vaccine

- reduce rates of shingles and post herpetic neuralgia in patients older than 50 years of age.

Venous ulcers

- result of chronic venous insufficiency secondary to venous reflux, venous obstruction, calf muscle pump dysfunction loss of venous wall elasticity

Mycobacterium

- rod shaped bacteria that are acid fast - if organism retains the priamry stain color (fuchsia) then its considered acif fast - if it takes the counter color (methylene blue) it is considered non acid fast - onset of immunocompromised patietns has brought TB and non-tuberculosis mycobacterium (NTM) infections to the forefront of medicine

Exanthema Subitum

- roseola infantum Human herpes virus type 6 and 7

Electrodesiccation

- scraping or burning off skin growth can be used for less serious skin cancers - pre cancers and benign growths - local anesthetic is administered - area is then cauterized until the bleeding stops

Intertrigo with longitudinal fissure

- secondary type infectionsa re now of consern

Rubeola period of transmission

- several days before onset of rash up to 5 days after lesions appear

Displastic nevus clinically

- share the ABCD features of melanoma - most commonly biopsied benign pigmented lesions -train the pt to observe - remove the larger/ uglier/ changing ones and the once that concern the patient

Bites

- size if adult vs child (<3 cm intercanine distance)

Allograft/ hemograft

- skin from same species(often cadaver) is used as a temporry covering until patient is ready for autograft

The complexity of benign nevi is bewildering

- somea re difficult to distinguish form melanoma

Cellulitis

- spreading superficial infection caused by group A or Straph aureus - develops at a site of previous trauma or lesion -as the skin becomes tener/ red/ warm/ swallen= pt becomes MALAISE /FEVER/ CHIILS/ HEADACHE -poorly defined margins and may be accompanied by lymphadenopathy - Bullous lesions may form if due to strep

Gram Positive Infections Associated with Toxin Production

- staphylococcal scalded skin syndrome - toxic shock syndrome - scarlet fever

Atopic dermatitis treatment and course

- systemic and multipronged approach - needs to incorporate education -skin hydration therapy and medications - identification and elimination of flare factors such as irritants/ allergens// infectious agents/ emotional stressors -treatment plans should be individualized -alternative anti-inflammatory and immunomodulatory agents may be necessary -coarse of the illness will vary from person to person -unfavorable prognostic factors can include widespread - -dermatitis in childhood/ -early age at onset/ -female gender/ -associated bronchial asthma/ - persistant dry or itchy skin in adults

tinia pedis info

- tends to be chronic - exacerbates in hot weather - opens potential for lymphangitis and cellulitis

Melanocytic nevi

- they come and then go -older individuals typically die without nevi

Scarlet Fever (Scarletina)

- toxic from group A strep infection -rash begins on the face/ neck/ upper chest then spreads to the abdomen and extremities - scarlet erythema appears along the slight prominence of the hair follicles -sand paper texture to the skin - rash blanches with pressure - spares the peri oral area while accentuating the creases of the antecubital areas/ groin/ axillary folds (pastias lines) -4 days the is extensive desquamation of the skin -tongue sheds the mucous lining = strawberry tongue TX: Penicillin

puritis without a rash

- treatment is symptomatic (lubrication with emolllients, calamine, oatmeal bath, chamomile preparations) -oral antihistamines supplemented with short - term use of topical or systemic corticosteroids for difficult cases

pyoderma

- two gram (+) cocci -STPHYLOCOCCUS AUREUS -GROUP A- BETA-HEMOLYTIC STREPTOCOCCI majority of skin and soft tissue bacterial infections

Poison ivy

- type IV hypersensitivity - Cell mediated - T cells (2-3 days) - Urushiol is the chemical

to reposition apatient

- use lifting devices and dont dragg them

Surgical treatment

- used in some stage III and IV pressure ulcers - most common approach is the use of muscle flaps

Periorbital cellulitis

-- more common then orbital - limited to the eye lid - common in children -sinus infection/ upper respiratory infection/ eye trauma --> predisposes Associated with fever/ erythema/ edema of the eye lid/ conjunctiva/ chemosis - pt preserves visoin and occular motion -rare for periorbital to progress to orbital

Contact dermatitis:

-11% of the elderly population, -includes allergy-and irritant-type reactions. -reduced ability to mount delayed hypersensitivity reaction, the elderly skin shows relatively less vesiculation or inflammation and early appearance of scaling, hyperpigmentation, and lichenification -Certain antimicrobials lanolin parabens dyes; plants; balsams; rubber; and nickel are among the most common allergens whereas alkaline soaps, detergents, or cleaners are more likely the culprits in cases of irritant dermatitis -Patch testing is useful in identifying the allergens.

Nodular melanoma

-15%-30% of melanoma cases most of which are in older adults -poor prognosis, it contributes to the higher mortality of older adults -difficult to identify because, though generally a rapidly growing dark papule, it lacks the other hallmark ABCD characteristics

Atopic dermatitis

-15-20% in early childrood industrialized countries - genetic bases influence by environmental factors - alterations in immunologic responses in T cells/ antigen processing/ inflammatory cytokines/ host defense proteins/ allergen sensitivity/ infection

RMSF presentation

-2-14 days after tick bite incubation -headache, fever, then chills, myalgias, arthralgias, and malaise -Erythematous blanching macules and/or papules 2-4 days after fever onset; starts at wrists/ankles and spreads centripetally; may involve palms, soles. Rash evolves over few days to petechial and purpuric lesions. = PERIPHERALLY and moves CENTRALLY -Thrombocytopenia, anemia, mild hyponatremia -Leukocytosis, moderately elevated protein, and a normal glucose level= CSF

Tinea versicolor treatment

-2.5% selenium sulfide shampoo daily for 2 weeks -ketoconazole shampoo 2 -Terbinafine solution 1% applied twice daily -systemic treatment is indicated, ketoconazole, fluconazole, and itraconazole are the preferred oral agents, and various dosing regimens are effective. -Recurrence is common and regular maintenance application of any of the topical agents helps to reduce high rates of recurrence

Genital Herpes

-22% of persons tested are seropositive for HSV-2 -5-30% of all first-episode genital herpes is HSV-1

more IV info

-25% albumin (.1 ml/kg/% burn) is begun 24 hrs after the burn -Follow with enteral feedings and salt-free solutions at 1 ml/kg/% daily -Adjust fluids based on urine output with a goal of 0.5 ml/kg/hr in adults and 1.0 mg/kg/hour in children -May require central venous monitoring to gauge fluid status in more severely burned individuals -Severe burns may necessitate fasciotomy to relieve pressure

Diabetes Mellitus

-30% of patients with DM develop skin lesions -Prevalence of cutaneous disorders does not differ between Types I and II -Type I have a tendency to get more autoimmune type lesions -Type II have a tendency to get more cutaneous infections

Burns Abuse

-3rd most common cause of injury related pediatric mortality -Most common intentional scalds - from immersion injuries and running hot water from a faucet -Symmetrical, clear margins, uniform depth, spares folds and resting point of gluteal area, 'glove' or 'sock' distribution, no splash marks

Acral-lentiginous melanoma

-5%-8% of melanoma cases, appears mostly in dark-skinned people= peaks at 70 -palms and plantar surfaces of the feet or at finger- and toenails -difficult to identify, most patients present in late stage, contributing to a poorer prognosis

Dog bites:

-80 % of all animal bites = Dog -15-20% become infected generally a polymicrobial infection -No good prospective studies on role of prophylactic antibiotic usage

Malignant Melanoma:

-80% of the fatalities from skin cancer -Older adults present with more advanced disease and aggressive subtypes - lymph nodes/ liver/ lung/ brain - common areas of metastases

Key Differences between Adult and Children Skin

-A child's skin is drier and tends to chap easily -It is 40-60% thinner than an adult's -It is less hairy -It has a weaker attachment between epidermis and dermis -It is at increased risk of injury, infection and percutaneous absorption

Churg-Strauss allergic granulomatosis

-A hypersensitivity reaction causes severe eosinophilia, vessel inflammation and granuloma formation in most major organs, especially heart and lung. Skin lesions appear mainly as purpura and subcutaneous nodules

Vitiligo

-A multifactorial acquired disease, with a complex pathogenesis that is not well understood. -The most accepted theories involve both genetic (inherited disorder) and non-genetic (autoimmune) factors playing a role in the destruction of melanocytes.

Predisposing Factors to candidiasis

-A warm humid environment -Hyperhidrosis -Occlusion of skin and hair follicles -Oral contraceptives -Antibiotic and systemic corticosteroid use -Diabetes mellitus -Immunosuppression -Renal failure, malignancy and other systemic diseases

Acanthosis Nigricans

-Acanthosis Nigricans is an acquired disorder most commonly associated with obese patients with insulin resistance. -It causes velvety, light brown to blackish markings on the skin. -These skin findings are usually found around the neck, under the arms or in the groin. -The elevated insulin levels in the body activates receptors on the skin causing a thickened abnormal growth.

Acute spongiotic dermatitis

-Allergic contact dermatitis - type IV hypersensitivity

Spider angioma

-Also known as "spider nevus" or "spider telangiectasia" -Found in the distribution of the superior vena cava -Form due to breakdown of muscular layer surrounding a cutaneous arteriole -Asymptomatic, but multiple lesions may indicate hepatic disease -May treat with electrodessication or laser

Systemic or disseminated-

-Amphotericin B, available in newer lipid-based formulations, -as well as caspofungin are effective in treating disseminated candidiasis

Acne process

-Androgens -Promote sebum production -Accumulation of sebum and keratinous material in pilosebaceous follicles -Partial or complete obstruction of the follicle forming comedones -Inflammation and acne vulgaris

Adapalene (Differin)

-Another topical retinoid agent -Anti-inflammatory activity -Available in gel or solution -Same spectrum of activity as Retin-A -Better tolerated than tretinoin gel. No sun sensitivity

immunohistochemistry

-Antibodies are manufactured against various molecules, have some sort of marker attached that can be visualized. -S-100 protein, SOX 10, Melan A, HMB-45, etc. -These are used when it is not clear that the lesion is melanocytic. Also used to look for tiny foci of cells in sentinel nodes.

Herpes zoster Treatment:

-Antiviral therapy = 72 hrs vesicular erruption for immuno deff pt -Early implementation and adequate dosage of antiviral agents will accelerate the healing of skin lesions/ reduce acute pain/ prevent postherpetic neuralgia -acyclovir is 800 mg//Valacyclovir (better)

Irritant/Contact Diaper Dermatitis

-Arises d/t contact with proteolytic enzymes in stool, irritant chemicals, e.g. soap, detergents, topical preparations, excessive heat, moisture or sweat retention in a warm local environment produced by the diaper -Typically affects convex surfaces of buttock, vulva, perineal area, lower abd, proximal thighs -Spares intertriginous creases

Tinea Capitis

-Arises from fungal infection of scalp - Trichophyton tonsurans, Microsporum canis -More common in ages 1-10 years of age -African-Americans typically more affected d/t hair structure -Presents as patchy hair loss with underlying area of scalp infected with fungal elements - white, scaly, flaky lesions -Contagious -Diagnosis - KOH preparation of fungal elements -Treatment - oral antifungal agents, medicated shampoo for scalp

Secondary psychiatric disorders

-Associate with disfiguring skin disorders -Disfigurement results in psychological problems (self-esteem, depression, phobias) -Feelings of shame, humiliation, lower quality of life

Melanoma is typically identified using the ABCDE

-Asymmetrical -Borders that are irregular or notched -Color variation of brown, black, blue or white -Diameter greater than 6 mm -Evolving (amelanotic melanoma may be pink or clear)

Skin Wrinkles

-Authorities recognize as many as five different subtypes of wrinkles. -The most common type of wrinkles on non-sun-exposed skin are fine wrinkles (glyphic wrinkles) that represent accentuation of normal skin markings. -Microscopically, this is due to focal thinning and decreased numbers of keratinocytes. This appears to be intrinsic to aging. - The deeper wrinkles in photodamaged skin demonstrate a groove in the epidermis associated with solar elastosis that protrudes on both sides of the groove. - -These deeper wrinkles are due to extrinsic aging, primarily resulting from ultraviolet light.

Superficial Pemphigus

-Autoantibodies against Desmoglein 1 -IF IgG and C3 intercellular space of epidermis, sometimes more superficially oriented. Usually spares the basal layer.

Pemphigus vulgaris info

-Autoantibodies to desmoglein 1 and 3 -Suprabasal clefting -IF within epidermis intercellular IgG -Flaccid blisters, may initially present with oral blisters -Serious chronic disease with mortality rate of 5-19%. -Treat with steroids.

Discoid lupus erythematosus

-Autoimmune dz. -Can involve many organs or just skin -Can be an interface dermatitis but can have blisters and prominent dermal mucin -IF linear IgG and C3

Frequency approach

-Because "frequent is frequent". -Taking into account the most likely culprits based on frequency data of a given region. -Patient's occupation and other individual exposures

Proprionibacterium acnes proliferation:

-Benzoyl peroxide -Topical and oral antibiotics -Topical retinoid

Tetracycline, Erythromycin

-Both decrease the number of P. acnes on the skin surface and have anti-inflammatory effects (Tetracycline more so than erythromycin) -Dosing: 250 to 500 mg bid -Side effects *Tetracycline - photosensitivity, staining of permanent teeth in children under 9, and yeast vaginitis *Erythromycin - GI upset, vaginitis

Diagnose

-By clinical appearance - immunohistochemical assay to determine type of HPV present - biopsy

Cutaneous candidiasis

-C. albicans has a predilection for colonizing skin folds -intertrigo= reference -genitocrural, gluteal, interdigital, inframammary areas, and beneath the pannus and axillary areas. -eruption appears as macerated red erythematous patches and thin plaques with satellite vesiculopustules

Candidiasis

-Candida never inhabits normal keratinized skin -Refers to a diverse group of acute and chronic integumentary or disseminated yeast infections -Most commonly caused by Candida albicans -Candida species are the most common cause of fungal infection in immunocompromised persons -Ubiquitous species that form true hyphae, pseudohyphae, and budding yeasts -May involve any part of the body. -limited to human and animal hosts, but have also been recovered from the hospital environment: floors, respirators, air-conditioning vents, countertops, and on medical personnel.

Pityriasis rosea

-Cause is unknown epidemiological evidence suggests infectious etiology viral exanthem associated with reactivation of human herpes virus (HHV)-7 and sometimes HHV-6. -Guttate psoriasis, pityriasis versicolor and secondary syphilis may cause confusion. -Supportive treatment, although mid-potency topical corticosteroids can reduce pruritus; high-dose acyclovir for 1 week may hasten recovery. -Recurrent disease is possible, but it is rare.

Purulent cellulities tx

-Clindamycin -Trimethoprin-sulfamethozazole -Doxycyclin -Minocycline -Linezolid

Pretreatment Assessment

-Clinical type and severity of acne Determines the type of treatment needed -Skin type -Presence of acne scarring: indicates need to consider aggressive tx. -Presence of post-inflammatory hyperpigmentation -Menstrual cycle history and signs of hyperandrogenism in women -Psychological impact of acne on the patient -Current and past skin regimens

Tretinoin (retinoic acid/ Retin A/ Avita)

-Comedolytic, often used in conjunction with antibacterial agents -Solution, gel, cream (0.05%-0.1%) -May produce significant skin irritation, erythema and dryness. -Best used once nightly, applied sparingly. -May develop sun sensitivity in the first two-three weeks. (thinning of the S. cornium) -Start with lowest dosage of cream and gradually increase -Warn that acne may initially appear exacerbated, but will improve thereafter

Miliaria

-Common newborn rash associated with warmer climates, incubator use or over-wrapping -Commonest in the first few weeks of life -Due to sweat retention from obstructed eccrine sweat glands in the stratum corneum -Clear pinpoint vesicles (crystallina), small discrete erythematous papules or papulovesicles (rubra) -Self-limited, resolves with cooler temperatures -Treatment - avoid excessive heat and humidity, avoid over application of emollients

Seborrheic Dermatitis

-Common rash in infants of unknown etiology -Presents as erythematous plaques with greasy yellow scales -predilection for areas rich with sebaceous glands e.g. scalp, cheeks, intertriginous areas, ears, eyebrows, diaper area -1-4 month old infants, tends to wax and wane -Treatment - remove scales on scalp with soft brush/comb, medicated shampoo and mineral oil for lesions -Seborrheic capitis is commonly referred to as "cradle cap"

dermatofibroma

-Common, benign fibrohisitiocytic lesions -Can be pigmented -If large and deep and densely cellular can be confused with dermatofibrosarcoma protuberans distinguish with CD 34

Drug Allergy

-Deposition of the drug in the skin. -Excessive therapeutic effect e.g. ecchymosis with warfarin. -Immune hypersensitivity in any of the 4 types. -Pharmacological side effects. -Unknown causes. Reactions may be limited to the skin or part of a systemic issue. Up to 12% of children treated with an antibiotic will experience a cutaneous reaction. As in the case of all rashes a thorough history must be taken.

Diabetic dermopathy

-Diabetic dermopathy is a type of asymptomatic skin lesion -It is characterized by dull-red papules that progress to well-circumscribed, small, round to oval, atrophic hyperpigmented skin macules usually seen on the shins. -Men are affected twice as often as women. - It is the most common of several diabetic skin conditions being found in up to 30-40% of diabetics. Similar lesions can occasionally be found in non-diabetics usually following trauma or injury to the area.

Marasmus Physical examination findings include

-Diminished weight and height for age -Apparently large head with staring eyes -Emaciated and weak appearance, irritable and fretful affect -Bradycardia, hypotension, and hypothermia -Thin, dry skin -Shrunken arms, thighs, and buttocks with redundant skin folds caused by loss of subcutaneous fat -Thin, sparse hair that is easily plucked

Xanthomas

-Dislipoproteinemias are classified as either primary or secondary -Yellow-brown, orange or pinkish macules, papules plaques or nodules -Histologically are an accumulation of xanthoma cells -characteristic of certain lipid abnormalities but none are specific because same form of xanthoma can be seen in many different diseases

TNPM

-Distributed diffusely over the face, forehead, chin, neck, and lower back -Self-limited, requires no treatment -Lesions disappear within 24-48h, hyperpigmentation fades gradually over weeks to months -Fluid from pustule reveals neutrophils

Topographic approach

-Distribution is usually the single most important clue to the diagnosis of ACD. -Typically, the area of greatest dermatitis is the area of greatest contact with the allergen. -Think cosmetic related especially with facial, eyelid, lip, and neck patterns. -Airborne related may be difficult to fit into this approach

Dermatitis (Eczema) Xerosis (Asteatotic Eczema):

-Dryness of the skin, most common skin disorder in the elderly -Increased transepidermal water loss, reduced sebum and sweat production, and decreased natural moisturizing factor, all lead to skin dryness -lower legs, it is often accompanied by intense itching, excoriation, or inflammatory changes recognized as asteatotic eczema -degrees of erythema, cracking, fissuring, or present with a "crazy paving" appearance -aggravating factors include low ambient humidity, -excessive bathing (especially using harsh soaps or detergents), - irritating clothing, - products containing alcohol or acetone. -Diuretic drugs and -cholesterol-lowering agents have also been shown to induce skin dryness

Alopecia Areata

-Due to chronic inflammation, maybe autoimmune disorder -Typically starts with small patches of hair loss, with normal appearing scalp. May have erythema, itching, tends to enlarge to large areas. -Regrowth possible initially, tends to relapse, progression to alopecia totalis (entire scalp) and or alopecia universalis (all body hair) in minority of cases. -Rx - topical or intralesional steroids, systemic medications if needed

Trichotillomania

-Due to compulsive urge to pull own hair -Result in incomplete hair loss -Hair of different lengths with unusual shape involving area of hair loss -Tends to involve the scalp primarily, eyebrow and lashes may also be involved. >10 years of age -May indicate anxiety, depression or OCD disorder -Treatment - behavioral modification - psychiatry evaluation

Alopecia Universalis

-Due to hairstyles that apply tension for prolonged periods of time -Non-inflammatory linear areas of hair loss at hair margins, part lines, or scattered regions. May result in permanent scarring if traction remains for too long -Treatment - avoid styles that result in traction for long periods.

Contact dermatitis treatment

-Education of the patient and providing realistic expectations. -Education of the patient in regards to before and after patch testing. -Avoidance of allergen. -Of increased difficulty is the identification of safe alternatives of products that usually do not contain a list of ingredients or materials. -Topical corticosteroids are the first line of treatments. Watch for potency and overuse. Remember, even people may have an allergic reaction to the prescribed cortisone cream! -The topical immune modulators tacrolimus and pimercrolimus can also suppress ACD. Good especially on the face and eyelids. -Oral steroids may be used when necessary -Chronic ACD may need prolonged as well as more aggressive oral therapy

Trimethoprim - sulfamethoxazole

-Effective in treatment of severe acne -Limited use due to the potential side effects (bone marrow suppression, Stevens-Johnson syndrome and toxic epidermal necrolysis)

Urticaria and AngioedemaTreatment

-Eliminate any underlying cause -Avoid any provoking factors or specific allergens -Treat with oral histamine type 1 receptor blockers such as cetirizine (Zyrtec) 10 mg daily, fexofenadine (Allegra) 180 mg daily -add ranitidine(Zantac), which is a H2 blocker -Oral corticosteroids can be used to control more severe symptoms -Adrenaline (epinephrine) used acutely or provided to patient for outpatient use (EpiPen 2 pack). -medications and treatments when indicated -H1's include Claritin, hydroxyzine, Benadryl, cyproheptadine.

P. acnes

-Enzymes produced by P. acnes may promote the degradation of the follicular wall and follicular rupture. -P. acnes surface proteins may play a role in antigenicity, triggering humoral and cell-mediated immune responses. -Heat shock proteins, which promote inflammation via the innate immune system, are produced by P. acnes. -Porphyrins produced by P. acnes may contribute to adjacent tissue damage and inflammation

Diagnostic Evaluation of Acne Vulgaris

-Evaluation of endocrine function -Medication history for acne inducing drugs -Examination of the skin for type and location of lesions

Erythema presentation

-Exanthem begins 17-18 days after inoculation -arthralgia and/or arthritis -Skin lesions

Tuberous sclerosis skin manifestations

-Facial angiofibromas -Periungual fibromas -Hypomelanic macules -Shagreen patches

New born skin

-Fetus skin is transparent with clearly visible blood vessels -As fetus ages skin matures, blood vessels become less visible -Vernix caseosa serves as a protective covering for fetus -Baby skin is usually soft, smooth and velvety -Desquamation starts usually 24-36 hours after birth through the 3rd week of life

Potentially severe reaction

-Fever and/or other symptoms of internal organ involvement -Lymphadenopathy -Evolution to erythroderma (exfoliative dermatitis) -Prominent facial involvement -Mucus membrane involvement -Skin tenderness, blistering, or shedding -Purpura

Toxic shock syndrome

-Fever: >38.9C -Rash: diffuse macular erythroderma -Desquamation 1-2 weeks after the onset (palms and soles) -Hypotension systolic BP <90 mm Hg -Multisystem involvement of three or more

Junctional Nevi

-Flat or minimally raised -Brown to black in color -May have darker pigmentation in the center

Differential Diagnosis

-Folliculitis -Rosacea

Folliculitis Pseudofolliculitis barbae

-Foreign body reaction to hair -If hair is cut below the surface (shaving) the sharp tipped whisker may curl back and penetrate into the skin. -less inflammation that with Staph. Folliculitis. -Generally occurs on the cheeks and neck of those with tightly curled hair which becomes ingrown -axilla, pubic areas and legs -50% of African-Americans

Salicylic acid:

-Found in many over-the-counter washes -Comedolytic activity -Well-tolerated although drying -May cause burning, peeling, irritation -Best used in patients with normal to oily skin

Multisystem involvement of three or more

-GI: N/V, diarrhea -Muscular: severe myalgia (CPK levels > 2X normal) -Mucus Membranes: (vaginal, oropharyngeal or conjunctival) hyperemia -Renal: BUN or creatinine at least twice the normal limits or pyuria without UTI -Hepatic: Total bilirubin, or liver enzymes at least twice the normal (hepatitis) -Hematologic: thrombocytopenia platelets< 100,000 mm3 -CNS: Disorientation or alteration in consciousness without focal neurological signs when fever and hypotension are absent

Treatment of Adolescent Acne

-Goals of treatment - prevent formation of comedones, reduce number of comedones, prevent scarring, prevent psychological stress -Topical agents - retinoid, keratolytic agents, antibiotics - for mild-moderate acne -Systemic agents - antibiotics, retinoid, hormonal therapies - usually for severe acne

Management of Diaper Dermatitis

-Good diaper hygiene - frequent changes, appropriate size -Zinc oxide and petrolatum-based or oil-based formulations -Fragrance free diaper wipe, detergents, creams -Topical agents -Systemic agents in severe cases used to think ammonia released from urine was major contributor to diaper rash but recent studies do not support finding General Principles - urinary wetness increases skin's permeability to irritants, increases diaper environment pH - intensifies activities of fecal proteases and lipases (major irritants)

Adolescent Acne

-Grades: mild - comedones alone, moderate - papules and pustules, severe- nodules and cysts. -Scarring can occur with any grade -Food or diet has not been identified as a causal factor for acne

Blue Nevus

-Head, neck, dorsal extremities, sacrum -Usually solitary -Blue to blue-black, uniform -Dome-shaped < 1 cm

Acquired Melanocytic Nevi: Predisposing factors

-Hereditary -Degree of sun exposure -Skin type -Diagnosis- made clinically -Moles with atypical features must be differentiated from melanoma >5 mm, irregular borders, asymmetry, variable pigmentation, change in appearance of a old lesion

How do you study/figure out/diagnose these diseases? What is the most important part of any interaction of a person with the health care establishment?

-History and Physical - no test is as important - we should have a differential in mind before ordering or doing anything - order the test to confirm or refute ideas

Evaluation of endocrine function

-Hyperandrogenism: PCOS most common cause in women. -Rapid appearance of acne in conjunction with virilizaton suggests an underlying adrenal or ovarian tumor. -Cushing's Disease and late onset congenital adrenal hyperplasia can experience acne vulgaris -Recommendations for initial screening for hyperandrogenism include DHEA-S, total and free testosterone

Anogenital warts (condyloma acuminata)

-Hyperkeratotic -dermal flesh-colored papules -from 1 mm to 10 cm masses Some subtypes of HPV have been associated with cervical carcinoma and squamous cell carcinoma of the penis and vulva

Common warrts (verruca vulgaris)

-Hyperkeratotic papule=tan cauliflower -Often thrombosed vessels appear as tiny black dots within the wart. on any skin surface but are prone to appear on the -hands -fingers -knees -points of trauma

Hypomelanosis of Ito

-Hypomelanosis of Ito is a rare inherited congenital disorder -Characterized by a whorled pattern of light patches found on the skin. The hypopigmented areas can be found in any part of the body abnormalities involving other organ systems, -central nervous system -ocular involvement.

Intrinsic aging

-Includes those changes that are due to normal maturity and senescence and thus occurs in all individuals. -Classically, intrinsic aging has not been considered to be preventable, but there is renewed interest in the role of antioxidants, such as vitamins C and E, in preventing intrinsic aging. Despite numerous articles in the lay literature, there is no proof that these treatments are effective

Topical agents

-Indicated when the infection does not involve the nails or hair(can be used as an adjunct). -Apply on visible rash as well as 2 cm beyond to catch any potential satellite areas -treat one week after resolution of the visible rash. -both over the counter and prescription medications -selenium sulfide or Selsun, zinc pyrithione, ketoconazole(Nizoral) 2%, tolnaftate, ciclopirox, miconazole, and clotrimazole

Cutaneous Body Image (CBI)

-Individual's mental representation of his or her skin, hair, and nails -Important clinical factor in deciding cosmetic procedures or other treatments -Assess for co-morbid, especially BDD

Epidermolysis bullosa

-Intraepidermal -E.B. simplex -Intralamina lucida/junctional-junctional E.B. -Sublamina densa/dermolytic-dystrophic E.B. -An acquired variant.. E.B. acquisita has antibodies to type Vll collagen. Separation is below basement membrane. Onset mid adult. -Difficult to treat.

Ramsay Hunt syndrome

-Involvement of facial or auditory nerves and consists of ipsilateral facial palsy and lesions of the external ear, tympanic membrane or anterior 2/3 of the tongue. - It can result in tinnitus, vertigo, deafness, or loss of taste

Dysplastic/atypical nevi

-Junctional component extends beyond intradermal component -Lentiginous growth(single cells) -Bridging nests -Random cells show nuclear enlargement -Lamellar fibrosis in papillary dermis

Tinea versicolor

-KOH) preparation of skin scrapings demonstrates the characteristic fungal spores and short cigar-butt hyphae ("spaghetti and meatballs) -methylene blue stain to the KOH preparation. enhances the visualization -Wood's lamp examination may show orange-yellowish fluorescence of involved skin. -Pityriasis rosea and tinea corporis may occasionally appear similar

Bradykinin also plays a role in angioedema

-Kinins activate endothelial cells which leads to vasodilation - inc vascualr permeability - NO production - arachedonic acid mobilization - stimulate sensory nerve endings to cause a burning dysesthesia = redness/ heat/ swelling/ pain

Nevus flammeus (port-wine stain)

-Large, flat macular patch consisting of mature capillaries. -Present at birth, usually will not fade. -Recent treatment therapies with laser have been successful.

Chronic Skin problems

-Lead to feelings of isolation -Trouble initiating and maintaining romantic relationships -Unequal treatment when applying for jobs and in the workplace -High prevalence of depression and anxiety -Trouble sleeping (can enhance inflammatory process)

Cephalic Pustulosis

-Lesions are located mainly on the forehead, nose and cheeks -Starts at a few weeks of age, peaks around 1 month -Resolves within a few months, usually without treatment -Treatment of severe cases - topical agents -Does not increase risk of adolescent acne

Systemic candidiasis

-Life-threatening infection occurring usually in immunocompromised or debilitated patients -C. albicans is the major pathogen although C. tropicalis has been cultured -disseminated candidiasis is steadily rising as the prevalence of immunosuppressed patients with longer life spans has also increased. -hematogenous access from the oropharynx or gastrointestinal tract when mucosal barrier function is compromised - 2ndary to chemo -intravenous catheters become contaminated Prolonged neutropenia is the most important predisposing factor.!!!!!! -Differentiate from bacterial sepsis.

pressure ulcers

-Localized area of tissue damage, usually developing where soft tissue is compressed between a bony prominence and an external surface for a prolonged period of time -arise as a result of a combination of interface pressure, shear and friction pressures, and abnormal skin moisture -Most common locations are sacrum, heels, ischial tuberosities, and trochanters -Capillary pressure ranges from 12 mm Hg in the venous system to 32 mm Hg in the arterial system. -Sustained pressure in excess of 32 mm Hg leads to decreased capillary blood flow and ultimately to tissue ischemia, capillary thrombosis, cell death and formation of a pressure ulcer

Management

-Longitudinal observation with removal and histology for suspicious lesions -Patients with a large number of acquired nevi increases the risk of melanoma so periodic total body skin checks should be done -Sun protection

Serologic tests

-Lupus - autoantigens of pemphigoid BP180 + BP230

Melasma management

-Management of melasma consists first limiting, exposure to ultraviolet light (sunlight and/or artificial light exposure such as from tanning booths). -Sunscreens should be used. -Depigmenting agents also known as "bleaching" creams are available as well as cosmetic coverage to blend skin area effected.

Nutritional Disorders

-Marasmus -Kwashiorkor -Pellagra -Scurvy -Zinc Deficiency

Reexcision recommendations

-Melanoma in situ 0.5cm -<1mm depth 1.0cm -1-2 mm 1-2cm (2cm if primary closure is possible -2-4mm 2cm ->4mm 3 cm -Dr Bernard Ackerman to the last malignant melanocyte.

Grading of DN

-Mild-moderate-severe -Severe are treated like melanoma in situ (5 mm margin reexcision)

Systemic Agents: Antibiotics

-Moderate to severe inflammatory acne or truncal acne -Improve inflammatory acne by inhibiting the growth of P. acnes within the pilosebacious unit.* -Tetracycline has a direct anti-inflammatory property * -More rapid clinical improvement than topical therapy -Should be prescribed for a limited course to limit antimicrobial resistance. Usually daily use for 6 months If an oral antibiotic is stopped and need to restart, Rx the same antibiotic as long as it remains effective * -Do NOT simultaneously treat with a topical and oral antibiotic -Prescribe benzoyl peroxide and a topical retinoid at the start of antimicrobial therapy

Mongolian spots

-Mongolian spots are the most frequently seen pigmented skin lesion seen in newborns. -They can be seen at birth or develop in a child's first year of life. Mongolians spots can be seen in all racial groups but they are more common in Asian and Native Americans. They are usually flat, blue-gray, green-blue, or brown in color. They can be single or multiple in a close area. The size, shape and location vary from patient to patient. The two most common areas that they appear are on the shoulders and sacral area, rarely affect the head or face. This skin spots, are benign and treatment is conservative.

Spitz Nevus

-Most appear during childhood -Face, extremities -Fast initial growth phase -Symmetric, < 1 cm -Pink, tan, or red-brown -Dome-shaped, hairless -Atypical ones can be confused with melanoma

Benign Neonatal Skin Lesions

-Most are transient -Tend to appear in the first few days to weeks of life -Disappear within a few days or weeks -Most are self-limiting, requiring no specific treatment -No systemic symptoms -No permanent sequel

Telogen Effluvium

-Most common cause of diffuse hair loss -Abrupt diffuse hair loss within 3 months of stressful situation -Frequently r/t stress e.g. major illness, surgery, severe weight loss. -Mature hair follicles switch prematurely to the telogen (resting) state, with shedding within 3 months -Self limiting, regrowth expected over ensuing months

Erythema Toxicum Neonatorum (ETN)

-Most common rash of full term newborns -Etiology is unknown -Rash tends to appear after 24h of life -Starts as blotchy, small erythematous macules and papules which evolve into pustules with erythematous bases.

Basal Cell Carcinoma:

-Most common type of skin cancer -peak incidence in the 8th decade of life. The most common sites are on sun-exposed skin, with 75% of lesions arising on the head and neck

Jugular venous pressure

-Much lower than arterial pressure -Determined by left ventricular output, blood volume, and the capacity of the right heart to receive blood and eject it onward into the pulmonary arterial system

Cigarette burns:

-Multiple -Grouped -Uniform size -Well defined borders, -Central crater -Scarring

Flea Bites

-Multiple, pruritic urticarial papules, usually <1 cm in diameter; they may be topped by a vesicle. -knees, legs of children -various stages of crusting if re-exposure occurs -Conservative topical therapy with corticosteroids and antipruritics, along with oral antihistamines, is usually sufficient for most flea bites -Antibiotics may be necessary should secondary bacterial infection develop -a flea infestation occurs, complete eradication of the insects is necessary to prevent additional bites

Pulmonary Disease Sarcoidosis

-Multisystem granulomatous disease of lungs, bones, CNS, lymph nodes, eyes and skin -Higher incidence in women and African-Americans -Skin Disease affects 25-35% of patients -Red to purple indurated plaques of the nose , mid-facial papules, annular plaques or nodules on the trunk and extremities. -Predilection for scars -Erythema nodosum is the most common manifestation

NTM Group IV Rapid Growers

-Mycobacterium abscessus and -M. fortuitum: 3rd most frequently recovered respiratory NTM in US High resistance to antibiotics

Group IV Rapid Growers

-Mycobacterium fortuitum -Mycobacterium abscessus

more treatment

-Neomycin Sulfate ointment (aminoglycoside) -Nitrofurazone cream, solution, or soluble dressing -With all 3 agents, beware of allergic reactions

Merkel cell carcinoma

-Neuroendocrine cell carcinoma -Must exclude metastasis from small cell carcinoma of lung -Survival at 3 yrs is 55% -Merkel cell polyoma virus is incorporated into the genome in many cases..?...

Neurofibromatosis

-Neurofibromas appear at puberty -Tumors increase in number and size as patient ages -Lisch nodules are pigmented melanocytic iris hamartomas

Halo Nevus (Sutton's nevus)

-Nevus outlined with a halo of depigmentation -Higher incidence with increased number of nevi and a history or FH of vitiligo -Commonly seen on the back -Typically seen in multiple lesions -Need to assess the central nevus for consideration of biopsy

Epidermolysis bullosa

-Non inflammatory, heterogenous group of inherited disorders. -Traditionally used electron microscopy to distinguish/describe. Most of these develop blisters after trauma. Some of these diseases are minimal and some are life threatening.

Pityriasis rosea

-Not a fungus at all but commonly misdiagnosed as one -acute, self-limiting disorder probably infective in origin, characterized by scaly oval papules and plaques that occur mainly on the trunk. -single primary lesion or "herald" patch -many smaller plaques appear, mainly on the trunk but also on the upper arms and thighs -Individual plaques are oval, pink and have a delicate peripheral scales. -They are distributed parallel to the lines of the ribs, radiating away from the spine -eruption fades spontaneously in 4-8 weeks

laboratory testing: atopic dermatitis

-Not indicated in the routine evaluation and treatment of uncomplicated AD. -IgE levels are elevated in approximately 70-80% of AD patients. -peripheral blood eosinophilia -roughly correlate with disease severity (eosinophilia) -increased spontaneous histamine release from basophils

Spectrum of skin disorders

-Nuisance to full blown psychiatric disorder -Can include trouble sleeping -Impact daily activities and social interactions -Influenced by personality traits, life situation -Influenced by the meaning of the disease in the patient's family and culture -Influenced by the timing and onset

Nevus Simplex

-Occur as solitary or multiple pink-red macular lesions that blanch when compressed -Found in 40-60% of infants -Frequently located on the eyelids, glabella and nape of the neck. -Commonly referred to as macular stain, stork bite, angel kiss, or salmon patch -They are benign lesions of no clinical significance -Most lesions resolve spontaneously within two years

Intradermal Nevi

-Often lose ability to produce melanin -Skin-colored to tan -Dome-shaped to pedunculated -Soft, rubbery texture -Speckles of brown pigment or hairs within the nevus

Increased sebum production:

-Oral isotretinoin -Hormonal therapies

Inflammation:

-Oral isotretinoin -Topical retinoid -Azelaic acid

Sq. C. Ca.

-Overall recurrence 4-10%...but lip and ear 11-20% -5 yr metastasis 5%...lip 11%, ear 14%. -Burns/scars 20% met -Penis, scrotum anus increased met rate

Erythema Nodosum

-Panniculitis or inflammation of subcutaneous fat tissue. -Painful, especially if pressed upon. -It looks like painful bruises on both of the shins. A few other bumps may be present elsewhere, for example, the knees, elbows, forearms and thighs. -Patients feel ill. (like having the "flu")! Most likely to occur between fifteen and thirty years of age. Women are affected 3X as often as men. #1 cause drugs: Sulfa, BCP The lesions start out slightly raised and bright red. Range in size from one half inch to several inches across. The color turns to a purplish red. As they start to fade they get a yellowish color. Associated with long standing Inflammatory Bowel Disease, Sarcoidosis, lymphoma, Strep throat

Contact dermatitis testing

-Patch testing is the standard method for identifying contact allergens -reproduce an eczematous reaction by the application of an allergen under occlusion for 48 hours on intact skin -miniature in vivo visualization of the elicitation phase of a delayed-type hypersensitivity (type IV) reaction. -Reading reactions elicited by the patch test is a crucial step in the patch-test procedure. -Another test is the lymphocyte transformation test (LTT

DM:Diabetic Neurotrophic Ulcers

-Peripheral neuropathy leads to unnoticed trauma -Vascular complications may lead to ulcers and complicate ulcer healing -Risk of amputation goes up 8X once these develop

Tinea versicolor

-Pityriasis versicolor -Caused by Pityrosporum orbiculare, normal skin organism. -Misnamed since it is not a "tinea" at all -well-demarcated hypo-or hyperpigmented scaling patches most typically on the anterior and posterior chest. -hypopigmentation is found as a result of the release by the organism of dicarboxylic acids that inhibit melanogenesis

Varicella zoster complications

-Postherpetic neuralgia -Ophthalmic zoster

Postinflammatory Hypo/Hyperpigmentation

-Postinflammatory hypo/hyperpigmentation is a common cause of acquired hypo/hyperpigmentary disorders. -It can be the result of a cutaneous inflammation, dermatological procedures or trauma from an injury. -Most cases will improve spontaneously within weeks or months if the primary cause is eliminated however, it can be permanent if there is complete destruction of the melanocytes in the involved area.

Sentinel lymph node

-Predictor of recurrence rates and survival -The rationale is :80% of patients with melanoma are stage 1 and 2...the survival is this group ranges from 53 to 98% -SLN is offered to help this group -8 year survival in pts with pos SLN=55%

History is important for interpreting biopsies

-Pregnant/teenage (hormones make nevi look atypical sometimes. -Traumatized or previously biopsied/recurrent nevi -Children -location

Diaper Candidiasis

-Presents as widespread, raised, beefy red lesions usually in sharply demarcated areas with pinpoint pustulovesicular satellite lesions* -Affects buttocks, lower abdomen, inner thighs -Usually arises secondary to irritation or other dermatitis -Caused by Candida species -Commonly follows systemic antibiotic use -Always look in the mouth for oral candidiasis -Treatment - topical antifungal preparations Satellite lesions - diagnostic hallmark!!!!!!!!!!!!!

Scalded Skin Syndrome (Ritter's Disease)

-Produced by an exfoliative exotoxin of S. aureus -in children; in neonates it is also termed pemphigus neonatorum -innocuous S. aureus infection of nares, throat, or umbilicus -sandpaper texture tender rash. Fever and a tender scarlatiniform rash -Within 24-48o, large, clear bullae develop which gradually shed, leaving a red, denuded base -Lateral traction on the skin causes it to wrinkle and eventually tear (positive Nikolsky sign)

Dermatitis Herpetiformis info

-Pruritic papules and vesicles -Related to gluten sensitive enteropathy

Renal Disease

-Pruritis -Most common cutaneous manifestation of renal disease -Seen in both peritoneal and hemodialysis patients (End Stage Renal Disease ESRD)

Non Pharm Treatments

-Psychotherapy -Hypnosis: Focus on an image associated with desired change, i.e., less itchy skin, tropical rainforest to counteract the drying condition of eczema -Relaxation training -Biofeedback -Operant conditioning -CBT -Meditation -Affirmation -Stress management -Guided imagery

Strawberry hemangioma

-Raised, bright red lesion with well-defined border. -Does not blanch with pressure. -Consists of immature capillaries. Present at birth or within 3 to 4 months -Disappears by age 5-7 years

DM:Bullous Diabeticorum

-Rapid onset of painless, tense blisters on hands and feet -Trauma and microvascular disease may play a role in development -Spontaneous healing in 2-5 weeks

new treatment modalities

-Recombinant growth factor therapy +Basic fibroblast growth factor +Platelet-derived growth factor BB -Allogeneic - cultured grafts (Dermagraft, Apligraf) -Electrical stimulation to enhance healing -Hyperbaric oxygen therapy - no controlled studies

Cavernous hemangioma

-Reddish-blue, irregularly shaped, solid, spongy mass of blood vessels. -May be present at birth, enlarge during the first 10-15 months and will not involute spontaneously.

Treatment in General

-Reduce scratching -Improve sleep -Manage psychiatric symptoms (e.g., anxiety, depression, embarrassment, social withdrawal) -Consider cutaneous side effects of psychiatric drugs

Lichen planus

-Relatively common -Lichenoid dermatitis, sometimes has small blisters -Can have oral involvement

pyoderma: impetigo causative organism

-S. aureus most commonly -group A B-hemolytic Streptococcus or mixture of both

Seborrheic Diaper Dermatitis

-Salmon-colored, greasy plaques with yellowish scale -Mainly in intertriginous areas -Check scalp, face and other areas e.g. neck, axillae, for similar lesions

causes of burns

-Scalding injury from hot liquids -Structural fires -Flammable liquids and gases -Electrical -Chemical

DM: Diabetic Eruptive Xanthomas

-Seen in uncontrolled DM and hypertriglyceridemia -Sudden crop on firm non-tender yellow papules with a red rim on extensors -Glucose control and lipid reduction reduces the lesions

Vascular Disorders

-Senile changes in skin vasculature show age-related decrease in vessel density and reduction of cutaneous blood flow -Decreased endothelial cell permeability and weakened ability to induce leukocyte adhesion contribute to compromised immune reaction. -With increased skin rigidity; decreased elasticity -as well as impaired inflammatory responses -aging skin is rendered more susceptible to injury and is less capable of undergoing modification or repair in response

Tinea cruris

-common in men - (groin) -athletes ('jock itch) -spreads to the upper thigh but rarely involves the scrotum. well-defined border ! superficial scaling.! scaly, pustular or vesicular T. rubrum, E. floccosum, or T. interdigitale

Human bites

-Serious more prone to develop infection. -Generally develop into cellulitis. Can also produce deep space infections, septic arthritis and osteomyelitis -Mixed polymicrobial infection with aerobes and anaerobes Tx: Tetanus I and D, debridement if needed, G stain and culture Augmentin, Doxycycline, Tetracycline

Bullous impetigo presentation

-Shallow erosions/flaccid blisters 0.5-3cm -Subcorneal collection of neutrophils -Gram positive cocci(often Staphylcoccus Aureus) -The bacteria locally produces a toxin...This entity is considered part of a group of related lesions..."staph. -Epidermolytic toxin syndrome" which includes staph scalded skin syndrome(babies,very young kids) Staphylcoccus Aureus!!!

treatment Sq. C.Ca

-Shave and curette -Excise -Moh's -Topical chemotherapy(5-FU) -radiation

Diabetic Dermopathy

-Shin Spots (pigmented pretibial papules -Most common cutaneous manifestation of diabetes -Benign asymptomatic red-brown macules on shins -No treatment required

Varicella presentation

-Small red macules: face and trunk -progress rapidly over 12-14 hours -papules, then vesicles, pustules, and finally crusts. -lesions are more abundant on the trunk and proximal upper extremities -sparing of the distal lower extremities. -Lesions are notoriously in various stages of healing throughout the body

Angiolipoma

-Soft, subcutaneous nodules ranging from 0.5 cm to 2 cm -Seen in young adults and adolescents -Located on the forearm and chest, often multiple -Resemble lipomas, but are painful, and histology shows adipose cells and capillary vessels

Atopic Dermatitis

-Stressful life events precede the disease in more than 70% of these cases -Interpersonal and family stress -Problems in psychosocial adjustment -Low self-esteem

What could cause a space to develop..make a blister

-Subcorneal pustule or separation -Loss of adhesion of keratinocytes -Keratinocyte necrosis -Basement membrane area disorders -Superficial dermal changes -Acute dermatitis that can make blisters -Chronic dermatitis...... -Classic immunobullous disorders -Non-inflammatory disorders

Squamous cell carcinoma

-Sun damage -Preceded by actinic keratosis -Sometimes HPV in immunosuppressed -Genetically predisposed xeroderma pigmentosum -Burn scars

Porphyria cutanea tarda

-Sun exposed areas often dorsal hands -Subepidermal blisters By the way... The porphyrias are a mind-numbingly complex group of disorders of porphyrin production, involved in heme production, abnormal proteins accumulate. In many of these diseases diagnosis requires extreme clinical acumen. Testing is often falsely negative.

Vitiligo

-Sun protection with hats, long-sleeved shirts, long pants, and a daily use of a sunscreen should be used on depigmented skin to prevent sunburns as well as to decrease further skin trauma and minimize pigment contrast between affected areas. -Depigmentation or bleaching of uninvolved skin can be an option if repigmentation is not successful. -Cosmetic coverage with concealers can blend skin color differences. Dipigmentation is considered more often when vitiligo affects more than 50 percent of the face or body, it is used to promote "one" skin color. -Patients need a clear understanding that this is a permanent procedure and causes total loss of sun protection. Cosmetic coverage with concealers can blend skin color differences Covermark, Dermablend, Dermacolor, and Veil are used.

Excision versus Mohs' Micrography:

-Surgical excision is an effective treatment for primary skin lesions -yields the most tissue loss -appropriate for low-risk, primary BCC, SCC, and melanoma to examine and confirm tissue removal -any recurrence should be treated with Mohs'.

Atopic dermatitis triggers

-Temperature change and sweating -Decreased humidity -Excessive washing -Contact with irritating substances -Contact allergy -Aeroallergens -Infectious agents- s. aureus is the predominant skin microorganism -Food -Emotional stress- does not cause but exacerbates

Bullous pemphigoid info

-Tense blisters, older patients -Chronic illness with remissions and relapses. -Usually successfully managed. Topical and oral low dose steroids, occasionally methotrexate. IF Basement membrane zone IgG and C3

Aplasia Cutis Congenita

-The congenital absence of skin on a portion of the scalp - vertex most commonly affected -Variable depth - epidermis, dermis, skull, dura -May be associated with underlying skull defect or intracranial malformations e.g. neural tube defects -Etiology unknown in most cases Hair collar sign - thicker, darker growth of hair around lesion of aplasia cutis congenital on scalp -Most cases are benign, with no associated conditions, some associated with limb abnormality, CNS disorders, trisomy 13, 4p- -Hair collar sign - indicative of underlying CNS abnormality -Heals with permanent scarring and loss of hair or minimal hair over affected patch - bald spot - solitary or multiple well-demarcated ulcerations or atrophic scars. -Treatment - plastic surgery, hair transplant for scalp, rx other associated conditions

Tuberous sclerosis

-The course of this disorder varies from individual to individual - Patients can present with symptoms at birth -Develop symptoms later on in life - Individuals can be effected in a spectrum from mild to severe

Dermis: chnages with age

-The dermal layer thins -Less collagen is produced -The elastin fibers wear out -Decrease function of the sebaceous and sweat glands contributing to dry skin -Combination of all of these cause the skin to wrinkle and sag.

Dermis-Epidermis

-The rete-ridges of the dermal epidermal junction flatten out. This makes the skin more fragile and easier to shear or tear. -This also decrease the amount of nutrients available to the epidermis by decreasing the surface area I n contact with the dermis. This leads to slower repairs and cell turnover

Systemic agents (usually oral)

-hair infection, nail infection, and extensive tinea infections. -griseofulvin, terbinafine or Lamasil, itraconazole or Sporonox, ketoconazole or Nizoral, fluconazole or Diflucan -Oral glucocorticoids may reduce the incidence of scarring associated with markedly inflammatory varieties of tinea capitis. and releive pain and infection= prednisone

Enhancement of pattern of hypomelanosis of Ito

-The woods lamp can help to enhance the pattern of hypopigmentation on the skin. -A biopsy as well as genetic testing may also be performed to aid in the diagnoses. -Cosmetic coverage can be used to cover up the lighter areas. Over time skin pigmentation may develop and blend with the normal skin. Other associated abnormalities require appropriate medical treatment.

Genetics and future dx and rx

-There are tests for small segments of DNA that can be detected by FISH assays to help distinguish benign from malignant -Likewise small segments that are touted to imply that a melanoma is more aggressive

Solar Lentigo

-These macules usually appear as multiple tan to dark brown in color and often have irregular borders, the areas can range from a few millimeters to >1 cm in diameter. -The distribution of solar lentigo is limited to sun-exposed areas, with particular sites of greatest accumulation being the face, dorsal hands, extensor forearms, and upper trunk. -The amount of solar lentigo macules increases with age, so they are most often seen in older adults.

Changes with Aging

-Thickened fingernails and toenails, grow slower, yellow discoloration -Generalized loss of body and head hair -Decrease in the number of functioning pigment producing cells = GRAYING -Some remaining pigment cells enlarge = "age spots" -Skin changes increase the vulnerability to infection and breakdown

Prognostic factors

-Thickness and size, >2cm diameter, >2mm thick, level-into fat -Perineural involvement -Location, lip, ear, neck -Keratoacanthoma variants are sometimes self-limited-controversial topic.

Tinea versicolor

-Tinea versicolor is a condition caused by a yeast type of fungus, that is normally found on the skin. -Tinea vericolor most often appear on the neck, upper chest, upper arms, and back. -It can appear as fine, dry, scales, on light reddish brown macules and patches. -Tinea versicolor can be easily be recognized if in doubt a KOH prep test can be done quickly in the office and will confirm the diagnosis.

Petechiae

-Tiny punctate hemorrhages less than 2 mm in diameter. -Will not blanch with pressure -Seen in mucus membrane as well as in skin -If discrete lesions, suspect a problem with platelet number or function.

Cutaneous candidiasis tx

-Topical antifungal preparations -Oral antifungal agents indicated for more resistant cases. affected areas need to be kept dry and protected from further maceration with greasy emollients. benzoyl peroxide bar or daily use of miconazole powder may also be helpful.

Follicular hyperproliferation and abnormal desquamation:

-Topical retinoid -Azelaic acid -Salicylic acid -Hormonal therapies

Acanthosis Nigricans

-Treatment is to improve the appearance of the area this includes: * Obesity *Agents that improve insulin sensitivity *Skin-directed therapy topical tretinoin or combination therapy with tretinoin and other agents can be effective

Systemic agents

-Trimethopim- sulfamethoxazole - clindamycin -cephalexin (keflex)

Examination of the skin for type and location of lesions

-Types of lesions, amount of lesions, location of lesions. -Evidence of hirsutism or virilization

Acne Vulgaris

-Typically affects areas of the body that have the largest hormonally responsive sebaceous glands -Typical lesions open and closed comedones and inflammatory lesions -No universal classification system. Description of the lesions and severity is used to determine treatment -General progression from Comedo acne to Nodular acne (tender inflammatory lesions) -Estimation of severity depends on a number of factors and are patient specific

Management of drug allergy

-Typically supportive. -Withdrawal of the offending medication. Most rashes will clear within 2 weeks. -Simple emollients or topical steroids for symptom relief. -Oral steroids and antihistamines as needed. -Patch testing can be appropriate at times. -Oral challenge testing is not recommended.

Common causes

-UV Exposure 80% head and neck -Also Xray treatment, arsenic ingestion, coal tar exposure -Immunosuppression -Nevoid basal cell carcinoma syndrome, autosomal dominant PTCH1 mutation (sonic Hedgehog pathway)

non genital outbreaks Gingivostomatitis

-Ulcerations: buccal mucosa -May mimic strep throat, coxsackie infection, "canker sores", candidiasis, and HIV infection

Renal Disease:Acquired Perforating Dermatosis of ESRD

-Umbilicated papules or nodules with central hyperkeratotic core -Up to 1 cm in diameter -Significantly more prevalent in DM patients -Extensor surfaces of limbs more commonly affected

Paraneoplastic: Papulosquamous Disorders

-Unilateral eczematous plaque of the nipple and areola -Resembles chronic eczematous dermatitis -Mean age onset: Mid 50's -Red scaling plaque, sharply marginated, oval with irregular borders -Strongly associated with an underlying invasive cancer of the breast

Bacterial Diaper Dermatitis

-Usually a secondary infection with irritant dermatitis -Commonly caused by staphylococcal or streptococcal bacteria -papules that progress to vesicles surrounded by erythema -Evolve to become pustules that enlarge and rapidly break down to form thick, adherent crusts with a characteristic golden appearance - classic appearance of impetigo -Evolution typically occurs over about one week -Specific treatment - appropriate antibiotics (topical or systemic)

Renal Disease Calciphylaxis

-Vascular calcification thrombosis and skin necrosis. Painful purpuric plaques and ulcerations -"Necrosis resembling a burn injury" -Deposits of calcium in tissue secondary to abnormal calcium and phosphate metabolism -Painful purpuric plaques and retiform purpura -More proximal the lesion the poorer the prognosis

Diaper Dermatitis

-Very common cutaneous disorder of infancy and early childhood -Peak incidence in late infancy - 9-12 months -Acute inflammatory skin reaction in areas covered by diaper -Usually d/t interaction triggered by prolonged contact with feces and urine, skin maceration, secondary bacterial or fungal colonization

Herpetic whitlow

-Virus infection of the hands or fingers Seen often in dentists, medical personnel, and self-inoculated from pts with genital herpes (caused by herpes simplex)

Acanthosis Nigricans

-Weight loss has been linked to improvements. Metformin and rosiglitazone (Avandia)may have some benefit for acanthosis nigricans related to insulin resistance. topical tretinoin 0.1% gel applied to localized areas of acanthosis nigricans for up to two weeks. Combination therapy with tretinoin and other agents can be effective. Once-daily application of tretinoin 0.05% cream and twice-daily application of 12% ammonium lactate cream or lotion for a few months. A triple combination cream containing tretinoin 0.05%, hydroquinone 4%, and fluocinolone acetonide 0.01% applied daily for one month.

Renal Disease: Nephrogenic Fibrosing Dermopathy

-Woody indurated plaques with peau d 'orange appearance -Usually symmetrical -Usually spares the face, neck, palms, soles -Can be progressive leading to joint contractures -In end stage renal disease, patients on dialysis, acute renal failure or after renal transplant

Intertigio treatmetn

-Zinc oxide ointment (butt balm) - keep area dry - usually reoccurs unless weight is lost

Tularemia

-Zoonotic infection caused by Francisella tularensis -Aerobic fastidious Gram negative bacterium -mammal vectors include lagomorphs and rodents: Rabbits/ beavers/ muskrats/ squirrels/ volves - can be aquired if youre a lab worker/ farmer/ veteranarian/ hunter/ landscapers/ meat handlers-- increased risks of tularemia - transmission occurs though contact with infected animal or biting insects (mosquito/ horse fly/ fleas) -tick exposure (bites) during summer months is common mode of transmission - Francisella is hardly in nature: however it can persist i animals carcasses/ mud/ water for several weeks - Clinical presentation: fever/ anorexia. malaise. headache. abdominal pain. emesis. diarrhea. - fever abates after a few days and then returns -rash can occur in multiple presentations: maculo-papular, vesiculo-papular, erythema multiforme/ erythema nodosum and urticarial DX: clinical presentation and high index of suspicion - Serology Tx: Streptomycin DOC Gentamycin sec mild cases: doxycyclin and ciprofloxin

Actinic Keratosis

-a premalignant lesion 10%-20% develop into Squamous Cell Carcinoma (SCC). -arises in the epidermis but may invade the dermis and therefore necessitates removal. -Rough, reddened ill-defined plaque on sun exposed areas (face, dorsum of hands). They may become tender or irritated -A subtype actinic cheilitis may develop on the lips

Acne Fulminans

-acute onset systemic condition -wide spread eruption of nodules + friable hemorrhagic plaques, together with fever and arthralgia. -Considered a systemic disorder -adolescent males primarily -Lesions usually involve the trunk -leukocytosis, elevated sed. rate and proteinuria

highest rates of new lesions are found

-among orthopedic populations and quadriplegics

Leishmaniasis

-ancient disease Mediterranean basin, Southern Europe, Central Africa, and parts of Southern and Central Asia [ Central and South America classified leishmaniasis as a category 1 disease (emerging and uncontrolled).

Cutaneous Infections: Fungal infections Treatment

-antifungal agents imidazoles -allylamines - keratolytic agents- salicylic acids/ lactic acids= moccasin-type tinea pedis -2x daily application is required 2-4 weeks

Stasis dermatitis: Tx

-application of a mild topical corticosteroid preparation controlling edema -leg elevation and compression stockings Treatment of ulcers involves compression/ leg elevation/ debridement= skin grafting - aspirin or pentoxifylline = helpful adjunctive treatment = improve peripheral blood flow = ulcer healing more rapidly

Stasis dermatitis: (Gravitational Eczema)

-approximately 7% of older adults, especially the obese -venous insufficiency -ill defined, dark erythema patches -variable scaling associated with the lesion and ulcerations -found in the medial paramalleolar area of the lower leg Secondary ulceration, cellulitis, and later post inflammatory hyperpigmentation can follow. -Venous or stasis ulcers are typically shallow and irregularly shaped

Lyme Borreliosis

-arthropod-borne illness in both the United States and Europe -Deer and birds are thought to be the primary drivers in dispersal of infected ticks into new areas

Salicylic or lactic acid

-as keratolytics to break up the thick scale on the surface of the wart

All pressure ulcers are colonized with

-bacteria - this does not equate with infection -those truly "infected" will likely be accompanied by clinical sighns of infection, redness, heat, swelling, pain, wound exudate, odor, leukocytosis.

Cantharidin

-blister beetle extract - plantar warts - mexico / canada popular - blistering

Angular cheilitis

-candidal cheilosis -erythematous fissures on the corners of the mouth. -Commonly encountered in habitual lip lickers -elderly patients with sagging skin -oral commissures. -mistaken for vitamin deficiencies/contact dermatitis. -type of inflammation of the lips and is the second most common type of lip infection -Riboflavin deficiency also predispose one to cheilosis

Kawasaki Dissaee occurs in

-children less than 5 years old

Gram Negative InfectionsCat Scratch Fever: Bartonella henselae

-claws infected with flea feces) bite or flea bite -Benign self-limiting zoonotic infection -primary skin lesion which is small (1.5 cm) and innocuous at the site of inoculation. -Erythematous base and either vesicular or popular. Less common is pustular. 3-10 days after inoculation and will last 1-3 weeks Regional lymphadenopathy (proximal to the inoculation site) about 2 weeks after DX: clinical finding/ serologic tests TX: self limiting - systemic involvment --> spleen/ liver/ eye/ CNS DOC is azithromycin dose pak

Folliculitis Pseudofolliculitis barbae DX

-clinical apperance

treatment

-comedones respond best to topical retinoid agents and acid products -inflamamotry lesions (papules + pustules) require either topical antibiotic agents for minor or oral atibiotics when major - severe acne unresponsive to systemic abx may require systemic isotretinoin therapy -painful nodules may respond best to intra-lesional corticosteroid injection -antibiotics for acne not only reduce microbe population- reduce inflammatory cell chemotaxis, modify the complement pathways, and inhibit the leukocyte and lipse production in propionibacterium acnes

Becker's Nevi

-common solitary lesion. -males, usually during the teenage years. The most common part of the body that these appear are on the shoulders, chest and upper back. When Becker's Nevi first appear, it starts as a brown flat patch that grows or expands to the size of a person's hand. -It may be irregular in shape. The color is dark brown to black in appearance, and can have course hair growth with thin the lesion. The condition is benign, no treatment is necessary. However, for cosmetic reasons, laser removal can be successful.

Vulvovaginitis vulvovaginal candidiasis

-commonly in women who are diabetic/pregnant, those completing a course of antibiotics, wearing of tight-fitting and synthetic clothing -immunosuppressed. -second most common cause of vaginitis -White plaques adhere to inflamed mucous membranes -creamy white to cheesy discharge with a mild odor. -spread by sexual intercourse - pruritus, burning, and pain-!!!!!!!!!!!!!!!!!!! - distinguish from bacterial vaginosis, trichomonas infections, and other STDs.

Leishmaniasis

-confirmation is mandtory -skin biopsy may be divided into three parts: -one for an impression smear, -one for histological examination, and another -one for culture presence of numerous extracellular and intracellular amastigotes aka Leishman-Donovan bodies tx; each case needs to be individualized based on the parasite species, extent of the disease, host immune and nutritional status, presence of intercurrent diseases, geographic region, and cost, availability and toxicity of the various therapeutic options

Hand/ foot and mouth Disease

-coxsackie virus -kids less than 10 years of age - Prodrome is 12-24o of fever, malaise, lymphadenopathy

Severe burns cause defects in both cellular and humoral immunity

-decreased number and activity of circulating helper T-cells -increased numbers of suppressor T-cells and diminution in levels of immunoglobulins

Pressure ulcers:

-decubitus ulcers or bedsores -more commonly seen in elderly patients, -especially those with long-term immobilization, -sensory impairment, - comorbidity, -diabetes, -malnutrition, -circulatory disorders Bony prominences (ischial tuberosities, sacrum and heels), particularly on the lower portion of the body are the sites of predilection Management: include treating associated medical conditions; relief of pressure or friction wound care including debridement, dressings, and control of bacterial infection

4th degree (deep burn necrosis)

-deeper burns extending into vital structures such as muscle and bone - most often caused by high voltage and prolonged contact with heat

Pruritus

-dermatological complaint of the elderly population -advanced age, affecting nearly one half of older adults (older than 60 years) at some time, usually without a rash -Patients with chronic renal or hepatic insufficiency, anemia, thyroid disease, diabetes mellitus, drug allergy, or underlying malignancy might have itch with or without a rash. -treat underlying disesae state

Atopic dermatitis

-disease of childhood that gives rise to poorly demarcated chronic pruritic papular inflammation of the skin -affect adults as well -atopic eczema -improve w age -50% of chldren retain evidence - skin barrier function // allergen sensitization // recurrent skin infections

third degree burn ( full- thickness)

-dry/ insensate bed which is depressed below the surrounding tissue -if blisters are present -fluid is hemorrhagic with the wound bed a deep red color -most flame/ grease/ deep immersion scald burns are full thickness

Common Findings in atopic dermatitis

-dryness -dennie- Morgan folds- below the margins of the lower eyelid -allergic shiners= darkening beneath the eyes -Atypical vascular responses such as facial pallor and white dermatographism (white line appears on skin within 1 minute of being stroked with blunt instrument) -Pityriasis alba -Keratosis pilaris- a common, autosomal dominant, genetic follicular condition characterized by the appearance of rough, slightly red, bumps on the skin -Ichthyosis vulgaris -Hyperlinearity of palms and soles -Conjunctivitis -Keratoconus- a congenital disorder involving the cornea. -Anterior subcapsular cataracts -Elevated serum immunoglobulin E -Immediate skin test reactivity

Seborrheic Dermatitis:

-eczema -sebum rich areas of the scalp, face and central chest -higher in patients with neurologic disease (e.g. Parkinson's and Alzheimer's disease -Faint erythematous patches with greasy scales may be distributed mainly on areas rich in sebaceous glands, including scalp, eyebrows, glabella, paranasal fold, postauricular area, and intertriginous areas -Malassezia yeast, a commensal flora on human skin, is implicated in its pathogenesis. -Treatment includes shampoo for the scalp, such as those containing zinc pyrithione, selenium sulfide, or ketoconazole, and a mild topical corticosteroid.

Melanoma follow up

-effective treatments, lesions commonly recur, especially BCC, SCC, and melanoma Having prior skin lesions is an independent risk factor for developing malignant lesions, making continued screening imperative, usually at 3 and 6 months after treatment, then every 6-12 months

Erythema facial rash

-facial rash fades, reticulated rash appears and lasts 5-9 days -recur for weeks to months, triggered by sunlight, exercise, temperature change or bathing -no vaccination

Pilar cysts

-firm, slow-growing subcutaneous nodules that originate from the root sheath of a hair follicle -Most commonly located on the scalp -Can be hereditary- autosomal dominant

Stage IV

-full thickness skin loss associated with extensive destruction/ tissue necrosis/ damage to muscle/ bone/ supporting structures such as tendons or joint capsules -undermining or sinus tracts may also be present

Transient Neonatal Pustular Melanosis

-full-term infants -Usually present from birth -Higher incidence in African Americans and babies with dark pigmentation -<1% in whites ~5% in Blacks -Superficial vesicopustular lesions that rupture easily and evolve into hyperpigmented macules with a collarette of scale

Albinism

-genetic defect with the production of melanin specifically with the enzyme tyrosine, which causes the body to be unable to make or transport melanin -Albinism is most commonly an inherited disorder which is passed down from previous generations with each parent having an albinism gene to give to their child

always refer to a wound as it is initially diagnosed

-healing stage II ulcer as example

Exanthema prodrone

-high fever: 38.9o to 40.6o which remains high (afternoon with morning remission) until the fourth day when it falls to normal -As fever falls, rash appears. -Babies "appear" well despite high fever, but febrile seizures are possible

pressure ulcer statistics

-hospitalized elders - prevalence of pressure ulcers is 15% -confined to bed or a chair for at least one week - prevalence of stage II or greater pressure ulcer is close to 28% -pressure ulcers generally occur within the first two week of hospitalization (within first 5 days if in ICU)

more risk factrs

-illness/ debility/ altered sensation to pain ~ spinal cord injuries ~dementia ~fracture ~malignancies ~narcotics

Dermal Layer Infections : Ecthyma

-impetigo like except the bacteria has invaded into the dermal layer therefore they scar. -Predilection for children and the elderly -Lesions are more common on distal extremities with regional lymphadenopathy present -Ulcers that form under a crusted surface infection -Can also be caused by direct contact with infected sheep and goat (viral)

Varicella initial infection

-in conjunctiva -mucosa of the upper respiratory tract accompanied by low-grade fever and malaise

Dysplastic nevus

-increased risk for melanoma development - 1DN= 2x risk >10 DN= 12x risk >100non DN= 3.4 x risk risk fir melanoma develpoment i na single DN is about 1:10000 per year

applied pressure of 70mm Hg for 2 hrs

-leads to tissue destruction pressure ulcers can also form when higher pressures are applied for a shorter time and more slowly at lower pressures for longer periods

Biopsy

-lesions larger than 6 mm, those with indistinct margins, or recurrence. = referral -referral for a biopsy is the best action to determine the type of lesion and its extent. -melanoma suspected, a biopsy should always be done

Urticaria and AngioedemaEvaluation

-make sure lesions are hives and not bites -physical urticaria e.g. dermatographism -acute or chronic -TAKE A GOOD HISTORY= esp meds - labs are of little value -CBC with differential, liver function tests, urinalysis, erythrocyte sedimentation rate (ESR) are often done to exclude systemic conditions. -Other tests for chronic or specific reactions when necessary -skin testing, RAST, food testing, food diaries, food elimination diets -Skin biopsy if indicated

Seabather's eruption

-marine dermatitis -acute dermatitis that begins shortly after bathing in seawater -larval forms of marine coelenterates= culprit coast of Florida and in the Caribbean for larvae of the thimble jellyfish; or off Long Island, NY -Papulovesicular rash occurring only in regions covered by swimwear. The eruption is caused by minute stings . -not noted until the bather has left the water (symptoms) -lesions begin within 4-24 hours after exposure as erythematous macules, papules, or wheals that may itch or burn. -Lesions present for 1-2 weeks; treatment is topical steroid cream to reduce inflammation -colloidal baths with starch or oatmeal, and antihistamines. Without proper history taken, the diagnosis of a viral syndrome may be made.

Mohs' micrographic surgery:

-maximum removal of the lesion with minimum removal of normal tissue -lowest rate of recurrence, and yields the best cosmetic result -standard treatment for any high-risk lesions on the face, head, neck, and genitalia, for aggressive lesions, and for tumors that develop from radiation sites entire margin of the tumor is examined in horizontal sections, whereas surgical excision examines random vertical sections

Ophthalmic zoster

-may lead to ocular complications in up to 70% of patients. -Refer to an ophthalmologist

Candidiasis

-microscopic examination skin scrapings or smears obtained from skin, nails, or mucosal surfaces that reveal hyphae, pseudohyphae, or budding yeast cells - KOH/ methyl blue/ gram stain= demonstration of fungal cells -Blood cultures if systemic candidiasis is suspected; can also culture nail or skin samples if needed. Blood cultures are positive in only 50%-60% of cases of disseminated infection. -serum (1,3)β-D-glucan detection assay -nonculture assay that measures level of β-glucan, a component of the fungal cell wall -high sensitivity (75%-100%), specificity (88%-100%) and positive predictive value with highly reproducible results

Cutaneous candidiasis

-moist occluded skin sites and on nail apparatus -Candida albicans -Predisposing factors: diabetes mellitus, obesity, systemic/topical glucocorticoids, broad-spectrum antibiotics, immunosuppressive drugs, and chronic debilitation -found in body folds: infra-mammary areas, groins, axillae, and intergluteal folds -Characterized by well-marginated erythematous eroded patches with satellite pustules at the periphery.

Chronic angioedema

-most common in middle aged women - symptoms greater than 6 weeks

Vitiligo

-most frequent depigmenting disorder affecting approximately 1% of the world's population. -The prevalence of vitiligo is consistent among genders and ethnic backgrounds. -It can develop at any age but typically develops between 10-30 years of age.

Muir Torre syndrome-auto dom

-multiple sebaceous tumors with internal neoplasms, esp colon cancers -subset of hereditary non-polyposis colon syndrome(Lynch syndrome -Tumors with microsatellite instability-mutations in DNA mismatch repair genes -screened for by immunostains then confirmed with PCR testing -colon cancers, endometrial cancers and some sebaceous skin lesions.

Candidal paronychia

-nails and the paronychial folds -diabetes mellitus or who habitually immerse their hands in water -as swollen, reddened nail beds with associated purulent discharge -Pain and erythema may extend along the entire nail plate and nail bed. -very often misdiagnosed as staphylococcal paronychia. thumb sucking

radial growth is absent in

-nodualr melanoma

Acne Conglobata

-nodular acne more common in males. -prominent on the back, chest and buttocks. -draining lesions, sinus tracts and severe scarring may occur. -No systemic symptoms

Albinism occurance

-oculocutaneous albinism and -ocular albinism

Most candida infections are mucocutaneous -oral candidiasis (thrush)

-oral candidiasis (thrush) -White patches affecting the tongue, buccal mucosa, palate, gingivae and oropharynx. -Mucosa bleeds easily when patches are scraped gently with a tongue blade. -friable pseudomembrane resembles cottage cheese or milk curds and consists of desquamated epithelial cells, fungal elements, inflammatory cells, fibrin and food debris -severe cases, the mucosal surface may ulcerate

Second degree

-partial thickness -contained within the dermis - heal from the wound base upwards in 1-4 weeks if adequate vascualr supply and hydration are present and if not secondary infected - blister with clear fluid - base of blister is pink - slightly raised from surrounding tissue

Erythema Inectiosum

-parvovirus B19 -edematous, erythematous plaques on the cheeks (slapped cheeks) and an erythematous lacy eruption on the trunk and extremities -Prodrome of fever, malaise, headache, coryza 2 days before rash

Syndrome autosomal dominant syndrome not precisely defined

-phenotype with increased DN and other nevi with one blood relative with melanoma(D1) -DN phenotype with at least 2 blood relatives with melanoma.

Solar lentigines:

-pigmented (tan or brown) macules on sun-exposed areas and are more common in fair-skinned people -Represent epidermal hyperplasia -indicators of sensitivity or excessive exposure to UV rays, and patients should be advised to take measures to reduce sun exposure -Atypical ones should be examined for the presence of lentigo maligna. Treatment: Cosmetic only

Prevention and Screening of melanoma

-prevention -Sun avoidance and protection are imperative. -Protective clothing like wide-brim hats and long-sleeves are important -UV-protection factor of at least 15 should be liberally and frequently applied. -total body examination screening (especially high risk individuals -self-skin exams and recognition of lesions through the ABCDE method -older adults have a higher occurrence of skin cancer than younger adults and are less functionally able to identify skin changes -skin exam should be a routine part of the primary care provider's practice. -practitioner should particularly examine the scalp, ears, nasolabial folds, and wrinkles of older adults.

Caring for Albinism

-primary care physician- to focus on preventive care education -A dermatologist- strongly advised for these individuals to have yearly skin exams -An ophthalmologist-annual eye examinations preventive care education such as the importance's of daily sunscreen usage with a SPF>30 containing both UVA and UVB protective components, the importance's of wearing protective clothing such as hats, UV blocking sunglasses and long sleeves, as well as sun avoidance. It is strongly advised for these individuals to have yearly skin exams (since sunburns and skin cancers are much more common and problematic), as well as annual eye examinations.

Treatment of vitiligo

-primary focuses of management should be on addressing any psychological issues associated with this disorder. -The goal of medical management is to help restore the skins color -This can be done trough restoring healthy melanocytes to the damaged skin(repigmentation). Repigmentation occurs slowly as the cells move back into these previously damaged areas, it can take months to years for this to reoccur. Adults and patients over the age of 12 should be treated with mid-potency (class III or IV) topical corticosteroids such as fluticasone ointment (Cutivate) or mometasone cream(Elocon) once a day for four to six month. -Children under the age of 12 should use lower potency (class V) preparations such as fluticasone cream (Cutivate) or desonide 0.05% cream (Desonate) once a day for four months. -Immunomodulators include (tacrolimus(Protopic), pimecroimus(Elidel) In 2005, the Unites States Food and Drug Administration (FDA) issued an alert about a possible link between topical tacrolimus and pimecrolimus and cases of lymphoma and skin cancer in children and adults, and in 2006 placed a "black box" warning on the prescribing information for these medications. -Vitamin D inhibit T cell activation and promote melanocyte maturation and differentiation. Topical calcipotriol (calcipotriene) and topical tacalcitol have been utilized in treatment regimens for vitiligo. The benefit of these treatments is controversial.

Varicella Zoster (shingles)

-primary varicella, the virus enters the sensory nerve endings and travels to the dorsal ganglion cells - latent -reactivated by some decline in cell-mediated immunity

Risk factors for pressure ulcers

-prolonged time in one position/ in bed/ wheelchair - head of teh bed more then 30 degrees= sheering -friction= pulling a patient up in bed / patietn with tremors or frequent spasms/ person with a cast or brace on are all more prone to injury

Leishmaniasis

-protozoa Leishmania and transmitted by the bite of infected phlebotomine sandflies Four major human diseases: localized cutaneous, mucocutaneous, diffuse cutaneous, and visceral. -interaction between Leishmania species and the immunologic status of the host -Diagnosis by organism isolation or by serology but species identification only possible with isoenzyme analysis and new molecular techniques. -Primary lesions occur = papule -site of a sandfly bite -over several weeks and become a dusky red-purple color. -lesion ulcerates, stops peripheral extension after 2 months, and eventually the nodule heals with a depressed scar after 3-6 months

Piebaldism

-rare autosomal dominant inherited disorder -Affected patients have patches of depigmented skin with hyperpigmented borders occurring principally on the midforehead, neck, anterior trunk, and mid-extremities. -Depigmented skin in piebaldism is generally considered unresponsive to medical or light treatment. -Dermabrasion and skin grafts are the preferred surgical procedures.

Acute lymphangitis presentation

-red linear streak -enlarged and tender which go from the portal of entry to a regional lymph chain -

Sun damage

-related to melanoma - SSC and BSC -neuroendocrine carcinoma of the skin=Merkel cell carcinoma -DNA repair mechanism is gradually impaired

Electrodessication

-requires local anesthesia - lesions are cleansed - injected with local and burned - scarring may be a problem

carbon -dioxide laser

-requires local anesthetic - surgeons using CO2 lasers on genital warts have had a predilection for contracting upper airway mucosal warts -probably from aerosolized viral particles

Angioedema

-same pathogenic mechanisms as urticaria -Pathology is in the deep dermis and subcutaneous tissue!! -Swelling is the major manifestation -overlying skin may be erythematous or normal -less pruritus but there may be pain or burning -acute or chronic: Chronic is an autoimmune disorder in 45% of patients.

If melanoma is thicker than 1 mm

-sentinel node biopsy is recommended to determine metastases. -older adults sentinel node biopsies are less frequently positive than in younger adults -may be a result of age-related lymphatic dysfunction or metastases at the hematologic level

Kawasaki clinical signs

-signs-lymphadenopathy, -fever, -strawberry tongue, morbilliform (scarletiniform) rash, on trunk and extremities, and induration of the hands and feet (which later desquamate). There may also be -diarrhea, -arthritis, -aseptic meningitis -cardiac complications

Pyodermas: Non-bullous impetigo

-small vesicle that ruptures and to expose a red moist base -Most frequently appear around the nose and mouth and limbs -honey colored crust forms which is adhered to the lesion -Multiple "satellite" lesions appear. -Usually asymptomatic

Rheumatological Disorders Pyoderma Gangrenosum

-sterile pustules, become hemorrhagic blisters, enlarge and ulcerate with dusky undermined edges -Ulcers are rapidly expanding and painful -Frequently on the legs (most common) or around stoma sites -50% of the patients will have underlying RA or inflammatory Bowel disease. More common in UC -Associated with underlying malignancies (leukemia)

Lepromatous leprosy

-summetry with plaquing

Squamous Cell Carcinoma:

-sun-exposed sites or arise from sites of trauma, radiation, or ulceration. -head and neck, but the hands, forearms, upper trunk, and lower legs are common sites -Metastasis is more common with SCC than BCC, depending on the lesion size, depth, and site. -Head and neck lesions are more likely to metastasize because of their proximity to core organs and vessels.

Gangrenous cellulitis tx

-surgical debridement and treatment with abx/ cultures

Henoch-Schonlein Purpura

-systemic vasculitis in children -Typical age of onset - 2-7 years -Males more affected than females -Seasonal incidence pattern - more cases reported in winter/spring -Commonly, history of preceding viral or bacterial infection in half to to-third of cases

Dermatofibrosarcoma Protuberans

-trunk/ prox ext young and middle age adults - 40% non protuberant at diagnosis - 1/3 recur locally, seldom metastasize - progression to higher grade sarcoma 10% = recurrent cases -5cm margins are usually recommended

Monitor healing

-two scales available for documenting healing of a pressure ulcer BWAT- bates- jensen wound assessment tool PUSH- pressure ulcer scale for healing

Cafe au lait spots

-uniformly hyper-pigmented brownish macules. They may be present at birth or appear during the first year. They can grow and increase in number during early childhood but then stabilizes over time. Up to 15 - 20 percent of the normal population have one to three café-au-lait macules. They are often harmless, however, the presence of six or more is presumptively suggestive of (NF1) Neurofibromatosis Type 1.

Surgical

-vein ligation of perforating veins

Dermatophytes enzymes

-virulence factors to allow adherence and invasion of skin, hair, and nails, and also to utilize keratin as a source of nutrients for survival. step 1: adherence to keratin step 2: followed by invasion and growth of mycelial elements inflammatory response of varying degree is developed by the host as a result

Rocky Mountain Spotted Fever Tx

-vital to begin empiric therapy while awaiting serologies -Doxycycline is the drug of choice for ALL ages even during pregnancy. -Chloramphenicol may be substituted if necessary

TX of furunculosis

-warm compresses - I and D - Abx not necessary can stop progression by taking oral antibiotics Prophylactic treatment of the nares with mupirocin (Bactroban) ointment BID X 5 days

Pyodermas: Non-bullous impetigo treatment

-wash with soap and water - 2% mupirocin oitment - 5 to 10 day course of oral antibiotics (cephalosporin or dicloxacillin) - lesions will heal without scaring

Dermatitis (Eczema)

-xerosis consists of avoidance of aggravating factors and hydration of skin. -bathe less frequently using a moderate-temperature bath, mild soaps, or soap substitutes. Application of bath oil helps form a thin film of oil on the body surface -Moisturizers need to be applied immediately after a bath -Optimal moisturizing products should have both occlusive and humectant properties Petrolatum, lanolin-based emollients, or moisturizers containing lactic acid or its salt are frequently suggested -topical corticosteroids may be needed if inflammation or itch is severe

Eruptive xanthomas

-yellow 1-4 mm papules with a red halo around the base -Appear suddenly in crops on buttocks and extensor surfaces -Pruritus is common. Associated with hypertriglyceridemia.

Milia

-~40-50% of newborns -retention cysts which arise from retention of keratin and sebaceous materials in pilosebaceous follicles -1-3 mm pearly white/yellow papules, commonly on the face and nose -Occasionally on upper trunk and limbs -Self-limiting, resolves within first 3-4 weeks of life

Isotretinoin Therapy

-¼ of patients will need to repeat a course of Accutane in the future; ½ will need other forms of ongoing therapy (topical or oral); ¼ will need no further therapy -Side effects - cheilitis, xerosis, conjunctivitis, pruritis, bone and joint pain, headaches, epistaxis, and nausea -Rare cases of pseudo tumor cerebri -Requires monitoring of liver enzymes, triglycerides

Psoriasis: 5 demensions

1) anticipation of rejection 2) feelings of being flawed 3) sensitivity to attitudes of society 4) guilt and shame 5) secretiveness

Cutaneous Infections: Bacterial Infections

1. The bacterial infections of skin in the elderly population may appear atypical in their symptoms and signs. 2. The most common ones are cellulitis and infected ulcers in this age group 3. It often affects the lower legs 4. The main differential diagnoses are deep vein thrombosis, allergic contact dermatitis, and stasis dermatitis

D2

100% incidence of melanoma

Adolescent Acne

12% females and 3% males persist into adulthood -A chronic disorder of pilosebaceous follicles Typically presents at puberty - 8-12 y, peaks at 15-18y, resolves ~ 25y ~ 90% of adolescents are affected -Equal race and sex distribution -Family history often positive -Typically affects face, neck, upper trunk, upper arms, shoulder - areas with abundant sebaceous glands

FOOD AND MEDICATIONALLERGY

2 types: urticaria/anaphylaxis food-exacerbated atopic dermatitis (AD) flare occurs within minutes to a few hours if the reaction is immunoglobulin E (IgE) mediated, but may take hours to days if the reaction is non IgE mediated. persistent lesions if the food is eaten chronically, and repeated exposure to the food may exacerbate skin symptoms

Pyodemas: Impetigo

2 types: Bullou non bullous Superficial infection of the epidermis characterized by crusted erosions or ulcers -Primary infection more common in children - secondary impetigo can occur in any age Bacteria enters at minor breaks in the skin and spreads (atopic dermatitis)

Incidence of psychiatric disorders among dermatology patients is estimated at

30-60% Physicians estimate 15-40% of patients feel their skin disease has a negative impact on well-being

Adolescent Acne pathogenesis

4 factors: -Presence of androgenic hormones -Sebaceous gland activity (stimulated by increased androgenic hormone) -Hair follicle blockage d/t abnormal keratinization of upper part of follicle -Propionibacetrium acnes proliferation in hair follicle (lives on the oil in hair follicle, breaks it down to free fatty acids which produces inflammation)

D1

50% chance of melanoma by ge 60

Cat bites:

500,000/year -Infection rate 50% teeth are slender, sharp closer together and have high colony counts. Teeth penetrate into bones, joint capsules and soft tissue easily -Pasturella multocida isolated in over 50% of the bites

Molluscum Contagiosum treatment

6-9 months without treatment although some may persist for years Adults can be treated with liquid nitrogen; children at times have hundreds of lesions and conservative therapy is best.

Bulla

>0.5 cm contain clear fluid

11 mm; 9mites/mm2; ulceration;pos sentinel node

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Superficial fungal infections

Noninflammatory - most commonly tinea versicolor Inflammatory Trichophyton , Microsporum , Epidermophyton Candida spp!!! Trichophyton is the most common species isolated in the US

Urticaria

A wheal-and-flare reaction in which localized intracutaneous edema(wheal) is surrounded by an area of redness -Typically pruritic -30 minutes or as long as 36 hours -millimeter or 6-8 inches in diameter -blanch with pressure as the dilated blood vessels are compressed -present in the superficial dermis and involve the vascular plexus in that location.!!!! -atopic patients most commonly

gangrenous cellulitis PE

Fulminant tissue destruction. Involved area is red, swollen and tender. -Underlying process more extensive than what is showing. -After a few days the area becomes purple, bullae develop and is followed by gangrene

Mycobacterium tuberculosis

Leprosy, Hansen's Disease -granulomatous disease caused by Mycobacterium leprae Clinicopathologic classification of leprosy (based on clinical, immunologic and bacteriologic findings) Tuberculoid (TL): Lepromatous (LL): Borderline (BL): Indeterminate

Contusion

Major trauma-induced hemorrhage usually associated with significant soft tissue swelling and tenderness

Alopecia Areata

Nonscarring type of hair loss on any hair bearing part of the body -Acute emotional stress may trigger -Comorbid with major depression, GAD, phobias and paranoid disorder -Strong family history and concurrent atopic and associated autoimmune diseases are common in these patients

Superficial Thrombophlebitis

Acute inflammation of a superficial vein from various etiologies

Psoriasis treatment

Adjunct treatments: -Biofeedback, meditation, hypnosis-induced relaxation, behavioral techniques, symptom-control imagery training, antidepressants

Foam dressings

Allevyn, Lyofoam, PolyMem, Optifoam, Coloplast, Curafoam -Semi-permeable cushioning dressings that absorb excess exudate -Suitable for non-infected Stage II, III pressure ulcers -Non-adherent, thus requiring a secondary dressing to hold them in place -May be left in place for 3 days

Onychomycosis tx

Antifungal drugs: terbinafine less potential for drug interaction and, therefore, is relatively safer for elderly patients compared with other azoles. However, it has low efficacy against other fungi

Varicella treatment

Antiviral therapy can be used to shorten the course of disease Varicella vaccine has been available since March of 1985 for healthy people over 12 mo of age.

mongolian spots

Are not associated with any type of skin cancer. The diagnosis is usually made clinically based on the presentation. Skin biopsy is rarely needed. These spots can fade as the child ages. Treatment is mostly conservative, since they appear in areas covered by clothing or they can be easily covered with cosmetics. Laser removal is an option.

Genital Herpes mode of transmission

Asymptomatic transmission: most common means of spreading since 50-90% of the transfers occur from a partner who is unaware of the presence of the infection

Grafting

Autograft- from injured person him/herself split thickness skin graft - epidermis with some dermis (thin/ intermediate/ thick) - remnant cells left behind repopulate "skin" so no wound closure needed Full thickness skin graft * Entire epidermis and dermis * donor site must be closed since no cells are left behind to repopulate

Kwashiorkor

Nutritional Deficiency -Decreased protein intake -Marked muscle atrophy with normal body fat and the presence of peripheral edema -Anasarca (generalized edema) -Moon face (round prominence of the cheeks) -Dry atrophic peeling skin (flaky paint)with confluent areas of hyperkeratosis and hyperpigmentation -Dry dull hypopigmented hair that that falls out easily -Presence of petechial and purpura

Folliculitis Pseudofolliculitis barbae TX

Avoidance. Stop shaving. Oral antibiotic when necessary (tetracycline or cephalosporin), corticosteroids

Pellagra

Nutritional DeficiencyPellagra -Niacin deficiency (Vitamin B3) -Triad of the 3 D's dermatitis, diarrhea and dementia -Rash develops as a sunburn on areas exposed to sunlight. -Later become dark pigmented, blister and sloughs -Photosensitive eruption around the neck known as "Casal's necklace"

Carbuncle Tx

Bacteremia is not uncommon, therefore carbuncles require treatment with an -anti-staph antibiotic and surgical drainage

Gram (-) infections

Bartonella infections - cat scratch fever - bacillary angiomatosis - tularemia

Epidermis:

Becomes thinner. The number of epidermal cells decrease by 10% per decade and they divide more slowly making the skin less able to repair itself quickly The stratum corneum loses its ability to retain water, and cell replacement, barrier function, and wound healing decrease

Atopic Dermatitis Adjunct Treatments

Brief dynamic psychotherapy Biofeedback CBT Relaxation techniques Hypnosis Benzodiazepines and SSRIs

Ecchymosis

Blue-black or purplish macule at least 2 to 2.5 cm in greatest diameter; often due to minor trauma

Acne Excoriee: Psychiatric comorbidity

Body image disorder, depression, anxiety, OCD, delusional disorders, personality disorders and social phobias

Borderline (BL)

Borderline (BL): intermediate between TL and LL. Well demarcated infiltrated erythematous plaque

Pyodermas: Acne vulgaris

Chronic inflammatory disease of the pilosebaceous follicles 2 types: Non-inflammatory: Inflammatory: Common locations include the face, neck, upper trunk (anterior and posterior) and upper arms

Zinc Deficiency

Nutritional Disorders -Acquired deficient intake, high fiber intake, malabsorption -Inherited (acrodermatitis enteropathica) zinc deficiency: defect in the intestinal absorption of zinc -Dermatitis, diarrhea, alopecia -Periorificial and acral distribution of pustules, bullae, and scaling

Scurvy

Nutritional Disorders -Vitamin C deficiency -Follicular hyperkeratosis with corkscrew hairs -Perifollicular hemorrhage -Gingival hypertrophy with erosive bleeding gums

Secondary psychiatric disorders

Can be "life-ruining" because of their visibility -Affect patients with significant psychological problems that have profoundly negative impact on their self-esteem and body image. -Depression, humiliation, frustration and social phobia may develop as a consequence of disfiguring skin disorder

Skin can prompt

Can prompt intense distress lead to shame, embarrassment

Peutz-Jegher Syndrome

Genodermatoses Associated with MalignancyPeutz-Jegher Syndrome -Hereditary Intestinal Polyposis -Autosomal dominant. Mutation of tumor suppressor gene STK11 -First presents in children (under 10 years old) -Dark periorificial and acral freckling (hyperpigmented spots) most markedly on the lips, oral mucosa, nose, hand, feet and ano-genital region -Patients develop hamartomatous polyps of GI tract which may give rise to cancer. -Associated with increased risk of early adenocarcinomas of the breast, cervix, uterus, ovaries, testicles pancreas, stomach, small intestine

Molluscum Contagiosum

Caused by a double-stranded DNA pox virus Common in childhood and young adults

Acute ischemia

Causes -Embolism - five p's: pain, pallor, paresthesia, pulselessness and paralysis -Thrombosis -Acute dissection -Trauma -Compression -Intra-arterial injections -Cold injury -Severe vasospasm presented with a sharp line of demarcation

Azithromycin

Caution as to the rising incidence of resistance.

CONTACT DERMATITIS

Cell-mediated (type IV), delayed type, hypersensitivity - due to environmental allergen -prior sensitization to a chemical is required for allergy to develop -Acute phase with pruritus, erythema, edema, and vesicles usually in area of direct exposure. -Chronic may display lichenified erythematous plaques which may spread beyond areas of direct exposure -Itch and swelling are key components -Hands, feet, and face are common sites -Patch testing is fundamental -Avoidance is the mainstay of treatment -Allergic (ACD) accounts for 20% of the cases and irritant (ICD) accounts for 80 % of the cases.

Cephalic pustulosis (formerly neonatal acne)

Cephalic pustulosis (formerly neonatal acne) - not true acne, face mostly affected

Trichtillomania

Childhood trauma and emotional neglect play a role in development, an obsessive-compulsive tendency Tension, relief from pulling hair Co-morbid: anxiety, depression, dementia, mental retardation, mood disorders, substance use, eating disorders Treatments similar to OCD which pathologic examination of the skin can be diagnostic The hair root undergoes a unique change called trichomalacia, which only occurs in patients with trichotillomania. Thus, if the patient continues to deny pulling his or her own hair, a skin biopsy can be helpful in determining the diagnosis

Hidradenitis Suppurativa

Chronic suppurative infection of apocrine sweat glands due to Staph. aureus. -recurrent infection: creation of sinus tracts and extensive scarring.

Venous Stasis/ Insufficiency

Chronic venous engorgement secondary to venous occlusion or incompetency of venous valves Signs: Edema, pigmentation, progresses often to ulceration

Combinations of these antibiotics and either retinoid or benzoyl peroxide are available:

Clindamycin 1.2% with tretinoin 0.025% gel Benzoyl peroxide 2.5% and adapalene 0.1% Benzoyl peroxide 5% and clindamycin 1% gel Benzoyl peroxide 5% and erythromycin 3% gel Benzoyl peroxide 2.5% and clindamycin 1.2% gel

Henoch-Schonlein Purpura

Clinical features - - palpable purpura (d/t vasculitis), polyarthritis, colicky abdominal pain, renal disease -Diagnosis is based on detailed history and characteristic clinical features -Skin biopsy - immune complexes in vessel walls contain IgA deposition - hallmark of diagnosis -Usually self-limited, supportive treatment, systemic steroids for GI and renal involvement

Superficial thrombophlebitis sign

Clot formation with a palpable "cord", pain and erythema along the course of the vein, tenderness, and occasionally low grade fever

treatment continued

Coal tar preparations --> reduce steroid potency in chronic AD. Not recommended for acutely inflamed skin Phototherapy- natural sunlight can be beneficial. UVA and UVB may be used. systemic glucocorticoids Cyclosporine- potent immunosuppressive drug that acts primarily on T cells by suppressing cytokine transcription Antimetabolites such as methotrexate and azathioprine interferon-γ, omalizumab, allergen immunotherapy, extracorporeal photophoresis, probiotics, Chinese herbal medications, and vitamin D

Compound Nevi

Compound NMN Uniformly pigmented papules and small domed nodules. (A) The lesion to the left is flatter and tan with a more elevated darker center; the larger lesion (on the right) is older and chocolate-brown; the left lesion is younger and has a predominantly junctional component at the periphery. (B) A heavily pigmented dome-shaped lesion in the eyebrow. It is sharply defined, uniformly black, smooth and slightly cobblestone-like surface, and sharply and regularly defined. It measures less than 5 mm.

Cutaneous Nontuberculous Mycobacterial Infections (NTM)

Group I Photochromogens Group II Scotochromogens Classified according to speed of growth, morphology and pigmentation of colonies on solid media (Runyon Classification) Chromogen: A strongly pigmented or pigment-generating organelle, organ, or microorganism.

Cutaneous Infections: Fungal infections Diagnosis

Confirmed with KOH preparation (10-20%) and microscopic examination for hyphae

Marasmus

Nutritional Disorders wasting of muscle mass and the depletion of body fat stores. common form of Protein Energy Malnutrition and is caused by inadequate intake of all nutrients, but especially dietary energy sources (total calories). children may have severe constipation and are ravenously hungry once refeeding is in progress

Venous lake

Dark blue to purple compressible papules caused by dilation of venules Usually solitary, 0.2 to 1 cm lesion commonly found on sun-exposed surfaces of the ear and face, especially the vermillion border of the lip geriatric population photocoagulation to eradicate for cosmetic purposes

Nummular dermatitis (discoid eczema):

Dermatitis (Eczema) -associated with low humidity (winter), xerosis, or emotional stress -distinct oval- or coin-shaped plaques which are pruritic -Lesions may weep or become crusted, scaly, or infected, and are often found on lower legs and forearms

Rubeola

On the fourth febrile day, erythematous macules and papules appear and may become confluent, especially on the face, neck and shoulders. Rash starts on the forehead, spreads inferiorly to involve the face, trunk and extremities, reaching the feet by the third day. Rash resolves in 4-6 days, leaving a residual yellow-tan discoloration or faint desquamation.

Hypertricosis Lanuginosa Acquisita

Paraneoplastic: Miscellaneous Lesions -Extensive growth of silky nonpigmented lanugo hair on the face, neck, trunk and extremities especially in sites that the patient perceived as hairless -Painful glossitis angular cheilitis also associated -Women affected more than men -Colorectal cancer most frequently associated followed by lung and breast

Hydrocolloid dressing

Duoderm/ granuflex/ Ultec -Self-adhesive, occlusive, semi-permeable, absorbent, and conformable -Suitable for low-to-moderately exuding Stage III, IV ulcers, especially those in "difficult" areas such as elbow, heel and sacrum -May be left in place for several days

DVT diagnosis

Duplex ultrasound (most common initial test), venography, nuclear-labeled platelets

Seborrheic Keratosis-

Epidermal Tumors benign proliferation of immature keratinocytes -May occur in young adults, but usually after age 50 -Genetic predisposition -Well demarcated, round or oval, with a verrucous surface, has a "stuck-on appearance" -Usually asymptomatic, but can be pruritic, painful, or bleed due to friction trauma Number of lesions range from one to hundreds, usually located on the trunk, face, and upper extremities Diagnosis is based on clinical appearance Biopsy may be needed if there are changes or concerns about malignancy (large lesions, rapid growth or changes, ulcerated lesions)

Dermatosis papulosa nigra (DPN)-

Epidermal Tumors multiple hyperpigmented papules on the face of people with darker skin tones Usually located on the face, but can be on the neck and trunk, size ranging from 1-5 mm Genetic predisposition Considered a variant of seborrheic keratosis

Dermatological Changes with Aging

Epidermis Dermis-Epidermis:

Cultural practices

Cupping - middle eastern, Egyptian, Chinese, Greek and European cultures for treating medical conditions Coin rubbing (spooning or friction stroking) - Chinese, Vietnamese, southeast Asian cultures Skin applications e.g. non-permanent tattoos, dyes

Sebaceous hyperplasia

Cutaneous Adnexal Tumors common lesion resulting from the enlargement of normal sebaceous glands -2-3 mm in size, skin-colored to yellowish or brownish papules, with a telangiectasia and central umbilication -Usually found on the forehead, nose, and cheeks of older individuals -Often confused with basal cell carcinoma (BCC) -Treatment: if suspicious for BCC, must biopsy. Otherwise treatment is for cosmetic reasons- cryosurgery, shave removal, electrocautery

Cyclosporine

Cyclosporine is a potent immunosuppressive drug that acts primarily on T cells by suppressing cytokine transcription -cyclophilin, an intracellular protein, and this complex, in turn, inhibits calcineurin, a molecule required for initiation of cytokine gene transcription

Neurofibroma

Dermal Tumor nerve sheath tumors comprised of neuromesenchymal cells -Usually a single lesion, soft, fleshy-colored/pigmented papule or nodule < 2 cm in diameter -Button-hole sign- direct pressure on the lesion appears to make a neurofibroma retract into the skin -No treatment is usually necessary unless the diagnosis is not clear, or the patient desires removal for discomfort or cosmetic reasons.

Dermatofibromas

Dermal tumor -Also known as benign fibrous histiocytomas -Can result from trauma, insect bites, or can be idiopathic -Firm, +/- pigmented, nodules, 0.3 to 1.0 cm in diameter -Usually in adults, females > males, on lower extremities -Usually asymptomatic, occasionally pruritic -Fitzpatrick's sign: lateral pressure produces a depression

Acrochordon (Skin tags)

Dermal tumor -Pedunculated lesions, usually at sites of friction -Common, increases with age, pregnancy, obesity, DM -Usually asymptomatic -Diagnosed based on clinical appearance

Benign Skin Lesions

Dermal tumors Epidermal tumors Cutaneous Adnexal Tumors Cysts Vascular tumors Subcutaneous fat tumors Acquired Melanocytic Nevi

A young 70 kg male fell backward into a campfire, receiving 2nd and 3rd degree burns over his entire back and posterior aspect of both arms. Upon hospitalization, what will his IV rate be?

Determine % BSA burned -Back - 18% -Posterior of both arms - 9% -18+9=27%

Epidermoid cysts

Diagnosis is made usually by the clinical appearance. Can get inflamed and infected- become larger, erythematous and painful. Can be confused with pilar cysts, lipomas, or abscesses

Vitiligo

Diagnosis: -The diagnosis of vitiligo is usually straight forward and no special testing is needed. -It is a cutaneous problem and does not affect an individuals physical health. -The condition cannot be cured, but treatments are available. be disfiguring and may have a significant psychological impact

Nummular dermatitis diagnoses

Diagnosis: must rule out Tinea corporis (ringworm) by doing a potassium hydroxide (KOH) slide.

Piebaldism

Disorder of melanocyte development, an absence of melanocytes in affected skin and hair follicles as a result of mutations of the KIT proto-oncogene -Normal pigmentation occurs on the hands, feet, back, shoulders, and hips. -Patients with piebaldism are generally otherwise healthy and have normal life spans. -Dermabrasion is a technique that uses a wire brush or a diamond wheel with rough edges (called a burr or fraise) to remove the upper layers of the skin.

Albinism

Disorders of Congenital Hypopigmentation -the complete or partial absence of pigment in the skin, hair and eyes -1 in 17,000 are effected by this disorder - albinos

Shower emboli

Do an abdominal ultra sound in this case - go to the heart - mitral lesion -listen for stenosis - do an echo of the heart something is causing the platelets to aggregate

Systemic agents

Doxycycline and Minocycline -"Newer" generation of tetracycline -Better tolerability and less incidence of P. acnes resistance -Minocycline is not used as first-line therapy due to a lack of clear additional benefit compared with tetracycline and doxycycline. -Concerns about minocycline having more severe toxicities than other tetracyclines. (vertigo, skin discoloration, serum sickness and lupus like syndrome) - Some patients who have failed therapy with doxycycline or tetracycline may respond to minocycline. -Tetracycline, doxycycline and minocycline NOT used in children under the age of 12 or pregnant women!!!!!!!!

mimic any dermatitis

Drugs can do that drugs can be involved in the development of many dermatitides

Hormonal Therapy

Hormonal therapy effective in post - menarchal women with moderate to severe acne vulgaris -considered for patients with hyperandrogenism Estrogen suppresses sebum production through estrogen mediated opposition of androgens within the sebaceous gland -Most commonly used are oral contraceptives and spironolactone -Spironolactone: Androgen receptor blocker. Competitively inhibits the binding of androgens to their receptors. Also inhibits the enzymatic conversion of androstenedione to testosterone Oral contraceptives: -Ethinyl estradiol in combination with acetate, desogesterol, or gestodene may improve acne -Tricyclen and Yaz - only OC approved by the FDA for hormonal treatment of acne. Useful especially in patients who flare near the time of menses

Skin Manifestations of Physical Child Abuse

Ecchymoses and contusions > 3 ecchymoses > 1 cm in diameter, at varying stages of evolution raise the suspicion of abuse -In areas that are normally protected and not easily injured during play e.g. posterior and medial thighs, hands, ears, buttocks and genitalia, abdomen -In non-ambulatory or pre-ambulatory children - most contusions arise during ambulatory movement, running and jumping, -Shape of ecchymoses - rope marks, belt straps, buckle marks may be pointers to abuse

Bullous pemphigoid

Eisinophils lining up

Benign Neonatal Rashes

Erythema toxicum Transient pustular melanosis Milia Miliaria Cephalic pustulosis (formerly neonatal acne

Erythema toxicum

Erythema toxicum - blotchy erythematous base with central pustule, filled with Eosinophils

Wheal

Erythematous, well-circumscribed, raised, edematous lesion that appears and disappears quickly

Pilar cysts treatment

Excision- the cyst wall is firm (unlike the epidermoid cyst), and does not rupture as easily

Staphylococcal scalded skin syndrome (SSSS)

Exfoliation occurs - superficial

Orbital cellulitis associated with

Ethmoid and Maxillary sinuses infections

Psychodermatology: Holistic Management

Evaluation: Skin manifestation and underlying social, family, and occupational issues (patient's psychosocial well-being, current stressors, interpersonal relationships and coping styles Diagnosis: Identify the psychological issues. Manage both dermatologic and psychologic aspects.

Acrochordon treatment

Excision Cryotherapy Electrodesiccation Treatment can cause bleeding New lesions frequently occur

Becker's Nevi

Hypertrichosis "islands" of hyperpigmentation

Cowden's Syndrome (Multiple Hamartoma Syndrome)

Genodermatoses Associated with Malignancy

Xeroderma Pigmentosa

Genodermatoses Associated with Malignancy

Gardner Syndrome

Genodermatoses Associated with MalignancyGardner Syndrome  -Familial Adenomatous Polyposis -Autosomal dominant. Mutation of tumor suppression gene APC -Triad of familial adenomatous polyposis, benign osteomas, and skin and soft tissue tumors. - Multiple epidermoid cysts are the most characteristic skin finding. Desmoid tumors may also be seen. -Congenital hypertrophy of the retinal pigmented epithelium is a reliable and early marker of disease. Colon cancer develops in all affected individuals requiring prophylactic colectomy.

Solar (actinic) elastosis:

Extrinsic Skin Conditions -changes due to abnormal elastotic fibers produced by fibroblasts in the papillary and superficial reticular dermis in response to UV light exposure. -Recent research suggests that they are the result of UVA damage to fibroblasts that results in the over-production and accumulation of elafin, which binds to elastic fibers making them resistant to normal degradation by elastase. -Large aggregates of these fibers impart a yellowish color and account for the yellow leathery appearance of sun-exposed skin in geriatric individuals. -Solar elastosis is often most easily appreciated in the posterior neck, where it is termed cutis rhomboidalis nuchae. !!!!

Nodular elastosis: with cysts and comedones

Extrinsic Skin Conditions -Nodular elastosis with cysts and comedones (favre-Racouchot syndrome) -marked solar elastosis and comedones on the lateral and inferior periorbital areas -Severe cases may demonstrate cysts -fibroblasts around the hair follicles are damaged by UV light and no longer produce normal elastic tissue -dilatation of the hair follicles, resulting in comedones and cysts -successfully treated with topical tretinoin cream and comedonal extraction

Solar or traumatic purpura (senile purpura):

Extrinsic Skin Conditions: -Common and benign condition of extravagated blood in the dermis -Characterized by ecchymotic, purpuric patches on the forearms, arms, or legs of older persons. -The condition usually follows minor trauma and commonly affects those who take aspirin or other blood thinners. Treatment is unnecessary and the extravagated blood is eventually reabsorbed

Facial angiofibromas

Facial angiofibromas which appears as a rash of reddish spots or bumps containing small blood vessels, they are located on the nose and cheeks in what is considered a butterfly distribution

Estimate central venous pressure

Find the highest point of oscillation in the internal jugular vein, or the point above which the external jugular veins appear collapsed, measure the vertical distance in cm between this point and the sternal angle and add it to 5 cm to estimate the central venous pressure

Acne Excoriee

Gender differences noted Men-excoriation more related to depression and anxiety women-immature personality and a cry for help

Purpura

Generic term for visible hemorrhage in the skin and mucous membranes Petechiae may become confluent to form "classic" purpura

Medication history for acne inducing drugs

Glucocorticoids phenytoin lithium Vitamins B2, B6, and B12

Trench fever:

Gram negative infections Bartonella quintana: small gram (-) rod - vector was the body louse - close quarters -poor hygiene -immunocompromised clinical manifestations: malaise/ fever/ HA/ arthralgia (shin)/ splenomegaly - also associated with bacteremia/ endocarditis/ bacillary angiomatosis DX: H and P / blood culture/ serology Tx: ID because antibiotic choice is problematic

Dermatitis herpetiformis immunostaining

Granular BMZ deposits of IgA IGa autoaintobodya t the tips of dermal papillae

Acute lymphangitis cause

Group A streptococcus, second most common is staphylococcus

Polymerase chain reaction (PCR)

HSV DNA fastest most reliable most sensitive technique

Acne Excoriee

Habitual act of picking skin lesions independent of acne severity -Immature coping and low self-esteem -More prevalent with females with late onset acne

Goal

Help patient have a sense of control over their conditions and reactions to them -Need to talk to patients about how they feel about disease and not assume—evaluate the psychological impact and treat those issues are extremely important

Bed bug bites

Hemiptera order encompasses two families of clinical significance. Cimicidae which includes bedbugs (Cimex lectularius). -attracted to the warmth and carbon dioxide production of their victim. -feed only once a week, and less often in cold weather -for 6-12 months without feeding -face, neck, arms and hands with several lesions in a row -Nocturnal feedings produce a linear arrangement of papular urticarial -Minimal symptomatic treatment of bites and good local wound care to prevent pruritus and secondary infection are sufficient in most cases

Varicose veins risk factors

Heredity, pregnancy, prolonged sitting or walking, weight-lifting

Stress/ skin ocnditoins

High stress exacerbates the skin disorder; upsets the patient more; increases stress; further exacerbates the skin disorder -Can't judge the impact of the skin disorder by the severity; mild cases can cause strong emotional impacts; need to talk to the patient and evaluate the psychological impact

Kwasaki treatment

IV immunoglobulins and aspirin

Discoid lupus erythematosus

IgG and C3 on the BM

Type II: Antibody-dependent cytotoxicity

IgG antibodies directed against an antigen on target skin cells or structures induce cytotoxicity by killer T cells or by complement activation

wound care

Immediate - immediate application of cool water - do not apply ice= acute vasoconstriction may contribute to ischemic injury as well as frstbite - cover with dry/ sterile/ sheets/ dressing

Small artery vasculitis - erythema nodosum

Painful raised, warm nodules often in the pretibial area, occasionally on thighs Numerous etiologies Isolated attacks can occur and can last for months

Pyodermas: Folliculitis

Infection of the hair follicles producing small erythematous or pustular lesions usually caused by Staphylococcus aureus Hot tub" folliculitis occurs in persons who have bathed in water contaminated by Pseudomonas aeruginosa. A pruritic papulo-pustular rash appears in moist areas or those areas covered by a bathing suit. Usually no therapy is required.

Furuncle Furunculosis:

Inflamed hair follicles a red, tender inflammatory nodule and can occur anywhere but preference to areas of friction. (Axilla, anterior thighs, buttocks). -becomes fluctuant and may spontaneously rupture.

Takayasu's aortitis

Inflammation and stenosis mainly of the aortic arch and its branches Depending on the location of stenosis, skin signs can include Raynaud's phenomenon, leg claudication, and ischemia due to emboli.

Psychodermatology

Interaction between mind and skin; need to understand the psychosocial and occupational context of skin diseases -Skin diseases can affect quality of a patient's life and can be caused by psychological stress, personality traits, or complications with a psychiatric disorder

Intertrigio

Intertriginous Infections -Non-specific inflammation of opposed skin. -Usually in the sub mammary region, axilla, groin and gluteal folds. -Increased moisture and maceration the stratum corneum becomes eroded. common in obese ppl

Hydrogels

IntraSite, Aquaform, Acrymed, Curagel -Water or glycerin-based dressings -Conform to wound surfaces -Suitable for Stage II, III ulcers -Desiccate easily, thus a secondary dressing is used to hold them to the wound -Need to be changed daily

Factors associated with aging of the skin

Intrinsic and Extrinsic

Mycobacterium tuberculosis

Inverse relationship between skin color and severity. Blacks have higher susceptibility but less severity -Involves the skin and peripheral nerves -Clinical manifestations: skin lesions that are hypo-pigmented or reddish patches. There is diminished sensation to the patches. Involves the skin and peripheral nerves) -DX: Leprosy should be considered in the setting of skin lesions that are chronic and not responding to treatments or when there is sensory loss within the lesions or in extremities. Consider travel history of patient and contacts. (migrant workers) Ziehl-Neelsen Stain TX: Rifampin, Dapsone touch = deminished sensation = mycobacterium

Dermatology

Involves a psychosomatic dimension: Relationship between psychological factors and skin diseases

Retinoid Therapy

Isotretinoin (Accutane) -THE single most effective agent for the treatment of severe acne -16-20 week course of treatment often produces remission that lasts months to years -High incidence of teratogenicity. (iPLEDGE Program) -Also associated with Inflammatory Bowel Disease

Postinflammatory Hypo/Hyperpigmentation

It is more common and prominent in people with darker skins, possibly because of the color contrast with their normal skin. There is no gender difference in the incidence of postinflammatory pigmentation disorders. (burns, chemical irritants or illness that causes a rash) (chemical peels, dermabrasion, cryotherapy, laser therapy)

Onychomycosis Dx

KOH examination or fungal cultures. It is essential to prove fungal infection and differentiate from other nail dystrophies before starting systemic treatment.

Potassium Hydroxide (KOH) preparation

KOH solution and gentle heating softens keratin and highlights the dermatophyte. Findings- Long narrow septated and branching hyphae 20% for nail scraping 10% for the skin

Alginates

Kaltostat, Sorbsan, Aquasan, AlgiSite -Highly absorbent dressings -Suitable for moderate to heavily exuding Stage II-IV pressure ulcers -Secondary dressing is needed to hold them in place -Minimum of daily dressing change needed

Rubeola presentation

Koplik's spots (tiny bluish-white papules with a red collar) appear on the buccal mucosa opposite the premolar teeth on or after the second day of febrile illness. lymphadenopathy Incidence has decreased by 98% due to immunizations

Patch:

Large macule (>1 cm), also used to describe large macule with scale

Tumor:

Large nodule

Plaque:

Large papule (>1 cm)

Bulla

Large vesicle

Morpheaform BCC

Least common, most aggressive, infiltrating deeper into the dermis than other BCC forms. It is difficult to identify because of its smooth, ill-defined, scar-like appearance.

Lepromatous (LL)

Lepromatous (LL): Small erythematous or hypo-pigmented macules that develop into papules and plaques with thickening of the skin. Bilaterally symmetrical, involving the earlobes, face, arms and buttocks

Clindamycin

Limited use due to the potential of inducing pseudomembranous colitis

treatment for candidiasis

Local - treat diabetes, soak dentures in nystatin solution, frequent diaper changes, use of barrier cream Oral- can use nystatin suspension or clotrimazole troches. Oral azoles may also be used. Example is fluconazole -Vulvovaginitis- topical preparations that are over the counter such as miconazole and clotrimazole. Prescription creams such as terconazole and econazole may be used as well. Usual treatment is 3-7 days. Oral agents if needed. Typically fluconazole 150 mg one time. Paronychia- is often resistant to therapy. The most important aspects of therapy include minimizing contributing factors such as water exposures, as well as drainage of any abscess -topical imidazole -oral azoles Onchyomycosis- oral itraconazole or fluconazole (triazoles) appear to be most efficacious -continuous or pulsed regimen. -Requires weeks not days to treat

Cherry angioma

Localized dilated blood vessels found primarily on the trunk, face and extremities as people age

pathophysiology

Loss of cutaneous barrier allows entry of bacteria * strep and staph, followed by pseudomonas as antibiotic usage increases - major complication is secondary infection with +Candida +Aspergillus +mucormycoses

Erythema migrans (EM)

Lyme borreliosis - Definite history of tick bite at the site of the lesion is obtained in only a small proportion of patients -Believed to be the result of the direct presence of the spirochete 3-30 days of the tick bite to develop pathognomonic appearance of expanding erythema encircling the bite site, -transition between the central zone and periphery being less well demarcated than between that of the periphery and adjacent skin -border is usually continuous and not patchy -lesion, sometimes described as round, is really more of an oval shape. -Lesion usually heals spontaneously, but may persist for as long as 6-12 months. Average is about 4 weeks

Milia

Milia - small retention cysts mainly on the face

Miliaria

Miliaria - rubra (prickly heat) - related to environmental temperature, tends to be generalized

Hidradenitis Suppurativa TX

Moist compresses, surgical drainage of fluctuant lesions and oral anti-staph antibiotics

Rocky Mountain Spotted Fever

M > F -Transmitted by Rocky Mountain wood tick, Dermacentor andersoni (western US) or American dog tick, Dermacentor variabilis (eastern US) bite. -Most prevalent during spring and early summer

LYMPHOMA

MYCOSIS FUNGOIDES (many types of lymphomas and leukemias involve skin, many lymphomas are primary in skin)

Rubella presentation

Macules and papules start on forehead, spread inferiorly to trunk and extremities on day one. Day two, facial rash clears. Day three, rash fades completely without residual pigmentary change or scaling Petechiae may appear on soft palate during prodrome

Skin Problems

Many clear or improve with standard therapies (antibiotics, anti-inflammatory drugs, topical medications) Others have a stronger mind-body connection that is important in treatment.

Skin Manifestations that mimic Physical Child Abuse

Mongolian spots -lumbosacral or buttock area -If undocumented in earlier exams, may be considered a newly appearing lesion. -Mongolian spots - fixed, homogenous blue-gray color, physical abuse - variable spectrum of colors -Histology of Mongolian spots - spindle-shaped melanocytes in the dermis

Melasma

Melasma is also known as chloasma and sometimes referred to as a mask of pregnancy.

Melasma

Melasma is also known as chloasma and sometimes referred to as a mask of pregnancy. -It is an acquired benign disease where brown patches develop on the face and neck. -It is more common in women then in men, and most often occurs during the second or third trimester of pregnancy. -A person taking oral contraceptives, hormone replacement therapy, or excessive sun exposure may also develop symptoms. -Pregnancy associated melasma usually fades slowly after delivery. -Similarly, the pigmentation associated with oral contraceptives and hormone replacement therapy fades slowly after discontinuation of oral hormones. -Symptoms will most likely reoccur with subsequent pregnancies or reintroduction of oral contraceptives or hormone replacement.

Skin lesions of Cutaneous larva migrans

Skin lesions usually last between 2 and 8 weeks, but have been reported to last for up to 2 years. -Diagnosis based primarily on clinical findings -Self-limiting illness since humans are "dead-end" hosts. If treatment is desired, thiabendazole, ivermectin or albendazole topically.

Group II Scotochromogens:

Slow growing and produce a yellow-orange pigment even when grown in dark -Mycobacterium szulgai

Neurofibromatosis 1:

Most common Characterized by: -Presence of café-au-lait spots, multiple neurofibromas and Lisch nodules (pigmented iris hamartomas) -Café-au-lait spots are tan to brown macules. Present at birth but may not appear for months. Size and number increase with age -Intertriginous freckling (pathognomonic sign) (ARMPIT) -Brown dome shape lesions (neurofibromas) on the body

NTM Group I Photochromogens

Mycobacterium marinum: (Swimming Pool Granuloma or Fish Tank Granuloma) Occurs at site of minor trauma (fingers, hands, elbows, knees). -Development of a papule or nodule that develop into ulcers and form a verrucous surface. Most lesions are solitary at onset DX: clinical presentation and index of suspicion. Patient with salt or fresh water aquarium. Gram stain and acid fast stain, cultures TX: surgical debridement, empiric antibiotics and treatment for M. marinum which consists of Clarithromycin plus rifampin or ethambutol ! slow growing yellow pigmentation in the light single type ulciration

NTM Group II Scotochromogens

Mycobacterium szulgae -Unusual pathogen -Can involve skin and lungs, Similar to tuberculosis -Also associated with bursitis Dark or in light Yellow pigmentation Very rare = can involve skin and lungs BRSA join inflamtion

Tuberous xanthomas

Slowly evolving yellow papules, nodules or tumors. Occur on the knees, elbows and extensor surfaces and palms

Polyarteritis nodosa

Multi-system necrotizing vasculitis of small and medium-size muscular arteries of unclear etiology, but strongly suggestive of an immunologic phenomenon. Unlike Wegener's and Churg-Strauss, the lung is usually spared. Skin manifestations include rash, purpura, nodules, livedo reticularis, Raynaud's phenomenon

Lyme Borreliosis

Multisystem disease caused by the spirochete Borrelia burgdorferi -, transmitted to humans by the bite of an infected ixodid tick. Transmission: prolonged attachment

NTM Group III Nonchromogens

Mycobacterium ulcerans: occurs at the site of inoculation. Legs most common. 3rd most common mycobacterium infection in the world (TB and leprosy) - know as Buruli Ulcer -large deep (into sub Q fat) painless ulceration -incubation 3 months DX: acid fast stain from the undermined edge - histology from punch bx Tx: antibitics (rifampin and Streptomycin) / debridement little to no color in light or dark

presence of six or more cafe au lait spots are presumptively suggestive of

NF1

Primary Care Physician

Need to think biopsychosocial Detective as to what is the underlying root. Are the psychological impacts being addressed, treated? Is there prevention that can be discussed (e.g., excessive tanning for melanoma)?

Cephalic Pustulosis

Neonatal Acne -Found in about 20% of infants -Due to effect of androgens (maternal and endogenous) on infant's sebaceous glands -It is an inflammatory reaction possibly to Pityrosporum (Malassezia) species -Presents as inflammatory papules/pustules without comedones -It is not true acne

Cherry Angiomas

Neoplasms: Benign Tumors -Benign vascular growths -Bright red, dome-shaped papules -Mainly distributed on the trunk and are commonly found in the elderly. -Treatment: Usually not required unless for cosmetic reason.

Acrochordons: (skin tag or soft fibroma)

Neoplasms: Benign Tumors -Soft, skin-colored to brownish, round or pedunculated, fibroepithelial polyp -Increasingly common with aging, it often occurs on the neck and in the intertrigionous regions. -Treatment: removal with scissors, electrodessication, and cryotherapy.

Neurofibromatosis

Neurocutaneous Disorders: Von Recklinghausen's Disease Neurofibromatosis 1: Neurofibromatosis 2:

Albinism

Oculocutaneous albinism and ocular albinism both are associated with numerous visual complications including: -light sensitivity -rapid eye movements(nystagmus) -inability of the eyes to move in unison(strabismus) - blurred vision (astigmatism)

Dressing tegaderm

Op-site, Tegaderm, Sorb Act Semi-permeable membranes -Suitable for Stage I ulcers and superficial wounds with minimal drainage -May be left on for up to 3 days -Do not provide any cushioning

Acquired Ichthyosis

Paraneoplastic: Papulosquamous Disorders -manifest with small, whitish to brownish, polygonal scales that lift up at the free edge and are widely distributed on the trunk and extensor surfaces of the extremities The palms and soles are usually spared. -virtually clinically indistinguishable from autosomal dominant ichthyosis vulgaris. -strongly associated with Hodgkin lymphoma: 70% of cases of paraneoplastic AI involve Hodgkin disease AI-associated malignancies include Kaposi sarcoma, cutaneous T-cell lymphoma, non-Hodgkin lymphoma, leukemias, and solid tumors (including those arising in breasts, lungs, or bladder

Acanthosis nigricans

Paraneoplastic: Papulosquamous Disorders hyperpigmented, velvety thickening of the skin that usually occurs in the intertriginous zones, including the axillae, groin, neck, and inframammary folds paraneoplastic AN involve: adenocarcinoma, -most commonly one arising in the gastrointestinal tract (stomach or liver ) -less commonly in the lungs, ovaries, uterus, breasts, kidneys, prostate or bladder

Hand/ foot and mouth Disease Lesions

Oral Cutaneous All lesions are self limiting and resolve in 7-10 days

Non purent tx

Oral: Dicloxacillin cephalexin clindamycin IV: cefazolin Oxacillin Clindamycin

Necrolytic Migratory Erythema (Glucagonoma syndrome)

Paraneoplastic:Erythematous Lesions -skin and mucous membranes are affected -Painful, migratory, erythematous, polycyclic patches or plaques with superficial pustules, vesicles, or bullae. -lesions are typically widespread, but they are accentuated in the intertriginous areas, lower abdomen, and proximal parts of the lower extremities. -triad with NME, glucose intolerance, and hyperglucagonemia. -Characterized by erythematous scaly plaques on acral, periorificial or intertriginous areas -Hyperglycemia, diarrhea, weight loss, and atrophic glossitis -Almost always associated with a glucagon-secreting alpha-cell neoplasm of the pancreas

Extramammary Paget Disease:

Paraneoplastic:Papulosquamous Disorders Clinically indistinguishable from that of Paget disease, except for its location -in persons with EMPD typically appear on the apocrine gland=gland-bearing perianal or vulvar skin -face and male external genitalia are described EMPD is itself a malignant lesion, involving an intraepithelial adenocarcinoma. -40 years of age -Women>men -underlying adnexal (apocrine gland) -carcinoma or cancer of the genitourinary tract or distal GI tract (Neoplasm of the anogenital and axillary skin) characterized by a solitary, pruritic (but painless), sharply demarcated, erythematous, superficial, eczematous, slightly infiltrated plaque

Inflammatory:

Papules: (less than 5 mm in diameter) Pustules: central core or purulent material Nodules: (greater than 5 mm). May become hemorrhagic or suppurative Cysts: Suppurative nodules cause epithelial-lined sinus tracts = scarring

Erythema Gyratum Repens

Paraneoplastic: Erythematous Lesions -(>80%) indicative of an underlying malignancy. -Wood grain appearance erythematous rings with trailing scale. -Grows very fast 1 cm/day -Usually spares hand and feet -Very pruritic -Skin findings usually precede malignancy diagnosis EGR are transitional cell carcinoma of the kidney and those arising in the lungs, esophagus, and breasts

Dermatomyositis

Paraneoplastic: Erythematous Lesions -inflammatory proximal myopathy with characteristic skin changes -Violaceous, scaly papules over the interphalangeal and metacarpophalangeal joints (Gottron papules) that evolve into atrophic telangiectatic macules -Heliotrope rash on the upper eyelids , Periorbital edema, a macular, red rash on the face and the V of the upper trunk that may become shiny and atrophic, with variable pigmentation and telangiectasias (poikiloderma) -The malignancies associated with DM are those common for the age, racial background, and sex of the patient, although incidences of ovarian, cervical, lung, and pancreatic and gastric carcinomas, in addition to non-Hodgkin lymphoma, may be unusually increased. -Although most malignancies are detected within 24 months of onset of DM, ovarian cancer is unusual in that it can occur even up to 5 years after onset

Most widely utilized method of replacement fluid therapy

Parkland formula Ringers lactate = 4 ml/kg/% burn in the first 24 hrs after the burn -½ is given over the first 8 hours after the burn (2 ml/kg/%) -¼ is given over the second 8 hours (1 ml/kg/%) -¼ is given over the third 8 hours (1ml/kg/%)

Vitiligo

Patches of skin with no pigmentation Embarrassment by appearance Associated with depression

Oral antibiotic therapy for impetigo

Prefered: Dicloxacillin Cephalexin Alternate for penicillin and cephalosporin hypersensitivity Erythromycin clarithromycin MRSA suspected - clindamycin -TMP-SMX -doxycyclin

Vitiligo treatment cont

Photochemotherapy with topical or oral psoralens Advise patients and give reassurance that this is a benign condition with a highly variable and often progressive course, provide patients with the multiple treatment options that are available. -Minigrafting techniques, with or without light phototherapy, and melanocyte transplantation have been used , but they are not widely available. -Ultraviolet A radiation (PUVA), or ultraviolet B (UVB) radiation phototherapy is used in patients with extensive vitiligo. -Patients must be referred to a dermatologist for ultraviolet radiation therapy

Drug Eruptions:

Polypharmacy is common among the elderly population -cutaneous adverse drug reactions while also complicating the effort to pinpoint the culprit -take the form of almost any dermatological disease, with exanthema and urticaria being the most common reaction morphologically -Drug exanthems are symmetric erythematous morbilliform, maculopapular eruptions, often associated with pruritus -occur within 1 week of initiation of a drug regimen and resolve within 2 weeks after discontinuation, although considerable variation exists -Wheals and flare reaction are characteristic of urticaria and often vanish rapidly on discontinuation of medication

Postinflammatory Hyperpigmentation

Postinflammatory Hyperpigmentation from acne

Postinflammatory Hypopigmentation

Postinflammatory hypopigmentation from psoriasis

Rubella prodrome

Prodrome - anorexia, malaise, conjunctivitis, headache, low-grade fever, URI symptoms Lymph nodes enlarge during prodrome; may remain enlarged for a week to several months

OCD

Psych COnditions causing skin problems Compulsive pulling of scalp, eyebrows, eyelash hair, biting nails, excessive hand washing

Phobic states

Psych COnditions causing skin problems Dirt and bacteria may lead to repeated hand washing, results in irritation

Secondary psychiatric disorders

Psychological problems caused by disfiguring skin disorders; Feel psychologically and socially devastated, e.g., burns, vitiligo, genital herpes

3 categories psychodermatologIc Disorders

Psychophysiologic disorders Primary Psychiatric disorders Secondary psychiatric disorders

DVT risk factors

Prolonged car/bus rides, immobilization, trauma, recent surgery, oral contraceptives or HRT, cancer, platelet aggregation

Psoriasis

Quality of life suffers due to visibility of psoriasis and need for lifelong treatment 5 dimensions More frequent depression symptoms and suicidal ideations Can interfere with sleep; Sleep deprivation can enhance inflammatory process Can affect sexual functioning (decline in activity)

majority of melanomas have a

Radial (in situ) growth phase before the development of invasive tumor - radial growth phase is greatest in lentigo maligna or -shorter duration in superficial spreading melanoma - acral lentiginous melanoma

Varicella zoster rashes

Rash begins as erythematous macules and papules -progress to vesicles (within 12-24 hrs) -pustules (in 3-4 days) -Crusts in (7-10 days)

Exanthema presenattion

Rash develops suddenly, often is fully developed within 12 hours and last 1-2 days

Pyogenic Granuloma: treatment

Removal is usually required due to frequent ulceration and bleeding. Malignant lesions look similar to PGs, so it is important to remove the lesion so that histopathology can be done if possible. Surgical treatments: excision, shave excision, and curettage Surgery is the most frequently used modality to treat a pyogenic granuloma Lower rate of recurrence and results in a specimen for pathology evaluation Higher risk of scarring

Eating disorders

Result of starvation, malnutrition, and purging methods=lanugo, dry scalp, brittle nails and hair, alopecia, etc.

Reiter's Disease

Rheumatological Disorders -Urethritis, arthritis, ocular findings, oral ulcers (painless) -Urethritis, Conjunctivitis, arthritis -Urethritis is initial manifestation in 80% of cases -Psoriasiform skin lesions, Predilection for extensor surfaces of legs and dorsum of hands -Keratoderma blenorrhagicum (feet) -Balantitis circinata (penis): psoriatic plaques. Painless

Pyoderma: Bullous Impetigo

Staphylococcus produced epidermolytic exotoxin -infants and children but seen in adults also -anywhere on the body but frequently on the trunk -more vesicles enlarge rapidly to form bullae. Fluid in bullae goes from clear to cloudy. -Honey colored crust forms when bullae collapses and if removed reveals a bright red inflamed base but little or no surrounding erythema

treatment of acne excoriee

SSRIs, doxepin, clomipramine, naltrexone, pimozide antipsychotics, antidepressant and an opiate antagonist Habit reversal behavior therapy

Culture

Sabouraud medium (4% peptone, 1% glucose, agar, water). -Function- Facilitates growth of dermatophytes.

Raynaud's phenomenon

Same signs and symptoms but etiology is due to -connective tissue disease, -neurogenic lesions, -drug intoxication, -pulmonary hypertension, -or trauma

Vasculitis

Segmental inflammation and necrosis of blood vessels Clinical syndromes are based on the appearance and histology of the lesions, the size of the vessels involved, and the organs affected

Neurotic Excorations

Self-inflicted lesions (pathological skin picking), uncontrollable urge to pick Personalities with compulsive and perfectionistic traits exacerbated by family and work stress Comorbid: OCD, anxiety, mood disorders, BDD, substance use, eating disorders, trichotillomania, compulsive buying, personality disorders

sensitization phase and the elicitation phase

Sensitization phase generally 10-15 days -small, lipophilic molecules with a low molecular weight (<500 Daltons). The unprocessed allergen is more correctly referred to as a hapten. Once the hapten penetrates the skin, it binds with epidermal carrier proteins to form a hapten-protein complex, which produces a complete antigen. Subsequent exposure to the antigen, or rechallenge, leads to an elicitation phase. Such rechallenge can occur via multiple routes, including transepidermal, subcutaneous, intravenous, intramuscular, inhalation, and oral ingestion

Rocky Mountain Spotted Fever Dx

Serologic examination using the indirect immunofluorescence assay (IFA) is the gold standard for diagnosis of RMSF. -diagnostic titer of ≥64 IgG and ≥32 IgM -Immunohistochemical staining of skin or organ tissue biopsy and polymerase chain reaction (PCR) may also confirm the diagnosis.

Dressings

Silver sulfadiazine (Silvadene) antimicrobial due to high tolerance, minimal side effects, low allergic rate, immediate eschar penetration and good antibacterial spectrum. Used on many second-degree burns

Psychophysiologic disorders

Skin disease not caused by stress, but exacerbated or worsened by stress Emotional triggers can bring on flare ups Stress management, relaxation techniques, benzodiazepines (short term) and SSRIs used to treat

Psychophysiologic disorders

Skin disorder worsened or affected by stress or other emotional states

Primary psychiatric disorders

Skin disorders in which the primary problem is psychological -Skin manifestations are self-induced

Erythema skin lesions

Skin lesions - confluent plaques over malar areas with a lacy, reticulated appearance over extensor surfaces of extremities, on the trunk and neck

Macule

Small flat lesion with altered color (<1 cm

Henoch-Schonlein purpura

Small venule vasculitis Abdominal pain, arthritis and renal involvement are common More common in children

Thromboangiitis obliterans (Buerger's Disease)

Smaller blood vessels of upper and lower limbs become obliterated by smooth muscle cell proliferation and intraluminal thrombosis Occurs more often in young men under 45 who smoke Presentation is often an ischemic, cyanotic digit despite an easily palpable peripheral pulse

Varicella virus transmission

Spread by inhalation of respiratory secretions or contact with skin lesions

Lyme Borreliosis stages

Stage I - erythema migrans - expanding annular lesion with distinct red border and partially clearing center Stage 2 - disseminated infection - fever, chills, myalgia, headache, weakness, photophobia, meningitis, carditis with heart block. Stage 3 - persistent infection - fever, lymphadenopathy, arthritis, encephalopathy, and polyneuropathy clinical grounds, identification of the organism from tissue sections and/or serologic testing Initial treatment with antibiotics

Common causes of furunculosis

Staph. aureus is the most common pathogen but also E. coli, P. aeruginosa, S. faecalis or anaerobes like Bacteroides and lactobacillus. - affects the microflora of the anatomic area

Polymyalgia rheumatica

Stiffness and pain in shoulder and hip muscles accompanied often by an inflammatory arthritis and weakness

Lipoma

Subcutaneous Fat Tumors soft, painless, subcutaneous nodules -Most common benign soft-tissue neoplasm, comprised of adipose cells enclosed by fibrous capsule -Range in size from 1 cm to > 10 cm -Occur anywhere, but most commonly on the trunk and upper extremities -Round, oval or multilobulated, can have more than one -Diagnosed clinically, biopsy is needed if increasing in size, painful, or firm -Rarely can transform into a liposarcoma

Toxic Epidermal Necrolysis associated with

Sulfonamide Anticonvulsants SSRi drugs

Cutaneous fungal diseases

Superficial - limited to the stratum corneum, hair, and/or nails. Deep - dermal and/or subcutaneous

Pitted keratolysis

Superficial cutaneous infections --weight bearing areas of the foot -associated with pedal hyperhidrosis - yoing adult males -MICROCOCCUS SEDENTARIUS - gram + = secrete exoenzyme (keratinase) = degrades keratin = makes pitting - mistaken for a fungal infectino its a defect in the thick keratinized skin of the plantar foot = sculpted pits of variable depth = depending on the thickness of stratum corneum

Erythrasma

Superficial cutaneous infections -chronic bacterial infection: CORYNEBACTERIUM MINUTISSIMUM -toes/ groin/ axillae - mimics fungal infection - oportunistic in warm humid climates= pt of flora - oportunistic in those w same shoes and clothing

Tinea faciei

Superficial dermatophyte infection limited to glabrous skin of the face pediatric and female patients= any surface of the face (upper lip and chin) Red, scaly lesions resembling tinea corporis; often confused with lupus erythematosis or rosacea. 9% of all superficial fungal infections in the pediatric population with dermatomycoses.

4 subtypes of melanoma

Superficial spreading melanoma Lentigo maligna melanoma Nodular melanoma Acral-lentiginous melanoma

Vitiligo surgical techniques

Surgery may be warranted when medical therapies fail; surgery can also be used in combination with medical therapy.

Acne Fulminans tx

Systemic glucocorticoids (o.5-1 mg/kg) for 4 weeks then oral isotretinoin and oral antibiotics

Basal cell carcinoma

The most common invasive carcinoma -BCC is also slow growing and only rarely metastasizes. -probably 1% can be locally aggressive -They occur in sun exposed sites in the elderly

Vernix -

Vernix - mixture of sebaceous gland secretion and epidermal debris

Genetal herpes presentation

Vesicle formation, ulceration, discharge, dysuria inguinal lymphadenopathy fever, myalgia, lethargy photosensitivity

Mind and Skin Connection

The skin and brain have the same ectodermal origin, affected by the same hormones and neurotransmitters -Interplay between neuroendocrine and immune system called NICS (neuro-immuno-cutaneous system); e.g., "psychological stress perturbs epidermal permeability barrier homeostasis" and may bring on inflammatory disorders like atopic dermatitis and psoriasis.

Acute spongiotic dermatitis

The term eczema is frowned upon and widely used. This is a broad group of lesions often representing an allergic reaction

Tuberous sclerosis

There is no specific treatment of tuberous sclerosis as each individual is effected differently, treatment is based on symptoms. Imaging: - including CT or MRI scans of the brain -ultrasound of the kidneys -DNA testing for mutations in the two genes discussed TSC1 or TSC2. Tuberous sclerosis is a lifelong condition and individuals should be monitored regularly by a physician to receive the best possible treatments.

TSC1 and TSC2

These proteins act as growth suppressions but due to this abnormal mutation, there is abnormal cell variation, development and growth of benign tumors

Hypomelanosis of Ito

This disorder can be diagnosed based on clinical findings. -Due to the association with neurologic abnormalities other consultations and imaging should be performed based on the patients history and physical exam findings. -Currently there is no treatment available for the skin findings.

Fungal infections

Tinea pedis and tinea unguium common cutaneous fungal infections in the elderly population -Intertrigo and paronychia related to Candida are also quite prevalent in this age group.

Pyodermas: Folliculitis Tx

Topical antibiotics are usually all that is needed occasionally oral antibiotics.

Diagnoses has 2 approaches

Topographic approach Frequency approach

gangrenous cellulitis predisposing factors

Trauma with tissue damage, surgery, decubiti, abscess, intestinal perforation, DM, alcoholism, parental drug usage

Management

Treat/Refer: -Patients frequently resist mental health referral. Family physicians can help support this when needed -Drugs used in treatment (e.g, steroids, retinoids) can lead to psychiatric symptoms -Nonpharmacolgic treatments considered

Cellulitis treatment

Treatment -Routine skin swabs (from open lesions) or aspiration (from fluctuant lesions or bullae) should be sent for detection of causative pathogen and tested for antibacterial sensitivity. Initial management should be penicillinase-resistant penicillin, (flucloxacillin or dicloxacillin) for 10 days. More severely ill patients, particularly those with medical disorders, such as diabetes mellitus, should be hospitalized and treated. Of note, there has been an alarming increase in the prevalence of methicillin-resistant S. aureus infection in the past decade.

Epidermoid Cysts treatment

Treatment- -Uninfected cysts may resolve spontaneously. -Infected cysts need incision and drainage Excision is best accomplished when the cyst is not inflamed. Anesthesia should be injected around the lesion instead of into the lesion to avoid rupturing the cyst wall. Antibiotics are used if cysts do not respond to drainage

Actinic keratosis treatment

Treatment: local destruction with cryo-therapy (liquid nitrogen), or curettage, topical application of 5-fluoruracil (Efudex Avoidance of sun exposure

Angiolipoma Treatment:

Treatment: single lesions can be excised, multiple lesions are more difficult, can use liposuction

Genital herpes are diagnosed by

Tsanck smear= gently scrape cells from the bottom of an erosin and place on a slide - Wright or Giemsa stain= used to accentuate the cells

Tuberculoid (TL):

Tuberculoid (TL): well defined hypo-pigmented lesions with raised edges. Vary in size from few millimeters to ones that can cover the entire trunk

Dermatofibroma- Treatment

Unless the lesion is symptomatic, no treatment is usually required. Excision is needed if the lesion changes, bleeds, or looks suspicious. Some patients want these lesions removed for cosmetic reasons. Can be treated with liquid nitrogen.

Pyogenic granuloma

Vascular Tumors dome shaped tumor on the skin or mucous membranes with a friable surface -Rapid growth over a few weeks to months than stabilizes, can bleed profusely after minor trauma, -Usually less than 1 cm in size Occurs in all ages, peaks in 2nd and 3rd decade of life and during pregnancy Location: Adults- trunk and extremities, children- head and neck Unknown etiology, rarely resolves spontaneously Reported trigger factors include trauma and medications

verrucae

Warts - many variety of Human papillomavirus (HPV) - double stranded DNA viruses that are host specific for humans

Erythrasma Dx

Woods lamp - show coral-red fluorescence KOH prep(-) for fungal elements

Chronic Ischemia

Worsening arteriosclerosis may eventually lead to cell death, gangrene

If a skin lesion has changed, or if the diagnosis is not clear after taking a good history and examination

a diagnostic procedure is indicated

Interferon gamma (IFNγ)

a dimerized soluble cytokine that is the only member of the type II class of interferons -critical for innate and adaptive immunity against viral, some bacterial and protozoal infections -IFNγ in the immune system stems in part from its ability to inhibit viral replication directly, and most importantly from its immunostimulatory and immunomodulatory effects

Omalizumab

a humanized antibody originally designed to reduce sensitivity to inhaled or ingested allergens, especially in the control of moderate to severe allergic asthma, which does not respond to high doses of corticosteroids

hapten

a small molecule that can elicit an immune response only when attached to a large carrier such as a protein; the carrier may be one that also does not elicit an immune response by itself. only the hapten-carrier adduct can initiate reaction

Pigmented BCC

appears similar to nodular BCC, but its black or blue pigmentation makes it appear like melanoma.

Discoid lupus erythematosus

arround the follicle mainly not he blood vessels like you fill see in a typical dermititis

provide analgesics

about an hour before debridement

cellulitis treatemtn

abx selection: depends on whether the clinical presentation consists of purulent or non purelent cellulities

Whitehead:

accumulation of sebum and keratinous material forming a microcomedo which grows into a closed comedo

Histopathology special stains

acid-Schiff and Grocott's methenamine silver -tissue may be obtained by skin or nail biopsy techniques. -stains fungal cell wall to detect fungal elements in tissue sections. -pink (PAS) or black (GMS) fungal elements noted in the stratum corneum.

outbreak associated with

acute poststreptococcal glomerulonephritis

The Koo-Menter Psoriasis Instrument (KMPI)

asks questions about feelings of self-consciousness and helplessness, the physical symptoms of the disease and more.

Tinea pedis (feet)

adults (especially young men), rare in children and predisposed to by communal washing, swimming baths, occlusive footwear and hot weather - athletes foot T. rubrum , T. mentagrophytes var. interdigitale and Epidermophyton floccosum. -Itchy interdigital maceration -Recurrent vesicles also occur -Damage/maceration of interdigital spaces may allow secondary bacterial infection to occur

Dermatophyte test medium

advancing border, subungual debris or affected hair embedded in the medium medium contains the pH indicator phenol red. Dermatophytes utilize proteins resulting in excess ammonium ion and an alkaline environmen incubation at room temperature for 5-14 days results in change in color of medium from yellow to bright red in the presence of a dermatophyte.

Rubella

aerosolized trans -respiratory droplets -Period of infectivity from end of incubation (14-21 days) to disappearance of rash

Most benign skin lesions can be diagnosed

after taking a good history and by its clinical appearance

Keratoacanthoma

aggressive type of SCC characterized by rapid growth, a static period, and spontaneous regression and recurrence symmetric in shape, and some lesions develop a keratinous plug.

toxic shock

all of this starts within the 1st couple of days

podophyllin

anogenital wart treatment - 20-50% solution - have pt wash it off after 4-6 hrs - may need up to 6 treatments - dont use during pregnancy

elicitation phase

antigen presenting cells and keratinocytes can present antigen and lead to recruitment of hapten-specific T cells -T cells will release cytokines which in turn create and stimulate a larger inflammatory reaction

Ramsay hunt syndrome treatment

antivirals (acyclovir, famciclovir, valacyclovir -decrease the duration of the outbreak but doesn't appear to affect the risk of post-herpetic neuralgia

Superficial BCC

appears as a thin, red, irregular, scaly plaque or eczematous-like patch. There may be single or multiple lesions, but they retain the pearly border and may bleed easily. It is more common in middle-aged adults on the torso and extremities.

Treatment of contact dermatitis

avoidance of the causative agents or products if feasible. Emollients and mild corticosteroids usually suffice for irritant dermatitis,

Lichen planus

band like infiltrate

BWAT

bates jensen wound assessment tool Evaluates 13 wound characteristics using a 5 point scale

Seborrheic keratosis:

benign tumor--> neoplasms -The most common type of benign tumors of epithelial origin. -Usually seen after the age of 30 years -Cause is unknown. Some think that a genetic predisposition might exist -Presents as well-circumscribed tan to greasy- brown hyperkeratotic plaques often occurs on face, trunk, and upper extremities -Congregate on the trunk -Therapy is not necessary -atypical or symptomatic lesions (pruritic or inflamed), -curettage or punch biopsy may be needed to differentiate from Bowen's disease, basal cell carcinoma, or malignant melanoma

Ecthyma Tx

benzoyl peroxide washes; Bactroban ointment TID (on the lesion and intranasally) Consider systemic antibiotic treatment (staph and strep)

Pilosebaceous Duct Obstruction

blockage in the follicular canal -Hormonal changes cause an increased amount of keratin and sebum which has been modified by the resident flora -Propionibacterium acnes Inflammation results from the proliferation of P. acnes The increased number of cornified cells adhere to the canal to form a plug (microcomedo). -This plug enlarges and becomes visible as a closed comedone (firm white papule). These can become inflamed (precursor to inflammatory acne papules, pustules and cysts. -follicular orifice opens (dilates) is becomes an open comedone (black head). These usually do not become inflamed

Psychodermatology

boundary between psychiatry and dermatology -Includes psychological problems that can arise when people have skin problems -Important because appearance is relative to self-esteem; body image -Patients with psychodermatologic disorders often resist mental health referral

in men tinea faciei tinia barbae

called tinea barbae= when a dermatophyte infects the beard area -very inflamed with red lumpy areas -pustules -crusting around the hairs (kerion -hairs can be pulled out easily. Surprisingly, -it is not excessively itchy or painful. affects farmers and is due to direct contact with an infected animal. face unilaterally and involves the beard area more often than the moustache or upper lip.

Rubella epidemic

decreased to 99% due to immunizations

Tinea

denotes a fungal skin infection which is often annular

classification is based on the

depth of injury

Hand/ foot and mouth Disease Cutaneous Lesions

develop with or shortly after the oral lesions. Hands are more commonly involved than the feet with small gray vesicles often running parallel to the skin lines

Dermatology Life Quality Index (DLQI)

developed by Findlay and Khan in 1992 and provides physicians with a 10-question survey for patients about the impact of a skin condition on work, leisure activities, social interactions and more.

Norton and Braden scales

developed to help in risk assessment --> commonly used on admission to LTCG or hospital

Drug eruptions diagnosis

diagnosis, careful investigation of medication history, including over-the-counter or herbal drugs, should be carried out. Prompt and accurate diagnosis enables early withdrawal of the inducing drug, which is critical for the elderly who are generally more vulnerable to severe drug reactions

Acne

disease of adolescents but may also begin in the 20's and continue into the 40-50's -primarily in oily (seborrheic) areas -keratinization pattern in the hair follicle with the keratin material becoming more dense and blocking secretion of sebum. -lesions are the result of a complex interaction between hormones, sloughed cells, and bacteria

Pitter keratolysis treatemtn

dryness - benzoyl peroxide wash - 20% aluminum chloride - erythromycin or clindamycin

Bullous pemphigoid

eisinophils line up along the basement membrane

"non stageable" since

eschar needs to be removed

acute care hospitals Reassesment should be perofmed

every 48 hrs

Eczema herpeticum

extensive outbreaks of cutaneous HSV in patients with preexisting skin disorders such as -atopic dermatitis/eczema

Extrinsic aging

external agents. The most important extrinsic factor is cumulative ultraviolet (UV) light exposure -accelerate aging of the skin include smoking and possibly environmental pollutants. -The cutaneous changes produced by sunlight are collectively referred to as dermatoheliosis. -wrinkles, yellow leathery skin, thin skin, hyperpigmentation, hypopigmentation, lentigo senilis (liver spots), telangiectasias, and senile (solar) purpura, are all secondary to damage from the sun or other UV light sources such as tanning booths.

Assessment of serum complement proteins

identifying patients with urticarial venulitis or serum sickness (C4-, C3-, C1q-binding assay for circulatory immune complexes), as well as those with hereditary and acquired forms of C1 INH deficiency (C4, C1 INH by protein and function, C1q level).

Raynaud's Disease

idiopathic spasm of the arterioles of the digits (occasionally of nose, tongue) causing intermittent skin pallor, cyanosis, and ulceration. Predilection toward young, otherwise healthy women

Guided imagery

imagine healthy skin, immune cells fighting back and restoring health

Atopic dermatitis

important features: -early age onset - atopy refers to a group of patients who had a personal or family history of one or more of the following diseases: hay fever asthma very dry skin eczema - immunoglobulin E reactivity - Xerosis- (dryness)

Factors which influence topical glucocorticoid potency

include the molecular structure of the compound, the vehicle, the amount of medication applied, the duration of application, occlusion, as well as host factors, including age, body surface area and weight, skin inflammation, anatomic location of treated skin, and individual differences in cutaneous or systemic metabolism.

Topical corticosteroids (TCS

increasingly recognized as allergens as well

topical glucocorticoid to cause adrenal suppression is greatest

infants and young children

Dermatophytes

infectious agents are classified in three asexual genera -Epidermophyton infect skin and nail -Microsporum infect skin and hair -Trichophyton : infect skin, nail and hair most common tinea pedis, nail infections, tinea cruris, and tinea corporis

Varicella Zoster prodrome

intense pain in the involved dermatome precedes the rash in 90% of cases

fine wrinkles near the eye are glyphic wrinkles

intrinsic to aging

Large Vessel Vasculitis-

involves arterioles and arteries

Motion of the affected area

is encouraged to prevent strictures from forming

pyoderma: Staphylococcus aureus

is not normal flora: can colonize the nares, perineum and axilla. Invades skin and causes impetigo, folliculitis, cellulitis and furuncles

Erythema multiforme

its idiopathic we dont know what causes it lymphocytes accumulating along the dermoepidermal junction where basal keratinocytes become vaculated

Carbuncle

large abscess (usually of staph origin) extending from an infected follicle into the subcutaneous fat -nape of the neck or on the back. -As the abscess extends, several points of drainage may form

nodule

large raised, rounded lesion >1cm

Wegener's granulomatosis

large vessel vasculitis Progressive disease characterized by granulomatous lesions of the respiratory tract, focal necrotizing arteriolitis and widespread inflammation of most major organs. Skin lesions appear as papules, vesicles, palpable purpura, ulcers or subcutaneous nodules.

Patch

larger flat area of altered color >1cm

Segmental vitiligo

less common subtype that presents as unilateral depigmented macules and patches that completely or partially occur in a dermatomal distribution

superficial type of tinia barbae

less inflammatory and resembles tinea corporis or bacterial folliculitis.

Surgical excision

limited for use in treating large - treatment-resistant warts - scarring is problematic - especially on the sole of the feet

fluconazole for vaginitis problem

liver complications

Junctional nevi

located at the dermal-epidermal junction

Compound nevi

located at the dermal-epidermal junction AND dermis

Intradermal nevi

located in the dermis

Oculocutaneous albinism

more severe and most recognizable form, it affects the eyes, skin and hair. -Oculocutaneous albinism is more common in Sub-Saharan Africans, African-Americans, and Native Americans. the lack of melanin in the skin results in individuals that appear extremely pale. These findings can be generalized over the entire body or may appear in patchy areas. Due to the lack of melanin found in their skin, this makes them more vulnerable to sunburns and skin cancers.

Toxic Epidermal necrolysis

mortality is 35% the whole epidermis necrosis Steven johnsons syndrome

Superficial spreading melanoma

most common across all age groups, representing about 70% of cases. It follows the ABCD characteristics of asymmetry, multi-colors, and irregular borders

Epidermoid cysts

most common cutaneous cysts Located anywhere on the body, often on the back, face, and chest Flesh-colored nodules, often with a central punctum Size ranges from a few millimeters to several centimeters Round and mobile on palpation

Generalized vitiligo

most common subtype, and is characterized by few to many widespread macules and patches that are often symmetrically placed

Nodular BCC:

most common. These lesions appear as a raised, firm papule or nodule, described as waxy, pearly, shiny, or translucent. The border appears to be a rolled edge. The lesions may form a central ulceration or scab and commonly have surface telangectasia, dilated red blood vessels. A common patient complaint is easy bleeding and scabbing.

Kawasaki disease

mucocutaneous lymph node syndrome A condition resulting from immune activation in response to an infectious agent

Contact dermatitis

nickel, thimerosol, and fragrance mix -most common occupational skin disease in the United States -90-95% of all skin disorders acquired in the workplace -common in all age groups -Women > men with nickel but ? due to ear piercing -cell-mediated, delayed (type IV) hypersensitivity reaction -subsequent sensitization of a genetically susceptible host, to an environmental allergen, which on reexposure triggers a complex inflammatory reaction. -allergic form, the individual must have sufficient contact with a sensitizing chemical, and then have repeated contact with that substance later. Only minute quantities of allergen are necessary -irritant form, no sensitization reaction takes place, and the intensity of the irritant inflammatory reaction is proportional to the dose—concentration and amount of the irritant

Discoid lupus erythematosus

nickolsky sighn dermal musin increase is also present

Cellulities Non-Purulent

no associated abscess or purulent drainage -empiric therapy for infections due to beta-hemolytic streptococcus and MSSA

Linear IgA bullous dermatosis

rare

Paraneoplastic Syndromes

rare disorders that are triggered by an altered immune system response to a neoplasm -clinical syndromes involving non-metastatic systemic effects that accompany malignant disease -appear before or concurrently with an internal malignancy -Cutaneous manifestations may develop before a diagnosis of malignancy is determined; thus, these findings may aid the physician in the early identification of malignancy. -cutaneous signs may be related to internal malignancy

Rubeola

red measles hard measles

Methicillin

resistant staph aureus (MRSA)is an increasing problem.

Overuse of topical steroids

result in cutaneous atrophy, -hirsutism, -folliculitis, -acne, - striae, -telangiectasias, -purpura, -changes in pigmentation -systemic side effects

Puritis with a rash

same, plus treatment of the skin disease (usually a secondary eczema) with topical or systemic corticosteroids

Sarcoptes scabiei

scabes -Human infestation caused by host-specific itch mite that lives its entire life cycle within the epidermis -close physical contact or by fomites -remain alive for 2-3 days in clothing or in bedding -Causes a diffuse, pruritic eruption after an incubation period of 4-6 weeks -Areas affected in order of prevalence: interdigital webs of hands, wrists, shaft of penis, antecubital crease, feet, genitalia, buttocks, axillae.

Tinea capitis

scalp ringworm -invades the hair shaft -M. canis, M. audouinii, T. tonsurans, and T. schoenleinii. -Usually affects children -patch of alopecia present with black dots indicating hairs that have been broken off. -pustules of the follicles are evident -extreme inflammation, a nodular lesion called a kerion develops!!! - NODULAR LESIONS

Sharp debridement

scalpel scissors (local anesthetic)

8-10 years

sebaceous glands begin to produce sebum

Ocular albinism

second main type - it only affects the eye person's skin and hair usually have a similar color seen in normal individuals.

Varicella complications

secondary bacterial infection with scarring in children and varicella pneumonia in adults.

Deep fungal infections

secondary to implantation hematogenous spread of an underlying systemic infection

Wood's ultraviolet light examination

tinea capitus

Erythromycin and Clindamycin

topical antibiotics -Available in pads, gels, solutions lotions, pledgeletts and roll on -May be used once to twice daily -Should NOT be used as monotherapy for acne -Better treatment efficacy when combined with retinoids or benzyl peroxide -Used with benzyl peroxide decreases the occurrence of bacterial resistance

Atopic dermatitis treatment

topical therapy: -cutaneous hydration = improve microfissures and cracks in the skin -warm soaking bath 10 min occlusive emollient or topical medication + occlusive emollient or topical medication - lotions taht contain water may be drying due to evaporative effect - anti inflammatory therapy is the corner stone of treatment for anti inflammatory eczematous skin lesions -low potency foams = face / genitalia/ intertriginous regions - use EMOLLIENT CREAMS with low dose steroid period for maintenance therapy - different potencies especially in pediatric patients - nonsteroidal immunomodulators = topical tacrolimus + pimecrolimus

Zoophilic

transmitted to humans from animals Cats, dogs, rabbits, guinea pigs, birds, horses, cattle and other animals are common sources of infection Transmission may occur through direct contact with the animal itself, or indirectly via infected animal hair

Pyoderma: Bullous Impetigo TX

treat topically with mupirocin TID x 5 days. If multiple best to use systemic oral antibiotics

Exanthema areas affected

trunk and neck

ETN

typically concentrated on the trunk, but frequently found on the forehead, face, extremities, palms and soles are usually spared -Pustular fluid reveals eosinophils on Wright or Giemsa stain -There's nothing toxic about ETN -Self-limited, resolves within 5-7 days

Molluscum Contagiosum lesions

umbilicated dome-shaped papules that may auto-inoculate from one part of the body to another

Dermatitis Artefacts

use something morethan fingernails—burning cigarettes, chemicals, sharp instruments to damage own skin

Intralesional therapy

used to reduce pain and swelling in nodules Dosing= triamcinolone 3 mg/ml- 0.1 to 0.3 ml injected with a 30 gauge needle

Biofeedback

uses special monitors to measure bodily functions you normally have no control over, such as blood pressure or heart rate, in order to give you a better understanding of what's going on in your body and to train you to gain a measure of control over it

Herpes zoster

varicella-zoster virus (VZV) and occurs more commonly in older individuals -pain can be misdiagnosed as other medical or surgical conditions, such as migraine, acute myocardial infarction, or acute abdomen, depending on the involved dermatomes. -vesicles develop on an erythematous edematous base in a unilateral, dermatomal distribution -predisposition is thoracic dermatomes (>50%), followed by trigeminal dermatome (10-20%). -Nasociliary involvement of ophthalmic branch of the trigeminal nerve is often heralded by vesicles near the nose tip (Hutchinson's sign) and may result in uveitis, keratitis, or conjunctivitis -Acute pain can occur before and throughout the course of skin eruptions

Flat warts

verruca plana - more flat --> topped and less hyperkeratotic than common warts -flesh-colored or with brown tones -grouped lesions on the face or on the legs of women who shave with a straight-edged razor

Tinea versicolor treatment

very mild cases with nonprescription(OTC) antifungal creams or a prescription antifungal cream, lotion, or spray can be used. -The most economical effective treatment is to apply a antifungal shampoo to the body as if it were a soap, leave it on for several minutes then rinse it off. For extensive cases oral antifungal for 5-7 days are effective in clearing the infection

Sebaceous Hyperplasia

visible enlarged sebaceous glands

nursing home residents assessment should be done

weekly for 4 weeks then quarterly

Melasma

well demarcated, hyperpigmented macules are seen on the cheek nose and forehead