LEIK Skin and Integumentary System Review

Pityriasis rosea

"CHRISTMAS TREE" pattern rash (rash on CLEAVAGE lines). "HERALD PATCH" largest lesion, appears INITIALLY.

Impetigo

"HONEY-colored" CRUSTS. Fragile bullae. Pruritic.

Scarlet fever

"SANDPAPER" rash with sore throat (strep throat).

Tinea Infections (DERMAtophytoses)

*BASELINE LFTs and REPEAT "2" WEEKS AFTER initiating SYSTEMIC antifungal treatment. Monitor. ■ GOLD standard: GRISEOFULVIN (microsize/ultramicrosize) daily to BID × "6 to 12" WEEKS. ■ AVOID HEPATOTOXIC substances (Alcohol, Statins, Acetaminophen).

Varicella-Zoster Virus Infections Treatment

*Most effective when TREATED "48 to 72" HOURS AFTER onset of RASH! Acyclovir (Zovirax) 5 × per day or valacyclovir (Valtrex) BID × 10 days for initial breakouts and 7 days for flare-ups. Most effective when started within 48 to 72 hours of when rash appears.

Herpetic Whitlow

A VIRAL skin infection of the finger(s) that is caused by HERPES SIMPLEX (type 1 (ORAL) or type 2 (GENTIAL) virus infection, from DIRECT CONTACT with either a cold sore or genital herpes lesion. ■ Self-limited infection: ANALGESICS or nonsteroidal anti-inflammatory drugs (NSAIDs) for pain PRN. ■ SEVERE infections: Treat with ACYCLOVIR (Zovirax).

Hidradenitis Suppurativa

A bacterial infection of the sebaceous glands of the axilla (or groin) by STAPHylococcus aureus (gram positive) that frequently becomes chronic. It is marked by fl are-ups and resolution. Usually both axillae are involved. Chronic episodic infection eventually leaves sinus tracts and heavy scarring.

Atopic Dermatitis (Eczema)

A chronic inherited skin disorder marked by extremely PRURITIC rashes that are located on the hands, flexural folds, and neck (older child to adult). The rashes are exacerbated by stress and environmental factors (i.e., winter). The disorder is associated with atopic disorders such as asthma, allergic rhinitis, and multiple allergies (family history). Classic Case Infants up to age 2 years have a larger area of rash distribution compared to teens and adults. The rashes are typically found on the cheeks, entire trunk, knees, and elbows. Older children and adults have rashes on the hands, neck, and antecubital and popliteal space (flexural folds). The classic rash starts as multiple small VESICLES that RUPTURE, leaving PAINFUL, bright RED, WEEPY lesions. The lesions become LICHENIFIED from chronic itching and can persist for months. FISSUREs form that can be secondarily infected with bacteria.

Boils (Furuncles)

A furuncle/boil is an infected hair follicle that fills with pus (abscessed). It looks like a round red bump that is hot and tender to touch. When it is fluctuant, it can rupture and drain purulent green-colored discharge. Apply antibiotic ointment BID and cover with dressing until healed.

Meningococcemia

A serious life-threatening infection caused by Neisseria MENINGITIDES (gram-NEGATIVE DIPLOcocci) that are spread by respiratory DROPLETS. Bacterial meningitis is a medical EMERGENCY. ■ Do not delay treatment if high index of suspicion—REFER to ED emergency department STAT. ■ COLLEGE students living in dormitories are at higher risk. If treated EARLY, mortality is LESS than 5%. The bodily damage is due to the endotoxin's effects on the endothelium of blood vessels. Classic Case ■ Described earlier under "Danger Signals." Labs ■ Lumbar punctures: culture cerebrospinal fluid (CSF). ■ Blood cultures, throat cultures, etc. ■ CT or MRI of the brain.

SHINGLES Infection of the TRIGIMINAL Nerve (Herpes Zoster Ophthalmicus)

A sight-threatening condition caused by REACTIVATION of the HERPES ZOSTER virus that is located on the OPTHALMIC branch of the TRIGIMINAL nerve (CN 5). Patient reports SUDDEN eruption of MULTIPLE VESICULAR lesions (ruptures into SHALLOW ULCERS with CRUSTS) that are located on ONE SIDE on the SCALP, FOREhead, and the sides and the tip of the nose. If herpetic rash is seen on the TIP of the NOSE, assume it is shingles until proven otherwise. The EYELID on the same side is swollen and red. The patient complains of PHOTOphobia, eye PAIN, and BLURRED vision. This is more COMMON in ELDERLY patients. Known as *OPHTHALMICUS! REFER to an OPTHALmologist or the ED as soon as possible.

Erysipelas

A subtype of cellulitis involving the upper dermis and superfi cial lymphatics that is usually caused by "Group A" STREPTOcoccus.

Tinea Versicolor

A superficial skin infection caused by YEASTS PITYROSPORUM ORBICULAR or PITYROSPORUM OVALE. Classic Case Complains of MULTIPLE HYPOPIGMENTED round MACULES on the chest, shoulders, and/or back that "appear" AFTER skin becomes tan from SUN exposure; ASYMPTOMATIC.

Impetigo

Acute superficial skin infection caused by gram-POSITIVE bacteria such as STREP PYOGENES (beta strep) or S. aureus. It is very contagious and pruritic, and is more common in warm and humid weather. Two types: bullous and nonbullous forms.

Severe Cystic Acne

All of the preceding findings plus PAINFUL indurated nodules and cysts over face, shoulders, and chest. Medications Isotretinoin (ACCUTANE) is a category X drug (extremely TERATOGENIC). Need to sign special consent forms. Females must enroll in approved pregnancy prevention program (iPLEDGE). Use two forms of reliable contraception. Prescribe 1-month supply only. MONTHLY PREGNANCY testing and show results to pharmacist before refills. Pregnancy test "1" MONTH AFTER discontinued. Discontinue if the following are present: ■ Severe depression, visual disturbance, hearing loss, tinnitus, GI pain, rectal bleeding, uncontrolled hypertriglyceremia, pancreatitis, hepatitis

Paronychia

An ACUTE LOCAL BACTERIAL skin infection of the proximal or lateral NAIL FOLDs (CUTICLE) that resolves after the abscess drains. Causative bacteria are STAPH aureus, STREPtococci, or PSEUDOmonas (gram NEGATIVE). Chronic cases are associated with coexisting onychomycosis (fungal infection of nails). Classic Case Complains of acute onset of a painful and red swollen area around the nail on a finger that eventually becomes abscessed. The most common locations are index finger and thumb. Reports a history of picking on a hangnail, biting off hangnail, or of trimming of the cuticle during a manicure.

Scabies

An INFESTATION of the skin by the Sarcoptes scabiei MITE. The female mite burrows under the skin to lay her eggs; transmitted by close contact. May be ASYMPTOMATIC the FIRST "2 to 6" WEEKS. Even AFTER treatment, the PRURITIS may PERSIST for "2 to 4" WEEKS (SENSITIVITY reaction to mites and their feces).

Psoriasis

An INHERITED skin disorder in which SQUAMOUS epithelial cells undergo RAPID MITOTIC division and ABNORMAL maturation. The rapid TURNOVER of skin produces the classic PSORIATIC PLAQUE. Classic Case The patients complains of PRURITIC ERYTHEMATOUS PLAQUES covered with fine SILVERY WHITE SCALES along with PITTED FINGERnails and TOEnails. The plaques are distributed in the scalp, elbows, knees, sacrum, and the intergluteal folds. PARTIALLY RESOLVING PLAQUES are PINK colored with minimal scaling. Patients with PSORIATIC ARTHRITIS will complain of PAINFUL RED, WARM, and SWOLLEN JOINTS (MIGRATORY arthritis) in addition to the skin plaques.

Tinea Infections (DERMAtophytoses)

An infection of SUPERFICIAL KERTINIZED tissue (skin, hair, nails) by TINEA YEASTS organisms. Tinea yeasts organisms are classified as DERMATOPHYTES. GOLD Standard: FUNGAL CULTURE of Scales/Hair/Nails/Skin Lesions: KOH SLIDE microscopy (low to medium power) reveals pseudohyphae and spores. Spaghetti and Meatballs

Contact Dermatitis

An inflammatory skin reaction due to contact with an irritating external substance; can be a single lesion or generalized rash (i.e., sea-bather's itch). Common offenders are: POISON IVY (rhus dermatitis) and NICKEL. Onset can occur within MINUTES to several HOURSafter skin contact. Classic Case Acute onset of one to multiple bright red and pruritic lesions that evolve into bullous or vesicular lesions; easily ruptures, leaving bright red moist areas that are painful. When rash dries, it becomes crusted; very pruritic and gets lichenified from chronic itching. The shape may follow a pattern (i.e., a ring around a fi nger) or have asymmetric distribution. Medications ■ Stop exposure to substance. Calamine lotion; topical steroids; oatmeal baths (Aveeno). ■ Severe rash: Oral prednisone for 12 to 14 days (wean). Avoid reexposure.

Cherry Angioma

BENIGN SMALL and smooth ROUND PAPULES that are a BRIGHT CHERRY-RED color. The sizes range from "1 to 4" MM. Lesions are due to a NEST of MALFORMED ARTERIOLES. It is ASYMPTOMATIC.

Black Box Warning

BLACK BOX Warning (Topical TACROLIMUS) ■ RARE cases of MALIGNANCY (including skin and lymphoma). Use SUNblock. AVOID if patient is IMMUNOCOMPROMISED. - SEVERE disease: ANTIMETABOLITES (i.e., METHOTREXATE), BIOLOGICS/ANTI-TUMOR NECROSIS FACTOR (TNF) agents BLACK BOX Warning (BIOLOGICS/ANTI-TNF agents) ■ HUMIRA, ENBREL, and REMICADE are associated with HIGHER risk of serious/fatal INFECTIONS, malignancy, TB, fungal infections, SEPSIS, etc. (BASELINE PPD, CBC with differential). ■ GOECKERMAN regimen (UVB light and TAR-derived topicals) may induce REMISSION in SEVERE cases.

Lyme Disease

BORRELIA BURGODOFERI

Melasma (Mask of PREGNANCY)

BROWN to TAN-colored STAINS located on the upper CHEEKS and FOREhead in some women who have been or are PREGNANT or on oral contraceptive pills OCP (estrogen). It is more COMMON in DARKER-skinned women. STAINS are usually PERMANENT but can LIGHTEN over time.

Rosacea (Acne Rosacea)

CHRONIC and relapsing skin inflammatory disorder that is common. There is NO CURE for ROSACEA. Management is aimed at SYMPTOM CONTROL and AVOIDANCE of TRIGGERS that cause exacerbations. Complications ■ RHINOPHYMA: HYPERPLASIA of tissue at the tip of the NOSE from chronic severe disease ■ OCULAR ROSACEA: Blepharitis, conjunctival injection, lid margin telangiectasia

Pityriasis Rosea

Cause UNKNOWN. SELF-LIMITING illness ("4 to 8" WEEKs) and ASYMPTOMATIC. ■ "HERALD PATCH": FIRST lesion to appear and largest in size; appears "2" weeks BEFORE full breakout. NO MEDICATIONS. Advise patient that lesions will take about "4" WEEKS to RESOLVE. ■ If HIGH RISK of STDs, check rapid plasma reagent (RPR) to rule out secondary SYPHILIS.

Anthrax

Caused by BACILLUS ANTRACIS (gram-POSITIVE rods). There are three types of anthrax (cutaneous, GI, and pulmonary). PULMONARY anthrax (inhalational anthrax) is caused by inhaling aerosolized spores through working with animal/wool/hides/hair, or through bioterrorism. Fulminant inhalational anthrax causes death within days. Symptoms are flu-like and associated with cough, chest pain with cough, hemoptysis, dyspnea, hypoxia, and shock.

Rocky Mountain Spotted Fever

Caused by the bite of a DOG tick or WOOD tick that is infected with the parasite RICKETTSIA RICKETTSII. If high index of suspicion, DO NOT DELAY treatment (do not wait for lab results). Treatment MOST EFFECTIVE if started WITHIN FIRST "5" DAYS of symptoms. DOXYcycline is the FIRST-line treatment for all age groups (CDC, 2011). Most cases occur in the SPRING and EARLY SUMMER. Classic Case Described earlier under "Danger Signals." Labs ■ Diagnostic: antibody titers to R. rickettsii (by indirect fluorescent antibodies) ■ BIOPSY of skin lesion (3 mm punch biopsy). CBC, LFTs, CSF, others *DO NOT WAIT FOR LABS to start TREATMENT!

Varicella-Zoster Virus Infections

Chickenpox (varicella) and herpes zoster (shingles) are both caused by the same virus. The PRIMARY infection is called chickenpox (VARICELLA) and the REACTIVATION of the infection is known as shingles (HERPES ZOSTER). After primary infection (chickenpox), the virus becomes latent within a DERMATOME (SENSORY GANGLIA) and is kept under control by an intact immune system. ■ Chickenpox: CONTAGIOUS from "1 to 2" DAYS BEFORE the onset of the rash and UNTIL all of the lesions have CRUSTED over (chickenpox and shingles). DURATION of illness is "1 or 2" WEEKS. ■ Shingles: CONTAGIOUS with the onset of the rashes UNTIL all the lesions have CRUSTED over Labs GOLD standard: VIRAL CULTURE, polymerase chain reaction (PCR) for ZDV. ■ Only a person who HAS HAD chickenpox (rarely the chickenpox vaccine) can get shingles. ■ About one in five people with shingles will suffer from PHN. POST HERPTIC NEURALGIA (Affects Nerves, Fiber, Skin, BURNING PAIN.

CARBUNCLES: Complications

Complications ■ Osteomyelitis; septic arthritis; sepsis. ■ Tendon and fascial extension. ■ Rarely, death (V. vulnificus infections have high fatality rates).

Melanoma

DARK-colored MOLES with UNEVEN TEXTURE, VARIEGATED COLORS, and IRREGULAR BORDERS with a DIAMETER of "6" MM or larger are observed. They may be PRURITIC. If melanoma is in the nailbeds (fungal melanoma), it may be very AGGRESSIVE. Lesions can be located ANYWHERE on the body including the RETINA. Risk factors include FAMILY HISTORY of melanoma (10% of cases), extensive/intense SUNLIGHT EXPOSURE, blistering SUNBURN in childhood, TANNING beds, high nevus count/atypical nevus, and light skin/eyes.

Acanthosis Nigricans

DIFFUSE VELVETY THICKENING of the skin that is usually located behind the neck and on the axilla. It is associated with DIABETES, METABOLIC syndrome, OBESITY, and cancer of the gastrointestinal (GI) tract.

Subungual Hematomaterm-38

DIRECT trauma to the NAILbed results in PAIN and BLEEDING that is trapped BETWEEN the nailbed and the finger/toenail. If the HEMATOMA involves ">25%" of the area of the nail, there is a high risk of PERMANENT ISCHEMIC DAMAGE to the nail matrix if the blood is NOT DRAINED. One method of draining (TREPHINATION) a subungual hematoma is to straighten one end of a steel paperclip or to use an 18-gauge NEEDLE and HEAT it with a flame until it is very hot. The hot end is pushed down gently until a 3 to 4 mm hole is burned on the nail. The nail is pressed down gently until most or all of the blood is drained or suctioned with a smaller needle. Blood may continue DRAINING for "24 to 36" HOURs.

Rocky Mountain Spotted Fever TREATMENT

DOXYcycline BID OR TETRAcycline QID (4 times daily) × "21" DAYS. REFER STAT.

Exam Tips

Differentiate between contact dermatitis and atopic dermatitis. The best clue is the unilateral location and the shape of the lesions in contact dermatitis. ■ Rashes that are very pruritic at night and located on the INTERDIGITAL WEBS and/or PENISare scabies until proven otherwise. Treat ENTIRE family. Wash linens/clothes in hot water. ■ Preferred antibiotic is AUGMENTIN for human, dog, and cat BITES. ■ Do not confuse ACTINIC keratosis (PREcursor to squamous cell CANCER) with SEBORRHEIC keratoses (BENIGN). ■ Diagnose hidradenitis suppurativa, psoriasis, RMSF, meningococcemia, erythema migrans (Lyme disease), contact dermatitis, rosacea. ■ Instead of SILVERY scales, may see "covered with FINE scales" with PSORIASIS ■ PSORALENS (TAR-derived topicals) used to treat psoriasis, ANTIMETABOLITE (methotrexate). ■ How to treat MILD and moderate acne. Mild acne is treated only with TOPICALS. ■ ACCUTANE in females: Use "TWO FORMS" of reliable BIRTH control. ■ "Herald patch" or a "Christmas tree" pattern is found in PITYRIASIS ROSEA. ■ PHN (post-herpetic neuralgia) prophylaxis: TRICYCLIC ANTIDEPRESSANTS (TCA), amitriptyline (Elavil). ■ A clue in a case scenario on cellulitis may involve a patient walking barefoot. ■ Recognize ERYSIPELAS versus other types of cellulitis. ■ Treatment for ROSACEA is topical metronidazole FLAGYL gel. ■ Recognize HERPETIC WHITLOW.

Bulla

Elevated superficial BLISTER filled with serous fluid and ">1 CM" in size. Example: Impetigo, second-degree burn with blisters, SJS lesions

Vesicle

Elevated superficial skin lesion "<1 CM" in diameter and filled with serous fluid Example: Herpetic lesions

Pustule

Elevated superficial skin lesion "<1 CM" in diameter filled with PURULENT fluid Example: Acne pustules

Early Lyme Disease

Erythema migrans is a skin lesion caused by the bite of an IXODES TICK infected with BORRELIA BURGODOFERI. If untreated, infection becomes systemic and affects multiple organ systems. Classic Case ■ Described earlier under "Danger Signals."

Macule

FLAT NONpalpable lesion "<1 CM" diameter Example: Freckles, lentigenes, small cherry angiomas

Plaque

FLATTENED ELEVATED lesions with VARIABLE shape that is ">1 CM" in diameter Example: PSORIATIC lesions

Rubella

GERMAN Measles at ANY AGE! -Headache -Low Grade Fever -Sore Throat -Coryza -LYMPHADENOPAHTHY -FORCHHEIMER Spots RASH starts at "FACE" then spreads CEPHALOCAUDALLY.

HIV

HIV esophageal Candida infections should be treated with systemic antifungals (fluconazole).

Vitiligo

HYPOPIGMENTED PATCHES of skin with IRREGULAR shapes. It is PROGRESSIVE and can involve large areas. It can be located ANYWHERE on the body and is more VISIBLE on DARKER skin.

Clenched Fist Injuries (Fist Fights)

High risk of INFECTION to joints (i.e., knuckles), fascia, nerves, and the bones. REFER to ED for treatment. There may be a foreign body embedded, such as a tooth (x-ray needed) and/or a fracture. ■ Necrotizing fasciitis: usually "Group A" strep or polymycrobial. ■ Reddish to purple color lesion that increases rapidly in size. Infected area appears indurated ("woody" induration) with complaints of severe pain on affected site.

Tinea versicolor

Hypopigmented round to oval macular rashes. Most lesions on upper shoulders/back. Not pruritic.

Xerosis

INHERITED skin disorder that results in extremely DRY skin and may involve mucosal surfaces such as the mouth (xerostomia) or the conjunctiva of the eye (xerophthalmia).

Actinic Keratoses: Treatment

If there are only a SMALL number of lesions, they can be treated with CRYOTHERAPY. With LARGE numbers, FLUOROROURACIL cream 5% (5-FU cream), a TOPICAL ANTINEOPLASTIC agent, is used over SEVERAL WEEKS.

Lyme Disease: Serum antibody titers

IgM means EARLY IgG means LATE "M" minutes it happens

Smallpox (Variola Virus)

Infects respiratory and oropharyngeal mucosal surfaces. "Eliminated" in 1977. Incubation period of 2 weeks. Flu-like signs/symptoms. Numerous large nodules appear mostly in the center of the face and on the arms and legs. Treatment is SYMPTOMATIC. Mortality rate is 20% to 50%. Smallpox Vaccine If vaccine is given within 3 to 4 days postexposure, can lessen severity of illness. Vaccinia immune globulin (for pregnant, immunosuppressed, etc.) is available from special clinics.

Measles

KOPLIK's spots are small white round spots on a red base on the buccal mucosa by the rear molars.

Rocky Mountain Spotted Fever Treatment

Medications DOXYcycline BID OR TETRAcycline QID (4 times daily) × "21" DAYS. REFER STAT. Complications ■ DEATH. NEUROLOGICAL sequelae (hearing loss, paraparesis, neuropathy, others).

...

Medications Topical steroids, topical retinoids (tazorotene), tar preparations (psoralen drug class).

CARBUNCLES (COALESCED BOILS) Several: NON-MRSA Treatment

NON-MRSA nonpurulent cellulitis: DICLOXAcillin PO (orally) QID × 10 days (preferred due to high rate of beta-lactam resistance). OR Cephalexin QID OR Clindamycin TID × "10" DAYS. ■ PENIcillin ALLERGIC: - Erythromycins (macrolides) - Second-generation Cephalosporins, Clindamycin. ■ Td BOOSTER: If last dose was more than 5 YEARS ago. ■ Recurrent cellulitis: Consider decolonozation. Muciprocin BID on nares × 5 to 10 days. ■ Elevate affected limb. Follow up with the patient within 48 hours. Refer cellulitis cases if: ■ Systemic symptoms develop (i.e., fever, toxic) or worsen. ■ The cellulitis is not responding to treatment within 48 hours. ■ Cellulitis is spreading quickly or is a small lesion with gangrenous center associated with large amount of pain (necrotizing fasciitis). ■ Patient is a diabetic, immunocompromised, or taking anti-TNF (rheumatoid arthritis).

Onychomycosis (Nails)

Nail becomes YELLOWED, THICKENED, and OPAQUE with debris. Nail may SEPARATE from nailbed (ONCHYLOSIS). Great toe is the most common location. Treated with SYSTEMIC ANTIFUNGALS, except for MILD cases. If mild, trial of TOPICAL treatment (PENLAC "NAILpolish").

Actinic Keratosis

OLDER to elderly FAIR-skinned adults complain of NUMEROUS DRY, round, and RED-colored lesions with a ROUGH texture that DO NO HEAL. Lesions are SLOW growing. Most common locations are SUN-EXPOSED AREAS such as the cheeks, nose, face, neck, arms, and back. The risk is highest for those with LIGHT-colored skin, hair, and/or eyes. In some cases, a precancerous lesion of SQUAMOUS CELL CARCINOMA is a possibility. Patients with early childhood history of severe SUNburns are at higher risk for squamous cell, basal cell carcinoma, and melanoma.

Rube"O"la O for Ordinary

ORDINARY Measles occurs at ANY AGE! -Conjunctivitis -Cough -Coryza -FEVER KOPLIK's SPOTS! RASH starts at "HAIRLINE" spreads CEPHALOCAUDALLY over 3 days!

Mild Acne (Topicals Only)

Open comedones (blackheads), closed comedones, small papules, small pustules. ■ Prescription meds: ISOTRETINOIN (Retin-A), BENZOYL peroxide with erythromycin (Benzamycin) cream, CLINDAmycin topical (Cleocin). Start at LOWEST dose: RETINOIC acid (Retin-A) 0.25% cream EVERY OTHER DAY at BEDtime × "2 to 3" WEEKS, then DAILY application at bedtime. PHOTOsensitivity reaction possible (use SUNSCREEN).

Superficial Candidiasis Treatment

Oral-Thrush: Complains of a severe sore throat with white adherent plaques with a red base that are hard to dislodge on the pharynx. Thrush in "healthy adults" who are not on antibiotics may signal an immunodefi cient condition. ■ Nystatin powder and/or cream in skin folds (intertriginous areas) BID. OTC topical antifungals are miconazole, clotrimazole. Prescription needed for terconazole, ciclopirox. ■ Keep skin dry and aerated. ■ Nystatin (Mycostatin) oral suspension for oral thrush (swish and swallow) QID. ■ "Magic Mouthwash" (viscous lidocaine, diphenhydramine, Maalox) is compounded by pharmacists and is for severe sore throat (thrush, canker sores, mouth ulcers). Note HIV ESOPHAGEAL INFECTIONS should be treated with SYSTEMIC ANTIFUNGALS (fluconazole).

Papule

PALPABLE SOLID lesion up to "0.5 CM" Example: Nevi (moles), acne

Scabies: Treatment

PERMETHRIN 5% (Elimite); apply cream to ENTRE body (head to soles); WASH OFF at "8 to 14" HOURS. ■ TREAT EVERYONE in the same household at the same time. Any CLOTHES/BEDDING used 3 days before and during treatment should be washed and dried using the HOT settings. ■ PRURITIS usually improves in "48" HOURS, but can last up to 2 to 4 weeks (even if mites are dead). DO NOT RETREAT (do WET MOUNT to check for live mites). Treat ITCH with BENADRYL and TOPICAL steroids. ■ Long-term care facility: TREAT ALL patients, staff, family members, and frequent visitors for scabies.

POST HERPTIC NEURALGIA: Treatment

POST HERPTIC NEURALGIA (Affects Nerves, Fiber, Skin, BURNING PAIN! Treatment ■ TRICYCLIC ANTIDEPRESSANTs: LOW dose Amytriptyline ■ ANTICONVULSANTS: Depakote, Gabapentin ■ LIDOCAINE PATCH

Actinic Keratoses

PRECANCEROUS precursors to SQUAMOUS CELL carcinoma. Classic Case Older to elderly adult complains of numerous DRY ROUND and red-colored lesions with a ROUGH texture that DO NOT HEAL; lesions SLOW growing; most common locations are SUN EXPOSED areas such as the cheeks, nose, face, neck, arms, and back; highest risk if LIGHT-colored skin, hair, and/or eyes; a PRECANCEROUS lesion of SQUAMOUS CELL carcinoma. Early childhood history of frequent SUNBURNS places person at higher risk.

Vitamin D Synthesis

People with DARKER skin require LONGER periods of sun EXPOSURE to produce vitamin D. A deficiency in PREGNANCY results in INFANTILE RICKETS (BRITTLE BONES, skeletal ABNORMALITIES).

Tinea Versicolor: Labs

Potassium hydroxide (KOH) slide: hyphae and spores ("spaghetti and meatballs").

*Meningococcemia

Purple-colored to dark red painful skin lesions all over body. Acute onset high fever. Headache. LOC changes. RIFAMPIN prophylaxis for close contacts.

Acute Cellulitis

Purulent form of cellulitis: STAPHyloccus aureas (gram-POSITIVE. Community-acquired MRSA now common. Most cases are located on the LOWER LEG (85%). ■ Nonpurulent form of cellulitis: Usually due to streptococci (but may also be staph). ■ Dog and cat bites: PASTURELLA multicoda (gram-negative). ■ Erysipelas: Group B STREPTOCOCCUS. ■ Puncture wounds (foot): Contaminated with soft-foam liner material or puncture wounds through sneakers. Rule out PSEUDAMONAS AERUGINOSA ■ VIBRIO VULNIFICUS: SALTWATER contamination, higher risk if liver disease or immunocompromised.

Rocky Mountain Spotted Fever

RICKETTSIA RICKETTSII

Roseola

ROSEOLA INFANTUM -Affects children "6-36" months old -Caused by HUMAN HERPES VIRUS 6 -ABRUPT HIGH FEVER -AFTER FEVER, Starts at NECK and TRUNK then spreads to the face and extremities.

Xanthelasma

Raised and YELLOW-colored soft PLAQUES that are located UNDER the BROW or upper and/ or LOWER LIDS of the EYES on the nasal side. It may be a SIGN of HYPERLIPIDEMIA if present in persons YOUNGER than "40" YEARS of age.

*Rocky Mountain spotted fever (Rickettsia ricketsii from tick bite)

Red spot-like rashes that fi rst break out on the hand/palm/wrist and on the feet/sole/ankles. Acute onset high fever. Severe headache. Myalgias.

Erythema migrans (BORRELIA BURGODOFERI)

Red target-like lesions that grow in size. Some central clearing. Early stage of Lyme disease.

Nevi (Moles)

Round MACULES to PAPULES (junctional NEVI) in colors ranging from light tan to dark brown. Their borders may be DISTINCT or slightly IRREGULAR.

Molluscum contagiosum

SMOOTH PAPULES "5"-mm size that are dome-shaped with CENTRAL umbilication with a WHITE "PLUG."

Basal Cell Carcinoma (BCC)

SUPERFICIAL form (30%) of BCC looks like a PEARLY or WAXY skin lesion with an ATROPHIC or ULCERATED center that DOES NOT HEAL. The color could be white, light pink, brown, or flesh colored. It may BLEED EASILY with MILD TRAUMA. This is MORE COMMON in FAIR-skinned individuals with long-term DAILY SUN exposure. An important RISK factor is SEVERE SUNBURNS as a CHILD. Central Depression, Volcano like lesion. *MOST COMMON SKIN CANCER!

Moderate Acne (Topicals Plus Antibiotic)

Same as indicated for mild acne plus large numbers of papules and pustules. Treatment Plan ■ Use PRESCRIPTION TOPICALS (i.e., Benzamycin) PLUS Oral TETRAcycline (Category D), or MINOcycline (Minocin) (causes HA, DIZZY), or DOXYcline. ■ TETRAcyclines can be given for acne starting at about AGE "13" Growth of PERMANENT teeth is FINISHED except wisdom teeth (or third molars), which erupt between the ages of 17 to 25 years. ■ TETRAcyclines (Category D): PERMANENT DISCOLORATION of growing tooth enamel. Tetracyclines DECREASE EFFECTIVENESS of oral contraceptives OCP (use additional method). NOT given during pregnancy or to children UNDER age "13." ■ Others: Certain oral contraceptives OC (Desogen, Yaz) are indicated for acne.

Molluscum contagiosum

Smooth papules 5-mm size that are dome-shaped with central umbilication with a white "plug."

Lipoma

Soft FATTY CYSTIC TUMORS located in the SUBCUTANEOUS layer of the skin. These could be of round or oval shape. These tumors can be large and are located mostly on the neck, trunk, legs, and arms. They are PAINLESS unless they become too large or are irritated or ruptured.

Seborrheic Keratoses

Soft and ROUND WART-like FLESHY growths in the trunk that are located mostly on the BACK Lesions on the same person can range in color from light tan to black. It is ASYMPTOMATIC.

Superficial Candidiasis

Superficial skin infection from the yeast CANDIDA ALBICANS. Environmental factors promoting overgrowth are: increased warmth and humidity, friction, and decreased immunity; Superficial skin infection from the yeast Candida albicans. Environmental factors promoting overgrowth are: increased warmth and humidity, friction, and decreased immunity; can infect skin (candidal intertrigo), mucous membranes (thrush, vaginitis), and systemically.Intertrigo/intertriginous areas of the body (or apposed areas of skin that rubtogether) can be infected by either fungal and/or bacterial organisms. Classic Case External: An obese adult complains of BRIGHT RED and SHINY lesions that itch or burn, located on the intertriginous areas (under the breast in females, axillae, abdomen, groin, the web spaces between the toes). The rash may have SATELLITE lesions (SMALL red rashes AROUND the MAIN rash).

Meningococcemia

Symptoms include SUDDEN onset of SORE THROAT, cough, FEVER, HA , STIFF NECK PHOTOPHOBIA, and changes in LOC (drowsiness, lethargy to coma). The appearance could be toxic. In some cases, there is ABRUBT onset of PETECHIAL to HEMORRHAGIC RASHES (PINK to PURPLE colored) in the axillae, flanks, wrist, and ankles (50% to 80% of cases). RAPID progression in fulminant cases results in DEATH within "48" HOURS. The risk is higher for COLLEGE students residing in DORMITORIES (the CDC recommends vaccination for this higher-risk group). It is spread by AEROSOL DROPLETS. RIFAMPIN PROPHYLAXIS is recommended for close contacts.

Screening for Melanoma

The "A, B, C, D, E" of MELANOMA: A (ASYMMETRY) B (BORDER irregular) C (COLOR VARIES in the same region) D (DIAMETER ">6" MM) E (ENLARGEMENT or change in size) Other symptoms to watch for include INTERMITTENT BLEEDING with MILD TRAUMA and itching.

Rocky Mountain Spotted Fever

The classic RASH looks like SMALL RED SPOTS (PETICHIAE) and starts to erupt on both the HANDS and FEET (including the PALMS and SOLES), rapidly progressing toward the TRUNK until it becomes GENERALIZED. The rashes appear on the THIRD 3RD day after the ABRUBT onset of HIGH FEVER (103 to 105 degrees) accompanied by a severe headache, MYALGIA, conjunctival injection (red eyes), nausea/vomiting, and arthralgia. Rocky Mountain spotted fever (RMSF) can be fatal, with a mortality rate ranging from 3% to 9%. In the United States, the highest incidence is in southeastern/south central areas of the country. Most cases of RMSF occur during the SPRING and EARLY SUMMER season.

Erythema Migrans (Early Lyme Disease)

The classic lesion is an EXPANDING RED RASH with CENTRAL CLEARING that resembles a TARGET. The "BULLS-EYE" RASH usually appears WITHIN "7 to 14" DAYS after a DEER TICK bite (range between "3 to 30" DAYS). The rash feels HOT to the touch and has a ROUGH texture. Common locations are the BELT line, AXILLARY area, BEHIND the knees, and in the GROIN area. It is accompanied by FLU-like symptoms. The lesion SPONTANEOUSLY RESOLVES within a FEW WEEKS. It is most common in the northeastern regions of the United States. Use of DEET containing REPELLENT on clothes and skin can repel DEER TICKS.

Stevens-Johnson Syndrome (Erythema Multiforme Major)

The classic lesions appear TARGET-like (or "bulls-eye"). Multiple lesions start erupting abruptly and can range from hives, blisters (bullae), petechiae, purpura, and hemorrhagic lesions that are painful. EXTENSIVE mucosal surface involvement (eyes, nose, mouth, esophagus, and bronchial tree) is observed. There could be a prodrome of FEVER with FLU-like symptoms BEFORE rashes appear. Stevens-Johnson syndrome (SJS) is a SEVERE and RARE hypersensitivity reaction caused by medicines, infections, and malignancies. The drug classes associated with SJS are the PENIcillins, SULFAs, BARBITUATES, and phenytoin (Dilantin). Mortality rate is 25% to 35%. "HIV-infected" patients have a 40-fold INCREASED RISK of SJS due to trimethoprim/sulfamethoxazole compared with the general population.

ACRAL LENTIGINOUS Melanoma

This is the most common type of MELANOMA in AFRICAN AMERICANSs and ASIANS, and is a SUBTYPE of melanoma (<5%). These dark brown to black lesions are located on the NAILBEDs (SUBUNGAL), palmar, and plantar surfaces, and rarely the mucous membranes. Subungual melanomas look like longitudinal brown to black bands on the nailbed.

Tinea Barbae

Tinea Barbae (BEARD Area) Beard area affected. Scaling with pruritic red rashes

Tinea Corporis or Tinea Circinata

Tinea Corporis or Tinea Circinata (Ringworm of the BODY) Ring-like pruritic rashes with a collarette of fine scales that slowly enlarge with some central clearing. Large numbers or severe cases can also be treated with oral antifungals.

Tinea Cruris

Tinea Cruris ("JOCK ITCH") Perineal and groin area has pruritic red rashes with fi ne scales; may be mistaken for candidal infection (bright red rashes with satellite lesions) or intertrigo (bright red diffused rash due to bacterial infection).

Tinea Manuum

Tinea Manuum (HANDS) Pruritic round rashes with fine scales on the hands. Usually infected from chronic scratching of foot that is also infected with tinea (athlete's foot).

Tinea Pedis

Tinea Pedis (Athlete's FOOT) Two types: Scaly and dry form or moist type (strong odor). Dry type with fine scales only. Moist lesions between toe webs, which are white-colored with strong unpleasant odor.

Tinea Versicolor: Medications

Topical selenium sulfide OR ketoconazole (Nizoral) shampoo or cream BID × 2 weeks. Oral antifungals have also been used.

Scabies

Very pruritic, especially at night. Serpenginous rash on interdigital webs, waist, axilla, penis.

Psoriasis: Special Findings AUSPITZ sign

■ AUSPITZ sign: PINPOINT areas of BLEEDING REMAIN in the skin when a PLAQUE s REMOVED.

TOPICAL STEROIDS

■ AVOID STEROIDS in case of suspected FUNGAL etiology because it will WORSEN the INFECTION. ■ Infants, children, and adults with THIN FACIAL skin: - DO NOT use FLUORINATED topical steroids. USE 0.5% to 1% HYDROCORTISONE. ■ TOPICAL steroids: HPA (hypothalamus-pituitary-adrenal) AXIS SUPPRESSION may occur with excessive or prolonged use. It can cause Striae, Skin Atrophy, Telangiectasia, Acne, and HYPOpigmentation. ■ CHRONIC STEROIDS can cause CATARACTS

Clinical Tips

■ About "80%" of CAT bites become infected. ■ Use ophthalmic grade/sterile cream/ointments for rashes near the eyes. ■ On thin skin such as the facial and intertriginous areas (skin folds), use low-potency topical steroids (i.e., hydrocortisone 1%). On thicker skin such as the scalp, back, or soles, may use higher potency steroids. ■ If beta STREPtococcus Group B infection in cellulitis, also at risk for developing POST GLOMERULAR NEPHRITIS as seen in STREP throat. Treat for "10" DAYS. ■ NOT ALL DOG BITES have to be treated with antibiotics (if they are not on the extremities).

Bites: Human and Animal

■ All bites and infected wounds need wound cultures with sensitivity testing (C&S). ■ Do NOT suture wounds at HIGH RISK for INFECTION: puncture wounds, wounds ">12" HOURS old ("24" HOURs on face), cat bites, bites wounds on compromised hosts. ■ Cartilage injuries (cartilage does not regenerate); refer to plastic surgeon. ■ Tetanus prophylaxis (if last booster ">5" YEARS, needs booster). ■ Follow up with patient within 24 to 48 hours after treatment. Referral of Wounds ■ Closed-fist injuries or crush injuries ■ Cartilage damage or wounds with cosmetic effects; refer to plastic surgeons ■ Compromised hosts: adult diabetics, absent/dysfunction of the spleen, immunocompromised

Hidradenitis Suppurativa Treatment

■ Amoxicillin/clavulanate (AUGMENTIN) PO BID OR DICLOXAcillin TID × "10" DAYS. ■ MUPIROCIN ointment to LOWER THIRD of NARES and under FINGERNAILs BID × "2" WEEKS. ■ Use ANTIbacterial soap (e.g., Dial), especially on axilla and groin areas. ■ AVOID underarm deodorants during acute phase.

Rabies

■ Bats, raccoons, skunks, foxes, coyotes (domestic animals can also have rabies). ■ Rabies immune globulin plus rabies vaccine may be required. Call local health department for advice. Consider if wild animal acts tame, copious saliva, unprovoked attack, or animal looks ill. ■ Option: Quarantine a domestic animal for 10 days (look for signs/symptoms of rabies).

Total Percentage of Body Surface Area (TBSA)

■ Body surface: "9%" (each ARM, HEAD) ■ Body surface: "18%" (each LEG, ANTERIOR trunk, or POSTERIOR trunk)

Impetigo Treatment

■ CEPHAlexin (Keflex) QID, DICLOxacillin QID × "10" DAYS. ■ PCN allergic: AZITHROmycin 250 mg × "5" DAYS (macrolides), CLINDAmycin × "10" DAYS. ■ If very FEW lesions with no bulla, may use topical 2% MUPIROCIN ointment (Bacitracin) × "10" DAYS. ■ FREQUENT hand-washing, shower/bathe daily to remove crusts.

Meningococcemia Treatment

■ Ceftriaxone (ROCEPHIN) 2 g IV every "12" HOURS PLUS VANCOmycin IV every "8-12" HOURS ■ Hospital; isolation precautions; supportive treatment

Meningococcemia Treatment

■ Ceftriaxone (ROCEPHIN) 2 g IV every "12" HOURS PLUS VANCOmycin IV every "8-12" HOURS ■ Hospital; isolation PRECAUTIONS; supportive treatment Complications ■ Tissue INFARCTION and NECROSIS (i.e., gangrene of the toes, foot, fingers, etc.) causing amputation ■ Death

Meningococcemia: Prophylaxis

■ Close contacts: RIFAMPIN PO every 12 hours × 2 days. ■ Meningococcal VACCINATION ecommended for all COLLEGE students living in DORMitories.

Erythema Migrans (Early Lyme Disease): TREATMENT

■ EARLY Lyme ONLY: DOXYcycline BID (twice daily) OR TETRAcycline × 14 days (AMOXIcillin if PREGNANT).

Early Lyme Disease Treatment

■ EARLY Lyme only: DOXYcycline BID (twice daily) OR TETRAcycline × "14" DAYS Pregnant: use AMOXIcillin Complications ■ Neurological system problems such as GUILLIAN-Barré syndrome ■ MIGRATORY arthritis, chronic fatigue, and so forth

Superficial Thickness (First Degree)

■ ERYTHEMA ONLY (no blisters). Painful (i.e., sunburns, mild scalds). ■ Cleanse with MILD soap and water (or saline): Cold packs for "24 to 48"HOURS. ■ Topical OTC anesthetics such as benzocaine if desired.

Psoriasis: Complications

■ GUTTATE psoriasis (DROP-SHAPED lesions): SEVERE form of psoriasis resulting from a BETA-HEMOLYTIC STREPTOCOCCUS Group A infection (usually due to STREP throat).

Full Thickness (Third Degree)

■ Initial assessment: Rule out AIRWAY and BREATHING compromise. Smoke INHALATION injury is a medical EMERGENCY. PAINLESS. Entire skin layer, subcutaneous area, and soft tissue fascia may be destroyed. ■ REFER: FACIAL burns, ELECTRICAL burns, THIRD-degree burns, CARTILAGINOUS areas such as the nose and ears (cartilage will not regenerate). Burns on GREATER than "10%" of body.

Psoriasis: Special Findings KOEBNER phenomenon

■ KOEBNER phenomenon: NEW PSORIATIC PLAQUE form OVER areas of SKIN TRAUMA.

Rosacea (Acne Rosacea) Treatment

■ Metronidazole (Metrogel) topical gel (TOPICAL FLAGYL) ■ AZELAIC acid (Azelex) topical gel ■ LOW-dose oral TETRAcycline or MINOcycline given over several weeks

Varicella-Zoster Virus Infections: Complications

■ PHN: More common in elderly and immunocompromised patients. Treat PHN with TRICYCLIC ANTIDEPRESSANTs (i.e., low-dose AMItriptyline), ANTICONVULSANTS (i.e., Depakote), or GABAPENTIN TID. Lidocaine 5% patch (Lidoderm) to intact skin. ■ Herpes zoster OPTHALMICUS (CN 5): Can result in CORNEAL BLINDESS. REFER IMMEDIATELY to ophthalmologist or ED (described under "Danger Signals"). ■ Others: RAMSAY HUNT syndrome (herpes zoster oticus or CN 8), refer to NEUROLOGIST

Onychomycosis (Nails): Treatment

■ PULSE therapy with systemic antifungals. BASELINE LFTs. Monitor periodically. ■ Oral FLUCONAZOLE 150 mg to 300 mg "WEEKLY" OR terbinafine (LAMISIL) weekly × several "WEEKS". ■ MILD cases: Penlac NAIL LACQUER × several "WEEKS". Works best in MILD cases of the fingernails.

Anthrax Treatment

■ Postexposure prophylaxis (exposure to bioterrorism event): CIPROfloxacin 500 mg PO BID × "60" DAYS (alternate is DOXYcycline PO)

Partial Thickness (Second Degree)

■ RED-colored skin with SUPERficial BLISTER (bullae). Painful (i.e., hot water/oil scalds, fire). ■ Use water with MILD soap or normal SALINE to clean broken skin (not hydrogen peroxide or full-strength Betadine). DO NOT RUPTURE blisters. Treat with silver sulfadiazine cream (SILVADENE) and apply dressings.

Paronychia: Management

■ SOAK affected finger in warm water for "20" minutes "3" TIMES a day. ■ Apply TOPICAL antibiotic such as triple antibiotic or mupirocin to affected finger after soaking. ■ Abscess: I&D Incision and drainage (use #11 scalpel) or use the beveled edge of a large-gauge needle to gently separate the cuticle margin from the nail bed to drain the abscess.

Contact Dermatitis: Treatment

■ STOP EXPOSURE to substance. CALAMINE lotion; topical STEROIDS; OATMEAL baths (Aveeno). ■ SEVERE rash: ORAL PREDNISONE for "12 to 14" DAYS (WEAN). Avoid reexposure.

CARBUNCLES (COALESCED BOILS): Suspect MRSA Treatment

■ Suspect MRSA: BACTRIM DS one tablet BID × "10" DAYS DOXYcycline PO BID × "10" DAYS OR CLINDAmycin 3 to 4×/day for "10" DAYS.

Psoriasis Treatment

■ Topical STEROIDS ■ Topical RETINOIDS (TAZOROTENE) ■ TAR preparations (PSORALEN drug class).

Atopic Dermatitis (Eczema) Treatment

■ Topical steroids are FIRST-line treatment. - MILD: HYDROcortisone 1% to 2.5%. - MEDIUM: TRIAMcinolone (KENAlog. ■ Medium to HIGH potency (HAlog) use × "10" DAYS and TAPER to WEAKER steroids, then STOP. ■ Systemic oral ANTIhistamines for PRURITIS (Benadryl, hydroxyzine). ■ Skin lubricants (Eucerin, Keri Lotion, baby oil). AVOID drying skin/XEROSIS since it will exacerbate eczema (i.e., no hot baths, harsh soaps, chemicals, wool clothing). ■ Hydrating baths (avoid hot water/soaps) followed immediately by application of skin lubricants (Eucerin, Keri Lotion, Crisco). Do not wait until skin is dry before applying.