Derm - Peds Primary Care 1 - Exam 2

What can you use to treat mastocytoma?

Cyproheptadine (Periactin)

Alopecia areata = -May be reaction to? -May have? -May complain of 1) Clinical presentation? (3) 2) treatment?

= Sudden loss of hair, comes out in clumps -May be reaction to stress -May have thyroid disease -May complain of tingling/burning 1) well circumscribed annular patches exclamation point hairs sparing of white hairs 2)Topical class 1 steroids, Intralesional steroid Topical irritant therapy Immunotherapy

ICD = ? 1) Prior exposure? 2a) exogenous and 2b) endogenous elements

= inflammatory rxn in the skin d/t exposure to a substance that can cause eruption in most people who come in contact w/it 1) NOT necessary, May occur from a single application w/severely toxic substances but Most commonly d/t repeated application from mildly irritating substances (soaps, detergents) 2a) Most important exogenous (irritant and environmental) factor = inherent toxicity of chemical for human skin 2b) Endogenous (host) factors = site differences in barrier function (face, neck, scrotum, dorsal hands more susceptible), atopic dermatitis (impaired barrier function, lower threshold for skin irritation)

Pityriasis alba = 1- Presents as? 2- Typically found in what patients? 3- Do not expect?

=Mild, often asymptomatic, form of AD on face (hypo-pigmentation from dry skin) 1- poorly marginated, hypopigmented, slightly scaly patches on the cheeks/patchy white spots 2- young children (with darker skin) often presenting in spring and summer when normal skin begins to tan 3- itching

What are the different forms of psoriasis? (6)

Napkin psoriasis - diaper rash doesnt get better Guttate (teardrop) psoriasis - tear drops all over Scalp psoriasis Erythrodermic psoriasis Pustular psoriasis Psoriatic arthritis

How do you treat painful piezogenic papules?

Restriction of weight-bearing exercise Weight loss Compression stockings Foam rubber foot pads or foam-fitting plastic heel cups Consultation with orthopedist or podiatry

What do you educate patients on about pityriasis alba? -Reassure that it generally? -Use? -If using __ and __ does not improve skin lesions, consider...

Reassure that it generally fades with time Use sunscreen to minimize tanning If moisturization and sunscreen does not improve skin lesions, consider low strength topical steroids

What is a good way to teach patients about hydrating the skin if they have AD? Basic Management for Mild Disease... Step 1: -antipruritic, anti-sting Step 2: Step 3: Do what with Moderate-to-Severe Disease?

Xerosis contributes to epithelial micro cracks, which allow entry of microbes and allergens 1) Skin Care: (1a) Warm soaking bath (10+mins) ... antipruritic (baking soda/oatmeal), DEC sting w/acute exacerbation (salt) -Dont bathe too frequently, no soaps (1b) Moisturizer (w/in 3 mins)... 3-4/daily PRN -Ointment = Vaseline, Petrolatum jelly, Crisco -Cream = Vanicream, Cereve, Cetaphil (1c) Cotton PJs (no polyester) ... Wet Wrap Therapy can be used in significant flares w/recalcitrant disease (2) Antiseptic: Dilute bleach baths x2/week (3) Trigger Avoidance: No soaps, lanolin/wool, temp extremes, known/proven allergens Everything above but add: Maintenance TCl or Topical Corticosteroid

TL has an allergic contact dermatitis, likely to her new eye shadow. What treatment would you recommend other than avoidance? a. Clobetasol ointment b. Desonide cream c. Fluocinonide gel d. Ketoconazole cream

b. Desonide cream = class 6 (okay for face) topical steroid

TL has an allergic contact dermatitis that responds to topical steroids. What is the best test to confirm the cause of her rash? a. Indirect immunofluorescent antibody (IIF) test b. Patch testing c. Prick skin testing d. Radioallergosorbent test (RAST)

b. Patch testing

What percentage of children with atopic dermatitis also have or will develop asthma or allergic rhinitis? a. 10% b. 15% c. 30% d. 35% e. 50%

c. 30% = asthma d. 35% = allergic rhinitis

HPI: A 16 year old with two months of red, chapped, painful hands. She works at McDonalds and washes her hands frequently No one else at work is experiencing similar symptoms. PMH: asthma as a child, intermittent hay fever Based on her history and exam findings, what is the most likely diagnosis? a. Allergic contact dermatitis b. Dyshidrotic dermatitis c. Irritant contact dermatitis d. Nummular dermatitis

c. Irritant contact dermatitis

Psoriasis is a __ __ __ disorder. 1-What are the clinical characteristics? 2-What are the most common sites? 3- __ __ is common 4- __ Sign = ?

chronic recurrent inflammatory disorder (of cornum stratum) 1- CIRCUMCISED, erythematous plaques covered w/micaceous scales, 2- Sites: back of elbows and knees, Buttocks, Scalp, and Nails 3- Koebner phenomenon is common 4- Auspitz's sign= Bleeds when scratched

What elements in the history are important to ask in children with AD? a. Does she scratch or rub her skin? b. Does the rash keep her awake at night? c. Which moisturizers are used and where? d. All of the above

d. All of the above

What is napkin psoriasis? Strep can follow with what skin condition after 1-2 weeks?

diaper rash that doesn't go away Guttate psoriasis

Which of the following statements is true about irritant and allergic contact dermatitis? a. ICD accounts for 80% of all cases of contact dermatitis, and is often occupationrelated b. In contrast to ACD, no previous exposure to the irritant is necessary in ICD c. In general, ICD remains at the site of contact and resolves in a few days after exposure, opposed to 1-3 weeks with ACD d. Symptomatically, pain and burning are more common in irritant contact dermatitis, contrasting with the usual itch of allergic contact dermatitis e. All of the above

e. All of the above

Which of the following statements supports the diagnosis of atopic dermatitis? a. Chronic nature of the rash b. Distribution of the rash c. Family history of atopic disease d. Symptom of pruritus e. All of the above

e. All of the above

What is telogen effluvium? What are some triggers?

generalized hair loss with no bare patches and abrupt onset = positive pull test triggers: blood loss, iron deficiency, thyroid imbalance, initiation of drugs, illness, stress

What is a mastocytoma?

red or red brown nodules composed of mast cells may urticate or form a blister

Contact dermatitis is... 2 types?

skin condition created by reaction to an externally applied substance • Irritant Contact Dermatitis (ICD) • Allergic Contact Dermatitis (ACD)

What is acne mechanica caused by?

occlusion and pressure form padding and face equipment in football, ice hockey, and field hockey

Describe what eyelid chronic allergic contact dermatitis might look like? (5) What are some causes of eyelid ACD? What would you use to treat eyelid allergic contact dermatitis?

pruritic, erythematous, scaly, slightly lichenified plaques on upper eyelids (usually more here than lower) Nail polish, Fragrances or preservatives in cosmetics (eye shadow) Desonide cream; Do not use ointments! Eyelid epidermis is thinner. Rub in well, come back if spreads. --if topical steroids (desonide) has to be used on eyelid (eyelid ACD) for >1 month = Derm referral (ophthalmologist - monitoring of intraocular pressure and dev of cataracts and glaucoma)

What do you do to treat abrasions?

Clean with soap and water Apply antibiotic ointment (Bacitracin) and cover

Blisters, if tense, need to be drained. To reduce friction once opened, what can you tell patients to do?

Cover

Seborrheic dermatitis: What should be used for treatment? (5) What patient education can you give regarding managing seborrheic dermatitis? (2) __ is an off label treatment for seborrheic dermatitis that has Black Box

(Antifungal) Antidandruff shampoo: 1 fails, switch group -- Selenium sulfide 2.5% (Selsun) -- Selenium sulfide 1% (Selsun Blue) -- Coal tar (no Rx needed- Neutrogenia T/gel) -- 1-2% pyrithione zinc (1% is Head and Shoulders) -- Ketoconazole shampoo *** Top choice (1) Freq cleansing with soap; (2) Outdoor recreation - sunlight helps but avoid sun damage Elidel

1-Seborrheic dermatitis occurs in what populations? 2-What is seborrheic dermatitis 3-What it caused by? 4-Seborrheic dermatitis responds to what? 5-If you see a patient - NOT infant or adolescent - with Seborrheic dermatitis, what should you be thinking? 6- Where do you see it on the body? (7)

-1- Infant ("Neonatal 2-3w, anterior fontanel") (cradle cap); Adolescent (dandruff) -2- Flaky scalp -3- Androgens and pityrosporum ovale (present on all people, but can be opportunistic) -4- Antifungals (anti-dandruff shampoo) -5- Is there (a) androgen excess (crossing growth curve in height), if not (b) Seborrheic form Tinea capitis, or (c) atopic dermatitis -6- where sebaceous blends in high freq (NOT eyelids) -Scalp, Eyebrows, Eyelashes -Forehead, Nasolabial fold, External ear canal, under breasts

1- Vitiligo is ___ disease with what underlying mechanism? 2- what lab tests do you order? 3-It is a/w with what colored eyes? 4- a/w what other autoimmune diseases 5- Teens with vitiligo or family history of vitiligo should avoid ? 6- Vitiligo can be along lines of __________.

-1- autoimmune ... Melanocyte destruction or damage leading to reduced or absent pigmentation of skin, hair, mucous membranes -2- Thyroid (TSH, Free T4) (more a/w hypothyroidism), Vitamin D (may be def in Antioxidants) -3-Tan and hazel/green eyes -4-alopecia areata, psoriasis, RA, celiac (Non segmental vitiligo = higher incidence of autoimmune thyroid disease) -5- hair dyes, & food rich in hydroquinone & phenol (blueberries, pears, mushroom) -6- Blaschko

How can you prevent ICD?

-Avoid irritant -Use PPE -Instead of soap, use less irritating substances (emollients - Dove sensitive bar soap, soap substitutes) -Care should be taken for several months after dermatitis has healed, as skin remains vulnerable to flares of dermatitis for prolonged period

topical CorticoSteroids: -super high potency -high potency -medium potency -low potency (2) Other option for AD?

-Class 1 = Clobetasol propionate 0.05% -Class II = Fluocinonide 0.05% -Class III-V = Triamcinolone ointment (strongest) to lotion (weakest) -Class VI = Desonide 0.05% -Class VII = Hydrocortisone 1% Topical Calcineurin Inhibitors: Great around eyes, can combine w/topical corticosteroids -Protopic ointment -Pimecrolimus (Elidel) cream ... black box = higher rate of lymphoma in rats

What class steroids can be safely used on the face?

-Class 6 (desonide) -Class 7 (hydrocortisone cream 1%) Regular use of class 1-3 steroids on thin skin will lead to steroid atrophy (thinning, easy bruising/purpura) and hypo pigmentation in darker skin.

1) Key to ACD Treatment? 2) Who should be referred? When taking a history about dermatitis, make sure to ask about:

1) Avoid exposure to offending substance 2) Chronic cases or patients with dermatitis involving over 10% of the BSA should be referred to a dermatologist, if they dont get better = refer Dermatitis specific: onset, location, temporal associations, treatment Daily skin care routine All topical products Occupation/hobbies Regular and occasional exposure (lawn care products, animal shampoos)

How do you treat ICD? 1) Basic 2) Prescribe 3) For Itch... (4) -- with occupational cases?

1) ID and avoid irritant 2) Topical steroids to reduce inflammation + emollients improve barrier repair 3) Itch: -Antihistamines often don't work, can try PO -Pramoxine=Topical anesthetic (aveeno anti itch) -Capsaicin= interferes with itch -Menthol= create a competitive sensation --Patch testing for suspected chronic irritant dermatitis to exclude an allergic contact dermatitis

Infantile Hemangiomas: Treatment (2) -Timing?

1) Propranolol -Must be started early‐reached 80% of size by 3‐5 months 2) Timolol (topical) -Timolol plus laser with varying response -75% regress without regrowth

Rhus Allergy: 1- initial episode occurs ___ days after exposure 2- Rhus dermatitis lasts? --Initial vs subsequent episodes? 3- Describe what rhus dermatitis will look like? Lesions that begin as __ __ --> __ or __ --Classic sign -- __ often form over ? days 4-Fomites?

1) initial episode occurs 7-10 days after exposure 2) 10 to 21 days depending on the severity -- Initial is the longest (up to 6 weeks!) 3) erythematous macules --> papules or plaques --Classic sign = Koebner phenomenon (linear streaks/papules, from scratching) --Blisters often form over 1-2 days 4) can be contaminated by the plant oil, lead to recurrent eruptions = Wash clothing, ect.

1) Nevus of Jadassohn? 2) how do you assess for active hair loss in telogen effluvium?

1) should be removed before adolescence --> increased rate of malignancy 2) Pull test: -grab at about 60 hairs and tug at them from proximal to distal end -removal of more than 6 hairs indicates positive pull test and active hair loss

The cause of AD is multifactorial, what are factors that may play a role? (4)

1- Genetics 2- Skin barrier dysfunction (Tcell Impairment) .. in part initiated by skin barrier defects (acquired or genetic) [underlying T cell mediated abnormality that makes them prone to viral and bacterial infection. AD GETS 2ndary INFECTED] 3- Impaired immune response - increased serum IgE levels are common and correlate with disease severity. inadequate innate immune response to epicutaneous microbes partially responsible for increased susceptibility to infections (staph and herpes). IgE antibodies are made against staph toxins. 4- Environment ...dry (damp is good - diaper area will always be clear d/t moisture)

Reaction involved in Allergic Contact Dermatitis: 1- Type/Occurs when? 2- Timing re 1st exposure ?? 3- Episode: initial, re-ex 4- Main symptom? 5- Presents as? 6- Spread?

1- Occurs when contact with a particular substance elicits a delayed type 4 hypersensitivity rxn 2a - sensitization process req 10-14 days ??? 3 -- initial episode occurs 7-10d after exposure, upon re-exposure, dermatitis appears w/in 12-48hrs 4- pruritus 5- eczematous, scaly edematous plaques with vesiculation distributed in areas of exposure (bilateral if exposure is bilateral - creams, gloves, shoes) 6- can be in area of contact but can also spread via blood (not by contact) and cause an ID reaction ? antihistamines dont work, do calm patient down

Pityriasis Versicolor: 1- clinical presentation= 2- On what body parts? 3- Cause? 4- more common with?

1- Widespread, superficial/minimal scaling hypo or hyper pigmented macules or flat papules 2- upper trunk, arms, neck and face 3- Superficial yeast infection d/t Malassezia 4- high humidity and temperatures/summer

How do you treat vitiligo? 1- timing? 2- prescribe?

1- early medical treatment is more likely to work in the first 2-5 years of the disease 2- Topical -corticosteroids (Class II - mometosone) -calcineurin inhibitors (tacrolimus) -vitamin D analogue (Calcipotriene) - use this for 3-4 months on face, 6-8 months on body

What is phyto-photodermatitis? 1--Occurs after... 2--Triggers? 3--Primary skin lesions range from __ __ to __ _ 4--What can follow the acute phase of this? 5--Can be mistake for? (3)

1--Occurs after contact with photosensitizing compounds in plants and exposure to sunlight 2--Furocoumarins= found in citrus fruits, celery, fig, parsnip, parsley, carrots, dill, perfumes 3--delayed erythema (24-48hr) to frank blisters 4-- postinflammatory pigment alteration = hyperpigmentation (melanin, which is normally found in the epidermis, "falls" into the dermis and is ingested by melanophages) 5--atopic dermatitis, type IV hypersensitivity reaction (contact dermatitis) or a chemical burn

What are the 5 types of dermatitis?

1--Seborrheic "= common, mild skin inflammation that presents as yellowish, oily, scaly patches of skin on scalp, face, ears (aka dandruff, cradle cap) 2--Atopic "= syndrome of 3 associated conditions that tend to occur in the same individual: atopic dermatitis, inhalant allergies, and asthma... skin is itchy, inflamed, vesicle formation, cracking, weeping, crusting, scaling. Dry skin is a very common." 3--Dyshidrotic "=irritation of palms (mostly) and/or soles -- clear, deep-seated blisters that itch, burn. It's 'tapioca pudding' like rash on the palms." 4--Nummular "=coin/round, isolated patches of irritated skin - commonly arms, lower legs - may be crusted, scaling, itchy" 5--Contact (allergic, irritant) "= skin has come into direct contact with an irritant"

Guttate Psoriasis: 1-Clinical presentation (4) 2-What are common sites? (3) 3-Pearl? Nail psoriasis: 4-clinical presentation 5-Gets confused with Inverse psoriasis? 6- clinical presentation, found where, key point?

1-Annular, localized erythematous to salmon colored plaques with hyperkeratosis 2-Trunk, abdomen, back 3- Strep can precipitate and treating this sore throat will clear it, though it can also be the herald for further psoriasis 4-Nail pitting, oil spots, subungle hyperkeratosis 5-Gets confused with fungal infection 6-Thick plaques found in folds (axillae, groin) that can get secondarily infected with candida

Pityriasis rosea: 1-clinical presentation= Begins... 2-Treatment? 3- ages?

1-Begins with a herald patch that goes into generalized, non-pruritic eruption within 2 weeks ---> oval, erythematous lesions, in lines of skin cleavage (Christmas tree pattern) 2-clears spontaneously in 6 weeks 3-Common in 20s

1) All patients with ACD need patch testing? -- How is it done? 2) A positive reaction on patch testing does not mean?

1_ No but refer for patch testing if don't know cause or if patient wants to know cause of ACD -- Best test to confirm the cause of ACD A) Series of allergens are applied to the back, and they are removed after 2 days B) On day 4 or 5, the patient returns for the results C) Pos rxns show erythema and papules or vesicles 2) does not mean that the patient's rash is due to that specific allergen. Elimination of the rash with removal of the allergen confirms the clinical relevance of the positive patch test.

What is the 1st, 2nd most common cause of allergic contact dermatitis? What are other causes? (3)

1st = Rhus dermatitis: poison ivy, poison oak, poison sumac (all contain resin-urushiol) ... "Groups of three, let them be" 2nd = nickel Other causes: Balsam of peru (in makeup/shampoo/cheap lotions), fragrances, formaldehyde, preservatives, rubber compounds, Neosporin, Vit E

What treatment do you recommend for rhus dermatitis? A) Most pts need? B) But with ___/___ involvement?

A) minor supportive care: •Topical steroids (class 3) for localized involvement •Topical or oral antihistamines may improve pruritus •Oatmeal soaks/calamine to soothe weeping erosions B) Severe/Face=oral steroids 1-2mg/kg/d, max 60mg/d -- 2 week taper of oral prednisone (mild - mod) -- 3 week taper if severe (Oral, patients may relapse if given for less than 2-3 weeks = no short bursts) Topical prednisone if localized and no ID reaction. Rub in well, come back if spreads.

How can you differentiate ACD from herpes zoster?

ACD is generally not well localized and not in groups More linear T cell mediated and can be spread in the blood

What is the difference between ACD and ICD? -Contact w/particular substance = Rxn type -Exposure -Spread -Resolves -Symptoms Test to differentiate?

ACD: elicits delayed type 4 hypersensitivity rxn -previous exposure -ID reaction possible -takes about 1-3 weeks to resolve -pruritis ICD: non immunologic, inflammatory rx -no need previous exposure -remains at site of contact -resolves in a few days -erythema & chapped skin, pain (w/ erosions or fissures) and burning, pruritis mild to severe --- doesn't worsen, easier to control Patch testing may be performed in cases with suspected chronic irritant dermatitis to exclude an allergic contact dermatitis

Many patients with dyshidrotic eczema also have a history of? What is the mainstay of treatment for dyshidrotic eczema?

AD Tinea pedis Potent topical steroids

Dermatitis or eczema: Acute = pattern of ___ __ that presents with (3) Chronic phase = pattern of...(5)

Acute - pattern of cutaneous inflammation that present with erythema, vesiculation, and pruritis Chronic - pattern of dryness, scaling , lichenification, fissuring, and pruritis "Eczema is a nonspecific term for many types of skin inflammation (dermatitis). Different categories of eczema include allergic, contact, irritant, and nummular eczema, which can be difficult to distinguish from atopic dermatitis."

What is the difference between alopecia and telogen effluvium?

Alopecia Areata = localized patches, hair comes out in clumps (tingling/burning) Telogen Effluvium = generalized thinning, +pull test (>6 hairs)

What can you do to treat pitted keratolysis?

Antibacterial soap + BP

Atopic Triad includes: -"atopic march"? -%s

Atopic dermatitis + Allergic rhinitis + Asthma -AD is often the first manifestation of the "atopic march" with asthma and Allergic Rhinitis following. -Asthma also develops in ~30% and AR develops in 35% of those with AD.

Jogger's nipples occurs in endurance athletes. What do you do to treat?

Bandaid Vaseline with loose clothing

Latex allergy... -can present as? (2) -Only...?

Can present as delayed or immediate hypersensitivity. -delayed= allergic contact dermatitis, often on dorsal surface of hands -immediate= immediate symptoms (burning, stinging, or itching w/or w/out localized urticaria) on contact with latex proteins Only Type IV hypersensitivity that can go from localized to (immediate hypersen) ANAPHYLAXIS

What is classic picture for atopic dermatitis? (4) 1-usually develops? 2-AD affects ~ __ - __% of childhood pop in U.S. 3-Prone to? 4-What is the primary sx of AD?

Chronic nature Cheeks Family history of atopic disease Pruritis 1-in 85% within 1st yr, in 95% <5 years 2-10% to 12% 3-Viral, fungal and bacterial infection 4-Pruritus: AD often called the "itch that rashes." Chronic, pruritic, inflammatory skin disease w/wide range of severity. Common to have waxing and waning.

What can you do to treat acne mechanica?

Clean after working out with BP or astringent

A child has AD with honey comb crusting, what has most likely happened? Ichthyosis vulgaris = How common is AD in developed countries?

Colonization with staph aureus ... impetigo Dry, plaque like skin affecting ~ 20% of children and 1-3% of adults

If you see vesicles on the dorsal foot, what skin conditions might this be? if you see vesicles on sides of feet and toes, what skin conditions might this be? If you see vesicles on soles of feet, what skin condition could this be? If you see vesicles on balls and heels of feet, what skin condition could this be?

Contact dermatitis Insect bites Dyshidrotic eczema Tinea pedis (often with scaling and interdigital maceration) Friction blisters

What is an important history question to ask that would point to psoriasis? Pityriasis rosea gets confused with syphilis and generalized tinea corporis, what is the difference?

Does it go away in the summer? Pityriasis rosea is never on hands and feet Syphilis is

How to you treat and prevent black nails?

Drainage if painful keep nails short and make sure the toe box is adequate Shoes must fit

What will you see in a child with AD on PE... -Lesions typically begin as ___ __, which then coalesce to form __ __ that may display __, __ or __ -Acute + subacute= vs -Chronic =

Erythematous papules that then coalesce to form erythematous plaques that may display weeping, crusting, or scale -Acute + subacute= intensely pruritic, erythematous papulovesicular lesions w/ excoriation & serous exudate in young children vs -Chronic = lichenification, papules, excoriations

Complications of AD include:

Ezcema herpeticum -can be severe and progress to disseminated infection and death -Systemic antiviral agents No smallpox vaccination for patient or household contacts --> eczema vaccinatum (potentially fatal) Fungal infection

How do you apply a topical corticosteroids?

Finger tip method -amount of steroid = distal interphalangeal joint to tip of finger = enough to cover area of 2 palms is equal to -apply thin layer 2x day Rub in well in affected area When applying over large areas of dermatitis or using occlusion (plastic wrap), possibility of significant systemic absorption is greatly increased, esp in infants and young children

Which vehicle is effective for acute weeping or vesicular lesions? Which vehicle is effective for dry, lichenified, or plaque like areas? Potent corticosteroids should not be used in what areas because higher risk for systemic absorption? (5) levels of steroid?

Gels - penetrate well, drying Ointments - occlusive agents and may lead to sweating Face, Eyelids, Intertriginous areas (neck), Young infants, Genitalia class 1 = very high potency ... class 7 = lowest potency

What can you do to help yourself visualize piezogenic papules?

Have patient stand up

Distribution of AD in different age populations? -Infants and toddlers: -Older children and Adolescents: -Adults: -All populations

Infants and toddlers: cheeks, forehead, scalp, EXTENSOR (front of legs, back of arms). SPARES nasolabial folds and diaper area. 2+yrs & Adolescents: FLEXOR (side of arms, backs of legs) including neck, elbow, wrist, ankle -lichenification: thickening of skin that occurs after continual scratching Adults: HANDS/WRISTS, face (particularly the forehead and around the eyes), & dyshyrotic (tapioca pudding rash on the palms) -lichenification All populations xerosis = dry skin, common characteristic of all stages

Topical steroid dosing in children

Low potency topical corticosteroids are safe when used for short intervals -ADE in long duration High potency must be used with caution and vigilant clinical monitoring for ADE in children Potent steroids should be avoided in high risk areas - face, folds, occluded areas (diaper)

Urticaria will move and presents as............ Cellulitis will present as ................ Herpes Zoster will present as.............. Bullous insect bites will present as..............

MOVING edematous plaques (not vesicles but the early lesions of ACD can be mistaken for urticaria) spreading erythematous, non-fluctuant tender plaque, often with fever painful eruption of GROUPED vesicles in dermatomal distribution Usually scattered -Not linear or grouped -No history of multiple bites

primary skin lesions

Macule - circumscribed area <1 cm of discoloration flat relative to surrounding skin. Patch - circumscribed area of discoloration, >1cm, flat relative to the surrounding skin. Papule - circumscribed, elevated, solid, <1 cm. Plaque - circumscribed, elevated, superficial, solid lesion, >1 cm in diameter. Vesicle - superficial, circumscribed elevation of the skin, <0.5 cm, that contains serous fluid. Bulla (pl. Bullae) - A raised, circumscribed lesion >0.5 cm that contains serous fluid. Pustule - < 1 cm in diameter, circumscribed superficial, puss filled elevation of the skin

What are treatments for psoriasis?

NP: Topical steroids... -can also use combo steroid + Vit D analogue -can also use combo steroid + tazarotene DERM: Phototherapy & Systemic agents

How do you treat non painful piezogenic papules?

None required

When do you refer to derm for ACD or ICD?

Not improving with removal of irritant/allergen or severe cases ACD for involvement of over 10% of BSA

You notice a flat, annular, non erythematous, minimally pruritic lesion on the forearm of a child. The child reports no history of papular lesion and states the rash has not changed and has been there over the past 6 weeks.The child is overall very dry. What is this?

Nummular eczema = patch of dryness that doesn't change

Nummular eczema vs Tinea Corporus

Nummular eczema = static Tinea Corporus = Grows bigger, develops central clearing and has a raised border

What are piezogenic papules?

Papules that resolve when patient is non-weight bearing. Increased incidence in overweight population. They mostly occur over posterior and lateral border of heels and often bilateral May present with heel pain

What can you tell patients to do to prevent blisters?

Petroleum jelly on "hot spot"

EpiCeram & Eletone = ___ is used to treat seborrheic dermatitis in AA and AD. It is a ...

Prescription emollient devices work well with AD in improving hydration barrier but can be $$$ and not covered by all insurance Fluocinolone acetonide low potent steroid

Foul smelling feet is due to what bacteria?

Pseudomonas

What can be used to treat calluses and corns?

Pumice stone or file Do not share tools

Insect Bite‐Induced Hypersensitivity: -Acronym *What is a very good treatment for bug bites?

SCRATCH: ... Sarna = good for bed bugs -- Symmetrical = exposed surfaces: face, neck, arms, legs -- Cluster = meal cluster/breakfast, lunch, dinner grouping of lesions characteristic of bedbug bites --Rover = pet -- Age = rarely seen in <2 yrs -- Target lesions are characteristic for IBIH, particularly in dark‐pigmented patients -- Confused/surprised these reactions are due to bugs -- History = not often a/w family hist, unlike w/scabies and atopic dermatitis where we see a strong family history correlation.

Black nails occur in runners, cyclists, and tennis players. it is essentially a _________. It is due to?

Sunungal hematoma Due to repeated trauma of nail against shoe

What do the new clinical guidelines say about treating atopic dermatitis?

Systematic multipronged approach: -skin hydration -topical anti-inflammatory -anti-itch -antibacterial -elimination of exacerbating factors Overall, treatment for AD includes LT use of emollients and gentle skin care and ST treatment for acute flares

AD: Other therapies: -Tar preparations? -Antihistamines? -May consider? -In patients with recurrent skin infections -No?

Tar preparations - not found to be efficacious Antihistamines - not recommended -supplementation with vitamin D, especially if they have documented low level or low intake -Dilute bleach bath (2oz in bath water 2x week) = reduce severity of AD. BUT if see crusting around the nose think colonized and treat with bactroban - oral steroids - come back worse than before

A patient presents with white hypo pigmentation of the facial skin that is overall very dry. He also complaints of abdominal pain and bloating. What skin condition do you expect this to be and what tests do you want to order?

Thyroid (TSH, Free T4) Vitamin D Celiac disease screening

When moisturizers fail, how can AD be treated?

Topical corticosteroids = mainstay of therapy, reduce inflam., pruritis --Maintenance = Low potency (class 5-6) topical corticosteroids for maintenance therapy (x2/week for 3-4 months once lesions are quiet) --Exacerbation = Med potency (class 3-4) over short periods of time... Taper strength once outbreak fully controlled, then switch to low potency steroid for 2x weekly

What antimicrobial and antiseptics can be used for AD? If high levels of MRSA?

Topical mupirocin/bactroban (x2/d for 7d) with bleach baths for 3 months Clindamycin, doxycycline, Bactrim (trimethroprim-suflamethoxazole)

How does dyshidrotic eczema (pompholyx) present on PE?

Very pruritic vesiculopapules on palms, soles, and sides of fingers vesicle fluid has been compared to tapioca pudding after healing , they often leave behind a mark with mahogany color (post-inflammatory hyper pigmentation)

What are the special considerations regarding seborrheic dermatitis in AA? What should they use? (2)

Weekly shampooing, not daily (1) Fluocinolone acetonide in oil as pomade ("corticosteroid, reduces the actions of chemicals in the body that cause inflammation" ) (2) Other option: mild to mod potency topical corticosteroid in ointment base ("but not too high since AA susceptible to tinea")

[Role of allergy in AD remains controversial]

[Food allergens as triggers of AD is more common in young infants and children -for children <5y/o with mod to severe AD that has been persistent in spite of optimized management and topical therapy. The child has reliable history of immediate allergic reaction after ingestion of food or both. -no extensive elimination diets based only on positive skin or specific IgE tests b/c of possible nutritional deficiency]

TL has bilaterally-symmetric, pruritic, erythematous, scaly, slightly lichenified plaques on her eyelids. What is the most likely diagnosis? a. Allergic contact dermatitis b. Atopic dermatitis c. Rosaea d. Seborrheic dermatitis

a. Allergic contact dermatitis

The exam shows erythematous plaques, consisting of confluent papules and weeping vesicles on his arms, legs, and neck bilaterally. Some of them are linear. What is the most likely diagnosis? a. Allergic contact dermatitis b. Bullous insect bites c. Cellulitis d. Herpes zoster e. Urticaria

a. Allergic contact dermatitis

HPI: Mark is a 9-year-old boy who was brought in by his father who is concerned about the "white spots" on Mark's face PMH: mild asthma, no history of hospitalizations Medications: albuterol when needed Allergies: none Family history: mother had a history of childhood atopic dermatitis What is the most likely diagnosis? a. Pityriasis alba b. Seborrheic dermatitis c. Tinea versicolor d. Vitiligo

a. Pityriasis alba

What are calluses and corns?

very thickened stratum corneum that is a response to friction can occur on feet or hands depending on activity

What do you want to tell patients to avoid if they have a mastocytoma?

vigorous rubbing hot baths Aspirin Alcohol Ibuprofen Codeine