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2012

DERMATOLOGY
REVIEW
Danielle Kruger, PA-C, MS Ed

PATIENTS HISTORY

It is often helpful to examine lesion before obtaining


any history nature of lesion may be apparent!
FOCUSED HISTORY FOR DERMATOLOGY
When and where did the rash or lesion start?
Single or multiple lesions?
Major locations or regions of involvement?
Characteristics of rash:

Pruritic
Crusting
Blistering
Painful

- Scaling
- Weeping
- Thickening
- Burning

Describe lesions as they initially appear and evolution


Evolution: is it healing or spread and developed over time?

PATIENTS HISTORY

FOCUSED HISTORY FOR DERMATOLOGY


Aggravating factors?
Heat, cold, sun, exercise, season
Scratching

History of contacts?
Sick contacts, pets or farm animals, travel, obvious irritant
(poison ivy, wool), environmental or occupational exposure

What therapy has been tried?


Dose, duration, frequency of actual use

Past treatment or evaluation?


Previous diagnosis and treatment, effectiveness
History of skin biopsy, results

Constitutional symptoms or ROS


Based on clinical scenario

PATIENTS HISTORY
FOCUSED

HISTORY FOR DERMATOLOGY

Any relevant past medical history?

Diabetes Mellitus
Atopy (eczema, asthma)
Previous skin cancers or other skin problems
History of STDs, HIV

Medications
Allergies
Any relevant family history?
Psoriasis, atopy
Melanoma, genetic conditions

PATIENTS PHYSICAL EXAM

DESCRIBING SKIN LESIONS


Location and Distribution

Symmetrical vs. asymmetrical


Sun-exposed areas
Flexor vs. extensor surfaces
Involvement of palms and soles

Type
Cyst, macule, papule, pustule, ulcer, vesicle

Color
Erythematous or non-erythematous lesions or bases
Blue, brown, pink, white
Hyperpigmented vs. hypopigmented lesions

Surface features
Crusting, rough, smooth, scaly or verrucous

PATIENTS PHYSICAL EXAM


DESCRIBING

SKIN LESIONS

Arrangement
Single or multiple
Unilateral, bilateral, generalized or disseminated
Grouped, annular, dermatomal, linear

Border and shape


Well- or poorly defined
Active edge
Round, oval, irregular or pedunculated

PSORIASIS

PSORIASIS

Common, chronic recurrent inflammatory skin disease


Etiology: genetic and environmental factors
Abnormal epidermal differentiation, hyperproliferation
Initiated and maintained primarily by T-cells
H&P: well demarcated, mildly pruritic erythematous
plaques
Usually involving elbows, knees, scalp and hair margin
Silvery or white waxy scales, bleed when detached
Nail changes: pitting, thickening, oil-spot, onycholysis
Koebnerization: new lesions at site of skin trauma
Auspitz sign: pinpoint bleeding with removal of scale
Guttate: acute, symmetrical eruption of drop-like lesions
usually on trunk and limbs of adolescents after strep throat
Tx: topical steroids, coal tar, retinoids, emollients, systemic
immunosuppressants, phototherapy (UVB, PUVA)
Complications: arthritis (30%)

PSORIASIS...Most commons
Gender? FEMALE
Age?

MEDIAN AGE = 24

Race?

CAUCASIAN

ATOPIC DERMATITIS

ATOPIC DERMATITIS

Common, chronic recurrent inflammatory skin disease


Etiology: cutaneous immune dysfunction, IgE-mediated
Strong genetic link: family & personal history atopy
H&P: pruritus the itch that rashes
Aggravated by sweat, contact sensitivity, wool, food
allergy, stress and anxiety
Erythematous, excoriated, scaling plaques and patches
More lichenification in chronic forms
Infant: cheeks, forehead, scalp, extensor surfaces
Child: flexor surfaces, fossae, wrists and ankles
Adult: hands
Tx: elimination of precipitating irritants, skin care, cotton
clothing, emollients, topical steroids, oral antihistamines
Complications: secondary infection

ATOPIC DERMATITIS
List four characteristics...

PRURITUS, ECZEMATOUS LESIONS,


XEROSIS, LICHENIFICATION

Complication of secondary infection with HSV?

ECZEMA HERPETICUM
Age? 95% diagnosed before 5 years-old

CONTACT DERMATITIS

CONTACT DERMATITIS

Irritant contact dermatitis: non-immunologic inflammatory


reaction to toxic chemical
No previous exposure is necessary
Ex: water, soap, detergents, solvents, alcohol
Allergic contact dermatitis: follows exposure to chemicals
previously sensitized to
Type IV hypersensitivity response
Ex: poison ivy/oak/sumac, nickel, bacitracin, latex
Appearance: Erythema, scaling papulovesicular lesions
Tx: Avoid exposure, topical moisturizers and steroids
Oral antihistamines and steroids if severe

CONTACT DERMATITIS
Leading cause of contact dermatitis in the world?

NICKEL

What diagnostic test may be utilized?

PATCH TEST

Mainstay of treatment for mild-moderate cases?

TOPICAL STEROIDS

SEBORRHEIC DERMATITIS

SEBORRHEIC DERMATITIS

Common, chronic recurrent inflammatory skin disease


Etiology: common in sebum-rich skin areas
Genetic link, overgrowth of endogenous yeast
H&P: burning, pruritus and scaling
Excessive dandruff
Orange-erythematous patches, loose dry or greasy scale
Erythematous, excoriated, scaling plaques and patches
Distribution: face, eyebrows, blepharitis, nasolabial
folds, scalp, chest, ears
Infant: cradle-cap
Tx: topical antifungals, medicated shampoo (coal tar,
selenium, antifungal), caution with steroids

SEBORRHEIC DERMATITIS
In addition to sebum, this dermatitis is linked to
immunologic abnormalities and activation of
complement related to what agent?

MALASSEZIA
During what season do patients have remission?

SUMMER

LICHEN PLANUS

LICHEN PLANUS

Acute or chronic inflammatory dermatitis


Etiology: immune-mediated (IgM) or autoimmune disease
H&P (7 Ps): symmetrical pruritic eruption
Flat-topped (planar), polygonal violaceous (purple)
papules which may show surface network of delicate
white lines (Wickhams striae)
Distribution: forearms, wrists, lower legs and thighs,
palms, soles, mucus membranes, genitals (penis), nails
Prolonged course 9-18 months
Koebner phenomenon: lesions at site of trauma
Tx: topical steroids, oral steroids or PUVA - resistant cases

LICHEN PLANUS
What infectious disease should be considered in
patients with widespread or unusual presentations?

HEPATITIS C
LP lesions in which location predispose to cancer?

ORAL or VULVAR LESIONS may


transform to squamous cell carcinoma

PITYRIASIS ROSEA

PITYRIASIS ROSEA

Acute, self-limiting disorder


Etiology: suspected Herpes virus infection (HHV 7)
H&P: mild pruritus, precedent URI
Herald patch(50%) single lesion, 2-10 cm in diameter
often found on the neck or trunk precedes rash
Eruption of many smaller pink scaling oval plaques
Appear mainly on the trunk, also upper arms and thighs
Christmas tree distributed parallel to ribs, radiating
away from the spine
Fades spontaneously in 4-8 weeks
Tx: supportive

PITYRIASIS...Most commons
Gender? FEMALE
Age?

MC = 10-35 years-old

Characteristic appearance of scale?


COLLARETTE or CIGARETTE PAPER

TINEA VERSICOLOR

PITYRIASIS VERSICOLOR

Chronic, often asymptomatic superficial fungal infection


MC in ages 15-24, hot, humid environment
Etiology: Malassezia furfur, pityrosporum or other yeast
H&P: Round to oval macules and patches on the trunk, back,
abdomen and proximal extremities
Variable color: white, orange-brown, dark-brown
Very fine, dust-like scale covers lesions
Do not tan in sun-exposed areas
Dx: KOH preparation
Tx: topical antifungal shampoo x 2 weeks, selenium sulfide,
oral agents for convenience (ketoconazole, fluconazole, etc)
Recurrences are common

IMPETIGO

IMPETIGO

Superficial, intraepidermal vesiculopustular skin infection

Etiology: Staphylococcus (MC) or streptococcus (GABHS), MRSA

Transmission: direct contact, contagious

H&P:
Single 2-4-mm erythematous macule rapidly evolves into
vesicle/pustule, and ruptures leaving honey-colored crusts
Lesions may be localized or extensive; self-inoculation common
Face and extremities are most commonly involved
Bullous impetigo: toxin-mediated erythroderma; top layer of
skin sloughs resulting in large areas of skin loss

Tx: Topical antibiotic (mupirocin) x 5 days for small lesions of nonbullous impetigo, removal of crusts with saline soaks, wound care
Oral Keflex or erythromycin for generalized infection or bullous
impetigo

IMPETIGO
MCC bullous impetigo? STAPH AUREUS
MC age for bullous impetigo?
90% cases in children <2 years
Complication of GABHS-impetigo?
POST-STREPTOCOCCAL GLOMERULONEPHRITIS

FOLLICULITIS

FOLLICULITIS

Primary inflammation of the hair follicle as a result of various


infections, follicular trauma or occlusion
Risk factors: shaving, immunosuppression, pre-existing skin disease,
long-term antibiotic use, occlusive clothing, humidity, obesity, DM
Etiology: Infection, physical or chemical irritation
Staph aureus, Pseudomonas (hot-tub) MC etiologies
H&P: Follicular pustules seen in hair-bearing areas
Distribution: face, scalp, chest, back, thighs, buttocks, axilla
Tx: Antibacterial soaps, topical antibiotic (mupirocin)
Oral Keflex, dicloxacillin, erythromycin for generalized infection
Eliminate carrier sites: mupirocin to nares or axilla BID x 5 days
If antibacterial therapy fails, consider fungal etiology
Treatment for pseudomonas folliculitis = Ciprofloxacin

FURUNCLE/CARBUNCLE

FURUNCLE, CARBUNCLE

Furuncle: acute abscess formation in adjacent hair follicles


Carbuncle: deep abscess formed in a group of follicles
causing a painful suppurative mass
H&P: Follicular pustules seen in hair-bearing areas
Furuncles are tender, erythematous pustules which
suppurate and heal with scarring; often occur on the
face, neck, scalp, axilla and perineum
Carbuncles may cause systemic symptoms
Tx: Topical antibiotic (mupirocin) + oral Keflex, cloxacillin,
or erythromycin for generalized infection
Prompt incision and drainage of abscesses

CELLULITIS

CELLULITIS

Acute spreading infection of dermis--subcutaneous


tissue

Etiology: Streptococcus pyogenes, Staphylococcus aureus


Risks: preceded by local trauma, surgery, abrasion,
dermatoses, Hx impaired lymphatic drainage, PVD, DM,
IVDA, IV catheters

Localized pain, edema, warmth, erythema, LAD


Area of spreading erythema, warmth, tenderness
Fever, chills, malaise, WBC
Dx: CBC, blood cultures, electrolytes, wound culture

Tx: Local wound care, oral Keflex, dicloxacillin

CELLULITIS
MC gender/age? MALES, age 45-64 years
Associated red streaking visible in the
skin proximal to the area of cellulitis is:
ASCENDING LYMPHANGITIS
Cellulitis in infants MCC by:
GROUP B STREPTOCOCCUS

VERRUCA PLANTARIS

VERRUCA VULGARIS

FILIFORM & FLAT WARTS

VERRUCA (non-genital)

Cutaneous intraepidermal viral infection causing benign


proliferations of skin and mucosa
Etiology: Human papilloma virus (HPV) over 100 types!
Transmission: direct or indirect contact
Verruca vulgaris (common warts): MC on hands and knees
Hyperkeratotic papules with rough, irregular surface
Filiform warts: MC on face, around lips, eyelids, nares
Long, slender growths
Deep palmoplantar warts (myrmecia)
Small, shiny papules progressing to deep, sharply
defined, round lesions with rough keratotic surface,
surrounded by calloused skin
More painful, seen in weight-bearing area (metatarsal
head, heel) or on hands (subungual)

VERRUCA (non-genital)

Flat or plane warts


Flat or slightly elevated, smooth or slightly
hyperkeratotic, flesh-colored papules; range from 15mm, may be grouped or confluence
MC found on the face, hands and shins
Mosaic warts: MC seen on palms and soles
Plaque of tightly compressed closely grouped warts
Other characteristics:
Disrupt normal fingerprint lines
Display small black dots (thrombosed capillaries)
Tx: conservative, benign neglect (65% remit in 2 years)
Pare down warts, cryotherapy, salicylic acid (70-80%
effective), podophyllin, electrodessication and curettage

CONDYLOMA ACUMINATUM

CONDYLOMA ACUMINATUM

MC STD annual incidence of 1%


Etiology: HPV
Highest among 17-33 year-olds, adolescents
Risks and Transmission: sexual contact; multiple sexual
partners, early first intercourse
H&P: painless skin-colored bumps, pruritus or discharge in
more than one area; Hx multiple lesions is MC
Males: affects the penis, Homosexuals: perianal area
Females: vulva, perineum, vagina, cervix
May appear pearly, filiform, fungating, cauliflower or
plaque-like; may bleed with trauma
Tx: cryotherapy, podophyllin, surgical incision
Oncogenic: HPV 16, 18, 31 - development cervical cancer
Vaccine now available (Gardasil), pap smear

HERPES SIMPLEX VIRUS

HERPES SIMPLEX TYPE 1 & 2

Common, acute, recurrent self-limiting vesicular eruption


Etiology: HSV 1 (facial, non-genital), HSV 2 (genital)
Transmission: inoculation of virus into susceptible mucosal
surfaces (oropharynx, cervix, conjunctiva)
Characteristic pathology:
Neurovirulence invade/replicate in nervous system
Latency maintain latent infection in nerve cell ganglia
proximal to site of infection
MC trigeminal and sacral nerve roots
Reactivation replicate/reactivate in area supplied by
ganglia; various stimuli (fever, trauma, sunlight)
HSV 1 reactivates more frequently in oral rather than
genital area, HSV 2 reactivated 8-10x MC in the
genital region than oral area

HERPES SIMPLEX TYPE 1 & 2

Primary infection latent, non-replicating virus in dorsal root


ganglion reactivate to form recrudescent lesions

H&P: recurrences are milder and shorter


HSV-1 primary infection: gingivostomatitis, vesicular lesions,
fever, malaise, local LAD x 2 weeks
MC in children age 6 months-5 years
HSV-1 recurrence: erythematous papule tiny, thin-walled
intraepidermal vesicles pustular and ulcerate
Prodrome (pain, burning, tingling)
HSV-2 primary infection: vulvovaginitis, penile or perianal
lesions, dysuria, fever, local LAD x 2 weeks
38% had 6 recurrences/year; 20% had over 10 recurrences

Tx: acyclovir, topical (Zovirax) or oral, prophylaxis

HERPES SIMPLEX
MC gender and race for HSV-2?
BLACK (45%), WHITE (17%)
FEMALE (25%), MALE (17%)

Vesicle to finger/hand from self-inoculation?


HERPETIC WHITLOW
Management of culture-positive HSV at delivery?
C-SECTION DELIVERY

HSV Standard Acyclovir Tx


First episode orolabial HSV

200mg PO 5x daily x 7-10 days

Recurrent genital HSV


200mg PO 5x daily x 5 days

Chronic suppressive Tx
400mg PO BID x 1 year

VARICELLA ZOSTER

ZOSTER SHINGLES
Acute, self-limiting dermatomal vesicular eruption
Etiology: Varicella Zoster virus recrudescence

H&P:
Previous history of chicken pox (VZV)
Pain, tenderness and paresthesias in dermatome
Erythema, grouped vesicles, pustules and crusts
Usually unilateral, may involve adjacent dermatomes
Thoracic most common
In elderly ophthalmic of CN V MC
May cause contacts to develop chicken pox

Tx: oral acyclovir, prophylaxis

VARICELLA ZOSTER
Involvement of cranial nerves V, IX and X with
peripheral facial nerve weakness and deafness:
RAMSEY HUNT SYNDROME
Pain that persists for >1 month following
resolution of the vesicular rash of Herpes Zoster:

POST-HERPETIC NEURALGIA

TINEA CAPITIS

TINEA CORPORIS

TINEA PEDIS

TINEA CRURIS

TINEA UNGUIM
ONYCHOMYCOSIS

DERMATOPHYTE INFECTIONS

Etiology: Dermatophytes (microsporum, trichophyton,


epidermophyton) or yeasts

Dermatophytes digest keratin skin, hair and nails

Transmission: human to human, animal or soil contact

Risks: heat, humidity, sweating, occlusion, DM,


immunosuppression, occupation or hobbies

H&P: Often annular lesions, asymptomatic or pruritic


Tinea capitis- alopecia with scale and inflammation
Tinea corporis single or multiple plaques, scaling,
erythema, active borders, central clearing
Tinea cruris inner thighs and inguinal folds

FUNGAL INFECTIONS

Tinea pedis interdigital dry or macerated, moccasin


type with dryness, scaling and erythema of plantar or
lateral foot, and vesicular type
Tinea manuum dryness, hyperkeratosis of palms
One hand, two feet disease
Tinea unguium change of color in nail, brittleness,
thickening, nail dystrophy, subungual debris
Distal subungual onychomycosis - most common
Dx: KOH prep, Woods lamp, fungal culture, biopsy
Tx: Topical antifungals for tinea corporis, cruris, pedis
Systemic antifungals for tinea capitis griseofulvin
Systemic antifungals for tinea barbae, onychomycosis

DERMATOPHYTES
MC pediatric dermatophyte infection?
TINEA CAPITIS
MC dermatophyte infection in US and world?
TINEA PEDIS
Wood light (UV light) examination is performed
mainly for which dermatophyte diagnosis?
TINEA CAPITIS

CANDIDIASIS

CANDIDA

MCC of fungal infection in immunocompromised PT

Oropharyngeal colonization in 30-55% of healthy adults

75% of women experience 1 episode of vulvovaginitis

In sepsis, Candida is now 4th MC isolate from blood culture

Risk: moisture, humid, obesity, DM, immunosuppression,


skin folds, Hx antibiotic use

H&P:
Genital: pruritic, painful vulvovaginitis, adherent white
plaques and inflamed mucosa, dysuria, dyspareunia
Candida balanitits sexually transmitted to males

Intertrigo: erythematous macerated appearance to


submammary, axillary, inguinal and gluteal body folds
Scalloped border with white rim of necrotic epidermis

CANDIDA
Oropharyngeal: thrush = sore mouth or tongue, white
plaques on erythematous buccal mucosa and tongue
Angular cheilitis fissuring to corners of mouth
Esophageal candidiasis: dysphagia, odynophagia,
retrosternal and epigastric pain, N/V
Hx of chemotherapy, the use of broad-spectrum
antibiotics or inhaled steroids, the presence of HIV
infection or hematological or solid-organ malignancy
Generalized cutaneous candidiasis: diffuse pruritic
eruption over trunk and extremities, increased severity in
the genitocrural folds, anal region, axilla, hands and feet

Central erythematous plaque with satellite lesions


Tx: topical or oral antifungals

PEDICULOSIS (LICE)

INFESTATIONS

Pediculosis: wingless 6-legged insects spread by direct


contact or fomites
Pediculus humanus head and body
Phthirus pubis pubic lice
Dx: observation of nits and mature lice
Tx: Pyrethrin, permethrin, lindane
Scabies: Sarcoptes scabiei mite
Transmitted via direct contact or sexual contact
Distribution: papules, pruritus and burrows in finger
webs, wrists, elbows, buttocks, genitalia, ankles
Dx: observation, microscopic evaluation of burrow
Tx: permethrin, ivermectin
Repeat treatment after 1 week, hygiene recommendation

HIDRADENITIS SUPPURATIVA

HIDRADENITIS SUPPURATIVA

Chronic, recurrent inflammatory condition wherein hair


follicles and apocrine gland ducts are occluded and become
secondarily infected
Associations: obesity, DM, smoking, genetic and hormonal
H&P:
Pain, odor and drainage affecting the axilla and groin
Double open comedones, pustules, nodules
Abscesses and sinus tract formation
Hypertrophic scarring
Tx: topical and systemic antibiotics (clindamycin,
tetracycline), intralesional steroids, isotretinoin, surgery

PEMPHIGUS VULGARIS

PEMPHIGUS VULGARIS

Uncommon autoimmune blistering disease affecting skin and


mucus membranes mediated by IgG produced against
keratinocyte cell surface molecules
Loss of cell adhesion (acantholysis), intraepidermal bulla
Involves mucosa in 50-70% of cases; MC oral may also
involve conjunctiva, esophagus, genitalia, anus
H&P: Recurrent painful skin and oral mucosa
Flaccid blisters with clear fluid, residual erosions
No scarring upon healing, but hyperpigmentation
Tx: May be treated in burn unit or ICU
Potentially life-threatening (5-15% mortality)
IV fluids, electrolyte balance, wound care
High dose Prednisone, immunosuppressants

PEMPHIGUS VULGARIS

MC age group affected? 50-60 year-olds


NAME THE SIGN: in active blistering, firm sliding
pressure with a finger separates normal-appearing
epidermis, producing an erosion:
NIKOLSKY SIGN
Best test for diagnosis?
BIOPSY WITH IMMUNOFLUORESCENCE

BULLOUS PEMPHIGOID

BULLOUS PEMPHIGOID

Chronic autoimmune subepidermal blistering disease that


rarely involves mucus membranes
IgG produced against antigens in the dermal-epidermal
basement membrane leading to subepidermal tense bulla
H&P: MC form = generalized bullous form
Lesions begin as pruritic hives and evolve to bulla
Large tense bulla and denuded areas on erythematous or
normal skin, predilection for flexor surfaces
10-25% have oral lesions
Bulla heal without scarring
Dx: biopsy of tissue with immunofluorescence
Tx: Topical or systemic steroids, immunosuppressants

BULLOUS PEMPHIGOID
MC age group affected?

Mean = age 65

In PTs who are treated, this disease remits in:


1.5-5 years

MOLLUSCUM CONTAGIOSUM

MOLLUSCUM CONTAGIOSUM

Self limited viral infection of the skin affecting children


and sexually active adults
Etiology: Pox virus (MCV)
Transmission: direct skin contact, autoinoculation, sexual
H&P:
Asymptomatic, occasionally pruritic or painful lesions
Firm, smooth, flesh-colored, dome-shaped umbilicated
pearly papules (2-6-mm in diameter)
Affects trunk and face of children
Affects genitals, inner thighs of sexually active adults
Tx: cryotherapy, curettage

MOLLUSCUM CONTAGIOSUM

Bimodal age distribution?


Childhood non-sexual
Early adulthood (15-29) STD
Any one lesion is present for about:
2 months
Treatment for HIV PT with widespread disease?
HAART

ACNE

ACNE

Inflammatory disorder of pilosebaceous follicles


Affects 85-100% of people some time during their lives
with a 90% prevalence in adolescents and young adults
Non-inflammatory follicular papules/comedones (mild form)
Inflammatory papules, pustules, nodules (severe form)
Etiology:
Follicular epidermal hyperproliferation with plugging
Hormonal influence, changes in lipid composition (excess
sebum, oily skin), inflammation and activity of P. acnes
Associations: genetics, make-up, PCOS
Medications: steroids, lithium, antiepileptic, androgens, OCP

H&P:

ACNE

Comedones (whitehead closed, blackhead open)


Inflammatory papules, pustules, cysts, nodules
Nodulocystic acne: inflammatory lesions >5-mm diameter

Tx: Topical salicylic acid, retinoids (Retin-A)


When topical or systemic antibiotic is used - should be in
conjunction with benzoyl peroxide to reduce resistance

Topical antibiotic (clindamycin, erythromycin)

Systemic antibiotics (minocycline, erythromycin, doxycycline,


Bactrim)

M&M: scarring, pain, psychological suffering

ACNE

To what locations are acne lesions predisposed?


Face, upper chest and back
densest areas of sebaceous follicles

What physiologic change initiates acne?


ANDROGEN-DHEA-S HORMONES

MC gender?

MC in males during adolescence


MC in females during adulthood

ACNE

What is the earliest lesion of acne?


COMEDONAL LESIONS NO INFLAMMATION

Side effect of topical retinoids?


SKIN IRRITATION, PEELING,
REDNESS, SUN SENSITIVITY

Best Tx for severe nodulocystic acne? Education?


ISOTRETINOIN TERATOGENIC

ACNE ROSACEA

ROSACEA

Common chronic inflammatory disorder of pilosebaceous


units and vasculature of the face

H&P:
Persistent erythema of central face x 3 months with
associated flushing, inflammatory papulopustular
eruption resembling acne and telangiectasias
Other characteristics: burning and stinging, edema,
plaques, dry and coarse appearance, ocular manifestation

Tx: avoid triggers

Topical antibiotics (metronidazole, clindamycin)

Oral antibiotics (azithromycin, metronidazole, tetracycline,


minocycline)

ROSACEA

TYPES:

1)

Erythematotelangiectatic central facial flushing, burning,


stinging; fine textured skin appears rough with scale

Exacerbated by stress, heat, spicy foods, sunlight, cold, alcohol


2)

Papulopustular - *classic* - small erythematous papules and


pinpoint pustules on central face; telangiectasias and flushing

3)

Phymatous marked skin thickening, irregular surface


nodularities of nose, chin, forehead, ears, eyelids; rhinophyma
Tx: topical isotretinoin and surgical correction

4)

Ocular - blepharitis, conjunctivitis, ocular telangiectasias

Patients may describe eye stinging or burning, dryness,


irritation with light, or foreign body sensation

ROSACEA
What microbe plays a role in pathogenesis?
DEMODEX MITE
MC age group/gender?
30-50 YEARS-OLD
FEMALE

SEBORRHEIC KERATOSIS

SEBORRHEIC KERATOSIS

MC idiopathic benign epidermal growth in middle-aged and


elderly patients
H&P:
Usually asymptomatic, occasionally pruritic or sore
Common on trunk, neck, arms, scalp
NOT ON palms, soles, mucus membranes
Gradual development of one or more sharply defined,
light-brown flat macules; develop velvety or verrucous
surface; stuck-on appearance
Variably pigmented brown, pink, brow, black spectrum,
wide range of sizes

Tx: liquid nitrogen cryotherapy


Curettage, excision, electrocautery and laser therapy

SKIN TAG (ACHROCHORDON)

SKIN TAG

Common benign fibrous growths of skin


Increase in size and number over time
Most common in older people and in obesity
H&P:
Asymptomatic, may be tender after trauma or torsion
Soft, skin-colored to dark brown pedunculated polyp
Common in axilla, neck and groin
Tx: for cosmetics or pruritus
Snipping with scissors under local anesthesia
Liquid nitrogen cryotherapy
Electrocautery

PARONYCHIA

PARONYCHIA

Soft tissue infection around proximal or lateral nail folds


MC hand infection (35%); MC in women
Acute: Hx of minor trauma; pain, erythema, tenderness,
swelling with pus collection in one of the lateral nail folds
Risks: nail biting, finger sucking, manicure, trauma, etc
Causes: STAPH AUREUS MC, Streptococcus,
Pseudomonas
Chronic: symptoms >6 weeks; episodic after exposure to
water; swollen, erythematous and tender nail folds without
fluctuance
Nail plates become thickened, discolored, ridges
Risks: water immersion (bartenders, florists, bakers,
homemakers), immunocompromised
Causes: CANDIDA MC

PARONYCHIA
Treatment for acute paronychia?
I + D as needed
PO AUGMENTION OR CLINDAMYCIN
(covers anaerobes)

Treatment for chronic paronychia?


TOPICAL ANTIFUNGALS

ERYTHEMA MULTIFORME

ERYTHEMA MULTIFORME

Acute, self-limited (1-4 wk) skin reaction to a variety of stimuli;


considered Type IV hypersensitivity reaction
Accounts for 1% outpatient dermatologist visits

Associations: HSV, Mycoplasma, medications

HALLMARK:
Iris or target-shaped lesion: dull-red macule with papule or
vesicle in center, flattens and clears, intermediate pale
edematous ring develops; periphery becomes cyanotic or
violaceous
Rash starts on extremities with centripetal spreading
Negative Nikolsky sign
Symmetrical and acral distribution, affects palms/soles

Tx: antipyretics, antihistamines, analgesics, topical steroid

ERYTHEMA MULTIFORME
MC age/gender?
MC MALES, 2nd-4th DECADES, and CHILDREN

Mucosal involvement in EM Minor vs. Major?


EM-Minor 1 mucus membrane (MC oral)
EM-Major At least 2 mucus membranes
(oral, conjunctiva, genital)

URI Prodrome in EM Minor vs. Major?


EM-Minor uncommon, mild EM-Major 50%

ERYTHEMA MULTIFORME
Common medications causing EM?
ANTIBIOTICS and ANTICONVULSANTS

If EM-Minor is recurrent, associated with orolabial


herpes outbreaks best management?
HSV PROPHYLAXIS

STEVENS-JOHNSON SYNDROME,
TOXIC EPIDERMAL NECROLYSIS

SJS & TEN


Mucocutaneous drug-induced or idiopathic reaction associated with
impaired capacity to detoxify intermediate drug metabolites
Associations: genetic susceptibility, drugs

H&P: skin tenderness, erythema, necrosis, desquamation


Skin lesions are predominantly central, blisters arise on
erythematous or pruritic macules (typical target lesions)
Involve two or more mucosal surfaces
SJS: <10% epidermal sloughing, Hx URI
MC in males (2:1), 2nd-4th decades and children

TEN: >30% epidermal sloughing, stronger drug association


Tx: remove offending drug, supportive care, Ophto assessment, ICU
or burn unit, wound care, supportive
Steroids and IVIG still controversial, becoming standard

High mortality rate (SJS 5%, TEN 30-40%)

SKIN CANCER

SKIN CANCER

BASAL CELL CA = MC form of skin cancer


Derived from basal stem cells of epidermis
SQUAMOUS CELL CA = 2nd MC form of skin cancer
Malignant keratinocytes with metastatic potential
Actinic keratosis is considered its pre-malignant lesion
MELANOMA = Melanocyte-derived skin cancer
Dysplastic nevus is considered premalignant lesion
Many arise in sun-exposed areas
Associations: chronic UV-damage, immunosuppression,
radiation, genetics, fair skin, light hair, etc
Dx of Skin Ca: biopsy and histopathology

BASAL CELL

SKIN CANCER

Persistent, non-healing papule or nodule that ulcerates or bleeds


Metastasis and death rare, locally invasive

SQUAMOUS CELL
Slow-growing, non-healing firm, indurated, scaly papule/nodule
MC on head, neck, dorsal hands and forearms

MELANOMA
Pigmented macule or plaque
MC superficial spreading malignant melanoma: 60-70%
Acral lentiginous melanoma: MC form in Africans, Asians and
Hispanics, palms and soles
Most important indicator of severity: DEPTH

TX SKIN CA: Excision, cryotherapy, electrocautery


Sentinel lymph node dissection, radiation/chemo (melanoma)

SKIN CANCER

Rodent ulcer? BASAL


Affects mucus membranes and lips? SQUAMOUS
Pearly papule with telangiectasias? BASAL
ABCDE of Melanoma?
Rolled borders?

BASAL

ASYMMETRY, IRREGULAR
BORDERS, COLOR VARIATION,
DIAMETER >6mm,
EVOLUTIONAL CHANGE

Metastasis to lung, liver, brain*, bone, GI? MELANOMA

ALOPECIA AREATA

ALOPECIA AREATA

Autoimmune and T-cell mediated loss of hair


Peaking prevalence: young adults (<25 years) and children
H&P: Round, oval patches of alopecia
Gradual, non-scarring loss of hair no pruritus,
inflammation or pain
Totalis loss of all scalp hair and eyebrows
Universalis loss of all body hair
Dx: biopsy of tissue exclamation point hairs, perifollicular lymphocytic infiltrate
Tx: topical or intralesional steroids, minoxidil
Topical immunotherapy (psorelen), PUVA, PR steroids

ANDROGENIC ALOPECIA

ANDROGENIC ALOPECIA

Most prevalent type of hair loss, MC in males


Progressive balding: genetic predisposition and action
of androgen (dihydrotestosterone) on scalp follicles
Age: often fully expressed in 40s; by 7th decade 80% males
have involvement, 50% women after menopause
H&P:
Males bitemporal recession crown frontal
(occipital and temporal margin remains)
Females central regression, diffuse thinning
Dx: biopsy atrophy of hair follicles, hormonal studies
Tx: topical minoxidil, PO finasteride, anti-androgens

FELON
Closed space infection of fingertip pulp
Thumb and index finger MC affected
Penetrating injury
MCC = Staph aureus
I+D, PO antibiotics

DYSHIDROSIS
Tapioca vesicles
Pruritus
50% Hx atopy
Tx: steroids

ERYTHEMA
NODOSUM
Anterior tibia
Septal panniculitis
R/O bacterial infection
and sarcoidosis

NEUROFIBROMATOSIS
Caf-au-lait spots
Crowe sign
Lisch nodules
Neurofibromas

PEUTZ-JEGHERS SYNDROME

Oral lentignes - intestinal polyposis


Intense surveillance

PAGETS DISEASE
Unilateral
eczematous plaque
Intraductal papilloma
do mammogram!
Surgical removal

VITILIGO
Autoimmune
loss of
melanocytes
Well-defined
depigmentation
Adolescents

DISCOID
LUPUS
Head and Neck
Scarring
Photosensitivity
Tx: steroids

ERYTHEMA
MIGRANS
Annular macule
Lymes disease
Ixodid tick

Borrelia borgdorferi

ALBINISM
Oculocutaneous MC
Absence of tyrosinase
Normal melanocytes

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