U3 medicine - dermatology pt 1

sunscreen

guidelines

-30 spf or higher

-broad spectrum (protects against UVA and UVB rays)

-reapply every 2 hours

skin

3 layers - epidermis (outer), dermis, hypodermis

function

protection of organs

sensation

regulation of temp

fitzpatrick scale

used to measure the skin types ability to tolerate sun exposure

i - always burns, never tans

ii - usually burns, tans minimally

iii - sometimes mild burn, tans uniformly

iv - burns minimally, always tans well

v - very rarely burns, tans very easily

vi - never burns, always tans

describing a lesion

-distribution

-morphology

-arrangement (annular, serpiginous, dermatomal)

macule

flat color change on skin less than 1cm

patch

flat color change on skin greater than 1 cm

papule

elevated, solid lesion less than 1 cm

plaque

elevated/raised

solid lesion greater than 1cm

nodule

solid, round or oval elevated lesion greater than 1 cm

pustule

circumscribed collection of pus

pus = leukocytes = bacterial infection

vesicle

fluid filled papules (elevated)

no pus

less than 1 cm

bullae

similar to vesicle but greater than 1 cm

superficial in epidermis only, thin walled

wheal

hives

firm, edematous papule or plaque

transient (last less than 24 hours, come and go)

scale

excess dead epidermal cells (aka keratin)

crust

collection of dried serum and cellular debris

a scab

erosion

focal loss of epidermis

heals without scarring bc doesnt penetrate below the dermoepidermal junction

ulcer

afocal loss of epidermis & dermis

heals WITH scarring

usually secondary to peripheral arterial disease which causes impairment of vascular or nutrient supply to the skin

fissure

linear split in the epidermis

sharply defined, nearly vertical walls

>usually also into the dermis as well

chronic fissures may scar

atrophy

thinning of the epidermis or dermis which causes a depression in the skin

skin appears thin, translucent and wrinkled with easily visible blood vessels

scar

an abnormal formation of connective tissue post dermal damage

initially scars are thick & pink but with time become white and atrophic

diagnostic techniques

shave biopsy

punch biopsy

excisional biopsy

shave biopsy

a scalpel or a razor blade is used to scrape the surface of the skin

only shaves epidermis (outer layer)

punch/excisional biopsy

sample from epidermis, dermis, and hypodermis

technique for obtaining diagnostic full-thickness skin specimens

KOH prep

potassium hydroxide prep

add KOH to skin scraping dissolves keratin but not the fungi

examine under microscope

fungal culture

bacterial culture and sensitivity

wood's lamp

>black light

dermatoscope

magnifier with a non-polarized light source

35% more accurate than clinical diagnosis with Melanoma

reduces the number of benign lesions excised

moh's surgery

a technique used to excise tumors of the skin by removing fresh tissue, layer by layer, until a tumor-free plane is reached

microscopically controlled serial excisions of a skin cancer

moh's surgery

gold standard

> highest Cure Rate

used in cosmetically sensitive areas and areas with high rate of metastasis like ears, lips, genitals, nose

used for

-aggressive, invasive subtypes of BCC or SCC

-large lesions (>2cm)

-melanoma (MM)

ED&C

electrodessication and curettage

basic skin procedure

technique of curettage using a sharp curette is followed by electrodessication

used for superficial BCC, SCC in situ

-results in SCARRING

I&D

incision and drainage

with or without a bacterial culture

cryotherapy

superficial skin lesions are frozen with liquid nitrogen for a few seconds

time depends on the desired diameter & depth of freeze

commonly used on actinic keratoses, seborrheic keratoses, warts

medications

beware of combination creams (Anti-fungal/Steroid)

potency can be increased by occlusion x 4 hours (gloves/seran wrap over skin)

caution when applying to areas of thin skin

may cause glaucoma/cataracts when used on eyelids

medications

palms/soles (thick skin) - ointment or cream

skin folds (always occluded) - cream or lotion

hairy areas (not vaseline) - lotion, solution, gel, foam

mucosal - non-irritating

enhance efficacy with occlusion

super high potency

class 1

clobetasol propionate 0.05%

high potency

class ii

fluocinonide 0.05%

medium potency

class iii-iv

triamcinolone acetonide oinment, cream, or lotion

low potency

class vi-vii

fluocinolone acetonide 0.01%

desonide 0.05%

hydrocortisone 1%

causes of acne

-bacteria: Propionibacterium acnes

inflammation

-hormones: androgen and their receptors

-excess sebum

-plugging of the follicle

acne vulgaris

in skin of color, can lead to permanent post-inflammatory hyperpigmentation

>treat aggressively to prevent this complication

acne vulgaris

appears in areas of sebaceous gland activity

face/chest/back/shoulders

comedonal acne

whiteheads (closed comedrones) and blackheads (open comedones)

inflammatory

inflammatory papules and pustules

nodulocystic

comedones, inflammatory lesions and large nodules with or without scarring

acne vulgaris treatment

creams, gels, washes, and foams

>retinoids, antibiotics, benzoyl peroxide

oral medications

>antibiotics, hormonal, isotretinoin

retinoids

used to treat comedonal and inflammatory acne

-Adapalene

-Tretinoin

-Tazarotene

antibiotics

used to treat inflammatory acne and P. acnes

-Clindamycin

-Erythromycin

-Dapsone

benzoyl peroxide

used to treat P. acne

ongoing research regarding conversion to benzene

antibiotics

oral meds used to treat inflammatory acne and P. acnes

-Tetracyclines

>Doxycycline, Minocycline

hormonal treatment

oral medication that targets androgen receptors to treat acne

contraceptive pills or spironolactone

isotretinoin

acutane - last line treatment

6-9 months

does not work for hormonal acne

vitamin A in high doses

targets excess sebum

teratogenic so has adverse fetal effects

register with Ipledge, monitor BW (Lipid panel, CBC, CMP) n

adverse effects: mood changes, depression, joint pain, dry lips, extreme photosensitivity

no association with IBS

hidradenitis suppurativa

chronic disease that targets apocrine gland skin sites, particularly the axillae and groin

starts at puberty

physical exam shows recurrent tender inflammatory nodules/abscesses, open comedones & sinus tracts with purulent drainage

confirm with bacterial culture

think inverse cystic acne

high incidence of depression/suicide

hidradenitis suppurativa treatment

weight reduction, smoking cessation, chlorhexidine

intralesional triamcinolone

incision & drainage

antibiotics n tetracycline (1st line), topical

prednisone (short term)

excision

biologics

>humira, cosentyx, bimzelx

folliculitis

inflamed hair follicles

-may be superficial or deep

-can affect anywhere there are hairs

tender red perifollicular papule, often with a surface pustule

folliculitis

infection, occlusion (blockage), irritation

if bacterial infection, commonly due to S. Aureus (gram positive)

bacterial treatment

oral cephalosporins

-cephalexin, cefadroxil

and/or

topical mupirocin

if yeast infection, due to malassezia (more itchy)

yeast treatment

topical treatments

-azoles (econazole or ketoconazole)

-selenium sulfide

or

systemic treatments

-fluconazole (Diflucan)

hot tub folliculitis

due to P. aeruginosa, bacterial infection

treatment

oral ciprofloxacin

or

topical gentamicin

rosacea

persistent erythema (redness) of the convex surfaces of the face including nasolabial fold

telangiectasia (blood vessels), flushing, erythematous papules and pustules

cause remains unknown

but

theories = sun damage, mites, abnormal vasomotor response to stimuli

or due to

steroid-induced rosacea: long term or too strong of steroids on face can cause rosacea

types of rosacea

phymatous (skin thickening, nose nodules)

ocular (involves the eye)

papulopustular (papules/pustules within the rosacea)

erythematotelangiectic (flushing)

rosacea treatment

can resemble early lupus

--> differentiate with nasolabial fold involvement, biopsy or labs (ANA)

topical treatment

-metronidazole

-azelaic acid (otc Finacea)

-sulfacetamide

-topical ivermectin (Soolantra)

systemic treatment

- low dose doxycycline

-avoid triggers (spicy foods, alcohol)

-gentle skin care regimen

-lasers for blood vessels

-rhinophyma - surgery, CO2 laser

seborrheic dermatitis

thought to be an abnormal inflammatory reaction to Malassezia (yeast) in sebum rich areas (scalp, central face)

aka dandruff or cradle cap

clinical findings

greasy scale on erythematous base

treatment

-infants = reassurance outgrow by 6 months and use Aquaphor or coconut oil

-adults = mild topical steroids (hydrocortisone cream) for short-term flares

and

topical antifungals (ketoconazole cream) for longterm control

seborrheic dermatitis

in skin of color, affected areas may present lighter in color and have no redness

erythema multiforme

aka EM minor

-sharply marginated, erythematous macules which become raised and edematous over 1-2 days

-acral predominance (palms/soles)

-typically a ring of erythema forms = 'target'

-strongly associated with preceding herpetic infection or Mycoplasma pneumonia

SJS

steven johnson syndrome - skin sloughs off

aka erythema multiforme major

-patients have EM like skin lesions that cover 10% BSA or less

-always has mucosal involvement (oral, ocular or genital)

-usually represent adverse reaction to medication

>mostly rxn to Sulfonamides or anticonvulsants

TEN

toxic epidermal necrolysis

same as SJS but with 30% or greater BSA

EM minor

most cases are self limited: 1-2 weeks

recurrence is common

usually no prodromal symptoms

may have orolabial herpetic outbreak 3- 14 days prior to EM rash

EM major

SJS

has 5% mortality rate

recurrence uncommon

prodrome

influenza-like symptoms 1-2 weeks prior to cutaneous lesions

toxic epidermal necrolysis

40% mortality

more than 30% of skin sloughs off'

concerns: secondary infections, sepsis

usually represent adverse reaction to medication

>most commonly Sulfonamides and anticonvulsants

EM minor

self limiting

no mucosal involvement

no systemic involvement

0% detachment of skin

EM major

SJS

5% mortality

mucosal involvement

usually systemic involvement

10-30% detachment of skin

TEN

40% mortality rate

mucosal involvement

systemic involvement

more than 30% detachment of skin

SJS or TEN

requires admission to hospital

TEN managed in burn unit

alopecia

loss of hair

-non-scarring hair loss due to hormonal, hair care/styles, immune system (alopecia areata), telogen effluvium (stress/nutrition/pregnancy/

COVID/secondary cause)

-scarring hair loss due to follicles destroyed by inflammation or discoid lupus

alopecia areata

non-scarring alopecia

auto-immune disorder

-complete hair loss of scalp (totalis)

or

-complete hair loss of body (universalis)

rapid and complete loss of hair in 1 or more round or oval patches (1-5cm) with 'exclamation point hairs' along periphery

treatment

can be difficult

localized hair loss = intralesional or topical triamcinolone

extensive hair loss = topical immunotherapy, oral JAK inhibitors, off-label treatments

androgenic alopecia

genetic balding

hair loss related to aging

sensitivity to DHT (dihydrotestosterone)

female

-hair loss around crown of head

-treatments are Minoxidil or Spironolactone

males

-hair loss in front temporal areas, vertex of scalp

-treatments are Minoxidil or Finasteride

paronychia

inflammation of the nail fold

presents with erythema, swelling, throbbing pain, can have pustular drainage

caused by bacteria, may have secondary candida colonization

treatment - systemic & topical antibiotics

onychomycosis

tinea unguim

subungual hyperkeratosis with scaling, yellow discoloration and onycholysis (end of the nail lifts) ¨

diagnosis: culture (clipping) or biopsy of nail plate

treatment is difficult

-topicals: ciclopirox

-systemic: terbinafine (lamisil)

erythema infectiosum (5th disease)

caused by parvovirus B19

physical exam

-mild fever and headache

-red slapped checks appear for 2-4 days

-lacy patch on limbs/trunk

complications

-spontaneous abortion

-polyarthropathy

treatment

-none

hand foot and mouth

usually caused by Coxsackie virus

common, mild, short lasting

very contagious - spreads by direct contact, nasal/oral secretions

physical exam

-flat pink patches evolve into blisters on heads/feet

-small vesicles in/around mouth

-red macules and papules on buttocks/arms/genitals

treatment

-don't pop blisters

-antiseptic mouthwashes

-pain meds for oral ulcers

-maintain fluid intake

-no vaccine or antiviral meds

measles

rubeola

caused by measles virus

morbillivirus family

high contagious via respiratory droplets

physical exam

-cough, conjunctivitis

-gray-white papules, Koplik spots

-high fever

-rash starts on rash and spreads within 24-36 hours and spread to entire trunk and extremities

-palms and soles have no rash

treatment

-can be prevented with vaccination

cellulitis

bacterial skin infection

acute, spreading inflammation of the dermis & subcutaneous tissue

-if possible send out bacterial culture of any drainage

treatment

start with Abx that covers H.flu, Strep, Staph

--> penicillin (dicloxacillin) or cephalosporin

severe case

--> 1st generation cephalosporin IV

possible surgical intervention

erysipelas

painful, macular rash with well-defined margins

superficial cellulitis (upper dermis) that extends into the superficial cutaneous lymphatics

abrupt onset & rapid progression

rash is typically confined to the face which becomes fiery red, but may progress to the extremities

treatment

-penicillin

impetigo

bacterial skin infection characterized by isolated pustules that become crusted and rupture

highly contagious gram-positive bacterial infection

S. aureus is the most common pathogen

2forms of impetigo = bullous impetigo and nonbullous impetigo

can spread cutaneously and systemically (rare)

impetigo

most common bacterial skin infection

approximately 10% of skin problems observed in pediatric clinics

occurs more frequently in a warm, humid environment

bullous impetigo is most common in neonates & infant

impetigo

bullous impetigo

-rapid onset of blisters that enlarge & rupture

nonbullous impetigo

-erosions covered by moist, honey-colored crusts

-begins as small, easily ruptured vesicles

-most common sites: face & extremities

impetigo treatment

antibiotics to cover gram-positive bacteria

systemic

-cephalexin (Keflex)

-Cefadroxil (Duricef)

topical

-mupirocin (Bactroban) is applied to lesions AND nares in chronic nasal carriers

-get bacterial culture

-encourage proper hand-washing

syphilis

caused by T. pallidum

transmission

T. pallidum enters the body via skin/mucous membranes through abrasions during sexual contact and transmitted transplacentally from mother to fetus during pregnancy

travels via circulatory system, invades the central nervous system

primary syphilis

primary lesion, or chancre develops at site of inoculation

painless, indurated macule/papule

highly infectious

heals spontaneously within 3-6 weeks

serologic tests for syphilis may not be positive during early primary syphilis

secondary syphilis

occur several weeks after primary chancre and may persist for weeks to months, very contagious

physical exam

-rough, red papules or patches on the trunk and frequently affects palms and soles

-the rash does not itch

-general malaise

may affect liver, kidneys, CNS, joints, eyes

latent syphilis

patient suppresses infection but no clinically apparent lesions

only evidence is positive serologic test

tertiary (late) syphilis

rare because of widespread availability of antibiotics

symptoms - gummatous lesions, cardiovascular syphilis

neurosyphilis

may occur at any stage, when T pallidum invades the CNS

symptoms - acute syphilis meningitis, ocular involvement or may be asymptomatic

congenital syphilis

may lead to stillbirth, neonatal death, infant disorders (deafness, bone deformities, neurologic impairment)

syphilis

serologic tests

-treponemal qualitative AND nontreponemal qualitative and quantitative

-perform HIV testing in all patients with syphilis

-public health laws require that all cases be reported to the state department

treatment

-penicillin IM

-alternative - Doxycycline or Tetracycline

candidiasis

opportunistic yeast

-oral infection can be 1st sign of HIV

-often follows antibiotic use, diabetes, obesity, poor self-care

-grows best in warm, moist areas

-body = intertrigo

>beefy, red papules/plaques in skin folds +/- satellite lesions; +/- thick 'cheesy' discharge

-oral = thrush

>whitish plaques on erythematous base of buccal mucosa

intertrigo treatment

keep area dry/clean

discontinue offending agent

topical/oral antifungals

thrush treatment

nystatin suspension

fluconazole (Diflucan)

-if breastfeeding infant must also treat mother's nipples topically

superficial fungal infections

tinea capitis - scalp

tinea corporis - body; ringworm' tinea cruris - groin & gluteal cleft; 'jock itch'

tinea manuum - palms

tinea unguim (onychomycosis) - nails

tinea pedis - soles; 'athlete's foot'

tinea capitis

dry scaling with moth-eaten hair loss

very inflamed mass/abscess (Kerion)

untreated may result in permanent scarring/baldness

may result in swollen lymph glands at the sides of the back of the neck

tinea capitis treatment

take culture

topical antifungals cannot reach infection and are ineffective

ketoconazole shampoo (nizoral) or selenium sulfide shampoo (otc) is moderately effective as adjunctive therapy

oral griseofulvin x 6weeks - 6 months

throw out hairbrush

tinea corporis

ringworm

well demarcated annular plaque with central clearing and peripheral scale

contagious

diagnosis

KOH prep (optional)

topical treatment

-azoles (econazole, ketoconazole)

tinea incognito

results when patient uses a potent topical steroid (not antifungal) on tinea corporis

drives fungus deeper into the skin; affects hair follicles

physical exam

regular red, scaly plaque with follicular papules

pustules = more severe and indicates Majocchi's Granuloma ¨

treatment

oral griseofulvin x 4-6 weeks

tinea cruris

jock itch

well-defined scaly plaque with widespread erythema

intensely pruritic

spreads through contaminated towels/sheets or autoinoculation

50% of patients also have on hands or feet

3x more common in men ¨

treatment

-keep groin dry, weight loss

topical antifungals

- azoles x 2-4 weeks