Dermatology Final Exam

Burns can arise from

-Heat
-Over exposure to sun
-Friction
-Chemical
-Electrical

First Degree burns symptoms

•Redness
•Pain
•Maybe some tiny blisters

2nd degree burns symptoms

•Affects epidermis and dermis
•Swelling, blisters, scaring
•Red and white splotches

2nd degree burns can also be called

Partial Thickness burn

3rd Degree burn AKA full thickness burn affect all of

- DERMIS
hair follices, sweat gland
appearance black brown leathery
can destroy nerves

3rd degree burns always require

skin grafts

4th 5th 6th degree burns you will see

fat muscle bone

Rule of nines

segmented body into different portions to determine treatment of burn

- TBSA- calculating total body surface area
-diff for infants/kids
-use for fluid replacement and infection

Burns- Parkland Formula

(4mls of fluid) X( weight in Kg) X( TBSA%)
= how much fluid u should get in first 8 hr of tx
1/2 is given in first 8 hours, remainder given over next 16hrs

100 kg female comes in with burns on entire torso calculate...

100kg x 4= 400 x TBSAentire torso (36)

divide by 2= for the first 8 hours

Impetigo presents with

honey colored crusts!!!!
•Common, contagious, superficial
- Can be after trauma or on normal skin
•Bullous and non bullous (crusted)

Impetigo bacterial species

•Strep or *Staph aureus* or combo
•Staph can colonize nose
•(you can worry about MRSA)

Impetigo Treatment

• MUPURICON (Bactroban) ointment 2-3 times a day


IF SEVERE-Oral antibiotics for severe or widespread-cephalexin minocycline, doxycycline

With impetigo watch out for

Post Streptococcal
Glomerulonephritis and nephritis
Serious secondary infections (infants)

Cellulitis

-Non necrotizing inflammation of the skin and sub cutaneous tissue
•Breach in the skin
•Erythema ill defined plaque
•Pain , Swelling, Warmth
•Lymphangitic spread

Cellulitis treatment

-Cool compresses
-Elevation (if leg involvement)
-Antibiotics aimed at staph and strep
-Empiric oral or IV antibiotics depending on severity and host risk factors (eg, immunocompromised) Consider MRSA risk factors and clinical features (eg, bullae)

Diagnosis - predictive tool score for Cellulitis

Has to be a score of 5-7 points
•Unilateral (3 points)
•Leukocytosis WBC count >10,000 (1 point)
•Tachycardia HR> 90bpm (1 point)
•Age > 70 years (2 points)

Risk Factors for Cellulitis

-History of DVT
-History of cellulitis with lymphangitis Immunosuppression
-Chronic edema, especially lower extremities
-Tinea pedis (compromised skin barrier)

Cellulitis lymphangitis is a serious infection which can present as

Streaking

Cellulitis Lymphangitis can spread

proximally towards lymph nodes

Erysipelas is a inflammatory form of

-CELLULITIS
•Lymphatic involvement (streaking)
•More superficial
•Well defined margins abrupt onset

Symptoms of erysipelas include:

Malaise, fever chills

Erysipelas is MORE

well demarcated

Causative agent for Erysipelas is mostly

Streptococci****
•Also S. aurius, Pneumococcus organisms and Klebsiella

Treat Erysipelas with

Penicillin*

Pressure Ulcers
(AKA bed sores)

•Lack of blood flow to the skin causes breakdown of tissue
•They don't blanch, or turn white, when touched and they get worse over time.
•become infected and grow deeper until they reach muscle, bone, or joints.

Who are pressure ulcers more common in

•Older adults- bedridden, nursing homes

Pressure ulcers start as

red, blue, or purplish patches on the body.

In the worst cases pressure ulcers can become

become life threatening.

Ways to prevent bed sores

•Egg Crates
•Special mattresses
•Move the patient!
• Wheelchairs shift position every 2 hours
•Bed ridden turn patient every 2 hours

NO REASON FOR PRESSURE ULCERS!

4 stages of pressure ulcers

Stage 1. A red, blue, or purplish area first appears on the skin like a bruise. It may feel warm to the touch and burn or itch.

Stage 2. Bruise becomes an open sore. Skin around the wound can be discolored and the area is painful.

Stage 3. Sore deepens and looks like a crater, often with dark patches of skin around the edges.

Stage 4. Damage extends to the muscle, bone, or joints and can cause a serious infection of the bone, known as osteomyelitis. SEPSIS.

Pressure ulcer treatment

•Clean wound
•Antibiotics-topical and oral
•Debridement of dead tissue
•Pain management
•Skin grafts

Stasis Dermatitis typically can commonly occur in individuals that are

50+

What causes stasis dermatitis

•DVT, Venous Insufficency
•Surgery -vein stripping and total knee arthroplasty
•Traumatic injury
•Being overweight
•Heart conditions such as CHF

Stasis Dermatitis Treatment

•Wearing compression stockings
•Applying petroleum jelly moisturizer or barrier cream
•Keeping feet elevated above the heart while sleeping
•Avoid standing for long
•Keep the skin clean
•Antibiotics for infection

Drug Reactions can be

Mild or Life threatening

Drug Reactions most common presentation

•Hives and morbilliform rashes are MC

Drug reactions can be from

•Can be from a drug itself
•Can also be from a combination of drugs - interaction

Most serious drug reaction

Anaphylaxis most serious (also DRESS)

Drug reaction onset

4-14 days

Examples of Drug Interaction

•Two drugs, such as aspirin and blood thinners
•Drugs and food, such as statins and grapefruit
•Drugs and supplements, such as gingko and blood thinners
•Drugs and medical conditions, such as aspirin and peptic ulcers

When a person has a drug rxn, a more serious type can be known as

DRESS syndrome
-Drug reactions with eosinophilia and systemic symptoms

Dress syndrome

-serious drug reaction affecting the skin and other organs
-MUCH SICKER
- mortality rate of up to 10%.
-Life threatening over reaction of the immune system
•Type 4 hypersensitivity reaction
• The damage occurs due to an overreaction from the immune system, which involves the activation of T-cells and the release of cytokines

Other Factors for dress syndrome

-a genetic predisposition to DRESS syndrome
-an inability of the liver to metabolize certain drugs
-the reactivation of certain viruses, such as the Epstein-Barr virus (EBV) or human herpesvirus 6 (HHV6)

Dress syndrome usually happens with

within 2-6 weeks of a person's first exposure to the drug

Many Culprit Drugs to dress syndrome...

•anticonvulsants
•antiviral drugs
•antibiotics
•allopurinol (Zyloprim)
•mexiletine (Mexitil)
•mood stabilizers and antidepressants
•biologic agents

Dress syndrome symptoms

•fever
•skin rashes or eruption
•eosinophilia
•atypical lymphocytosis
•swollen lymph nodes*****
•inflammation of internal organs

Criteria for diagnosing DRESS

•hospitalization
•acute rash
•a reaction that is likely drug-related
•In addition, three out of the four issues below should be present:
•fever higher than 38°C
•enlarged lymph nodes in at least two sites
•involvement of at least one internal organ
•blood count abnormalities

Treatment of DRESS

Supportive
Early systemic corticosteroids
STOP THE DRUG!!!

Erythema Multiforme

•Acute, self limited sometimes recurrent immune mediated mucocutaneous eruption

90% of erythema multiforme is caused by

upper respiratory infections (MC HSV-1)

Someone with erythema multiforme will present with

TARGET LIKE LESIONS of the face, palms extremities and trunk
-Vesicles and erosions on oral mucous membranes common

Causes of Erythema Multiforme

•Infections
•Immunizations
•Radiation
•Sarcoidosis
•Menstruation
•Wide variety of bacteria, viral, fungal and parasitic infections

Erythema multiforme presentation

"Target" lesions: Dusky center +/- blister Pale ring Erythematous halo

Histology EM

Lymphocyte accumulation in dermal- epidermal interface; subepidermal cleft formation

when you see EM, always have to think about....

Evolving SJS AND TENS

Clinical Presentation of EM

•Abrupt onset of skin lesions
•Round well defined TARGETOID like lesions- three concentric rings

•SKIN BIOPSY- severe epidermal necrosis- not diagnostic-

Managment of EM

supportive
if HSV= anti-virals.

Chest X-ray if respiratory symptoms

Symptomatic treatment: Oral antihistamines, cool compresses, wet dressings
Treat underlying infection
Remove offending drug
Steroids can suppress symptoms

SJS and TENS

•Both are rare idiopathic, life-threatening adverse reactions usually due to medications- rarely infectious
•Necrosis of epidermal cells of the skin and mucosa
•Prodromal 1-3 day influenza like symptoms
•Dusky targetoid plaques evolving into areas of sloughing denuded skin
•Nickolsky Positive
•Differentiated by the % of BSA affected
•Patients usually hospitalized in BURN unit

How do you differentiate SJS AND TENS

SJS <10% BSA detaches

TENS >30% BSA detaches

Common sites for pressure ulcers

Sacrum, Calcaneus ,Ischial tuberosity, Trochanter
65% Pelvic region
30% lower limbs

Complications of pressure ulcers

Local infection
Osteomyelitis
Squamous cell carcinoma- Marjolin's ulcer

Cellulitis clinical features

Rubor
Calor
Dolor
Tumor
Poorly defined borders
Almost always unilateral!
Fever, chills, malaise, leukocytosis

Cellulitis Pathogenesis

Immunocompetent hosts: Streptococcus pyogenes or Staphylococcus aureus most common
Direct inoculation

Immunocompromised hosts: Mix of Gram-positive cocci and Gram-negative bacilli Hematogenous seeding

EM major vs EM minor

EM major: Mucous membrane involvement, systemic symptoms
EM minor: Less severe, no mucosal disease

Acne Vulgaris

Inflammatory disorder
presence of open and closed comedones pustules nodules papules and cysts of skin
-socially debilitating
-associated with teenage depression
-mild mod severe
-genetic component

The most common skin disorder

Acne

Acne causes

-excess oil
-clogged hair follicles- hyperkerinization/obstruction
-bacteria- cutibacterium acne
-friction/pressure on skin (helmets, cellphones, tight collars)
-often appears during changes of hormone levels-androgen rise

Things that worsen acne

stress
chocolate
dairy
certain oils found in hair and skincare products

Acne Treatment- Mild

OTC benzoyl peroxide
salicylic acids
sulfur
azeleic acids
retinols

Acne Treatment- Moderate/Severe

oral abx -doxycycline, minocycline
females- spironolactone(anti androgenic)
oral contraceptives
isotretinoin

DONT use oral and topicals in

pregnant or breast feeding women

Side effects for doxycycline

sun sensitivity
upset stomach
headache
psuedotumor cerebri

Side effects for minocycline

black stools
diarrhea
nausea upset stomach
headache
blue/grey pigmentation of skin

Rosacea

common disorder that mostly affects skin of face and eyes
adults 30-50
14 million people have and most do not know
theory: microscopic skin mites, disorder of blood vessels
cause unknown

Rosacea treatment

Metronidazole
azelacic acid
ivermectin
lasers
topicals that reduce redness by constricting blood vessels
sodium sufacetamide
oral abx- minocycline low dose
IDENTIFY TRIGGERS

Rosacea can be characterized by

flushing, telangiectasia, enlarged oil glands, pustules and burning heat sensation

3 stages of rosacea

1. Flushing and diffuse redness
2. Add pustules papules and enlarged oil glands
3. Rhinophyma- most women dont progress to this stage

Psoriasis

immune mediated disease characterized by inflammation caused by a dysfunction of immune system
-overactive immune system= speeds up skin cell growth
-plaques build up burning itching

Normal cells shed in about____ days , while psoriatic cells shed in _____days

28, 4

Psoriasis is most commonly found on the

elbows, knees and scalp

1 in 3 people with psoriasis will also have

Psoriatic Arthritis

Psoriasis can present as

raised pink scale silvery plaques on extensor surfaces of elbows and knees
but can be anywhere

Psoriasis variants

Vulgaris *
Pustular
Guttate- spares palms and soles

Psoriasis treatment Mild

Topical Steriods

Psoriasis treatment Moderate

add UVB Puva descaler such as Retin A calcipotriene

Psoriasis treatment Severe

methotrexate, biologics

Perioral dermatitis

common acneiform eruption
monomorphic papules around mouth and nose
pathogenesis unknown
-toothpase,topical or inhaled steriod use

98% of time perioral derm is caused by

a topical cream or over exfoliating the skin in these areas

Perioral dermatitis treatment

DC all topical creams
-tacrolimus
-pimencrolimus
-topical erythromycin, clindamycin
-metronidazozle

Hidradentitis Suppurativa

chronic inflammatory follicular disorder of apocrine gland bearing skin
-painful persistent boil like lesions
-follicular rupture release keratin and bacteria
-vigorous inflammatory response, abscess/sinus tract formation with sometimes severe scarring

Hidradentitis suppurativa is more common in

women

Hidradentitis suppurativa most commonly found in

-axillae, skin folds, anogenital regions

Tnf-a increase correlates with

disease severity

Hidradentitis Suppurativa comorbidity burden with

HTN
OBESITY
Metabolic syndrome
PCOS
IBD
tobacco

Treatment for Hidradentitis Suppurativa
MILD

Topical oral abx
intralesional steroid injections
spironolactone

Treatment for Hidradentitis Suppurativa
MODERATE

TNF inhibitors, dapson, cyclosporine, oral retinoids

Treatment for Hidradentitis Suppurativa
SEVERE

excisions and deroofing

Fungal Infections- Tinea
tinea-worm

closely resemble other skin infections
dermatophytes

Confirm tinea with

KOH exam