Derm E1: Cumulative Review

Based on what she said in class! Do not promise that i got everything that she said

What causes Scarlet Fever?

Group A Streptococcus (S. pyogenes)

What are the clinical features of Scarlet Fever?

• diffuse erythematous “sandpaper” rash that blanches

• starts in groin/axilla → trunk, spares palms/soles

• circumoral pallor

• strawberry tongue

• pastia lines

What is the tx for Scarlet Fever?

• 1st line

  • Penicillin V

  • Amoxicllin: kids

• 2nd line

  • Cephalosporins

  • Clindamycin

  • Macrolides -Azithromycin

What causes folliculitis?

S. Aureus - most common; P. aeruginosa -hot tub

What clinical features are associated with folliculitis?

• superficial: perifollicular papules/pustules w/ erythema ± pruritus

• deep: nodules, furuncles

• hot tub: papules/pustules on trunk and buttocks in bathing suit distribution

What is the tx for folliculitis?

• mild: topical mupirocin, topical Clinda

• moderate/severe: Dicloxacillin, Cephalexin

• MRSA: Bactrim, Clinda

• Hot tub: cipro

What causes Impetigo and Ecthyma?

S. Aureus or Group A Streptococcus

What are the clinical features of Ecthyma?

“punched-out ulcers” covered w/ yellow crust surrounded by raised violaceous margins

What are the clinical features of non-bullous impetigo?

most common; begins as pustules overlying erythema, lesions break → golden/honey crusts; involve face and extremities; well localized

What are the clinical features of bullous impetigo?

due to S. Aureus toxin A; vesicles enlarge to form flaccid bullae w/ clear yellow fluid → become darker and more turbid → rupture → thin brown crust; only on the trunk

What is the tx for Impetigo?

• localized 1st line: Mupirocin (bactroban) ointment

• extensive: Cephalexin or Doxycycline

What is unique about Erysipelas?

involves upper dermis and superficial lymphatics; clear demarcation of involved tissues; Milian’s ear sign

What is unique about cellulitis?

involves the deeper dermis and subcutaneous tissue, spreads more; purulence

What causes Erysipelas and Cellulitis?

S. pyogenes -MCC or S. Aureus

What are the shared clinical features of Erysipelas and Cellulitis?

skin erythema, edema, and warmth; fever

What is the tx for Erysipelas and Cellulitis?

• Outpt: Cephalexin;

  • PCN allergy → Bactrim

• Inpt (septic or immunocompromised):

  • IV Vanc + Cefepime

  • PCN allergy → IV Vanc + levofloxacin

What are the clinical features of Erythrasma?

limited to body folds, Asx or pruritic, duration varies, well demarcated, brown-red or tan patches ± scaling

What is the tx for Erythrasma?

• 1st line

  • topical erythromycin or clindamycin

• 2nd

  • topical miconazole or benzoyl peroxide

• Severe: oral Abx

  • clarithromycin

  • erythromycin

What is the cause of Syphilis?

Treponema pallidum -a spirochete

How is Syphilis transmitted?

direct contact w/ an infectious lesion, fetal infection via placenta

What are the clinical features of Primary Syphilis?

painless ulcer or chancre -heal spontaneously, non-tender regional LAD

What are the clinical features of Secondary Syphilis?

diffuse, bilateral, symmetric maculopapular rash +palms/soles, copper brown lesions, Condyloma Lata, regional LAD, cutaneous ulcerations

What are the clinical features of Late stage Syphilis?

gumma, neurosyphilis, AR, AA, aortitis

What is the tx for Syphilis?

PCN G benzathine; Alt: Doxy

-late stage = longer prescription time

What causes Chancroid?

Haemophiles ducreyi

What are the clinical features of a Chancroid?

painful genital ulcers w/ irregular borders covered by a gray or yellow exudate

What is the tx for a Chancroid?

• 1st line: Azithromycin or Ceftriazone

• Alt: Erythromycin

What causes Rubella (German Measles)?

Rubella virus

What are the clinical features of Rubella?

low fever, cough LAD, Exanthem: pink or red non-confluent maculopapular rash, face → trunk, spares palms/soles, Forcheimer spots: red macules or petchial spots on the soft palate

What is the tx for Rubella?

supportive care: antipyretics, hydration

What is the cause of Rubeola (measles)?

Rubeola virus

What are the clinical features of Rubeola?

• stage 1: incubation

• stage 2: prodrome - High fever, cough, coryza, conjunctivitis (3 C’s)

• Stage 3: Koplik spots, exanthem: begins at hairline → spreads craniocaudally and centrifugally

• Stage 4: recovery, cough may persist

What is the tx for Rubeola?

supportive, Vitamin A, Ribavirin -high risk pts

What is the cause of Roseola Infantum (6th disease)?

Human Herpes virus 6 (HHV-6)

What are the clinical features of Roseola?

acute onset high-fever up to 104 → small rose-pink maculopapular rash, begins on the trunk and spreads, nonpruritic

What is the cause of Hand, Foot, and Mouth Disease?

Coxsackie A16, Coxsackie A6, Enterovirus A71

What are the clinical features of Hand, Foot, and Mouth Disease?

mild fever, reduced appetite, oral lesion w/ halo of redness, painful vesicles, refusal to eat, rash of hands/feet + palms/soles

What is the cause of Erythema Infectiosum (Fifth Disease)?

Parvovirus B19

What are the clinical features of 5th Disease?

fever, HA, nausea → malar rash w/ circumoral pallor, “slapped cheek appearance”, lacy eruption on the trunk, palms/soles spared, aplastic crisis

What are the clinical features of Herpes Labialis “cold sores”?

pruritis, burning, tingling pain, grouped vesicles on an erythematous base, ulceration on oral mucosa

What are the clinical features of Herpes Genitalis?

pruritis, burning, tingling pain, grouped vesicles, painful ulcers, dysuria, inguinal LAD

What would you see on a Tzanck smear of HSV?

multinucleated giant cells

What is the tx for HSV?

supportive, antivirals: Acyclovir, Valacyclovir

What causes Varicella (chicken pox)?

Varicella Zoster Virus

What are the clinical features of Chicken Pox?

fever, malaise, anorexia → pruritic rash, starts on face and spreads, “dewdrop on a rose petal”, asynchronous rash in various stages

What is the tx for Varicella?

• <12 and immunocompetent → supportive

• > 12 and immunocompetent → antivirals (Acyclovir)

• immunocompromised → IV Acyclovir

What causes Herpes Zoster (Shingles)?

reactivation of latent VZV

What are the clinical features of Shingles?

fever, malaise, paresthesias → painful, unilateral eruption of vesicles along dermatomes, rash does NOT cross midline

What is the tx for Shingles?

antivirals: Acyclovir, Valacyclovir, Famciclovir

What is the most common sexually transmitted infection?

anogenital HPV

What is the tx for Condyloma acuminatas seen in HPV?

• 1st line meds

  • Imiquimod

  • Podofilox

• 1st line procedures

  • cryotherapy, surgical removal

How do you dx Tinea infections?

intial: KOH -look for segmented hyphae

definitive: culture

What are the clinical features of Tinea Capitis?

scaly patches w/ alopecia, Kerion -painful inflammatory plaque w/ pustules and thick crusts

What is the tx for Tinea Capitis?

• 1st line: oral Griseofulvin

  • watch for heptotoxicity and leukopenia

• Alt: oral terbinafine

  • obtain LFTs prior to starting

What are the clinical features of Tinea Faciei?

small scaly papules that evolve to form an annular plaque; Tinea barbae involves the beard

What are the clinical features of Tinea Manuum?

hyperkeratotic eruption of the palms, typically unilateral, associated w/ tinea pedis

What is the most common Dermatophyte infection?

Athlete’s foot (Tinea pedis)

What is the primary cause of Tinea infections?

Trichophyton rubrum

What are the clinical features of Tinea Pedis?

interdigital pruritic erythematous lesions, hyperkerotic moccasin pattern, vesiculobullous inflammation

What is the tx for most Tinea infections?

• 1st: topical azoles

• alt: Topical Terbinafine

• Oral antigungal

  • Terbinafine, Itraconazole, Fluconazole

What are the clinical features Tinea Corporis (Ringworm)?

pruritic, circular erythematous, scaling patch or plaque that spreads centrifugally, central clearing and raised border; EXCLUDES feet, groin, hand

What should you NOT give for tinea (fungal) infections?

topical steroids

What are the clinical features of Tinea Cruris?

erythematous scaly patches, proximal medial thigh, spreads centrifugally w/ partial central clearing, scrotum is typically spared

What is the tx of Tinea Cruris?

• 1st line: miconazole drying powder

• Alt: “azoles” antifungals

What causes Tinea Incognito?

usage of steroids on a fungal infection

What are the clinical features of Tinea Incognito?

atrophy, purpura, exaggerated lesion deep red/violaceous w/ follicular papules or pustules, can be asx or pruritic/ painful

What is the tx of Tinea Incognito?

oral antifungal (Terbinafine or Itraconazole)

What are the clinical features Onychomycosis?

opaque, thickened, discolored/yellowing, flaking nails, subungual hyperkeratosis

What is the tx for Onychomycosis?

Oral terbinafine or Ciclopirox

What would KOH show for Candidiasis?

budding yeast and pseudo-hyphae

What is the cause of Pityriasis Versicolor (Tinea Versicolor)?

Malassezia Furfur

What are the clinical features of Tinea Versicolor?

well-demarcated hypo-hyperpigmented oval or round macules, fine scaling, skin will nOT tan, ± mild pruritus

How would you dx Tinea Versicolor?

KOH: short hyphae and yeast cells in a “spaghetti and meatball” pattern

Wood’s lamp: yellow/green fluorescence

What is the tx for Tinea Versicolor?

Selenium sulfide, Ketoconazole, Fluconazole

What is the tx for most Pediculosis infections?

Permethrin

What is the cause of Lyme Borreliosis?

Borrelia burdorferi: G- spirochete via Deer ticks

What are the clinical features of Stage 1 (early localized) Lyme disease?

erythema migrans “bulls eye” or “target” lesion, flu-like sx

What are the clinical features of Stage 2 (early disseminated) Lyme disease?

cranial nerve palsies, AV block, HA, pericarditis

What are clinical features of Stage 3 (late) Lyme disease?

persistent arthritis, encephalopathy, Bells palsy, peripheral neuropathy

How do you dx Lyme disease?

Initial screening: ELISA or IFA

confirmatory: Western blot

What is the tx for Lyme disease?

• Early Localized

  • Adults: Doxy

  • Kids: Amoxicillin

• Early disseminated

  • doxy

• Late

  • Doxy

  • AV blocks/neuro sx: IV Ceftriaxone

What can be given as prophylaxis of Lyme disease?

Doxycycline

What causes Rocky Mountain Spotted Fever?

Rickettsia rickettsia via wood & dog ticks

What are the clinical features of Rocky Mountain Spotted Fever?

fever, Blanching erythematous macular rash → petechial, starts on wrists, ankles, palms, soles → spreads to trunk, abd pain, focal neuro signs

What is the tx for Rocky Mountain Spotted Fever?

Doxycycline

Alt: Chloramphenicol

What are the clinical features of a Brown Recluse bite?

• initial: usually painless, red plaque, central pallor

• 2-8 hrs: pain develops, blue discoloration or bullseye appearance

• 24-48 hrs: dry eschar that will ulcerate

What is the tx for a Brown Recluse bite?

supportive, most heal spontaneously, do not debride, no antivenom, ABx if secondary infxn

What are the clinical features of a Black Widow bite?

• local: pain at the bite site, blanched circular patch w/ surrounding red perimeter “target”; does NOT become necrotic

• 30 min-2 hrs: muscle pain, severe abd pain w/ rigidity; tremor, weakness, paresthesia, HA, N/V

• tachycardia, diaphoresis, hypertension

What is the tx for a Black Widow bite?

• mild: clean the wound, NSAIDS, tetanus prophylaxis

• moderate/severe: wound care, IV morphine and diazepam, antiemetics, tetanus prophylaxis

• hospitalized, muscle relaxers

• IF unresponsive to opioid and benzo therapy → antivenom can be administered

When is a biopsy of a NMN indicated?

if any of the melanoma ABCDE criteria is met; concern for melanoma

What are the clinical features of Atypical Nevi?

> 5mm, asymmetrical, variegated color, prominent macular component, papular center (“fried egg”), w/ notched, irregular, or ill-defined borders

When would you refer an Atypical Nevi to derm?

assymmetry, > 6mm, irregular borders, abnormal color

What are vascular tumors?

neoplastic, grow independently, due to increased proliferation rates of endothelial and vascular cells

What are vascular malformations?

non-neoplastic structural abnormalitites, normal endothelial cell growth, includes capillary, lymphatic, venous, arteriovenous malformations

What is a Pyogenic Granuloma?

benign vascular tumor of the skin or mucous membranes

What are the clinical features of a Pyogenic Granuloma?

starts as small, red papule that grows rapidly, friable and bleeds, ± collarette scale at the base of the lesion

What would you see on a dermoscopy of a Pyogenic Granuloma?

pink homogenous papule w/ white septa

What is the tx for Pyogenic Granuloma?

• topical

  • Imiquimod or Timolol

• procedural

  • cryotherapy, laser, excision

• avoid trauma

• table salt

What is an Infantile Hemangioma?

most common vascular tumor characterized by a growth phase and an involution phase

What are clinical features of a superficial Infantile Hemangioma?

soft bright red papule or nodule