J CM Derm pt 2

6 classic rashes of childhood

1. rubeola 9measles)

2. scarlet fever

3. rubella (german measles)

4. 4th disease (duke’s disease)

5. 5th disease (erythema infectiosum)

6. roseola infantum

descending rash with a prodrome of cough, coryza, and conjunctivitis 2n1s

rubeola (measles)

koplik spots 2n1s

rubeola (measles)

(pearly white elevated spots on erythematous background opposite to molars on buccal mucosa)

rubeola (measles) cause, prodrome, sx*

cause: morbillivirus

prodrome: cough, coryza (runny nose), conjunctivitis

blanching erythematous rash (begins on face → extremities)

koplik spots

scarlet fever cause

group A strep

Scarlet Fever (Scarlatina) sx*

BLANCHING rash w/ erythematous macules that coalesce

sandpaper quality, starts on head/neck → trunk

strawberry tongue

pastia’s lines

circumoral pallor

skin desquamates (comes off in scales/flakes)

pastia’s lines definition

skin creases in the axillae, elbows, and groin might develop lines that are brighter red than the rest of the rash

rubella (german measles) cause*

togavirus

Rubella (German Measles) sx*

cervical and posterior auricular adenopathy

Forchheimer Spots → petechiae on palate

fever, rash, conjunctivitis occur simultaneously

rash starts face → down body (palpable petechiae)

duller in color than measles

Forchheimer Spots

(rubella)

“slapped cheek” rash on face 2n1s

5th disese (erythema infectiosum)

Fifth Disease (erythema infectiosum) cause*

human parvovirus (B19)

Fifth Disease (erythema infectiosum) presentation*

irritability and high fever first → slapped cheek rash and lacy rash on extremities

reticulating rash in 5th disease

Roseola Infantum (exanthem subitum) cause*

HHV 6 and 7

Roseola Infantum (exanthem subitum) sx*

high fever in otherwise well appearing child

rash appears as fever goes away, starts on neck/trunk → extremities

group A coxsackieviruses cause what?

herpangina

hand-foot-and-mouth disease

(picornaviridae family, genus enterovirus)

hand-foot-and-mouth (HFM) disease

severe pharyngitis, febrile, will not eat

coxsackie virus disease

Gianotti-Crosti Syndrome (Papular acrodermatitis of childhood)

occurs after viral disease

self-limiting

lymphadenopathy in truncal area

erythema toxicum

“baby acne”

harmless

kawasaki disease sx

• AKA mucocutaneous lymph node syndrome

• changes to mouth/lips (cracked/erythematous lips, strawberry tongue, circumoral pallor)

• polymorphous rash

• conjunctivitis

• erythema of palms/soles

• unilateral cervical lymphadenopathy

kawasaki disease complications/sequelae

myocarditis → cardiomyopathy

complication = aseptic meningitis

tx for kawasaki’s disease*

IVIG

high dose steroids

ASA

hair growth cycle

• Anagen → growing phase (2-4 years)

  • The normal hair shaft grows about 1 cm/month

• Catagen → transitional phase (2-4 months)

• Telogen → resting phase (2-4 weeks)

  • It is normal to lose up to ~100 hairs a day

Telogen effluvium definition and cause

stress causes hair roots to be pushed prematurely into the resting phase

cause: childbirth, stress, surgery

Alopecia Areata and types

starting early in life (children and young adults) = less likely to get better

occurs in sharply defined areas

patterned type (most common): 1+ patches → regrowth

Diffuse type (alopecia totalis) → involves entire scalp → poorer chance for permanent regrowth

Complete type (alopecia universalis) → involves entire body → poorer chance for permanent regrowth

Alopecia Areata skin signs*

• Non-scarring

• No S/Ss of inflammation

• No scale

• Short “exclamation mark” hairs seen in area

• Positive hair pull test

• Fine “vellus” hairs seen when regrowth starts, might be pigmented 

  • Peach Fuzz

• nail pitting

→ clinical diagnosis

poorer prognostic factors in alopecia areata*

• Onset in childhood

• alopecia totalis or alopecia universalis

• Duration >1 year

• Ophiasis → Band-like involvement of the peripheral temporal and occipital scalp 

• Nail involvement

• Atopy

• FH

• Comorbid autoimmune disease (Cicatricial alopecia)

Cicatricial alopecia

scarring alopecia in discoid lupus causing total destruction of hair follicle

treatment for alopecia areata*

• For small and solitary patches

  • No tx needed → Spontaneous regrowth

  • intralesional steroids / topical therapies

• For large and numerous patches 

  • Intralesional steroids

  • Minoxidil 

  • Topical immune sensitizers

  • Systemic steroids x 3 months

exclamation mark hairs

= alopecia areata

warts are the _ _ of the epidermis

benign lesion

verrucae → warts cause

cause: HPV

Vaccine exists for specific serotypes → 6, 11, 16, 18

transmission by simple contact

verrucae → warts types

1. verrucae vulgaris

2. verruca plantaris

3. verruca plana

4. condyloma acuminata

5. cervical dysplasia and neoplasia

Verrucae Vulgaris

• what is it

• what might you find

• location

common warts (HPV 1, 2, 4)

• Flesh colored to grey-brown, hyperkeratotic papules/plaques w/ scale or filiform

• +/- black dots (thrombosed capillaries)

• hands, periungual skin, elbows/knees, face

Verruca Plantaris

plantar warts (HPV 1, 2, 4)

plantar surfaces of feet

often painful

verruca plana*

flat warts (HPV 3, 10)

small (1-3), flat topped pink/tan/brown papules

forehead, legs, dorsal hands, chin, neck

condyloma acuminata*

genital warts, hpv 6 and 11

infx of anogenital skin and intra-oral issues

fleshy papules w smooth/velvety moist surfaces

can coalesce to form larger cauliflower-like mass

frequently recur after tx

low chance → malignancy

cervical dysplasia and neoplasia

HPV 16, 18, 31, 33, 45

can begin as warts that are NOT condylomata

assoc with squamous cell carcinoma of cervix, labia, penis, anus, oral cavity, tongue

bowenoid papulosis

bowenoid papulosis definition

rare intermediate stage between warts caused by high risk serotypes (usually 16) and Bowen disease (squamous cell carcinoma in situ)

tx for verrucae (warts)

OTC (salicylic acid or liquid nitrogen), surgery

caustic acids (flat, plantar, common anogenital warts): cantharidin, tricholoracetic acid

chemo:

• 5-Fluorouracil (Efudex) → for flat warts

• Imiquimod (Aldara) → for anogenital warts

• Podophyllotoxin (Podofilox) → for anogenital warts

The body's immune system can destroy the warts w/o any tx; most will resolve spontaneously over weeks to months but harder if immunosuppressed

Androgenetic Alopecia (aka male pattern baldness) pop, sx*

most common form of alopecia

30-40% of M and F

non-scarring, starts at hairline and goes back

Androgenetic Alopecia (aka male pattern baldness) tx*

topical minoxidil

finasteride (more effective than minoxidil)

hair transplants

name for resting stage of hair growth cycle

telogen

if there’s stress → more hair in resting phase

telogen effluvium top 2 causes

childbirth

surgery

Onychomycosis (tinea unguium) definition

fungal infx of the finger/toe nail plates

15-20% of pop b/w 40-60 yo

Onychomycosis (tinea unguium) etiology

dermatophytes → trichophyton rubrum and mentagrophytes most common (don’t have to know exact)

candida more often seen in fingernails

Onychomycosis (tinea unguium) diagnosis

examine all nails and skin to r/o other disease that can mimic onychomycosis

•  If all nails are affected, fungus is unlikely 

• Psoriasis, lichen planus, eczema, trauma, habitual, picking of cuticles

Scrape proximal nail bed for KOH/fungal culture

fingernails grow at a rate of ? per month, toenails grows at a rate of ? per month

3 mm/month

1 mm/monthy

Onychomycosis (tinea unguium) tx*

• what test

• what is NOT effective

• what IS effective

• what is something to educate pts

check CBC/LFTs before, at 6 weeks and at end of tx

topical tx is NOT effective

oral therapy has highest success rate (50-80% effective but 15-20% relapse w/in 1 year)

^ terbinafine (lamisil), finger = 6 weeks, toenail = 12 weeks

itraconazole (fixed or pulse therapy)

nails do NOT appear clear for 6-12 mos after tx!!

proximal subungal onychomycosis

yeast onychomycosis (yeast)

paronychia definition

Painful inflammation of the nail fold surrounding the nail plate

paronychia acute vs. chronic forms*

acute: bacterial (staph), precipitated by trauma or chemicals

chronic: fungal (candida), repeated wet activites, several fingers

felon definition, cause, tx

bacterial infx of fleshy part of fingertip (distal)

cause: injury, extension of paronychia

tx: salt water soak, abx, i&d, do NOT incise on fleshy part, only lateral

Cherry Angioma

adults, elderly

confused with spitz nevus of childhood

1-5 mm

red-purple papules

pyogenic granuloma

sudden eruption of lesion

• 5-10 mm, soft red papules

• Arise on skin

• Friable and bleed easily!!!*

common on head/neck and hands, kids/young adults

1/3 occur after local trauma

Acanthosis nigricans*

• A reactive skin pattern associated w/ obesity, DM, hypothyroid, cushing’s syndrome, malignancy 

  • Common thread in insulin resistance

acanthosis nigricans sx*

• gray-brown to black, rough to velvety, thickened plaques and prominent skin lines

• occurs in flexural areas

• asymptomatic

→ tx = weight loss and tx of underlying conditions

Vitiligo definition

A complete loss of skin pigmentation d/t a decrease in both number and function of melanocytes

vitiligo epidemiology

• age

• assoc with?

• examples where you see this

dark pigmented skin, can effect any race

½ of cases <20 yo

associated with high homocysteine levels (cell destruction)

• Seen in graves disease, addison’s disease, hypothyroidism, pernicious anemia, T2DM, melanoma 

vitiligo PE*

• Well demarcated borders of depigmentation

• Macules/patches

• dorsa of hands, face, axilla, genitalia, or around body openings

types of vitiligo*

• Generalized (most common) → Widespread and symmetric distribution 

• Focal → Isolated distribution

• Universalis → total depigmentation 

• Unilateral/segmental → dermatomal distribution on one side

• Mucosal → MMs only

vitiligo tx*

most effective: phototherapy w/ sun protection

others: topicals, depigmentation, skin grafts, cosmetic coverup, tattooing

most common benign vascular neoplasm of childhood

hemangioma

hemangioma complications

when ulcerates(diaper area) or obstruct vital functioning

→ hypopig, telang, stretched skin, scar

Port Wine Stain definition*

type of vascular malformation

variant of nevus flammeus

pink/red midline (unilateral) macule/patch

port wine stain complications*

1. sturge-weber syndrome**

2. dermal fibrosis

3. soft tissue/bone hypertrophy

sturge-weber syndrome definition

trigeminal nerve branches

→ glaucoma, seizures, intellectual impairment

complication of port wine stain

milia definition*

• 1-2 mm superficial white/yellow keratin containing epidural cyst

• eyelids, cheeks, and forehead

• Occurs at any age

• No treatment necessary 

epidermal inclusion cysts*

• definition

• contains what

firm, mobile, painless nodules

contains KERATIN (no sebum)

epidermal cysts originate where*

epidermis

pilar cysts originate where?*

infundibulum of hair follicles

seborrheic keratosis definition, age, malignant potential*

benign epidermal growth of immature keratinocytes

>50 yo

no malignant potential

Seborrheic Keratosis features*

• Warty “Stuck on” appearance

• Scaly, hyperpigmented, well circumcised lesions

Seborrheic Keratosis tx

no tx needed unless cosmetic problems

liquid nitrogen

shave biopsy blade

Keratoacanthoma definition*

sudden appearance of 1-2 cm skin-colored, dome-shaped papule w central keratin filled plug

can → SCC

spontaneous regression wks-mos

Sebaceous hyperplasia definition

• unique-ish finding

• what is it?

• sx?

• you put pressure, what do you see?

1-2 mm soft pale yellow/skin colored umbilicated papules

(scattered and enlarged sebaceous glands)

uniform telangiectasia

no sx but yields sebum w/ pressure

Sebaceous hyperplasia - location, pop

face

older adults

Dermatofibromas - definition, sx, what sign, location*

0.3 - 3 cm flesh to brown, firm, dome shaped or depressed, non-fixed, movable nodule

Asymptomatic

Lateral pressure → Fitzpatrick sign “dimple/retraction sign”

extremities

Skin tags - definition, location, pop, sx*

1-10 mm flesh to brown, soft pedunculated/flat/filiform or sessile

eyelids, neck, intertriginous areas

females, >30, obese

asymptomatic

Hypertrophic scar is confined to what site*

site of injury

keloid definition, cause, pop*

extends beyond site of injury

d/t inappropriate fibroblast proliferation from trauma

benign tumor, NEVER becomes malignant

darker skin types, above waist

Cutaneous horns - definition, location, appearance*

Keratinous skin tumors in the shape of conical projections above the surface of the skin

face or hands

appearance of horns, woods, coal

Lipomas - definition, features*

• benign tumor composed of adipose tissue

• Most common benign form of soft tissue tumor 

• Soft to the touch, moveable, generally painless

Most common benign form of soft tissue tumor

lipomas

Nevi (Moles) - features, cause, sx*

cause: proliferation of melanocytes

benign BUT can → malignant melanoma

childhood-young adulthood (sus if >30)

sun-exposed skin

asymptomatic

with nevi (moles), when are you suspicious?*

>30 yo

sun protected areas

sudden skin sx of itch/pain/bleeding

Congenital Melanocytic Nevus - inc risk of, appears when*

INC risk of melanoma!!

timing: birth or infancy

mongolian spots vs. congenital melanocytic nevi

mongolian spot (congenital dermal melanocytosis): benign, flat congenital birthmark w/ wavy borders + irregular shape (pictured above)

entrapment of melanocytes in the lower half to 2/3 of dermis

harmless and usually fade by school age

junctional common pigmented nevi*

b/w the epidermal and dermal layers of skin

pigmented (a tiny bit raised)

risk of dev cancer

compound pigmented nevi*

features of junction and dermal nevi

pigmented and papular

dermal pigmented nevi*

deep papular lesion

appears later in life

Blue Nevus

intense pigment deeper in dermis

nevus spilus

black pepper appearance

tan macule w/ several smaller brown nevi

spitz nevus

dome shaped red/pink papule seen in kids

hard to distinguish from melanoma → remove

halo nevus

central placed nevus surrounded by white halo of depigmentd skin

adolescence

gradually involute and disappear → residual white patch

Dysplastic (Atypical) Melanocytic Nevi - definition

• inc risk of ?

• when do you want to excise?

• benign or cancerous?

part of spectrum b/w benign nevi and melanoma

inc risk of malignancy depending on atypia severity

surgical excision of signs of dysplasia = ABCDE criteria

NOT BENIGN!

ABCDE criteria (for biopsy for cancer/dysplastic melanocytic nevi)

A = asymmetry, B = border irregularity, C = color variation, D = diameter > 6mm, E = enlarging/evolving