Derm: Benign Skin Lesions, Malignant Skin Lesions, Hail/Nail/Pigment D/O, Rheumatology , Derm: Bacterial/Viral/Fungal Skin Infections, Viral Exanthems , Derm: Acne & Rosacea, Infestations & Bites, Burns, Inflammatory & Allergic D/O, Bullous & Desquam…

Skin tag

Acrochordons

Can be a marker for insulin dependence

Flesh-colored to brown, often pedunculated, fleshy papules

Commonly on eyelids, axilla, neck and groin

Acanthosis nigricans

Velvety thickening w/ hyperpigmentation of the skin

Commonly seen w/ DM

Most common on the neck, groin and skin folds

Dermatofibroma

Benign tumor of the skin

Firm, hyper pigmented papules w/ darkening of outer ring

Dimples when you put pressure on outer sides of the growth

Common on extremities

Milia

Tiny epidermoid cyst

Occurs in all age groups

Oil gland is clogged

White-yellow papules

Fixed and persistent

Epidermal Inclusion Cyst

Most common dermal cyst

Arises from hair follicles

Contain degenerating keratinocytes, rancid smell when opened

Mobile nodule w/ overlying punctum

Must remove in entirety!

Lipoma

Subcutaneous collection of fat

Soft, SQ nodule w/o overlying skin changes

Common on trunk and proximal extremities

Keloid

Results from abnormal wound healing leading to overgrowth of scar tissue

Variety of different colors

Raised and cosmetically disfiguring

Common at earlobes and upper trunk

High recurrence rate

Cherry Angioma

Common vascular growth

+30y

Familial inheritance

Bright red to violaceous

Commonly seen on trunk

Hemangioma of Infancy

Most common tumor of infancy

Females > males

Localized red to purple, non-blanching, nodule or plaque w/ telangiectasia

Regresses gradually

Port Wine Stain

Associated w/ Sturge-Weber syndrome

Irregularly shaped, red to purple, macule or patch that is present at birth and does not resolve spontaneously

Large lesion usually follows dermatomal distribution

Nevus Flammeus Nuchae

Type of port wine stain

Stork bite

Present in 1/3 of newborns

Nevus

Mole

Symmetrical, flesh-colored, tan-brown macule or papule

Located anywhere

Atypical Nevus

Dysplastic mole

Not cancer, but has a greater potential to evolve to melanoma

Located anywhere

Surgical excision recommended

Solar Lentigo

Sun spots, liver spots, age spots

Smooth, flat, symmetrically pigmented macule or patch found on areas of sun exposure

Identifies pts who may be high risk for skin cancer

Seborrhetic Keratosis

Most common benign epithelial tissue

Color variable

Velvety to verrucous

Can be extensive

Greasy, stuck on quality

Actinic Keratosis

Premalignant skin lesion

If it turns into cancer, most turn into squamous cell carcinoma

Erythematous papules or plaques w/ rough, gritty feel like sandpaper in sun exposed areas

Needs to be removed!!

Cutaneous Horn

Appearance of an animal horn w/ a papular or nodular base and a keratotic cap

Usually a SCC or SCC in situ at base of horn

Should be biopsied then removed surgically

In situ

a skin cancer on top of the skin (epidermis only)

Squamous Cell Carcinoma in Situ

Bowen's disease

Pink to red lesions, slightly scaling surface, small erosions, may be crusted

Asymptomatic but may bleed

Nodule formation indicates further invasion

Surgical excision

Squamous Cell Carcinoma

Malignant tumor of keratinocytes

Usually arises from precancerous lesions

Papules, plaques or nodules, w/ hyperkeratotic debris and/or central ulceration

Surgical decision or MOHS

Basal Cell Carcinoma

Most common type of skin cancer

Malignant tumor that is locally invasive, slow growing and destructive

Oval/round, pearly pink papule or nodule

Telangiectasias throughout

Rolled borders

Surgical excision or MOHS

Melanoma

The most malignant tumor of skin

Malignant transformation of melanocytes of the dermal-epidermal junction

Becomes invasive and metastatic

TNM classification

Superficial Spreading Melanoma

Most common type of melanoma

Growth of tumor is horizontal rather than vertical (deep) into skin

Back on men

Back and legs on women

Nodular Melanoma

Rapid growth, more aggressive melanoma

Spreads vertically, so tumor is thicker (deeper)

Any site, trunk, head, neck

Lentigo Maligna Melanoma

Melanoma that occurs on chronically sun damaged skin

More common in elderly

Slow progression

Tumor spreads horizontally, not vertically

Face, neck, dorsum of hands

Acral Lentiginous Melanoma

Melanoma that is more common in darker skinned individuals

Lesions are easy to miss

Palms, soles, subungal

Subungal Melanoma

Dark streak under the nail

Dark streak under the nail that involves the nail fold

+ Hutchenson's sign

Hutchenson's sign

Darkening of the nail that involves the nail fold

Subungal melanoma

Skin cancer associated w/ + Hutchenson's sign

vertical spreading

What is a negative prognosis indicators for melanoma?

Non-cicatricial alopecia

Hair loss with no clinical sign of tissue inflammation, scarring or atrophy of skin

Good news for the hair follicle

Cicatricial alopecia

Hair loss with evidence of tissue destruction such as inflammation, atrophy, and scarring

Destroys hair follicle and causes permanent loss

Alopecia Areata

solitary or multiple areas of hair loss

Alopecia Totalis

total loss of terminal scalp hair

Alopecia Universialis

Total loss of terminal body and scalp hair

Alopecia Ophiasis

Bandlike pattern of hair loss over periphery of scalp

Male of Female Pattern Hair Loss

Most common form of hair loss

Alopecia androgenetica

Large genetic factor

Scalp skin is normal

Hairs in areas of hair loss are finer in texture and eventually atrophies completely

Men = frontotemporal and vertex areas

Hamilton Classification

Stages of male pattern hair loss

Ludwig Classification

Stages of female pattern hair loss

Tractional Alopecia

Occurs as a result of pulling from hairstyles, helmets, headbands, etc

Paronychia

Acute infection of lateral or proximal nail fold

Associated w/ hangnails or nail biting

Felon: progression into deeper soft tissue pulp space

Melasma

Mark of pregnancy

Macular light-to-brown, hyperpigmentation that occurs in sun-exposed areas

Color is usually uniform and symmetric

Lesions has serrated, irregular and geographic borders

May disappear

Vitiligo

Complete absence of melanocytes

Many different theories for etiology

Onset after stressful event

Totally white macules on skin and loss of pigmentation

Woods lamp

Chronic disease

Woods lamp test

Diagnostic test commonly used in Vitiligo

Osteoarthritis

Most common form of joint disease

Degeneration of articular cartilage

Joint pain that worsens throughout the day w/ activity

Morning stiffness that resolves w/in 30m

DIP joint, 1st MCP joint, knees or hip

Bouchard's nodes (PIP)

Heberden's nodes (DIP)

Osteoarthritis

Joint pain that worsens throughout the day w/ activity

Morning stiffness that resolves w/in 30 mins

Dx?

Osteoarthritis

Bouchard's and Heberden's nosed seen on PE

Dx?

Rheumatoid Arthritis

Chronic inflammatory d/o w/ polyarticular, symmetrical joint involvement

+ Systemic symptoms

Swan neck and Boutonnière deformities

Rheumatoid nodules

Prolonged morning stiffness

Joints: soft tissue swelling in wrists, MCP, PIP

Fetty syndrome: triad of RA, splenomegaly, neutropenia

Psoriatic Arthritis

Any form of inflammatory arthritis associated with/ psoriasis that is RF-

Arthritis: DIP, sausage digits, sacroiliitis

Nails: pitting, transverse depression and onycholysis

Eyes: conjunctivitis. anterior uveitis

Rheumatoid Arthritis

Prolonged morning stiffness

Dx?

Rheumatoid Arthritis

Swan neck and Boutonnière deformities on PE

Dx?

Reactive Arthritis

Reiter's syndrome

Triggered by bacterial infections of GI or GU tract

Classic triad: conjunctivitis, urethritis, arthritis --> can't see, pee, or climb a tree

Dactylics: sausage digits

Ulcers in mouth in

Antibiotics may help

Reactive Arthritis

Can't see (conjunctivitis), Can't pee (urethritis), Can't climb a tree (arthritis)

Dx?

Ankylosing Spondylitis

Inflammation of the axial skeleton associated w/ +HLA-B27

Low back pain w/ decreased mobility Symmetrical inflammation of SI joints, gradual onset, relieved by exercise and worse w/ rest

Bamboo spine on imaging

Ankylosing Spondylitis

+ HLA-B27

Dx?

Ankylosing Spondylitis

Bamboo spine on imaging

Dx?

Ankylosing Spondylitis

Pain relieved by exercise and worse w/ rest

Dx?

Gout

Pain in joint caused by deposition of uric acid crystals

Acute mono arthritis usually in 1st MTP (big toe)

Joint aspiration = negatively birefringent monosodium urate crystals

uric acid crystals

Gout is caused by the deposition of ___ in the joint space.

Pseudogout

Monoarthritis caused by calcium pyrophosphate dihydrate

Pain in swelling in one joint usually knee, wrist, or elbow

Joint = positively birefringent rhomboid CPPD crystals

Calcium pyrophosphate dehydrate

Pseudogout is caused by the deposition of ___ in the joint space.

Fibromyalgia

Chronic pain and fatigue w/ no clear organic cause

Widespread pain > 3 months

11/18 tender points of the body

Diagnosis of exclusion

Fibromyalgia

Pain and fatigue w/ no clear cause

Dx?

Systemic Lupus Erythematosus

Chronic autoimmune d/o w/ multisystem involvement

Young females

Butterfly rash, discoid rash, photosensitivity

+ANA in 96%

Immunosuppressive agents

Lupus

+ ANA

Dx?

Raynaud Phenomenon

Exaggerated response to cold temperature that results in transient digital ischemia

Bicentennial disease: white, blue, red

Symmetric intermittent attacks in the cold

Scleroderma

Chronic multisystem autoimmune disease w/ deposition of collagen in the skin and other organs

Females 4x more common

CREST = calcinosis, raynaud's phenomenon, esophageal dysfunction, sclerodactyly, telangiectasis --> NEED TO KNOW THIS FOR TEST

Sjogren Syndrome

Idiopathic autoimmune disease characterized by dry mouth, dry eyes, salivary gland enlargement

40x higher risk for lymphoma

Polymyositis / Dermatomyositis

Idiopathic inflammatory muscle disease

Dermatomyositis = polymyositis + heliotrope rash (purple discolorations and edema of eyelids)

Gottron papules: erythematous rash on extensor surfaces of fingers, elbows, knees

Muscle: gradual and progressive painless symmetrical proximal upper and lower extremity muscle weakness (raising from chair, combing hair), polyarthritis

Elevated muscle enzymes

Polymyositis

Gradual and progressive muscle weakness

Dx?

Polymyositis

Elevated muscle enzymes

Dx?

Polymyalgia Rheumatica

Inflammatory disorder of the muscles and joints

Proximal joints only

Pain > weakness

Pts that also have giant cell arthritis

Polymyalgia Rheumatica

Pain > weakness in the proximal joints

Dx?

Polyarteritis Nodosa

Necrotizing vasculitis of small and medium arteries

Abd pain, renal involvement, arthralgias, neuropathy, CHF

Skin lesions: livido reticular (picture), nodules, purpura

Need to confirm w/ a tissue biopsy

Impetigo

S. aureus infection of the epidermis which may extend into the dermis

Occurs from minor superficial breaks in the skin or secondary infections from other dermatologists conditions

Common in children

Nonbullous Impetigo

PE:

Erosions w/ honey-colored crusts and surrounding erythema

Bullous Impetigo

blisters containing clear, yellow or slightly purulent fluid w/ an erythematous base

Antibiotics (Mupirocin ointment)

Treat according to C&S

Tx for Impetigo

Folliculitis

S. aureus infection in the upper part of the hair follicle

May extend deeper into follicle if untreated/chronic

Folliculitis

PE:

Multiple small, erythematous "follicular" papules and pustules scattered in areas of hair growth

Antibiotics

Tx of Follixulitis

Hot Tub Folliculitis

Occurs on the trunk and extremities after immersion in a hot tub

Pseudomonas aeruginosa

Self-limiting

Pseudomonas aeruginosa

Etiology of Hot Tub Folliculitis

Pseudofolliculitis Barbae

AKA razor bumps

FB inflammatory rxn surrounding ingrown hairs from shaving

Furuncle

Acute, red, hot, tender nodule or abscess that evolves from a folliculitis

S. aureus

Carbuncle

A deeper infection composed of interconnecting furuncles

S. aureus

Systemic antibiotic

Tx for Furuncle and Carbuncle

Cellulitis

Inflammation and infection of the dermal and SQ tissue (deeper infx)

Cellulitis

PE:

Erythema, warmth, and edema of affected area

Will not be bilateral and will blanch on palpation

Possible lymphangitis

Erysipelas

Inflammation and infection of the upper layers of skin (more superficial)

Erysipelas

PE:

Erythema, warmth, and edema of affected area

Painful, well-defined erythematous, shiny, edematous plaques

S. aureus

Beta-hemolytic strep

Etiology of Cellulitis and Erysipelas in Adults

S. aureus

Beta-hemolytic strep

Hemophilus influenza B

Etiology of Cellulitis and Erysipelas in Children

Oral antibiotics

IV antibiotics w/ rapid spreading lesions, lymphangitis, high fever, comorbid dx, DM, HIV

Tx of Cellulitis and Erysipelas

Staph Scalded Skin Syndrome

Neonates, infants, young children

S. aureus that produces exfoliative toxins secondary to an infection

Staph Scalded Skin Syndrome

PE:

Ill-defined erythema w/ fine, sandpaper appearance

24h later, deeper erythema and painful skin

Superficial sloughing begins

Skin appears wrinkled and can be removed w/ gentle pressure

Hidradenitis suppurativa

Chronic suppurative disease of apocrine gland-bearing skin Involves axillae and anogenital region, rarely scalp

Onset usually at puberty

Hidradenitis suppurativa

PE:

Initial lesion is very tender, red, inflammatory nodules/abscess that may resolve on its own or require tx

Tender sinus tracts forms

Fibrosis and hypertrophied scars can form

Acute: I&D, triamcinolone injections

Chronic: oral antibiotics, prednisone taper, accutane, biologics

Surgical

Tx for Hidradenitis suppurativa

Pilonidal Cyst

Abnormal pocket of skin that usually contains hair and skin debris

Located near the tailbone at the superior gluteal cleft

Usually occurs when hair punctures the skin and then becomes embedded