Dermatology pt 1

Fitzpatrick Chart

1-6

AUSRNN

Basal cell and squamous cell carcinomas

Head and neck

40% of melanomas in men

Back

40% of melanomas in women

Legs

List the acneiform eruptions

Acne vulgaris

Rosacea

Perioral dermitis

Folliculitis

Describe the pathogenesis of acne vulgaris

1. Inc sebum

2. Keratin and sebum plug -> comedone

3. Bacetria proliferates in follicle and releases inflam agents

4. Inflammatory repsonse, pustule formation -> nodules

Key features of acne vulgaris

Keritinization

Androgens

C.acnes (loves sebum)

What does increased androgens do in acne?

Inc sebum

Excess androgens can be caused by

Cushings, PCOS, contraceptives, hormone therapy

Hallmark of acne vulgaris

Comedones

Clinical findings of acne vulgaris

-polymorphic

-face/neck/upper chest/back/shoulders

-comedones

-scarring,hyperpigmentation

Why would you order a lab when dealing with acne vulgaris if they are not typically indicated?

-want to rule out endocrine problem

-prescribing accutane

What labs must you order if you are going to prescribe accutane?

LFT (liver function)

Lipid panel

Hcg

Differentials for acne vulgaris

Rosacea

MRSA

Folliculitis

Drug induced

Just around mouth -> perioral dermitis

What would you prescribe for mild acne?

Topical antibiotic: clindamycin and erythromycin w/ a benxyl peroxide gel (2,5,10%)

Topical retinoids (0.01-0.1) (adapalene, retinoi acid, tazarotene)

What would you prescribe for moderate acne?

Mild Tx + oral antibiotics

Which antibiotics would you give for moderate acne? (Dosage and route)

Minocycline - 100mg - daily or

Doxycycline - 100mg - BID

Which antibiotic is most effective for moderate acne?

Doxycycline but it has increased inflammatory properties

Severe acne treatment

Oral accutane 0.5-1mg a day for about 6 months (cumulative to 120 mg)

Why do you get a lipid panel with accutane?

Hypertryglyceridemia occurs in about 25% of cases so do not want to give to an at risk patient

What is rosacea?

Chronic inflammatory disorder of PILOSEBACEOUS UNITS + increased reactivity of capillaries

Rosacea, usually a history of

Flushing and blushing

Peak age and gender for rosacea

40-50

Females

Rosacea clinical findings

Papules, telangiectasias, redness of nose and cheeks, rhinophyma (males)

There is an absence of what in rosacea?

Comedones

Labs are not typically done for rosacea but what may you be looking for?

S aureas

Demodex foliculorum

Rosacea differentials

Acne

Periorial dermitis

Seboorhic dermitis

Folliculitis

SLE

Management for Rosacea for everyone:

Eliminate triggers

Wear sunscreen everyday

Systemic treatment of rosacea is most effective, you administer what?

-monocycline or doxycycline 50-100mg daily-BID

-isotretinoin 0.5-1mg/day if severe and unrepsonsive to ABX

What topical agents can you give for rosacea?

Metronidazole cream 0.75 BID or 1% daily

Ivermectin 1% cream if Demodex infestation

Risk factors of perioral dermitis

-young women 16-45

-topical glucosteroids

Clinical findings of perioral dermatitis

-1 to 2 mm erythematous papulopustues sparing the vermilion border

Differential diagnoses for perioral dermatitis

Allergic contact derm

Acne

Atopic derm

Management of perioral dermatitis starts with

Stopping all facial cosmetics, topical products, and avoiding topical glucosteroids

Topical meds for perioral dermatitis

-metronidazole gel 0.75% BID or 1% daily

-erythromycin or clindamycin 1% gel BID

Systemic meds for perioral dermatitis

Minocycline or doxycycline 100mg BID x 2 months

Common cause of folliculitis

Bacteria: S.aureas, pseudomonas aeruginosa (hot tub), gram negative

Hallmark finding of folliculitis

Hair extending through center of pustule

Labs are not typically needed for folliculitis, but what would warrant a lab

Gram stain or cx to differentiate bacterial vs nonbacterial

KOH scraping for mites or yeast

In pseudofolliculitis Barbae, papule will be

Near the follicle, not in it

Bacterial folliculitis treatment

Topical sulfa wash or clindamycin + BP wash

What can you do to get rid of staph colonization folliculitis?

Antibiotics, bleach baths

Malassezia folliculitis

Topical sulfacetamide lotion -/+ oral fluconazole

Demodex folliculitis

Topical 5% permethrin lotion

Oral ivermectin weekly

Oral metronidazole daily

Three cycles of hair growth

Anagen -growth

Catagen -degeneration

Telogen - rest

Noncicatricial (non scarring) alopecia:

No tissue inflammation, scarring, or atrophy of skin

Scarring alopecia:

Inflammtion, atrophy, scarring

Non scarring alopecia

Pattern hair loss

Alopecia areata

Telogen effluvium

Anagen effluvium

Clinical findings of pattern hair loss

-scalp is normal

-women: look for other signs of viralization

-finer and shorter

Labs for pattern hair loss

TSH, T4, iron, ferritin, CBC,ANA

Women: check testosterone too

Treatment of pattern hair loss

Topical minoxidil 5% or foam OTC

Can add oral finasteride 1 mg/day for non child bearing

What can you prescribe for women only with pattern hair loss

Oral spironolactone

Who's most affected in AA?

Young adults and children

Clinical findings of AA

Exclamation mark hair

Sharply defined patch with normal scalp skin

Labs for AA

ANA (rule out lupus)

TSH

KOH (rule out tinea capitis)

Treatment of AA

Intralesional corticosteroid inj

Oral JAk inhibitors

Clinical findings of telogen effluvium

Diffuse shedding

Gentle hair pull

Beaus lines

Labs for telogen effluvium

CBC, iron, ferritin -> r/o iron deficnecy anemia

TSH

ANA

Treatment for telogen effluvium?

NONE! Reassure patient

Causes of anagen effluvium

Radiaiton

Anagen effluvium can have a ___ after radiation is discontinued

Rapid regrowth period

What are absent in the exam of scarring alopecia?

Follicular markings

Mainstay treatment for scarring alopecia

High potency steroids

Erythemous plaques, scattered kerototic follicular plugs

CCLE

Viola does discoloration of the scalp, most common on parietal scalp of middle aged women

Lichen planopilaris

Most commonly occurs in African American women, chemical or heat, begins at crown

CCSA

Onchyomycosis (tinea unguium) caused by

Trichophyton rubrum

What is mandatory with onchomycosis

Laboratory diagnosis

What is most effective in treating onychomycosis?

Systemic: oral terbinafine, daily for 12 wks

What should you check before administering terbinafine?

Liver enzymes, CBC, kidney dysfunction

Infection of lateral or proximal nail folds

Paronychia

Acute paronychia

S aureus

Chronic paronychia

Irritation from water or candida

Acute paronychia treatment

l&d, topical ABX

Cellulitis present -> consider oral ABX

Chronic Paronychia treatment

Topical corticosteroids + anticandidal BID

Treatment of felon

Uregent l&d + oral/IV antibiotics

Rapid onset, widespread, symmetric erythemous eruption

Drug eruption

Drug eruptions differentials

Contact dermatitis

Lichen planus

Urticaria

Maculopapular or morbilliform eruptions

ABX, anticonvulsants, allopurinol, NSAIDS

Urticaria's eruptions

Penicillins, cephalosporins, NSAIDS

Fixed drug eruptions

Tetracyclines, NSAIDS, barbs

Rash, 2nd week of medication therapy, no associated symptoms

Simple eruption

Involve multiple organ systems and can be life threatening, show up 6 weeks later of medication therapy

Complex drug eruption

Shearing away of normal appearing skin at the edge of a blister by applying lateral pressure

Nikolskys sign

Nikolskys sign helps differentiate

Intraepidermal blisters from subepidermal blisters

What is typically required in DIHS treatment

Corticosteroids