Divine Intervention Derm

Atopic Dermatitis

• Pt presents with dry skin and intense pruritus

• On PE erythematous papules and vesicles crusty lesions and oozing.

• Fam. hx. of asthma.  

Eczema presentation:

• adults: flexor surfaces 

• children: extensor surfaces (think antecubital fossa) first before flexor surfaces 

• What is the classic finding in a person with chronic atopic dermatitis? Lichenification (what happens when you scratch a lot)

• MC infectious agent or complication of eczema? staph aureus.

• What is the type of hypersensitivity reaction in eczema? Type 1 

Contact dermatitis 

• Pt acquired nickel with a lot of itching around wrists?  Contact dermatitis

• What are other types of allergic reactions in contact dermatitis? medication patches, poison ivy 

• Grouped vesicles in a linear distribution -> poison ivy 

Psoriasis

• See rash at extensor surfaces, think psoriasis

Xerotic eczema

• 79 y/o (old people in general) that presents to dermatologist bc really dry skin on the left shin (tree-bark appearance at lower extremities). On PE skin is red/dry, neck-like fissures. Skin reaction gets worse in the cold, dry winter months. 

Treatment for eczema, general terms

• Tx emollients. Topical glucocorticoids 

• Special cases:

  • Do NOT use topical glucocorticoids on dermatitis of the face

  • One of the MCCs of acne on the face on NBME exams? topical corticosteroids

Plaque psoriasis

• 36 y/o Mexican male with thick erythematous plaques with silver scales on elbow (Extensor surface)

• Show on elbow, knees, scalp, ears, genitalia 

• Classic exam findings in psoriasis -> very thick NAILS. yellow, nail-pitting, Hispanic

• Things that worsen: beta-blocker, NSAIDS, ace inhibitor, oral steroids, tetracycline 

Guttate psoriasis 

• Pt. with papules and plaques on their trunk. Looks like tiny tiny drops.

• Patient recently developed group A skin infection (i.e., strep pyogenes)

• Tx. Vitamin D analog - topical calcipotriene; retinol; anthralin; or tar prep

NEVER give oral/IV steroids for psoriasis. Systemic steroids can worsen psoriasis. 

Erythroderma

• Pt with a hx of psoriasis and is taking steroids. Skin turns really red. 

• Complication: electrolyte abnormality (loss of fluid) 

Lichen planus

• Pt. has noticed a lot of pruritus these past few days on wrists and ankles. Noticed purplish papules shaped like polygons.

• Tx. topical corticosteroid 

Pityriasis rosea 

• Pt over the last two weeks has pruritus. Noticed circular or rectangular lesion on trunk (Herald patch), under axillae and lasts for weeks. 

• Tx. topical steroids and antihistamine for pruritus

Seborrheic dermatitis 

• Pt. has oily, scaly lesion on eyebrow on scalp, nasolabial folds, chin or perineal cysts 

• Tx. selenium sulfide shampoo 

• If pt is young person sexually active with tons of lesions that resemble seborrheic dermatitis -> screen for HIV 

• Typically also seen in patients with Parkinson's disease

Rosacea

• 35 y/o female with redness of cheeks/nose whenever she eats spicy food or drinks alcohol has facial flushing. Can see papules/pustules. 

• Usually >30 y/o female 

• Don't confuse this patient with malar rash on lupus. Rash of lupus SPARES nasolabial folds. People with lupus DO NOT have papules, pustules on face or flushing episodes. 

Adrenal Tumor (DHEA) or Gonadal (Sertoli-leydig tumor) 

• Woman who suddenly develops severe acne and hirsutism with menstrual problems or signs of virilization.  

Hidradenitis suppurativa 

• Pt. with a history of diabetes who have had chronic lesions under axilla, breasts or in gluteal clefts. Nodules, cysts, comedones, a lot of scarring. 

• Pathophys: apocrine sweat glands. 

• Tx. Clindamycin or Rifampin also Infliximab 

• Definitive Tx. excision of lesions  

Acne vulgaris

• Open and closed comedones, papules, pustules, nodular lesions. Distribution at face, neck or upper trunk 

• Tx. topical retinoid or salicylic acid or benzoyl peroxide.

  • Not work? Add a topical antibiotic (e.g., erythromycin, clindamycin).

    •  Not work? Add an Oral antibiotic (tetracycline)

      •  Not work? Give isotretinoin 

• If pt has acne, visual headaches worse in the morning -> idiopathic intracranial hypertension. 

• What labs to order before giving isotretinoin? LFT's, B-HCG 

• Don't give preggos isotretinoin or tetracycline

• Pt with PCOS + acne (hyperandrogenism) DOC = OCP's. 

Bacterial folliculitis

• Athletic patients with pustules and papules on the scalp (anywhere with hair) centered around hair follicles. 

• MCC: staph aureus

• Tx. mupirocin 

Hot tub folliculitis

• Pt in a community pool/hot tub liquidly chlorinated

• MCC: pseudomonas

Hot tub lung

• MCC: mycobacterium avium intracellularly complex 

Dermatophyte Skin Infections (Tinea

• MCC trichophyton tonsurans > microsporum species > epidermal phyton species 

Tinea pedis

• Scaling from toes to areas of achilles heel (athlete's foot)

Tinea corporis (ringworm)

• Erythematous circular red lesion with vesicles with "Central clearing" 

Onychomycosis / nail fungus

• Yellow, thick nails or really white. Distal edge (farthest away from skin is elevated)

Cutaneous candidiasis.

•  Red, itchy skin with red satellite lesions. After scraping- >  KOH prep see spores and pseudohyphae.

Tinea versicolor or pityriasis versicolor

• Hypopigmented macules on upper trunk or back. On prep: "spaghetti and meatball pattern"

• MCC: malassezia furfur 

Tx general

• All tinea: topical antifungals: Clotrimazole (any -azole) 

  • Special exception: 

    • Tinea Capitis (head): oral medication - terbinafine, griseofulvin 

    • Griseofulvin (penetrates keratin containing tissue)

    • cutaneous candida: topical nystatin or other azole 

    • Tinea versicolor: selenium sulfide or topical azole

Molluscum contagiosum

• Pt. with umbilicated papule on skin (can de adult or kid)

• cryotherapy or curettage 

• Remember assoc. with HIV! 

Pt. is a 31 y/o male who is active military who came back from Afghanistan (Iraq, Saudi Arabia, Peru etc.) 2 to 3 weeks ago. On his arm (or anywhere typically on upper extremities) there is a painless, purplish ulcerating papule. 

• Dx

  • Leishmaniasis 

    • Transmission

      • Sandfly

    • How to diagnose?

      • Skin Biopsy

    • Treatment

      • Amphotericin B or Paromomycin

Pt is 50 or older there is a recombinant zoster vaccine

• NOT live attenuated. 

• Can start administer 50 y/o

  • Eligible 

• Reduce risk of post-herpetic neuralgia

• Reduce incidence of zoster 

Pt is over 60 y/o there is a live-attenuated  zoster vaccine

• live -attenuated given to those over 60

• Immunocompetent 

  • If has HIV or CLL or immunodeficiency, do NOT give a live-attenuated vaccine 

Typical vignette for zoster: pain, rash dermatomal distribution. 

• But, if patient has a “zoster explosion” in body

  • NBS: Screen for HIV 

Pt has a sudden outbreak of molluscum contagiosum

• NBS: Screen for HIV

Pt has porphyria cutanea tarda

• NBS: Screen for Hep C 

Pt. with zoster with vesicular rash spread in dermatomal distribution on first branch of trigeminal nerve, tip of nose and eye (Opthalmic branch)

• Refer to ophthalmologist 

  • Zoster ophthalmicus 

Pt has vesicles in the ear and anterior sensation of taste of ⅔ tongue gone. Paralyzed upper and lower part on one side of face (like bell’s palsy) in the Cranial 7 pattern. 

• Ramsay Hunt Syndrome (herpes zoster oticus)

  • Treatment

    • Acyclovir

Post-herpetic neuralgia 

• Treatment

  • Gabapentin

  • nortriptyline, amitriptyline (be careful in elderly)

Do not give steroids in herpes zoster!!

Pt is a young kid, homeless who comes with referral. Itchy rash between finger webs, penis, scrotum. 

• Dx

  • Scabies (sarcoptes scabies)

  • How?

    • Mite burrows in the upper layer of skin

  • Disseminated scabies

    • HIV, immunocompromised 

  • How to diagnose?

    • Swab tissue and find mites and eggs on KOH prep 

  • Treatment

    • Permethrin (also family members)

    • Ivermectin 

    • Wash everything in hot water 

    • DO NOT pick Lindane lotion

      • Neurotoxic, induces seizures in children 

Pt. with an itchy lesion in skin. On exams, grouped papules that are very itchy. “Breakfast lunch and dinner lesions” Red circles in very close approximation. Usually in the morning. 

• No real treatment (do antihistamines topical steroid etc)

Pt. with a history of HIV with brown lesions that look like a tan. Well demarcated plaques, papules with a “Stuck-on” appearance

• Dx

  • Seborrheic keratosis 

• What to do with it?

  • Excision

  • Liquid nitrogen

Pt with sudden onset with tons and tons of stuck on appearances. What to screen for?

• GI malignancy (colonoscopy, EGD etc etc)

17 yo female not sexually active. Has warts. Flesh colored papules. Genital warts. Those are the things known as?

• Condyloma acuminatum [Do not confuse with Condyloma latum (syphilis) - do not confuse!] 

• Treatment

  • Topical salicylic acid (works for acne)

  • Cryotherapy 

  • Podophyllin 

• Most likely sequelae?

  • Spontaneous resolution

• Red lesion on sun exposed spots (Face, back) lesions with “rough sandpaper appearance/ texture; bad rough spot”

  • What is it?

    • Actinic keratosis

      • Precursor to?

        • Squamous cell carcinoma 

      • Treatment 

        • Topical agent (5-FU)

        • Imiquimod 

• Biggest RF for skin cancer -> sun exposure 

  • UV-A vs. UV-B light

    • UVB light is worse 

      • Thymidine-thymidine dimers form

• Primary preventive strategy for skin cancer? 

  • Use clothes that will protect you from the sun 

    • Pick sunscreen if there is no answer choice that gives you sun protective clothing or sun avoidance 

• Pt was rescued from a fire. Has healed over time with plastic surgery. On his scalp there are lesions that haven’t resolved. Have been slowly evolving. 

  • Dx

    • Squamous cell cancer (usually bottom lip, but you can get it anywhere - like the scalp, ear, and neck)

• Pt has a red nodule that has continued quickly growing over time, and looks like a volcano. Contains a lot of keratin, debris at the center. Looks like it’s going to erupt. 

  • Dx

    • Keratoacanthoma

  • Treatment

    • Excision of lesion

  • Keratin indicates what?

    • Squamous malignancy

• Pink pearly, translucent lesions with telangiectasias on upper lip 

  • Dx

    • Basal cell carcinoma 

  • Spread?

    • Likes to spread horizontally 

    • Very rapidly destructive

  • Treatment

    • Resection

    • Sometimes Mohs surgery (same as micrograph surgery) 

• Pt with a lesion on skin with many different colors (black, brown), which is not round or oval, more irregular borders

  • Dx

    • Melanoma 

      • Criteria

        • Asymmetry

        • Borders - irregular 

        • Color variation (brown, red, black, blue)

        • Diameter - > 6mm we get worried

        • Evolution - changing over time

• Pt with a history of dysplastic nevus. 

  • Risk factor for melanoma

  • Looks a lot like melanoma. 

    • Dysplasia leads to cancer 

• Pt with a family history of melanoma. With a ton of dysplastic nevi.

  • Dx

    • Familial melanoma dysplastic syndrome

      • Inheritance

        • Autosomal Dominant 

• Melanoma

  • Different types

    • Nodular

      • Worse prognosis

    • Acral lentiginous

      • African american with melanoma under nail bed

      • Not as bad prognosis as nodular

    • Lentigo maligna 

      • Pt has a melanoma that is on the face, upper-trunk, prominently exposed to sun

    • Superficial spreading melanoma

      • Best prognosis

      • Shows up on back in men. Legs in women. 

      • Good prognosis

  • Treatment

    • Complete excision 

    • More than 1 mm thick, send a sentinel lymph node biopsy

    • Prognosis

      • Breslow depth/thickness

• Pt sat on couch and has been itching with wheeling of skin

  • Treatment

    • Antihistamine

• Pt with angioedema do NOT have hives!

• What is the most common medication that people report an allergy to?

  • Penicillin 

    • If they try to test patient on allergy

      • Do skin testing (not RAS(?) or ELIZA test)

    • Pt with anaphylaxis?

      • Anti-staph, cephalosporins should be avoided

• Pt. is a 6 y/o male with lyme disease. Given doxycycline (or adult that gets treated for syphilis, lyme disease) develops fever, headache, myalgia, malaise, sweating, headache, hypotensive

  • Dx

    • Jarisch-Herxheimer reaction 

      • Treponema pallidum or borrelia etc. when you treat spirochetes they will explode and release endotoxins (penicillins are cell wall inhibitors) 

      • Resolves quickly

      • Supportive care

      • Continue antibiotic

      • Not an allergic reaction 

• Pt recently took TMP-SMX for cystitis. Last two days the patient has an edematous face. Generalized skin reaction. Person AST/ALT and eosinophil elevated, elev. Lymphocytes and generalized lymphadenopathy

  • Dx

    • Hypersensitivity syndrome (Type IV) 

    • Dress Syndrome (same thing)

    • Treatment

      • IVIG 

Person who recently start a drug regimen for acne – it’s an oral regime, this person lives in California (or any state with tons of beaches) and they went to the beach and they’re having a bunch of bad, extensive sunburns, even when they been using sunscreen [remember you should NOT apply sunscreen to a baby that is less than 6 months old] think about → TETRACYCLINE PHOTOSENSITIVITY

• Remember drugs that cause photosensitivity: “SAT for photo” mnemonic

  • S: sulfonamides; permethrin-sulfadiazine, TMP-SMX, sulfasalazine (IBD)

    • It could be by days or months, even years of use of sulfonamides [ie, person being treated with TMP-SMX for PCP prophylaxis for a year]

  • A: amiodarone [person that recently start an antiarrhythmic treatment and start having sunburns]

  • T: tetracycline; Lyme disease question, RMSF question, question of a person being treated for acne (oral tetracycline)

• Patient being treated for pyelonephritis with IV ciprofloxacin, and they have flushing on the body, really hypotensive, with muscle aches & pains → “RED MAN SYNDROME” (vancomycin also causes this!)

• Patient that recently started some kind of ATB, and a few days later they start to notice these round/oval discrete lesions on the torso, buttocks, back, etc → drug eruption, on NBME they call this a “fixed drug eruption”

• Collage student, 21 years old, pharyngitis (throat pain) 3 days ago and went to the student clinic where they gave her oral ampicillin, and she develop a diffuse rash all over her skin after taking ampicillin for 2 days → infectious mononucleosis from EBV

• Patient that for the past 2 days has been taking ATB or they just tell you this patient has had painful erosions on the oral mucosa and they tell you they see this purulent bullae and vesicles on the skin, and when they apply slight pressure over the skin you notice a lot of purulence (like purulent discharge and stuff), think about PEMPHIGUS VULGARIS (positive Nikolsky sign!)

  • It affects trunk, extremities (especially the more proximal extremities like arms or thighs) and DEFINITELY the oral mucosa and positive Nikolsky sign

  • Dx: direct immunofluorescence! You notice IgG deposits between the cells “intercellular deposition of IgG”

• BULLOUS PEMPHIGUS → tense bullae/blisters = Nikolsky sign is negative. Dx is also direct immunofluorescence, and you find a linear pattern in the basement membrane. NO ORAL MUCOSAL INVOLVEMENT

  • Linear deposition of IgG in the basement membrane you can find it in 2 disorders in the test: bullous pemphigus (in the skin) and in Goodpasture syndrome (in the kidneys or in the lungs – it’s a nephritic sd presentation, type II HPS reaction)

  • Pemphigus vulgaris & bullous pemphigus are type II HPS reactions

  • Treatment of choice for any pemphigus →  oral steroids; if the person is not getting better, best next step in management is plasmapheresis (2^nd line treatment) (In addition to steroid o   therapy, which of the following medications can be added to decrease the morbidity or hasten sx resolution… Plasmapheresis)

• Person with iron deficiency anemia with very itchy vesicles in elbows, knees, back, buttocks (lot of extensor surfaces) + low weight celiac disease and this person has DERMATITIS HERPETIFORMIS

  • 1^st step in management is to exclude gluten from diet, usually this works, but if you don’t see this as an answer choice, the 2^nd line treatment is dapsone

  • If a guy is started on dapsone for dermatitis herpetiformis, and then they start to have hematuria and indirect hyperbilirubinemia → G6PD deficiency!!

  • Remember Dapsone is also used in the treatment of leprosy! You give a triple therapy: dapsone, rifampin, and clophazimine.

  •  Dapsone is sometimes used for PCP prophylaxis

• IV drug user, that on the back of his hands has vesicles/bullaes and notice more of these vesicles after he hit his hand on a table or some minor trauma that should not cause that kind of skin reaction, especially on the back of the hands → PORPHYRIA CUTANEA TARDA!

  • Which of the following is the biggest risk factor for PCT hepatitis C. About 50% of people that have PCT tend to have HepC infection. Test the patient for hepatitis C, HCV PCR or HCV antibodies in serum.

  • Since is a heme synthesis disorder, if you take urine from them and put in on the Woods lamp the urine will give a dark orange color

  • If you do direct immunofluorescence, you’ll see IgG deposit around capillaries that line the dermis and around the basement membrane

• Patient with vesicles in the lip or in genitals, and they say they had these lesions many times but you also notice this person also has multiple “bull’s eye” lesions in the skin → ERYTHEMA MULTIFORME

  • Biggest risk factor for erythema multiforme in this patient? Having a lot of HSV infection, especially on a recurrent basis.

  • It can also be caused by drugs: sulfonamides, penicillin, phenytoin.

  • Tx: stop the drug, supportive care, fix any electrolyte problem

    • Specific scenario with a person with EM + recurrent HSV infection → best long-term management? Suppressive acyclovir (like on a regular basis – prophylactic). Is NOT going to work in the acute setting!

• STEVEN-JOHNSON SYNDROME (SJS) & TOXIC EPIDERMAL NECROLYSIS (TEN)

  • Person with flu-like sx, like myalgias, fever, and then they start having skin erosions & skin pain with a positive Nikolsy sign. The percentage of the skin that is affected is what tells you what you’re dealing with:

    • If is less than 10% of the skin: SJS

    • If is more than 30% of the skin: TEN

    • Between 10-30%: SJSTEN combination

  • 1^st step in management? STOP THE DRUG!

  • Patient with a bad presentation, particularly TEN → get them into a burn unit – UCI!

• African-American female, with painful lesions on lower extremities, they are round and tender → ERYTHEMA NODOSUM

  • Associated with sarcoidosis, coccidiomycosis, IBD

• African-American female + sarcoidosis, purple colored lesions in her nose, around her eyes, in a malar style distribution (like around the cheeks) → “lupus-like” presentation, think about something called LUPUS PERNIO, is a classic dermatologic finding in the face in a person with history of sarcoidosis

• 23 year old male, history of chronic bloody diarrhea, 3-5 months, lost a lot of weight during this period, and now he has a very painful ulcer, necrotic that is very exudative, with lot of discharge from the ulcer, with raised edges, it is on his lower extremities → PYODERMA GANGRENOSUM (classically found in patients with IBD). Best next step in management? COLONOSCOPY! usually is UC that has this association.

• Patient chronically been treated, has ESRD, and is being receiving treatment for an epidural abscess found on MRI 2 days ago, over the last 12h this patient is having induration of the skin, the skin is very thick and very tight → NEPHROGENIC SYSTEMIC FIBROSIS (NSF), it is caused by Gadolinium (usually when getting an spinal imaging they use gadolinium)

  • Most likely predisposing factor for this disease? ESRD; they get it in the context of getting gadolinium

• Patient with ESRD, really painful nodules under the skin, they look red/brown → CALCIPHYLAXIS

  • In ESRD patients have ↑↑ phosphate → not able to maintain an appropriate solubility product for Ca⁺² and phosphate → this will begin to precipitate in the skin as red/brown nodules

• IV drug user, over the last 3 days, and is having big breakouts like oily lesions on skin, head, basically like seborrheic dermatitis that suddenly breaks out, best next step in management? Test for HIV

• Patient that had recent cardiac catheterization OR was recently diagnosed with vasculitis; and now it has net-like lesion in the extremities → LIVEDO RETICULARIS.

• Patient with velvety lesions on flexor surfaces, like in the neck or under the breast → ACANTHOSIS NIGRICANS, usually due to insulin resistance, ex DM; it can also be a sign of a GI malignancy.

o   In OBGYN is a patient with PCOS

• Patient with genetic syndromes like familial hyperlipidemia → xanthomas/xanthelasmas in the eyes, especially on the eyelids, around the ankles, soles

• Patient with proximal muscle pain and/or weakness and hands looks like concrete, fissured, thick [think about a mechanics hand?], this is a very classic finding on a person with autoimmune myopathies like polymyositis or dermatomyositis

• Person with Hb 7, SCr has being progressively ↑↑↑ over the last year, and has had 3 episodes of pneumococcal pneumonia, and you notice this patient has a large tongue and has sallow skin, it means that the skin looks like kind of wax → MULTIPLE MYELOMA.

  • MM can present as amyloidosis on a test, people who have amyloid tend to get big tongues, restrictive cardiomyopathy, they can get amyloid kidney disease.

• Crusted lesions around the nipple, kind of looks like eczema → PAGET DISEASE OF THE NIPPLE. They need mammogram and a core biopsy of the breast, because they tend to have underlying infiltrating intraductal carcinoma

• Middle-age patient with a lot of eczema (especially on flexor surfaces), like under the feet, elbows, or underside of the knees, also this person has been losing weight & new onset diabetes → GLUCAGONOMA. The skin lesions are called NECROLYTIC MIGRATORY ERYTHEMA.

• Patient with history of HIV with a low CD4 count and went swimming recently (beach, pool), now has a painless lesion that started on arms or trunk, but has quickly become necrotic and is painless → ECTHYMA GANGRENOSUM