Step Up to Medicine: Chapter 11 Diseases of the Skin and HS Disorders

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CONTACT DERMATITIS: irritant and allergic

WHATS THE DIFF?!

Irritant: if a detergent, something caustic or acidic - frequent handwashing.
-no prior sensitization needed, reaction is immediate.

allergic: delays HS reaction (type IV)
-no history of atpoy is needed for allergic contact.
-sensitization of skin occurs 1-2 weeks after initial exposure to allergen
-2nd exposure leads to dermatitis hours to days after reexposure.
-common allergens include that of poison ivy, oak, sumc, iodine, nickel, rubber.
-meds that can cause this include: neomycin (AG), topical anesthetics and cosmetics)

ACUTELY: erytematous papules and vesicles with OOZING
CRONICALLY: crusting, thickening, scaling, lichenification; pruritic; can last 4-5 days

most common site of melaoma?

back

how often should a pt be turned to prevent decubitis ulcerations

q2 hrs

Treatment of warts:

-if not resolved spontaneously within 1-2 years ten
-freezing lesion with liquid nitrogen (applied on cottom swab)
-ASA (compound W) applied for several weeks
-5FU cream or retinoic acid cram for flat warts
-surgical excision or laser therapy
-PODOPHYLLIN FOR GENITAL WARTS

SCABIES:

-human skin mite
-makes burrows in skin on abdomin - spares the neck, face, palms, soles.
-female mites lays oocyte.
-delayed type IV HS reactions occurs toward mites eggs and feces causing serious itching.
-look in ginders, wrists, elbows, feet penis scrotum buttocks axillae.
-predominant itching at night.
-CONFIRM DX by scaping the burrow with a scapel and exmainit it unde ra scope to detect the mites, ova.
-treatment: permethrin overnight full body 8-10 hours. 1x treatment. Do it to the close contact individuals around you. May have itches last 2 weeks post. this is normal these are the dead mites.
-alternative treatment to permethrin is LINDANE lotion

Growth phases of melaoma

1. Radial (initial)
-growth is lateral within epidermis - good prognosis with this

2. Vertical (later)
-growth extends into reticular dermis and beyond.
-lymph and hematogenous mets occur
-depth of invasion is the MOST important indicator of prognosis

Psorisis

silvery scales with AUSPITZ sign (pinpoint bleeding if removal of the scale.
-can involved any part of body. most often the knees elbows
-pitting nails or oycholysis (distal separation of the nail from the nail bed is common
-two methods to treat (topically with corticosteroids and cacipotrients vita D derivative) or by that of systemic treatment if severes which iclues that of MTX, infliximab and cyclosportine. Phosotchemotherapy and acitretin can work also.

If moderate psoriasis - do combo with topical steroids and calcipotriene
If severe psoriasis - do combo acitrentin plus phototherapy.

Seborrheatic dermatitis

chronic condition of unknown etiology. Resembles that of dandruffed skin, looks like cradle cap. Common problem - expecially in pts wit oil skin. Loko at the hairline behaind the ears, under breasts, groin area. Can be complicated by 2/2 infection. No cure. Treat symptomatically witH SUN EXPOSURE, DANDRUFF SHAMPOO, TOPICAL JETCONAZOLE, TOPICAL CORTICOSTEROIDS.

SHINGLES

-reactivation of VZV remains dormant in DRG and reactived suring stesses.
-typical in patients >50YO; if younger than assume immunocompromised pt
-contagious if OPEN otherwise not.
-severe pain in dermatomal distribution
-pain BEFORE RASH!
-common sites are the thorax, trigeminal neuralgia (ESPECIIALY OPTHALMIC DIVISION RESULTING IN HERPES ZOSTER OPTHALMICUS) -
-can be debilitating - dissemination with meningoencephalities and DEAFNESS
Treatment: keep lsions clear, asa and cetaminopen for pain. Antiviral meds are good. Corticosteroids for postherpetic neuralgia is still controversial

Common self limiting viral infection that isc ommon in sexually active young adults that can lead to small papules with central umbilication. Often asmptomative but in HIV patients the lesion can becoe extensive. Tranmission is skin to skin, and highly contagious. Persiss up to 6 months but sponteously regresses with TIME.

Viral infection that causes this:
Treatment?

Pox virus
THIS IS MULLUSCUM CONTAGIOUSUM
-treatment is 2/2 curettage, drops containing podophyllin and cantharidin, cryosurgey. Scarring is a risk factor.

12 YO boy with scaly, mildy pruritic rash on arms without ever muscle pain n/v/d/ or back pain.

Most likely dx =
most likely treatment =

Tinea corporis
Terbinafine (topical antifungal)

Disseminated gonococcal infection presents with

tenosynovitis (pain along tendon sheaths)
polyarthralgia
vesiculopapular rash

LICHEN PLANUS AND THE 4 P's to diagnose it

Pruritic, polygonal, purple, pustules
-chornic and inflammatory
-seen on wrists shins oral muscosa and genitals.
-treat with glucocorticoids

Vitiligo

chronic depigmentation of the skin - unkown etiology
-hereditary is sspected
-demarcated areas of skin that become amelonitic. most common on face and associated with DM, hypotheroid and pernicious anemia.
-topical glucocorticoids and photochemotherapy used to promote repigmentation.

SCC

less common than BCC but can become malignant
-proliferation of epidermal cells
-sunlight expoure is an important RF
-chorni skin damage and immunosuppressive therapy also risk factors
-crusting with ulcerated nodules or erosions are common
-MAJORLINS ULCER - a SCC ariring froma crhonic wound that tends to be very aggressive
-prognosis is good if completely resected (95%). Lymph node involved not so good.

FEATURES of anaphylaxis

1. Cutaneous findings: pruritis, erythema urticara angioedema
2. respitaory findings - SOB, respitaory distrss, asphyxia
3. CV findings - hypotension, shock , arrhtymias
4. GI findings - n/v/d/crampy pain

most common sites of decubitis ulcerations

sacrus, ischial tuberosity, greater trochanter, heels of feet, malleoli, occiput, elbows and back

Treatment of melaoma

early detection most importnat way to prevent death.
-perform lymph node dissection if nodes are invovled.

Seborrheic keratosis

completely benign
-seen after age 30
-"stuck" on appearance to skin
-traetment no necessary unless if cosmetically.

-lquid nitrogen would be the option or currettage in the OUTPT seting

what is seborrheic keratosis?

A seborrheic keratosis ("Seborrheic verruca," and "Senile wart")
- is a noncancerous benign skin growth that originates in keratinocytes.
-Like liver spots, seborrheic keratoses are seen more often as people age.
-"barnacles of old age"
-various colors, from light tan to black.
-They are round or oval, feel flat or slightly elevated (like the scab from a healing wound), and range in size from very small to more than 2.5 centimetres (1.0 in) across
-resemble warts,though they have no viral origins.

****only the top layers of the epidermis are involved, seborrheic keratoses are often described as having a "pasted on" appearance. ****Some dermatologists refer to seborrheic keratoses as "seborrheic warts"; these lesions, however, are usually not associated with HPV, and therefore such nomenclature should be discouraged.

General characteristics of ACNE VULGARIS

1. inflammatory condition of skin
2. obstruction of sebaceous follicles leads to proliferation of PROPIONIBACTERIUM ACNES (anaerobic bacterium in the sebum.
3. Formation of comedone "pimples" or if severe, inflammatory papules or pustules.
4. RISK factors: male, puberty, cushings, oily copmlexion, androgens

1. Obstructive = white heads or closed comedones
2. Open = black heads or open comedones

Actinic keratosis

predominants in individuals with fair skin who are in the sun
-predisposes 2/2 SCC
-typically on the face
-prevention to acoid sun exposure and use sunscreen
-treatment options include: scraping; freezing with liquid nitrogen; application of topical 5FU.
-once developed, can still continue to develop without exposure to sun.

Pityriasis rosea

Herald patches that look like ring worm. THen generalized to a rash with oval shaped lesions that look like xmas treees.
-not contagious
-common to trunk arms and thighs. NOT on face
-spontaneously remits within 6-8 weeks without treatment
-no treatment besides antihista for the itching

Sites of metastasis for MELANOMA

#1 LYMPH > LUNG > LIVER > BRAIN > BONE

Treatment for contact dermatitis

ROIDs - 10-14 days

Decubitis ulcer stage

1 - nonblanching erythema and skin is intact
2 - partial thickness loss; varying amounts of dermis present
3- full thickeness skin loss - goes to subq tissue but not trhough fascia
4- full thickness loss - through tissue, fascia, muscle, to bone - increased risk for infection 2/2 osteomyelities and possible amputation

HPV that causes warts v. cancer

6, 11 = warts
16, 18 = CANCER

EM --> SJS --> TEN --> go to ICU

SJS is the most severe form of EM. Toxic epidermal necrolysis is the most severe form of SJS.
-SJS and TEN involvement is extensive and severe with detachment fo the epidermis.
-involves the eyes and mouth - scary.
-potentially life threateneing - 5% mortality for SJS, 30% for TEN
-half of all cases are 2/2 to meds. This also inflcues the drugs associated with EM but also cabamazepine (what we use for trigenminal nerualiga), and vancomycin/rifampin.
-ADMIT TO ICU with aggressive rehydration and symptomatic managment

How is rosacea treated?

Topical antibiotics like metronidazole

Insect sting allergy:
1. insects responsible?
3. Reaction:
4. treatment

-yellow jackets, honeybees, wasps, yellow and baldfaced hornets
-nonallergic reaction is localized swelling with pain some itching and redness. Subside in several hours. This is a NORMAL REACTION TO IT
-allergic reaction is marked swelling and redness over large area around sting site. Lasts for several days and somtimes presents with mild systemic manifestiosn like n/v/malaise. Prescribte antihistamines and analgesic for symptoms. Short course of prenisonde for seere cases
-analphylaxid can occur and be factal.

THUS tretament: ice and oral antihistamines if ild - if severe treat for anaphylaxis and pull out the EPI

what can cause cradle cap in infants?

seborrheic dermatitis 2/2 a fungal infection or vitamin a deficiency or lack of biotin.

Plantar wart (verruca plantaris)

painful when walking; solitary or multiple in nature; can cause foot painw ith pressure.
-appeas flesh colored with rough hyperkertotis surface

Dry, scaling ring shaped lesions on the body that are pruriritc with central clearing that presents rapidly

Tinea corporis

ALLERGIC REACTIONS
1. URTICARIA
2. ANGIOEDEMA
3. DRUG REACTIONS
4. FOOD REACTIONS

URTICARIA - release of mediators from mast cells; increased vascular permeability. edmeatous wheals that are fleeting in nature and disappear within hours and return to another lcoation. Blanch with pressure and cause pruritis or stinging. Antihistamines are effective for symptomatic relief and steroids if severe
ANGIOEDEMA - similar to urticaria but involve deeper areas f the skin, no superficial. cn be caused by any precipitants of urticaris, ACE i are a specific acuse of angioedema that occurs within 1 week of administration. It can usually affect only the eyelids, lips, tongue, genitals, hands feet - urticaria can be anywhere. If severe this can lead to life threatening airway obstruction. Can invove the FI trat leading to n/v. Treatment is similar to urticaria. If severe then administere SN epi for laryngeal edema or bronchospasm.
Drug allergy: most drug reactions are not related to allergy. DI HS reactions can affect multple systems: dermatologica is the most common, pulmonary dinging (asthma, pneumonitis), renal manifestations )AIN, NEPHROTIC), or hematological manifestations, thrombocytopenia, HA, eos, agranulocytosis (PTU)). If suspected then ask about recent changes in pt meds. Allergy rxn appears within 1 mon of drug. NOT < than one week - r/o drug allergy if this is the case.
FOOD: HS are usualyl Ig (type II) - or IgE mediated. Most common response is to eggs, peanutm milk soy tree nuts shell fish wheat chochlate and legumes. Dematologica manifestiatoin are the most common (itchy redness, urticaria, andiogedema); GI manidestations n/v/d. anaphylactive reactions - respitatory system can be fatal; cutanous manifestaions.

Bullous pemphigoid v. Pemphigous vulgaris

BP: less severe, AI, subepithelial blishses on abbdomen groin and extremities
-less easily reuptured than in PV
-treat with systemic glucocorticoids +/- AZA for AI

PV: AI blishtering condition resulting in the loss of normal adhesion between cells (acantholysis) - starts in mout and becoes generalized.
-blisteres rupture - painful erosion
-fatal if left untreatment

ALlergic contact dermatitis (HS IV) is seen with?

nickel, formaldehyde and poisoning

MOST COMMON PRESENTATION OF MELAOMA

CHANGING MOLE

Dermatophytes:

Treat tinea capitis and onchomycosis with ORAL ANTIFUNGALS - griseofulvan; treat the remainder with topical antiguncal like ketoconazole or miconizole

what does the photo below indicate?

rosasea

diagnosis of melanoma

exisional biopsy - dont mess around with the shave or punch BS...not as accurate to assess.

MELANOMA - the beast

Most aggressive but least likely
-#1 cause of death 2/2 skin CA
-RF: fair skin, red hair, numerous moles, sun exposure before 14 with severe burns, sunny environment, family hx, xeroderma pigmentosa, increasing age, large number of moles (nevi); dysplastic nevus (numerous atypical moles)
-IF DYSPLASTIC NEVUS + FAMILY HX = 100% chance of developing it melanoma

Treatment of decubitis ulcerations

1. local wound care (if superficial)
2. wet to dry dressings or would gel for deeper ulvers
-surgical debridgement of necrotic tissue
-antibiotic if evidence of infection

What is rosacea?

chronic reddening of the face in caucasian women (primarily 30-50). Expect erythema, telangiectasia and papules with redness. No comedones.

STAY AWAY FROM - alcohol, hot neverages and extreme temperatures. Reduce emotional stress.

Treatment: induce with Metronidazole (flagyl) +/- tetracycline for MAINTENANCE therapy. If no good response the therapy, use isotretinoin for daily use.

BCC

-most common form of skin cancer
-arises from basal layer of cells in epidemis. most important RF is the sun
-occurs in fair skinnened individuals who burn easily.
-head and neck (NOSE!) most common site
-THE THREE P's = PEARLY< PINK< PAPULE!
-rolled edges with surface telangiectases
-mets is RARE - local destruction
-BCC surgical removal is the cure

Erythema nodosum seen in which diseases and how do you treat it

GAS, Sarcoidosis, TB, syphilis, pregnancy, FUNCAL INFECTIONS, IBD and OCPs , sulfas. Can be idiopathic

Order the proper tests for each of the above to fingure out the causality. THen treat accordingly.
-prescribe bed rest, leg elevation , NSAIDS.

ANAPHYLAXIS

most severe form of allergy - this is a systemic allergic rection (usually type I iGE)
-occurs within seconds to minute
-food is the most commmon cause, meds, radiocnotrast, blood product, stings, bites, latex, hormones, ragweesd.
-prgress within seconds to life thretening situation characteried by shock or respiratory compromise.
-TREATMENT
1. CAB - intubate if unprotected airway
2. GIVE EPI!!!!! Give IV if severe 1:10000; SC if less severe 1:1000
3. GIVE antihistmine both H1 and H2 and corticosteroids as welll
-SUPPORTIVE CARE --- FLUIDS and O2

Treatment regimen of ACNE VULGARIS in STAGES:

1. Mild to moderate -- washing with topical peroxidases - 1-2x/day

ADD: if needed, topical retinoids if dails above - peeling of skin which prevents clogged pores

ADD: if needed, topical erythromycin, clindamysin to suppress P. acnes

2. If moderate to severe and begin to get nodules -- begin oral therapy with tetracycline or minoycline or doxycycline, clindamycin or TMP SMX

ADD: Oral retinoids (ISOTRETINOIN) fr CYSTIC acne. Remember these are teratogenic. Don't admin oral therapy until all other topical creams have been attempted

what is seborrheic dermatitis? how does it differ from actinic keratosis and seborheic keratosis?

actinic is associated with squaa and has a scle like appearance and is most commonly 2/2 sun exposed areas lf the skin

seborrheic keratosis are the barnacles of old age that occur in older pts and are completely benign! can resemble melanoma but often looknlike war ts that can be pulled off

seborrheic dermatitis is per wiki: also known as "seborrheic eczema"
-is an inflammatory[2] skin disorder affecting the scalp, face, and torso.
-Typically, seborrheic dermatitis presents with scaly, flaky, itchy, and red skin.
-It particularly affects the sebaceous-gland-rich areas of skin.
-In adolescents and adults, seborrhoeic dermatitis usually presents as scalp scaling similar to dandruff or as mild to marked erythema of the nasolabial fold.

causes: fungal
-Genetic, environmental, hormonal, and immune-system factors
-illness, psychological stress, fatigue, sleep deprivation, change season
-excessive vitamin A intake can cause seborrhoeic dermatitis
-Lack of biotin, pyridoxine (vitamin B6) and riboflavin (vitamin B2)
-Those with immunodeficiency (especially infection with HIV)
-neurological disorders such as Parkinson's disease (for which the condition is an autonomic sign) and stroke are particularly prone to it.

symptoms: hairloss

Erythema multiforme is which illnesses and treatment

Lyme DZ, HSV
-bulls eye lesions can become bulous.
-pruritis and painful
-caused by meds that can followan infection by SC.
-medications that can implccate include the SULFAS, penicillins and other AB phenytoin, allopurinal, and barbs too.
-if initiated early when first symptoms of HSV infection appears then acyclovir can help to present the HSV associated EM.

Clinical features of MELANOMA - know your ABCs?

Asymmetry
Border irregularity
Color variegation - pink - blue - black
Diameter > 6 mm
Elevation

SPITZ NEVI

well circumscribed rasied lesion commonly consued with melaoma - color VARIES
-complete resection is recommeneded regardless.

Hereditary angioedema

def in C1 esterase inhibitor characteried by recurent episodes of angioedema that can be life threatening.

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