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Dermatology List of Commons

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ACNE VULGARIS
Acne often occurs during puberty but can start through 40's. Genetic and hormonal causes; activated by androgens in those who are genetically disposed. More severe and more common in males. Resistant case in females possibly due to hyperandrogenism with PCOS. Follicular plugging, sebum retention, overgrowth of bacteria (Propionibacterium acnes) with release of irritant fatty acids. Skin also regards extra sebum as a foreign body

S/S: open (blackheads) and closed comedones (whiteheads) are hallmark, papules, pustules over face, neck, upper chest/back, shoulders; may be inflammatory or cystic/nodular

D/Dx: rosacea has papules and pustules in middle of face but also has flushing, telangiectasias, and no comedones). Folliculitis causes pustular eruption on face in patients taking abx or with otitis externa but this is due to a gram (-) folliculitis. Miliaria (heat rash), tinea can cause facial pustules. Steroid reaction with systemic or topical facial use. In patients with HIV, folliculitis is common

Tx: do not scratch, reduce insulin resistance with low glycemic diet/weight loss. For comedonal try topical retinoids first such as tretinoin and adapalene (not in pregnancy). Then try benzoyl peroxide (water-based), and then try topical abx - macrolide class (clindamycin and erythromycin). For papular or cystic inflammatory acne (moderate) try topical abx with benzoyl peroxide. Oral abx - tetracycline class (also doxycycline or minocycline). In pregnancy use topicals only (clindamycin, erythromycin, azelaic acid). Steroid intralesional injections (triamcinolone) for papules and cysts. Laser dermabrasion

Complications/Side Effects: abx can cause contraceptive failure. Chronic, flares common with spontaneous remission, resistance can develop
ACNE CONGLOBATA
Rare and very severe form of acne

S/S: interconnecting abscesses and scarring. Nodulo-cystic to chest, shoulders, back, buttocks, upper arms, thighs, and face. Foul smelling sero-purulent material in cysts. May be associated with anabolic steroid use, hidradenitis suppurativa or pyoderma granulosum

Tx: isotretinoin (Ipledge) and prednisone

Complications/Side Effects: oral retinoids (isotretinoin) are teratogenic and have significant side effects such as dryness, depression, pseudotumor cerebri, and increased lipids
ROSACEA
Chronic facial disorder with neurovascular component. More common in white, Celtic descent; face has a rosy hue

S/S: erythema and telangiectasia to face (cheeks and nose commonly), flushing easily. Papules and pustules (similar to acne) can occur also, perioral common but no comedones present. Glandular component: nose soft tissue hyperplasia: rhinophyma. Heat, cold, alcohol, exercise, sunlight, spicy foods can exacerbate. Ocular: FB sensation, erythema, tearing, pain, blurry vision with blepharitis and keratitis which often needs abx

D/Dx: acne vulgaris has comedones, SLE has no pustules

Tx: suck on ice cube to decrease facial erythema. Use sunscreen, life-long management needed. Topical metronidazole (flagyl) or systemic tetracycline class antibiotics if topical tx fails (doxycycline). Avoid exacerbating factors, sunscreen, use benzoyl peroxide for pustules. Use topical retinoids for adjunct maintenance. Ocular: artificial tears and topical antibiotic

Complications/Side Effects: may develop rhinophyma over time but can treat surgically
HIDRADENITIS SUPPURATIVA
Chronic inflammatory lesions (sterile abscesses) of axilla, groin, buttocks and below the breasts. More common in early adulthood, females, and with obesity

S/S: multiple open comedones, inflammatory papules, nodules and abscesses which leads to scarring. Recurrences common; PMS flares often

D/Dx: acne, epidermal inclusion cyst (expand over a few days and produce cheesy not purulent material).
Furunculosis has postive cultures for bacteria or candida. Culture to exclude furunculosis, otherwise clinical

Tx: I&D to relieve pain/swelling, oral abx (tetracycline class). Treat pain with NSAIDS. Prevention: topical antibiotics (clindamycin) and antibacterial scrubs. Suggest weight loss, smoking cessation, and loose fitting clothing

Complications/Side Effects: cellulitis/localized infection, antibiotic resistance. Recurrence is common
ECZEMA/ATOPIC DERMATITIS
Onset in adolescence or early adulthood. Common in families with atopy (genetic predisposition to allergic IgE mediated disorders such as asthma, allergic rhinitis, and atopic dermatits)

S/S: hyperirritable itchy, red, rough, exudative plaques on flexural surfaces and face, eyelids, neck, upper trunk, nipples, wrist, hands, antecubital/popliteal folds. Acute: vesicles or weeping (may have secondary staph infection). Chronic: lichenified and dry. Black patients lose skin color in lichenified areas. May be widespread. Tends to recur; most have onset in childhood. Onset uncommon after 30 y.o.

D/Dx: seborrheic dermatitis is less pruritic, has frequent scalp and face involvement, greasy and scaly lesions and responds quickly to treatment. Psoriasis has rough red plaques with discrete borders that are covered with white scales. There are no scales in eczema

Tx: use less/milder soap and take shorter/less showers to avoid drying of the skin. Avoid allergens and irritating fabrics. Emollients/lubricants: aquaphor, vaseline, eucerin. Topical corticosteroids: medication strength chosen according to severity but then taper steroid and add emollients as dermatitis clears. Use topicals when acute/subacute and taper to skin care and intermittent use; reserve systemic for severe cases. Start oral prednisone and taper over 2-4 weeks. Use oral antihistamines at night (hydroxazine- "atarax", diphenydramine "benadryl") at bedtime as they sedate. Use oral antibiotics if crusted, pustules, fissures (look behind ear): cefazolin or doxycycline unless MRSA is suspected. Phototherapy can help certain patients with recalcitrant disease with or without coal tar or psoralen with UVA light (PUVA). Use colloidal oatmeal and high potency steroids for weeping lesions. For chronic/dry lesions use high to ultra-high potency, tar preparations, nightly occlusion may help. Use moisturizers and intermittent topical preps for maintenance. Topical NSAIDs to prevent flares

Complications/Side Effects: eczema herpeticum (generalized herpes simplex infection), use acyclovir.
Do not give smallpox vaccincation to eczema patients due to risk of widespread vaccinia infection (skin and systemic manifestations of vaccine)

Prognosis: some resolve in adulthood, others chronic
CONTACT DERMATITIS
Due to irritants or allergic response; skin contact. Most common causes are plant based, topical antimicrobials, anesthetics, nickel, rubber, oils/preservatives, and tapes. Location suggests cause

S/S: itching, burning, erythema, patterned/localized, edema/warmth. Allergic dermatitis presents as vesicles with weeping and crusting. Irritant cause redness and scaling but no weeping vesicles

D/Dx: impetigo: (staph or strep infection of skin) is ruled out by gram stain and culture. Atopic dermatitis does not have a history of contact with specific irritant agents. More easily seen as a chronic condition or one that waxes and wanes. Scabies has itchy burrows, especially on finger webs and in wrist creases. It affects penile glands and shaft. Mites, ova and brown dots of feces visible microscopically. Diagnose clinically based on exposure hx and pattern/location. Gram stain/culture if crusted, patch testing if chronic/recurrent

Tx: irritant: use topical corticosteroids. Allergic: high potency topical corticosteroids and taper to medium; calamine or sarna lotion given in between steroid dressing treatments. For subsiding dermatitis use medium potency topical steroids. For severe use prednisone p.o. and taper (12-21 days)

Complications/Side Effects: eczema herpeticum (generalized herpes simplex), use acyclovir. Do not give smallpox vaccincation to eczema patients due to risk of widespread vaccinia infection (skin & systemic manifestations of vaccine)

Prognosis: some resolve in adulthood, others chronic
DYSHIDROTIC ECZEMA
Vesicular hand (fingers, palms) and foot (soles) dermatitis. Sudden onset of many deep-seated pruritic, clear, "tapioca-like" vesicles. Later scaling, fissures and lichenification occur. No sweat gland abnormalities. Onset is 12-40 years. Half of patients have atopic background. Emotional stress is a trigger; also hot, humid weather

S/S: outbreaks last several weeks with pruritis at site of new vesicles. Pain in fissures. Skin lesions early on: vesicles, tapioca-like in clusters. Later: papules, scales, painful fissures and lichenification. Secondary infections can travel to lymph nodes

D/Dx: contact dermatitis, atopic dermatitis, scabies, tinea pedis (athlete's foot). Culture to r/o Staph. KOH prep to r/o dermatophytosis. Recurrent attacks are the rule; disease free intervals last weeks to months

Tx: wet dressing for early stage (vesicles). Topical application of flexible collodion for fissures. High-potency steroids, occlusive dressing for 1-2 weeks
SEBORRHEIC DERMATITIS
May occur with psoriasis, also early in HIV disease and Parkinsons. Biphasic: seen in infants and early adulthood (30's-40's common)

S/S: dry scales/dandruff or oily yellowish shedding skin (often on erythematous plaques except on scalp).
Found on scalp, face, external ear, eyelid margins, chest, back, and body folds

D/Dx: rosacea, tinea, pityriasis, SLE, psoriasis, eczema, pemphigus foliaceous

Tx: scalp: zinc or selenium shampoos daily, alternate with ketoconazole 1 or 2% weekly. Tar shampoo (also works for psoriasis); topical corticosteroid solutions if necessary. Eyelids: (marginal blepharitis) gentle baby shampoo. Other areas: Low potency corticosteroid as needed; ketoconazole 2% can be added; topical NSAIDS alternative. Life long disorder; recurrences common
PSORIASIS
Common, chronic inflammatory skin disease present mostly on extensor surfaces. Immune mediated (T-lymphocytes and dendritic cells). Obesity worsens psoriasis, genetic component, environmental triggers. Onset: age 20-30 and then 50-50 (bimodal). May occur after strep throat or with HIV. Koebner's Phenomenon: lesions develop at site of minor injury of irritation site. Guttate (many lesions after strep infection), Plaque (most common). May be associated with psoriatic arthritis

S/S: red, sharply defined plaques with silvery scales, scalp scaliness, extensor surfaces (knee/elbow), palms/soles, and nails (pitting on nails or oncholysis).
Distal joint arthritis of only a few sites. Itch may occur and be severe. Often have a pink or red intergluteal fold

D/Dx: atopic dermatitis, candidiasis/intertrigo (skin condition due to macerating effect of heat, moisture and friction, with itch, sting and burning). Cutaneous manifestations of reactive arthritis

Tx: treatment based on body surface area affected (BSA) and psychosocial impact of the disease on patient. Never use systemic corticosteroids to treat flares of arthritis. Phototherapy for patients with numerous small plaques. Tar shampoo or salicylic acid gel for scalp lesions. For larger plaques but less than 3% BSA involved: high/ultra-high potency steroids 2-3 weeks BID, then taper to mid-potency. Vitamin D analog ointments (calcipotriene/calcitriol). Occlusive hydrocolloidal dressings works in 30-40% when used alone. NSAID ointments for groin and facial psoriasis because calcipotriene can cause irritation to groin and face. Generalized Disease: >10% BSA, narrowband UVB phototherapy TID, photo chemotherapy, PUVA. Methotrexate 25 mg weekly for severe psoriasis (monitor liver for cirrhosis) and give with folic acid to prevent the nausea caused by MTX. Acitretin (synthetic retinoid but is a teratogen; wait 3 years to have children) is best for pustular psoriasis; cyclosporine for severe cases. But use with 2nd agent to prevent rebound Newer therapies include tumor necrosis factor (TNF) inhibitors such as infliximab, adalimumab, etanercept for pustular or chronic plaque type. IL-12/23 monoclonal antibodies: ustekinumab in place of TNF inhibitors

Prognosis: Chronic, may be refractory, may develop metabolic syndrome
ICHTHYOSIS
Hereditary; involves excess accumulation of scale due to an excessively thickened stratum corneum. Severity ranges from mild to life threatening. Skin surface appears to have a fish-scale appearance. Most common type of ichthyosis is ichthyosis vulgaris. It is a mild, generalized hyperkeratosis most pronounced on lower legs. Age of onset: 3-12 months. Equal incidence in males and females

S/S: xerosis(dry skin) with fine powdery scaling; most apparent on the shins. Also on arms, back, buttocks and lateral thighs. Cheeks and forehead possibly.
More than half of these patients also have atopic dermatitis. Labs show excessive keratin accumulation.
May improve in summer, humid climes, adult

D/Dx: acquired ichthyosis that is a paraneoplastic syndrome, drug-induced ichthyosis, epidermal dermatophytosis. Diagnosis is usually clinical

Tx: hydrate stratum corneum. Apply petrolatum after a bath. Keratolytic agents: propylene glycol-glycerin-lactic acid. Systemic retinoids (isotretinoin), watch toxicity and use for severe cases intermittently
ACANTHOSIS NIGRICANS
Diffuse, velvety thickening of skin with hyperpigmentation especially in axilla and body folds.
Due to heredity, endocrine disorders (DM), obesity, meds and cancer (adenocarcinoma of GI or GU tract).
Onset in childhood or puberty; epidermal changes due to hypersecretion of pituitary peptide and effect of hyperinsulinemia

S/S: skin appears dark, dirty, thickens to look velvety. Most commonly on axillae, back of neck, groin, anogenital area, and antecubital fossa. Mucous
membranes can be involved

D/Dx: icthyosis; nicotinic acid ingestion. Get labs to r/o DM and associated carcinoma

Tx: treat associated disorder
PEMPHIGUS VULGARIS
Intraepidermal blistering disease that involves skin and mucous membranes. Autoimmune (autoantibodies to adhesion molecules) and drug-induced or can be related to neoplasms. Present in middle age

S/S: unexplained/spontaneous, tender
blisters/crusts/erosions that rupture and cause pain. Nikolsky Sign: superficial detachment of skin after pressure or trauma. Oral lesions often appear first

D/Dx: erythema multiforme, drug reactions, bullous impetigo, contact dermatitis, bullous pemphigoid dermatitis herpetiformis. Microscopy (light, DIF, IIF). ELISA assays find autoantibodies that are trying to destroy cell adhesion molecules. On biopsy: disruption of normal connections between the cells of the epidermis stratus corneum.

Tx: systemic corticosteroids (prednisone 60-80mg/daily). Topical okay if limited disease. DMARDS/immunosuppressants (azathioprine, mycophenolate) are steroid sparing agents over the long term needed for treatment of this disease

Complications/Side Effects: Staph aureus septicemia which can be fatal, malnutrition/dehydration. Admit for IV nutrition/antibiotics in severe cases
BULLOUS PEMPHIGOID
Autoimmune skin disorder. Benign; exacerbations and remissions common. Seen in older adults; mostly in males

S/S: tense blisters and bullae on flexural surfaces, oral lesions. A benign pruritic disease, can be localized, vesicular, erythematous, nodular, etc.

D/Dx: biopsy with microscopy (light or DIF-find IgG and C3)

Tx: prednisone daily, antibiotics/antimicrobials or DMARDS (MTX) or immunosuppressants alternatively for refractory patients. Dapsone is very effective for mucous membrane type
PITYRIASIS ROSEA
Mild, acute inflammatory disease seen mostly in female adolescence and young adulthood (age 10-35 most common). Common in fall and spring

S/S: herald patch: oval, fawn-colored plaque, 1-2 weeks prior to rest of rash. Cigarette paper centers (crinkled) with a collarette scale. On trunk, classic is a christmas tree pattern. Hyperpigmentation seen in dark-skinned patients

D/Dx: syphilis, tinea, seborrheic dermatitis, psoriasis (silvery scales), medication or vaccine reaction

Tx: self-limiting (about 6-weeks), no treatment needed unless symptomatic (itchy) or hyperpigmentation persists. UVB therapy, oral prednisone, topical corticosteroids medium potency, oral antihistamines
LICHEN PLANUS
Inflammatory pruritic disease (mild to severe): lymphocytes infiltrate the upper dermis of penis, lips, tongue, and of buccal, esophageal, and anorectal mucosa. Most common in middle age patients. Association with Hep C. Drug-induced lichen planus from sulfonamides, tetracycline, quinidine, NSAIDS, HCTZ, and mercury-containing amalgams

S/S: pruritic, violaceous, flat-topped, angulated (polygonal) papules with fine white lacy overlay/streaks (Wickham striae). Koebner's phenomenon may be seen on flexor surfaces, wrists, genitalia, and mucous membranes

D/Dx: psoriasis (extensor surfaces, silvery scales), graft-versus-host disease, syphillis. If found on mucous membranes r/o leukoplakia (precancerous condition)

Tx: topical corticosteroids BID (high potency) for localized disease in nonflexural areas. Oral corticosteroids for severe cases. Narrow band UVB phototherapy, PUVA, or photochemotherapy (oral retinoid plus PUVA)

Prognosis: Recurrences common

Complications/Side Effects: squamous cell carcinoma develops in 5% of patients with erosive oral or genital lichen planus and may occur in esophagel lichen planus
ERYTHEMA MULTIFORME MINOR
Acute inflammatory disorder. Sudden onset of symmetric red skin lesions with history of recurrence, herpes associated most common. Mycoplasma infection (walking pneumonia)

S/S: target lesions (iris lesions) on extensor surfaces, hands, feet and mucous membranes commonly. Most cases follow herpes infection

D/Dx: skin biopsy is diagnostic. Urticaria comes and goes in 24 hours. Drug eruptions, autoimmune disease (pemphigus and pemphigoid)

Tx: prevention of herpes by treating with acyclovir can reduce the recurrence
ERYTHEMA MULTIFORME MAJOR
Acute inflammatory disorder. Sudden onset of symmetric red skin lesions with history of recurrence. Stevens Johnson Syndrome (SJS), Toxic Epidermal Necrolysis (TEN). SJS when <10% BSA skin loss occurs. TEN when >30% BSA skin loss occurs. SJS/TEN: 10-30% BSA skin loss (overlap)

S/S: multiple lesion types, targets may have blister in center, trunk more commonly affected. Drugs are the most common cause of erythema multiforme major in adults

D/Dx: skin biopsy is diagnostic. Urticaria comes and goes in 24 hours. Drug eruptions, autoimmune disease (pemphigus and pemphigoid)

Tx: stop offending agent if detected. Admit patient to burn unit for hydration IV and nutritional status maintenance. Open lesions treated like burns with constant monitoring for infection. High mortality for SJS/TEN if >30% BSA is affected. Corticosteroids for severe cases (high dose 100-250mg/daily for short course), but no actual proof that they work

Complications/Side Effects: vision loss with SJS/TEN
ERYTHEMA NODOSUM
Inflammatory condition of the subcutaneous layer. Association with strep, fungal infections, TB, gastroenteritis infections, diverticulitis, syphillis, sarcoidosis, Behcet disease, pregnancy, meds, BCPs, IBD, or may be idiopathic. If all diagnostic tests for the above diseases are negative, there is a risk of developing sarcoidosis later on

S/S: very tender, erythematous nodules usually on extensor surfaces of lower legs lasting weeks, turning into "bruise like" lesions without scarring. Fever, malaise and arthralgia may precede

D/Dx: polyarteritis nodosa, bruises, thrombophlebitis. Obtain clinical history/PE for infections, CXR to r/o TB, antistreptolysin-O titer (ASO), and complete blood count

Tx: self-limiting, treat underlying cause if found. NSAIDS, potassium iodide drops, but steroids for severe cases

Prognosis: lesions disappear in 6 weeks; may recur
PYODERMA GANGRENOSUM
Usually occurs if a systemic disease is present, especially chronic ulcerative colitis. Rapidly evolving, idiopathic, chronic, and severely debilitating

S/S: bleeding nodules/pustules. Very painful. As lesions break down, they ulcerate and release pus with blood. Most common sites include LEs, buttocks, abdomen, and face.

D/Dx: atypical mycobacterial infection, clostridial infection, deep mycoses, stasis ulcers. Clinical findings plus course of illness, elevated sedimentation rate with ESR

Tx: high doses of P.O. glucocorticoids or IV glucocorticoid pulse therapy possibly adding intralesional triamcinolone. Treat underlying associated disease

Prognosis: lasts months to years without tx. Healing extends from center to body periphery. New ulcers form as old ones heal. Slight trauma provokes new lesions
RASHES IN THE ACUTELY ILL AND FEBRILE PATIENTS
Contagious diseases presenting with rash and fever as the major findings include viral illnesses (rubella, enterovirus, parvovirus), and bacterial infections (strep, staph, meningococcus, typhoid, and syphilis)

Look at configuration (annular, iris), arrangement (linear, zosteriform), exposed areas (centrifugal or centripetal), site of first appearance (eg. Rocky Mountain spotted fever occurs first on wrist and ankles), and temporal evolution (eg. measles spreads from head to toes in 3 days but rubella spreads rapidly from head to toes in 24-48 hours, then clears)
ACQUIRED MELANOCYTIC NEVOCELLULAR NEVI
Common acquired new growth in caucasians, less common in blacks. Adults have about 20, commonly occur in family clusters. Commonly called moles, most disappear by age 60. Sun exposure induces nevi to form

Significance: risk of melanoma is related to numbers of common nevi and to dysplastic nevi

Generally are asymptomatic. But if lesion starts to itch and becomes tender, excise it and do biopsy
PORT WINE STAIN
Irregular shaped, red or violet macular vascular malformation of dermal blood vessels present from birth. Different types include salmon patch on nape of neck in infants and tends to regress on its own.
Sturge Weber: PWS associated with eye vascular malformations and dura/arachnoid. Systemic: may be associated with epilepsy, MR, glaucoma

S/S: starts as macular but can form nodules with age. Most commonly involve face

D/Dx: diagnosis is clinical but r/o glaucoma and CNS involvement. CT shows vessel calcification in brain

Tx: copper vapor laser treatment is quite effective
CHERRY ANGIOMA
A benign skin growth made up of blood vessels, fairly common and vary in size. They can occur almost anywhere on the body, but usually develop on the trunk. They are most common after age 30. Cause is unknown, but tend to be inherited (genetic)

S/S: bright cherry-red, small, pinhead size to about 1/4 inch in diameter. Smooth, or can stick out from the skin

Dx: sometimes a skin biopsy may be used to confirm the diagnosis

Tx: usually do not need to be treated. If they affect the patient's appearance or bleed often, angiomas may be removed by burning (electrosurgery/cautery), freezing (cryotherapy), laser, or shave excision. Removal usually does not cause scarring
SPIDER ANGIOMA
A type of telangiectasis found slightly beneath the skin surface, often containing a central red spot and reddish extensions which radiate outwards like a spider's web. They are common and may be benign, presenting in around 10-15% of healthy adults and young children. However, having a large number may be a sign of liver disease

Tx: with electro or laser surgery
PYOGENIC GRANULOMA
AKA lobular capillary hemangioma, is a relatively common benign vascular lesion of the skin and mucosa; cause is unknown. Neither infectious nor granulomatous. The lesion usually occurs in children and young adults as a solitary, glistening red papule or nodule, prone to bleeding and ulceration. Pyogenic granulomas typically evolve rapidly over a period of a few weeks, most often on the head, neck, extremities, and upper trunk. Often arises in pregnancy (or rarely with oral contraceptive usage), particularly on the gingiva or elsewhere in the oral mucosa, and then is termed the "pregnancy tumor". Pyogenic granuloma has also been reported throughout the gastrointestinal tract and upper airway, at various ocular locations, the CNS, the bladder, and the internal vasculature

D/Dx: a number of malignant tumors may clinically mimic pyogenic granuloma, making histopathologic confirmation important if the presentation is atypical

Tx: removal of pyogenic granuloma is indicated to alleviate any bleeding, discomfort, cosmetic distress, and diagnostic uncertainty
SEBORRHEIC KERATOSIS
Beige/brown/black; up to 20 mm. Common in the elderly. Velvety or "stuck on" appearance. Scaly/greasy, usually multiple. Sudden eruption of many, itchy SK on trunk is a sign of internal malignancy, commonly gastric adenocarcinoma

Tx: cryotherapy, curretage/electrodessication if itchy, bothersome, or for cosmesis
LIPOMA
Single or multiple collections of fat cells; movable against overlying skin. Especially on neck, trunk and extremities. Remove them when small as they do enlarge
DERMATOFIBROMA
Very common, button-like dermal nodule.
Important only for its cosmetic appearance and mistaken for malignant melanoma when the fibroma is pigmented. Color varies, seen most commonly in adult females

D/Dx: primary malignant melanoma, blue nevus, Kaposi's sarcoma, metastatic carcinoma. Domed or depressed with a "dimple sign" when the lesion is compressed between two fingers
KELOIDS
Growth of extra scar tissue where the skin has healed after injury

Tx: for these lesions, no treatment is highly effective. For patients who are prone to form these lesions, avoid cosmetic procedures (eg. ear piercing.) Intralesional steroid such as triamcinolone may work well in scar, but less well in keloids
SKIN TAGS
Common, tan or brown, round/oval polyp 1-10 mm in size. More often in middle-age or elderly. More so in females or obese. Becomes tender/bleeds with trauma

Tx: simple snipping with a scissors or electrodessication
ACUTE SUN DAMAGE (SUNBURN)
Transient skin inflammation due to UV exposure, is an example of photo toxicity. Phototoxic drugs can lead to sunburn: sulfa drugs such as chlorothiazides and furosemide, tetracycline class od meds, phenothiazines, naproxen, and amiodarone

S/S: pruritus, pain, tenderness, erythema. Also headache, chills, feverishness and weakness. If severe we see vesicles, bullae, edema. A normal reaction to sun does not cause rashes (scarlatiniform macules, papules, or plaques which occur with an abnormal reaction). Found in exposed areas but sunburn can occur in areas covered with clothing

D/Dx: r/o phototoxic meds, SLE (do serology blood work), and porphyria

Tx: use suncreen, no swimming from 11 am - 2 pm. Moderate sunburn treated with cool wet dressings, topical steroids. Treat with NSAIDS systemically. If very severe, hospital management for fluid and infection prevention. Topically use cool dressings and steroids

Complications/Side Effects: history of blistering sunburns in youth is a risk factor for developing malignant melanoma and basal cell carcinoma years later
DRUG-INDUCED PHOTOSENSITIVITY
Adverse reaction of skin due to simultaneous exposure to certain drugs and UVR or visible light. Free radicals are formed and they damage nuclear DNA or cell membranes. Two types: phototoxic (an exaggerated sunburn response) and photoallergic (an immunological response where the eruption is papular, vesicular, eczema-like and occurs only in those previously sensitized). Phototoxic type is more prevalent. Causes: amiodarone, thiazides, coal tar and derivatives, doxycycline, furosemide, nalidixic acid, some other tetracycline derivatives, phenothiazines, piroxicam, and sulfa drugs.

S/S: immediate erythema or urticaria, delayed sunburn pattern developing in 16-24 hours, delayed (72-96 hours) melanin hyperpigmentation. Pruritus, burning, stinging. Looks like an exaggerated sunburn

D/Dx: porphyria, photosenstivity due to other diseases such as SLE

Tx: stop offending agent
PORPHYRIA CUTANEA TARDA
Patient complains of "fragile skin", vesicles and bullae particularly on dorsum of hand, especially after minor trauma with sun exposure. Diagnosis is confirmed by pinkish red flourescence in urine when examined by Wood's lamp. Also find urinary porphyrins. Deficiency of 5th enzyme in heme synthesis pathway; associated with liver disease, alcoholism, Hep C, and medications (males on estrogens for prostate therapy; females on BCPs 18-30 y.o.)

S/S: painless blisters and fragile skin on dorsums of hands; may have hyperpigmentation and increased facial hair. Sun exposure is also a trigger

D/Dx: pseudo-PCT caused by other drugs; dishydrotic eczema. Obtain liver function tests and look for elevated urine porphyrins, hemochromatosis

Tx: cessation of meds, alcohol, phlebotomy, and antimalarials remove excess porphyrins from the bloodstream. Excess iron helps to trigger this process, thus, phlebotomy reduces iron levels in the blood
ACTINIC KERATOSIS
AKA solar keratosis

S/S: flesh-colored, pink, or slightly hyperpigmented,
rough, sandpaper texture on sun exposed areas

D/Dx: consider biopsy if comes back or won't resolve

Tx: cryotherapy, flurouracil cream x 2-3 weeks, imiquimod cream 5% x 3-6 weeks. Even minimal exposure on a daily basis causes cumulative damage over time (eg. in older individuals whose hair is thinning). Thus, advise such patients to always have a hat in the car/home ready to use when spending time outdoors

Complications/Side Effects: chance of progression to squamous cell carcinoma
BASAL CELL CARCINOMA
Most common form of skin cancer. May arise from actinic keratosis. Common in middle/older-aged caucasian adults; males>females. UV exposure, up to 50% recurrence

S/S: papule/nodule (60%), central scab or erosion; flesh colored, pearly lesion with rolled edges and telangectasia in sun-exposed area (head/neck most commonly), superficial type (30%)

D/Dx: nevi, molluscum, SCC, keratoacanthomas (little volcano)

Tx: excisional biopsy, curettage and electrodessication (but not for head and neck lesions), Mohs surgery (98% cure rate)
SQUAMOUS CELL CARCINOMA
May arise from actinic keratosis. Immunosuppression increases risk in more aggressive types. Common in fair-skinned organ transplant recipients. UV exposure; head and neck most common

S/S: small, hard ulcerating nodules. SCC in situ = Bowen's Disease (intraepidermal squamous carcinoma)

D/Dx: AK, BCC, warts, amelanotic melanoma. Shave (deep), punch or excisional biopsy, TNM staging

Tx: excision, Mohs, frequent monitoring (recurrence) and evaluation for mets. Radiation therapy, curretage, electrodessication. Chemotherapy for mets
MELANOMA
Leading cause of death due to skin disease. Types include nodular, ocular, acral lentiginous (arises on palms, soles, and nailbeds), mucous membrane melanoma. Main genes are CDKN2A or INK4a/ARF. It is the depth of the melanoma lesion, not the skin surface area that determines cure rate. ABCDEs of skin cancer*

S/S: irregular notched border with color spread. Irregular elevation pattern or ulceration. Multiple colors or bleeding without trauma

D/Dx: atypical nevi

Tx: excisional biopsy with 1-2mm margins for diagnosis/management. Lymph node biopsy if high risk features or over 1mm in thickness. Once diagnosis confirmed, wide local excision 1-2 cm margin. Sentinel node biopsy in intermediate to high risk lesions. Adjuvant therapy: refer to specialized centers for treatment of intermediate-risk and high-risk patients. Limit exposure to natural and artificial UV light. Use sunscreen with broad spectrum (UVA/B) with at least SPF 15 daily. Apply sunscreen frequently/liberally. Wear protective clothing. Regular skin exams
VITILIGO
Autoimmune disorder in which melanocytes are destroyed. Generally in darkly pigmented individuals. May present with thyroid disease, DM, Addison's, and other systemic diseases

D/Dx: enhanced with Wood's lamp

Complications/Side Effects: individuals are more prone to AK and skin cancers. Psychosocial impact
ALBINISM
Absent or reduced melanin synthesis. Mostly genetic (genodermatosis); some forms related to deafness. Other causes include leukoderma from therapies (steroids, bleaching, cryotherapy) and post-lichenified skin
MELASMA
Melasma causes brown to gray-brown patches on the face, cheeks, bridge of nose, forehead, chin, and above their upper lip. It also can appear on other parts of the body that get lots of sun, such as the forearms and neck. Women are far more likely than men to get melasma. It is so common during pregnancy that some people call it the mask of pregnancy. Hormones seem to trigger melasma

Tx: wearing sunscreen every day and reapplying the sunscreen every 2 hours. Dermatologists also recommend wearing a wide-brimmed hat when you are outside
KAPOSI
S/S:
D/Dx:
Tx:
Complications/Side Effects:
CUTANEOUS ANTHRAX
A cutaneous anthrax infection most commonly enters the body through a cut or other sore on your skin. It's by far the most common route the disease takes. It is seldom fatal

S/S: a raised, itchy bump resembling an insect bite that quickly develops into a painless sore with a black center. Swelling in the sore and nearby lymph glands

Tx: treat outpatient, using oral doxycycline. Alternatively, any quinolone can be used for a total course of 7-14 days in patients who cannot take doxy. Both have excellent bioavailability
CELLULITIS
Diffuse infection of dermis and subcutaneous layers that spreads. Most commonly due to Staph or Strep (group A beta hemolytic) gram positive organisms. Leg common (tinea, intertrigo, venous insufficiency, diabetes)

S/S: tender, swollen, red, expanding. Systemic symptoms can lead to septicemia and shock

D/Dx: DVT and necrotizing fasciitis (subcutaneous air/crepitus- surgical emergency). Obtain CBC, WBCs leukocytosis, and neutrophilia, culture, and sensitivity. Obtain blood cultures if suspect bacteremia/septicemia

Tx: IV or parenteral abx: nafcillin , oxacillin, cefazolin, or vancomycin (draw level 0.5h before 5th dose if checking levels) or daptomycin (creatinine clearance [CrCl] > 30 mL/min). Transition patients to oral medication if improving (eg. cephalexin). Cover strep and staph empirically (or double oral if only option). Cephalexin (Keflex) 4x daily for 10 days for mild or after discharge. Must hospitalize for severe local symptoms or unstable vital signs. For hx or suspicion of MRSA: vancomycin, clindamycin, or bactrim and beta lactam, or doxycycline with rifampin
SCALDED SKIN SYNDROME
A syndrome of acute exfoliation of the skin typically following an erythematous cellulitis due to staphylococcal infection. It varies from a few blisters localized to the site of infection to a severe exfoliation affecting almost the entire body. Most common in children and neonates due to lack of immunity and immature renal clearance capability (exfoliative toxins are renally excreted)

S/S: general malaise, fever, irritability, skin tenderness

D/Dx: toxic epidermal necrolysis (higher mortality). In SSSS, the mucous membranes are spared. In TEN, the mucous membranes are almost always affected (mouth, conjunctiva, trachea, esophagus, anus, vagina)

Tx: treatment consists of supportive care and eradication of the primary infection. Watch out for MRSA
ERISIPELAS
Superficial form of cellulitis

S/S: pain, malaise, chills/fever, facial/cheek erythema starting with one spot and spreading. Rash is tense, well demarcated, smooth, hot, and edematous

D/Dx: benign bacillary infection causing cellulitis of fingers and hands in fishermen and meat handlers. Blood cultures may be positive for leukocytosis

Tx: bedrest and IV or oral antibiotics (GABHS and staph), penicillin VK, dicloxacillin, or 1st generation cephalosporins
ERYTHEMA MIGRANS
Common cutaneous manifestation of Lyme's disease appears 3-30 days after bite, due to the Borrelia burgdorferi bacteria. Presents as flat or slightly raised erythematous area that expands with central clearing. Ixodes (deer ticks) must feed 24 hours or more

S/S: early symptoms include flu-like sx, headache, stiffness, myalgia, arthralgia, cardiac/neuro, and involvement (rare). Late symptoms include arthritis, paresthesia, and acrodermatitis chronicum atrophicans (bluish-red discoloration/swelling)

Tx: doxycycline x 2-3 weeks. Changes for cases of neuro, cardio, and arthritic complications or for acrodermatitis chronicum. Prophylaxis indicated in certain situations. Amoxicillin if pregnant
FOLLICULITIS
Infection of hair follicles, staphylococcal most common. For hot tub folliculitis think Pseudomonas aeruginosa (1-4 days after bathing in contaminated pool/hot tub). Nonbacterial causes include friction, oils, and perspiration. Pseudofolliculitis: ingrown hairs

S/S: pruritic or tender pustular lesions in areas of hair growth

D/Dx: acne vulgaris, pustular miliaria, impetigo, eosinophilic folliculitis (AIDS). Eosinophilic folliculitis presents with red or skin-colored, dome-shaped papules and pustules. It may look rather like acne or other forms of folliculitis. Diagnose clinically, but gram stain and culture are supportive

Tx: benzoyl peroxide, use of antibacterial soaps, 1st generation cephalosporins (cephalexin) or penicillanase-resistent penicillins (dicloxacillin) for 1-2 months. For gram negative organisms consider isotretinoin. For hot tub folliculitis consider oral fluoroquinolone class (ciprofloxacin). For MRSA, treatment with oral clindamycin is best (macrolide class). Treat with bactroban (mupirocin) topical antimicrobial for staph carriers. Avoid untreated swimming areas, limit oils and use cool/cotton clothing that is not too tight. Control blood sugars
FURUNCULOSIS & CARBUNCLES
An abscess or boil caused by Staphylococcus aureus of the hair follicle and subcutaneous tissue. A carbuncle consists of several furuncles of adjoining follicles forming a deep mass with multiple drainage areas

S/S: extremely painful inflammatory abscess that enlarges and becomes fluctuant and opens releasing pus and other tissue

D/Dx: epidermal inclusion cyst, cystic acne, hidradenitis suppurativa. Culture pus (and nares if necessary)

Tx: I&D, moist heat may help. Oral antibiotic adjunctive therapy includes 1st generation cephalosporins (cephalexin) or doxycycline, TMP/SMX or clindamycin for MRSA
IMPETIGO
Infection from staphylococci or streptococci. Ecthyma: a deep form of impetigo as the same bacteria causing the infection are involved but ecthyma causes deeper erosions of the skin

S/S: crusted superficial erosions and blisters filled with purulent material or other lesion types with honey-colored crusting with erythema underneath if removed. If deeper will see ulceration/scarring

D/Dx: contact dermatitis, herpes simplex. Culture and gram stain to confirm, treat empirically while waiting

Tx: bacitracin or mupirocin (Bactroban) topical antimicrobials AND oral antibiotics: 1st generation cephalosporins (cephalexin) or tetracycline class (doxycycline). If considering MRSA use doxycycline, clindamycin (macrolide class) or TMP-SMX (Bactrim)(sulfonamide). Bleach/scrub surfaces and avoid contact (contagious)
PARONYCHIA
Acute inflammation of nail folds/subungual. Acute infection usually due to S. aureus. Ingrown nail due to over-manicuring, or tight-fitting shoes. Chronic causes include contact with water frequently, irritants, or trauma/manipulation

S/S: painful, swelling with purulence/drainage occurring over time, redness, trauma to nail bed

Tx: warm compresses, soaks, separation of lateral nail fold from nail, mupirocin ointment, I&D if severe or draining, removal of nail. Antibiotics: cephalexin vs. bactrim

Complications/Side Effects: watch for severe pain, or more generalized swelling as it can lead to osteomyelitis!
PILONIDAL CYST
A pilonidal cyst occurs at the bottom of the tailbone (coccyx) and can become infected and filled with pus. Once infected, the technical term is pilonidal abscess.
Pilonidal abscesses look like a large pimple at the bottom of the tailbone, just above the crack of the buttocks. It is more common in men than in women and usually happens in young people up into the fourth decade of life

S/S: pain, swelling, and redness at the bottom of the spine, draining pus, fever

Tx: a pilonidal cyst is an abscess or boil. It needs to be drained or lanced to improve. Like other boils, it does not improve with antibiotics
ACUTE LYMPHANGITIS
S/S:
D/Dx:
Tx:
Complications/Side Effects:
TINEA
Fungal infection (mycotic), grows best in moist environments, aka "ringworm". Transmittable person to person and animal to person (cats commonly). Common in wrestlers or other sports with a lot of contact
Diagnosis confirmed by KOH testing of scrapings showing pseudohyphae and budding yeast

S/S: circular/oval shaped lesions with scaly border and central clearing, or scaly patches with more distinct border. Face and arms common

D/Dx: annular psoriasis, lupus, syphillis, granulma annulare, pityriasis rosea. Biopsy with PAS testing can also confirm if scraping negative

Tx: topical antifungals Miconazole, clotrimazole, terbinafine, butenafine (broad spec imidazoles for macerated tinea pedis) 1-2 weeks after lesions appear resolved. Oral agents if non-responsive: griseofulvin, itraconazole, or terbinafine as alternatives. Urea lotion/cream can help with tinea of soles and aluminum soaks for tinea pedis if macerated
TINEA CRURIS
"Jock Itch", Found in the groin and gluteal cleft area; may also have pruritus ahi

S/S: itchy, sharply demarcated lesions with cleared center with actively scaling edges. Hyperpigmentation and/or pustules may also be seen

D/Dx: candidiasis, seborrheic dermatitis, intertrigo
TINEA PEDIS
"Athlete's foot"

Tx: topical antifungals Miconazole, clotrimazole, terbinafine, butenafine (broad spec imidazoles for macerated tinea pedis) 1-2 weeks after lesions appear resolved. Oral agents if non-responsive: griseofulvin, itraconazole, or terbinafine as alternatives. Urea lotion/cream can help with tinea of soles and aluminum soaks for tinea pedis if macerated. Prevention: use of powder and keeping feet/body folds dry; treat infected household pets

Prognosis: usually resolves within 1 month or less, may reoccur
CONDYLOMA ACCUMINATA
Anogenital warts are the most common viral sexually transmitted disease in the United States. Due to HPV, warts can be located on skin and/or mucous membranes. Common (vulgaris), plantar, lat, filiform (warts with fingerlike projections), genital/anal. 150 subtypes: HPV 1 (plantar warts), HPV 6/11 (anal warts). Spread through skin to skin contact

S/S: papules, usually flesh colored, may be tender or itchy, rough, disruption of skin lines. Scraping shows hyperkeratotic debris and thrombosed capillaries

D/Dx: lichen planus, clavus (corn), SCC, amelanotic melanoma, condyloma lata (SYPHILIS!)

Tx: salicylic acid for common or plantar warts, occlusion therapy, podopyllum resin (category X), trichloroacetic acid, cryotherapy or imiquimod for genital warts. May also consider operative or laser therapy
HERPES SIMPLEX
"Cold sores", genital herpes, or ocular disease. HSV Type I: more common, usually mouth, and usually acquired during childhood. HSV Type II: STD, located areas of sexual contact such as oral, genital, anal. HSV I and II and found both in oral and genital regions. Viral infection with latent and lytic stages. Risk factors include HIV, immunosuppression, high risk sexual behavior, female, and black race

S/S: burning, stinging, pain with cluster of vesicles on lips, penis labia, anus, buttocks, lymphadenopathy/malaise, fevers sore throat, dysuria, ulcerations. SX MAY PRECEED RASH! Often up to 10 days to resolve

D/Dx: chancroid, pyoderma, syphilis, contact dermatitis, herpes zoster

Tx: oral antivirals first line therapy: acyclovir, valacyclovir, famciclovir x 7-10 days. If recurrent or pregnant after 36 wks and genital lesions: antivirals daily. Antiviral topical therapy. Pain management: Lidocaine topical, NSAIDS. Obtain viral cultures of lesion, HSV serology (Western blot or ELISA) - establish infection and for STD screening

Complications/Side Effects: pneumonitis, meningitis, encephalitis, disseminated disease, HIV
HERPES ZOSTER
Acute eruption due to reactivation of varicella virus. Air droplet transmission can cause reactivation of infection. Adults; Over 90% have VZV. Risk factors include immunosuppression, HIV, and illness/stress

S/S: pain/tingling/burning unilaterally along a dermatomal pattern, vesicles appear after start of pain and disappear before pain is resolved, grouped vesicles. Trunk and face most common; eye can be affected. Lymphadenopathy, fever or malaise common. Symptoms can last 4-5 weeks

D/Dx: contact dermatitis, herpes simplex, erysipelas

Tx: oral antivirals first line x 1 week (same meds as for HSV). If Ophthalmic branch of CN V involved, need ophthalmology consult. Taper oral corticosteroid (prednisone 60mg/day). To treat pain: TCA, opioids, gabapentin (neurologic - calcium blocker). Capsaicin ointment, lidocaine, nerve blocks (amitriptyline or gabapentin). Prevention: Zostavax for 50 y.o. and over

Complications/Side Effects: nerve damage/paralysis, encephalitis, post-herpetic neuralgia, visual impairment
MOLLUSCUM CONTAGIOSUM
Caused by poxvirus. Infection by autoinoculation, wet skin to skin contact, or sexually transmitted. Common in immunosupression

S/S: dome-shaped, waxy or pearly gray, centrally umbilicated papules

D/Dx:

Tx: cryotherapy or curretage, retroviral treatment for AIDS patients
ANOGENITAL PRURITUS
Due to intertrigo, psoriasis, lichen simplex chronicus, seborrheic, contact dermatitis, or irritating secretions such as diarrhea, leucorrhea, trichooniasis, or local disease, oxyriasis. Up to 1/3 of causes of anogenital pruritus are due to nerve impingements of the limbosacral spine. If no skin disorder is identified, referral for evaluation of lumbosacral spine disease

S/S: itching, chiefly nocturnal, of the anogenital area. Examination is highly variable, ranging from no skin findings to excoriations and inflammation of any degree, including lichenification
PEDICULOSIS
Parasitic infection through contact (including sexual), sharing of clothing, bedding, and hairbrushes. Common in children and others with close contacts. Types: pediculosis pubis (Phthirus pubis), pediculosis corporis and pediculosis capitis
Can transmit endemic illness

S/S: itching, pyoderma (skins disease have pus in skin), nits on hair, louse on skin or clothes,
"maculae ceruleae" with pubic lice (bluish stain on skin caused by bites)

D/Dx: seborrheic dermatitis, eczema, anogenital pruritis

Tx: permethrin rinse 1% (8 hrs). Alternatives include malathion lotion, topical ivermectin/spinosad, petrolatum. Clothing bedding washed/dried high temps, treat sexual contacts
SPIDER BITES
Most arachnids do not bite. Lactrodectus: widow spiders (black is worse), found outdoors, in garages, and in wood piles. Loxosceles: recluse spiders, found inside basements and dark places

S/S: local reactions are most common: papules, wheals, pustules, bite marks, tender nodule.
Spontaneous resolution within 10 days common. Systemic reactions less common. Widow: muscle pain, tremors, weakness, HA, n/v, shaking, generalized erythema, target lesion with punctum, tachycardia, hypotension. Recluse: sphingomyelnase; skin necrosis/ulceration, malaise, nausea, vomiting, fever, tachycardia, hypotension. Rare: acute hemolytic anemia, disseminated intravascular coagulopathy, rhabdomyolysis, myonecrosis, renal failure, coma, and death

Tx: remove living arthropods (mouthparts needed for ticks). Antihistamines, topical steroids, preventing reinfestation (education). Clean wound, ice/elevate, pain management; benzodiazepines, antivenom. For prevention use deet, wear long sleeved-pant clothing, mosquito nets, permethrin, frequent cleaning
SCABIES
Caused by Sarcoptes scabies, acquired through contact or bedding

S/S: severe itching, excoriations with burrows in between web spaces (interdigital), wrists, elbows, axillae, breasts, and feet

D/Dx: acute contact dermatitis, bedbug or flea bites. Use microscopic exam wet mount visualization of organism/ova/feces to confirm

Tx: permethrin 5% cream (for 12 hrs) x 2 doses (1 week apart). Wash with high heat all bedding/clothing. Treat all house hold members. Alternatives include sulfur/petrolatum x 3 days or ivermectin if resistant