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Dermatology: MODULE X
Terms in this set (35)
A patient comes to the clinic after being splashed with boiling water while cooking. The patient has partial thickness burns on both forearms, the neck, and the chin. What will the provider do?
Clean and dress the burn wounds.
Order a CBC, glucose, and electrolytes.
Perform a chest radiograph.
Refer the patient to the emergency department (ED).
Patients with burns on the face, potential circumferential burns, and any patient at risk of airway compromise should be referred to the ED for evaluation and treatment. The provider should do this urgently and not clean and dress the wounds or order diagnostic tests.
A patient sustains chemical burns on both arms after a spill at work. What is the initial action by the health care providers in the emergency department (ED)?
Begin aggressive irrigation of the site.
Contact the poison control center.
Remove the offending chemical and garments.
Request the Material Safety Data information.
The initial response to a chemical burn is to remove the patient's clothing and the offending chemical. Aggressive irrigation is usually recommended next, but providers should first determine the source to make sure that it is safe to use water. Contacting Poison Control and getting MSDS information are useful measures after the clothing and chemical is removed.
When recommending an over-the-counter topical medication to treat a dermatologic condition, which instruction to the patient is important to enhance absorption of the drug?
Apply a thick layer of medication over the affected area.
A solution spray preparation will be more effective on hairy areas.
Put cool compresses over the affected area after application.
Use a lotion or cream instead of an ointment preparation.
Hairy areas are difficult to penetrate, so in these areas, a solution, foam, spray, or gel may work better. Applying a thicker layer does not increase skin penetration or effectiveness of a medication. Warm or inflamed skin absorbs medications more readily; cool compresses will decrease absorption. Lotions and creams are not as readily absorbed as ointments, which have occlusive properties.
A provider is prescribing a topical dermatologic medication for a patient who has open lesions on a hairy area of the body. Which vehicle type will the provider choose when prescribing this medication?
Gels are an excellent vehicle for use on hairy areas of the body. Creams and ointments are not recommended for hairy areas. Powders should be avoided in open wounds
An adult patient has been diagnosed with atopic dermatitis and seborrheic dermatitis with lesions on the forehead and along the scalp line. Which is correct when prescribing a corticosteroid medication to treat this condition?
Initiate treatment with 0.1% triamcinolone acetonide.
Monitor the patient closely for systemic adverse effects during use.
Place an occlusive dressing over the medication after application.
Prescribe 0.05% fluocinonide to apply liberally.
Treatment with 0.1% triamcinolone acetonide is appropriate in this case, because it is a class 4 corticosteroid and may be used on the face and is suggested for use for these conditions. Systemic side effects are rare when topical corticosteroids are used appropriately. Occlusive dressings increase the risk of adverse effects and are not recommended. 0.05% fluocinonide is a class III corticosteroid and should not be used on the face.
Which is the primary symptom causing discomfort in patients with atopic dermatitis (AD)?
Itching is incessant, and patients usually develop other signs at the site of itching. None of the other options are associated with AD.
A patient diagnosed with atopic dermatitis asks what can be done to minimize the recurrence of symptoms. What will the provider recommend?
Lubricants and emollients
Prophylactic topical steroids
Emollients and lubricants are used long-term to reduce flare-ups. Calcineurin inhibitors can be
helpful for managing chronic moderate to severe eczema. Oral diphenhydramine helps with
symptoms of itching but is not used to prevent symptoms. Corticosteroids should be used sparingly to treat symptoms and stopped once the inflammation has subsided.
A patient who has atopic dermatitis has recurrent secondary bacterial skin infections. What will the provider recommend to help prevent these infections?
Bleach baths twice weekly
Frequent bathing with soap and water
Low-dose oral antibiotics
Topical antibiotic ointments
Bleach baths and intranasal mupirocin have been shown to reduce bacterial superinfections of the skin. Frequent bathing with soap and water may increase flare-ups and increase the risk for superinfections. Oral and topical antibiotic prophylaxes are not recommended.
A patient with chronic seborrheic dermatitis reports having difficulty remembering to use the twice daily ketoconazole cream prescribed by the provider. What will the provider order for this patient?
Burrow's solution soaks once daily
Oral itraconazole (Sporanox)
Selenium sulfide shampoo 2.5% as a daily rinse
Itraconazole is effective for moderate to severe symptoms and is an alternative for those who do not wish to use topical treatment. Burrow's solution and selenium shampoo rinses are not indicated. Oral corticosteroids are usually not given.
A child has plaques on the extensor surfaces of both elbows and on the face with minimal scaling and pruritis. What is the likely cause of these lesions?
Children with psoriasis often have lesions on the face and have less scaling than adults. Psoriasis tends to present on extensor surfaces, while atopic dermatitis occurs on flexor surfaces. Guttate psoriasis appears as teardrop-shaped lesions that appear on the trunk and spread to the extremities and are occasionally seen after streptococcal infections in adolescents. Seborrhea usually occurs on the scalp
A patient diagnosed with psoriasis develops lesions on the intertriginous areas of the skin. Which treatment is recommended?
High-potency topical steroids
Oral corticosteroid injections
Topical steroids with vitamin D
Topical, low-potency steroids
Patients with intertriginous psoriasis should be treated with low-potency topical steroids. High-potency steroids usually produce maximum benefit in 2 to 3 weeks and research suggests combining high-potency steroids with vitamin D analog is best. Oral corticosteroids are used for recalcitrant symptoms.
A patient with severe, recalcitrant psoriasis has tried topical medications, intralesional steroid injections, and phototherapy with ultraviolet B light without consistent improvement in symptoms. What is the next step in treating this patient?a. Cyclosporine
d. Oral retinoids
Methotrexate has shown good efficacy in treating recalcitrant psoriasis. Cyclosporine and oral retinoids are effective but have serious side effects. Etanercept and other biologic agents are effective but expensive and should be tried after all other treatments have failed.
An adult patient has greasy, scaling patches on the forehead and eyebrows suggestive of seborrheic dermatitis. What is included in assessment and management of this condition? (Select all that apply.)
Begin first-line treatment with a topical antifungal medication.
Evaluate the scalp for dry, flaky scales and treat with selenium sulfide shampoo.
Teach the patient that proper treatment is curative in most instances.
Topical antibacterial medications may be used to prevent Malassezia proliferation.
Use topical steroids for several weeks to prevent recurrence of symptoms.
ANS: A, B
First-line therapy may include topical antifungals or corticosteroids. Adults with symptoms on the face or eyebrows are likely to have scalp lesions, since this is usually a "top-down" disorder. The condition is chronic and recurrent. Antibacterial medications are used for secondary bacterial infections but do not treat Malassezia, which is a fungus. Topical steroids should be used on a short-term basis.
A previously healthy patient has an area of inflammation on one leg which has well-demarcated borders and the presence of lymphangitic streaking. Based on these symptoms, what is the initial treatment for this infection?a. Amoxicillin-clavulanate
b. Clindamycinc. Doxycyclined. Sulfamethoxazole-trimethoprim
This patient has symptoms consistent with erysipelas, which is commonly caused by staphylococcal or streptococcal bacteria. These may be treated empirically with penicillinase-resistant penicillin if not allergic. Clindamycin, doxycycline, and sulfamethoxazole-trimethoprim are used for methicillin-resistant staphylococcus aureus infections.
A patient has vesiculopustular lesions around the nose and mouth with areas of honey-colored crusts. The provider notes a few similar lesions on the patient's hands and legs. Which treatment is appropriate for this patient?
Mupirocin, 2% ointment
Culture and sensitivity of the lesions
This patient has symptoms of impetigo which has spread to the hands and legs. Mupirocin, 2% ointment, should be applied three times a day for 10 days. It is not necessary to obtain a culture since this can be treated empirically in most cases. MRSA is unlikely, so sulfamethoxazole-trimethoprim is not indicated. Surgical referrals are generally not indicated.
A patient with a purulent skin and soft tissue infection (SSTI). A history reveals a previous MRSA infection in a family member. The clinician performs an incision and drainage of the lesion and sends a sample to the lab for culture. What is the next step in treating this patient?
Apply moist heat until symptoms resolve.
Begin treatment with amoxicillin-clavulanate.
Wait for culture results before ordering an antibiotic.
Because of a history of exposure to MRSA, the patient is likely to be colonized and should be treated accordingly. Small lesions may be treated with moist heat, but the likelihood of MRSA requires treatment. Amoxicillin-clavulanate is not effective for MRSA. Treatment should be started empirically.
A patient who has never had an outbreak of oral lesions reports a burning sensation on the oral mucosa and then develops multiple painful round vesicles at the site. A Tzanck culture confirms HSV-1 infection. What will the provider tell the patient about this condition?
Antiviral medications are curative for oral herpes.
The initial episode is usually the most severe.
There are no specific triggers for this type of herpesvirus.
Transmission to others occurs only when lesions are present.
In herpesvirus outbreaks, the initial episode is generally the most severe. Antiviral medications may prevent outbreaks, but do not cure the disease. HSV-1 has several specific triggers. Transmission to others may occur even when lesions are not present
A patient who has had lesions for several days is diagnosed with primary herpes labialis and asks about using a topical medication. What will the provider tell this patient?
Oral antivirals are necessary to treat this type of herpes.
Preparations containing salicylic acid are most helpful.
Topical medications can have an impact on pain and discomfort.
Topical medications will significantly shorten the healing time
Topical medications may alleviate discomfort, but do not shorten healing time. Oral antivirals may help shorten healing, but are not necessary as treatment, since the disease is usually self-limiting. Salicylic acid should not be used because it can erode the skin.
A patient who has recurrent, frequent genital herpes outbreaks asks about therapy to minimize
the episodes. What will the provider recommend as first-line treatment?
All three oral antiviral medications help reduce the number of occurrences and the frequency of asymptomatic shedding. Famciclovir and valacyclovir are more costly and no more effective, so should not be first-line therapy. Topical medications are not useful with recurrent, frequent genital herpes.
When evaluating scalp lesions in a patient suspected of having tinea capitis, the provider uses a Wood's lamp and is unable to elicit fluorescence. What is the significance of this finding?
The patient does not have tinea capitis.
The patient is less likely to have tinea capitis.
The patient is positive for tinea capitis.
The patient may have tinea capitis.
Although some fungal species causing tinea capitis are fluorescent with a Wood's lamp, Trichophyton tonsurans, the most common cause or tinea capitis, does not, so lack of fluorescence does not rule out the infection, make it less likely, or diagnose it. Which medication will the provider prescribe as first-line therapy to treat tinea capitis?
Systemic antifungal medications are used for widespread tinea and always with infections that involve the nails or scalp. Oral ketoconazole should be avoided due to risks of hepatotoxicity and serious drug interactions.
A patient has a pruritic eczematous dermatitis which has been present for 1 week and reports similar symptoms in other family members. What will the practitioner look for to help determine a diagnosis of scabies?
Bullous lesions on the soles of the feet and palms of the hands
Intraepidermal burrows on the interdigital spaces of the hands
Nits and small bugs along the scalp line at the back of the neck
Pustular lesions in clusters on the trunk and extremities
The scabies mite typically burrows no deeper than the stratus corneum and burrows may be found in the interdigital spaces of the hands, among other places. Bullous lesions may occur with impetigo. Nits and small bugs are characteristic findings with pediculosis. Pustular lesions represent superficial skin infections.
The provider is prescribing 5% permethrin cream for an adolescent patient who has scabies.
What will the provider include in education for this patient?
a. All household contacts will be treated only if symptomatic.
Itching 2 weeks after treatment indicates treatment failure.
Stuffed animals and pillows should be placed in plastic bags for 1 week.
The adolescent's school friends should be treated.
Bedding and clothing of persons with scabies should be washed in hot water and dried on hot dryer settings. Items that cannot be washed should be put in plastic bags for 1 week. All household contacts should be treated. Itching may persist because of the secondary dermatitis for up to 2 weeks and does not represent treatment failure. Casual contacts do not require treatment.
11. A patient with intertrigo shows no improvement and persistent redness after treatment with drying agents and antifungal medications. The patient reports an onset of odor associated with a low-grade fever. What will the provider do next to manage this condition?
Culture the lesions to determine the cause.
Evaluate the patient for HIV infection.
Order topical nystatin cream.
Prescribe a cephalosporin antibiotic.
This patient has symptoms of a secondary bacterial infection. The lesions should be cultured and the results used to determine the appropriate antibiotic. Patients with recurrent candida infections should be evaluated for underlying HIV infection, diabetes, and other immunocompromised states. Topical nystatin cream is used for candida infection and these symptoms are consistent with bacterial infection. Antibiotics should be chosen based on culture results.
An older patient experiences a herpes zoster outbreak and asks the provider if she is contagious because she is going to be around her grandchild who is too young to be immunized for varicella. What will the provider tell her?
An antiviral medication will prevent transmission to others.
As long as her lesions are covered, there is no risk of transmission.
Contagion is possible until all her lesions are crusted.
Varicella-zoster and herpes zoster are different infections.
ANS: CHerpes zoster lesions contain high concentrations of virus that can be spread by contact and by air; although they are less contagious than primary infections, contagion is possible until all lesions are crusted. Antiviral medications shorten the course, but do not reduce transmission. Covering the lesions does not prevent transmission. Herpes zoster and varicella-zoster are the same.
A patient has a unilateral vesicular eruption which is described as burning and stabbing in intensity. To differentiate between herpes simplex and herpes zoster, which test will the provider order?
a. Polymerase chain reaction analysis
ANS: AThe PCR is a rapid and sensitive test that can differentiate between the two. Serum Ig levels are not diagnostic. The Tzanck test identifies the presence of a herpes virus but does not differentiate between the two types. Viral culture will differentiate, but it is not rapid.
1. What instructions will the primary care provider give to parents of a child who has scabies who is ordered to use 5% permethrin cream? (Select all that apply.)
Apply the cream at bedtime and rinse it off in the morning.
It is not necessary to wash bedding or clothing when using this cream.
Massage the cream into the skin from head to toe.
The rash should disappear within a day or two after using the cream.
Use once now and repeat the treatment in 1 to 2 weeks.
ANS: A, E
Permethrin cream should be applied from the neck down in children and rinsed off in 8 to 12 hours. The treatment should be done once and then repeated in 1 to 2 weeks. Bedding and clothing should be washed thoroughly. Adults should apply from head to toe, since the scabies can infest the hairline of adults. The rash may still be present for several weeks after treatment.
When recommending ongoing treatment for a patient who has recurrent intertrigo, what will the provider suggest? (Select all that apply.)
Aluminum sulfate solution
Burrow's solution compresses
Topical steroid cream
ANS: A, B
Aluminum sulfate solution and other drying agents are recommended, and Burrow's solution compresses may be soothing. Cornstarch is ineffective and may result in fungal growth. Nystatin cream is used only for candida intertrigo. Topical steroids may promote infection
A patient has acne and the provider notes lesions on half of the face, some nodules, and two scarred areas. Which treatment will be prescribed?
Oral clindamycin for 6 to 8 weeks
Topical benzoyl peroxide and clindamycin
This patient has moderate acne, based on symptoms of lesions on half of the face with nodules and a few scars. A combination of topical benzoyl peroxide and clindamycin is recommended. Oral antibiotics are reserved for severe cases. Oral isotretinoin is used only for recalcitrant cases which are severe and have not responded to other treatments. Topical antibiotics should be used as monotherapy.
A provider is considering an oral contraceptive medication to treat acne in an adolescent female. Which is an important consideration when prescribing this drug?
A progesterone-only contraceptive is most beneficial for treating acne.
Combined oral contraceptives are effective for non-inflammatory acne only.
Oral contraceptives are effective because of their androgen enhancing effects.
Yaz, Ortho Tri-Cyclen, and Estrostep, are approved for acne treatment.
Three oral contraceptives have a labeled use for acne treatment: Yaz, Ortho Tri-Cyclen, and Estrostep. Progesterone-only contraceptives may worsen acne. Combined oral contraceptives are effective in reducing inflammatory and non-inflammatory acne. Oral contraceptives are effective because of their antiandrogen effects, since androgen induces sebum production
A female patient is diagnosed with hidradenitis suppurativa and has multiple areas of swelling, pain, and erythema, along with several abscesses in the right femoral area. When counseling the patient about this disorder, the practitioner will include which information?
Antibiotic therapy is effective in clearing up the lesions.
It is often progressive with relapses and permanent scarring.
The condition is precipitated by depilatories and deodorants.
The lesions are infective, and the disease may be transmitted to others.
Although lesions may be treated with antibiotics, other medications, and drainage, the disease is often progressive, with relapses and permanent scarring. Deodorants and depilatories are not implicated as a cause. The disease is not transmitted to others, although the organisms may cause other infections in other people.
When counseling a patient with rosacea about management of this condition, the provider may recommend (Select all that apply.)
applying a topical steroid.
avoiding oil-based products.
eliminating spicy foods.
exposing the skin to sun.
using topical antibiotics.
ANS: C, D, F
Patients with rosacea should avoid oil-based products and eliminate spicy foods, alcohol, and hot fluids. Topical antibiotics may be used if pustules are present. Topical steroids are not recommended. Patients do not need to avoid makeup and should avoid the sun.
Which medications may be used as part of the treatment for a patient with hidradenitis suppurativa? (Select all that apply.)a. Chemotherapyb. Erythromycin
c. Infliximab d. Isotretinoin e. Prednisone
Hidradenitis suppurativa is not malignant and chemotherapy is not used. Erythromycin, infliximab, isotretinoin, and prednisone are all used.
A primary care provider is performing a Tzanck test to evaluate possible herpes simplex lesions. To attain accurate results, the provider will perform what intervention?
Blanch the lesions while examining them with a magnifying glass.
Gently scrape the lesions with a scalpel onto a slide.
Perform a gram stain of exudate from the lesions.
Remove the top of the vesicles and obtain fluid from the lesions
The Tzanck test requires removing the tops from vesicular lesions in order to obtain fresh fluid from the base of the lesions. Blanching of blue to red lesions under a microscope helps to evaluate whether blood is in the capillaries of the lesions. Scraping lesions onto a slide is done to evaluate the presence of hyphae and spores common with candidiasis or fungal infections. Gram staining is performed to distinguish gram-positive from gram-negative organisms in suspected bacterial infections.
When examining a patient's skin, a practitioner uses dermoscopy for what purpose? (Select all that apply.)
a. Accentuating changes in color of pathologic lesions by fluorescence
Assessing changes in pigmentation throughout various lesions
Determining whether lesion borders are regular or irregular
Differentiating fluid masses from cystic masses in the epidermis
Visualizing skin fissures, hair follicles, and pores in lesions
Dermoscopy is used to visualize the epidermis and superficial dermis and can reveal changes in pigmentation throughout lesions, whether borders are regular or irregular, and the various fissures, follicles, and pores present in lesions. The Wood's light, or black light, is used to fluoresce lesions to accentuate changes in color. A direct light source is useful for differentiating fluid masses from cystic masses.
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