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Terms in this set (56)

Immunosuppressant (systemic corticosteroids)
Your patient most probably has Pyoderma gangrenosum, which is a ulcerative skin lesion of an uncertain etiology; in more than 50% of cases, it is associated with systemic diseases, most commonly inflammatory bowel disease. It usually develops rapidly and can progress from a pimple to an ulcer in 1 or 2 days. In a process termed pathergy, new ulcerations may occur after trauma or injury to the skin. Pain is the predominant symptom, but symmetrical arthritis, myalgias, and malaise are also common. When the lesions heal, they usually leave the scars that are often cribriform. Immunosuppression is the mainstay of treatment; it is believed that dysregulation of the immune system (specifically, altered neutrophil chemotaxis) is involved. Most clinicians use both topical and systemic therapy. The most commonly used treatments include topical potent corticosteroids or tacrolimus to treat early lesions; systemic corticosteroids, TNF-α inhibitors, or other anti-inflammatories or immunosuppressants are used to treat more severe manifestations.

Surgery or debridement is contraindicated because of the presence of pathergy. Even if there was no pathergy, surgery is contraindicated because skin trauma can trigger the pathergy.

Acyclovir is not indicated; the clinical picture is not consistent with acute herpes infection and the patient is not immunocompromised.

Fluconazole is not indicated; the clinical picture is not consistent with tinea (or any other fungal infection).

Paracetamol alone probably will not relieve the debilitating pain. Sufficient pain medication in this case will probably include paracetamol and some other medication, sometimes opioids.
brown recluse spider
The brown recluse spider is one of only about 4 spiders capable of being dangerous to humans. They are native to the Midwestern and Southeastern sections of the United States. The bite from one can cause death if treatment is not given. The brown recluse spider can be recognized by the "violin" pattern found on its back. They are usually dark brown in color and have dark brown to black colored legs. They usually do not attack unless frightened or when they touch the skin of an animal or human. They can be found in closets, basements, sleeping bags, woodpiles, or other warm, dry places.

The venom of a brown recluse spider is extremely poisonous, and its toxin causes damage to cells and tissues. This is done through the use of enzymes that can destroy cell membranes. This can lead to the local destruction of the skin. It can also spread to the blood vessels and fat. The skin becomes necrotic in the area of the bite, which is characteristic for this spider. The immune system becomes activated as with other insect bites.

Brown recluse spider bites can lead to necrosis of the skin, destruction of red blood cells, blood clot formation, acute renal failure, coma, and death.

Symptoms of a brown recluse spider bite can be similar to a bee sting. There can be mild erythema, pain, itching, and myalgias. These symptoms usually develop within a few hours. Within a few days, the area will heal. In severe cases the patient may develop fever, nausea, vomiting, blistering, and eventually necrosis of the affected skin.

The diagnosis can be made through the patient's history and by examining the affected area. Laboratory analysis should include a complete blood count, urinalysis, electrolyte, and renal function tests. Usually no specific tests are done.

Treatment usually consists of tetanus immunization, antihistamines, and antibiotics. In some cases, steroid treatments are used. This is usually reserved for patients who have an underlying illness such as anemia or renal failure.
kaposi's sarcoma
The patient's Mediterranean origin and typical lesions on the legs makes the diagnosis of Kaposi's sarcoma likely.

Kaposi's sarcoma (KS) is caused by human herpesvirus type 8 and is thought to arise from endothelial cells. There are several forms, which include:

Classic KS, an indolent form, usually occurs in elderly men of Mediterranean origin without AIDS, such as in this patient. Typically it presents as purple plaques or nodules on the lower limbs. Treatment is by cryotherapy, electrocoagulation, or radiotherapy.
AIDS-related form is the most aggressive form, with widely disseminated purple papules or plaques on the skin, mucous membranes, and viscera. Treatment is by chemotherapy.
Lymphadenopathic form involves lymph nodes and skin.
There are several types of malignant melanomas, which include:

Superficial spreading melanomas, which present as plaques with blue-black spots.
Nodular melanomas, which present as rapidly growing dark papules or plaques.
Lentigo maligna melanomas, which present as brown macules with scattered darker spots on sun-exposed areas such as the face.
Acral lentiginous melanomas are the most common form in African-Americans, and they develop on the palms, soles, subungual skin, and mucous membranes.
Patients with basal cell carcinomas (BCC) can present with a shiny, pearly nodule (noduloulcerative BCC), or with erythematous, scaling plaques (superficial BCC), or with a solitary, flat, yellowish plaque (morpheaform BCC).

Patients with squamous cell carcinomas (SCC) may present with a red papule or crusted plaque on the lips, ears, neck, or hands, which may ulcerate, invade the underlying tissue, and metastasize.

In Paget's disease of the breast, patients present with a unilateral, sharply marginated, red scaly rash affecting the nipple and areola. There may also be an underlying mammary duct carcinoma.
erythema nodosa
Erythema nodosa is an acute inflammatory condition characterized by painful nodules on the anterior aspect of the legs. It is often symptomatic of a bacterial, viral, or fungal disease or drug eruption. This occurs most often in women and between the ages of 20 - 30 years. Clinical features include acute fever, malaise, and joint pain. Lesions are nodular, painful, red, and shiny. The symptoms last 2 weeks and heal without scarring.

Urticaria is chronic or acute and is characterized by wheals and papules. Itching and prickling sensations are constant. Both sexes are affected equally and it's often seen in childhood or teen years. The presenting areas are the arms, legs, thighs, and waist. The most common cause is an allergy to medications, foods, or physical agents. The symptoms usually disappear within 6 months (acute) or can last longer (chronic).

Erythema multiforme is characterized by macules, papules, vesicles, and bullae. It occurs secondary to a toxic influence. There may or may not be a prodromal period with a sore throat, diarrhea, and fever. The lesions are red macules or papules and are seen on the sides of the neck, face, legs, genitalia, and mucosa membranes. A typical lesion is a 'target' or 'iris' lesion. The course is generally 3 - 4 weeks.

Erythema Ab Igne is often called toasted skin syndrome; it occurs secondary to exposure to heat from flames or heating appliances. The course is generally benign, but may have a potential for malignant changes. The lesions are red, mottled skin with hypo- or hyperpigmentation. After many years of constant exposure, hyperkeratotic papules, plaques, and ulcers may occur.

Nummular eczema has round, coin-like (nummular) lesions; there is a distribution on the extensor surface of the extremities as well as the posterior portion of the trunk, buttock, and legs. Purulent drainage is not uncommon. Treatment includes topical steroids, systemic antibiotics, and antihistamines; exposure to water should be decreased, and drying agents are used when oozing is present.
lichen simplex chronicus
Lichen simplex chronicus consists of a well-circumscribed, scaly plaque with lichenification and hyperpigmentation due to chronic scratching or rubbing (which can also occur during sleep). It commonly involves the occiput, back of the neck, arms, dorsum of the feet, and ankles. Management includes the use of oral antihistamines, topical, or intralesional injection of, glucocorticoids, as well as breaking the itch-scratch cycle.

Stasis dermatitis is characterized by erythematous, pruritic scales with oozing patches, usually over the medial aspect of the ankles. Hyperpigmentation and stasis ulcers may also be present. It develops on the lower limbs due to chronic venous incompetence. Management includes using topical glucocorticoids and emollients, as well as avoiding irritants. Patients should also be encouraged to wear compression stockings and elevate the affected limb as much as possible.

Asteatotic eczema is characterized by fine cracks which may be erythematous, usually on the pretibial surfaces of elderly people during winter; they may also be pruritic. Management includes the application of topical emollients and avoidance of irritants.

Contact dermatitis in the acute phase is characterized by sharply demarcated, weeping, edematous, eczematous plaques. There is usually a history of contact with an allergen. Management includes avoidance of irritants and application of topical glucocorticoids.

Lichen planus is characterized by pruritic, polygonal papules; they are flat-topped and violaceous in color, and they have a network of gray lines (Wickham's striae) on the surface. They commonly develop on the wrists, legs, and genitalia. Management includes using topical glucocorticoids, though many patients have spontaneous remissions.
tinea versicolor
Tinea versicolor is a fungal infection common in adults and adolescents. The most commonly affected areas include the chest, back, and shoulders. Occasionally, it can be found on the face. It causes the affected skin to change color and become either lighter or darker. It was believed to be caused by a yeast called Malassezia furfur, but recent evidence points to Malassezia globosa as the cause. Tinea versicolor can recur; therefore, treatment may need to be repeated in the future. The affected skin becomes reddish-brown to brown or may be light in color. Initially, the lesions are well-defined, round to oval, scaly macules. Over time, they tend to coalesce and form patches with various amounts of shading. The colors can be darker or lighter than the unaffected skin.

Darker patches may disappear shortly after treatment is started; however, lighter patches may take a long time to go away. The skin discoloration is not permanent, and the color will eventually return to normal.

Diagnosis can be confirmed by using an ultraviolet light (Wood's light). The affected areas usually fluoresce and appear to be orange in color. If they do not fluoresce, the skin will appear darker than normal skin. A scraping of the skin will show the presence of hyphae in a characteristic 'spaghetti and meatballs' appearance when exposed to potassium hydroxide. Diagnosis can also be confirmed through microscopic analysis. A scraping of the area placed in potassium hydroxide solution will show hyphae if a fungal infection is present.

Tinea versicolor can be treated with several preparations that are applied to the skin. Over-the-counter preparations usually contain miconazole, ketoconazole, or clotrimazole; they can be found in shampoo or cream form. There are also prescription strength versions of these preparations. Oral medications (e.g., itraconazole or ketoconazole) also exist.

Vitiligo causes a loss of pigmentation.

Psoriasis causes raised, scaly patches that do not fluoresce under UV light.

Tinea unguium is a fungal infection of the nails.

Seborrheic dermatitis causes patches of thick, scaly, crusty skin; it occurs mainly on the scalp. It can also appear in areas with oil glands (e.g., the folds of skin as in those of the face, groin, and armpits).
urticaria
Urticaria is chronic or acute and is characterized by wheals and papules. Itching and prickling sensations are constant. Both sexes are affected equally, and it's often seen in childhood or teen years. The presenting areas are the arms, legs, thighs, and waist. The most common cause is an allergy to medications, foods, or physical agents. The symptoms usually disappear within 6 months (acute), but they can last longer (chronic).

Erythema nodosa is an acute inflammatory condition characterized by painful nodules on the anterior aspect of the legs. It is often symptomatic of a bacterial, viral, or fungal disease or drug eruption. This occurs most often in women and between the ages of 20 - 30 years. Clinical features include acute fever, malaise, and joint pain. Lesions are nodular, painful, red, and shiny. The symptoms last 2 weeks, and the lesions heal without scarring.

Erythema multiforme is characterized by macules, papules, vesicles, and bullae. It occurs secondary to a toxic influence. There may or may not be a prodromal period with a sore throat, diarrhea, and fever. The lesions are red macules or papules and are seen on the sides of the neck, face, legs, genitalia, and mucosa membranes. A typical lesion is a "target" or "iris" lesion. The course is generally 3 - 4 weeks.

Erythema ab igne, often called toasted skin syndrome, occurs secondary to exposure to heat from flames or heating appliances. The course is generally benign, but may have a potential for malignant changes. The lesions are red, mottled skin with hypo- or hyperpigmentation. After many years of constant exposure, hyperkeratotic papules, plaques, and ulcers may occur.

Nummular eczema has round, coin-like (nummular) lesions with a distribution on the extensor surface of the extremities as well as the posterior portion of the trunk, buttock, and legs. Purulent drainage is not uncommon. Treatment includes topical steroids, systemic antibiotics, and antihistamines; decreasing exposure to water is recommended, and drying agents are used when oozing is present.
psoriasis
Psoriasis is a very common chronic inflammatory condition of the skin. The lesions are variably pruritic and are characterized by sharply demarcated papules and rounded plaques. A silvery scale is frequently observed covering the erythematous plaques. Depending on the distribution and character of the lesions, psoriasis can be further categorized into several sub-groupings. The most common subtype (plaque type) of psoriasis is usually distributed on the elbows, knees, sacral area/gluteal cleft, and scalp. However, there is also a less common variety known as inverse psoriasis. This is where the plaque lesions form in intertriginous regions in addition to scalp, palms, and soles. Because of the moisture in the intertriginous areas, scales may not be evident. Other forms of psoriasis include eruptive or guttate psoriasis as well as some variants where the lesions are more pustular in character. The etiology of psoriasis is not well defined, but there may be some association with certain medications, such as lithium and beta-blockers.

Atopic dermatitis is the skin's reaction to allergy, be it food, asthma, or animal dander, etc. In children and adolescents, it is frequently localized to the flexural skin creases of the antecubital and popliteal fossae. Skin injury is more often a result of scratching than of the atopic process itself, and these individuals have a higher incidence of Staphylococcus aureus skin infections than do unaffected patients. Patients with atopic dermatitis are advised to avoid irritants and to keep skin moist (which includes avoiding hot showers and profuse scrubbing). Treatment often includes the judicious use of low-dose topical glucocorticoids and conservative administration of antihistamines to reduce the itching.

Intertrigo is not an answer choice, but discussion here may be helpful. Stedman's Medical Dictionary (26th edition) defines intertrigo as: "irritant dermatitis occurring between folds or juxtaposed surfaces of the skin, as between the buttocks, between the scrotum and the thigh, beneath pendulous breasts, etc., caused by friction, sweat retention, moisture, warmth, and concomitant overgrowth of resident microorganisms, and occurring in young children and obese adults." Therefore, a patient with intertrigo could indeed have candidiasis, but a patient with candidiasis does not necessarily have intertrigo.

Candidiasis occurs because of overgrowth of this group of yeasts in particular areas of the skin, those that are chronically wet, and especially in the intertriginous zones of the groin and beneath pendulous breasts. Patients with diabetes, chronic intertrigo, and cellular immune deficiency (as in HIV) are particularly susceptible. Obese patients have more intertriginous areas and are thus at risk. The rash is said to be macerated (i.e., displaying a waterlogged or soaked appearance characteristic of the dead surface skin). It is also described as erythematous, with marked inflammation, and it may be in a "satellite lesion" distribution. That is, smaller lesions a couple of cm out from the main larger one, which the "satellites" appear to orbit. The lesions may show scaling and skin scrapings will show pseudohyphae and yeast forms.

Lichen planus is a condition that produces primary lesions described as pruritic, polygonal, flat-topped violaceous papules. Lesions may show thin grey lines (Wickham's striae), and they have a tendency to occur on wrists and shins, but can occur anywhere on the skin. Mucous membranes including the buccal mucosa can be involved. The etiology is not completely understood, and the course is variable, but the lesions usually disappear spontaneously within several months to 2 years. Treatment may include topical glucocorticoids.

The rash of secondary syphilis can indeed manifest as moist pink lesions in the intertriginous regions. This occurs in about 10% of patients with secondary syphilis, and the lesions are called condylomata lata. However, secondary syphilis is not the best answer. While syphilis is notorious for masquerading as other diseases, there are certain clues to look for that are more typical of syphilis. The rash, which may be subtle, usually manifests as symmetric mucocutaneous lesions with some truncal distribution. Furthermore, nontender generalized lymphadenopathy is usually present and the primary chancre of syphilis will still be present in about 15% of patients with secondary syphilis. Finally, RPR should be positive in a patient with secondary syphilis. Other factors to consider are the patient's obesity, diabetes, complaints of vulval pruritus consistent with candidal vulvovaginitis, and positive HIV status. In summary, secondary syphilis would be an appropriate consideration in this patient, but it would not be the best answer in this case. Of parenthetical note, IV drug users have a high (upwards of 25%) false positive rate by reagin-type tests, such as RPR.
Permethrin 1%
The correct response is Permethrin (1%). The patient described in the above scenario is displaying classic signs and symptoms of an active head lice infestation, which is also known as pediculosis capitis. In the US, head lice manifestation is most common among preschool- and elementary school-aged patients. Transmission of actual lice in most cases is by direct contact with the head of an infested patient. Indirect contact may also lead to infestation; this occurs through contact with the infected person's personal belongings (combs, brushes, hats). Patients will more commonly complain of severe itching of the head as well as even the nape of the neck, a sensation of something crawling on them, visually seeing the louse and/or eggs (termed nits), and in very rare or severe cases, cervical adenopathy or impetigo.

The gold standard for diagnosing head lice is finding live louse on the head; however, it is more commonly done by visualizing the tiny eggs that they lay. These are usually located within 1 centimeter of the scalp, and they can be more easily seen at the nape of the neck or behind the ears. Eggs are attached to the shaft of the hair and cannot be removed easily. A practitioner also has to be mindful that many other objects have and can be mistaken for lice nits, including dandruff, hair casts, scabs, dirt, hair spray droplets, or even other insects.

Treatment should not be initiated unless there is clear diagnosis of head lice. Permethrin 1% is the most studied pediculicide in the US and is the least toxic to humans. It is considered first-line treatment and is the correct answer. Malathion 0.5% has also been used as a treatment for head lice, but it is not the first choice. This product has been taken off the market 2 times, most recently due to long application time, a strong odor, and flammability potential. It contains an extremely high alcohol contact (78% isopropyl alcohol); therefore, very strict instructions must be given to the patient and their parents to avoid any situations of extreme heat or fire (hair dryers, curling irons, smoking, etc.). Lindane 1% is available for treatment of lice and scabies; however, there is a known side effect of central nervous system toxicity in humans; reported seizures have occurred in children who have used this product. Benzyl alcohol 5% is also an acceptable treatment; however, it would not be the preferred treatment in the patient above due to the fact that common side effects seen include pruritus, erythema, pyoderma, and even ocular irritation. Crotamiton 10% is not indicated for treatment of head lice, but it is considered a treatment option for scabies. Studies have suggested potential use in patients with active head lice; however, no conclusion has been made on the safety of its use in children, adults, or pregnant women.
Moist dressing
According to conventional pressure ulcer staging criteria (National Pressure Ulcer Advisory Panel or NPUAP) the patient in this case scenario has a Stage II pressure ulcers. Stage II pressure ulcers are characterized by partial thickness skin loss of the epidermis and/or dermis presenting as abrasion, blister, or shallow crater.

Treatment of stage 2 pressure ulcer includes:

Keeping the wound clean. Wash the lesion with saline solution to keep it clean. Use gauze dressings moistened with saline to cover the skin, keep it clean, and retain the wound's natural fluids. Dry dressings or bandages can slow the healing process or make the sore worse.
Using prescribed ointments or creams, such as those that contain enzymes that may help speed the healing process.
Maintenance of a nutritional diet with adequate protein, in order to promote healing and healthy skin.
Removing dead skin or tissue (debridement).
In evaluating and managing pressure wounds, it is important to note the difference between wound infection and contamination (colonization). The basic difference between the 2 conditions lies in the concentration of organisms in the wound. An infected wound contains a larger number of microorganisms than a contaminated wound. According to the Agency for Health Care Policy and Research (AHCPR), stage 2, 3, and 4 pressure ulcers should all be considered as colonized with bacteria.

Because all stage 2, 3, and 4 ulcers are invariably colonized by bacteria, debridement and topical or systemic antibiotics is helpful. According to this patient's examination, there is no evidence of necrosis, excessive drainage, or infection at this time. Proper wound cleansing and debridement should prevent bacterial colonization from proceeding to the point of clinical infection. A contaminated wound will heal, but an infected wound will not.

The use of antibiotics in the management of pressure ulcers is reserved for those pressure ulcer lesions complicated by infection. Infectious complications include bacteremia and sepsis, cellulitis, endocarditis, meningitis, osteomyelitis, septic arthritis, and sinus tracts or abscesses.
basal cell carcinoma
Basal cell carcinoma usually begins as a small indented nodule localized around hair follicles, typically in sun exposed regions of the skin. It typically begins to form an ulcerated center as it enlarges. This type of tumor rarely metastasizes but is locally invasive. It can be quite disfiguring. Excision is necessary to prevent its spread.
Melanoma is typically a highly pigmented tumor of the skin, often seen in sun exposed regions. This tumor metastasizes widely and early on. The lesion may be a constellation of pigment colors, ranging from black to blue to red. The borders are frequently uneven. Tumors may arise from other organs including the meninges, throat (pharynx and larynx), and eye. Satellite nodules may also be seen distant from the main tumor site. Due to the aggressive character of this tumor, wide and deep incisions are necessary, along with tumor staging, if there is the possibility of metastasis.

Molluscum Contagiosum is caused by a large DNA pox virus. This disease is typically seen in children and sexually active young adults. The lesion presents as a pearly, flesh colored papule approximately 2-10mm in diameter, often with a central umbilication. These lesions are often seen on the skin or mucous membranes. Treatment includes currettage and dessication or liquid nitrogen. Diagnosis is supported by the presence of intracytoplasmic inclusions in a KOH preparation of crushed tissue.

Squamous Cell carcinoma is also a slow growing tumor often found on sun exposed surfaces of the skin. This cancer does eventually metastasize. The lesion appears as a raised plaque which tends to ulcerate. Unlike basal cell carcinomas, this tumor originates in skin and squamous mucosa, which can result in lesions involving the skin, cervix, tongue, esophagus and lips. Histologically, this tumor may range from a more indolent type of tumor, containing keratin pearls of concentric lamellated keratin to a very anaplastic nature, where no pearls are evident. Squamous cell carcinoma metastasizes via lymphatics and then to the rest of the body. Excisional biopsy is required to determine the type of skin cancer and treatment necessary.

Lipoma is a subcutaneous, soft round to oval mass of fatty connective tissue. The lesion is approximately 3-5mm in diameter and surrounded by a delicate capsule. The lipoma is normally a benign growth, but constant enlargement may cause compressive effects on surrounding tissues. Local excision is the usual mode of treatment.
This patient is presenting with a target-lesion rash, typical of erythema multiforme, which is a relatively common type IV hypersensitivity reaction. In about 50% of cases of erythema multiforme, no cause is identified. Other causes are infection and medications, including anticonvulsants. In this patient's case, her rash occurrence suspiciously followed the initiation of a new medication. Erythema multiforme is an acute, self-limited condition; it can range in severity from a rash and mild malaise and pruritus (erythema multiforme minor) to a much more severe condition, involving mucosal surfaces and possible desquamation with erythema multiforme major. The most important treatment of erythema multiforme, when a medication is attributed as the cause, is immediate discontinuation of the new medication. Other recommended treatments vary with the severity of the condition. Antihistamines, topical and oral steroids, and analgesics (if needed) are all appropriate treatments for erythema multiforme.

Acyclovir is an antiviral, which is helpful in erythema multiforme associated with herpes simplex virus (HSV) infection. Nothing in this patient's history suggests a recent herpes infection.

Doxycycline is a tetracycline antibiotic. It is useful for several bacterial infections and several dermatologic conditions, ranging from acne to anthrax. It does not have a role in the treatment or prevention of erythema multiforme.

Methotrexate is an immunosuppressant medication used for a variety of conditions, such as rheumatoid arthritis and severe psoriasis. This patient's rash is not suggestive of psoriasis, and methotrexate would not be appropriate.

Vancomycin is an antibiotic; it is used for severe bacterial infections. It has no role in treating erythema multiforme, but its use could cause various skin rashes, such as Stevens-Johnson syndrome and toxic epidermal necrolysis.
Auspitz sign
The diagnosis in this woman is chronic plaque psoriasis. When the scales over a plaque are scraped, it leads to appearance of multiple bleeding points. It appears as a moist red surface through which dilated capillaries are torn at the tip of the elongated dermal papillae. This sign is secondary to parakeratosis, elongation of the dermal papillae, thinning of stratum malphighii, and dilatation and tortuosity of papillary capillaries.

Auspitz sign is neither sensitive nor specific for psoriasis. This sign may not be elicited in inverse, pustular, erythrodermic, or guttate psoriasis. It may additionally be seen in nonpsoriatic conditions such as Darier's disease and actinic keratosis.

Carpet tack sign refers to the presence of horny plugs on the undersurface of follicles, which are revealed when scales are removed from erythematous plaques in discoid lupus erythematosus, though it is not diagnostic for it. It may be seen in certain other conditions, such as seborrheic dermatitis and pemphigus foliaceous, but these conditions are associated with loose scales.

Scratch sign refers to the loosening and appearance of a barely perceptible scale in pityriasis versicolor when scratched with a fingernail. This sign may be negative if the person has recently washed the area, or if the lesion has been recently treated.

The Koebner phenomenon refers to the appearance of new lesions on lines of trauma, which are often linear. It is seen in psoriasis, lichen planus, and vitiligo, apart from other conditions.

Rovsing sign is not a dermatological sign. It refers to increased pain experienced in the right lower quadrant when the left lower quadrant of the abdomen is palpated. It may be seen in appendicitis.