Beruflich Dokumente
Kultur Dokumente
Google automatically generates html versions of documents as we crawl the web. Dermatology Review Cecilia Dowsing-Adams, MD Department of Family Medicine University of Tennessee, Memphis Objectives
1. Recognize and treat common skin conditions. 2. Diagnose and treat common bacterial skin infections. 3. Identify and treat mycotic and viral infections. 4. Identify aging skin and precancerous lesions. 5. Discuss other dermatologic disorders.
2. Secondary lesions
Macule
Papule
Nodule
Wheal
Pustule
Vesicle
Bullae
Scale
Crust
Erosion
Loss of part of the epidermis Depressed, moist Follows rupture of a vesicle or bulla
Ulcer
Fissure
Linear crack or break from the epidermis to the dermis Moist or dry
Atrophy
Scar
Cyst
Lichenification
A thickened and roughening of the skin Appears as exaggeration of skin markings Usually cased by rubbing
Telangiectasias
Excoriation
Keloid
A fibrous hyperplasia usually at the site of a scar Grows beyond the boundaries of the wound Excessive collagen formation during healing
Patch
Tumor
Primary lesions
Macule: flat, circumscribed alteration in skin Papule: small, solid circumscribed elevation Plaque: large, flat lesion greater then 10mm Nodule: small, circumscribed solid elevation 10-20mm in diameter extends in deeper tissue
color
Primary lesions
Wheal: relative transient round or flat lesion usually colorless or pale should not last over 72 hours
Pustule: circumscribed elevated lesion that Bullae: vesicle larger than 10mm
Secondary lesions
surface of skin
Erosion: Loss of part of the epidermis Depressed, moist Follow rupture of a vesicle or bulla
Secondary lesions
Fissure: Linear crack or break from the epidermis to the dermis Moist or dry
lesion
Lichenification: A thickened and roughening of skin Exaggeration of skin markings Usually caused by rubbing
Keloid: Fibrous hyperplasia usually at the site of a scar Grows beyond boundaries of the wound Excessive collagen formation in healing
Sebaceous glands are everywhere except: palms, soles, dorsa of the feet, and lower lip Primarily affects face, chest, back and upper outer arms It usually occurs at puberty with sebum production triggered by increased androgen levels; TestosteroneDHT DHT increases the size and metabolic rate of the sebaceous gland Estrogen sebaceous gland output
Acne Vulgaris
Increase production of sebum leads to colonization with propionibacterium acnes and inflammation ensues. Follicular epithelial lining becomes altered and forms plugs called comedones Glucocorticoids, anabolic steroids, lithium, some OCPs, and iodides may exacerbate disease
Acne Vulgaris
Symptoms/exam
o o
Presents with noninflammatory comedones (blackhead and whiteheads) Presents with inflammatory papules, pustules, and cysts
Non-pharmacologic o Face washing, oil-free moisturizers Mild acne o Topical benzyl peroxide (2.5%) gel o Add topical tretinoin or adapalene o Add topical clindamycin or erythromycin o Add systemic tetracycline
Moderate to Severe pustular acne o Systemic antibiotics (4 months): tetracycline, doxycycline, clindamycin, erythromycin, minocycline, TMP-SMX o Isotretinoin (Accutane) 13-cis-retinoic acid Beta HCG must be done prior to initiation of therapy 2 forms of birth control
Recurring, chronic disorder of the pilosebaceous units, Acne of the aged patient (40-60) Characterized by erythema and pustules Aggravating factors include exercise, stress, hot liquids, spicy foods, and ETOH
Acne Rosacea
Symptoms/Exam
- Initially presents with flushing - Erythema and telangiestaias on the central face - Papules, pustules and occasionally lymphedema - Distribution is important (cheeks, nose, forehead and chin) - No comedones are seen
Non-pharmacologic o Avoid precipitating factors Pharmacologic o Topical metronidazole gel or cream (0.75%) o Topical sodium sulfacetamide lotion o Tetracycline, doxycycline, or erythromycin for 2-3 months o Use isotretinoin for severe disease
Acne Rosacea
Rhinophyma (large nose) is a complication affecting primarily middle-aged men Irreversible (electrodessication may improve cosmesis)
A chronic, pruritic eczematous skin disease o Itch-scratch cycle, worsening rash Onset is usually before age 7 o 3 Stages: Infant Childhood Adulthood (least common)
Atopic Dermatitis
Environmental stress triggers reactions on genetically compromised skin (not allergen related)
Atopic Dermatitis
Major Diagnostic Criteria (3 or more) o Pruritus o Typical morphology and distribution o Flexural lichenfication in adults o Facial and extensor involvement in children o Dermatitis chronically relapsing o Personal or family history of atopy asthma, allergic rhinitis, atopic dermatitis
Atopic Dermatitis
Symptoms/exam o Acute lesion include vesicles and serous exudates o Lichenification, excoriation and fibrotic plaques are characteristic of chronic disease o Other findings include xerosis (dry skin), infraorbital skin folds (Dennie-Morgan lines), periorbital darkening, hyperlinear palms, and keratosis pilaris
Atopic Dermatitis
Triggers: o Temperature change and sweating o Decreased humidity o Excessive washing o Foods (eggs, milk, peanuts, wheat)
o o
Non-pharmacologic
Pharmacologic
- Anti-inflammatory
Pharmacologic
- Anti-pruritic agents
Phototherapy
Common, chronic inflammatory disease Malassezia furfur yeast probable cause Once established, it may persist Older patients (especially those bedridden and those with Parkinsons) have chronic and extensive disease
Seborrheic Dermatitis
Distribution of scaling and inflammation: head and trunk where sebaceous glands are most prominent
- Scalp and scalp margins (dandruff/cradle cap) - Eyebrows - Base of eyelashes - Nasolabial folds - External ear canals - Posterior auricular fold Seborrheic Dermatitis
Symptoms/exam o Dry or greasy, yellow, sharply demarcated scales on an erythematous base o Crust and fissures can develop and can become superinfected
Scalp
Intertriginous areas
Face
- Topical steroids not to be used as maintenance therapy - +/- 2% ketoconazole cream Pityriasis Rosea Pityriasis Rosea
Benign, self-limited eruption Generally affects adolescents and young adults as a response to a viral infection Affects females more often than males
Pityriasis Rosea
Symptoms/exam o Herald patch appears several days before the rest of the rash o Days later small plaques appear on the trunk, arms and thighs o Delicate peripheral collarette of scale distributed parallel to the lines of the ribs, creating Christmas tree distribution
Pityriasis Rosea
Symptoms/exam
Directed to symptom relief with antihistamines for itching Moderate-potency steroids may be used for itching if necessary Spontaneous resolution usually occurs within 1-2 months.
Psoriasis Psoraisis
Chronic, noninfectious disease Immune-mediated inflammatory response Lifelong disease affecting ~1-3% of the population Bimodal distribution (peaks at 22 and 55 years of age)
Psoraisis
- Infection (strep)
Symptoms/exam o Red, scaling papules which coalesce to oval plaques with sharp margins o Covered by silvery, white thick scales which bleed when removed (Auspitzs sign) o Epidermal hyperpigmentation with bilateral involvement of extensor surfaces, scalp, palms, and soles
Psoraisis
Symptoms/exam o Nail involvement: nail pitting oil spots Onycholysis (lifting of the nail plate)
Psoraisis
Symptoms/exam o Guttate psoriasis generally follows a streptococcal infection and presents with an acute symmetrical eruption o Associated arthritis can develop
Psoraisis Treatment
Pharmacologic o Potent topical steriods o Calcipotriol (vit D der.) donovex o Intralesional steriod injections (kenalog 5-10mg) o Topical retinoids
Psoraisis Treatment
Pharmacologic (systemic) o Phototherapy - UVB o Photochemotherapy PUVA o Oral retinoids o Methotrexate and other immunomodulatory drugs in severe cases
Delayed (type IV hypersensitivity Previous sensitization must have occurred Upon reexposure to an allergen, dermatitis occurs to 2 days later Common agents: nickel, chromium, neomycin, and oleoresin (poison ivy, poison oak, poison sumac)
Symptoms/exam o Intensely pruritic, erythematous papular rash with indistinct margins o Distribution depends on allergen and pattern of exposure to the allergen
Non-pharmacologic o Avoid allergen Pharmacologic o Medium- to high-potency topical steriods o Cool compresses Burrows solution=Aluminum acetate 1:20 o Antihistamines o Severe cases: short course of oral corticosteriods
Breakdown of the normal epidermal barrier Reaction may be initiated by a common irritant or a one-time exposure to an allergen Patients with compromised skin barriers are at higher risk
Symptoms/exam o Erythema, fissures, and pruritus o Bullae may develop in severe cases o Often affects the hands (web spaces) o May affect the face and eyelids Diagnosis: patch test to distinguish from allergic contact dermatitis
Non-pharmacologic
Avoid triggers Restore normal epidermal barrier Use emollients Pharmacologic o Topical corticosteriods o Oral corticosteriods are of little benefit if irritant is not removed
o o o
An intensely pruritic, chronic recurrent dermatitis Typically involves the palms and soles
Dyshidrotic Eczema
Symptoms/exam o Starts as an episode of intense itching o Formation of small vesicles o Desquamation occurs over 1-2 weeks o Leaves fissures and erosions
Pharmacologic o Medium to high-potency topical corticosteriods o Systemic steroids in severe cases o Recalcitrant cases may respond to PUVA or UVA
A superficial, pustular infection of the hair follicles Causative agent is usually Stap. aureus
Folliculitis
Symptoms/exam o Clusters of small, pruritic erythematous lesions o Pustules may be centrally located o Lesions are generally found in hair-bearing areas
Folliculitis Treatment
Non-pharmacologic o Hygeine is key Pharmacologic o Systemic and topical antibiotics in acute infections o Carrier sites (nose) must be treated with mupirocin (bactroban) in chronic infections along with systemic antibiotics
Bacterial infection that results from breach of skin barrier Most frequently among middle-aged and elderly individual Risk factors: leg ulcers, trauma, venous insufficiency, obesity
Cellulitis
Symptoms/exam o Fever, chills and myalgias o Rubor, calor, tumor, and dolor o Most commonly affects the extremities o Regional lymphadenopathy is common o Lymphangitis may be present o +/- abscess
Cellulitis
Pathogens o Furuncles, carbuncles or abscesses S. aureus (MRSA?) o Diffuse with no defined portal - Strep o Facial cellulitis in children H. influenza o Regional lymphadenopathy is common o Post-puncture wound - Pseudomonas o +/- abscess
Cellulitis Treatment
Infectious Disease Society of America guidelines: Penicillinase-resistant semisynthetic penicillin or a first generation cephalosporin unless Strep or Stap resistant is common in the community Clindamycin or vancomycin for PCN-allergic patients
Erysipelas Erysipelas
Acute inflammation of the dermis Causative agent: Strep. pyogenes Elderly and immunocompromised patients at higher risk
Erysipelas
Symptoms/exam o Well-demarcated erythema, edema, and tenderness o Typically affecting the face and lower legs o Systemically ill, fever, chills and malaise o Lesions can rapidly advance
Erysipelas Treatment
Superficial skin infection Children > adults Contagious and autoinocuable Causative agents Staph and Strep Usually involves face, neck and extremities
Impetigo
Symptoms/exam o Primary lesions are vesicles/pustules that easily rupture o Spread rapidly and become crusted (honey-crusted)
Impetigo Treatment
Non-pharmacologic o Remove crust with saline soaks Pharmacologic o Topical mupirocin (Bactroban) o Systemic antibiotics for severe cases (empiric treatment for Stap/Strep)
Hidradenitis Suppurativa
Hidradenitis suppurativa
Chronic, suppurative process Results from occlusion of follicles and secondary inflammation of apocrine glands More common in females (especially hirsute females)
Hidradenitis suppurativa
Symptoms/exam o Recurring, deep boils for > six months in flexural areas o Commonly affects the axillary, groin, vulva, perineal or perianal areas
There is no cure Goal is to reduce the extent and progression of disease; and to allow regression of scars and sinuses in more extensive disease
Topical clindamycin Antiandrogens and retinoids have yielded mixed results Severe disease requires surgical treatment
Stage I - abscess formation, without sinus tracts; drug therapy Stage II recurrent abscess with tract formation, single or multiple widely separated lesions; drug therapy and limited excision of recalcitrant lesions Stage III diffuse involvement, or multiple interconnected tracts and abscesses across the entire area; unlikely to benefit from medical therapy; wide surgical excision.
Most common type of fungal infections of skin and nails Usually it is localized, erythematous, scaly lesion that form as vesicles/pustules with satellite lesions
Tinea
o o
T. capitus: occurs primarily in children Treat with griseofulvin, terbinafine and intraconazole T. pedis: athletes foot, interdigital maceration Treat with topical antifungal cream Resistant cases may require oral antifungals
Tinea
Differentiation is site dependent o T. corporis: ringworm, sharply demarcated margins with scaling Treat with antifungal cream o T. cruris: jock itch, male predispostion, risk factors are obesity and sweaty physical activity Treat with topical antifungals Talc or desiccant powders may prevent recurrence
Tinea Vesicolor
Chronic fungal skin infection Resulting with pigmentary changes of the skin Causative agent Pityrosporum orbiculare Typically affects young adults
Tinea Vesicolor
Symptoms/exam o If fair-skinned, brown or pink, superficially scaly macules o If darker-skinned, hypopigmented superficially scaly, macules
Pharmacologic o Topical antifungal Clotrimazole Miconazole o Selenium sulfide lotions o Ketoconazole shampoo
Pharmacologic o Ketoconazole 400 mg single dose (short-term cure 90% of the time) o Systemic antifungal, itraconazole for 7 days for resistant cases
Candidiasis Candidiasis/Intertrigo
Fungal infection with predilection of moist areas Intertriginous area most common sites involved Risk factors: o DM, obesity, sweating, heat, maceration o Systemic and topical steriod use o OCPs and antibiotics may be contributory
Candidiasis/Intertrigo
Symptoms/exam o Vesiculopustular enlargement with rupture o Erosion and confluency ensues o Sharply, demarcated plaques with scaly borders and surrounding erythema o Satellite lesions
Candidiasis/Intertrigo Treatment
Discrete umbilicated papules Involves the trunk, face and neck Causative agent DNA pox virus Usually in children or young adults Spread is by direct contact (towels)
Molluscum Contagiosum
Symptoms/exam o Lesions usually occur is groups o Dome shaped lesion with central umbilication
Non-pharmacologic o Lesions can be removed via expression with forceps o Lesions can be removed with curetage under local anesthesia o Lesions can be removed with cryosurgery
Viral Exanthems
Rash associated with a viral illness Exanthems are usually generalized Etiology: o Enterovirus o Echovirus o Coxsackie virus
Viral Exanthems
Symptoms/exam o Erythematous, maculopapules o Palms and soles may be involved o Rash typically fades without pigmentation o Systemic Fever, nausea, vomiting Photophobia, LAD, sore throat, encelphalitis
Vesicles on an erythematous base HSV enters the host through abraded skin or intact mucous membranes HSV I, 90% oral lesions HSV II, 90% genital lesions
Herpes Simplex
Symptoms/exam o Painful, recurring vesicular eruptions o Primary eruptions is longer and more severe that recurrences o Primary infection: fever, LAD, and malaise o Recurrence is limited to mucocutaneous area of involved nerve o Prodromal tingling, burning, or pain
Six or more recurrences of genital herpes per year, treat daily for life Denavir (penciclovir) 1% cream for labial sores Suppress 70 to 80 percent of symptomatic recurrences:
o o o
Acyclovir 400 mg BID (Zovirax) Valacyclovir 1 gm q daily (Valtrex) Famciclovir 250 mg BID (Famvir)
Highly infectious viral illness Incubation average of 14 days after exposure by airborne droplets or vesicular fluids Can be associated with increase risk of infection in pregnant women
Varicella
Symptoms/exam o Prodrome of low grade fever, headache and malaise o Concurrent macules/papules to vesicles to crusted lesions
Varicella Treatment
Varicella vaccine is recommended Avoid salicylates (Reyes syndrome) Acyclovir and immune globulin for immunocompromised host Antivirals, acyclovir are clinically effective in shortening rash if started within 72 hours of its onset
Varicella
Complications o Bacterial skin infections o Congenital varicella Fetal varicella when acquired early in pregnancy (first 20 weeks) Low birth weight, mental retardation, seizures, GI/GU/skeletal problems, dermatomal hypoplasia o Encephalitis o Pneumonia
Varicella
Complications o Congenital varicella Neonatal varicella when acquired late in pregnancy Newborns affected with chickenpox which may disseminate to multiple organs-prompt antiviral therapy
Shingles, rash in a single, unilateral dermatonal distribution Pre-eruptive itching or burning Eruptive phase has typical varicella appearance
Symptoms/exam o Preherptic neuralgia usually 4-5 days before the eruptions (up to 100 days) o Fever, headache, and malaise o Regional LAD o Thoracic region involved in 2/3 of cases varicella is centripetal
Antivirals: reduces pain, inflammation, vesicle formation and viral shedding o Valtrex 1 gm po TID x 7 days Pain meds o Xylocaine 0.5% SQ o Epidural injections
Prevention and treatment of postherpetic neuralgia o Amitriptyline 25 mg q d x 90 days o Lyrica (Pregabalin) o Zotrix (Caspaicin) cream o Merck vaccine reduces the incidence Valtrex 1 gm po TID x 7 days of zoster but does not eliminate it
Rubeola (Measles)
Symptoms/exam th o Morbilliform rash on 4 day begins around ears and head and then spreads caudally o Fever, cough, conjunctivitis, coryza (3 Cs)
Rubeola (Measles)
Symptoms/exam
o o
Koplik spots located on the buccal mucosa precede the rash Usually atypical in adults with fever and vesicular rash
Supportive Therapy o Acetaminophen o Increase fluid intake Prevention by live attenuated vaccine (MMR)
Rubeola (Measles)
Rubella Rubella
AKA German measles 3-day measles Togavirus Spread transplacentally or through respiratory droplets
Rubella
Symptoms/exam o Cervical and posterior auricular adenopathy with URI symptoms, H/A and N/V o Rash is described as palpable petechiae o Prodrome of malaise, low grade fever, and conjunctivitis
Rubella
Symptoms/exam
o o
Exanthem consisting of discrete rose pink macules that begin on the face and spread downward over 1-3 days +/- Forcheimers sign-petechia on palate
Rubella Treatment
Supportive Therapy o Rest o Increase fluid intake Prevention by live attenuated vaccine (MMR)
Rubella
Complications: o Usually self limiting o Spontaneous abortion o Congenital rubella-cataracts, heart disease, deafness, microcephaly
AKA Fifth Disease Caused by Parvovirus B19 Transmitted by respiratory secretions Ususally affects children 4 10 years of age
Erythema Infectiosum
Symptoms/exam o Slapped cheek appearance o +/- prodome of fever, malaise, headache, myalgias o Erythemous, edematous, confluent plaque on the malar face lasts 1-4 days
Erythema Infectiosum
Symptoms/exam o Eruptions of erythematous macules and papules o the extensor surfaces of extremities, trunk, and neck o Exanthem becomes confluent-lacy and reticulated
Eruption generally lasts 5-9 days May recur for months with sunlight, exercise, heat, or stress
Erythema Infectiosum
Primary infection in pregnant women is associated with nonimmune fetal hydrops and fetal demise
Infection where the female mite burrows into skin and lays eggs Causative agent Sarcoptes scabiei Highly contagious Spreads through prolonged contact with infected host
Scabies
Symptoms/exam o Pruritic papules, pustules, and burrows o Usually located in the web-spaces of hands o Symptoms are worse at night o Involves axilla, antecubital fossa, gluteal crease, genitalia, nipples and waistband
Scabies
Symptoms/exam o Itching and rash are due to type IV hypersensitivity reaction to mite eggs and feces o Two to four week delay between infection and onset of symptoms
Scabies Treatment
Non-pharmacologic o Wash clothes and linens in hot water o Consider treating family members who share the same room Pharmacologic o Apply permethrin 5% below the neck and leave for 8 hours o May be repeated in 1 week
Scabies Treatment
Non-pharmacologic
Wash clothes and linens in hot water Consider treating family members who share the same room Pharmacologic o Apply permethrin 5% below the neck and leave for 8 hours o May be repeated in 1 week
o o
Aging Skin and Cutaneous Oncology Basal Cell Epithelioma Basal Cell Carcinoma
Most common skin cancer Occurs in sun exposed area, especially the face and ears 5 Types: o Nodular o Superficial o Micronodular o Infiltrative o Morpheaform
Symptoms/exam o Shiny, pearly-gray papule with an umbilicated center and telangiectasias o Rodent cell ulcers
Non-pharmacologic o Sun avoidance is key to further prevention o Excision or destruction of small lesions (electrodesiccation and curettage) o Advocate for Mohs surgery if larger than 2 cm, recurrent morpheaform, aggressively tumors, critically located o Margins of 4 mm normal skin gives a 98% complete excision
Premalignant lesion to squamous cell carcinoma Superficial keratotic lesion Increased incidence in fair-skinned patients More often felt than seen
Symptoms/exam o Red, keratotic papule that feels rough o Can be red to yellow or keratonize to form a horn (must biopsy base to R/O SCC)
Non-pharmacologic o Use sun blocks and avoid excessive sun exposure Pharmacologic o Topical 5-fluorouricil (5-FU) cyctostatic agent which inhibits enzymes in tumor cells o Topical imiquimod
Cryotherapy with liquid nitrogen (limited lesions) Curettage followed by electro or radio frequency to stop bleeding
Common in middle-aged and elderly May arise with base of AK, within HPV-induced lesions, and within burn and radiation scars Present in sun exposed area
Symptoms/exam o Rapid growth with central ulceration and raised indurated borders, hyperkeratotic o Metasis occurs and depends on size, location, tumor differentiation and depth of invasion (>6 mm at risk)
Melanoma Melanoma
Malignancy of melanocytes occurs on any skin 7th most common cancer in the USA
Superficial spreading has better prognosis than nodular melanoma (grows downward)
Melanoma
Malignant melanoma risk (MMRISK) o Moles, atypical o Moles, total number > 50 o Red hair and freckling o Inability to tan o Severe sunburn st o Kindred, 1 degree relative
Melanoma
Symptoms/exam o Changing moles ABCDEs Asymmetry Borders Color Diameter Evolution Grows suddenly, begins to bleed, itch, or becomes painful
Melanoma Treatment
Excision with appropriate borders Sentinel lymph node dissection for melanoma > 1 mm thick to determine need for adjuvant therapy Close follow-up
Most common sexually transmitted disease Benign clinical lesions on mucous membranes HPV induces hyperplasia and hyperkeratosis
Human Papillomavirus
Symptoms/exam o Small papular, cauliflower-floret o Keratotic warts o Flat-topped papules/plaques (most common on cervix) o Lesions are skinned colored, pink, red, tan, brown
Immunologic response o Spontaneous regression involves cell mediated immunity and interferons o AIDs patients tend to have more Often several attempts: o Topical salicylic acid (keratolytic therapy) o Liquid nitrogen (cryosurgery) o Duct tape o Electrocautery
Inflammatory vasculitis Need fever for >5 days PLUS 4/5 of the following o Conjunctivitis (bilateral) o Strawberry tongue, fissures o Erythematous rash starts palms/soles o Enlarged lymph nodes o Desquamation of fingers/toes with swelling
Kawasakis Disease
Increased WBC, ESR; may be anemic +/- plts Associated with increased risk for coronary artery Treat with high-dose ASA (100mg/kg/day through the 14th day or until afebrile, then 3-5mg/kg/day for 6-8 weeks), IV gamma-globulin (2gm/kg given over 10 hours or 400mg/kg/day for 4 consecutive days.
Most common of benign skin tumors Widely variable presentation from flat, brown macules to raised blackened verruccous lessions need to be familiar with variations to prevent unnecessary destructive procedures.
Sign of Leser-Trelat (eruptive SK as sign of internal malignancy) Treatment: Cryo, Curettage, Shave bx technique
Purpuric Drug Reaction Meningococcemia Diabetic, neuropathic ulcers on the soles. Alopecia Areata Cushings syndrome Acute systemic lupus erythematosus Bibliography
Color Atlas & Synopsis of Clinical Dermatology, Fitzpatrick et al, 4th ed. 2001 First Aid for the Family Medicine Boards, Tao Le et al, 2007 Dermatlas.org.http://dermatlas.med.jhml.edu/derm http://www.aafp.org http://www.UpToDate.com http://www.merk.com