1

Anthropods
SCABIES PEDICULOSIS PEDICULOSIS PUBIS LYME DISEASE
CAPITIS (crabs/pubic/body lice)
(head lice)
Presentation eggs and their casings (nits)
attach to the hair shaft and eggs
hatch in approx 10 days

Distribution fingerwebs, wrists, groin, sides of scalp, especially at lateral and can occur anywhere on the body
hands and feet, torso, breasts posterior aspects

Lesions Linear or waxy ridges 0.5 -1.0
mm long (where mite has
burrowed) with pustules, vesicles
and nodules ( not always readily
seen)
Secondary
erythema, crust and excoriation
due to scratching
Sign
primary papules with secondary
excoriations, erythema, crust
cervical lymph nodes may be
enlarged
papules or macules with
secondary blue grey macules
(bite sites)
characterized by an expanding
erythematous macule or patch
with central clearing at the site of
a tick bite
Erythema Migrans is initial skin
manifestation; seen in 60 - 80 %
of people with Lyme disease
usually expands to more than 5
cm diameter
flu-like symptoms often
accompany skin lesion for a few
days to 6 weeks after tick bite

Symptom Intense Pruritis→(hallmark of severe pruritis usually of sides severe itching in pubic area less
scabies) d/t hypersensitivity rxn to and back of scalp often axillary area or eyelashes,
mite & its feces with eczematization and possible
secondary infection

Dx scabies preparation -find a burrow
on hands or feet; burrow is
scraped at its base
material is on glass slide and
covered with KOH, mineral oil
-demonstrate mites, mite eggs or
mite feces
based on careful observation of
the scalp
lice may be seen but more
common to see nits attached to
the hair shaft
nits can be distinguished from
hair debris: nit has an intact shell
casing totally surrounding it,
allowing to slide up and down
along the hair shaft when combed
nits usually seen attached to hair
shafts
lice may appear as small moving
freckles, and brown specks on
underwear are mite feces
magnifying glass helpful
understand early manifestations
as to prevent serious sequelae of
Lyme disease
(ie neurological – Bell’s palsy,
encephalitis; cardiac: heart block;
arthritis)
2
or examined ie well attached
History Transmission: Transmission: Sexual activity endemic area/activities ie
skin to skin contact; head to head contact or sharing camping, hiking, hunting
infested combs, hats etc
mites live only a few hours on erythema migrans within 1 -2
fomites (bedding or clothing) months of tick bite

other family members often flu-like symptoms during summer

have similar symptoms months

Duration Symptoms usually occur 3-6 several weeks and resolves

weeks after the primary infestation spontaneously
DDx 1.Insect Bites 1.Seborrheic Dermatitis 1.Normal tick bites
→ confined to an area →won’t stick → lesions aren’t bigger than 5 cm
→itching dissipates → scales are easily scraped, but diameter and last less than 7 days
nits are firmly attached to hair
2. Eczema shaft and not easily removed 2.Cellulitis
→flexor surfaces →localized heat & tenderness
→family not affected →no central clearing

2. Folliculitis 3.Contact Dermatitis

→ pustules and crusting are → pruritis predominates, along
scattered throughout the scalp, no with progression to vesiculation
nits → no systemic complaints

4.Tinea Corporis
→also central clearing, but
scaling

5.Spider Bite
→ pain and ulceration at site of
bite are acute; central clearing not
seen
6.Pityriasis Rosea
→ herald patch may resemble
erythema migrans initially but no
history of endemic exposure

7.Erythema Multiforme
→ target lesions
→ hands, feet, mucous
membranes
→hx of drug use or recent illness
Image
3
Hair
ALOPECIA AREATA
Presentation Produces an area of smooth,
discrete hair loss
Distribution usually the scalp but can
occur on any hair bearing
area
Lesions alopecia in smooth circular
discrete areas
patches may coalesce into
bizarre patterns
Exclamation hairs (black dots
of hair broken off close to
scalp) are found at
expanding edges
areas of regrowth: initially
have fine hypopigmented
(white) vellus hairs
Sign Severe emotional stress can
be contributing factor
nail involvement: fine pitting
of the proximal nail plates
Telogen effluvium ANDROGENIC Hirsutism
ALOPECIA
hair that flows out increasing scalp visibility in male pattern overgrowth of androgen-dependent
a typical distribution terminal hairs in female patients
m/c cause of diffuse
scalp hair loss causes: androgen excess due to familial, idiopathic,
drug induced
reversible loss of
mature, terminal hairs often occurs in women with endocrine disorders:
usually secondary to polycystic ovarian disorder, adrenal hyperplasia, or
significant stress→ crash pituitary disorder
diet, emotional stress,
medications, postpartum,
post surgery, nutritional
def/excess
women: more diffuse and
rarely complete; increases
at menopause male-pattern: beard, chest, upper shoulders and
groin
men: M-shaped pattern in
frontal hair-line
50% of hair is lost before
becomes noticeable →
clinician should not
discount complaints of
hair loss in someone
who still has a full head
4
Symptom
Dx presentation and presence of
exclamation points
hair root (plucked hair) is
narrower and less pigmented
than normal
History 20% of individuals have a
family Hx
Duration
Pathophysiology
DDx 1. Tinea Capitis
→Scaling
2.Nervous Hair Pulling
(trichotillomania)
→bizarre pattern of broken
hairs of various lengths as
of hair
1. Pull test: pull gently
on 2-3 dozen hairs at
same time
more than 5 telogen
(club) hairs is abnormal
2. Patients should count
hair loss each day
peak of disease:
hundreds of hair lost daily
- telogen hairs
3. History of inciting
event
--> diffuse hair loss that
peaks around 3-4 months
after initial event
A stress triggers more
hairs into telogen phase
(resting)
1.Anagen effluvium:
→loss of growing
(anagen) hair; because
majority of hair is in this
phase, acute loss
involves 80-90% of hair
→disease results from
family history in females is
especially important
examine scalp for other
signs of hair disease ie
follicular plugging
women: menstrual pattern,
acne, hirsutism
there is a shortening of the
anagen hair cycle with
subsequent production of
shorter, thinner hair shaft
called follicular
minimization
causes often involve
hormones
1.Androgen excess in 1. Hypertrichosis:
women: →excessive hair growth in non-androgen
→ history: fertility, dependent areas
menstrual, new onset of
acne, signs of hirsutism
2.Telogen effluvium:
→usually associated with
5
compared with smooth hair
loss of alopecia areata
3.Androgenetic alopecia
→onset of hair loss is
gradual and with a typical
distribution pattern
no exclamation point hairs
found
chemotherapeutic agents
10-14 days after
treatment
2. Androgenetic
alopecia:
involves gradual, not
acute hair loss from the
frontal hairline or vertex
an acute event ]
→hair pull results +
→history of precipitating
event or drug
→ biopsy may be
necessary to distinguish

can be difficult to 3.Diffuse alopecia

differentiate in women areata:
→hair loss occurs on other
body sites

→more acute in onset and

doesn’t follow a classic
distribution

Image

Nails
Paronychia Onychomycosis Psoriasis vulgaris: nails
Presentation an inflammation involving the lateral and Fungal infection of the nail 25% of psoriasis px’s
posterior fingernail folds
Distribution proximal and lateral nail folds Feet m/c especially → great toe nail fingernails and toenails especially with
concomitant arthritis
Lesions acute: pustules Piting
Yellow oil spots
secondary: erythema, edema, Subungal hyperkaeratosis debris
maceration, scale
Sign separation of nail plate distally and
laterally from the nail bed

nail dystrophy is caused by fungal

involvement which accounts for the
subungual hyperkeratotic scale and
debris

thickening & crumbling

Symptom acute: pain & erythema of posterior or
lateral nail folds followed by development
of a superficial abscess

chronic: abnormal seperation of proximal

6
nail fold from nail plate allows for
colonization
Dx Clinical Findings based on clinical findings of subungual
hyperkeratotic debris, friable nail and
coexisting tinea pedis

KOH test -let sit 10 minutes positive in

50%

History predisposing factors: diabetes, mellitus, Predisposing factors:

over manicuring, occupations that require family history, underlying systemic
individuals hands soaked in water disease ie psoriasis, immune
suppression, poor circulation
Duration often disappears spontaneously
DDx 1.Herpetic whitlow:
• exposure to HSV 1. Psoriasis:
• lab test → tzanck smear • nail piting
may coexist
2. Subungal onychomycosis:
• nail plate is friable and nail folds 2. Nail dystrophy secondary to
not predominantly involved eczema:
No crumbling/debris
3. Pseudomonal nail infection: may coexist
nail plate has a blue green tint
Image

Drug Eruption
Morbilliform Drug Eruption
Presentation diffuse eruptions characterized
by blanching, erythematous
papules and macules in
response to a drug
Distribution
Lesions
Fixed Drug Eruption
Occurs in an asymmetric pattern
at same sites with each challenge
of drug
extremities, glans penis, mucous
membranes
→macules, papules, bullae with
secondary erythema, purplish hue,
erosion and hyperpigmentation
Phototoxic Drug Eruption Photoallergic Drug Eruption
occur as result of drug’s May spread to areas not exposed to sun
ability to enhance the skin’s
reaction to ordinary light
eczematous; similar to contact dermatitis
eczematous; similar to
contact dermatitis
Confined to light exposed
areas
resemble sunburn that
occurs within 24 hours after
UV exposure

→ round and discrete and range

from small, localized to large
bullae
7

→ erosions occur if bullae have

erupted

Sign
Symptom
Dx based on clinical appearance
and history
History
Duration these eruptions typically occur
7 –10 days after drug started
and continue until 2 weeks after
drug has been stopped
DDx 1. Viral Exantham
→much shorter duration
→ no history of drug use
2. Pityrasis Rosea
→ herald patch
→ centripital scale
→ heal as persistent,
hyperpigmented macule
characteristic skin lesions w/ hx of
recurrent lesions at same site
each time drug is taken
1. Erythema multiforme:
• Target lesions and lesions
don’t occur in same location
2.Herpes simplex:
• lesions occur as grouped
blisters on an erythematous
base and confined to one site
• Tzanck smear positive
Occurs 24 hrs after sun 48hrs after sun exposure
exposure
1. Allergic contact 1. Allergic contact dermatitis:
dermatitis: →involvement of shaded areas and
→involvement of shaded history of exposure to contact allergens
areas and history of
exposure to contact 2. Lupus erythematous light eruption:
allergens →systemic findings often present
2. Lupus erythematous
light eruption:
→systemic findings often
present

Image