Papules and pustules are raised bumps with obvious inflammation. These are red spots (papules) and may have a head (pustules). The Nodule is a solid lesion, one of the most painful lesions HYPERLINK "http://www.popthatzit.com/acne-treatment/noncomedogenic/" \o "Noncomedogenic" Noncomedogenic : Not likely to cause comedones. HYPERLINK "http://www.popthatzit.com/acne-treatment/retinoid/" \o "Retinoid" Retinoid : A natural or synthetic substance derived from vitamin A. Dermatology diseases Acne vulgaris Appearance Occurs at puberty, onset can delay into 3rd or 4th decade Hallmark: Open and closed comedones (blackheads) Face and upper trunk Severity varies from: purely comedonal to papular pustular inflammatory acne to cysts or nodules Treatment Education and diet (weightloss can improve) Comedonal Acne( treat according to severity, generally mild soaps Topical retinoids Benzoyl peroxide Antibiotics—to decrease pustular & comedonal lesions Comedo Extraction—open/closed blackhead removal Papular Inflammatory Acne (antibiotics (topically or orally) Retinoids: like Vit A Atopic dermatitis (eczema) Associated characteristics Common (2-3% of population) An “itch that rashes” Usually WORSE during the winter time Pruritic Areas of skin commonly involved May affect any area of body, BUT typically starts in antecubital or popliteal fossae Flexural areas Usually spares moist, intertriginous (when two pieces of skin rub together) areas Associations Often seen coupled w/ allergic rhinitis (“hay fever”) or asthma—atopic diseases Usually begins in childhood and improves w/ age Secondary infection common Increased susceptibility to disseminated viral infections (e.g. eczema herpeticum) Treatment (treat the itch AND rash) Topical steroids Topical and systemic antipruritics (e.g. menthol lotions, antihistamines) Topical tar medications Mild soaps—counsel about bathing habits Emollients (substances that soften and smooth the skin) INCLUDEPICTURE "http://t2.gstatic.com/images?q=tbn:ANd9GcQkkjmwfBcHYQQEpiO74xmdoEgcLF5oFTpANHjXFYANRFM_fzE&t=1&usg=__zvSp38s984RAq1mV9tYyT5MryfY=" \* MERGEFORMATINET INCLUDEPICTURE "http://t2.gstatic.com/images?q=tbn:ANd9GcQkkjmwfBcHYQQEpiO74xmdoEgcLF5oFTpANHjXFYANRFM_fzE&t=1&usg=__zvSp38s984RAq1mV9tYyT5MryfY=" \* MERGEFORMATINET Basal cell carcinoma Appearance Pearly papule, erythematous patch > 6mm or nonhealing ulcer sunexposed areas (Face, trunk, lower legs) Often w/ overlying telangiectatic vessels Risk factors most common malignant skin tumor chronic sun damage or radiation exposure history of bleeding fair-skinned person w/ hx of sun exposure Clinical manifestations Can leave broad hypopigmented area Treatment Excision Electrodesiccation/ curettage Mohs Surgery (removal & freeze) Likelihood of reoccurrence is really high Appropriate follow-up treatment Up to ½ will develop 2nd lesion, must be monitored regularly ABCD Rule A: asymmetry, B: Border irregularity, C: color, D: diameter Bug bites Hymenoptera (bees, wasps, yellow jackets, hornets, ants) KNOW THIS Appearance Fire Ants( sting w/ arc; toxin makes necrotic pustule (sterile) Wasps ( can sting multiple times Clinical manifestations as a result of bite or sting Major cause of death (due to anaphylaxis) Appropriate treatment Must remove stinger if present OTHER Africanized (“killer”) bees now in US “imported” fire ant becoming very important regionally in NC Fleas Appearance Rash primarily on lower extremities Clinical manifestations as a result of bite or sting Appropriate treatment Usually associated w/ pets OTHER: Common locally Bedbugs (now in 2% of households) Appearance Linear (think they have breakfast, lunch, dinner) Papular urticaria Find brown “blood” on sheets (really its bedbug feces) Clinical manifestations as a result of bite Scratching to open wounds Appropriate treatment Aggressive hygiene and removal of infested occupant OTHER: Mostly nocturnal (except wheel bug) Blister beetles (Coleoptera) KNOW THIS Appearance Cause blister due to secretion of cantharidin (“Spanish fly”) Clinical manifestations as a result of bite or sting Appropriate treatment Can be left alone and will diminish and heal Lice (Anoplura) General Parasitic ion of the skin of the scalp, trunk, or pubic area nits on hair shaft or lice on skin or clothes occur among people who live in overcrowded dwellings w/ inadequate hygiene. Appearance Head louse (Pediculosis humanus var capitis) Elongate body Lay eggs (nits on hair shaft Unable to establish infestation in persons w/ very curly hair (e.g. A.A.) Pubic Louse (Phthirus pubis) Short, rounded body( so can stay on curly hair) “crabs” that usually spread venerally Lay nits on short hair shafts (pubic, axillary, eyelashes) Body Louse (Pediculosis humanus var corporis) Elongate body Usually seen in homeless and derelict patients Lay nits in seams of clothing Rx: nix or Kwell Clinical manifestations as a result of bite or sting Itching may be very intense in body louse Secondary excoriations as a result of scratching Appropriate treatment Head Louse: permethrin (OTC topical cream) Pubic Louse: permethrin rinse + permethrin cream Body Louse: don’t live on person, live in clothes—WASH THEM! Ticks (acarina) Appearance Flat, slightly raised lesion that expands with central clearing Clinical manifestations as a result of bite NOTE: 24-48 hours to transmit diseases we are worried about RMSF Lyme Appropriate treatment Must remove the tick, INCLUDING the mouth If mouth not removed, can result in tick bite granuloma OTHER Common locally Amblyomma americanum (Lone Star Tick) Dermacenter variabilis (Dog Tick) Dermacenter andersonii (Wood tick) Ixodes spp. (deer tick) Black Widow spider (ARACHNID) Appearance Common locally Has red hour glass shape on the belly Clinical manifestations Usually painless bite leads to muscle spasm beginning centrally (abdominal) and spreading peripherally DEATH—usually elderly, ill, or children, pancreatitis like pain, if bit on upper extremitiy, you’ll have chest pain, lower you have abdomen pain Appropriate treatment Muscle relaxants (Valium, Robaxin), calcium, antivenom Brown Recluse Spider (ARACHNID) Appearance not found locally usually Clinical manifestations as a result of bite Bite is necrotic INCLUDEPICTURE "http://t1.gstatic.com/images?q=tbn:ANd9GcSBSclwd_bSnpgvrCN4-L01rSkVlqzB42njoyQXSOYtw7aTzh8&t=1&usg=__EAwwWyqmRTBtJzCCs3VHRvNz3MM=" \* MERGEFORMATINET , get bullae within 24-48 hours Appropriate treatment Controversial (Dapsone) Bullous pemphigoid (Blistering Disease—dermatological emergency) Age predispositions/ Predisposing factors NEGATIVE NIKOLSKY SIGN Persons over the age of 60 (often in 70s and 80s) Men are 2X likelihood of women Autoimmune skin disorder Clinical manifestations Characterized by formation of bullae or blisters Remitting in 5-6 years (exacerbations and remissions) Appearance of blisters may be preceded by urticarial or edematous lesions for months Areas affected Flexural areas Localized, vesicular, vegetating, erythematous, erythrodermic, nodular Lab testing Dx via biopsy and direct immunofluorescence examination IgG and C3 are found at dermal-epidermal junction Treatment MILD( ultrapotent corticosteroids (prednisone) Tetracycline or erythromycin Dapsone (effective in mucous membrane pemphigoid) Cellulitis BEEFY RED Erysipelas Organism—aspirate culture usually not helpful (low yield) β-streptococcus pyogenes Presentation bright red w/ well demarcated border) Treatment Penicillin or Eryhtromycin H. flu cellulitis Organism—aspirate culture usually not helpful (low yield) associated w/ H. flu meningitis Presentation Most frequently in children Treatment Cephotaxime, ceftriaxone, SMX-TMP, cipro, chloramphenicol INCLUDEPICTURE "http://t3.gstatic.com/images?q=tbn:ANd9GcSE5zuTsuVcjO5Ms_5OUez1rlXDOAmCDOXdnDuBHMzGzvJrHv0&t=1&usg=__p_Iq_kSq0JBfHspSPRhhZfxPHUw=" \* MERGEFORMATINET INCLUDEPICTURE "http://t3.gstatic.com/images?q=tbn:ANd9GcSE5zuTsuVcjO5Ms_5OUez1rlXDOAmCDOXdnDuBHMzGzvJrHv0&t=1&usg=__p_Iq_kSq0JBfHspSPRhhZfxPHUw=" \* MERGEFORMATINET Chicken pox Presentation “dew drops on a rose petal” Characteristics Zanc Smear + Treatment ( Vaccine available Symptomatic Burow’s soaks when needed Acetaminphen Antibiotics for secondary infections Immunosuppresed Patients: high dose IV acyclovir Special Circumstances (immunosuppression/ newborns): zoster immune globulin Contact dermatitis (allergic and irritant) Associated characteristics ALLERGIC: requires cell-mediated immunity in sensitized individual Intesely pruritic Something that is developed due to exposure Poison Ivy: blister w/ fluid (note: not spread by fluid, rosin spreads it (SEE PICTURE) IRRITANT: no allergic mechanism No itch Painful Areas of skin commonly involved Areas in contact w/ irritant or allergic substance Associations IRRITANT: due to irritating substances coming in contact w/ skin (chemicals, pesticides, harsh soaps, bleach, plant saps, etc), dichromates (esp. in cement workers) ALLERGIC: Toxicodendron (poison ivy, oak, sumac,) nickel, paraphenylendiamine, ethylenediamine, formaldehyde, rubber/latex additives, leather thanning agents (shoes, belts, etc.), fragrance, dichromates, etc OTHER COMMON SENSITIZERS include: Neomycin (found in medications) Treatment Removal or protection fro irritating/allergic substances Topical Corticosteroids (systemic sometimes needed in allergic contact dermatitis) Cutaneous candidiasis (fungal infection) INCLUDEPICTURE "http://t1.gstatic.com/images?q=tbn:ANd9GcQ3chG-mfgIU3jt6BwxUtxjjctNIyi4gHLteWxlWgRifiLr-UU&t=1&usg=__Lsr1kGoUfIy1iGX2fmlptLPr9a4=" \* MERGEFORMATINET Clinical manifestations May have spores on KOH On skin, usually very inflammatory w/ satellite lesions clinically “diaper dermatitis”—usually a mixed problem of candidiasis and irritant eczema May flare psoriasis in intertriginous areas Areas affected Effect moist areas of the body Breast, groin, web spaces b/t fingers & toes Organisms may coexist w/ dermatophytes (trichophyton mentagrophytes) Treatment Topical anti-candida agents Topical nystatin ointment Topical 1% clotrimazole w/ 1% hydrocortisone cream (Ketoconazole (Nizoral), Itraconazole (Sporanox), Fluconazole (Diflucan), Nystatin (Mycostatin, Nilstat), Terbinafine (Lamisil) May add low potency topic steroid of very inflammatory If patient on antibiotics, will be more susceptible to this. Discoid lupus erythematosus (DLE; systemic skin disease) Appearance (if appropriate) Localized red plaques, usually on face due to photosensitivity Scales are dry and “thumbtack-like” Involves scalp, face, and external ears Atrophy, telangiectansia, depigmentation, and follicular plugging Clinical manifestations that result Scaling, follicular plugging, atrophy, dyspigmentation, and telangiectasia of involved areas Hair loss on scalp lesions Associated common disease processes that produce it INCLUDEPICTURE "http://t1.gstatic.com/images?q=tbn:ANd9GcQZHLe3bShBsrk1TMyzdvpqJchBWja1wWPI3Z0jfwwIVyFPHPk&t=1&usg=__C0wH_dTSzQbZC4tniLfDmp9na1E=" \* MERGEFORMATINET Protect from sunlight—high-SPF PHOTOSENSITIVE Treatment Limit sunlight exposure High-potency corticosteroid creams at night, covered with thin film Drug eruption Epidemiology Purpura, not going to blanch Incidence of adverse cutaneous drug reaction is around 2-3%. Elderly patients are more likely to have a problem with a drug and also to be on multiple meds. Antimicrobial drugs are the most likely to cause a drug eruption Seizure meds are also often implicated and often the cause of more serious drug reactions Dyshidrotic eczema Appearance palmar/plantar eczema with vesicles and blisters Usually starts on the margins of the hands/feet or fingers Epidemiology chronic, excessive exposure to water/detergents, harsh chemicals, or allergens Associated symptoms hand eczema, very pruitic Tests KOH stain to exclude tinea infection Treatment avoid irritants and identify contact allergens Tx co-existant infection topical glucocorticoids wear protective gloves (vinyl), cool moist compress( topical steroids Epidermolysis bullosa congenital (autosomal dominant) Appearance genetic blistering disease Superficial blistering occurs in EPIDERMIS, so least severe Junctional- autosomal recessive. Blister forms at BASEMENT MEMBRANE zone. More serious form due to mucosal involvement. Dystrophic autosomal dominant and recessive. Blister forms in the UPPER DERMIS Erysipelas (type of cellulitis) General Superficial cellulitis caused by STREPTOCOCCUS PYOGENES Affected areas include face and lower extremities Clinical manifestations Sx: pain, malaise, chills and moderate fever. A bright red spot at first but then spreads to form a tense demarcated hot plaque. Spreads in hours to days Lesion can be edematous and can be pitted with finger Predisposing factors Open wound or penetrating trauma can infect area and Staphylococcus aureus infection can occur. In young children Hemophilus influenza may be the cause Treatment Bed rest and penicillin or erythromycin (antibiotic) Erythema infectiosum Causes Parvovirus B19 that infects erythroid precursor cells. Virus is widespread and transmitted via respiratory secretions and saliva, placenta and administration of blood products. Clinical manifestations (different in various populations) Children – “slapped cheek” appearance, maculopapular evanescent rash on the trunk and limbs Immunocompromised- transient aplastic crisis and pure red blood cell aplasia Adults- polyarthritis that mimics lupus erythematosus and rheumatoid arthritis involving the joints of the hands, knees and feet. Erythema migrans (Acute infection with LYME DISEASE) Appearance Expanding red rash with SHARPLY DEFINED BORDER (typically) central clearing Usually appears within 3-32 days after a tick bite Center of the rash is the site of inoculation Causitive agent Borrelia burgdorferi – spirochete that may later invade the joints, the central nervous system, or the conducting system of the heart Will have joint pain, fever, chills Erythema multiforme (least severe) Etiology PRECEEDING INFECTION VIRAL infections: herpes simplex, Epstein-Barr, coxsackie, varicella, HIV, Hep C, molluscum contagiosum virus BACTERIAL infections: particularly Mycoplasma pneumonia FUNGAL infection: Histoplasma capsulatum and Coccidiodies immitis MEDS: sulfonamides, penicillins, barbituates, NSAIDs VACCINES: Tetanus/diphtheria, Hep B Protozoan infections Radiation therapy Premenstrual hormone changes Sarcoidosis Pathophysiology Possible immunologically mediated lymphocytic reaction to infectious agent drug at dermal-epithelia junction Signs and symptoms “iris” lesions Can be purple Flat/raised a typical lesions, macules w/ or w/o bisters Poorly defined border Cyanotic center, Bright erythematous border Commonly occurs in mouth, involving skin and sometimes mucous membrane Symmetrically distributed ( palms, soles of feet, dorsum of hands, and extensor surface of extremities and face Lesions may coalesce and become generalized Treatment Treat underlying cause or disease agent Withdrawal of any drugs causing it Symptomatic treatment with oral antihistamines and topical corticosteroids for mild cases Erythema nodosum Appearance: Tender, red NODULAR rash on SHINS Clinical manifestations: Typically arises in conjunction with another illness a streptococcal, fungal, or tubercular infection bowel disease; occult cancer, sarcoidosis Biopsy ( inflammation of subcutaneous fat NEED to find underlying cause of rash (i.e. diagnose other illness Cause of some other disease….manifestation Folliculitis (inflammation of hair follicle by infection, chemical irritation, or physical injury) Organism Staph aureus (especially through nasal carriage) Pseudomonas aeruginosa (exposure to contaminated pools and hot-tubs) Candida folliculitis related to recent antibiotic or corticosteroid use Presentation Multiple small papules and pustules, with red base pierced by central hair Treatment Gram-stain to see which bacteria ( treat according to type of bacteria Furuncles and carbuncles Furuncles = boils Carbuncles = coalesced boils Organism Acute abscess of hair follicle because of bacterial infection (often Staph. Aureus) Presentation Painful erythematous papules/ nodules (1-5 cm) with central postulation Larger than folliculitis Located in areas prone to friction or minor trauma (e.g. underneath belt, anterior thighs, back of neck, buttocks May be singular or multiple No fever or systematic symptoms Treatment Suppression of pathogenic strain (if topical treatment fails) ( dicloxacillin/cloxacillin In general: if boil is well defined ( incise and drain pus Remove pus for antibiotics to penetrate Topical antibiotics Gonococcemia (Gonococcal arthritis) Appearance Erythematous macules, papules, pustules, or vesicles on reddened bases Hot joints, pustules ( for DISSEMINATED FORMS) Females primarily because men know about gonorrhea (drips) hemorrhagic pustules lesions in acral (pertaining to peripheral body parts) distribution that can involve palms and soles. Most common in young women during menses or pregnancy. FIND SEXUAL HISTORY Treatment: 3rd generation cephalosporin antibiotics (eg: ceftriaxone, cefotaxamine, ceftizoxime and synovial fluid drainage. Strong antibiotics Complete recovery is the rule. Herpes simplex Characteristics Initial infection that occurs in small children is called herpes gingivostomatitis. Herpes simplex presents as painful, red blisters or ulcers at site of contact contagious and may be spread to other people and/or to other body parts of the infected person. Types Type I: Primarily around mouth and will recur in that area, but may also appear in genital area. Used to be common on the finger until dentists and hygienists wore gloves. Pictures: Plate 18 & 19 CMDT, pg. 179 Bate’s. Treatments: Recurrent herpes labialis: symptomatic prescription only (Campho-Phenique gel) Primary herpes labialis: sympt. Rx only (Acyclovir, Valacyclovir, Famciclovir (severe)) Type II: Primarily occurs in genital areas and will recur there, but may also appear around mouth. Herpes simplex causes at least 95% of all erythema multiforme minor cases. UV light is most common flare factor for labial herpes simplex. Treatments: Recurrent genital herpes: Acyclovir Prophylaxis (try tapering off in 6-12mos) Or interventional prescription (treat each individual episode). prodome for 5 days. Primary genital herpes: Oral Acyclovir or other p.o. antivirals for 10 days Burows solution soaks/sitz baths. HSV in Immunosuppressed Patients: Acyclovir or other p.o. antivirals prescription. IV Acyclovir if severely immunosuppressed. Ophthalmic Herpes: Viroptic added to systemic regimen. Impetigo Etiology Staphlococcus or Streptococcus. Appearance Straw to honey-colored custs or fragile blisters and erosions (“bullous impetigo”). Common with fever Treatment: Macrolides, dicloxacillin, primarty cephalosporin; mupirocin in mild cases. Penicillin Herpes zoster (aka shingles) Etiology varicella zoster (chicken pox virus). Recurrent infection occurring along dermatomes (trigeminal nerve most common. T4-T6 also common). Characteristics Initial symptoms: headache, fever, malaise, then burning pain, itching, oversensitivity, “pins and needles” tingling, and numbness People > 55 years old Presents as a painful skin rash with blisters, often in a stripe in a limited aread on one side of the body. Later becomes vesicular, forming small blisters & eventually become cloudy/darkened (fill w/ blood) crust over, and then fall off Differencial Dx Distinguished from herpes simplex by clinical appearance or may get a Tzank smear or culture. Individuals over age 55 have significant risk of developing post-herpetic neuralgia (pain, altered sensation in affected area, muscle weakness, and/or tremors). Treatments: Young, healthy patient: symptomatic prescription Prednisone Healthy, elderly patient in severe pain: Acyclovir, Valacyclovir/famciclovir (prevent post-herpetic neuralgia; of questionable benefit) Immunosuppressed patient: Acyclovir p.o. Severely Immunosuppressed: high dose IV Acyclovir. Ophthalmic Zoster: Viroptic Post-Herpetic Neuralgia: Zosterix topically or Elavil (25mg TID) ± Prolixin (1mg TID) Special circumstances (newborns, immunodeficiencies): zoster immune globulin. Kaposi's sarcoma (malignant skin lesion) Appearance presents as purple plaques or nodules on cutaneous or mucosal surfaces. Commonly involves the GI tract. Associated Diseases Associated with AIDS and HIV (secondary to HIV infections). Human herpes virus 8 or Kaposi sarcoma-associated herpes virus resent in all forms of Kaposi sarcoma. Treatment: Anti-HIV antiretrovirals: < immunosuppressive medications (w/ AIDS/HIV related Kaposi sarcoma), Cryotherapy Chemotherapy or radiation, laser surgery, systemic therapy, liposomal doxorubicin, or paclitaxel. Lichen planus Lichen planus: 7 Ps: Purple, Polygonal, Planar, Papules, Pruritic, Peripheral (distribution), Penile (distribution). Koebner’s phenomenon: trauma can induce lesions usually seen along linear scratch marks. Often seen on flexor surfaces and on the trunk. White, reticulated oral mucosa leukoplakia is diagnostic. May occur in mouth alone and lead to an ulcerative gingivostomatitis. Idiopathic disease that is often self-limited (70% resolve spontaneously in 15 months). Some meds can cause lichen planus-like (“lichenoid”) drug eruptions. Treatment: topical corticosteroids, antipruritics, rarely systemic prescriptions. “Lichenified” – skin is thickened and itches. Picture: Plate 40 CMDT Lichen simplex chronicus Lichen simplex chronicus: a.k.a. Circumscribed Neurodermatitis. Thick, pruritic, lichenified plaque often on ankles, nape of neck, perineum, and groin but may occur anywhere. Rectangular, thickened, hyperpigmented patchese. Is self-perpetuating by an itch-scratch cycle that is difficult to disrupt. Treatment: Topical steroids, topical and systemic antipruritics (eg: menthol lotions, antihistamines), topical tar medications, mild soaps, emollients. Picture: plate 7 CMDT Malignant melanoma Malignant melanoma: Leading cause of death due to skin disease. Pigmented lesions with irregular notched borders where pigment appears to be leaking into the normal surrounding skin. Lesions may be flat or raised. Be suspicious of moles that change in appearance, bleed, ulcerate, or stand out from the patient’s other moles. Tumor thickness/depth is the single most important prognostic factor. Probably relationship to recurrent sunburn history. May be amelanotic. Treatment: Excision. Pictures: pg. 186 Bate’s. ABCDE, E=evolution or elevation Meningococcemia Meningococcemia: Caused by Neisseria meningitides. Presents with a prodome of an upper respiratory infection followed by fever, chills, arthralgias, vomiting, and headache. Cutaneous lesions are initially macular erythema (maculopapules) with central petechiae. Later they become purpuritic. Lesions may be very angulated (stellate purpura) gunmetal gray and star shaped. Often on trunk, lower extremities, and areas of pressure (eg: waistline). Diagnosis confirmed by spinal fluid or blood culture. Pictures: Slides 5-7 of Dermatologic Emergencies powerpoint. DO antibiotics FIRST before anything!!!!!!!!! Molluscum contagiosum Molluscum contagiosum: Caused by a poxvirus, the largest virus known to man. Presents as single or multiple dome-shaped or brick-shaped waxy papules, 2-5mm in diameter that are umbilicated. Lesions are initially firm, solid, flesh-colored, then become soft, whitish, or pearly gray and may suppurate. Seen on face, lower abdomen, and genitals. Lesions spread by wet skin-to-skin contact, including sexually transmitted. May be on genitals and pubic region in sexually active patients. Common in patients with AIDS. Individuals with atopic dermatitis may experience extensive involvement, particularly if they have been treated with topical steroids. HPV infections may be more difficult to manage and may spread quickly. Picture: Plate 36 CMDT Treatment: Curretage or application of liquid nitrogen. Necrotizing fasciitis SEVERE TYPE OF CELLULITIS Appearance rapidly spreading infection involving the fascia of deep muscle. At presentation, may be severe cellulites, but the presence of systemic toxicity and severe pain, Clinical Manifestations anesthesia of the involved area because the nerve endings are destroyed as the infection advances. Associated Diseases Streptococcal Toxic Shock Syndrome (STSS) invasion of skin and soft tissue Risk factors: old and young patients with underlying medical condition. Bacteremia occurs in most cases and the mortality rate is roughly 8-%. acute respiratory distress syndrome kidney failure. Bacteria such as Group A Streptococcal Infection can cause Necrotizing fasciitis. bacteria release toxins which destroy the surrounding tissue. Treatment: Surgical exploration is mandatory when the diagnosis is suspected. Removal of the infected and dead tissue is necessary. Early and extensive debridement is essential for survival. Intravenous antibiotics are also begun. Pemphigus (vulgaris)BAGGY FLACCID BLISTERS PRIMARLY IN ORAL MUCOSA, NIKOLSKY SIGN , Row of tombstones seen on IgG immunofluroescense, same for Bullous pemphigoid Pemphigus (vulgaris): From the notes: Autoimmune blistering disease where an IgG develops against the desmosomes that hold the epidermal cells together. Develops in young adults. Oral mucosa is usually involved, widespread blisters and erosions. Nikolsky is positive. Prednisone is the treatment of choice. Additional information from CMDT: Uncommon intraepidermal blistering disease occurring on the skin and mucous membranes. It is an autoimmune disease that is idiopathic. Onset is usually in middle age. Pemphigus may be drug induced from penicilamine, captopril, and others. Appearance: Flaccid blisters easily ruptured ( multiple erosions and crusted plaques. The “Nikolsky’s sign” epidermis separates w/ pressure. Associated symptoms: Begins on mucosal surfaces ( mucocutaneous. -Mouth, scalp, face, neck, axilla, groin, and trunk -Severe skin pain, some pruritis Diagnosis: Relapsing crops of bullae. Often preceded by mucous membrane bullae, erosions, and ulcerations. Superficial detachment of the skin after pressure or trauma variably present (Nikolsky sign). Lesions often appear first on the oral mucous membrane and rapidly become erosive. Acantholysis on biopsy. Immunoflurescence studies are confirmatory. ELISA assays can detect autoantibodies to intercellular adhesion molecules. Complications: Secondary infection commonly occurs and is a major cuase of morbidity and mortality. Also, a disturbance in fluid, electrolyte, and nutritional intake ca occur as a result of painful oral ulcers. Pityriasis rosea – SUNLIGHT HELPS!! (PSORIASIS TOO) Pityriasis rosea: A common mild, acute inflammatory disease that is 50% more common in females. Young adults are principally affected, mostly in the spring and fall. (Pityriasis means scaling) Papulosquamous , occurs in winter months. Herald patch to Christmas tree. From notes: often begins with a “herald patch” (2-6cm annular lesion) which can mimic a dermatophyte infection multiple oval erythematous lesions with a “collarette” of scale lesions occur most commonly on trunk and proximal extremities usually asymptomatic but may itch occurs in “epidemics” usually in cool/cold months (infectious etiology ?? -- however, not generally contagious amongst family members) 20% of cases begin with prodrome of low-grade fever, malaise, adenopathy usually lasts 1 - 3 months and then clears can be confused with syphilis (check RPR, VDRL ?) Rx = topical or systemic corticosteroids, ultraviolet light (UVB), antipruritics Diagnosis: KOH prep may show branching hyphae, culture helpful. Porphyria cutanea tarda (THIS AND LUPUS ARE PHOTOSENSITIVE) Dorsal parts of hands and forearms, associated with certain meds ( like alcohol and birth control), sun sensitive Porphyria cutanea tarda: Noninflammatory, painless blisters on sun-exposed sites, especially the dorsal surface of the hands. Patients experience hypertrichosis, skin fragility. Cases are sporadic and hereditary. The disease is associated with ingestion of certain medications (e.g., estrogens), and liver disease from alcoholism or hepatitis C. This is an endogenous defect in some metabolic pathways gives rise to photosensitivity. This disease represents a defect in an enzyme (Uroporphyrinogen decarboxylase) critical in the heme metabolic pathway. This leads to an accumulation of precursor products that absorb light and induce free radicals. Clinically the disease presents with blisters, milia and skin fragility on the backs of the hands and forearms. There is often hyperpigmentation and hypertrichosis. The diagnosis is made by clinical suspicion and a 24-hour collection of urine for a porphyrin profile. Treatment: Stop all triggering medications and/or stop alcohol use. Very low dose of antimalarials (such as Hydroxychloroquine), alone or in combination with phlebotomy (without oral iron supplementation) will increase excretion of porphyrins, improving the skin disease. Psoriasis Psoriasis: A disorder of epidermal proliferation. Psoriasis is a common benign, chronic inflammatory skin disease with a genetic basis. AUSPITZ PHENOMENON Well-demarcated erythematous scaly plaques; elbows, knees, scalp, gluteal cleft frequently involved. Treatment Topicals: 1. Initial=topical steroid ointment BID-TID/Tar shampoo/sunlight 2. If required, add Tar qhs (Estar gel, Aquatar gel, Balnetar bath, etc.) 3. Dovonex - Vitamin D analog - Expensive! 4. Tazarofene (Tazorac®) – expensive: Pregnancy category X. Oral Agents: 1. Soriatane® 2. MTX 3. Biologics/Others Rocky mountain spotted fever Rocky Mountain Spotted Fever: Rocky Mountain spotted fever (RMSF) is the most severe tick-borne rickettsial illness in the United States. This disease is caused by infection with the bacterial organism Rickettsia rickettsii. Despite its name, most case of RMSF occur outside the Rocky Mountain area. Over half of the cases are in NC, SC, TN, OK, and AR. Symptoms: An influenza-like prodrome followed by chills, fever, severe headache, myalgias, restlessness, and prostration; occasionally, delirium and coma. Red macular rash appears between the second and sixth days of fever, first on the wrists and ankles and then spreading centrally; it may become petechial (a small red or purple spot on the body, caused by a minor hemorrhage). Serial serologic examinations by indirect fluorescent antibody (IFA) confirms the diagnosis retrospectively. Treatment: Deoxycycline or chloramphenicol (in pregnant women) EMBED PowerPoint.Slide.8 SHAPE \* MERGEFORMAT SHAPE \* MERGEFORMAT Rosacea – MAINLY CENTRAL FACE, ON NOSE Rosacea: A chronic facial disorder. A neurovascular component (erythema and telangiectasis and a tendency to flush easily). An acneiform component (papules and pustules) may also be present. A glandular component accompanied by hyperplasia of the soft tissue of the nose. Topical corticosteroids applied to the lower face can induce Rosacea-like conditions. Appearance: Erythema, telangiectases, superficial pustules; predominantly on central face Epidemiology: Caucasians of northern European background -Pts w/ dark skin -Mainly adults, >30 -More common in women, more severe in men Associated symptoms: Facial flushing in response to heat, emotional stimuli, alcohol, hot drinks, or spicy foods -Complicated by inflammatory disorders of eye Treatment: Patients should wear sunscreen. Metronidazole is topical treatment of choice (an antibiotic that happens to also be anti-inflammatory). Tetracycline bid should be used when topical therapy is inadequate (for acne portion) Sarcoidosis (THE GREAT PRETENDER – LOOKS LIKE A LOT, COMMON IN YOUNG AA WOMEN) Sarcoidosis: (Non-caseating granulomas) Multisystem granulomatous disease that can involve any organ system Epidemiology Common in southeastern US Women > men 3:1 More common in Blacks May appear on the skin in various forms Typical skin manifestation is translucent papules around nose and mouth Evaluation includes skin biopsy, chest x-ray, ACE level, and Ca++ level Treatment with systemic steroids Papules often seen on edge of nose. SHAPE \* MERGEFORMAT SHAPE \* MERGEFORMAT SHAPE \* MERGEFORMAT Scabies – KWELL USED Scabies: Caused by an infection of S. scabiei. It usually spares the head and neck (although even these areas may be involved in infants, elderly, and AIDS patients). Infection is from contact of an infected person (including bedding). Appearance: Intensely itchy rash w/ burrows -Localized to hands and wrists Diagnosis: Look for burrows, CAN DO INK TEST, WILL SEEP DOWN INTO BURROW KOH to rule out fungal Treament: Elemite or Kwell -Wash everything in hot water, if not washable then seal in plastic bag for 1 week, HAPPENS IN HANDS AND WRISTS FIRST SHAPE \* MERGEFORMAT SHAPE \* MERGEFORMAT SHAPE \* MERGEFORMAT SHAPE \* MERGEFORMAT Seborrheic dermatitis – CRADLE CAP IN BABIES Seborrheic dermatitis- Erythematous scaly patches on scalp, face, ears, and less commonly on central chest, axillae, groin. Usually asymptomatic but may itch Associated with “oily skin” and may be due to overgrowth of Pityrosporum yeast which thrive on sebum The most common cutaneous manifestation of HIV infection Treatment- topical corticosteroids; topical ketaconazole or econazole; shampoos with tar, selenium, salicylic acid, zinc, or ketaconazole, WITH CHILDREN, BRUSH OFF AND WASH HAIR Common Office Dermatology Handout; CMDT pg 106, CMDT Plate 12 Sporotrichosis Most common form begins with a hard, nontender nodule that later develops with lymphatics. Caused by Sporothrix schenckii; fungal infection. Usually primary inoculation (e.g., Thorn injury) with lymphatic spread Diagnosis - biopsy for stain/culture Typically affects immunocompromised individuals; especially with AIDS or alcoholism. Treatment: Itraconazole 200-400 mg daily for several months. Cutaneous Infections Handout; CMDT pg 1399 Squamous cell carcinoma Usually pink, pinkish/red papule with overlying keratinous scale. Usually related to chronic sun exposure. Hallmark sign is a nonhealing ulcer or warty nodule. Treatment: excision, electrodessication/curettage, Moh's surgery Common Office Dermatology Handout; CMDT pg 134 Stevens Johnson syndrome Type of erythema multiform; drug reaction. New identification as was once called "Erythema Multiform Major" May be macular, papular, urticarial, bullous, or purpuric. Reaction where target lesions develop on skin and mucosa from an adverse response to medication; especially the oral mucosa. Adverse reaction to Dilantin for SJ Treatment is a bit conflicting, recent research suggests corticosteroids are primary treatment option. Topical therapy is not very effective. Plate 31 CMDT; CMDT pg. 127; Drug Eruptions Handout Tinea infections Tinea infections- Ring shaped lesions with advancing border/central clearing or scaly patches with distinct border. TRYCHOPHYTON RUBRUM (Most common fungus involved!!!!)RING SHAPED, USE Microscopic scrapings/KOH confirm Dx. Long hyphae, no spores on KOH. Associated with infected cat on occasion, itching may also be associated. Tinea pedis (feet), cruris (groin), corporis (body), manuum (hand)--treat with topical antidermatophyte (see chart) unless severe (where oral agent used). Treatment = continue for 3-4 weeks after rash clinically clear. GRISEOFULVIN – USE FOR TINEA CAPITIS – ORAL ANTIFUNGAL KNOW THIS!!!!!!!!!!!!!!!! CMDT pg. 107; Cutaneous Infections Handout Tinea versicolor TSHIRT SHAPED!!! CAUSED BY PITYROSPORUM Velvety, tan, or pink/white macules that do not tan. Fine scales that aren't visible but exposed once lesion is scraped. Central upper trunk most common site. "Spaghetti and meatballs" on KOH. Yeast and short hyphae on KOH. Treatment: 1.Selsun or Excel 2.5% suspension overnight to area of rash once weekly x 4-6 wks. Then use 1% Selenium shampoo (Selsun Blue) to wash and shampoo QD to help prevent recurrence. 2.Topical anti-TV agents (imidazoles usually used)--expensive unless localized area. Terbinafine (Lamisil®) spray. 3.Ketoconazole 200 mg PO (qd-bid) x 2-7 days. CMDT pg 109; Cutaneous Infections Handout Toxic epidermal necrolysis – FIRST HAS TARGET MORPHOLOGY AND THEN FULL FIELD NECROSIS Type of erythema multiform; drug reaction. (TEN) - severe mucosal involvement with areas of full field necrosis of the epidermis. Characterized by > 30% BSA (body surface area) skin loss Adverse reaction to drug Phenobarbital. Treatment: referred to burn unit. Raised purpuric target-like lesions, central blistering, two zones of color change. CMDT pg 127; Drug Eruptions Handout Urticaria eruptions of wheals or hives Raised, itchy and evanescent (comes and goes over 24 hour period) Adverse reaction to penicillin Treatment: regiment of antihistamines. Drug Eruptions Handout; CMDT pg 125; CMDT Plate 30 Venous stasis ulcers – CHRONIC EDEMA, THEN DERMATITIS, THEN ULCERS associated with past history of varicosities, irregular ulceration of medial lower leg, edema of the legs Chronic edema followed by dermatitis. Compression stockings used to reduce edema are best prevention. Treatment: locally cleaning and replacing dressings, metronidazole gel. Pentoxifylline 400 mg 3x daily for systemic treatment. CAN PREVENT WITH PRESSURE STOCKINGS CMDT pg 143; CMDT Plate 45 Warts –PLANTAR WARTS GROW INTO THE SKIN, CAN SEE BLACK DOTS (SEEDS) . Warts- verrucous papules on skin/mucous membranes, usually no larger than 1cm. Prolonged incubation period (2-18 months) with about 50% having spontaneous cures (~2 years for common warts) Caused by human papillomaviruses; HPV. VERRUCAS ARE EXTERNAL WARTS Usually asymptomatic, tenderness occurs with plantar warts and itching occurs with anogenital warts. Prevention is available in form of vaccine for teenage and young adult women. Various wart removal techniques (liquid nitrogen, laser therapy, operative removal, keratolytic agents/occlusion) Plantar warts No Rx. 40% salicylic acid plasters (Mediplast). Bleomycin intralesional 1 mg/cc (experimental at this time). Laser. Filiform warts, flat warts, common warts No Rx. Cryosurgery. Electrosurgery. Chemical Rx = (Compound-W, Duofilm, Viranol, Occlusol, etc.). Cantharidin - Has been taken off the market by FDA. Intralesional Bleomycin (experimental). Laser. Condyloma acuminata Moist warts (e.g. vagina, rectum); Rx = podophyllin 20-50% or surgical ablation; Aldara®. Dry warts - (e.g. penile shaft) - cryosurgery; condylox® for home Rx. Common Office Dermatology Handout, CMDT pg 131; CMDT Plate 35 STRAWBERRY HEMANGIOMAS – BIRTH MARKS – VERY RED BUT EVENTUALLY GO AWAY. RAISED RED AND BUMPY, DILATED BLOOD VESSELS PYRODERMA GANGRIOSUM – COMMON WITH RHEUMATOID ARTHRITIS. An ulcer with distinct purple border, commonly on shins. REMEMBER PURPLE BORDER AROUND JUICY ULCER VASCULITIS – PALPABLE PURPURA, ACUTE INFFLAMMATION OF POST CAPILLARY VENULES IN THE SKIN.