Derm

Front 1

- Drug eruption; Lupus erythematosus; Pityriasis rosea; Seborrheic dermatitis; Syphilis (secondary); Vitiligo

Back 1

Macules

Front 2

- Atopic dermatitis; Drug eruption; Erythema multiforme; Lichen planus; Lupus erthematosus; Psoriasis; Secondary syphilis

Back 2

Papules

Front 3

- Drug eruption

Back 3

Scales

Front 4

- Insect bites; Urticaria

Back 4

Wheals

Front 5

- Bullous pemphigoid; Drug eruption; Eczematous dermatitis, atopic; Eczematous dermatitis, contact; Erythema multiforme; Herpes simplex; Herpes zoster; Scabies

Back 5

Vesicules and Bullae

Front 6

- Drug eruption; psoriasis syndrome

Back 6

Pustules

Front 7

- Atopic dermatitis

Back 7

Lichenification

Front 8

Description: Most common skin cancer. Slow growing, superficial eroding ulcer that derives from & resembles epidermal basal cells.

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BCC

Front 9

S/sx: Begins as shiny papule &, after a few years, shows a shiny, pearly papule with telangiectasia & central ulceration. Recurrent crusting & bleeding is not unusual. It is common for lesions to crust & heal, lowering the doctor’s & patient’s level of concern. It is well vascularized & bleeds, never remits. Develops a rodent ulcer – years of intermittent crusting & healing – center of necrosis with crusty border that eventually collapses.
Dx: Use ABCDEs, history.

Back 9

BCC

Front 10

Description: Second most common on sun-exposed areas, may look like a red papule, plaque, scaly surface.

Back 10

SCC

Front 11

S/sx: Clinical appearance is variable. May begin as red papule or plaque with a scaly, crusted surface & may become nodular, sometimes with a warty surface. The bulk of the lesion may lie below the surrounding skin. Resembles eczema, contact dermatitis. Often affects head & ears.
Tx: Mohs’ surgery – microscopic controlled excision of tissue

Back 11

SCC

Front 12

Description A multicentric, vascular neoplasm caused by HSV type 8 that has three forms: a. Indolent; b. Lymphadenopathic; c. AIDS-related. Kaposi's sarcoma is a cancer that causes patches of abnormal tissue to grow under the skin, in the lining of the mouth, nose, and throat or in other organs.

Back 12

Kaposi’s Sarcoma

Front 13

S/sx: Patches, barely elevated, usually erythematous/violaceous, made of neoplastic cells and blood cells. First usually appearing on trunk and mucosa. Often no symptoms. Mb painful. Mb lymphedema.
Dx: Biopsy. CXR. Endoscopy. Bronchoscopy. (d/t visceral locations and internal bleeding).
Progression: If the cancer spreads to the digestive tract or lungs, bleeding can result. Lung tumors can make breathing hard.

Back 13

Kaposi’s Sarcoma

Front 14

Tx: Depends on location and progression of the lesions. Tx for AIDS virus itself can reduce the lesions. Indolent superficial txd c cryotherapy, electrocoagulation or electron beam radiation. Tx usually a combination of: surgery, chemotherapy (etoposide, vincristine, vinblastine, bleomycin, doxyrubicin), radiation (x-ray therapy), or biological therapy. HIV tx drugs: (not on blue print)

Back 14

Kaposi’s Sarcoma

Front 15

Description: Soft, moveable, subcutaneous nodules with normal overlying skin. Soft fatty tumor not visible on skin, not usually painful unless impinging on a nerve. Feel firm, rubbery, non-tender, occurring in flank, SI area. Can become large, often affecting women.
S/sx: (above)
Dx: Clinically. Biopsy if size increases.

Back 15

Lipoma

Front 16

Description: A malignant melanocytic tumor arising in a pigmented area, such as skin, mucus membranes, eyeballs, fingernails, palms of hands, CNS. Doesn’t need to be deep before it metastasizes – less than 2 mm. If in doubt, biopsy. 40-50% develop from pigmented moles.

Back 16

Melanoma

Front 17

Description Superficial or deep bacterial infection & inflammation of the hair follicles, usually 2ndary to S. aureus (P. aeuruginosa in hot tub = hot tub folliculitis).
S/sx Can be recurrent. Waxy & shiny. Pustule or nodule. May become chronic when numerous/deep.
Tx: If acute tx systemically with oral antibiotics; topical is adjunctive.

Back 17

Folliculitis

Front 18

Description Acute, tender perifollicular inflammatory nodules d/t staph infections. Often occur in healthy young persons. Cluster cases may occur among teenagers in crowded quarters with poor hygiene.
S/sx Usually on neck, breasts, face, buttocks. Most painful on skin closely attached to underlying structures – nose, ears, fingers. Initial nodule becomes a 5-30 mm pustule that discharges a core of necrotic tissue & sanguineous pus. Rotting by-product & bloody pus that does not smell good. May recur.
Tx: I&D or prescription soap. Intermittent hot compress if single. On nose or face, on immune-compromised pt, or pt with multiple, culture & tx with non PCN antibx (celphalosporin, e.g.). Continuous Abx if recurrent. Consider Echinacea d/t antimicrobial & affinity for skin, Arctium lappa, Calendula (boils)

Back 18

Furuncles (boils)

Front 19

Description Subcutaneous spread of staph, resulting in deep suppuration, extensive sloughing, slow healing, scarring. More common in males.
S/sx Furuncles often found on nape of neck. Pt mb healthy, but have DM. Old age, chronic disease, immune suppression predispose. Mb accompanied by fever & prostration. Carbuncles go deeper than furuncles & can scar. Will cluster & suppurate. Slow healing.
Tx: Same as furuncles. Graphites (neck, suppurates), Nat Mur (neck), Hepar sulph (fetid); Arctium Lappa (boils)

Back 19

Carbuncles - A cluster of furuncles (boils) with SQ spread of staph infxn.

Front 20

Superficial vesciculopustular skin infxn
Description Usually staph, sometimes strep. Most common in children ages 2-6yoa at arms, legs, & face. Enters skin through cut or abrasion; contagious; mb 2nd to HSV or HZV. Bullous.
Tx: Mupirocin ointment TID; if no response in three days, tx systemically. Homeopathic: AntCrudum (corners of mouth; thickening crusts), Graphites (Thick crusts with honey discharge), Mercurious (Scalp, red, inflamed), Sulphur (itches & burns, moist, oily skin, worse night), Cal Carb (recurring in children).

Back 20

Impetigo –

Front 21

Description Diffuse, spreading acute inflammation within solid tissues. No cellular necrosis or suppuration. Strep pyogenes (Group A beta hemolytic strep) is the most common cause of superficial cellulitis.
S/sx Infection is most common in the lower extremities. Cutaneous abnormality often precedes the infection. Presents with local erythema & tenderness, often with lymphangitis & regional lymphadenopathy.
Tx: Mild cellulitis tx as outpt with regimen of oral Abx. Re-evaluate at 24-48 hrs. If not improved, consider hospital admission.

Back 21

Cellulitis

Front 22

Description: Severe infections, typically from a mixture of aerobic & anaerobic organisms that cause necrosis of subcutaneous tissue, usually included in the fascia.
Etiology: Flesh-eating bacteria. Extend to subcutaneous tissue from an infection or trauma. Extremities are the most common sites, perineum the second most common site. Fournier’s disease when male genitalia involved. Patients with diabetes mellitus may be predisposed.
S/sx: Very painful. Gross findings are edema & necrosis of subcutaneous tissue. Skin red, hot, swollen with progression. Violaceous discoloration, bullae, crepitus & dermal gangrene may occur. Positive for fever, with systemic toxicity, tachycardia, altered mental status, hypotension. Mortality about 30%.

Back 22

Necrotizing fasciitis

Front 23

Description caused by the bacterium Borrelia burgdorferi, & is transmitted to humans by the bite of infected blacklegged ticks (Vector-borne).
S/sx Typical symptoms include fever, headache, fatigue, & the characteristic skin rash called erythema migrans. If left untreated, infection can spread to joints, the heart, & the nervous system.
Tx: Most cases of Lyme disease can be treated successfully with a few weeks of antibiotics. Abx: Amoxicillin, Doxycycline, Azithromycin

Back 23

Lyme Disease

Front 24

Acute, self-limiting intraepidermal vesicular eruptions caused by HSV1 (usually oral) or HSV2 (usually genital) with recurrent attacks. Eruptions usually recurrent at same location; often preceded by a prodrome. Lesions are grouped vesicles on erythematous bases. Vesicles quickly become pustules that rupture, weep, & crust. The skin may result with punched-out ulcerations. DDX: impetigo (gram stain, no prodrome, not recurrent same location); contact dermatitis (hx, allergen test), fungal infxn (KOH).

Back 24

Herpes Simplex:

Front 25

intraepidermal vesicular eruption occurring in a dermatomal distribution due to reappearance of latent Varicella-zoster virus in patients who have had Varicella. Zoster also has a prodrome that may simulate a migraine, pleurisy, myocardial infarction or appendicitis. The eruption is characterized by groups of vesicles on an erythematous base situated unilaterally along the distribution of a cranial or spinal nerve. DDX includes HSV which may also in a dermatomal fashion

Back 25

Herpes Zoster/(”shingles”):

Front 26

Tx:
High lysine, low arginine foods
Vitamin C, Zinc, B6
Lysine, 500mg qd preventative; 1200mg qd for outbreaks
Anti-viral herbs: Glycyrrhiza, Melissa, SJW (shingles and neuralgia)
Acyclovir, vancyclovir, famcyclovir
Herpes zoster: Think IM B12.

Back 26

Herpes Simplex & H. Zoster, 2

Front 27

Description A poxvirus infection characterized by skin-colored, smooth, waxy umbilicated papules 2-10 mm in diameter.
Etiology Transmission is often venereal.
S/sx Lesions are usually asymptomatic. It is a self-limited epidermal viral infection, characterized by skin-colored papules. Discrete, solid skin-colored papules 1-2 mm in diameter, central umbilication. In healthy individuals, they resolve spontaneously.
Tx: Usually resolves in 6-9 months without tx. Consider herbs: Echinacea, Allium sativum, Melissa off., Glycyrrhiza. Podophyllotoxin 0.5% cream applied bid. Cryotherapy, electrodessication.

Back 27

Molluscum Contagiosum

Front 28

Description A highly transmittable ectoparasitic infection, characterized by superficial burrows, intense pruritis, & secondary infection.
Etiology Caused by Sarcoptes scabiei. Easily transmitted via skin-to-skin contact.

Back 28

Scabies (the itch) = mites

Front 29

Description Infestation by lice, which can involve the head, Pediculosis humanus capitis), the body (Pediculosis humaus corporis), or genitalia, (Phthirus pubis).
S/sx Head & pubic lice live on the host while body lice live in garments. Body lice are important vectors of organisms that cause epidemic typhus, trench fever, & relapsing fever. Itching may persist 1-2 wks post tx.

Back 29

Pediculosis

Front 30

Tx: Conventional: Permethrin cream 5% (Elimite) if > 2mo. Watch for 2ndary infection. Provide symptom relief: antihistamine (e.g.: diphenhydramine hydrochloride). Tx household members and close personal contacts. Provide reassurance. Mb tea tree oil.

Back 30

Scabies & Lice Tx

Front 31

Description an asymptomatic, idiopathic, hypopigmentary condition that most commonly affects dark skinned children (3-16 yo) presenting early on with mildly erythematous, slightly scaling patches with indistinct margins followed by a 1-4 cm white patch with a fine powdery (pityron/”bran-like) scale most common located on the face (children) or upper arms (young women).
Etiology Inability of cells of epidermis to contain water – so leaky force kills melanocytes. More common in young African-American women.
S/Sxs Mildly pruritic scale.
DDX: T. versicolor (+KOH, Woods light), vitiligo (sharp demarcation, complete depigmentation, no scale).

Tx: 1% hydrocortisone for inflammation. Consider skin restorative nutrients (omega 3s, Vit A and C, Zinc). UVB. Consider anti-fungal herbs: Achillea millefolium etc.

Back 31

Pityriasis alba

Front 32

Description A recurrent pruritic inflammatory eruption characterized by small, discreet polygonal flat-topped violaceous papules that may coalesce into rough scaly patches often accompanied by oral lesions.
Etiology Cause is unknown.
S/sx 4 P’s – pink, polygonal, pruritic, papules that coalesce. Onset may be acute, gradual. First attack persists for weeks, months. Lesions usually symmetrically distributed on flexor surfaces of wrists, legs, trunk, glans penis, & oral/vaginal mucosa. Lesions may become large, scaly, & verrucous. Lichen planus is self-limiting, often seen in immune suppressed.
DDX Carcinoma, candidiasis, aphthous ulcers, chronic erythema multiforme.

Tx: Tetracycline; topical corticosteroids (hydrocortisone, Triamcinolone). Topical retinoic acid; Vit A, D, and beta-carotenes; omega 3/fish oils; Glycyrrhiza; Hydrastis and other berberines

Back 32

Lichen Planus

Front 33

Description A mild inflammatory skin disease of unknown cause characterized by scaly lesions & a self-limited course. Most common in young adults.
S/sx/course A herald patch, usually on trunk, precedes the generalized eruption by 5-10 days. A single patch develops, then 1 or 2 weeks later there is a generalized secondary eruption in a typical distribution pattern. It is self-limiting, remitting spontaneously within 6 weeks without therapy. May be a herpes virus.

Tx: Possible benadryl. Due to possible viral initiated skin cx. Consider anti-viral herbs.

Back 33

Pityriasis rosea

Front 34

Description An inflammatory scaling disease of the scalp, face & occasionally other areas.
Etiology The inflammatory reaction is to Pityrosporum yeasts & the products that break down oil. Results in cradle cap.
S/sx Occurs with redness & scaling in regions where the sebaceous glands are most active, such as the face & scalp, presternal area & body folds. Seborrheic dermatitis of the scalp causes flaking, i.e., dandruff. Symptoms develop gradually. Dermatitis presents as dry, greasy, diffuse scaling of the scalp with variable pruritis. More severe disease manifests yellow-red scaling papules along the hairline, behind the ears, in the external auditory canal, eyebrows, bridge of nose, nasolabial folds, over sternum. Can inflame & alternate with dry scaly form. Usually worse in winter, with stress, & with neurologic disease.

Tx: Mb d/t defects in metabolism in VitB6 and long-chain f.a. Pyridoxine gel, topical. Selenium sulfide shampoo 2.5%. VitD3 cream. Skin nutrients.

Back 34

Seborrheic dermatitis

Front 35

ACTINIC KERATOSIS/solar/senile keratosis: a precancerous neoplasm confined to the epidermis caused by UV light presenting as ROUGH, SCALING PATCHES OR PAPULES. DDX includes: Seborrheic keratosis (well demarcated, “pasted-on”); In situ SCC/Bowen’s disease (larger plaque with poorly defined margins, BX); SCC (BX); Superficial Basal Cell Carcinoma (red, slightly scaling, well-demarcated eczematous-appearing patch which may become centrally eroded & crusted, BX).
This is a preCA SQUAMOUS cell CA….
Same tx protocol as for SCC.

Back 35

Actinic keratosis

Front 36

Description A chronic inflammatory disorder, usually beginning in middle age or later.
Etiology Cause unknown; distribution most common in fair complexioned individuals
S/sx Telangiectasia, erythema, papules, pustules primarily in the central area of the face, rarely on the trunk & extremities. Tissue hypertrophy (esp. of the nose = rhinophyma) may result.

Back 36

Rosacea

Front 37

local wheals & erythema in the superficial dermis.

– pruritis is followed by wheals that may remain small (1 to 2 centimeters) or enlarge. Large wheals may be clear in the center. Crops appear & subside over a period of hours. Can reappear in another site. If chronic, underlying chronic disease should be ruled out.

Back 37

Urticaria –

Front 38

– a deeper swelling due to edematous areas in the deep dermis & subcutaneous tissue; may also involve mucus membranes

– more diffuse & painful swelling of loose subcutaneous tissue, especially of the dorsum of hands & feet, eyelids, lips, genitalia, & mucus membranes. Edema of upper airways can cause respiratory distress with stridor (mimics asthma).

Back 38

Angioedema

Front 39

Description A chronic, pruritic, bullous eruption usually in the elderly. Considered autoimmune. IgG autoantibodies bind to the skin basement membrane. This activates complement and inflammatory mediators, and thus attracts inflammatory cells to the basement membrane. These inflammatory cells are postulated to release proteases, which degrade hemidesmosomal proteins and lead to blister formation. Eosinophils are present, although their presence is not an absolute diagnostic criterion.
Progression A chronic inflammatory disease. If untreated, can persist for months or years, with periods of remissions/ exacerbations. Remits usually within 1.5-5 years. Patients with aggressive or widespread disease, those requiring high doses of corticosteroids and immunosuppressive agents, and those with underlying medical problems have increased morbidity and risk of death. Average age at onset - 65 years,

Tx: Oral prednisone. May need tetracycline and nicotinamide. Rolled oats in bath (anti-pruritic), Stellaria media

Back 39

Bullous Pemphigoid

Front 40

Acute or chronic inflammation, often asymmetric or oddly shaped, produced by substances contacting the skin & causing toxic or allergic reactions.
Etiology Caused by a primary chemical irritant or an allergen (Type IV delayed hypersensitivity reaction)
Two Types of Irritation:
1.Primary irritants – dermatitis can appear in minutes to days, depending on the nature of the irritant. Mechanism of injury to the skin differs according to the agent.
2.Allergic contacts – allergy can develop at any time to previously benign substances & drugs. Topical drugs are a MAJOR cause of allergic contact dermatitis. Some substances require exposure to sunlight to initiate a toxic reaction, i.e., perfumes, coal tar, psoralens, oils.
S/sx Pruritis, bullae, vesiculation. Lesions usually limited to area of contact.
DDX Typical skin changes & history of exposure. Site of the initial lesion is an important clue.

Tx: Watch for secondary infection. Prednisone, bethamethasone dipropionate, benadryl, zyrtec, etc. Querc

Back 40

Contact Dermatitis

Front 41

Description A common, recurrent disease characterized by dry,
well-circumscribed silvery, scaling plaques of various sizes.
Etiology Precipitating factors include local trauma, systemic drugs & withdrawal from corticosteroids. May flare after group A beta hemolytic strep infection in peds.
S/sx Onset is gradual, course usually includes remission & recurrence. Usually involves scalp, extensor surfaces, sacral area, buttocks, penis, nails, eyebrows, axillae, umbilicus, & anogenital area. Occasionally generalized. Lesions, usually pruritic, ovoid, red plaques/papules covered with overlapping thick, silvery, shiny, slightly opalescent scales. Lesions heal without scarring. Nail involvement in 30-50% of patients, which may resemble a fungal infection with stippling, pitting, fraying, discoloration. Psoriatic arthritis affects a small percentage of patients & may be as crippling as RA (RF negative). This arthritis does not get better.

Tx: Topical corticosteroids, topical vit D (calcipotriol),

Back 41

Psoriasis

Front 42

Description: Soft, small, flesh colored or hyperpigmented pedunculated, found in epidermis, usually multiple on neck, axilla, groin area. Associated with aging. A large number at one time may be of concern for underlying diabetes.

Tx: Cryotherapy, electrodessication, excision.

Back 42

Skin Tags:

Front 43

Description: Common, contagious, epithelial tumors. Etiology: Caused by at least 60 types of human papillomavirus (HPV). Most common in peds, least common in elders. S/sx: Common warts, verrucae vulgaris, are sharply demarcated, rough surfaced, round or irregular, firm & light gray, yellow, brown, or gray black. Nodules 2-10 mm in diameter. Most common sites subjected to trauma – fingers, elbows, knees, face, periunguim, plantar surfaces. Dx: Can be differentiated from corns & calluses by their tendency to pinpoint bleeding when the surface is pared away.

Back 43

Warts.

Front 44

Description Characteristic pink-to-red papulosquamous annular plaques with raised borders, expand peripherally & tend to clear centrally. Usually secondary to Trichophyton sp.

Back 44

Tinea Corporis (ringworm of the body)

Front 45

Description Lesions usually found in 3rd-4th interdigital space that spreads to plantar surface of arch. Secondary to Trichophyton sp.
S/sx Toe web lesions often macerate & have scaling borders, may be vesicular. Worse warm/damp. Itching & pain, may be mild to severe. May be complicated by secondary bacterial infection, cellulitis, lymphangitis due to breaks in skin through which S. aureus or group A strep can invade.

Back 45

Tinea Pedis (Athlete’s foot)

Front 46

Description Toenail infection more common than fingernails. The nails thicken, become lusterless & debris accumulates under the free edge. Can affect all 10 toes. Secondary to Trichophyton sp. DM, immunosuppression CV insufficiency mb predisposed.

Back 46

Tinea Unguium (ringworm of the nails)

Front 47

Description Infections of the skin (usually occurring in moist, occluded, intertriginous areas) skin appendages, or mucus membranes. Caused by yeasts of Candida.
S/sx A beefy red superficial infection of skin, mucosal surfaces that forms satellite lesions. Likes warm, moist skin, common under breasts, crural areas, inflamed, hot, itchy. Intertrigenous infection that is well demarcated, red, sometimes itchy, exudative patches of varying size & shape. Rimmed with satellite lesions – small, red-based papules & pustules. Occurrence is axillary, inframammary, umbilicus, groin, gluteal folds, diaper rash, between toes & fingers. Perianal candidiasis produces white macerated pruritis ani.

Back 47

Candida (Moniliasis)

Front 48

(yeast, not fungi)
Description An infection characterized by multiple (usually asymptomatic) scaly patches varying from white to brown.
Etiology Caused by Pityrosporum orbicular. Common in young adults. Scaling lesions are tan, brown, white. Tendency to coalesce on chest, neck, face. Lesions do not tan, but are hypopigmented sun spots. Itching is rare, except when patient is overheated.

TX: Treated with anti-fungals (see slide 54). Pigment change may last months after tx, but will return to normal. Selenium sulfide topical, zinc pyrithione, sulfur-salicylic acid, short course itraconazole. Iontophoresis with copper sulphate or iodine. UV light. Vitamin A, selenium.

Back 48

Tinea Versicolor

Front 49

is characterized by pruritis, erythema, & vesiculations; wet, weepy, runny, oozing, sticky serous discharge, redder. Crusts over. Can lead to secondary bacterial infections. Lymph node swelling, lymphadenopathy are common. Itches.

Back 49

Acute eczema/dermatitis

Front 50

is characterized by pruritis, xerosis, hyperkeratosis, fissuring. Can led to lichenification, chronic itching, less red, indurated, some pale crusty, itchy.

Back 50

Chronic eczema/dermatitis

Front 51

An inflammatory eruption characterized by symmetric erythematous, edematous or bullous lesions of the skin or mucous membranes. Cause unknown in 50% of cases. Infectious disease (HSV) is most common cause, followed by drugs.
S/sx Sudden onset with erythematous macules, papules, wheals, vesicles, bullae, mainly on distal portion of extremities & face. May be hemorrhagic lesions of lips & oral mucosa. Malaise, arthralgia & fever are frequent. Attacks can last 2-4 weeks & recur in fall/spring for several years. Stevens Johnson syndrome is a severe form of erythema multiforme with bullae of mouth, throat, anogenital regions & conjunctiva.
DDX Bullous pemphigoid, urticaria, dermatitis herpetiformis, aphthous stomatitis.

Back 51

Erythema Multiforme

Front 52

Uncommon, potentially fatal autoimmune skin disease with intradermal bullae & extensive erosions on apparently healthy skin & mucus membranes.
S/sx: Bullae appear first in mouth, where they rupture, leaving painful erosions. Mouth pain & blood with blisters. Any area of stratified squamous epithelium may be affected. Chronic in elderly. Significant life-threatening skin disease.
DDx: Other chronic oral ulcers, other bullous dermatoses.
** REFERRAL

Back 52

Pemphigus

Front 53

Characterized by sharply demarcated hypopigmented areas, often symmetric. Hair is usually white in these areas.
Etiology Usually acquired, cause unknown. May follow trauma, especially of the head. Associated with underlying conditions, such as Addison’s disease, diabetes mellitus, pernicious anemia, thyroid dysfunction. Melanocytes stop functioning. Absence of pigment.
Not reversible. Cosmetics used to cover up.

Back 53

Vitiligo

Front 54

Persistent inflammation of the skin of the lower legs, commonly associated with venous insufficiency.
S/sx Usually of the ankle with edema, erythema, mild scaling & brown discoloration. Hyperpigmentation, fibrosis of the skin & subcutaneous tissue, ulceration. Loss of hair, loss of pedal pulses, lack of healing.

Back 54

Stasis Derm

Front 55

Infection follows nail margin or goes under nail & suppurates. Acute can begin as hang nail. Rapid onset of pain, swelling & erythema. Chronic has insidious onset. A circulatory problem.

Back 55

Felon