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192 Cards in this Set
- Front
- Back
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In what populations is Erysipelas most common?
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young children and the elderly
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Erysipelas involves what layers of the skin?
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The upper layers, ie. epidermis.
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What is the primary cause of erysipelas?
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Group A Streptococcus, strep pyogenes
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What are the common sites of erysipelas?
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Cheeks and Ears
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What are the systemic manifestations of erysipelas?
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Fever, chills, regional lymphadenopathy.
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What is the fever range associated with systemic erysipelas?
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99-101 degrees
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What are the four ways to make a Erysipelas diagnosis?
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Typically based upon history and physical examination
Wound Gram stain and culture WBC - Will be elevated Erythrocyte Sedimentation Rate - Will be elevated |
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What are the oral treatments for Erysipelas?
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1st line = Penicillin
Amoxicillin Erythromycin |
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In what situation do you not use oral therapy?
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If the patient is toxic, ie. systemic toxicity.
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Which of the oral agent treatments are associated with severe gastrointestinal difficulty in some patients?
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Erythromycin
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What is a good alternative to Penicillin, for the treatment of erysipelas? Ie. if the patient is allergic to penicillin.
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Clindamycin, also cefalexin = Keflex,
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What should be noted about the use of Clindamycin, or other cephalosporins, in the use of treating erysipelas?
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In up to 10% of patients who have an allergic reaction to penicillin, can also have an allergic reaction to Clindamycin = cephalosporins.
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What are the IV/Parenteral treatments for erysipelas?
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Ceftriaxone (Rocephin) or Cefazolin (Ancef)
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In what populations is cellulitis seen in predominately?
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Middle age, the elderly and the immunocompromised.
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What are the etiological organisms for cellulitis in adults and children?
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Staph. aureus, GAS, MRSA
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What are the etiological organisms for facial and periorbital cellulitis?
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Haemophilus influenzae
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What are the etiological organisms for cellulitis secondary to a dog or a cat bite?
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Pasteurella multocida
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When cellulitis is seen with IV drug abusers what is the etiological organism associated with the infection?
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S. aureus
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Crepitant Cellulitis is caused by what etiological organism?
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The Clostridia species. This is what is also known as gas gangrene.
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What is the organism that causes hot tub folliculitis, cellulitis due to penetrating trauma, cellulitis in immunocomprimised and hospitalized patients.
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Pseudomonas aeruginosa
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What are the primary manifestations of cellulitis?
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Borders are rough, and less defined, expanding
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What parts of the body are usually affected by cellulitis?
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The lower extremities.
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What are the systemic manifestations of cellulitis?
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Fever, chills, malaise, anorexia, lymphadenopathy, lymphangitis, septicemia may develop.
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What fever could you possibly see if cellulitis becomes systemic?
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102-103 degrees
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What are the ways of diagnosing cellulitis?
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Typically based upon history and physical examination.
Wound gram stain and culture WBC Erythrocyte sedimentation rate Blood Cultures X-Rays |
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What are the oral agents to treat Cellulitis EXCLUDING MRSA, also what etiological organisms are you trying to kill?
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You are trying to kill Staph and Strep.
The first line agent is Cephalexin (Keflex) Dicloxacillin and Clindamycin are also used. |
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If someone is allergic to penicillin, which drug would you give to treat Cellulitis EXCluding MRSA?
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Clindamycin
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What other organism can clindamycin cover?
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MRSA
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What are the Parenteral/IV therapies for cellulitis EXCluding MRSA?
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The first line is Cefazolin (Ancef), also Nafcillin or Oxacillin, and Clindamycin
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Which IV drugs are only given if it is not MRSA?
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Cefazolin (Ancef) and Nafcillin and Oxacillin
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What are the oral therapies for MRSA
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Trimethoprim-Sulfamethoxazole (Bactrim DS) is the first line agent.
Also used are doxycycline, clindamycin, and linezolid. |
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Which oral MRSA therapy is contraindicated in women who are pregnant and children?
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Doxycylcline
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What are the parenteral/IV therapies for MRSA
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Vancomycin is the first line agent, Daptomycin and linezolid are also used.
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What is the oral therapy used to treat cellulitis due to a dog or cat bite?
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Amoxicillin/Clavulanate (Augmentin), is the first line.
Doxycyline is also used, but remember its toxicity to pregnant women and to children. |
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What are the parenteral/IV therapies for cellulitis due to a dog or cat bite?
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Ampicillin/Sulbactam (Unasyn)
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What are the three main considerations for Erysipelas and cellulitis treatment?
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1. Elevation of head of the bed or extremity depending on the site of infection.
2. Warm compresses 3. Narcotic, Tylenol or Ibuprofen for fever and pain relief. |
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Symptomatic treatment of erysipelas and cellulitis are typical within how many hours? Also, how many hours until you see a visible improvement?
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Symptomatic treatment is typical within 24-48 hours.
Visible improvement may take up to 72 hours. |
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What is the typical length of treatment for cellulitis and erysipelas?
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This depends on the response, but is usually 7-14 days.
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What are the non-melanoma skin cancers?
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Basal cell carcinoma
Squamous cell carcinoma |
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What is the most common form of skin cancer?
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Basal cell carcinoma
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Where does a basal cell carcinoma arise from?
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The basal keratinocytes.
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What are the four types of basal cell carcinoma?
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1. Nodular
2. Sclerosing 3. Superficial 4. Pigmented |
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These BCC's are pearly, shiny, translucent papules or nodules?
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Nodular BCC's
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These BCC's feel indurated, and may look like scars?
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Sclerosing or Morpheaform BCC's
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These BCC's are scaling plaques that may be misdiagnosed as dermatitis?
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Superficial BCC's
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These BCC's have some translucency, and may be mistaken for melanoma?
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Pigmented BCC's
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What type of BCC is this?
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Nodular BCC
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What type of BCC is this?
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Sclerosing or Morpheaform BCC
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What kind of BCC is this?
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Superficial BCC
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What type of BCC is this?
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Pigmented BCC
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Where do most Squamous cell carcinomas arise from?
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Actinic keratoses
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What is the definition of Squamous cell carcinoma?
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It is a malignant tumor of keratinocytes.
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What are the three types of SCC?
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SCC in situ (Bowen's Disease)
Invasive SCC Keratocanthoma |
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What type of SCC sometimes goes away on its own, and also is sometimes mistaken for a wart?
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Keratoacanthoma
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What type of Squamous cell carcinoma is this?
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Squamous cell carcinoma in situ
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What type of squamous cell carcinoma is this?
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Keratoacanthoma
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What type of squamous cell carcinoma is this?
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Invasive Squamous Cell Carcinoma
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What are the two types of biopsy methods?
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Shave biopsy and punch biopsy
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Which of the two methods of biopsy are faster?
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Shave biopsy
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When performing a biopsy on Basal CC and Sqaumous CC, what is the best place to take the sample from?
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It doesn't matter, the cells are uniform throughout.
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What are the primary treatment plans for non malignant skin cancers? There are seven of these.
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Elecrodessication and curettage
Excision Topical therapy Photodynamic therapy Liquid nitrogen cryotherapy (cryosurgery) Moh's micrographic surgery (MMS) Radiation therapy |
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When is it best to use E&C for treatment of NMSC?
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Primarily for low risk lesions.
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What are the advantages of using E&C?
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It is quick, it spares healthy adjacent tissue, it is low risk, has few complications, doesn't cost very much and it is well tolerated.
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What are the disadvantages of E&C?
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It has limited use, a poor cosmetic outcome occurs in certain areas.
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What are the advantages of using surgical excision?
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It is extremely affective, you are able to evaluate the margins, and there is a good cosmetic result.
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What are the disadvantages of using surgical excision?
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It may be invasive, may require skin grafting, it is more expensive that E&C and cryosurgery.
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What is the only FDA approved topical therapy for NMSC?
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5-Fluorouracil (Carac cream)
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What is liquid nitrogen under pressure in a closed container?
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Cryotherapy, or Cryosurgery when used.
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What are the advantages of cryotherapy?
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High cure rate, low expense
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What are the disadvantages of cryotherapy?
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It is not for recurrent, large, deeply invasive, poorly defined SCCs and BCCs.
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What treatment might be useful for elderly patients who don't want to undergo excision?
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cryotherapy
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What is the gold standard for treating many high risk BCCs and SCCs?
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Moh's Micrographic Surgery
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What are the advantages of Moh's?
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Precision, excellent long term care rates, sparing of normal tissue, good cosmetic results.
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What are the disadvantages of Moh's?
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High cost and it is a long procedure that can take all day.
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What are the five main indications for Moh's surgery?
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1. Recurrent tumors
2. Aggresive histologic patterns (morpheaform, infilitrative) 3. High risk site (periorbital, nasal, pre or postauricular, lips) 4. Ill defined borders 5. Incomplete excision. |
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In what 2 cases are radiation therapy used to treat NMSC?
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Patients unable to tolerate surgery use this treatment.
Also in elderly patients with large tumors. |
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How often should NMSC patients have follow ups?
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Skin exams every 3-6 months during the first year, and then every 6-12 months in later years. This is due to a 50% rate of re-occurrence.
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What locations do you normally see BCC?
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Face, head and neck.
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What areas do you normall see SCC?
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Face, head, neck, lips, genitals, soles of feet.
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What is a melanoma?
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It is a tumor of the melanocytes, the pigment producing cells of the skin.
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What are the risk factors for melanoma?
MMRISK |
M - Moltes:atypical
M - MOles > 50 common moles R - Red hair and freckling I - Inability to tan: skin phototypes I/II S - Sunburn:severe sunbrn. bf 14yo K - Kindred: family history CKDKN2a and CDK4 genes. |
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What is the ABCD for recognizing melanoma?
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A - Asymmetry
B - Border - edges are uneven, notched are ragged C - Color - various shades of black, tan, and brown. D - Diameter - >6mm, around the size of a pencil eraser. |
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This type of melanoma is the most common type, asymmetric pigmented lesion with variation in color and outline.
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Superficial spreading melanoma
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This type of melanoma may be flat or raised, associated with photodamaged skin.
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Lentigo melanoma maligna
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These melanomas are blue, black, or red papule or nodule.
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Nodular melanoma
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These melanomas may be flat or raised on palm soles or nail beds, no known association with sun exposure, most common type in darker skin phenotypes.
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Acral lentiginous melanoma.
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What type of melanoma is this?
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Superficial spreading melanoma
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What type of melanoma is this?
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Lentigo Maligna Melinoma
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What type of melanoma is this?
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Nodular melanoma
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What type of melanoma is this?
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Acral Lentiginous melanoma
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of the seven point checklist how many minor signs, and what are they, should you have before you refer someone for biopsy?
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You can see 3-4 minor signs without a major sign, consider referral.
1. Inflammation 2. Bleeding or crusting 3. Sensory change 4. Diameter >7mm |
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What are the major signs from the seven point referral check list and when should you refer someone for a biopsy?
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There are three major signs:
1. Change in size 2. Change in shape 3. change in color If any of these occur a biopsy should be done. |
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What are the three items used to stage a melanoma?
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AJCC (American joint committee on cancer) staging system.
Breslow Thickness chart Clark's level of tumor invasion |
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What are the main treatments used for melanoma? There are four main ones.
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Surgery, Sentinal lymph node biopsy, radiation and chemotherapy, adjuvant therapy ie. vaccines and cytokines.
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What is used, when treating melanoma, for diagnosis, staging and is a treatment of choice.
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Elliptic Excision.
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This procedure is both a staging and prognostic tool for melanoma treatment. It is a procedure that allows a selective sample of the 1st draining lymph nodes from a tumor site.
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Sentinel lymph node biopsy and lymphatic mapping.
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The detection of intranodal deposits of melanocytic cells usually indicates what when performing sentinel lymph node biopsy.
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Metastatic cancer.
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What are the two drugs used in melanoma chemotherapy, and what are they usually meant to do?
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The drugs are dacarbazine and temozolomide, they are usually to relieve symptoms or decrese tumor in size in patient with mets.
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This is a treatment for melanoma where the drug is delivered directly into the arm or leg, the flow of blood to and from the limb is temporarily stopped with a tourniquet.
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Isolated limb perfusion.
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What are the main three things when doing a melanoma work up?
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Depends upon staging, Chest X-Ray, and Blood Work
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How often should someone who has had melanoma have skin exams?
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Every 3-6 months.
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What are three less common types of skin cancer?
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Merkel cell carcinoma
Kaposi Sarcoma T-cell lymphoma of the skin |
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This less common type of skin cancer is usually seen in patients over 65, it grows fast and is usually in sun exposed areas.
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Merkel cell carcinoma
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This less common type of skin cancer is caused by Hepres virus 8, and is seen in AIDS patients, It can eventually invade airway.
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Kaposi Sarcoma
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This less common type of skin cancer can be mistaken for psoriasis, it is caused by a malignancy of T helper cells. It usually requires several biopsies to confirm diagnosis.
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T-Cell lymphoma
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What type of cancer is this?
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Merkel Cell Carcinoma
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What type of cancer is this?
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Kaposi sarcoma
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What type of cancer is this?
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T-Cell Lymphoma
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What condition is described as an acute self limited papulosquamous exanthem?
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Pityriasis Rosea
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What is the age of onset for pityriasis rosea?
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Adolsecents through adults.
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When does Pityriasis Rosea peak, and what time of year is it more common?
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It peaks from 20 to 29 years of age, and it is more common in the spring and fall.
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What is the recurrence rate of Pityriasis Rosea?
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The recurrence is very rare.
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What types of symptoms are seen in the prodromal phase of Pityriasis rosea?
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Malaise, headache, mild constitutional symptoms.
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What is a very common clinical marker for Pityriasis rosea?
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The Herald Patch?
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This is normally found on the trunk, it is a single, oval lesion anywhere from 2-10 cm in diametere. It can have a pink, salmon-red to erythamatous appearance. It is also slightly raised with a fine collarette scale, which trails the advancing border?
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Herald Patch
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What are the raised papules and plaques with a collarette scale that occur days to weeks later, and are smaller lesions on the trunk, prsimal to extremities, rarely on the face/palms/soles?
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Exanthem
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What do the secondary exanthem lesions in Pityriasis rosea follow, as far as alignment?
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They line up/follow langer's lines
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What is the pattern of langer's lines?
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Christmas tree or Fir tree distribution on the back, V shaped pattern on upper chest, align transversely across the lower adbomen and back.
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This is more common in African Americans, and the lesions are more common on the distal extremities, may include the palms and soles.
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Reverse Pityriasis
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What are the four main things to make a clear diagnosis of Pityriasis Rosea?
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1. It is usually diagnosed clinically
2. Perform a KOH preparation with microscopic view to rule out tinea 3. Perform a VDRL to rule out secondary syphilis 4. Biopsy, but this is very rarely indicated. |
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How do you treat Pityriasis rosea?
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You don't have to treat the actual disease, it goes away on its own in 6-12 weeks.
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In what two ways are the symptoms of Pityriasis rosea treated?
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1. Symptomatic of pruritius via antihistamines, calamine lotion and steroids.
2. UVB phototherapy or natural sunlight - has been shown to decrease duration of rash and associated itching. |
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What is a major risk with using UVB phototherapy for the treatment of Pitryiasis rosea?
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It can cause post inflammatory hyperpigmentation. This means that areas can remain darker in color than the rest of the patients body.
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This dermatological condition is defined as an acute or chronic inflammatory mucocutaneous dermatosis.
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Lichen Planus
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What is Lichen Planus classified as?
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Papulosquamous exanthem
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What is the age of onset of Lichen Planus, and what gender is it more common in?
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Age of Onset = 30-60 y/o
Slightly more common in females. |
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What drugs can induce lichen planus? 6 of them
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Gold, Anti-Malarial drugs, thiazide diuretics, NSAIDS, beta blockers, ACEI
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What must you test for if someone presents with Lichen Planus?
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Hepatitis C
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What is one of the first big clues as to whether or not a patient has Lichen planus?
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If the patient says that it doesn't itch, then it probably isn't Lichen planus.
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What is described as polygonal, planar (flat topped) discrete papules and plaques from 1-10mm?
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Lichen planus
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What are the six P's, associated with Lichen Planus skin lesions?
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1. Purple
2. Pruritic 3. Polygonal 4. Planar 5. Papules 6. and Plaques |
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Apart from the six P's, what are two other common features of Lichen Planus?
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Violaceous with reticulated white scale (Wickham striae), Common on flexor surfaces of the wrists, shins, lumbar back and feet.
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What areas is Lichus planus common on?
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Flexor surfaces of the wrists, shins, lumbar back and feet.
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Lichen planus and psoriasis may appear in areas that are exposed to trauma. What is the name of this phenomenon?
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Koebner's Phenomenon
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Lesions that cause intense pruritus, and post-infammatory hyperpigmentation are associated with?
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Lichen planus
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These lesions are white, lacy reticular pattern on buccal mucosa, tongue, lips and gingiva. They can become erosive, and painful.
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Lichen planus mucosal membrane lesions.
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Where are Lichen planus lesions on the genitalia most common?
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On the glans penis and vulva.
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If you have gential and mucosal membrane Lichen planus lesions, that won't go away, what must you consider?
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Squamous cell carcinoma.
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Lichen planus lesions of the hair are called?
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Lichen planopilaris
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This ultimately destroys the hair follicles, and hair regrowth doesn't occur, as well as a resultant scarring alopecia?
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Lichen planopilaris
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How is Lichen planus usually diagnosed?
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Diagnosis usually based on clinical presentation and punch biopsy.
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What are the two pathological findings for Lichen planus?
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Band-like-infiltrate of lymphocytes at the epidermal-dermal junction. Epidermal changes include wedge shaped hypergranulosis and irregular acanthosis - thickening of skin.
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What is the Tx for early or localized skin lesions associated with Lichen planus?
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topical corticosteroids
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What is the tx for lichen planus that is resistant and has hyperkeratotic lesions?
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Intralesional injections of triamcinolone.
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What is the tx. for generalized lichen planus lesions?
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Oral corticosteroids
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If you have corticosteroid resistant lichen planus lesions, how do you tx?
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Retinoids or phototherapy with psoralens (PUVA)
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How do you treat the oral lesions of lichen planus?
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corticosteroid mouthwash such as Orabase or Fluocinomide (Lidex)
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The majority of lichen planus cases spontaneous remit after how long?
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One year, the average is 6 months to 2 years
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This is described as typically an acute, self limited reaction 1-3 weeks long, occurring in patients of all ages, peaking between 20-40 y/o, more frequent in males than females.
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Erythema multiforme
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Erythema multiforme is considered a __________, and its most common etiology is?
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Type IV hypersensitivity
Herpes simplex virus |
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What etiology is common with erythema multiforme in children?
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Mycoplasma pneumoniae
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What drugs can induce erythema multiforme?
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Barbiturates, NSAIDS, penicillins, phenothiazines, sulfonamides, metformin, ciprofloxacin, and bupropion
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After having these vaccinations, erythema multiforme can sometimes occur?
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Diphtheria-tetanus, Hepatitis B
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What are the prodromal symptoms of Eyrthema multiforme?
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Fever - usually low grade, malaise, myalgias, sore throat, cough
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Erythema multiforme usually has what characteristics?
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Target or iris lesion: Round shape with three concentric zones - center dark or dusky area, paler pink or edematous area and then a red peripheral outer zone.
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What are the most characteristic places for Erythema multiforme lesions?
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On the dorsa of the hands and extensor aspect of the extremities.
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What three other areas can be affected by Erythema multiforme?
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Eyes, Face and mucous membranes.
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What usually makes up a minor erythema multiforme case?
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Usually confined to the extremties, face. Classic target lesions with little or no mucous membrane involvement. Usually associated with herpes simplex outbreak.
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What usually denotes a major case of erythema multiforme?
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Always has mucous membrane involvement, extensive surface area involvement with confluent lesions, Bulbous lesions are more common with positive Nikolsky sign.
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When does erythema multiforme usually resolve?
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It usually resolves spontaneously in 3-5 weeks.
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What do you give for the symptomatic relief of erythema multiforme?
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Oral antihistamines and topical/oral steroids for symptomatic relief.
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What do you do to treat the underlying etiology of Erythema multiforme?
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If associated with a herpes outbreak, then make sure to use Acyclovir.
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This skin condition is characterized as a papulosquamous exanthem, it is a chronic condition with exacerbations and remissions, affects 3-5 million in the US?
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Psoriasis
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What is the most common form of psoriasis?
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Psoriasis vulgaris
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What medications induce psoriasis?
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systemic glucocorticoids, lithium, antimalarial drug, beta blockers
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What infection precipitates guttate psoriasis?
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Strep
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What is a diagnostic test that you can do to see what the cause of psoriasis is?
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you can perform a throat culture or an Antistreptolysin O Titer for strep.
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What is the dermatopathology for psoriasis?
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Thickening of the epidermis
Increased mitosis of the keratinocytes Inflammatory cells in the dermis and epidermis |
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What are the four types, and which of the four is the classical presentation, of Psoriasis Vulgaris?
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1. Acute Guttate
2. Chronic Stable 3. Palmoplantar 4. Inverse The classic presentation is Chronic stable. |
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What are the two severe forms of Psoriasis?
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Pustular psoriasis and psoriatic erythroderma
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What usually precipitates accute guttate psoriasis?
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an acute strep infection.
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This classic lesion begins as a papule and coalesces to form a plaque that is often pruritic. This is a well demarcated, erythematous plaque with thick silvery white scales.
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Chronic stable psoriasis
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This sign is seen when removal of a chronic stable psoriasis scale reveals droplets of blood.
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Auspitz sign
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What are the preferred sites for a chronic stable psoriasis?
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Extensor surfaces, elbows and knees, lower back, and scalp.
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This diagnostic sign is a hallmark of psoriasis on the hands?
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Nail pitting.
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What are the treatment options for psoriasis?
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Steroids, Vitamin D Derivatives, Retinoids, Immunosuppressants, Coal Tar and Anthralin.
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What is the mainstay treatment for Psoriasis?
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Topical steroids
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How do Vitamin D derivatives work and what should the prescribed with?
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Inhibits keratinocyte proliferation and has anti-inflammatory effects. It is best used in combination with a topical steroid.
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What precautions must be taken when using Topical retinoids such as Tazorotene for the tx of psoriasis?
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It is teratogenic.
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What is the most effective psoriasis tx. for thin band lesions?
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Phototherapy
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What are the tx options for moderate to severe psoriasis >20% coverage?
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PUVA, Oral Retinoid, Suppressive agents.
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What is a precaution when using PUVA therapy?
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It can lead to an increase risk/rate of non-melanoma skin cancers, especially BCC.
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What is the most effective tx. for pustular psoriasis?
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Soriatane, an oral retinoid.
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What are some important things to know about Soriatane?
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It is very teratogenic, up to three years after using the drug. It can also cause problems with LFT's and triglycerides.
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What are the three immunosuppressive agents for treating psoriasis?
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Methotrexate, Cyclosporine, and Hydroxyurea
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This immunosuppressive agent is good for psoriatic arthritis. It is also good for severe psoriasis unresponsive to other agents. It is a folic acid antagonist.
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Methotrexate
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What are the major risk factors with methotrexate?
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You can not drink while on this drug, it is also not only teratogenic for females, but also males. It has many side effects including hepatotoxicity, bone marrow toxicity, and numerous drug interactions.
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What are things that you need to monitor if you have a patient on methotrexate?
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LFT
CBS Creatinine |
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This immunosuppressive agent is used for extensive disease unresponsive to other agents. It is very useful for rapid, short term control followed by transition to another agent.
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Cyclosporine
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What are two very important things that should be done before giving someone Cyclosporine?
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Check BP and Creatinine twice before starting treatment.
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This drug is best for chronic plaque psoriasis. It is an alternative to methotrexate and has less hepatotoxicity than methotrexate.
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Hydroxyurea
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What is the main side effect with hydroxyurea?
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bone marrow toxicity.
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