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91 Cards in this Set

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Vesicles
Circumscribed
Fluid containing
Epidermal elevations
Size < 5 mm
Lose identity in short time  bullae ( > 5 mm) or pustule
Bullae/Blisters
Rounded or irregularly shaped lesions
Fluid filled elevations  serous or seropurulent material
Bullae > 0.5 cm
Blister > 1 cm
Unilocular or multilocular
Pustules
Circumscribed
Raised lesion
May vary in size and shape
Contains a purulent exudate
Pus is composed of leukocytes with or without cellular debris, may contain bacteria or may be sterile
Diseases with vesicles
Herpes Simplex
Varicella
Herpes Zoster
Scabies
Dyshidrosis
Contact Dermatitis
Herpes Simplex
Clinical
clustered small vesicles
Recurrent episodes
Herpes Simplex
Course
5-14 days per episode
-Viral shedding until crusted 4-7 days
-Genital herpes --> asymptomatic shedding between outbreaks
Herpes Simplex
Diagnosis
Tzanck smear, culture, PCR
Herpes Simplex
Treatment
sunscreen
symptomatic
acyclovir
famciclovir
valacyclovir
HSV -1
orolabial lesions
HSV-2
Genital lesions
order: bullae, vesicles, blisters
vesicles < bullae < blisters
Orolabial Herpes
“Cold sore” or “Fever blister”
HSV-1 in 95% of cases
Prodrome: tingling, itching or burning
Variable symptomatology: local discomfort, headache, nasal congestion, flu-like symptoms
Sun exposure --> trigger
RECURRENCES: cheeks, eyelids, earlobes, intraorally
Genital Herpes
HSV-2 in 85% of cases
Spread by sexual contact
Primary infection: grouped blisters and erosions in the vagina, rectum, penis x 7-14 days
Fever, flu-like symptoms, vaginal pain and dysuria
Management should be individualized
dysuria
Difficulty or pain in urination
Herpetic Whitlow
Tenderness and erythema on the lateral nail fold
Deep-seated blisters develop 24-48 hours later
55% of cases between 20-40 yo
More often seen in dentist, dental hygienists and health care workers
- not seen as commonly anymore because of hand sanitizer
Herpetic keratoconjunctivitis
Common cause of blindness in USA
Punctate or marginal keratitis or dendritic corneal ulcer --> disciform keratitis --> scars
Topical corticosteroids --> perforation of the cornea
Recurrences are common
Varicella (Chicken Pox)
Varicella Zoster virus
90% of cases in children < 10 yo
Incubation period is 10-21 days
Transmission: direct contact with lesions and respiratory route
Varicella (Chicken Pox)
Clinical
Fever, malaise, single vesicles on trunk and face
-“Dew drops on a rose petal”
-Spreads out as first lesions heal
-Old lesions become umbilicated
Varicella (Chicken Pox)
Complications
secondary bacterial infection
osteomyelitis (rare)
pneumonia (adults)
Varicella (Chicken Pox)
Treatment
early acyclovir in adolescents and adults, topical antipruritic lotions, oatmeal baths, keep environment cool
-antibiotics are given as 2ndy tx
Why is aspirin contraindicated in Variclla
Reye's Syndrome
Herpes Zoster
Varicella zoster virus
After natural infection or immunization, virus remain latent in the sensory dorsal root ganglion cells
Reactivation --> immunosupression, age
Clustered small vesicles along a dermatome
Pain may precede the eruption
May have lesions outside the dermatome
Herpes Zoster
Course
10-21 days until clear
Viral shedding the first week
Pain may be severe (burning, lancinating or triggered)
May recur in 5% of patients
Post-herpetic neuralgia more frequent in patients over the age of 50
Herpes Zoster
Diagnosis
clinical
Tzanck prep
culture?
PCR
biopsy
Herpes Zoster
Treatment
analgesics
thymidine kinase inhibitors (acyclovir, valacyclovir, famciclovir)
antibiotics
Post-herpetic neuralgia
Treatment
local applications of heat
capsaicin
lidocaine 10% gel
nerve blocks
systemic steroids
tricyclic antidepressants
gabapentin
Scabies
Cause
Disease caused by mite --> Sarcoptes scabiei
Scabies
Clinical
itchy red papules and vesicles
Web spaces, body folds, genitalia, breasts, elbows, wrists, ankles
Scabies
Course
2-6 weeks after exposure
Scabies
Diagnosis
KOH scrap
scabies prep, response to treatment
Scabies
Treatment
lindane
permethrin 5%
Crotamiton
thiabendazole
sulfur 10%
ivermectin 200 microgram/kg
Dyshidrotic Eczema
Pompholyx
Etiologic factors: psychogenic, primary fungal, fungal id, drug reaction and idiopathic
Sweat glands play a secondary role
Itchy, tiny, clear vesicles on sides of digits, palms and soles
Course: episodic flare, related to stress?
Skin may become dry, cracked, flaky
Dyshidrotic Eczema
Diagnosis
clinical
Dyshidrotic Eczema
DDX
contact dermatitis
palmo-plantar psoriasis
Dyshidrotic Eczema
Treatment
topical steroids
tannic acid
tar
light treatments
methotrexate for severe disease
antibiotics for secondary infection
avoid water and stress?
Allergic Contact Dermatitis
Clinical
angular or linear distribution, history of exposure
Allergic Contact Dermatitis
Course
lesions develop within 1-10 days
Allergic Contact Dermatitis
Causes
poison ivy, oak, sumac
Nickel, rubber, thimerosal
Neomycin, latex preservatives
Allergic Contact Dermatitis
Rx
remove agent, corticosteroids
Allergic Contact Dermatitis
Allergic Disease
Do they recommend neosporin?
No b/c neosporin has neomycin
Bullous Diseases
Bullous Impetigo
Erythema Multiforme
Pemphigus vulgaris
Bullous Pemphigoid
Porphyria Cutanea Tarda
Bullous Impetigo
common, highly contagious bacterial skin infection of children
Bullous Impetigo
Dx
Gram stain, culture --> S. aureus
Bullous Impetigo
Tx
mupirocin 2% (Bactroban)
systemic antibiotics
Bullous Impetigo
Complications
Staphylococcal scalded skin syndrome
glomerulonephritis
scarring
Erythema Multiforme
Precipitating Factors
Infections: herpes simplex (50%), Orf, Histoplasma capsulatum, mycoplasma pneumoniae
Radiation therapy
Medications: (sulfa)
Erythema Multiforme
Clinical
abrupt onset of symmetrical fixed red papules -->1-2 cm target (Bullseye) lesions on dorsa of hands, forearms, palms, neck, face and trunk. Mucosal involvement occurs 25%
Erythema Multiforme
Acute, self-limited, recurrent disease
bulls eye lesions
Pemphigus Vulgaris
Autoimmune disease
Equal frequency in men and women; 5th or 6th decades
Thin-walled, big flaccid, easily ruptured blisters... denuded areas
Mouth involved (60%) then body --> groin, scalp, face, neck, axillae or genitals
Pemphigus Vulgaris
Dx
Nikolsky Sign
Direct immunofluorescence shows intercellular IgG staining
Antibodies to desmoglein 3 --> Elisa
Nikolsky sign
absence of cohesion in the epidermis; lateral pressure on unblistered skin and having the epithelium shear off
Pemphigus Vulgaris
Treatment
silver sulfadiazine 1%
systemic corticosteroids
other immune modulating agents (azathioprine, cyclophosphamide, methotrexate)
Bullous Pemphigoid
Autoimmune disease, affects the elderly
Intense pruritic eruption with large tense blisters (subepidermal)
Most often begins on lower extremities. Other sites: groin, axillae, flexor surfaces of forearms
Associated with diabetes mellitus, rheumatoid arthritis, dermatomyositis, ulcerative colitis, lymphoproliferative disorders
What is deeper Pemphigus Vulgaris or Bullous Pemphigoid?
Bullous Pemphigoid
Bullous Pemphigoid
Dx
Circulating basement membrane zone antibodies (IgG)  70%
Direct immunofluorescence shows linear deposits of IgG and C-3 along the BMZ
Indirect immunofluorescence on salt-split skin
Bullous Pemphigoid
Tx
corticosteroids (lower doses than PV)
immunosuppressives (azathioprine, methotrexate, mycophenolate mofetil)
Porphyria Cutanea Tarda
Metabolic disease: abnormal porphyrin metabolism (Uroporphyrin decarboxylase)
Porphyria Cutanea Tarda
Clinical
photosensitivity --> blisters, erosions on dorsa of hands and arms; heal with scarring, milia and dyspigmentation
Hyperpigmentation of the face, neck and hands
Increased facial hair
Photosensitivity
Porphyria Cutanea Tarda
Triggers
ETOH, estrogens, iron overload (66%), hepatitis C, hepatitis B
Porphyria Cutanea Tarda
Diagnosis
pink or coral-red fluorescent urine (increased uroporphyrins) under a Wood’s UV light
Porphyria Cutanea Tarda
Treatment
remove trigger
decrease iron (phlebotomy)
alpha interferon for hepatitis C
antimalarials
What disease is associated with Porphyria Cutanea Tarda?
diabetes mellitus, lupus
Diseases with pustules
Acne vulgaris
Acne rosacea
Folliculitis
Candidal intertrigo
Acne Vulgaris
A chronic inflammatory disease of the pilosebaceous unit
True acne is a follicular process beginning with the comedon
Rupture results in inflammation
-Papules, pustules, or cysts
What is the most common dermatologic condition treated by physicians in the US?
Acne Vulgaris
Acne vulgaris incidence
40-50 million individuals/year
What age does acne vulgaris predominate in?
Acne can occur at any age --> predominately teens
85% of 12-24 year old
3% of 35-44 year old
Acne Vulgaris
Classification
According to type of lesion:
Comedonal, papulopustular, cystic
According to severity:
Mild, moderate, severe
Acne Vulgaris
Topical Treatment
Tretinoin
Benzoyl peroxide
Antibiotics
Azelaic acid
Salicylic acid
Alpha-hydroxy acids
Acne Vulgaris
Oral Treatment
Antibiotics: doxycycline, minocycline
Estrogens (oral contraceptives)
Retinoids (Accutane  40 mg bid x 4 months)
Antiandrogens: spironolactone
Which acne drug is teratogenic?
Accutane

So don't use during pregnancy
Rosacea
Most common in fair-skin individuals
Third or Fourth decades of life
Pathogenesis related to vascular hyper-reactivity
(lesser role: Role of Demodex folliculorum and Propionibacterium acnes)
Rosacea
Triggers
Hot drinks
red wine
spicy food
soy sauce
oral niacin
topical steroids
Vascular rosacea
flushing and facial erythema with or without telangiectasia
Papulopustular rosacea
central facial erythema with papules or pustules
Ocular rosacea
foreign body sensation
burning
dryness
itching
ocular photosensitivity
blurred vision
Granulomatous rosacea
firm, brown or red papules or nodules
Rosacea
Oral Treatment
Metronidazole 1% gel qd
Tetracycline, 250 mg bid
Doxycycline, 100 mg qd (best b/c low dose)
Minocycline 100 mg qd
Rosacea
Topical Treatment
Sodium sulfacetamide 10%
Azelaic acid 20% bid
Erythromycin 2% bid
Clindamycin lotion bid
Metronidazol 200 mg bid
Rosacea
Interventional Treatment
Telangiectasias: Laser treatment
Rhinophyma: Laser, cryosurgery, electrosurgery
Folliculitis
Clinical
pustules at hair follicle, especially the extremities
Folliculitis
Complications
rupture of follicle with carbuncle or furuncle
Folliculitis
Dx
culture, clinical
Staphylococcus aureus (normal inhabitant of anterior nares in 20% adults)
Folliculitis
Treatment
antibacterial soap, oral antibiotics, mupirocin; rifampin (600 mg/day 10 days)
Candidal Intertrigo
typical causes
Typically caused by C. albicans but other species can cause infection
Candidal Intertrigo
Clinical
groin, under breasts, abdominal fat, axillae
Red, moist areas with satellite papules and pustules
Candidal Intertrigo
Diagnosis
clinical, KOH, culture
Candidal Intertrigo
Treatment
topical antifungals
Silvadene
zinc oxide
oral antifungals (fluconazole, itraconazole)
Other Sources of Blisters
Burns
Acute fungal infections causing tinea corporis
Drug Reactions (Stevens-Johnson, TEN)
Friction
Insect Bites
Many autoimmune blistering diseases
What is seen with immunofluorescence with Bullous Pemphigoid vs. Pemphigus Vulgaris?
PV: Direct immunofluorescence shows intercellular IgG staining
BP: Direct immunofluorescence shows linear deposits of IgG and C-3 along the BMZ
Indirect immunofluorescence on salt-split skin