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167 Cards in this Set

  • Front
  • Back
What cells are located in the epidermis?
-Keratinocytes
-Melanocytes
-Langerhans cells
-Merkel cells
What structural elements are located with melanocytes
Produce melanin which gives us pigmentation and protects us from the sun
How many melanocytes for each keratinocyte?
1 melanocyte for each keratinocyte.
What are some important structures and facts about the basement membrane zone (BMZ) of the epidermis aka dermal-epidermal junction?
Structures
1. Lamina lucida
2. Basal lamina
3. Anchoring fibers
Important fact:
Many blistering diseases of the skin have their origin in the BMZ
What is the main function of the dermis and its structures?
Support all dermal structures:
Dermal Structures:
Blood vessels; nerves; sweat glands (apocrine and eccrine), sebaceous glands, hair follicles, nails, & matrix.
What does the matrix of the dermis consist of?
Collagen, elastic fibers, & Ground substance.
What are the primary skin lesions?
-Macule
-Patch
-Papule
-Plaque
-Pustule
-Vesicle
-Bullae
What are the secondary skin lesions?
-Scale
-Crust
-Erosion
-Ulceration
-Fissure Atrophy
-Scar
What is a flat area of discoloration < 1cm?
Macule
What is a flat area of discoloration >= 1 cm?
Patch
What is a raised palpable lesion < 1 cm?
Papule
What is a raised palpable lesion >= 1 cm?
Plaque
What is a raised fluid filled bump that is filled with pus?
Pustule
What is a raised fluid filled lesion < 1 cm that is filled with serous exudate (clear or cloudy)?
Vesicle
What is a raised fluid filled lesion >= 1 cm that is filled with serous exudate (clear or cloudy)
Bullae
What is a red plaque that is superimposed with stratum coreum that should not be there?
Scale
What is dried heme and exudates on a lesion called?
Crust aka scab
What is a circumscribed loss of epidermis called?
Erosion.
Note it is only epidermis
What is a circumscribed area loss of epidermis & deeper layers called?
Ulceration
What is a circumscribed linear erosion/ulceration called?
Fissure
What is a circumscribed thinning of the skin called?
Atrophy
This is a hypertrophic area of the skin, which happens to be thicker than surrounding skin. What is this called?
Scar
What is this called?
Macule
What is this called?
Patch
What is there lesions called?
Papules and Plaques
What are these lesions called?
Vesicles and Bullae.
What are these lesions called?
Vesicles and Bullae
What are these lesions called?
Vesicles and Bullae
What is this?
Pustules
What is this?
Pustules
What is this?
Nodule
What is this?
Tumor (squamous cell carcinoma)
What is this?
Wheals (urticaria)
What is this?
Wheals (urticaria)
What is this?
Lichenification
What is this?
Lichenifaction
What is this?
Fissure
What is this?
Burrows
What is this?
Scale
What color does erythrasma fluoresce under wood's light?
Coral red color fluoresence under wood's light. See slide 27 of 74 in Office Procedures in Dermatology
What does KOH test for?
Fungi
What does Gram Stain test for?
bacteria
What does Scabies prep test for?
scabies
What does Tzanck smear test for?
Herpes Simplex Viruses. You are looking for multinucleated giant cells
What kind of conditions (_____alop:ecias) are the following
*Alopecia areata
Telogen effluvium
Androgenetic alopecia
Trichotillomania
Non-scarring alopecias
What alopecia disorder is associated with thyroid disease?
Alopecia areata
Does vitilago have an association with thyroid disease?
Yes
-Detachment of nail from its bed at distal/lateral attachments
-Creates a subungual space that collects dirt and keratinous debris
Pseudomas can develop and cause a greenish discoloration
Onycholysis
-Transverse line in nail, usually seen in all 20 nails and correlates to a form of systemic disease
-Occurs after any severe, sudden, acute, usually febrile illness
-Correlates to telogen effluvium of the hair
Onychoschizia-Beau’s Lines
Biting of the nails
Onychophagia
-Chronic infectious condition
--15-20% people 40-60 years old
--90% of the elderly
-Incidence has been rising due to: age, diabetes, immunosuppression, poor peripheral circulation, trauma
-Can be portal of infection (diabetics)‏
-Spreads to: other nails, skin, people
-Socially unacceptable
Onychomycosis
Premenopausal females are less likely to be infected- suggesting that estrogen may have a protective effect
Prepubertal children rarely affected-possibly due to faster growth of nails, less trauma
Onychomycosis
Patterns of onychomycosis
-distal subungal onychomycosis
-superficial white onychomycosis
-proximal subungal onychomycosis
______ is the most common type of onychomycosis.
It is most often caused by Trichophyton rubrum or Trichophyton mentagrophytes.
The manifestation of distal/lateral subungual onychomycosis begins with initial fungal penetration of the stratum corneum from the hyponychial area or from the nail fold.
The disease is characterized by a yellow-brown discoloration of the nail plate, onycholysis, and subungual hyperkeratosis.
Distal/lateral subungual onychomycosis
_______ _____onychomycosis
The fungi directly invade the nail plate.
The most common causative agent is T. mentagrophytes. Species of Fusarium or Acremonium may also be the etiologic agents.
Almost always found in toenails, superficial white onychomycosis is characterized by a white, crumbly, sometimes powdery, appearance. The initial lesions may be randomly dispersed but will eventually coalesce to include the entire surface of the nail. This infection is capable of producing progressive dystrophy of the nails.
Superficial white onychomycosis may also be a sign of HIV infection.
Superficial white onychomycosis
______ _______ onychomycosis Penetrates the proximal portion of the nail
Hallmark sign of HIV infection
Occurs in both fingernails and toenails
Proximal subungal onychomycosis
What is the disease based on the following:
Pitting
Subungual hyperkeratosis
Onycholysis
Oil Spot- yellow spots under the nail plate
Affects 25% of patients with psoriasis
Most treatments are unsatisfactory
Psoriatic Nail Disease
-Diabetic peripheral neuropathy
-Ulceration of 3rd toe from elongated, mycotic nail
Onychogryphosis
Based on the following what is this?:
Epidermal tumors caused by the human papillomavirus (HPV)
Verrucae
Based on the following what is this?
Common contagious tumors
Seen most commonly in children, young adults
Transmitted by direct human-to-human contact
3 common types of cutaneous warts: common, plantar, flat
Verrucae
Self-limited epidermal viral infection
Flesh-colored to pink umbilicated papules, usually grouped
Can have central keratotic plug
Seen in children and sexually active adults.
-Two separate diseases – 99% is classical condition in children (5 per week)
-Second condition is rare 1 per year
Molluscum Contagiosum
MCV is a pox virus
Transmitted via skin-to skin contact
Can koebnerize
Can be extensive in HIV+ patients
Usually resolve in 6 months
Mollusum Contagiosum
-As the viral lesions heal they tend to hypertrophy and crust over
-Represents ‘immune response’ to therapy
-Some form of destruction
-Drying agent
-Irritate the lesion. Create an inflammatory response. The inflammatory response activates the Immune system response.
This a sign of a Immature immune system.
Molluscum Healing
What is the most prevalent STD?
Herpes Simplex...The gift that keeps on giving :-)
What is the prevalence of Herpes?
45 million people
What do Primary Care Physicians think about herepes with respect to their patient population?
Although Genital Herpes is one of the most common STDs, many primary care physicians believe it is virtually nonexistent in their patient population?
(50/300 = 15 %) ~ 1 in 6 patients
What are group vesicles on erythematous base?
Herpes, Herpes, Herpes
Valtrex, Valtrex, Valtrex!!!
What percent of adults are exposed to herpes simplex type 1?
85 %
Where do recurrent infections of Herpes occur?
mucocutaneous sites, oral mucosa are rarely involved.
What are these?
UV exposure, fever, colds, stress
Precipitating factors for recurrent herpes infections.
Bullseye targetoid lesions are called?
Erythema Multiforme
What is the number one cause of Erythema Multiforme?
Herpes Simplex Virus
With Herpes Simplex Virus recurrence happen at the site of ________.
innoculation
At time of ___________, HSV ascends peripheral sensory nerves and enters sensory or autonomic nerve root ganglia where latency is established
innoculation
Any herpetic infection around the eye requires examination of the cornea.
Periocular herpes
Vesicles have dried up and erosions remain
______ should always be in your d/d when you see crusted erosions
herpes
Most commonly associated with eczema but can be seen with other disorders
Associated with fever, malaise, irritability
Lesions are not ‘grouped’ but disseminated (everywhere)
Eczema Herpeticum
Initial lesions are usually papules and are not usually observed, quickly evolve into vesicles which appear as “dewdrops on a rose petal”
Vesicles umbilicate and rapidly evolve to pustules and crusts over 8-12 hours
Lesions develop in crops and will be seen in all stages of evolution
Varicella Zoster
Lesions first develop on face and scalp and spread inferiorly to trunk and extremities
Most profuse in areas least exposed to pressure
Mucous membranes-including nose, conjunctiva, pharynx, larynx, trachea, Gi tract, urinary tract and vagina can be involved
Varicella Zoster
Mortality rate in children is 1 per 50,000 cases or 100 deaths annually
Complications in children: bacterial superinfections, encephalitis, Reye’s syndrome
Adults: Prolonged recovery, pneumonia (16%), encephalitis, arthritis, carditis, orchitis
Mortality rate in adults is 15/50,000 cases
Varicella Zoster
Varicella immunization is 80% effective in preventing primary VZV infection
Uncertain how long immunity lasts
Zoster still occurs, rate is unknown
Varivax
Reactivation of VZV
Unilateral pain and a vesicular eruption limited to a dermatome
70% of cases age>50
1/3 as contagious as varicella
Herpes Zoster
Prodromal stage: Neuritic pain precedes eruption by 3-5 days
Active vesiculation: 3-5 days
Crust formation: day 2 - 3 weeks
Postherpetic neuralgia: months to years
Zoster "Shingles"
Nasocilliary branch of the trigeminal nerve is involved
Refer to Ophthalmology
Hutchinson’s Sign
Pain lasting> 30 days after lesions have cleared
Corticosteroids have been used with antivirals to reduce PHN
Ticyclic antidepressants (nortriptyline) and gabapentin have been shown to be helpful
Lidocaine patches and capsaicin cream
Frequent contact with children seem to decrease the incidence of zoster
Post herpetic Neuralgia
-Sites of predilection : Thoracic 50%, trigeminal 10-20%, lumbosacral/ cervical 10-20%
-7 times more common in immunocompromised patients, esp. HIV +
Zoster
May 25, 2006 – The FDA approved the first vaccine for zoster
The agency cleared the vaccine -- known as Zostavax -- for use in adults age 60 and older: studies showed it prevents zoster roughly half the time.
More than 1 million cases of Zoster yearly in US
Vaccinated patients are 1/3 less likely to develop PHN, and have fewer lesions and pain
Zostavax
What is this list:
Drug eruption
Secondary syphillis (check RPR)‏
Guttate psoriasis
Eczema
Parapsoriasis
Erythema multiforme
Pityriasis Rosea Differential Diagnosis
-Acute eruption with a distinctive morphology, and a characteristic course
-Starts with a primary or “herald” plaque usually on the trunk
-1-2 weeks later a generalized secondary eruption develops in a typical pattern
-Spontaneous remission in 6 weeks
-Usually only MILDLY pruritic
Pityriasis Rosea
Acute or chronic dermatosis involving skin and/or mucous membranes
Characterized by the “4 P’s” : Pruritic, Purple, Polygonal, Papules
Typical distribution: flexor surfaces (wrists) lumbar region, eyelids, shins, scalp, penis
Oral lesions typically show a lacy white reticular pattern on the buccal mucosa, can also be erosive
Lichen Planus
Nails: can cause destruction of the nail fold and nail bed.
Scalp: scarring alopecia
Koebner phenomenon
May be associated with Hepatitis C
Lichen Planus
-Sexually transmitted disease caused by Treponema pallidum
-Starts with a painless ulcer at site of innoculation
-Goes on to become systemic with secondary and tertiary stages
Syphillis
Teeming with spiroketes; palms & soles
Syphillis
Painless chancres at innoculation site; goes away
Syphillis
-Appears 2-6 months after primary infection and 2-10 weeks after appearance of primary chancre
-May have ‘acute illness syndrome’: fever, chills, arthralgia, myalgia, malaise
-Skin lesions: macules & papules scattered over trunk, neck, palms and soles
-Hair loss: ‘moth-eaten’ alopecia on scalp and beard areas
-Condyloma Lata: Soft, flat-topped pink papules on perianal area
Secondary Syphillis
-Aka: “The great imitator”……can look like any papulosquamous disease
-Lesions associated with secondary syphillis are ‘teeming with spirochetes
Still Secondary Syphillis
-Develops 2-60 years after primary lesions
-Noduloulcerative: plaques and nodules with scars healed in the center
-Gumma: rubbery lump or deep lesion found in subcutaneous tissue
Tertiary Syphillis
Acne is a multifactorial inflammatory disease affecting pilosebaceous follicles
Pathogenesis is not completely understood
Microcomedo is the primary acne lesion
Acne Vulgaris
-Abnormal desquamation of follicular keratinocytes
-Sebum production
-Proliferation of Propionibacterium acnes
-Inflammation and immune response
4 major factors in the etiology of acne vulgaris
What are the subtypes of hyperplasia
-Vascular
-Papulopustular
-Sebaceous Hyperplasia
-Ocular
-Flushing and persistent central facial erythema, +/- telangiectasia
-Edema can develop from recurrent vasodilation
Vascular Rosacea
What kind of Rosacea?
-Persistent facial erythema with transient papules and pustules
-Not centered around a comedo
-Keratinization defects play no role in rosacea
Papulopustular Rosacea
What kind of Rosacea?

-Initial process is overgrowth of sebaceous glands
-Skin appears thicker and smoother
-Irregular surface enlargement and nodularities develop as fibrosis occurs
Sebaceous Hyperplasia
What kind of rosacea?

-Occurs in up to 50% of rosacea patients
-Foreign body sensation in the eyes, burning or stinging, dryness, itching, photosensitivity, recurrent styes, blurred vision, telangiectasia of the sclera, periorbital edema
-Meiobian gland impaction-decreased lipid in tear film, greater tear evaporation, irritability of the eyes
Ocular Rosacea
Characteristic

Papules and Pustules: Yes
Erythema: yes
Telangiectasia: yes
Comedones: No
Usually Age > 25-30: Yes
Rosacea
Characteristics
Papules and Pustules: Yes
Erythema: No
Telangiectasia: No
Comedones: Yes
Usually Age < 25: Yes
Acne
What are these lesions?
-Seborrheic keratosis
-Cherry angioma
-Spider angioma
-Melanocytic nevus
-Halo nevus
Benign Tumors of the skin
What skin lesion?
-Most common benign epithelial tumor
-Hereditary
-Start at around age 30
-Can be few or multiple
-Vary in morphology and color depending on location of body
Seborrheic keratosis
What skin lesion?
-Very common, bright red to violaceous domed papules
-Can thrombose and appear black
-Most commonly on the trunk
-Develop around age 30
-Can be multiple
-Only a cosmetic nuisance
Cherry angioma
What is this skin lesion?
-One of the most common lesions in Caucasians
-Most adults have 20
-Appear in early childhood
-Gradually involute around 60
Acquired Melanocytic Nevus
What is this skin lesion?
-Nevus surrounded by a halo of leukoderma or depigmentation
-Immunologic phenomenon via action of cytotoxic lymphocytes
-Nevus will usually disappear in months-years
-Skin repigments in months-years
-May occur on one or multiple nevi
-Possible precursor to vitiligo
Halo Nevus
What kind of tumors are the following lesions?
-Basal cell carcinoma
-Squamous cell carcinoma
-Malignant melanoma
Malignant Tumors of the skin
What type malignant tumor?
-Most common type of skin cancer
-Slow growing
-Locally invasive and destructive but not metastatic
-Usually in sun-exposed areas in fair-skinned people
Basal Cell Carcinoma
What type of skin cancer is described?
-Typically looks like a ‘pearly’ shiny papule with overlying telangiectasia and rolled borders
-Center may be ulcerative
-Several variants: superficial, sclerosing, pigmented
Basal Cell Carcinoma
What is this a description of ?
It can look like a shiny bump or nodule that is pearly or translucent and is often pink, red or white. In dark-haired people it can be tan, black or brown.
Basal Cell Carcinoma
You are think you patient has eczema and your treat her with steroids. It does not clear. What does she have? What should you do?
Superficial Basal Cell Carcinoma (BCC);
Biopsy
This is a common appearance of what?

-a pink growth with a slightly raised, rolled border and a crusted indentation in the center, similar to a donut with an indented center.
Basal Cell Carcinoma
What are the three ways to prevent basal cell carcinoma?
hat, sunglasses, and sunscreen
Whatkind of cancer does the following describe?
-2nd most common type of skin cancer
-Sun exposed areas in fair-skinned people
-Erythematous, keratotic nodule, may ulcerate
Squamous Cell Carcinoma
What type of cancer?
Can metastasize (3-4%)
Most common skin cancer in black patients
Can occur in burn scars-Marjolin’s ulcer- met rate is 20%
Squamous Cell Carcinoma
What is the most common skin cancer in black patients?
Squamous Cell Carcinoma
What is this lesion?
Basal Cell Carcinoma
What is this lesion?
Basal Cell Carcinoma
What is this lesion?
Squamous Cell Carcinoma
What type of cancer? What disease do this boy has?
Squamous Cell Carcinoma. Xeroderma Pigmentosum
This is a seven-year-old girl. What disease does she have? What lesions do you see?
She has xeroderma pigmentosum. Multiple actinic keratoses & SCCs
What is this?
Melanoma
What is this?
melanoma
What is this?
melanoma
What are the ABC's of melanoma?
Asymmetry
Border irregularity
Color
Diameter
Every type of change.
What should you do with any type of change in the skin that doesn't go away in a timely manner?
Check it.
What is the most common dermatophyte.
T. rubrums
What is this most common candida pathogen?
C. Albicans
What conditions shows "spaphetti and meatballs" on KOH?
T. versicolr
This slide prepared with KOH, shows "spaghetti and meatballs" What is the pathogen
T. versicolor
Tinea capitis
Scalp
Tinea pedis
Feet (athletes foot)
Tinea manuum
Hands
Tinea cruris
Groin
Tinea barbae
Beard, hair
Tinea corporis
Body
Tinea unguium
Nails
Tinea unguium
(onychomycosis)
Etiologic agent is Phaeoannellomyces werneckii
Mostly seen in the tropics
Brown to black lesion on hands and feet
Tinea nigra
Dimorphic fungus
In soil and on plants (rosebushes and mulches)
Worldwide
Occupational disease of gardeners, florists, farmers etc.
Sporothrix schenckii
Painless papule – enlarge then open sore – along lymphatic drainage you will nodules
See a case every few years
Sporotrichosis
Genetic, environmental and immune factors
Genetics: risk of developing AD significantly higher if parents have an atopic disease
Environmental: food/aeroallergens, various non-allergic factors, ie. Trauma, low humidity, sweating, emotional stress, any viral infection, xerosis
Immune: Upregulation of interleukins, persistent monocyte activation, increased eosinophil infiltration in the skin and elevated serum levels of IgE
Etiologic factors of atopic dermatitis
Which immunoglobulin is elevated in contact dermatitis?
IgE
Typically, Infantile eczema affects the facial areas
Teens and older children tend to develop it in the folds of the antecubital and popliteal fossae
Adults tend to develop lesions on the hands, feet and trunk but this can vary greatly among individuals
Presentation of Atopic dermatitis will vary with age.
These are ______________
Tachyphylaxis (diminishing efficacy)
Skin side effects
Atrophy, telangiectasia, striae, dyspigmentation
HPA-axis suppression (reduced cortisol)
A greater concern in children because:
Higher body surface area (BSA) to weight ratios than adults
Occlusion in diaper areas increases absorption
Cushing’s syndrome and potential for growth retardation
Risk of cataract and glaucoma
Issues associated with treating the skin with topical steroids
Classic delayed cell-mediated hypersensitivity reaction
Sensitization can occur quickly with strong sensitizers, like poison ivy, or over years
Antigen is absorbed in skin by Langerhans cells-processes antigen and takes it to lymph nodes and T cells-sensitized T cells then enter blood circulation-then all of the skin becomes hypersensitive to the allergen
Etiology of contact dermatitis and sensitization.
Localized form of lichenification
Characteristic feature of AD but can occur independent of AD
Results from rubbing and scratching at an area for months to years
Often related to emotional stress
Patients often say that the scratching becomes pleasurable and will scratch until it bleeds
Lichen simplex chronicus
Occurs in the winter in elderly
Skin is dry, ‘cracked’, fissured with slight scaling
Persists for months
Due to too frequent bathing in hot water and too much heat in the house
asteatotic eczema
Chronic, pruritic, inflammatory dermatitis occurring in the form of coin shaped plaques
Common on lower legs of elderly men in the winter months
nummular eczema
Hypopigmented to slightly pink, lightly scaly plaques on face, trunk, arms
Associated with AD
Pityriasis Alba
Chronic, self-limited dermatosis of the dermis
Annular plaques usually on hands and feet
Common in children
Disappears in 2 yrs in 75% of pts
Recurrences are common
Often dx as tinea
granuloma annulare
What is this?
Lichenification
What is the target of biologic agents used for treatment of psoriasis
TNF
T-lymphocytes (T-cells)
Major defect mediating psoriasis
TNF is a critical mediator of psoriatic inflammation, playing a central role in the inflammatory response
Psoriatic plaques have high levels of TNF
TNF can trigger multiple destructive effects, including ____ levels in the skin causing epidermal _______.
excess;thickness.
List the biologic agents used to treat psoriasis.
Etanercept (Enbrel) -TNF
infliximab (Remicade) - TNF
adalimumab (Humira) - TNF
efalizumab (Raptiva) - T cells
alefacept (Amevive) - T cells
Definition of Psoriasis
Psoriasis is a systemic, chronic genetic disease that is not contagious. Psoriasis is characterized by raised, thick inflammed patches of skin that are covered by silvery-white scales and are associated with local itching or burning.
What is this a description of ?
Immune system is mistakenly triggered which speeds up the growth cycle of skin cells
Normal cell matures and sheds in 30 days
Psoriatic skin cell matures in 3-4 days
Instead of shedding, the cells build up and form plaques
Etiology of Psoriasis
Population affected: 7 million (2.6% of US population)‏
Gender: Equal distribution between men and women
Age of onset: Mean 28 years
New cases: Between 150,000 and 260,000 cases/year
Undertreatment: 50% with active disease not currently treated
Outpatient costs: $1.6 to $3.2 billion/year
Psoriasis Statistics
Psoriasis on <5% of BSA
Does not Impact on patient’s quality life
Treatment
Moisturizers, OTC products, topical steroids, vitamin D3 and A derivatives
Treatments have no known serious risks
Clinical Definition of Psoriasis: Mild
Body surface area
Psoriasis  5% of BSA
Impact on patient’s life
Psoriasis does impact quality of life
Expectation is that therapies will improve quality of life
Treatment
Phototherapy, topicals, and systemic oral medications
Therapies have toxicities associated with long term use that limit effectiveness and may be inconvenient, expensive, and time-consuming
Clinical Definition of Psoriasis: Moderate to Severe
Body surface area
Psoriasis on generally >10% of BSA
Impact on patient’s life
Disease may alter the patient’s quality of life
Patients may be willing to accept medications with potentially significant side effects
Treatment
A satisfactory response is usually not achieved by treatments that have minimal risks
Severe Psoraisis