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326 Cards in this Set
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A 45-year old healthy woman with no significant PMH presents for evaluation of a skin lesion. She does not have a family hx of skin cancer. The lesion is symmetric, with well-defined borders, 4 mm, and uniform coloration. She is not able to assess whether the lesion has changed recently and does not give a history of itching or bleeding at the site of the lesion.
What is the most likely diagnosis? |
Benign nevus |
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A 45-year old healthy woman with no significant PMH presents for evaluation of a skin lesion. She does not have a family hx of skin cancer. The lesion is symmetric, with well-defined borders, 4 mm, and uniform coloration. She is not able to assess whether the lesion has changed recently and does not give a history of itching or bleeding at the site of the lesion.
What are the reassuring features? |
- Size <6mm - Symmetric - Uniform color - Well-defined borders |
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A 45-year old healthy woman with no significant PMH presents for evaluation of a skin lesion. She does not have a family hx of skin cancer. The lesion is symmetric, with well-defined borders, 4 mm, and uniform coloration. She is not able to assess whether the lesion has changed recently and does not give a history of itching or bleeding at the site of the lesion.
What are the next steps in treatment? |
- Reassurance - Surveillance (examine at subsequent visits and patient education on self-examination |
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What is an abscess? |
A closed pocket of pus |
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What is a bulla? |
A blister greater than 0.5 cm in diameter (plural: bullae) |
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What is a cyst? |
A closed, sac-like, membranous capsule containing a liquid or semisolid material |
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What is a macule? |
A discoloration on the skin that is neither raised nor depressed |
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What is a nodule? |
A small mass of rounded or irregular shape that is greater than 1.0 cm in diameter |
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What is a papule? |
A small, circumscribed elevated lesion on the skin that is less than 1.0 cm in diameter |
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What is a plaque? |
A plateau-like, raised, solid area on the skin that covers a large surface area in relation to its height above the skin |
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What is an ulcer? |
A lesion through the skin or mucus membrane resulting from loss of tissue |
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What is a vesicle? |
A small blister less than 0.5 cm in diameter |
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Annually, how many new cases of melanoma are diagnosed in the U.S.? |
>68,000 |
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Annually, how many new cases of skin cancer (melanoma, squamous cell carcinoma, and basal cell carcinoma) are diagnosed in the U.S.? |
>1 million |
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Annually, how many deaths does skin cancer cause? What percentage are due to melanoma? |
~10,000 (80% due to melanoma) |
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What are the risk factors for skin cancer? |
** UV radiation exposure - Hx of skin cancer - Family hx of skin cancer - Fair skin - Red or blonde hair - Propensity to burn easily - Chronic exposure to toxic compounds such as creosote, arsenic, or radium - Suppressed immune system |
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What are the four basic types of melanoma? |
- Superficial spreading melanoma - Lentigo maligna - Acral lentiginous melanoma - Nodular melanoma |
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What is the most common type of melanoma? |
Superficial spreading melanoma |
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How does superficial spreading melanoma present? |
- Raised borders - Brown lesions with pinks, whites, grays, or blues - More common in elderly |
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How does superficial spreading melanoma progress? |
- Lesion spreads superficially along top layers of skin before penetrating into deep layers - Superficial, or radial, growth phase is slower than the vertical phase (when it may invade into dermis or other tissues) |
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How does the presentation of superficial spreading melanoma differ between the genders? |
- Men: more commonly affected on upper torso - Women: more commonly affected on legs |
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How does lentigo maligna melanoma present? |
- Most often in elderly (commonly in 7th decade of life) - Usually on chronic, sun-damaged skin such as the face, ears, arms, and upper trunk - Tan to brown lesions with very irregular borders |
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Which type of melanoma is the least common? |
Lentigo maligna |
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Which type of melanoma is the most common in Hawaii? |
Lentigo maligna |
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Which type of melanoma is most common in African Americans? |
Acral lentiginous melanoma |
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Which type of melanoma is most common in Asians? |
Acral lentiginous melanoma |
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How does acral lentiginous melanoma typically present? |
- Begins in situ - Usually found under the nails, on the soles of the feet, and on the palms of the hands - Flat, irregular, dark brown to black lesions |
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Which type of melanoma is most likely to be invasive at the type of diagnosis? |
Nodular Melanoma |
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How does nodular melanoma typically present? |
- Brown to black lesions that arise from nevi or normal skin - Typically is invasive at the time of diagnosis |
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What are the classic characteristics of a suspicious skin lesion? |
- A: Asymmetry - B: Borders - C: Color - D: Diameter - E: Elevation and Evolving |
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What is the "A" of the suspicious skin lesions? |
ASYMMETRY: - Benign: symmetric (right half looks like left half) - Malignant: asymmetric (in >2 axes) |
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What is the "B" of the suspicious skin lesions? |
BORDERS: - Benign: well defined - Malignant: ragged or blurred |
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What is the "C" of the suspicious skin lesions? |
COLOR: - Benign: uniform color - Malignant: variegated (2 or more colors) |
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What is the "D" of the suspicious skin lesions? |
DIAMETER: - Benign: <6 mm - Malignant: >6 mm |
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What are the "E"s of suspicious skin lesions? |
ELEVATION: - Benign: flat surface - Malignant: raised surface
EVOLVING: - Benign: stable in size and appearance - Malignant: enlargement, changes in thickness, or bleeding |
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What is the necessary treatment for benign nevi? |
- Monitor visually - Educate patient on what to look for and when to come back for re-evaluation |
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If a pre-existing nevus changes or if you find a new pigmented lesion, what should you do? |
Completely excise with a 2 to 3 mm margin around the lesion |
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If a suspicious skin lesion is excised with a 2-3 mm margin and is determined to be malignant, what further treatment should be done? |
- Lesion should be completely excised with 5-mm margins by a physician trained in plastic surgical technique - Patient should be observed on an annual basis for any new or changing skin lesions |
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What kind of biopsy should be done for a raised lesion? |
Shave biopsy |
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What kind of biopsy should be done for a flat lesion? |
Punch biopsy or elliptical excision |
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What should you do for a lesion that is too large for a complete excision? |
Biopsy the most suspicious part of the lesion |
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What is the most important piece of information for prognosis in melanoma? |
Thickness of the tumor (aka Breslow measurement) |
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What characteristic about melanomas makes it have a low rate of metastasis and a high cure rate with excision? |
< 1mm thick |
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How do you prevent skin cancers? |
- Reduce exposure to UV radiation - Avoid the sun between 10am and 4pm - Wear sun-protective clothing when exposed to sunlight - Wear a sunscreen with SPF of >15 - Avoid artificial sources of UV radiation |
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What do basal cell and squamous cell carcinomas arise from? |
Epidermal layer of the skin |
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What are the risk factors for basal cell and squamous cell carcinomas? |
- Exposure to UV radiation, especially sun exposure and tanning beds - History of actinic keratoses and HPV infection of skin (for squamous cell carcinoma) |
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What is the most common type of all cancers? |
Basal cell carcinomas |
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What is the typical appearance of a basal cell carcinoma? |
- Pearly papules - Often with a central ulceration or multiple telangiectasias - Growing lesion that may bleed or itch |
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What is the prognosis of basal cell carcinomas? |
- Rarely metastasize - Can grow large and can be locally destructive |
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How do you treat basal cell carcinomas? |
Excision |
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What is the prognosis of squamous cell carcinomas? |
Higher rate of metastasis than basal cell carcinomas but risk is still low |
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What is the typical appearance of squamous cell carcinomas? |
- Irregularly shaped plaques or nodules with raised borders - Frequently scaly, ulcerated, and bleed easily |
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How do you treat squamous cell carcinomas? |
Excision |
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A 36-year old man is noted to have a bothersome "mole" that on biopsy reveals malignant melanoma. The pathologist comments that this histology is the most common type of melanoma in both males and females and has two growth phases. Which type is the most likely finding? |
Superficial spreading melanoma
(Most commonly occurring melanomas in both men and women) |
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A 49-year old fair skinned woman is noted to have a lesion on her right upper back that seems to have grown over the past year. It is noted to be 8 mm in diameter. The physician obtains an excisional biopsy, and it returns as malignant melanoma with invasion. Which of the following is the most likely finding on the biopsy? |
Nodular melanoma
(Most aggressive melanomas and are usually invasive at time of diagnosis. This has grown quickly and is invasive.) |
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A 54-year old African-American man is noted to have a dark "spot" on his palm of his hand that his wife noticed has become irregular in shape. On biopsy it is a malignant melanoma. Which is the most likely histology in this patient? |
Acral lentiginous melanoma
(Found on palms of hands, soles of feet, and under fingernails and toenails. Most common type in African Americans and Asians.) |
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A 45-year old African-American woman presents for routine exam. You notice a 9-mm diameter lesion on the palm of her right hand that is dark black, slightly raised, and has a notched border. When asked about it, she says that it has been present for about a year and is growing. A friend told her not to be concerned because "black people don't get skin cancer." What is your advice? |
This lesion is suspicious for a primary melanoma and needs further evaluation immediately
(Suspicious for aural lentiginous melanoma and needs evaluation. Skin cancers are more common in persons with lighter skin, they can occur in persons with any skin color or tone.) |
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A 70-year old woman presents for evaluation of a lesion on her left cheek. It has been present for several months. It is slowly growing and bleeds if she scratches it. On exam, you find a 7-mm diameter pearly appearing papule with visible telangiectasis on the surface. What is the appropriate management of this lesion? |
Excision
(Likely a basal cell carcinoma and should be treated with excision. Likelihood of metastatic spread is low, these lesions can grow and be locally destructive.) |
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A 16-year old adolescent girl has been stung by a wasp and is having a painful, itchy local reaction. She has no history of previous allergic reactions. The patient's mother is calling and asking you to manage the situation over the phone.
What is the most appropriate antibiotic to use? |
No antibiotic treatment is indicated as this is a local reaction |
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A 16-year old adolescent girl has been stung by a wasp and is having a painful, itchy local reaction. She has no history of previous allergic reactions. The patient's mother is calling and asking you to manage the situation over the phone.
What therapy may be beneficial? |
- Local applications of ice - NSAIDs or acetaminophen for pain - Anti-histamine for itching |
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A 16-year old adolescent girl has been stung by a wasp and is having a painful, itchy local reaction. She has no history of previous allergic reactions. The patient's mother is calling and asking you to manage the situation over the phone.
What immunizations if any are appropriate? |
Tetanus-diphtheria booster, if not up-to-date |
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What kind of bugs cause the majority of cases of sting or bite-induced anaphylaxis? |
- Wasps - Yellow jackets - Hornets - Honeybees - Bumblebees - Fire ants |
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What causes the local reactions from insect bites? |
Toxic properties of venom |
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What causes the severe reactions from insect bites? |
Allergic reaction to venom allergens |
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Why should stingers be promptly removed? |
If the stinger remains in it may lead to continued injection of the bee venom
It is more important to rapidly remove the stinger than to locate a scraping implement |
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How should you remove a stinger? Why? |
Scrape or brush the stinger off of the skin (e.g., with a credit card or driver's license)
If you grasp the base of the stinger it may result in compression of a venom-containing sac, resulting in increased venom release |
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What is hymenoptera? |
Order of insects which includes wasps, yellow jackets, hornets, honeybees, and fire ants, and make up the majority of insect stings |
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What mediates a large local allergic reaction? Signs? |
- Mediated by immunoglobulin (Ig) E reactive to the Hymenoptera venom - Causes redness or warmth of the skin at the area of insect sting |
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What happens when you get stung by a Hymenoptera species? |
Local reaction --> redness, swelling, pain, and itching at site of injury
Histamine like reaction in response to the venom from the stinger
Occurs immediately and last for a few hours |
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What are the characteristics of a delayed reaction to stingers? |
Large local allergic reaction mediated by IgE reactive to Hymenoptera venom
Often confused with cellulitis, as large areas (>10 cm in diameter) of redness and warmth develop over 24-48 hours |
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How do you treat the delayed reaction to stingers? |
- Not infectious, will not respond to antibiotics - Best treated with ORAL STEROIDS early after the ting - Tetanus prophylaxis should be reviewed and updated if necessary |
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If you have previously had a delayed reaction to stingers, what should you expect if you get stung again in the future? |
- Likely to have similar reactions to subsequent stings - History of this type of reaction does not result in an increased risk of anaphylaxis to subsequent stings |
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How common are anaphylactic reactions to stings? |
Up to 4% of the population may have a systemic reaction to a Hymenoptera sting |
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What is your risk for subsequent anaphylaxis to a sting after an anaphylactic reaction? |
Those who have had a systemic reaction have a 50% or greater risk of having a systemic reaction to future stings |
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What are the symptoms of a systemic reaction to a sting? |
- Nausea - Generalized urticaria - Angioedema - Hypotension / Shock - Airway edema - Death |
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When does a severe immediate hypersensitivity reaction usually occur? |
Within minutes of the sting |
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How should you treat anaphylaxis? |
Assessment and management of the ABCs (Airway, Breathing, and Circulation), with intubation if necessary, IV access, and fluid resuscitation at 10-20 mg/kg (usually 500-1000 cc) ASAP
*Subcutaneous or IM injection of 0.3-0.5 ml of 1:1000 solution of epinephrine should be given as quickly as possible (repeat in 10-15 minutes if needed)
- May also use antihistamines, steroids (if severe), and bronchodilators |
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What is the correct dosing and route of administration of epinephrine following anaphylaxis to a stinger? |
Subcutaneous or IM injection of 0.3-0.5 ml of 1:1000 solution of epinephrine, repeat in 10-15 minutes if needed |
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What monitoring is needed for a patient following an anaphylactic reaction? |
They need to be observed in the hospital for 12-24 hours as the symptoms can recur |
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What should you do if you have a history of anaphylaxis to stings? |
- Prescribe an epinephrine injector kit to carry with for immediate access at all times (update often as it expires in 6-12 months) - Avoid wearing perfumes, bright clothing, and avoid walking barefoot |
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What can be done to reduce your risk of future anaphylaxis to stings? |
Desensitiziation therapy --> reduces by up to 50% |
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How should you initially manage a patient with an animal bite? |
ABCs and protect of the current injury (splinting of fractures, protection of cervical spine, etc) and control of bleeding and assessment of injuries incurred |
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What history should be gathered from a patient following an animal bite? |
- Type of animal involved - Situation regarding the bite (was the animal provoked or unprovoked) - Vaccination status of animal (especially rabies vaccination) |
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What are most cases of human rabies caused by? |
- Bats - Skunks - Dogs - Foxes |
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How should you treat an animal bite after managing the ABCs and bleeding? |
Local cleaning of the sound(s) with soap and water, irrigation with saline, and debridement of devitalized tissue ASAP
This may be all that is needed for smaller wounds |
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What affects the risk of infection after an animal bite? |
- Larger and deeper wounds are more likely to be infected than smaller, superficial wounds - Hand wounds also tend to have increased risk of infection - Presence of chronic illnesses or immune suppression - Type of animal
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How often do dog bites get infected? Do cat and human bites get infected more or less often than dog bites? |
- 20% of dog-bite wounds become infected - Cat and human bites have a higher occurrence of infection |
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Dog and cat bites get infected with what kinds of bacteria? |
- Staphylococci - Streptococci - Anaerobic species - Pasteurella species |
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Human bites get infected with what kinds of bacteria? |
- Staphylococci - Streptococci - Haemophilus species - Eikenella species - Anaerobes |
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Should bite wounds be closed? |
- Primary closure of bite wounds is controversial and should be limited to lacerations less than 24 hours old
- Deep puncture and wounds with signs of infection should not be primarily closed |
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What vaccinations should be given following a bite wound? |
Tetanus vaccination should be updated as needed
Animal control authorities should be contacted for guidance regarding rabies vaccinations |
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Is antibiotic therapy necessary following a dog, cat, or human bite? |
Antibiotic prophylaxis for 5-7 days for patients with moderate to severe wounds from dog, cat, or human bites
*Augmentin (Amoxicillin-Clavulanate) given orally is appropriate for most wounds
If cellulitis is present, longer courses (7-14 days) are required |
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What therapeutic option is useful in treating both bee stings and bite wounds? |
Tetanus vaccination |
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A 22-year old woman develops a progressively enlarging red hot area on her leg following a yellow jacket sting. She states that the sting was sharp and of brief duration and she was able to fully remove the stinger with tweezers. She did not suffer from any systemic anaphylaxis. She has no previously known allergens. She sees you in the office a day after the sting and says that the lesion is still enlarging despite using OTC corticosteroid cream and a first-generation antihistamine.
Which of the following is the most appropriate treatment for this patient? |
Oral prednisone
(This is an IgE mediated reaction. It may respond to a course of oral steroids. At least 50% chance a similar reaction will occur if she were stung again, but unlikely to develop anaphylaxis in the future so does not require prophylaxis. History of a sting makes cellulitis less likely.) |
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You see a 7-year old boy a day after he was bitten by his pet dog. According to the mother, the dog bit the child after he snuck up on the dog and grabbed its tail. The dog has had all its vaccinations, including rabies. The child has had no fever, has full movement of the injured limb, and has no sign of neurologic or vascular injury. The wound is on the child's forearm, is not deep, and is not bleeding, but has developed about 2 cm of erythema surrounding the site.
What is the most appropriate treatment? |
Oral amoxicillin-clavulanate for 7-14 days
(Does not appear to require hospitalization. Likely is developing cellulitis which requires oral antibiotic treatment for 7-14 days.) |
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You see a 43-year old man who 2 days prior was in a fist fight and sustained a deep laceration wound around the knuckles from where he struck the face of another man. He was intoxicated at the time and upon return home he did not clean the wound and went straight to sleep. He now has purulent drainage, pain, erythema, and fever. There is no rash and he has not noted any spreading of the erythema. An x-ray of the hand shows a hairline fracture of the fifth metacarpal with swelling and bruising noted over the affected area.
What is the most likely organism causing infection? |
Eikenella corrodens (most common in closed fist injuries)
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A mother brings in her 6-year old child who was bitten on the hand while playing with a rabbit that was recently obtained from a neighbor. The child's wound is on the volar surface of the right second finger just distal to the proximal interphalangeal joint.
What step in the management of bite wounds is most effective in preventing wound infection? |
Saline irrigation and wound care
(Rodents and rabbits are neither reservoirs of the rabies virus nor have been shown to transmit rabies virus to humans. Tetanus prophylaxis should be considered in all bite wounds. Antibiotic prophylaxis may be indicated in high-risk bites (located on the hand, late presentation, cat bites) and should be directed at staph, strep, anaerobes, and Pasteuralla species as appropriate.) |
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What dermatologic conditions have a strong genetic component? |
- Acne - Atopic dermatitis - Psoriasis - Skin cancers - Dysplastic nevi - Neurofibromatosis - Tuberous sclerosis |
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Does the US Preventive Services Task Force recommend a whole-body skin exam by PCPs or patient skin self-exams? |
There is not enough evidence to assess the balance of benefits and harms for the detection of cutaneous melanoma, basal cell cancer, or squamous cell skin cancer in adult general population
It may be worth screening patients with high risk for skin cancer |
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What kind of people are at higher risk for melanoma? |
- Fair skinned - >65 years - Patients with many atypical moles - Those with more than 50 moles
- Family history - Substantial history of sun exposure and sunburns |
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What is the risk for a second basal cell carcinoma (BCC) after having a history of BCC? |
>40% in the next 3 years |
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What is the most efficient way to do a skin exam? |
- Do a history simultaneous to the physical exam - Ask questions while you examine the patient
(1) Look carefully at lesion - determine type (2) Touch the lesion (3) Observe distribution (groups, rings, lines) (4) Observe remainder of skin, nails, hair, and mucus membranes |
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What is the term for a circumscribed flat discoloration (up to 5 mm)? |
Macule |
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What is the term for a flat non-palpable discoloration (>5 mm)? |
Patch |
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What is the term for an elevated solid lesion (up to 5 mm)? |
Papule |
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What is the term for an elevated solid lesion (>5 mm)? |
Plaque - often a confluence of papules |
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What is the term for a palpable solid (round) lesion, deeper than a papule? |
Nodule |
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What is the term for a pink edematous plaque - round or flat-topped and transient? |
Wheal (hive) |
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What is the term for an elevated collection of pus? |
Pustule |
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What is the term for a circumscribed elevated collection of fluid (up to 5 mm in diameter)? |
Vesicle |
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What is the term for a circumscribed elevated collection of fluid (>5 mm in diameter)? |
Bulla |
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What is the term for excess dead epidermal cells? |
Scale (desquamation) |
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What is the term for a collection of dried serum, blood, or pus? |
Crusts |
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What is the term for superficial loss of epidermis? |
Erosion |
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What is the term for a linear loss of epidermis and dermis? |
Fissure |
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What is the term for a depression in the skin from thinning of epidermis and/or dermis? |
Atrophy |
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What is the term for an erosion caused by scratching? |
Excoriation |
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What is the term for thickened epidermis with prominent skin lines? |
Lichenification |
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What questions will help you diagnose and plan the treatment of different skin lesions? |
- Onset and duration of skin lesions - continuous or intermittent? - Pattern of eruption - where did it start? how has it changed? - Any known precipitants, such as exposure to medication (prescription and OTC), foods, plants, sun, topical agents, or chemicals (occupation and hobbies)? - Skin symptoms - itching, pain, paresthesias? - Systemic symptoms - fever, chills, night sweats, fatigue, weakness, weight loss? - Underlying illness - diabetes, HIV? - Family history - acne, atopic dermatitis, psoriasis, skin cancers, dysplastic nevi? |
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What are the most important in-office tests in assessing skin disorders? |
- Microscopy - Wood's light exam - Surgical biopsy |
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How do you diagnose a suspected fungal infection? |
Microscopy: - Scrape some of the scale from the skin lesion onto a microscope slide - Add KOH - Look for hyphae of dermatophytes or pseudohyphae of yeast forms of Candida or Pityrosporum species - Start on 10 power and confirm your findings on 40 power |
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What can Wood's light exam help you to diagnose? |
Tinea Capitis and Erythrasma |
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How do you diagnose Tinea Capitis? |
Wood's light exam - caused by Microsporum species, produces a green fluorescence |
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How do you diagnose Erythrasma? |
Wood's light exam - produces a coral red fluorescence |
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What are the types of surgical skin biopsies? |
- Shave - Punch - Elliptical |
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What are the beneficial effects of topical corticosteroids? |
Anti-inflammatory and anti-mitotic effects |
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What are the adverse effects of topical corticosteroids? |
Occur with regular use over weeks to months - Skin atrophy (epidermis becomes thin and superficial capillaries dilate) - Hyperpigmentation, telangiectasis, striae
(Atrophy is usually reversible in months but the striae are irreversible) |
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What are the possible adverse effects of the fluorinated steroids (strongest) when applied continuously to the face? |
- Perioral dermatitis - Rosacea-like and acneiform eruptions |
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What is an appropriate topical corticosteroid for a dry lesion? |
Ointment or moisturizing lotion |
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What is an appropriate topical corticosteroid for a moist or weeping lesion? |
Cream or gel |
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What is an appropriate topical corticosteroid for a hair-covered area? |
Lotion or liquid prep |
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What is an appropriate strength of topical corticosteroid for the face and genitals? |
Thin skin - weakest strength, avoid atrophy |
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What is an appropriate strength of topical corticosteroid for the soles of hands and feet? |
Thickest skin - if lesion is severe and thickened (lichenified), may need most potent strength |
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What is an appropriate strength of topical corticosteroid for areas other than the face, genitals, and soles of hands/feet? |
Use strength appropriate to severity and thickness of lesion |
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What is a low potency topical corticosteroid? |
1% hydrocortisone (OTC) |
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What is a low-moderate potency topical corticosteroid? |
0.05% desonide |
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What is a moderate potency topical corticosteroid? |
0.1% triamcinolone |
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What is a high potency topical corticosteroid? |
0.05% fluocinonide |
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What is a super-high potency topical corticosteroid? |
0.05% clobetasol propionate |
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What are the types of topical corticosteroids from lowest to highest potency? |
- Low: 1% hydrocortisone (OTC) - Low-moderate: 0.05% desonide - Moderate: 0.1% triamcinolone - High: 0.05% fluocinonide - Super-high: 0.05% clobetasol propionate |
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How should the age of the patient affect your prescription of topical corticosteroids? |
Avoid the use of high-potency topical steroids in infants and children because they have greater surface area per body mass than adults; they therefore have greater risk and consequences of systemic absorption |
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How does the "vehicle" (substance in which the steroid is dispersed) affect your steroid choice? |
The type of vehicle affects the potency of steroid because it determines the rate at which the steroid is absorbed through the skin |
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What are the characteristics of the texture/content of "creams"? |
- Mixture of oil and water, may contain alcohol - White color, may be somewhat greasy |
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What are "creams" best used for? What negative effects may they cause? |
- Best for moist or exudative lesions - Cosmetically most acceptable - Better in skin folds than ointments
- May cause stinging and irritation to broken skin - May be drying |
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What are the characteristics of the texture/content of "ointments"? |
- Base is frequently petroleum jelly - Translucent and very greasy |
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What are "ointments" best used for? What negative effects may they cause? |
- Best for dry lesions - lubricating - Increased absorption of steroid and therefore enhances potency
- Greasy feeling persists after application - May get on clothes and be transferred from hands to surfaces at work - Cosmetically less acceptable in daytime (may be used at night and apply cream during day) - Too occlusive for exudative lesions and areas of skin folds (groin) - Too messy for hair-covered areas |
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What are the characteristics of the texture/content of "gels"? |
- Greaseless mixtures of propylene glycol and water - May contain alcohol - Clear and jelly like |
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What are "gels" best used for? What negative effects may they cause? |
- Useful for exudative lesions
- May be drying |
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What are the characteristics of the texture/content of "solutions and lotions"? |
- Water and alcohol base - Solutions usually clear - Lotions have a milky appearance |
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What are "solutions and lotions" best used for? What negative effects may they cause? |
- Best for scalp and other hair-covered areas: penetrates easily and doesn't make hair greasy
- May cause stinging and irritation to broken skin |
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How do you determine the duration of therapy? |
- Should be the time it takes for resolution of symptoms or lesions - High potency steroids should not be used continuously for longer than 2 weeks (they can be used intermittently for chronic conditions, such as psoriasis, in a pulse-therapy mode) |
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What is pulse-therapy mode? |
Apply every weekend, with no application during the week |
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What can you do to treat dry lesions to minimize steroid exposure? |
Liberal use of emollients between steroid applications |
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What bacterial infections can affect the epidermis? |
- Impetigo - Ecthyma (impetigo with ulceration) - Bullous impetigo |
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How do you treat bacterial infections of the epidermis (impetigo, ecthyma, bullous impetigo)? |
Topical mupirocin or oral antibiotic that covers GABHS and Staph aureus (consider CA-MRSA coverage) |
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What bacterial infections can affect the dermis? |
- Erysipelas - Cellulitis (dermis and subcutaneous tissue also) |
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How do you treat bacterial infections of the dermis (erysipelas and cellulitis)? |
Oral or IV antibiotics based on severity (consider CA-MRSA coverage) |
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What bacterial infections can affect the dermal appendages (hair follicles, nail folds)? |
- Folliculitis - Carbuncle, furuncle - Paronychia - Abscess |
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How do you treat bacterial infections of the dermal appendages (folliculitis)? |
Topical or oral antibiotic |
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How do you treat bacterial infections of the dermal appendages (carbuncle or furuncle)? |
I&D |
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How do you treat bacterial infections of the dermal appendages (paronychia)? |
I&D |
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How do you treat bacterial infections of the dermal appendages (abscess)? |
I&D (consider antibiotics for CA-MRSA coverage) |
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What bacterial infections can affect the subcutaneous tissue / fascia? |
Necrotizing fasciitis |
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How do you treat bacterial infections of the subcutaneous tissue / fascia (necrotizing fasciitis)? |
- Hospitalize - IV Antibiotics - Debridement |
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What oral antibiotics cover Group A Beta-Hemolytic Strep (GABHS) and S. Aureus? |
- First line: Dicloxacillin, Cephalexin - Second line: Clindamycin for severe PCN allergy |
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What are most bacterial skin infections caused by? |
Staph aureus (greater than half may be CA-MRSA!) |
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What antibiotics treat methicillin-sensitive S. aureus? |
- Cephalexin - Dicloxacillin - Clindamycin |
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What are risk factors for MRSA infection? |
- Non-Hispanic black race - Use of antibiotic in past month - Reported spider bite - History of MRSA infection - Close contact with person with similar infection |
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What antibiotics can be used to cover CA-MRSA? |
- Trimethoprim/Sulfamethoxazole (100%) - Rifampin (100%) - Clindamycin (95%) - Tetracycline (92%) |
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What is the term for the superficial skin infection often characterized by "honey" crusts? |
Impetigo |
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What is the classical presentation of Impetigo? |
- Superficial skin infection - "Honey" crusts - May be vesicular or bullous - In children often around the nose and mouth |
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Who is prone to impetigo infection? |
Homeless people due to sleeping on the streets and lack of hygiene |
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How do you treat Impetigo? |
Antibiotics that cover S. aureus and S. progenies for 7-10 days (Cephalexin or Dicloxacillin) |
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What are some variations of Impetigo? |
Ecthyma and Bullous Impetigo |
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Which skin condition presents as an ulcerated punched-out base? |
Ecthyma |
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What is a life-threatening more severe variation of bullous impetigo? |
Staphylococcal Scalded Skin Syndrome (SSSS) |
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What causes Staphylococcal Scalded Skin Syndrome (SSSS)? |
Bullae are caused by exfoliating toxin |
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How do you treat Staphylococcal Scalded Skin Syndrome (SSSS)? |
- Emergent hospitalization - IV antibiotics - Fluids - Supportive therapy |
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What commonly causes cellulitis? |
- Beta-hemolytic Streptococci - S. aureus |
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What is Erysipelas? |
Superficial cellulitis with prominent lymphatic involvement causing lesions that are raised above the level of surrounding skin with a clear line of demarcation between involved and uninvolved tissue
Frequently caused by beta-hemolytic strep (commonly on extremities) |
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What typically causes cellulitis? |
Begins with a break in the skin caused by trauma, a bite, or an underlying dermatosis (e.g., tinea pedis) |
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What is folliculitis? |
Infection or inflammation of the superficial portion of the hair follicle |
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What causes folliculitis? |
- Often by S. aureus - Hot-tub folliculitis - Pseudomonas - General folliculitis - also by Pityrosporum yeast or occlusion of hair follicles with tight fitting clothing |
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How does folliculitis classically present? |
Perifollicular erythema, papule, or pustules
Lesions are associated with hair follicles |
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How do you treat folliculitis? |
- Avoid occlusive clothing and contaminated hot tubs - Use of topical or oral antibiotics or antifungals |
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What is an abscess? |
Localized collection of pus |
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What is a furuncle? |
AKA boil; abscess that starts in a hair follicle or sweat gland |
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What is a carbuncle? |
When a furuncle extends into the subcutaneous tissue |
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What are most skin abscesses caused by? |
S. aureus with MRSA the predominant pathogen |
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How do you treat abscesses (including furuncles and carbuncles)? |
I&D --> drain pus so lesion can heal
Systemic antibiotics, whether parenteral or oral, do not adequately penetrate an abscess to cure the infection
If there is significant surrounding cellulitis, systemic antibiotics may be needed as an adjunct to I&D |
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What is necrotizing fasciitis? |
Deep infection by "flesh-eating bacteria" of the subcutaneous tissue and fascia |
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How does necrotizing fasciitis typically present? |
Diffuse swelling of arm and leg, followed by appearance of bullae with clear fluid that may become violaceous in color
Marked systemic symptoms like pain out of proportion to skin lesion |
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What commonly causes necrotizing fasciitis? |
S. pyogenes (often after varicella or minor injuries like scratches and insect bites)
Polymicrobial (~5 pathogens, most originate from bowel flora like cloakrooms or anaerobic bacteria) |
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What can necrotizing fasciitis lead to? |
- Cutaneous gangrene - Myonecrosis - Shock - Death |
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How do you treat necrotizing fasciitis? |
Surgical debridement and IV antibiotics |
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What clinical features suggest the presence of a necrotizing infection? |
- Severe, constant pain - Bullae - Skin necrosis or ecchymosis (bruising) that precedes skin necrosis - Gas in soft tissues detected by palpation or imaging - Edema that extends beyond the margin of erythema - Cutaneous anesthesia - Systemic toxicity, manifested by fever, tachycardia, delirium, renal failure - Rapid spread, especially during antibiotic therapy |
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What is the cause of warts? |
HPV (>100 subtypes) |
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What is the characteristic appearance of warts on the hands? |
"Verruca vulgaris" - raised and hyperkeratotic |
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What is the characteristic appearance of warts on the soles of the feet? |
"Plantar warts" - flat, disrupt skin lines, have dark dots visible in them, and may be quite painful |
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What is the characteristic appearance of warts on the face or legs? |
"Verruca plana" or "flat warts" - seen in groups |
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What is the characteristic appearance of warts on the genitals? |
"Condylomata acuminata" - cauliflower appearance, transmitted sexually, 90% caused by HPV 6 |
|
|
How effective is the quadrivalent HPV vaccine? |
- Need to treat 8 patients to prevent an episode of genital warts - Need to treat 324 patients to prevent a case of cervical cancer |
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What is the natural history for most warts? |
Eventually regress |
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What are the first-line therapies for verruca vulgaris (hands)? |
Salicylic acid or cryosurgery |
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What are the first-line therapies for plantar warts (feet)? |
Salicylic acid or cryosurgery |
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What are the first-line therapies for flat warts (often in groups on the face or legs)? |
Salicylic acid, topical tretinoin (Retin-A), cryosurgery, or imiquimod (Aldara) |
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What are the first-line therapies for Condylomata Acuminata (genital warts)? |
Podophyllin resin, podofilox (Condylox), trichloracetic acid, cryosurgery, or imiquimod (Aldara) |
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What is the major characteristic of herpes infections? |
Virus lies dormant in dorsal root ganglia, leading to recurrences |
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What is the characteristic appearance of herpetic skin infections? |
Vesicular eruptions with surrounding erythema, progress to ulcers or crusts, then re-epithelialize over the course of days or weeks |
|
|
What is the cause of "cold sores"? |
Herpes gingivostomatitis or labialis = caused by HSV (most commonly type 1, but sometimes time 2) |
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|
What are the symptoms of "cold sores"? |
- May affect entire mouth (gingivostomatitis) - May be accompanied by fevers, chills, and malaise - Recurrent episodes often occur on the lips (labialis) and are milder, sometimes asymptomatic, but accompanied by viral shedding |
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|
What is the presentation and cause of genital herpes? |
- Herpetic lesions on the genitals, anus, or buttocks - First episodes are more severe, subsequent episodes range from moderate to asymptomatic but are accompanied by viral shedding / transmission - Most commonly due to HSV type 2, but sometimes type 1) |
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When can you spread genital herpes? |
Can be spread during and between active episodes because infected people can shed virus asymptomatically
Active ulcers create a higher risk of acquiring HIV during sexual contact with HIV-positive individuals |
|
|
What are the symptoms of chickenpox? |
- Few days of fever and respiratory symptoms - Characteristic vesicles on a red base begin on trunk and spread to extremities over several days |
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What are the potential complications of HSV and VZV? Who is at risk for these? |
- Encephalitis - Disseminated infections - Post-herpetic neuralgia (PHN)
- Occur especially in infants or immunosuppressed individuals |
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What is post-herpetic neuralgia (PHN)? |
Prolonged and painful after effect of HSV or VZV - Presents as chronic pain in the dermatome previously infected with herpes zoster |
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How can you decrease your likelihood of getting post-herpetic neuralgia (PHN)? |
Zoster vaccine (approved for patients older than age 60) - decreases PHN by approximately one case per 1000 person years |
|
|
How effective is the zoster vaccine? |
- Decreases incidence of zoster by approximately 6 cases per 1000 person-years - Decreases incidence of post-herpetic neuralgia by approximately 1 case per 1000 person-years |
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|
How do you treat HSV or VZV? |
- No cures, goals are to decrease pain, viral shedding, duration of symptoms, and to prevent recurrences - In HSV a daily prophylactic oral med can prevent/reduce recurrences - In Zoster, early antiviral treatment can prevent PHN
*Acyclovir, Famciclovir, and Valacyclovir |
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|
What is the only med to treat acute varicella (chickenpox)? |
Acyclovir |
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|
What can be done in childhood to reduce prevalence of genital infections? |
Male circumcision - reduces incidence of new HSV-2 infections and reduced prevalence of infection with high-risk HPV subtypes |
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|
What are the most common causes of fungal infections in the skin? |
- Dermatophytes (--> tinea infections / ringworm)W - Candida - Pityrosporum species |
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What is the typical dermatophyte infection? |
Tinea corporis (of the body): - Annular appearance with central clearing, redness, and scale on the perimeter
Also tinea capitis (head), tine pedis (feet) |
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What is the cause of Tinea Versicolor? |
Inflammatory reaction to the yeast-like Pityrosporum (Malassezia fufur) |
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What does Candida cause? |
- Thrush - Balanitis - Vaginitis - Rashes in groin and under breast |
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What is the presentation of tinea capitis? |
Dermatophyte infection of the head - Patchy alopecia (hair loss) - Broken hairs and scaling
Affects the hair shaft and follicle |
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How do you treat tinea capita? |
Oral antifungal meds: griseofulvin, itraconazole, terbinafine for 4-8 weeks
Topical antifungals are NOT effective |
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How do you treat tinea corporis (body)? |
- Small areas may respond well to topical anti-fungals * Topical OTC antifungals (miconazole, clotrimazole) are first-line agents
- Large areas may require oral antifungals (griseofulvin, terbinafine, itraconazole) for 2-4 weeks |
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How should you treat small areas of tinea corporis? |
- Small areas may respond well to topical anti-fungals * Topical OTC antifungals (miconazole, clotrimazole) are first-line agents |
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|
How should you treat large areas of tinea corporis? |
Large areas may require oral antifungals (griseofulvin, terbinafine, itraconazole) for 2-4 weeks |
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What should you think of when you see a red lesion in the groin? How do you differentiate? |
- Tinea cruris (tinea of the groin) - red and scaling without the central clearing of tinea corporis - Candida - more red and with satellite lesions - Erythrasma - superficial bacterial infection that may be pink or brown and may show coral red fluorescence under UV light |
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How should you treat a red lesion in the groin? |
For TINEA CRURIS --> topical or systemic anti-fungals (depending on severity)
If not sure whether it is TINEA vs Candida --> choose anti fungal that covers dermatophytes and Candida (e.g., azoles and terbinafine (Lamisil)) |
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How does tinea pedis present? |
Tinea of the feet - May present as macerated white areas between toes - May present as dry red scaling on the soles or sides of the feet (moccasin distribution) - Less commonly, presents with vesicles |
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How should you treat tinea pedis? |
Same as for tinea corporis or tinea cruris: * Topical OTC antifungals (miconazole, clotrimazole) are first-line agents - May require oral antifungals (griseofulvin, terbinafine, itraconazole) for 2-4 weeks if not responding to topical therapy (Cochrane review found oral terbinafine >> oral griseofulvin for tinea pedis) |
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How can you diagnose fungal skin infections? |
Treat a skin scraping with KOH and analyze under a microscope for classic hyphae or yeast forms (77-88% sensitive, 62-95% specific)
Or a fungal stain (Swartz-Lambkins) will make hyphae stand out from epithelial cells
Fungal cultures are more expensive and require 1-2 weeks to grow |
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|
What is the term for fungal infection of the nails? |
Onychomycosis (or tinea unguium) |
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|
How should you treat onychomycosis (nail fungal infection)? |
- Topical antifungal agents do not work well - Oral antifungal agents may cause liver toxicity (3-4 months for toenails and 2 months for fingernails) * Most effective treatment is Terbinafine (250 mg daily for 16 weeks) |
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|
What is the differential diagnosis for dystrophic nails besides fungal infections? |
- Psoriasis - Lichen planus (picture) - Trauma |
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|
How do you diagnose fungal infections of the nails? |
- KOH prep from subungual scrapings (80% sensitive, 72% specific) - Nail culture (59% sensitive, 82% specific) - Distal nail clipping sent in formalin for periodic acid-Schiff (PAS) staining by pathologist (92% sensitive, 72% specific) |
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|
What is atopic dermatitis? Characteristic presentation? |
- Type of eczematous eruption - Itchy, recurrent, and symmetric - Often on flexural surfaces or on face as infant - Personal or family history of asthma and allergic rhinitis common |
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How does atopic dermatitis present in infancy? |
More commonly on the face |
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How does atopic dermatitis present after infancy? |
Dry, scaling, and red lesions are typically on the flexural surfaces such as the antecubital or popliteal fossa |
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What causes atopic dermatitis? |
Not typically caused by a specific allergen, but develops from a number of trigger factors in patients with a strong genetic predisposition to develop eczematous eruptions |
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|
What is allergic contact dermatitis? How does it present? |
- Allergic response to an allergen such as the chemical found in poison ivy or poison oak plant (rhus dermatitis) - Often linear and vesicular lesions |
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What are common contact allergens? |
- Poison ivy - Poison oak - Nickel in jewelry and belt buckles - Chemicals in deodorants and cosmetics |
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|
What is irritative contact dermatitis? |
The contestant works as an irritant rather than as an allergen
Eg, diaper dermatitis secondary to feces and urine |
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What is the presentation of dyshidrotic eczema? |
- Seen on the hands and/or feet - Tapioca-like vesicles occur between the fingers or toes along with scaling - Scaling inflamed skin can proceed to develop painful cracks and fissures |
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|
What is the presentation of nummular eczema? |
Coin-shaped (nummus = coin in Latin) with erythema and scale; it is found most often on the lower legs |
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How do you treat dermatitis / eczema? |
(1) Avoid skin irritants (e.g., drying soaps), bathing in hot water (which dries out skin and increases pruritus) (2) Use emollients or moisturizers (3) Treat inflammation with a topical steroid or other anti-inflammatory agent like topical immunomodulators (4) Stop the scratch-itch cycle (little evidence antihistamines improve outcomes) (5) Treat any secondary bacterial infection that may develop (e.g., impetigo with weeping/crusting) - cover S. pyogenes and S. aureus |
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|
What causes lichen simplex chronicus? Effect? |
Chronic scratch-itch cycle --> skin gets thickened with prominent skin lines visible (lichenified) |
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|
How do you treat lichen simplex chronicus? |
Potent topical steroid ointments to penetrate the thick plaque and moisturize the cracked pruritic skin |
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|
What are topical immunomodulators that can be considered in dermatitis/eczema treatment? Mechanism? |
Tacrolimus and Pimecrolimus - Use in adults and children >2 years for short-term intermittent treatment, who are unresponsive to or intolerant of other treatments (due to risk for cancer)
Mechanism: calcineurin inhibitors, as effective as topical steroids without risk for skin atrophy |
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|
What is seborrhea? |
Superficial inflammatory dermatitis - characterized by erythema and scaling on the scalp (dandruff) and face (eyebrows, eyelids, nasolabial creases, behind the ears, forehead, cheeks, around the nose, under beard/mustache); also may be over sternum, in axillae, summary folds, umbilicus, groin, and gluteal creases
Areas associated with greatest number of pilosebaceous units producing sebum |
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|
How prevalent is seborrhea? |
3-5% in young adults
Incidence increases with age, especially common in people with Parkinson disease and HIV |
|
|
What is the cause of seborrhea? |
Inflammatory hypersensitivity to epidermal, bacterial, or yeast antigens
Also these patients have a profusion of Pityrosporum (Malassezia) on the skin |
|
|
What is the clinical course of seborrhea? |
- Remissions and exacerbations - Most common precipitating factors are stress and cold weather |
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|
How do you treat seborrhea? |
Direct treatment at inflammation and Pityrosporum: - Topical low-potency steroids (especially use low-potency on face - 1% hydrocortisone cream/lotion or desonide cream/lotion) - If scalp seborrhea is severe, high-potency steroid like fluocinonide solution or clobetasol solution - Apply antifungals to affected areas (shampoos that contain selenium sulfide, zinc pyrithione, ketoconazole, or coal tar derivatives)
For skin - ketoconazole cream |
|
|
What is the typical presentation of psoriasis? |
Well-circumscribed, red, scaling, plaques with white thickened scales |
|
|
What areas of the body may be affected by psoriasis? |
- Scalp - Nails (10-40% of patients) - Extensor surfaces of limbs - Elbows - Knees - Sacral region - Genitalia |
|
|
What nail changes are associated with psoriasis? |
- Pitting - Onycholysis (detachment from nail bed) - Subungual keratosis |
|
|
What are the treatment options for psoriasis? |
Most common: high-potency steroids, but often require combination therapies
- Emollients - Topical steroids - Topical vitamin D (calcipotriene or calcipotriol) - Topical tar and tar shampoo - Intralesional steroids - UV light - Topical retinoids
- Systemic options: methotrexate, acitretin, cyclosporine, injectable biologics |
|
|
What combination therapies for psoriasis enhance steroid therapy? |
- Topical combination of calcipotriene and betamethasone (more effective than either alone) - Tazarotene (topical retinoid) with topical steroids (increases effectiveness of both agents and reduces incidence of local adverse effects - local irritation due to tazarotene) |
|
|
What therapy is counter-intuitively contraindicated in the treatment of psoriasis? Why? |
Systemic steroids - they can precipitate severe flares and generalized pustular disease |
|
|
What is the best schedule for administering potent topical steroids for chronic psoriasis therapy? |
Pulse therapy on weekends - helps to avoid the side effects and loss of efficacy |
|
|
Which therapy can be used to treat facial and intertriginous psoriasis to limit/avoid steroid adverse effects? |
Tacrolimus and Pimecrolimus |
|
|
What is acne? Where does it occur? |
Inflammatory disease of the pilosebaceous unit (sebaceous glands and their associated small hairs)
Caused by blockage of the pilosebaceous unit with sebum and desquamated cells, accompanied by an overgrowth of P. acnes in the follicle |
|
|
What do pilosebaceous units consist of? What do they produce? |
- Consists of sebaceous gland and associated small hairs - Glands produce sebum - complex lipid mixture, to maintain hydration of the skin |
|
|
What are non-inflammatory lesions of acne? |
Open comedones (blackheads) and closed comedones (whiteheads) |
|
|
What are the inflammatory lesions of acne? Cause? |
When there is a disruption of the follicle wall, P. acnes, sebum, hair, and cells extrude into the dermis --> inflammation --> Papules, Pustules, Nodules, and Cysts |
|
|
What are the exacerbating / risk factors for acne? |
- Genetics - Androgens - Stress - Excessive friction on skin (e.g., with sweat bands and helmet straps) - Cosmetics - Medications (corticosteroids, lithium, isoniazid, hormonal contraception with increased androgenicity) |
|
|
What medications can increase the chances of developing acne? |
- Corticosteroids - Lithium - Isoniazid - Hormonal contraception with increased androgenicity |
|
|
What are topical medications for acne? |
- Benzoyl peroxide - antimicrobial effect - Topical antibiotics (clindamycin and erythromycin B) - Combination topicals (benzoyl peroxide with antibiotic) - Retinoids |
|
|
What are systemic medications for acne? |
- Oral antibiotics (tetracycline, doxycycline, minocycline, erythromycin) - Estrogen-dominant birth control pills - Isotretinoin (Accutane) |
|
|
What are the oral antibiotics and doses for acne treatment? |
- Tetracycline 500 mg qd-bid - Doxycycline 100 mg qd-bid - Minocycline 50-100 mg qd-bid - Erythromycin 250-500 mg bid |
|
|
What are the important things to know about taking oral tetracycline for acne treatment? |
- Inexpensive - Need to take on an empty stomach - Avoid within 2 hours of calcium or calcium containing products |
|
|
What are the important things to know about taking oral doxycycline for acne treatment? |
- Inexpensive - Well tolerated - Increases sun sensitivity |
|
|
What are the important things to know about taking oral minocycline for acne treatment? |
- Expensive - Less resistance of P. acnes |
|
|
What are the important things to know about taking oral erythromycin for acne treatment? |
- Inexpensive - Frequent GI disturbance |
|
|
When is isotretinoin (Accutane) indicated for treatment of acne? |
Cystic and scarring acne that has not responded to other therapies |
|
|
How should you treat mild comedonal acne? |
Topical retinoids and/or azelaic acid
No place for oral antibiotics |
|
|
How should you treat mild papulopustular acne? |
- Topical antibiotics and benzoyl peroxide - Retinoids - Azelaic acid - May add oral antibiotics if topical agents are not working |
|
|
How should you treat moderate inflammatory (papulopustular or nodulocystic) acne? |
- May start with topical antibiotic, benzoyl peroxide, and oral antibiotic - Oral antibiotics are often essential at this stage - Retinoids - Consider stopping oral antibiotics when topical agents are working well |
|
|
How should you treat severe cystic or scarring acne? |
Isotretinoin |
|
|
What are the risks associated with isotretinoin (Accutane)? |
Birth defects - need to confirm two negative pregnancy tests and two forms of birth control in a woman before prescribing |
|
|
When starting topical retinoid therapy, how should you proceed? |
- Begin with formulations that cause the least inflammation (lower potency tretinoin / Retin-A and adapalene / Differin)
- For oily skin and more severe acne, may help to use stronger preps (tretinoin gel, adapalene gel, or tazarotene gel) |
|
|
What does a patient need to know when starting retinoid therapy (tretinoin, adapalene, tazarotene, azalaic acid)? |
Increases sun sensitivity - warn about sun safety measures |
|
|
What are the signs of sun damage to the skin? |
Photoaging --> Mottled hyperpigmentation and wrinkling
Also can cause precancers like actinic keratosis and lentigo maligna |
|
|
What are the most common skin cancers? |
Basal cell carcinoma (80%) Squamous cell carcinoma (16%) Melanoma (4%) |
|
|
Where does basal cell carcinoma typically present? |
Head and neck |
|
|
What are the three major morphologic types of basal cell carcinoma? What do they look like? |
- Nodular (picture) - raised and pearly with telangiectasis; may ulcerate and bleed and become crusted - Superficial - look like SCC, red or pink, flat, scaling plaques that may have erosions or crusts - Morpheaform (sclerosing) - rare, flat, and scarlike |
|
|
What does squamous cell carcinoma look like? |
Superficial BCC or more elevated and nodular; frequently hyperkeratotic and bleed easily |
|
|
What is Actinic Keratosis? |
Premalignant skin lesion - risk of progression to primary SCC is 0.6% at 1 year and 2.6% at 4 years |
|
|
What should you do when a lesion is more thickened and indurated than a typical actinic keratosis? |
Biopsy to determine a definitive diagnosis before initiating treatment |
|
|
How do you treat actinic keratosis? |
Cryotherapy for small numbers of lesions or topical field treatment for areas with many lesions
Approved topical agents include 5-fluorouracil, imiquimod, and diclofenac
Photodynamic therapy is another option |
|
|
What are some benign pigmented lesions that can be confused with melanoma? |
- Acquired nevi - Congenital nevi - Seborrheic keratoses - Dermatofibromas - Lentigines |
|
|
What does a seborrheic keratosis typically look like? |
Large and pigmented with irregular borders; verrucous and with a stuck-on appearance, but they can be flat and irregular |
|
|
What are red flags in skin wounds? |
- Deformity, severe swelling, increased pain on stressing bone --> check for fracture - Inability to visualize wound extent --> check for injury to deep structure - Difficulty controlling bleeding --> check for injury to large vessel - Altered function --> check for injury to nerve or musculoskeletal structures |
|
|
When should you get an x-ray or other imaging modality following a skin wound? |
When a deeper foreign body is suspected |
|
|
What tests should be done following a skin wound? |
Test for immunity or exposure to communicable disease (e.g., HIV, hepatitis B) if exposure results from the injury |
|
|
What should you give to treat pain for a patient with a skin wound? |
Often acetaminophen or NSAIDs are adequate but if bleeding, avoid use of aspirin and NSAIDs initially
May consider opiates (codeine or hydrocodone) for more painful injuries, in combination with acetaminophen |
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When should you inquire about tetanus immunization status? |
Whenever a patient has injured their skin! |
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What are the characteristics of tetanus-prone wounds? |
Contamination, devitalized tissue, puncture, muscle involvement, or >24 hours old |
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What should you do for a "tetanus prone wound"? |
- Give a tetanus booster if the patient has not had one within 5 years - For clean wounds, give if patient has not had one in 10 years
- If the patient has not had the primary tetanus immunization series, administer tetanus Ig too (recommend a tetanus booster in 1 month, in 6 months, and in 12 months) |
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What is the recommended scheduling of tetanus boosters for a patient who has not received the tetanus immunization series who requires treatment for a skin wound? |
- Give tetanus booster with tetanus immune globulin - Repeat booster in 1 month, in 6 months, and in 12 months |
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What is a contusion? Cause? |
A bruise - results from trauma that injures underlying soft-tissue structures, while leaving epidermis intact
Cellular, vascular, and lymphatic damage causes blood and other fluids to leak into the tissue, producing swelling and discoloration (ecchymosis) |
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What is a hematoma? |
A palpable knot of blood that occurs when enough extravasated blood collects following trauma |
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How long can large bruises with hematoma formation take to resolve? |
Weeks |
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What are the colors of a bruise? |
Blue / Purple --> Yellow / Brown (as the blood is converted to hematin and reabsorbed) |
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How should you treat an area that will likely or has formed a contusion? |
Elevate the affected part and apply pressure and ice
Do not aspirate or otherwise drain hematoma because they may recur or you may introduce infection
Apply cold for 5-30 minutes several times daily until swelling stops, usually at least 48 hours after injury |
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What should you do if the amount of bleeding seems out of proportion to the injury? |
Consider an underlying hemostatic disorder, but remember that tissue fragility normally increases as people age, and many people taking aspirin or NSAIDs on a regular basis |
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What is a rare complication of hematoma? |
May develop myositis ossificans with calcification in the involved tissue |
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What causes an abrasion? |
Scraping trauma that removes the epidermis |
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How should you treat an abrasion? |
Clean with soap and water or another cleansing agent; may require anesthesia if large
Apply topical anesthetic agents for superficial abrasions and use injectable anesthetic (e.g., lidocaine) for deep or dirty wounds
Irrigate with sterile saline or a mild antiseptic solution
Use forceps or gauze to remove ground in dirt or asphalt |
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Why are abrasions so sensitive? |
Many nerve endings are exposed after scraping off the epidermis |
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How can you prevent a "road rash tattoo"? |
Remove ground in dirt or asphalt from abrasions: wrap petrolatum (Vaseline) gauze or gauze with Bacitracin around the fingers and wipe off the asphalt and other foreign material embedded din the skin |
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What should you do after you have cleaned an abrasion? |
Keep the wound moist and free of infection until it re-epithelializes: - Apply vaseline or topical antibiotic (Bacitracin) - Cover with a clean non-stick dressing - Alternatively, semiocclusive transparent wound coverings that hasten re-epithelialization by retaining moisture while allowing oxygen to reach the wound - May need to see patient every day or two if abrasion is extensive until infection seems unlikely (systemic antibiotic prophylaxis is usually not indicated) |
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What should you do if an abrasion begins to have a purulent exudate or there is spreading erythema? |
Obtain a culture and start an appropriate antibiotic |
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What are the goals of laceration repair? |
- Achieve hemostasis - Prevent infection - Preserve function - Restore appearance - Minimize patient discomfort |
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What are the three phases of wound healing? |
1) Initial lag phase, days 0-5, no gain in wound strength 2) Fibroplasia phase, days 5-14, rapid increase in wound strength (only 7% by end of week 2) 3) Final maturation phase, begins day 14 and continues until healing is complete, CT remodeling occurs, wound gains up to 80% of normal skin strength |
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What is the first phase of wound healing? What happens? |
1) Initial lag phase, days 0-5, no gain in wound strength |
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What is the second phase of wound healing? What happens? |
2) Fibroplasia phase, days 5-14, rapid increase in wound strength (only 7% by end of week 2) |
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What is the third phase of wound healing? What happens? |
3) Final maturation phase, begins day 14 and continues until healing is complete, CT remodeling occurs, wound gains up to 80% of normal skin strength |
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How can you treat a wound during the first two phases of wound healing? |
Nonabosrbable skin sutures or staples - gives the wound strength
After non absorbable skin sutures are removed, wound closure tapes or previously placed deep, absorbable sutures may be important in the final stage |
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What are the indications for immediate wound closure? |
- Lacerations open and <18 hours old (<24 hours on face) - Bite wounds in cosmetically important areas (requires close follow up) |
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What are the contra-indications for immediate wound closure? |
- Puncture wounds - Wounds >18 hours old (>24 hours old on face) - Animal or human bite wounds (exceptions include facial wounds and large wounds from dog bites) |
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What are the closure methods for lacerations? |
- Sutures - Staples - Tapes - Glue (tissue adhesive - is acceptable alternative to standard wound closure with sutures) |
