Vesicles, Blisters And Pustules

Front 1

Vesicles

Back 1

Circumscribed
Fluid containing
Epidermal elevations
Size < 5 mm
Lose identity in short time  bullae ( > 5 mm) or pustule

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Bullae/Blisters

Back 2

Rounded or irregularly shaped lesions
Fluid filled elevations  serous or seropurulent material
Bullae > 0.5 cm
Blister > 1 cm
Unilocular or multilocular

Front 3

Pustules

Back 3

Circumscribed
Raised lesion
May vary in size and shape
Contains a purulent exudate
Pus is composed of leukocytes with or without cellular debris, may contain bacteria or may be sterile

Front 4

Diseases with vesicles

Back 4

Herpes Simplex
Varicella
Herpes Zoster
Scabies
Dyshidrosis
Contact Dermatitis

Front 5

Herpes Simplex
Clinical

Back 5

clustered small vesicles
Recurrent episodes

Front 6

Herpes Simplex
Course

Back 6

5-14 days per episode
-Viral shedding until crusted 4-7 days
-Genital herpes --> asymptomatic shedding between outbreaks

Front 7

Herpes Simplex
Diagnosis

Back 7

Tzanck smear, culture, PCR

Front 8

Herpes Simplex
Treatment

Back 8

sunscreen
symptomatic
acyclovir
famciclovir
valacyclovir

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HSV -1

Back 9

orolabial lesions

Front 10

HSV-2

Back 10

Genital lesions

Front 11

order: bullae, vesicles, blisters

Back 11

vesicles < bullae < blisters

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Orolabial Herpes

Back 12

“Cold sore” or “Fever blister”
HSV-1 in 95% of cases
Prodrome: tingling, itching or burning
Variable symptomatology: local discomfort, headache, nasal congestion, flu-like symptoms
Sun exposure --> trigger
RECURRENCES: cheeks, eyelids, earlobes, intraorally

Front 13

Genital Herpes

Back 13

HSV-2 in 85% of cases
Spread by sexual contact
Primary infection: grouped blisters and erosions in the vagina, rectum, penis x 7-14 days
Fever, flu-like symptoms, vaginal pain and dysuria
Management should be individualized

Front 14

dysuria

Back 14

Difficulty or pain in urination

Front 15

Herpetic Whitlow

Back 15

Tenderness and erythema on the lateral nail fold
Deep-seated blisters develop 24-48 hours later
55% of cases between 20-40 yo
More often seen in dentist, dental hygienists and health care workers
- not seen as commonly anymore because of hand sanitizer

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Herpetic keratoconjunctivitis

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Common cause of blindness in USA
Punctate or marginal keratitis or dendritic corneal ulcer --> disciform keratitis --> scars
Topical corticosteroids --> perforation of the cornea
Recurrences are common

Front 17

Varicella (Chicken Pox)

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Varicella Zoster virus
90% of cases in children < 10 yo
Incubation period is 10-21 days
Transmission: direct contact with lesions and respiratory route

Front 18

Varicella (Chicken Pox)
Clinical

Back 18

Fever, malaise, single vesicles on trunk and face
-“Dew drops on a rose petal”
-Spreads out as first lesions heal
-Old lesions become umbilicated

Front 19

Varicella (Chicken Pox)
Complications

Back 19

secondary bacterial infection
osteomyelitis (rare)
pneumonia (adults)

Front 20

Varicella (Chicken Pox)
Treatment

Back 20

early acyclovir in adolescents and adults, topical antipruritic lotions, oatmeal baths, keep environment cool
-antibiotics are given as 2ndy tx

Front 21

Why is aspirin contraindicated in Variclla

Back 21

Reye's Syndrome

Front 22

Herpes Zoster

Back 22

Varicella zoster virus
After natural infection or immunization, virus remain latent in the sensory dorsal root ganglion cells
Reactivation --> immunosupression, age
Clustered small vesicles along a dermatome
Pain may precede the eruption
May have lesions outside the dermatome

Front 23

Herpes Zoster
Course

Back 23

10-21 days until clear
Viral shedding the first week
Pain may be severe (burning, lancinating or triggered)
May recur in 5% of patients
Post-herpetic neuralgia more frequent in patients over the age of 50

Front 24

Herpes Zoster
Diagnosis

Back 24

clinical
Tzanck prep
culture?
PCR
biopsy

Front 25

Herpes Zoster
Treatment

Back 25

analgesics
thymidine kinase inhibitors (acyclovir, valacyclovir, famciclovir)
antibiotics

Front 26

Post-herpetic neuralgia
Treatment

Back 26

local applications of heat
capsaicin
lidocaine 10% gel
nerve blocks
systemic steroids
tricyclic antidepressants
gabapentin

Front 27

Scabies
Cause

Back 27

Disease caused by mite --> Sarcoptes scabiei

Front 28

Scabies
Clinical

Back 28

itchy red papules and vesicles
Web spaces, body folds, genitalia, breasts, elbows, wrists, ankles

Front 29

Scabies
Course

Back 29

2-6 weeks after exposure

Front 30

Scabies
Diagnosis

Back 30

KOH scrap
scabies prep, response to treatment

Front 31

Scabies
Treatment

Back 31

lindane
permethrin 5%
Crotamiton
thiabendazole
sulfur 10%
ivermectin 200 microgram/kg

Front 32

Dyshidrotic Eczema

Back 32

Pompholyx
Etiologic factors: psychogenic, primary fungal, fungal id, drug reaction and idiopathic
Sweat glands play a secondary role
Itchy, tiny, clear vesicles on sides of digits, palms and soles
Course: episodic flare, related to stress?
Skin may become dry, cracked, flaky

Front 33

Dyshidrotic Eczema
Diagnosis

Back 33

clinical

Front 34

Dyshidrotic Eczema
DDX

Back 34

contact dermatitis
palmo-plantar psoriasis

Front 35

Dyshidrotic Eczema
Treatment

Back 35

topical steroids
tannic acid
tar
light treatments
methotrexate for severe disease
antibiotics for secondary infection
avoid water and stress?

Front 36

Allergic Contact Dermatitis
Clinical

Back 36

angular or linear distribution, history of exposure

Front 37

Allergic Contact Dermatitis
Course

Back 37

lesions develop within 1-10 days

Front 38

Allergic Contact Dermatitis
Causes

Back 38

poison ivy, oak, sumac
Nickel, rubber, thimerosal
Neomycin, latex preservatives

Front 39

Allergic Contact Dermatitis
Rx

Back 39

remove agent, corticosteroids

Front 40

Allergic Contact Dermatitis

Back 40

Allergic Disease

Front 41

Do they recommend neosporin?

Back 41

No b/c neosporin has neomycin

Front 42

Bullous Diseases

Back 42

Bullous Impetigo
Erythema Multiforme
Pemphigus vulgaris
Bullous Pemphigoid
Porphyria Cutanea Tarda

Front 43

Bullous Impetigo

Back 43

common, highly contagious bacterial skin infection of children

Front 44

Bullous Impetigo
Dx

Back 44

Gram stain, culture --> S. aureus

Front 45

Bullous Impetigo
Tx

Back 45

mupirocin 2% (Bactroban)
systemic antibiotics

Front 46

Bullous Impetigo
Complications

Back 46

Staphylococcal scalded skin syndrome
glomerulonephritis
scarring

Front 47

Erythema Multiforme
Precipitating Factors

Back 47

Infections: herpes simplex (50%), Orf, Histoplasma capsulatum, mycoplasma pneumoniae
Radiation therapy
Medications: (sulfa)

Front 48

Erythema Multiforme
Clinical

Back 48

abrupt onset of symmetrical fixed red papules -->1-2 cm target (Bullseye) lesions on dorsa of hands, forearms, palms, neck, face and trunk. Mucosal involvement occurs 25%

Front 49

Erythema Multiforme

Back 49

Acute, self-limited, recurrent disease
bulls eye lesions

Front 50

Pemphigus Vulgaris

Back 50

Autoimmune disease
Equal frequency in men and women; 5th or 6th decades
Thin-walled, big flaccid, easily ruptured blisters... denuded areas
Mouth involved (60%) then body --> groin, scalp, face, neck, axillae or genitals

Front 51

Pemphigus Vulgaris
Dx

Back 51

Nikolsky Sign
Direct immunofluorescence shows intercellular IgG staining
Antibodies to desmoglein 3 --> Elisa

Front 52

Nikolsky sign

Back 52

absence of cohesion in the epidermis; lateral pressure on unblistered skin and having the epithelium shear off

Front 53

Pemphigus Vulgaris
Treatment

Back 53

silver sulfadiazine 1%
systemic corticosteroids
other immune modulating agents (azathioprine, cyclophosphamide, methotrexate)

Front 54

Bullous Pemphigoid

Back 54

Autoimmune disease, affects the elderly
Intense pruritic eruption with large tense blisters (subepidermal)
Most often begins on lower extremities. Other sites: groin, axillae, flexor surfaces of forearms
Associated with diabetes mellitus, rheumatoid arthritis, dermatomyositis, ulcerative colitis, lymphoproliferative disorders

Front 55

What is deeper Pemphigus Vulgaris or Bullous Pemphigoid?

Back 55

Bullous Pemphigoid

Front 56

Bullous Pemphigoid
Dx

Back 56

Circulating basement membrane zone antibodies (IgG)  70%
Direct immunofluorescence shows linear deposits of IgG and C-3 along the BMZ
Indirect immunofluorescence on salt-split skin

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Bullous Pemphigoid
Tx

Back 57

corticosteroids (lower doses than PV)
immunosuppressives (azathioprine, methotrexate, mycophenolate mofetil)

Front 58

Porphyria Cutanea Tarda

Back 58

Metabolic disease: abnormal porphyrin metabolism (Uroporphyrin decarboxylase)

Front 59

Porphyria Cutanea Tarda
Clinical

Back 59

photosensitivity --> blisters, erosions on dorsa of hands and arms; heal with scarring, milia and dyspigmentation
Hyperpigmentation of the face, neck and hands
Increased facial hair
Photosensitivity

Front 60

Porphyria Cutanea Tarda
Triggers

Back 60

ETOH, estrogens, iron overload (66%), hepatitis C, hepatitis B

Front 61

Porphyria Cutanea Tarda
Diagnosis

Back 61

pink or coral-red fluorescent urine (increased uroporphyrins) under a Wood’s UV light

Front 62

Porphyria Cutanea Tarda
Treatment

Back 62

remove trigger
decrease iron (phlebotomy)
alpha interferon for hepatitis C
antimalarials

Front 63

What disease is associated with Porphyria Cutanea Tarda?

Back 63

diabetes mellitus, lupus

Front 64

Diseases with pustules

Back 64

Acne vulgaris
Acne rosacea
Folliculitis
Candidal intertrigo

Front 65

Acne Vulgaris

Back 65

A chronic inflammatory disease of the pilosebaceous unit
True acne is a follicular process beginning with the comedon
Rupture results in inflammation
-Papules, pustules, or cysts

Front 66

What is the most common dermatologic condition treated by physicians in the US?

Back 66

Acne Vulgaris

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Acne vulgaris incidence

Back 67

40-50 million individuals/year

Front 68

What age does acne vulgaris predominate in?

Back 68

Acne can occur at any age --> predominately teens
85% of 12-24 year old
3% of 35-44 year old

Front 69

Acne Vulgaris
Classification

Back 69

According to type of lesion:
Comedonal, papulopustular, cystic
According to severity:
Mild, moderate, severe

Front 70

Acne Vulgaris
Topical Treatment

Back 70

Tretinoin
Benzoyl peroxide
Antibiotics
Azelaic acid
Salicylic acid
Alpha-hydroxy acids

Front 71

Acne Vulgaris
Oral Treatment

Back 71

Antibiotics: doxycycline, minocycline
Estrogens (oral contraceptives)
Retinoids (Accutane  40 mg bid x 4 months)
Antiandrogens: spironolactone

Front 72

Which acne drug is teratogenic?

Back 72

Accutane

So don't use during pregnancy

Front 73

Rosacea

Back 73

Most common in fair-skin individuals
Third or Fourth decades of life
Pathogenesis related to vascular hyper-reactivity
(lesser role: Role of Demodex folliculorum and Propionibacterium acnes)

Front 74

Rosacea
Triggers

Back 74

Hot drinks
red wine
spicy food
soy sauce
oral niacin
topical steroids

Front 75

Vascular rosacea

Back 75

flushing and facial erythema with or without telangiectasia

Front 76

Papulopustular rosacea

Back 76

central facial erythema with papules or pustules

Front 77

Ocular rosacea

Back 77

foreign body sensation
burning
dryness
itching
ocular photosensitivity
blurred vision

Front 78

Granulomatous rosacea

Back 78

firm, brown or red papules or nodules

Front 79

Rosacea
Oral Treatment

Back 79

Metronidazole 1% gel qd
Tetracycline, 250 mg bid
Doxycycline, 100 mg qd (best b/c low dose)
Minocycline 100 mg qd

Front 80

Rosacea
Topical Treatment

Back 80

Sodium sulfacetamide 10%
Azelaic acid 20% bid
Erythromycin 2% bid
Clindamycin lotion bid
Metronidazol 200 mg bid

Front 81

Rosacea
Interventional Treatment

Back 81

Telangiectasias: Laser treatment
Rhinophyma: Laser, cryosurgery, electrosurgery

Front 82

Folliculitis
Clinical

Back 82

pustules at hair follicle, especially the extremities

Front 83

Folliculitis
Complications

Back 83

rupture of follicle with carbuncle or furuncle

Front 84

Folliculitis
Dx

Back 84

culture, clinical
Staphylococcus aureus (normal inhabitant of anterior nares in 20% adults)

Front 85

Folliculitis
Treatment

Back 85

antibacterial soap, oral antibiotics, mupirocin; rifampin (600 mg/day 10 days)

Front 86

Candidal Intertrigo
typical causes

Back 86

Typically caused by C. albicans but other species can cause infection

Front 87

Candidal Intertrigo
Clinical

Back 87

groin, under breasts, abdominal fat, axillae
Red, moist areas with satellite papules and pustules

Front 88

Candidal Intertrigo
Diagnosis

Back 88

clinical, KOH, culture

Front 89

Candidal Intertrigo
Treatment

Back 89

topical antifungals
Silvadene
zinc oxide
oral antifungals (fluconazole, itraconazole)

Front 90

Other Sources of Blisters

Back 90

Burns
Acute fungal infections causing tinea corporis
Drug Reactions (Stevens-Johnson, TEN)
Friction
Insect Bites
Many autoimmune blistering diseases

Front 91

What is seen with immunofluorescence with Bullous Pemphigoid vs. Pemphigus Vulgaris?

Back 91

PV: Direct immunofluorescence shows intercellular IgG staining
BP: Direct immunofluorescence shows linear deposits of IgG and C-3 along the BMZ
Indirect immunofluorescence on salt-split skin