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IM - COMMON DERMATOLOGIC PROBLEMS

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tonystep1's version from 2017-08-15 19:09

COMMON DERMATOLOGIC PROBLEMS CLINICAL FEATURES

Question Answer
Acne Vulgarisinflammatory condition of the skin that is most prevalent during adolescence. // Obstructive acne: closed comedones (whiteheads) or open comedones (blackheads) // Inflammatory acne: Lesions progress from papules/pustules to nodules, then to cysts, then scars.
RosaceaA chronic condition resulting in reddening of the face (mainly the forehead, nose, and cheeks) // Mostly affects Caucasian women between 30 and 50 years of age // The most common skin findings include erythema, telangiectasia, papules, and pustules with redness, typically affecting the face
Seborrheic DermatitisCommon locations: scalp (dandruff), hairline, behind ears, external ear canal, folds of skin around nose, eyebrows, armpits, under breasts, groin area (skin folds) // Scaly patches with surrounding areas of mild to moderate erythema // Usually asymptomatic, but pruritus can occur
Irritant contact dermatitisThe rash is usually very pruritic - chemical or physical insult to the skin (e.g. , contact with detergents, acids, or alkalis, or from frequent hand washing) . // The rash begins shortly after exposure to the irritant (in contrast to the allergic type, which begins several hours to a few days later) . // A previous sensitizing event is not needed to produce the rash (i.e. , it is not an immunologic reaction) .
Allergic contact dermatitis is a delayed-type hypersensitivity reactionThe rash is usually very pruritic. - Sensitization of the skin occurs l to 2 weeks after the first exposure to the allergen // Subsequent exposure leads to dermatitis hours to days after the reexposure. // Common allergens include poison ivy, oak, and sumac; iodine; nickel; rubber; topical medications (e.g., neomycin, topical anesthetics) ; and cosmetics
Pityriasis RoseaPapulosquamous eruption-Initially, "herald patches" that resemble a ring worm (multiple round/oval patches) appear, and then a generalized rash with multiple oval-shaped lesions appears. // The rash is classically described as having a Christmas tree-type appearance // It is common on the trunk and upper arms and thighs, and is usually not found on the face. Pruritus is often present, and varies in severity.
Erythema NodosumErythema nodosum appears as painful, red, subcutaneous, elevated nodules, typically located over the anterior aspect of the tibia (less commonly on the trunk or arms)
Erythema Multiforme (EM)EM is an inflammatory skin condition characterized by erythematous macules/papules that resemble target lesions ("bull's-eye lesions") that can become bullous // Skin lesions may be pruritic and painful
Stevens-Johnson Syndrome and Toxic Epidermal NecrolysisSystemic manifestations include fever, difficulty eating, renal failure, and sepsis. // Potentially life-threatening (mortality rate is 5% for SJS and 30% for TEN) // Half of all cases are due to medications (e.g., sulfa drugs, penicillins, barbiturates, phenytoin, allopurinol, carbamazepine, vancomycin, rifampin) . In many cases, no specific cause is identified.
Lichen PlanusChronic, inflammatory lesions of unknown etiology // (4 Ps) Pruritic, polygonal, purple, flat-topped papules // Most commonly seen on wrists, shins, oral mucosa, and genitalia
Bullous PemphigoidMultiple subepithelial blisters on abdomen, groin, and extremities // Elderly people are most commonly affected. // Blisters are less easily ruptured than in pemphigus vulgaris.
Pemphigus VulgarisAutoimmune blistering condition resulting in loss of normal adhesion between cells (acantholysis) // Starts in oral mucosa; may become generalized // Blisters rupture, leaving painful erosions // Most commonly affects elderly people, often fatal if untreated
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TREATMENT OF COMMON DERMATOLOGIC PROBLEMS

Question Answer
Mild to moderate Acne VulgarisInstruct patient to: keep affected area clean (vigorous washing is unnecessary); reduce or discontinue acne-promoting agents (certain make-up, creams, oils, steroids, androgens). // Begin with topical benzoyl peroxide (2.5%)-should be applied once or twice daily. // Add topical retinoids if the above fails. // Add topical erythromycin or topical clindamycin
Moderate to severe nodular pustular acnePrescribe systemic antibiotic therapy: tetracycline, minocycline, doxycycline, erythromycin, clindamycin, and TMP-SMX // Add oral retinoids (e.g., isotretinoin) for severe cystic acne that is not responsive to the above treatments.
RosaceaTopical metronidazole (gel form) is effective and is applied twice per day for several months // Systemic antibiotics (e.g. , tetracycline) are used for maintenance therapy. // If the patient does not experience an appropriate response, prescribe isotretinoin for daily use.
Seborrheic DermatitisSunlight exposure often helps // Dandruff shampoo (over-the-counter) is usually adequate // Topical ketoconazole (to decrease yeast count on skin) has been found to be effective. // Topical corticosteroids are appropriate in severe cases.
Contact DermatitisAvoid the contact allergen! // Apply cool tap water compresses. // Apply topical corticosteroids // Prescribe systemic corticosteroids (e.g., prednisone, l mglkg/day) for severe cases. Continue for lO to 14 days and then taper.
PityriasisIt spontaneously remits within a few (6 to 8) weeks without treatment. There is no treatment other than antihistamines for pruritus. Recurrences are rare.
Erythema NodosumMany causes: Streptococcus infection, sarcoidosis, inflammatory bowel disease, fungal infections, pregnancy, medications (e.g., oral contraceptives, sulfa drugs, amiodarone, antibiotics), syphilis, tuberculosis; many cases are idiopathic // Treat the underlying condition, if known. // Prescribe bed rest, leg elevation, NSAIDs, and heat for symptoms. Potassium iodide may help.
Erythema MultiformeIf initiated early when the first symptom of HSV infection appear, acyclovir can help to prevent HSV-associated EM. // Medications implicated include sulfa drugs (most common) , penicillin and other antibiotics, phenytoin, allopurinol, and barbiturates.
Stevens-Johnson SyndromeHalf of all cases are due to medications (e.g., sulfa drugs, penicillins, barbiturates, phenytoin, allopurinol, carbamazepine, vancomycin, rifampin) .// Admit patient to an ICU. // Withdraw the suspected medication; aggressive rehydration and symptomatic management.
Lichen PlanusTreat with glucocorticoids
Bullous PemphigoidTreat with systemic glucocorticoids with or without azathioprine
Pemphigus VulgarisTreat with systemic glucocorticoids and other immunosuppressants
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CLINICAL FEATURES OF SKIN CONDITIONS RELATED TO MICROBIAL INFECTION

Question Answer
WartsMost warts are asymptomatic unless "bumped." Plantar warts can be painful during walking // .Some warts may bleed. // Warts are unsightly and can be disfiguring
Molluscum ContagiosumIt manifests as small papules (2 to 5 mm) with central umbilication. // A common, self-limited viral infection caused by a poxvirus; common in sexually active young adults and in children // In HIV-positive patients, lesions can be extensive
Herpes Zoster (Shingles)Severe pain and rash in a dermatomal distribution // Pain comes before the rash. // Rash is characterized by grouped vesicles on an erythematous base. If severe, lowgrade fever and malaise may be present.
Tinea corporisBody/trunk // Pinkish annular lesions // visualization of hyphae from skin scrappings prepped with KOH
Tinea capitisScalp // Areas with scaling with hair +/- pruritius // Wood's lamp flouresece with Microsporum spp. otherwise it is Trichophyton spp.
Tinea unguiumNails // Elderly people // Thick, opacified nails
Tinea pedisYoung adults // Scaling , erythema. pruritus //
Tinea crurisGroin , inner thigh // males>>females // Areas of scaling, erythema - spares scrotum
ScabiesSevere pruritus-This is often the most severe during the night. The head and neck are usually spared. // Burrows-Linear marks (several millimeters in length) represent the tunneled path of the mite. // Scratching may lead to excoriations.// Eczematous plaques, crusted papules, or secondary bacterial infection may develop
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TREATMENT SKIN CONDITIONS RELATED TO MICROBIAL INFECTIONSurgical excision or laser therapy

Question Answer
WartsFreezing lesion with liquid nitrogen (applied on a cotton swab)-multiple treatments may be necessary // Salicylic acid (Compound W)-applied daily for several weeks // 5-FU cream or retinoic acid cream for flat warts // Podophyllin for genital warts
Molluscum ContagiosumMultiple treatment modalities are effective (e.g., curettage, drops containing podophyllin and cantharidin, cryosurgery) , but scarring is always a risk.
Herpes Zoster (Shingles)Keep the lesions clean and dry. // Prescribe analgesics for pain relief (aspirin or acetaminophen; codeine if needed). In severe cases, administer a local injection of triamcinolone in lidocaine // Prescribe antiviral agents (acyclovir, famciclovir, valacyclovir) to reduce the pain, decrease the length of illness, and reduce the risk of postherpetic neuralgia
ScabiesPermethrin 5% cream (Elimite) // Should be applied to every area of the body (head to toe), even under fingernails and toenails, around the genital area, and in the cleft of the buttocks. // Patients should leave cream on overnight (>8 to 10 hours) and wash it off the next morning.
Dermatophyte InfectionsTopical antifungals // Oral Griseofulvin for tinea capitis and tnea ungium
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