BENIGN TUMORS

I. EPIDERMAL

A. Keratosis

1. Actinic--sun induced, premalignant ill-defined pink keratotic plaques in sun

exposed distribution.

2. Seborrheic--flesh colored to brown waxy verrucous plaques. Well defined

lesions, global distribution. No malignant potential. Sign of Leser-Trelat.

B. Keratoacanthoma--sun induced. "Self-healing" squamous cell carcinoma.

Extremely rapidly growing indurated keratotic pink nodule with central crater and

keratin core.

C. Skin Tag--acrochordon, fibroepithelial polyp. Flexural folds. ?Associated with

GI polyps.

D. Clavus--"corn". Thick localized callus with keratin plug.

E. Verrucae--warts. Human papilloma virus, 60 known subtypes.

1. Flat

2. Plantar

3. Vulgaris

4. Filiform

5. Venereal--condyloma acuminata

F. Cutaneous Horn--indurated pink papule with keratin horn. Wart, actinic

keratosis, r/o squamous cell carcinoma

G. Nevus Sebaceus of Jadassohn

II. DERMAL

A. Dermatofibroma--firm, pink-brown plaque or nodule. + "dimple" sign. Lower

leg distribution, female greater than male.

B. Hemangioma

1. Capillary

2. Cavernous

3. Cherry angioma

C. Pyogenic Granuloma--rapidly growing hemangioma with "collarette", Friable,

purulent surface.

D. Lipoma--moveable firm rubbery subcutaneous nodule(s) with distinct capsule.

Isolated or numerous. Often familial.

E. Epidermal Inclusion Cyst--"sebaceous" cyst, "wen".

III. PIGMENTED

A. Nevus

1. Dermal

2. Junctional

3. Compound

4. Congenital

5. Blue

6. Dysplastic--over 5 mm. Macular. Irregular notched borders. Variegated

pigment from pink to brown, eccentrically.

7. Halo

B. Lentigo--tan maculae, "liver" spots.

1. simplex

2. actinic

C. Ephelid--freckle

Rovner

MALIGNANT TUMORS

I. Basal Cell Carcinoma--sun induced. Minimal metastatic potential

A. Nodular--pearly, telangiectatic borders. "Rodent" ulcer.

B. Superficial--eroded, scaling pink plaques.

II. Squamous Cell Carcinoma

A. Sun-induced--little metastatic potential. Often arise from existing actinic

keratosis. Indurated pink scaling plaques.

B. Mucosal--dangerous with high metastatic potential.

C. in situ--Bowen's Disease. Well defined psoriasiform plaque in sun exposed

area(s).

III. Melanoma

A. Types

1. Superficial Spreading 2. Nodular

3. Lentigo maligna (Hutchinson's freckle)

(i) Lentigo maligna melanoma

4. Acro-lentiginous

B. Prognosis

1. Type

2. Location ("BANS" areas)

3. Depth

a Clark's level

b Breslow scale:

Depth %Survival (5 yr)

0--.75 mm 98-100%

.75--1.5 mm 90--95%

1.5--3.0 mm 50--75%

over 3.0 mm less than 50%

C. Treatment

1. wide local excision

2. ?lymph node dissection - [sentinel lymph node]

3. chemotherapy

4. immune modulation

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INFLAMMATORY DISORDERS

I. ECZEMA--Dermatitis

Acute--"juicy" red ill defined plaques with or without vesiculation; pruritus

Chronic-lichenification--scaling thickened pink plaques with increased skin

markings; pruritus

A. Contact--unusual configuration and distribution limited to areas of contact

1. Allergic--

a specific sensitivity, not dose dependent

b eg: poison ivy, Nickel, fragrances,

c preservatives, Neomycin

2. Irritant--non specific

a dose dependent

b eg: soaps, lye

B. Seborrheic--"dandruff"

1. scalp, central face, chest ("oily" areas)

2. ill defined, greasy, yellow scaling pink plaques

3. Pityrosporum ovale

C. Dyshidrotic--"Pompholyx"

1. palms, soles

2. "tapioca" vesicles

D. Stasis--shins - edema, with diffuse erythema, scaling and purpura

E. Xerotic--"dry" skin

F. Atopic--asthma

1. flexural fold involvement

2. food allergies (milk, eggs, nuts, wheat, citrus)--RAST testing

3. familial

4. cataracts

G. Treatment: identification and avoidance of offending agent(s)--patch test

1. steroids-topical and systemic

2. antihistamines

3. moisturizers

4. antibiotics (Staph aureus)

II. PSORIASIS

3% of American population

Etiology unknown--increased cell turnover

Polygenic inheritance

A. Vulgaris

1. well defined pink plaques with "micaceous" scales

2. distribution

a elbows, knees

b gluteal cleft

c scalp

d nails--pitting, oil staining

e sites of trauma--"Koebner phenomenon"

B. Pustular

1. sterile pustules, lakes of pus with diffuse erythematous background

2. palms and soles most frequent sites

3. eruptive (von Zumbusch)--generalized involvement, often steroid induced

C. Guttate

1. Wide spread, small "raindrop spattered" plaques

2. post Strep, viral infections

D. Psoriatic arthritis--occurs in 3-5% of psoriasis patients

1. mono-articular--most common

2. mutilans (distal interphalangeal, "pencil in cup")--pathognomonic

E. Treatment:

1. topical steroids

2. tar

3. UVB

4. PUVA

5. Methotrexate

6. Retinoids

7. vitamin D

8. cyclosporine

III. LICHEN PLANUS

A. Flat topped violaceous polygonal plaques with white lacy striae (Wickham's)

B. ankles, wrists

C. oral (buccal mucosa)

D. nails (pterygium)

E. extreme pruritus

RovnerREACTIVE ERYTHEMAS

I. Urticaria, Angioedema Type I hypersensitivity

Red wheals, plaques with central translucency; pruritic!

Lesions recur in crops and waves, each lasting under 24 hours

Acute--under 6 weeks

Chronic--over 6 weeks

A. Types:

1. Angio[neurotic]edema--swelling of lips, genitalia, eyelids

2. Contact--rare; DMSO, cinnamates

3. Papular--insect bite reaction

4. Dermographism

5. Hereditary Angioedema--complement mediated

B. Etiology

1. Drugs--antibiotics (PCN, sulfa) salicylates

2. Foods--shellfish, tartrazine dyes

3. Physical Factors--heat, cold, pressure

4. Stress

C. Treatment--antihistamines

1. Steroids

2. epinephrine

II. Erythema Multiforme

Symmetric target "Iris" lesions, often involving palms, soles

Resolving within days to weeks

A. Etiology

1. Infectious--Herpes virus, mycoplasma, deep fungi

2. Drugs-- -phenobarbital, PCN, sulfa

B. Treatment--self limited

1. ? steroids

2. antihistamines

3. treat underlying condition

C. Variants

1. Steven's Johnson Syndrome

a Erythema multiforme with bullous, erosive lesions

b Mucosal involvement

c Severe, potentially life threatening

2. Toxic Epidermal Necrolysis

a Widespread denudation, sloughing of inflamed skin

b Mortality--over 50%!

III. Erythema Nodosum (panniculitis)

A. painful subcutaneous nodules on anterior shins, bilaterally

B. bruising with pink/yellow/purple shiny plaques or nodules

C. NO ulceration

D. Etiology: Infectious (viral, Strep, deep fungi)

E. Drugs (BCP's, PCN)

F. Inflammatory Bowel Disease

G. Sarcoid

H. Treatment--self limited, lasting up to several weeks

1. NSAID's

2. steroids

IV. Drug Reactions--Type IV hypersensitivity (except urticaria)

A. Morbilliform--symmetric, pruritic coalescent pink papules and plaques

1. typically begins within 1 week of new drug

2. Bactrim, PCN

B. Urticaria

C. "Fixed"--phenolphthalein (Ex-Lax); Tetracyclines

D. Phototoxic--Tetracyclines, Thorazine, NSAID's

E. Alopecia--heparin, coumadin

F. Bullous--griseofulvin, nalidixic acid

G. Lupus Erythematosus--hydralazine, procainamide, INH

H. Psoriasis--lithium

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INFECTIOUS DISEASES OF THE SKIN

I. Viral

A. Herpes simplex (types I and II)

1. Primary

2. Recurrent

B. Zoster--reactivated Varicella

C. Molluscum Contagiosum

D. Human Papilloma Virus

1. Warts

2. Condyloma acuminata

3. Cervical dysplasia

4. Laryngeal polyps

E. Exanthems

1. nonspecific--similar to morbilliform drug reaction

2. specific

a Fifth Disease--Parvovirus

b Sixth Disease (Roseola)--HSV VI

c Hand, foot and mouth disease--Coxsackie virus

d ?Pityriasis Rosea - ?HSV VII

II. Bacterial

A. Impetigo

1. Staph aureus, NOT Strep

2. Honey colored crusts, erosions with a red base

3. May be bullous

4. Treatment:

a Systemic antibiotics

b Topical antibiotics ineffective except Bactroban!

B. Cellulitis

1. Staph, Strep, H. influenza (children)

2. Tender, bright red dermal plaques with indistinct borders

3. Constitutional symptoms--fever, arthralgias, malaise

C. Erysipelas

1. Strep usually causative

2. Extremely well demarcated red indurated plaques

3. Recurrence is frequent

D. Mycobacteria

1. Leprosy--M. leprae

Tuberculoid Borderline Lepromatous

TT BT BB BL LL

2. Atypical Mycobacterium--

a M. marinum

b Fish tank (swimming pool) granuloma

E. Pseudomonas--hot tub folliculitis

F. Disseminated

1. Gonococcemia

a rare, painful hemorrhagic pustules

b palms and soles

c septic arthritis

2. Meningococcemia

a gun metal grey hemorrhagic pustules

b EXTREMELY DANGEROUS

3. Rickettsia--Rocky Mountain Spotted Fever

a wood tick vector

b acral hemorrhagic papules

III. Fungal

A. Superficial

1. Dermatophytes

a "ringworm, athlete's foot, jock itch"

b annular scaling pink plaques with central clearing

c Skin--Tinea corporis, cruris, pedis, etc.

d Hair--Tinea capitis

e Nail--Tinea unguium

f 3 genera

i Trichophyton spp

ii Epidermophyton

iii Microsporum spp

g Diagnosis--KOH slide

h Treatment

i topical--imidazoles

ii systemic--griseofulvin, ketoconazole

2. Candida--C. albicans

a bright red plaques with satellite pustules

b skin: moist intertriginous areas (groin, glans, angles of mouth)

c oral: thrush

d Treatment: nystatin, imidazoles (NOT griseofulvin)

3. Pityrosporum

a P orbiculare, ovale

b normal commensal in oily areas

c Tinea Versicolor (Malassezia furfur)

d Folliculitis

B. Deep

1. Begin as self limited acute respiratory infection with fever, cough with

eventual spread to skin (in rare instances)

2. Histoplasmosis

a oral lesions

b Ohio River basin

c Erythema multiform, Erythema nodosum

3. Blastomycosis

a Eastern USA

b vegetative, verrucous plaques

4. Coccidioidomycosis

a Pacific Southwest

b EM, EN

5. Paracoccidioidomycosis--Amazon basin

6. Sporotrichosis--verrucous papules, nodules, plaques, peat moss, rose thorns

IV. Infestations

A. Scabies--Sarcoptus scabii

B. Pediculosis

1. capitus--head lice

2. corporis--body lice (organisms found in seams of clothes only, not on body)

3. pubis

a pubic lice "crabs"

b also may affect eyelashes

V. Parasites

A. Cutanea larva migrans (creeping eruption)

B. Schistosomiasis--(duck itch, swimmer's itch)

VI. Spirochetes

A. Syphilis--Treponema pallidum

1. a. Primary--chancre: painless, indurated ulcer at inoculation site, RPR

negative

2. Secondary--Pityriasis rosea like rash 1 to 6 months after 10 infection

a brown macules on palms and soles

b mucous patches

c Condyloma lata

d RPR positive; spirochetes recoverable from all lesions

e latent--RPR remains positive; no lesions

3. Tertiary--5 to 30 years after latency

a gumma

b arthritides

c cardiac, neurologic involvement

B. Lyme Disease

1. Borrelia burgdorferii

2. deer tick vector

3. triphasic course:

a 10--Erythema chronicum migrans

b 20--Fever, arthritis

c 30--Late sequelae (cardiac, neurologic)

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GENODERMATOSES

I. Ichthyoses

1. Genetically determined conditions with thick scaling plates

2. Two mechanisms:

a Increased cohesiveness (I. vulgaris, X-Linked Ich).

b Increased cellular production (lamellar Ich., epidermolytic hyperkeratosis)

3. Infants often present with membrane ("colloidian baby")

4. Symptoms:

a pruritus

b cosmesis

c bacterial 20 infections

d odor

e ectropion

f fluid, electrolyte imbalance

5. Treatment:

a antibiotics

b moisturization (LacHydrin)

II. Neurofibromatosis (von Recklinghausen's)

A. Autosomal dominant

B. cafe-au-lait macules (at least 6 greater than 1 cm.)

C. neurofibromas

1. typical

2. plexiform-may eventuate in neurosarcoma

D. pheochromocytoma

E. acoustic neuroma

F. **Crowe's sign--axillary freckling

G. **Lisch nodules

III. Tuberous Sclerosis

A. Autosomal dominant

B. Ash leaf macules

C. Adenoma sebaceum (angiofibromas)

D. **Shagreen patch

E. mental retardation

IV. Peutz Jaegher's

A. Autosomal dominant

B. Multiple lentigines

C. Small intestinal polyps (pre adenocarcinomatous)

V. Gardiner's

A. Autosomal dominant

B. multiple cysts

C. colonic polyps (premalignant)

VI. Osler-Weber-Rendu

A. Autosomal dominant

B. Familial hemorrhagic telangiectasia

C. Telangiectases on lips, oral mucosa, skin

D. Bleeding from CNS, GI tract

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BULLOUS DISORDERS

I. Epidermolysis Bullosa--noninflammatory inheritable blistering disorders,skin

fragility

A. E.B. Simplex

B. E.B. Letalis (junctional)

C. E.E. Dystrophica

D. Treatment: trauma avoidance

1. cool environs

2. antibiotics, local wound care

3. steroids

4. Dilantin

II. Pemphigus

A. Superficial

1. P. foliaceous

2. P. erythematosus

B. Deep

1. P. vulgaris

2. P. vegetans

C. flaccid bullae on uninflamed base

D. + Nikolsky sign

E. Pathogenesis: autoantibodies to intercellular cement

F. Histopathology

1. acantholysis

2. intrerepidermal bullae

3. + immunofluorescence intracellularly in epidermis

G. Treatment:

1. Steroids!

2. immunosuppressants

III. Bullous Pemphigoid

A. Tense bullae on inflamed base

B. Nikolsky sign

C. Pathogenesis: autoantibodies to basement membrane zone protein

D. Histopathology

1. no acantholysis

2. intact epidermis overlying bulla with eo's, PMN's

3. + immunofluorescence at DE junction

E. Treatment: Steroids, immunosuppressants

IV. Dermatitis Herpetiformis

1. Intensely pruritic papulovesicles over elbows, knees, buttocks

2. gluten enteropathy (asymptomatic)

3. Pathogenesis: IgA antibodies in dermal papillae

4. Histopathology: Necrosis of dermal papillae with PMN's

5. Treatment:Dapsone, gluten free diet, antihistamines

V. Porphyria Cutanea Tarda

A. Blisters on dorsal hands with sun exposure

B. Zygomatic hypertrichosis

C. Marked skin fragility

D. Pathogenesis:

1. defect in uroporphyrinogen decarboxylase

2. increased porphyrins excreted in urine (positive fluorescence)

E. Aggravated by BCP's, EtOH

F. Treatment:

1. phlebotomy

2. antimalarials

3. EtOH avoidance

4. sunscreens

Rovner

COLLAGEN VASCULAR DISORDERS

I. Lupus erythematosis

A. Discoid LE (DLE)

1. pink, violaceous well defined plaques in sun exposed distribution

2. scarring, including alopecia

3. follicular plugging, atrophy

4. ANA-negative

5. no systemic manifestations

6. Treatment:

a steroids (systemic, topical)

b antimalarials

c sunscreens

B. Systemic LE (SLE)

1. autoimmune antibody/antigen complex deposition with Type III inflammation

2. drug induced

a hydralazine

b procainamide

c isoniazid INH

3. 4 or more ARA criteria for diagnosis:

a malar ("butterfly") rash with sun exposure

b discoid lesions

c photosensitivity

d oral ulcers

e arthritis

f serositis (pleuritis, pericarditis)

g renal disease

h neurologic sx's (seizures, neuropathy, psychosis)

i hematologic (anemia, pancytopenia)

j immunologic (anti-DNA ab's; LE prep; false + RPR) ANA

4. Treatment:

a steroids

b immunosuppressants

c antimalarials

d sunscreens

C. Subacute LE (SCLE)

1. ANA negative lupus

2. +SSA, SSB antibodies (anti Ro, anti La)

3. less cardiac, renal involvement compared to SLE

4. small, annular red plaques in sun exposed areas

5. Neonatal lupus:

a (infants born to mothers with SCLE)

b 30 heart block

c discoid lesions

d anemia, "HELP" syndrome (Hepatic Enzymes Low Platelets)

e usually resolves within 6 months, but heart block permanent

II. Dermatomyositis

A. Inflammatory disorder of proximal muscles, skin

B. Associated with internal malignancy 25 to 50% in patients over 55

C. Skin:

1. "heliotrope" rash

2. Gottron's papules

3. periungual telangiectases

D. Muscle: limb/girdle weakness with abnormal EMG findings

E. Laboratory:

1. elevated CPK, Aldolase

2. + ANA

3. ESR elevation

F. Treatment

1. treat underlying malignancy

2. steroids

III. Scleroderma

A. Morphea (localized)

1. atrophic plaques without systemic involvement

B. CREST Syndrome

1. Calcinosis cutis

2. Raynaud's disease

3. Esophageal strictures

4. Sclerodactyly

5. Telangiectases

C. PSS (Progressive Systemic Sclerosis)

1. proximal sclerosis

2. pulmonary fibrosis

3. renal disease

4. cardiac (restrictive cardiomyopathy)

D. Treatment:

1. steroids

2. d-penicillamine

Rovner

VASCULITIS

Definition: Inflammation with necrosis of blood vessels resulting in variable clinical

presentations depending upon:

1. size of vessel

2. type of vessel

3. histological infiltrate

Pathophysiology:Antigen-Antibody Complex Formation

Immune Complex Deposition

Complement Derived Chemotaxis

PMN Lysosomal Enzyme Release

Vessel Wall Injury, Necrosis

VASCULITIS

I. Vasculitis - Types

A. Hypersensitivity Group (Leukocytoclastic)

1. Vessel type: small, usually post capillary venules

2. Symptoms: Skin-Palpable Purpura

a vesicles, bullae, ulceration

b urticaria (collagen vascular disease)

3. Systemic:

a Joints--arthritis (50%)

b Renal--hematuria

c Other--GI tract

4. Etiology:

a Infectious (Strep, viral, Rickettsial)

b Drug Reaction

c Collagen vascular disease

d Cryoglobulinemia

e Internal Malignancy

f Henoch-Schonlein Purpura

i Palpable purpura (dependent areas-legs and buttocks)

ii Abdominal pain

iii Arthritis

iv Hematuria

v Increased IgA

g Idiopathic

5. Laboratory work-up

a CBC, Platelets

b Urinalysis, BUN, Creatinine

c Chest x-ray

d ANA

e Cryoglobulins

f Serum Protein Electropheresis

g ESR (nonspecific)

6. Differential Diagnosis:

a Thrombocytopenia

b Sepsis

7. Treatment

a removal of offending agent

b steroids

c dapsone

B. Polyarteritis Group (Periarteritis)

1. Polyarteritis Nodosa

a Vasculitis of small-medium sized arteries with segmental (skip)

involvement.

b Symptoms:

i Constitutional

ii Renal--hypertension, glomerulonephritis

iii Neuromuscular--arthritis, myalgia, sensorimotor neuropathy

(mononeuritis multiplex)

iv Gastrointestinal--functional

v Cutaneous--Livedo reticularis, Nodules (painful shiny red nodules

in crops usually on lower extremities), Ulcerations

vi Other--cardiac, CNS

c Laboratory Work-Up: Nonspecific

d Treatment:

i Steroids (50% 5 yr. survival)

ii Cyclophosphamide (80% 5 yr. survival)

iii None (10% 50 year survival)

2. Churg-Strauss

a Allergic granulomatous angiitis

b Asthma, Eosinophilia

c Pulmonary vessel involvement--100%

d Splenic involvement--70%

C. Granulomatous

1. Wegener's Granulomatosis

a Granulomatous vasculitis of upper and lower respiratory tract,

glomerulonephritis, and other small arteries

b Symptoms:

i Respiratory Tract--100%

ii sinusitis, rhinitis, septal destruction, cough, dyspnea

iii Renal--80% glomerulonephritis

iv Cutaneous--40-50% nodules, ulcers

v Other--joints, CNS, cardiac

c Laboratory work-up

i ESR markedly elevated

ii Chest x-ray (cavitary lesions, nodules)

d Treatment:

i 90% 2 yr. mortality without treatment

ii cyclophosphamide and steroids

2. Giant Cell Arteritis

a Temporal Arteritis (Polymyalgia Rheumatica)

b Giant cell infiltrate of large arteries (temporal, carotid)

c Severe, disabling musculoskeletal pain,

d Blindness without immediate steroids in high doses

e ESR extremely elevated (over 100)

II. SYSTEMIC DISEASE

A. Pruritus

1. Thyroid (hyper- or hypo) TSH, T4

2. Renal disease BUN, Creatinine

3. Hepatic disease LFT's

4. Malignancy (Hodgkins Disease) Chest x-ray

5. Polycythemia vera CBC, platelets

6. Diabetes glucose

B. Endocrine

1. Adrenal

a Addison's Disease

i Hypoadrenalism

ii generalized bronzing

iii dark pigmentation on gums

b Cushing's

i Hyperadrenalism

ii moon facies

iii buffalo hump

iv hirsutism

v acanthosis nigracans

2. Thyroid

a hyperthyroidism--pretibial myxedema, thyroid acropachy

b hypothyroidism--myxedema, alopecia, xerosis, macroglossia

3. Diabetes Mellitis

a Necrobiosis Lipoidica Diabeticorum

b Diabetic Dermopathy

C. Malignancy

1. Pruritus

2. Dermatomyositis

3. Acanthosis Nigracans

4. Acquired Ichthyosis

5. malignant down - lanugo hairs

D. AIDS

1. Oral hairy leukoplakia--EB virus

2. Kaposi's Sarcoma

3. Sudden, severe Seborrheic Dermatitis

4. Molluscum contagiosum-- refractory

5. Unusual or opportunistic infections

6. Bacillary angiomatosis

7. Chronic cutaneous herpes virus infections

8. Lipodystrophy

Rovner

DISEASES OF SKIN APPENDAGES

I. Pilo-sebaceous unit

A. Acne : inflammatory papules, cysts, or nodules due to follicular plugging and

anaerobic breakdown of trapped sebum due to Propionbacterium acnes.

1. Types:

a A. vulgaris

b A. cosmetica

c A. fulminans

d A. conglobata

e Chloracne--dioxin induced (Agent Orange)

2. Treatment:

a avoidance of comedogenic materials

b Retin-A (tretinoic acid)

c Benzoyl peroxide

d Antibiotics:

i tetracyclines

ii erythromycins (topical or systemic)

iii amoxicillin, Bactrim

iv clindamycin (Cleocin-T), usually topical

e Accutane (isotretinoic acid)

f Diet and acne cleansers have NO therapeutic effect

II. Sweat ducts

A. Eccrine --Miliaria

1. Miliaria rubra--"prickly heat" perifollicular papules

2. Miliaria crystallina--crystal clear superficial vesicles, febrile

3. Miliaria profunda--hyperthermia, no skin signs

B. Apocrine

1. Hidradenitis suppurativa--cysts, nodules, sinus tracts and scarring in axillary,

inguinal areas

III. Alopecia

A. Scarring--DLE, lichen planus, male pattern

B. Non scarring

1. Alopecia areata--stress induced; pernicious anemia, thyroid disease

2. Telogen effluvium--post partum, stress, crash diets, febrile illness, drugs

3. Anagen effluvium--chemotherapy, trichotillomania

IV. Nails

A. Tinea unguium

B. Psoriasis

C. 1/2 and 1/2 nails--renal disease

D. White nails (Terry's nails)--liver disease

E. Nail Tic Deformity

V. Pigmentation

A. Melasma, chloasma--reticular hyperpigmentation in sun exposed areas of face,

more common in females, estrogen induced

B. Vitiligo

1. Autoimmune--may be associated with thyroid anti-microsomal antibodies and

pernicious anemia; symmetric depigmentation, accentuated by Wood's light

exam; etiology unknown, may run in families

Treatment: psoralens, UVB or UVA, topical steroids

2. Contact: phenols (photographic developers)

Surgery of the Skin

CRYOTHERAPY: minus 40˚ Centigrade for 30 seconds with LN2

wart, keratosesnot suitable for tissue requiring histopathologic exam

ELECTROCAUTERY: ElectrodesiccationElectrofulgurationElectrocauterization

HemostasisSuperficial lesions, except warts; telangiectases

CURETTAGE; wart, keratosesBasal Cell Carcinoma--E&C Electrodesiccation and curettage

SCALPEL SURGERY; "cold steel" surgeryElliptical excision --3 times the width of lesionAnesthesia-- 1% xylocaine w/ or w/o epinephrine

Benadryl injectableSaline

Closure primary--subcuticular sutures for hemostasis and

tension placement

Secondary--packing Granulation

Flaps and grafts--large wounds, cosmesis, function

LASER SURGERY; argon--vascular tumorsCO2--warts, condylomaNeodymium: YAGTunable dyes--vascular, pigmented, and other solid tumors

MOH'S (CHEMO) SURGERY: recurrent malignant tumorsAffords potential best cosmetic result

SKIN BIOPSY: punchshave

RovnerTOPICAL DERMATOLOGIC THERAPY

IV. VEHICLES (BASES)

A. POWDERS

1. reduce friction; absorb moisture

2. eg. talc, cornstarch, Zeasorb

B. SHAKE LOTIONS/EMULSIONS

1. suspension of non-soluble in liquid/oil

2. drying, soothing

3. eg. Calamine

C. SOLUTIONS

1. active medication dissolved in aqueous or alcohol solution

2. useful in hair bearing areas

D. GELS

1. similar to a solution, but with an added polymer to provide substance - less

"runny" than solutions

E. CREAMS

1. oil-in-water (light) or water-in-oil (heavy)

2. require preservatives, emulsifiers, stabilizers

3. cosmetically acceptable

F. OINTMENTS

1. nonaqueous base, usually petrolatum

2. greasy, cosmetically not desirable, especially in hair bearing areas

3. usually best delivery system in terms of effectiveness

G. PASTES

1. nonvanishing, thick wax based, remain on skin

2. cosmetically unacceptable, messy

V. SOAKS, BATHS

A. soothing anti-inflammatory, antipruritic, may be anti- infective or used to dry

oozing areas or loosen debris in wounds

B. Examples:

1. colloidal oatmeal (Aveeno) - soothing

2. Aluminum Subacetate (Dome Boro's) - drying. antibacterial

3. Daikon's Solution - saline with sodium hypochlorite - good debriding agent

4. Tar - anti-inflammatory, useful for eczema, psoriasis

5. Oil - soothing, hydrating

VI. ANTI- INFLAMMATORY

A. TOPICAL STEROIDS

1. Potency (as determined by vasocontrictor assay):

a Classification: Class I - super potent - Class VII - least potent

b Concentration

c Vehicle

d Substitution (fluorination, esterification)

2. Usage

a Type of skin

b Area to be covered - 30 gms per total body application

c Location to be treated - facial and intertrigenous areas require special

attention

d Cost - generic vs. Brand-name

B. TAR PREPARATIONS

1. May be compounded with steroids

2. Messy, staining, potentially irritating

a LCD (Liquor Carbonis Detergens)

b Anthralin - synthetic

c Pine Tar Extracts

C. SPECIAL CASES

1. Viaform

a Useful in intertrigenous areas

2. Topical Antihistamines and Anesthetics

a Any preparation ending with "-dryl" or "-caine" (eg. Benedryl,

Caladryl, Benzocaine) is potentially sensitizing. Zonalon (topical

doxepin) may be effective

3. Capsaicin

a Depletes substance P

VII. TOPICAL ANTIBIOTICS

A. ANTI-INFECTIVES

1. Bacitracin, Polymixin B, Neomycin - wound healing, - prophylaxis only

Polysporin , Neosporin

NB: Products with neomycin (eg. "triple" antibiotic) should be avoided due to

high incidence of hypersensitivity!

2. Mupiricin (Bactroban) - effective for impetigo

3. Cleocin, Erythromycin - folliculitis

4. Sulfonamides (Azulfidine) - burns

5. Cleansing Agents

a Soaps - Deodrant (Triclosan)

b Scrubs

i chlorhexidene (Hibiclens)

ii povidone/iodine (Betadine)

iii hexachlorophene (PhisoHex)

c Alcohol

d Hydrogen Peroxide

B. ACNE

1. Erythromycin

2. Clindamycin

3. Tetracycline

4. Meclocycline

5. Sulfonamides

6. Metronidazole (Flagyl) - rosacea

VIII. TOPICAL ANTI FUNGALS

A. Candida, yeast

1. nystatin (Mycostat)

B. Fungi

1. Powders

a useful in prevention

i tolnaftate

ii micostatin

iii undecylenic acid

2. Shampoos

a Zinc - (Head & Shoulders)

b Tar - (T-Gel)

c Selenium Sulfide - Selsun Blue

d Nizoral

3. Creams/Lotions

a Imidazoles

i clotrimazole (Lotrimin)

ii Ketoconazole, econazole, miconazole

b Cyclopirox (Loprox)

c Allyl Amines (Lamisil)

Rovner SYSTEMIC DERMATOLOGIC THERAPY

IX. ANTIBIOTICS - Widespread, deep or potentially life threatening infection, (eg.

folliculitis, cellulitis, ecthyma)

A. Anti-Staphylococcal

1. Erythromycin

2. Beta-lactamase resistant Penicillins (Dicloxacillin, Augmentin)

3. Cephalosporins (Keflex, Duricef)

4. Penicillin and Tefracycline are NOT appropriate.

B. Anti-Streptococcal

1. Erythromycin

2. Penicillins

C. Acne

1. Tetracyclines, Minocycline, Doxycyclene

2. Erythromycins

3. Amoxicillin

4. Trimethoprim/sulfa (Bactrim)

5. Clindamycin

6. Cephalosporins (Duricef)

X. ANTI-FUNGALS - Widespread or deep infections; nail infections

A. Griseofulvin

1. eg. Gris Peg, Fulvicin

2. Dermatophyte infections only - no yeasts!

3. Potentially hepatotoxic, phototoxic

B. Imidazoles

1. eg. Ketoconazole (Nizoral), Itraconazole (Sporanox)

2. Drug interactions

3. Potential hepatotoxicity

C. Allyl Amines - (Lamisil)

XI. ANTI-HISTAMINES

A. Sedating

1. Hydroxyzine (Atarax)

2. Diphenhidramine (Benadryl)

3. Cyproheptadine (Periaction)

B. Non-sedating

1. Terfenadine (Seldane) Interaction with Macrolides

2. Astemizole (Hismanal) and imidazoles

3. Loratadine (Claritin)

C. Mildly sedating

1. Cetirizine (Zyrtec)

XII. STEROIDS - used to control acute flare of eczema, pemphigus,urticaria, and

other inflammatory dermatoses except psoriasis

A. Prednisone - usual dose is 0.5 to 1 mg/kg tapering over 3 to 4 weeksB. Other - equivalence:

Decadron Triamicinolone, Prednisone Hydrocortisone Methyl Prednisdone Prednisolone 0.75mg 4mg 5mg 20mgMay be given PO, IM, IV, or intralesionally

XIII. RETINOIDS - teratogenicA. Accutane (isotretinoin) B. Tegison (etretinate)C. Arotonoids

Rovner

PEDIATRIC DERMATOLOGY

I. CLASSIC EXANTHEMS

A. First Disease (MEASLES, Rubeola)

1. Etiology: myxovirus

2. Clinical: age of onset after 6-12 months, 10-11 days' incubation, then fever,

coryza, rash

3. Enanthem: Koplik's spots - 1-2 days prior to onset of rash

4. Exanthem: morbilliform

a eruption 14 days after inoculation

b Posterior scalp-- neck-- face-- trunk, upper extremities

c 2-3 days' duration

5. Sequelae: neurologic in up to 50%

6. Prevention:

a live attenuated vaccine (MMR) after 12 months

b earlier killed vaccines led to atypical measles

B. Second Disease (SCARLET FEVER)

1. Etiology: erythrotoxin from Group A Beta-hemolytic Strep, usually from

pharygeal infection ("Strep" Throat)

2. Clinical: Sudden, severe after 2-4 days' incubation with fever, sore throat,

headache

3. Exanthem:

a oropharyngeal erythema

b "Strawberry" tongue

4. Sequelae:

a rheumatic fever 2-3 weeks post infection

b glomerulonephritis

5. Treatment: Penicillin

C. Third Disease (RUBELLA, German Measles)

1. Etiology: paramyxovirus

2. Clinical:

a 12-25 days' incubation

b 4-5 day prodrome (fever, malaise) with adenopathy (post cervical)

3. Exanthem:

a 2-3 day course

b small pink papules on face with peripheral spread to trunk and arms over 1

day

c clearing in upper extremity, with involvement of lower extremity

4. Enanthem:

a Forchheimer's spots - petechiae on soft palate

b coincident with exanthem

5. Sequelae:

a Usually none

b Neonatal Rubella Syndrome

6. Prevention: live attenuated virus (MMR)

D. Fourth Disease (Duke's Disease)

1. Historical significance only

2. ? ECHO virus exanthem

3. ? Scarlatiniform eruption

E. Fifth Disease (Erythema Infectiosum)

1. Etiology: Human Parvovirus

2. Clinical:

a children 5-15 years

b mild constitutional symptoms

c 1-2 week duration, waxing and waning

3. Exanthem:

a "slapped" cheek appearance

b reticulated erythema over upper back, shoulders, buttocks

4. Enanthem: none

5. Sequelae: none, but adults may have lingering malaise, arthragias, fever

F. Sixth Disease (Exanthem Subitum, Roseola)

1. Etiology: Herpes Virus VI

2. Clinical:

a young children (6 months to 2 years)

b 10-12 days' incubation

c High fever spike, 2-3 days' duration

3. Exanthem:

a abruptly follows defervescence

b short lived (1 day's duration)

c faint pink macules from neck to trunk

d facial sparing

4. Enanthem: none

5. Sequelae: febrile seizures, (non specific)

6. Prevention: none

II. VARICELLA (CHICKEN POX)

A. Etiology: Varicella Zoster Virus

B. Clinical:

1. 10-20 days' incubation

2. 1 day prodrome of fever, malaise

C. Exanthem:

1. successive crops

2. congested papules becoming vesicular ("dew drop on a rose petal"), then

crusted

3. central distribution (face, scalp, trunk) palms, soles spared

4. 1 week's duration (maybe up to 3 weeks)

D. Enanthem: flaccid vesicles progress to white ulceration on hard palate, tonsillar

pillars

E. Sequelae:

1. uncommon in immunocompetent

2. Zoster (Shingles)

F. Treatment: Acyclovir, Valcyclovir, Famcyclovir

G. Prevention: Vaccine

III. KAWASAKI'S DISEASE (mucocutaneous lymph node syndrome)

A. Etiology: uncertain

B. Clinical: infants, young children

C. Criteria:

1. 5 or more days of fever

2. conjunctivitis

3. Strawberry tongue, oropharyngeal erythema

4. erythema and subsequent peeling of hands, feet

5. scarlatiniform rash

6. acute cervical adenopathy

7. elevated platelets

D. Sequelae: coronary arteritis, aneurysms

E. Treatment:

1. ? Antibiotics

2. ? Steroids

IV. COMMON CHILDHOOD PROBLEMS - (treatment considerations)

A. Atopic Dermatitis

B. Warts

C. Molluscum Contagiosum

D. Poison Ivy

E. Ringworm

F. Drug eruptions

G. Viral Exanthems

H. Acne

I. Impetigo

NEONATAL DERMATOLOGY

I. "TORCH" SYNDROME - "blueberry muffin baby"

A. Toxoplasmosis

B. Other

C. Rubella

D. Cytomegalovirus

E. Herpes Simplex

II. COMMON NEONATAL ERUPTIONS

A. Erythema Toxicum [Neonatorum]

B. Neonatal Acne

C. Milia