derm study guide

Derm Study Guide • How to describe a lesion:

o Flat= MACULAR o Raised= PAPULAR o If the lesion is small and

flat, it’s a MACULE o If the lesion is large and flat,

it’s a PATCH o Small and raised= PAPULE o Large and raised= PLAQUE o Small and fluid filled=

VESICLE o Large and fluid filled=

BULLAE o Small and filled with pus=

PUSTULE

Anything under the skin and round= NODULE

• Descriptive terms of derm: o Border (smooth, not well demarcated) o Size o Color o Shape o Distribution

What is this??????

ACNE!

Lesion Description

FLAT RAISED

<1cm

macule papule

>1cm

patch plaque

Wednesday, November 6, 13

Lesion Description

pustule

nodule


Lesion Description

pustule

nodule


MODERATE ACNE


Why is acne a horrible disease? o HUGE psychological impact. Strongly associated with anxiety and

depression o You are more likely to have depression and anxiety with acne than

with cancer!!!

Pathophysiology of Acne

1. During ADRENARCHE (a few years before puberty), get DESQUAMATION of cells in the hair follicle (aka they grow and block) AND too much sebum production (because of androgens)

2. PLUG forms! This is called a MICROCOMEDONE

3. In PUBERTY, P. acnes decides to grow. This causes inflammation and immune sensitivity (but NOT an actual infection

-‐The Lesions of Acne:

• Comedones o Open= black head (filled with dirt and gunk) o Closed= white head

• Inflammation

12

Psychologic Impact: Anxiety and Depression

02

468

1012

1416

Anxiety Depression

Mea

n H

AD

Sco

re

Psychiatric—depressed

Psychiatric—anxious

Acne

Psoriasis

General dermatology population

Cancer

HAD = Hospital Anxiety and Depression Scale. Kellett SC et al. Br J Dermatol. 1999;140:273-82.


Acne Pathophysiology

HairSkinsurfaceSebumFollicle

Sebaceousgland


General Treatment of Acne • Topical agents

o Retinoids o Benzyl peroxide (OTC) o Abx o Salicylic acid o Combos

• Oral o Abx o Hormones….aka BCP o Isotretinoin (Accutane) o Corticosteroids

• Other o Laser and light therapy

Mild Acne: -‐ see both open and closed comedones -‐ NO inflammation -‐ Acne begins with mild

Treatment of Mild acne

o Topical retinoids § Different kinds..: tretintoin, adapalene, tazarotene

Moderate Acne: -‐Open and closed comedones

INFLAMMATION

-‐Treatment of moderate acne -‐Topical retinoids -‐PLUS benzyl peroxide (reduces inflammation) -‐Plus ABX (oral or topical)

MILD ACNE


TREATMENT TARGETSCOMEDONES

Treatment: Topical Retinoids (tretinoin, adapalene, tazarotene)


TREATMENT TARGETSCOMEDONES and INFLAMMATORY LESIONS

Treatment: Topical Retinoids,

Benzoyl Peroxide,

Antibiotics (topical or oral)


Severe Acne: -‐open and closed comedones -‐more inflammation -‐inflammation forms “sinus tracts” -‐cysts and nodules -‐scarring potential

-‐Treatment of severe acne -‐topid retinoids+ benzyl peroxide + ORAL abx or BCP -‐really start to think about isotretinoin (works very well for these cases) What is this?????????

Atopic Dermatitis! Description of dermatitis (aka eczema)

-‐ POORLY demarcated lesions (hallmark!) -‐ Lots of excoriation and inflammation

SEVERE ACNE


ATOPIC DERMATITIS


-‐ More common in kids -‐ Family history

-‐ Face and extensors common in young ;

-‐ Flexors in adults

Nummular dermatitis:

o Coin-‐like round lesions o Adults only

Treatment of Dermatitis: -‐ Avoid irritants -‐ Frequent BATHING! MUST be followed by moisturizing

o Most effective treatment is to trap water in deeper layers of skin with lotion

o Have severe cases bathe more than 1x/day -‐ Topical corticosteroids and immunomodulators -‐ Oral antihistamines…..Only really work by sedating the kids so they don’t

scratch -‐ AVOID ORAL STEROIDS!

o Causes rebound -‐ AVOID oral abx

o Increases resistance of Staph which is HIGHLY colonized on dermatitis patients

o Only use when a crusty, infected lesion present

ATOPIC DERMATITIS


ATOPIC DERMATITIS


What is this?????

Psoriasis!!!

-‐ Hallmark of psoriasis: SCALY, WELL DEMARCATED, SILVER-‐WHITE PLAQUES

-‐no excoriation -‐no inflammation -‐thick, white scale

Pathophysiology of psoriasis -‐ very thick layers of keratin from overactive keratinocytes -‐keratinocytes move up to superficial layers of skin from deep layers in a few days, when it should take almost a month. As a result, they can’t be shed quickly enough, so get plaques!

Most common areas affected: -‐Joints: elbows and knees -‐Eyes common in kids

PSORIASIS


PSORIASIS


41

PSORIASIS


Diaper region can also be affected…..misdiagnosed as diaper rash

Scalp also super common! But difficult to treat

Which one is psoriasis?

(Answer: trick question. They are both psoriasis) What is the diagnosis?

(good job, its dermatitis)

41

PSORIASIS


PSORIASIS

DERMATITIS


PSORIASIS


PSORIASIS

DERMATITIS


Inverse Psorasis -‐ Develops in FOLDS instead of

joint -‐ Often misdiagnosed as tinnea -‐ How to tell if its tinnea: tinnea

will have a region of clearance in the middle

Guttate psoriasis

-‐ Tons of little psoriasis plaques all over chest

-‐ Commonly seen in kids after a Strep infection

Nail psoriasis

Strongly associated with arthritis…so better ask patients about it.

Psoriasis treatment!

-‐ Topicals o Steroids o Intralesional steroids o Tazorac

45

INVERSE PSORIASIS


GUTTATE PSORIASIS


NAIL PSORIASIS


o Salicylic acid o Tar o Calcipotriene (vit D analogue) o Protopic (for inverse psoriasis)

-‐ Others o UV light (special medical tanning bed)…works really well, but

requires 3x/week o Methotrexate….oldie but goodie. Try topicals first o Most patients are successfully treated with topicals, but if not, try UV,

then methotrexate What is this???

Herpes! Fun Facts about The Herp.

-‐ Loves Labial areas -‐ Groups in vesicles with

erythematous base -‐ LOTS of vesicles -‐ Can live other places besides

the lip….like the cheek -‐ Herpes ≠ impetigo (seriously

she loved this concept)

What’s the problem here?

-‐ LOOKS LIKE IMPETIGO -‐ Impetigo= bacterial infection that is NEVER recurrent

o Some bad docs don’t understand this and refer their patients to dermatologists for “recurrent impetigo”…but its really herpes

Treatment of Herpes Simplex:

50

HERPES SIMPLEX


HERPES SIMPLEX


-‐if you are immunocompetent -‐ Nothing or a round or two of

antivirals -‐ Acyclovir -‐ Valtrex -‐ Famvir

if you are Immunocompromised (or get >6 HSV outbreaks/year):

-‐ Suppressive antiviral therapy!

-‐If you are a neonate born with herpes from your mom -‐This is really BAD! -‐treat ASAP w/IV antivirals

What’s this?

Correct answer: It’s NOT herpes! It’s Impetigo caused by Staph! NO vesicles present! At one time there were blisters, but they have since crusted over. What’s this?

HSV! See how it’s very different from impetigo???

HERPES SIMPLEX

IMPETIGO


HERPES SIMPLEX

IMPETIGO


What’s this?

Impetigo…..remember: CRUSTY BLISTERS

Herpes or Impetigo?

HSV!

Bullae Impetigo

Common Benign Cutaneous Growths Common theme: all seen in adults Seborrheic Keratoses

-‐thick, rough, raised -‐completely harmless -‐can be waxy and dry -‐have a “stuck on appearance”

IMPETIGO


56

IMPETIGO


Seborrheic Keratoses


Impetigo

Herpes Simplex


-‐Common in AAs

Cherry Angiomas

-‐very common -‐more numerous in 40’s and 50’s -‐usually small papule

Epidermoid Cysts

-‐form when your normal oils are secreted into a closed area

-‐completely harmless until they become inflamed…..then super painful -‐often have a little pore on top Inflamed Epidermoid Cyst

Treatment of Epidermoid cysts: Inflammed: -‐Incision and drainage -‐inject with corticosteroids -‐Excision

Non-‐inflammed: -‐no treatment -‐remove entire sac if repeatedly becoming inflamed (excision)



61



Cherry Angiomas


66

Epidermoid Cysts(Epidermal Inclusion Cysts)


Epidermoid Cysts


Epidermoid Cysts - inflamed


Here’s a step-‐by-‐step guide if you want to learn to do this: http://ispub.com/IJPS/7/1/4654

Pigmented Lesions Ephelides -‐freckles, liver spots, age spots -‐NOT cute! They mean you have skin damage Solar Lentigines -‐another form of sun-‐related skin damage -‐more liver and age spots

Melnocytic Nevi -‐the common mole -‐develop as kids, young adults

Inflamed Cyst: Incision and Drainage (I&D)

Intralesional Corticosteroids Excision

Non-inflamed Cyst: No treatment Excision

Epidermoid Cysts - Treatment

Wednesday, November 6, 13 Solar Lentigines


KidsYoung adultsOlder adultsCongenital

Melanocytic Nevi (“moles”)

epidermis

dermis


-‐Junctional Nevi…..what they begin as during childhood -‐flat -‐no nests of cells to cause them to be raised

-‐Compound nevi….when junctional nevi become raised -‐teens, adults

-‐Dermal nevi…..when you are old, your moles become even more raised and lose their color

-‐these might eventually go away. Congenital GIANT melanocytic nevi

-‐Develop near the hair follicle, which is why they are hairy -‐want to try to remove these because very prone to becoming cancer

Melanocytic Nevi -kids

JunctionalOr Compound


Melanocytic Nevi -kids

JunctionalOr Compound


Melanocytic Nevi - adults

Dermal


Melanocytic Nevi – congenital


Melanoma A – asymmetric B-‐ Border uneven C-‐ multiple colors D-‐ Diameter >1/4 inch E-‐ evolving. Any change at all…such as bleeding or itching

Risk Factors: -‐ Family history (1st degree

relative) -‐ Numerous nevi -‐ Multiple dysplastic nevi -‐ Hx of BLISTERING sunburn

as a kid -‐ Fair skin -‐ Tanning Beds -‐ Immunosuppression -‐ Giant congenital nevi

Melanoma Prognosis -‐ Best= Breslow thickness. How

deep the cancer goes in biopsy o Determines how large

margins for removal need to be

o And if you need to check lymph nodes

o Might want to also do a CXR and blood chem

Melanoma Treatment

-‐ Excision w/wide margins -‐ Sentinal lymph node biopsy -‐ Interferon -‐ Chemo

Melanoma


85

Melanoma


85

Melanoma


Melanoma


Melanoma


derm study guide

Documents

o flat

depression o

o laser

gunk o

papular o

macular o

macule o

comedones o open