Pruritus
-Unmyelinated C fibers
-Stimuli: light touch,
temperature changes, emotional stress
-Pruritoceptive itch: inflammation, dryness
-Neuropathic itch: post herpetic
-Psychogenic itch: parasitophobia
-Itch caused by systemic disease: Chronic kidney disease
-Internal causes: liver disease, renal failure,
hypo/hyperthyroidism, IDA, PV, malignancy (lymphoma), neuropsychiatric
-Central/Neurogenic
-Cholestasis/Atopic Dermatitis
Xerosis (dry skin)
causes: old age, dry scented soaps, scrubbing, vigorous
washing, frequent bathing, guava soaps, bayabas. use tangential lighting for
you to see the cracks clearly
Xerotic eczema
-background of xerosis
-pruritus occurs before lesions appear
Pruritus ani
-secondary to contact
dermatitis, rule out CD. use of wet wipes is a common CD cause
-hemorrhoids, anal tags, leakage
of GI secretions
-candida,
-parasites- E. vermicularis
Pruritus scroti
-lichen simplex chronicus-
circumscribed neurodermatitis
-Pyschogenic pruritus is the
most frequent type
-low potency steroids
Pruritus vulvae
-vulvovaginal candidiasis10%,
Trichomonas vaginalis
-unspecified dermatitis(54%)
-lichen sclerosus, lichen planus, psoriasis(inverse type)
Lichen
simplex chronicus- multiple erythematous to
hyperpigmented, papules some coalescing to form plaques, topped with
excoriations and crusts, athe the_, measuring_x_
a. Thickened
leathery skin
b. exaggerated
skin markings-most often hyperpigmented
Prurigo nodularis
-itchy nodules, usually at the
extensors.
-anterior legs
-treated by stopping scratching. give moisturizers, mild
soap, emolients, johnsons baby soap, milf unscented soap.
Nail
Distal
subungual onychomycosis
-most common
-t. Rubrum
-distal nail bed &
hyponychium
-secondary involvement of underside of nail plate of
fingernails and toenails
Proximal subungal onychomycosis
-associated with HIV
-t.rubrum & t.megninii
-nail plate from proximal nail
White superficial
-can be scraped of
-t.rubrum &
t.metangrophytes, cephalosporium,
aspergillus, fusarium
-small chalky white spots on nail plate
Candidal onychomycosis
-candida albicans
-"wet workers" (water --> destroy cuticle
--> fungi enter) -paronychia
-fingernails afected
Onychomycosis
-topical: clotrimazole,
amorolfine
-systemic antifungals (terbinafine (DOC for
dermatophyte onychomycosis), itraconazole, fluconazole, azoles if candidal)
-precaution: liver disease (LFTs)
Bacterial paronychia
-swelling with pus
-s. Aureus
-mani, pedi
Nail Psoriasis (psoriatic onychomycosis)
-nail pitting (can also be seen
in alopecia areata)
-oil spots/salmon patches
(pathognomonic)
-subungual hyperkeratosis
(thickening)
-onycholysis
-onychodystrophy
-proximal matrix: pitting,
beau's lines
-distal matrix: onycholysis
-nail bed: oil spots, subungual
hyperkeratosis,
onycholysis, splinter
hemorrhages
-proximal & lateral nail folds: cutaneous psoriasis
-methotrexate tx.
Hair
Infundibular area (hair outside
to entrance into skin)
Middle portion (upto the
attachment to arrector pili)
Lower portion
a.
Anagen -synthesis phase 3 yrs
b.
Catagen- transition phase 3 weeks
c.
Telogen- resting phase 3 mosHair growth: half an
inch per month
No hair on palms, soles, labia minora
Alopecia areata
-round/oval bald spot
-"broken exclamation mark
hair" (distal end is thicker and more pigmented)
-can involve scalp or facial
hair
-good prognosis: postpubertal
onset
-improve with corticosteroid
injections
-poor prognosis: atopic dermatitis, childhood onset,
widespread involvement, duration longer than 5 yrs, onychodystrophy, ophiasis
(loss of hair along the temporal and occipital scalp)
Alopecia totalis - loss of all hair in the scalp
Alopecia
universalis - loss of all hair
Telogen effluvium
-transient falling of hair due
to premature entry into telogen phase
-3 mos after stressful event: pregnancy, fever,
surgery, rapid wt loss, drugs -hair regrowth after 3-6mos
Trichotillomania
-hair pulling disorder
-assoc with OCD
-hair at varying lengths
Non scaly inflammatory
nodules
Folliculitis
-Infection inflammation of hair follicle usually caused by
s. Aureus
S. Barbae
-Autoinoculation
-Pustules are superficial
Furuncle
-Nodule with central
suppuration, tenderness
-Nape, axilla, buttocks
-DM, atopic dermatitis, any form
of immunosuppression
-Tx: warm compress, penicillinase resistant penicillin, I
& D if fluctuant
Recurrent Furunculosis
-3 or more episodes per year
-Secondary to staphylococcal carrier state prophylaxis
-Intranasal mupirocin BID for one week every month
-rifampicin 600mg/day dicloxacillin (MSSA) or TMPSMX (MRSA) × 10
days
-clindamycin 150mg/day x 3 mos
-immunosupressed states- DM, HIV
Carbuncle
-2 or more furuncles together
Scrofuloderma-
non tender
Hansen's dx
*missed slide
Fite faraco stain
Ridley Jopling classification system
TT: polar tuberculoid
BT: borderline tuberculoid
BB: borderline leprosy
BL: borderline lepromatous
LL: lepromatous leprosy
Borderline: unstable phases
Skin prick test (test for
numbness)
Indeterminate leprosy
-Early lesion
-Appears
before host make definitive immunologic , non or few afb -Hypopigmented -stable
TT - Polar
Tuberculoid
-Cell mediated immunity is
strong
-Saucer shaped (annular, periphery is
elevated), rulenout fungal infection -Can spontaneously cure
BT -
Borderline Tuberculoid
-Immunity is strong enough to restrain infection but
insufficient for self-cure. -No hope for cure
- multiple asymmetric lesions
|
-Satellite lesion or pseudopods (dd:
candida or |
|
|
intertrigo) |
|
BB-
Borderline Leprosy
-borderline immunity
-annular large plaques
-Most unstable
-Swiss cheese appearance
BL
- Borderline Lepromatous
-Inverted
saucer shaped
LL
Lepromatous Leprosy
-No cell mediated immunity
-Unrestricted bacillary replication
-Difuse dermal infiltration
-Widespread nodules or plaques
-Madarosis, saddle nose,
anhydrosis, Leonine facies(dd lymphoma)
-stable
- (+) hyposthesia
Multibacillary:
dapsone, rifampicin, clofazimine. Day
2 onwards: dapsone, clofazimine
Paucibacillary: rifampicin,
clofazimine
Adverse effects of drugs:
Dapsone -bacteriostatic
-hemolytic
anemia
-methemoglobinemia
-psychiatric problems (psychosis) rarely
Clofazimine
-red
brown Kasama niyo si santos? of the skin, conjunctiva
-red urine, stools, sputum,
sweat, tears
-drynes of skin
Rifampicin -bactericidal
-red
urine
-hepatitis
-thrombocytopenia
-psychosis
-decrease efectiveness of systemic steroids
Scrofuloderma
-nodules secondary to direct
extension from cervical lymph node, non tender
-characteristic cord like scars
-anti-kochs tx
Cellulitis
-subcutaenous
-ill defined plaque
-staph. aureus or Strep. pyogenes
Bullous cellulitis -tinea pedis
Erysipelas
-well defined plaque -grp A strep
Fixed drug eruption
-NSAIDS most common cause
-targetoid lesion always on the
same area
-lips(para, naproxen, mefenamic) genital area
Miliaria rubra
-Hot humid climates
-Back, intertriginous areas, popliteal areas
Miliaria crystallina
-Clear superficial vesicles with no inflammatory
reaction -Tight clothing
-No tx, just cold compress
Miliaria pustulosa
-Non follicular pustules (vs folliculitis) bec eccrine
sweat glands do no exit thru the pores
Scabies
-Intensely pruritic papular
lesion, can come with excoriation, contain mites, eggs or feces
-Finger webs, axilla, popliteal,
axilla, extremities, inguinal
-Sarcoptes
scabiei var hominis
Obligate human parasitic mite
Burrows in stratum corneum
Live in human for 3 days only
Close contacts
Humans are the only reservoir
Contaminated clothes and beddings
Sensitization: 2-4 wks after onset of
infestation
If reinfection: days
-IMPT: nocturnal pruritus, close
personal contact, circle of hebra
-Tx: permethrin 5% lotion, sulfur (if pregnant, apply
everyday), lindane (with cytotoxicity)
-Prevention: soak linens in very hot water for 15mins or
more then dry under the sun, vacuum all rugs, carpets, furniture, ALL personal
contacts should be treated at the same time, regardless if symptomatic or not,
if patient is poor: can pack clothing in garbage bag for a week (since mites
only live for 3 days)
Arthropod
bites -Central punctum
Bed bugs -Bites
in rows
Pediculosis capitis/corporis/pubis Capitis
-Children
-Secondary inflammation,
-Most common: retroauricular
-Permethrin 1% shampoo, use a fine toothed comb for
grooming (use only once), do not shampoo 24hrs after application, not ovicidal
(so repeat after 1 wk) -secondary impetigo is common.
Corporis
-Mite lays eggs in seams of
clothing
-Homeless people with poor hygiene
Acne
-Propionibacterium acne
-Hallmark lesion: Comedone
-can have papules, pustules,
nodules, cysts...
-4 features: hyperkeratosis of
follicular infundibulum, sebum, propionobacterium acnes, androgen
A.
Microcomedone
B.
Comedone
C.
Inflammatory papule/ pustule
D. Nodule
First choice in mgt:
*consider physical removal of
comedones
Comedonal
(blackhead/whiteheads): Topical retinoid: tretinoin, adapalene
Papular/pustular (mild): Topical
retinoid + topical antimicrobial: benzoyl peroxide
Papular/pustular (moderate):
oral antibiotic + topical retinoid +/- BPO
Nodular (0.5-1 cm, moderate):
oral antibiotic + topical retinoid + BPO
Nodular/conglobate (severe): oral isotretinoin
Acneiform
-monomorphic follicular
papules/acne
-cause: steroids (oral and topical)
Vascular disorders
Diascopy
-test for blanchability
-blanching (dilatation of BV) vs
non blanching
(extravasation of RBC)
-blanching:
erythema, sunburn, photosensitivity, urticaria, angioedema, dermographism,
morbilliform drug eruption, EM, exfoliative dermatitis -Nonblanching: purpura, vasculitis
Sunburn
-erythema, tenderness,
blistering
-UVA: aging; UVB causes sunburn;
UVC: ozone
-water resistant: 40mins; water
proof: 80mins
-spares suncovered areas
Phototoxicity: type 3 hypersensitivity Photoallergy:
type 4 delayed hypersensitivity; photopatch test
Contact dermatitis: patch test
Urticaria
-wheals (evanescent: doesn't
last >24hrs)
-acute (<6 weeks: food,
drugs, infection); chronic (>6 weeks: parasitism, dental caries, thyroid dx,
autoimmune diseases)
-mast cell degradation--> release of histamine
Angioedema
-swelling of subcutaneous layer
-common cause: ACE inhibitors and ARBS -ask if
there is dyspnea (might have swelling in respiratory passages) - treatment:
epinephrine
Dermatographism
-drawing hehe
Morbilliform reaction
-also called maculopapular
rash/exanthem
-most common causes: adverse drug eruption and viral
infection
Erythema multiforme
-Dusky center, pale ring,
erythematous surrounding
-adult:HSV (1>2)
-child: mycoplasma pneumonia
-minor: 1 mucosal surface
-major: involvement of more than 2 mucosal surfaces
Exfoliative dermatitis
-Generalized erythema and
scaling
-psoriasis, atopic dermatitis, eczema, allergic contact,
irritant contact dermatitis - more than 90% of skin is invovled
Non blanchables
Purpura
-flat macule/patch
-petechiae --> purpura -->
ecchymoses
-vascular dysfunction, trauma, coagulation disorders,
thrombocytopenia
Vasculitis
-hallmark: Palpable Purpura
(inflammation of blood vessels)
-secondary to extravasation of
RBC from blood vessels
-type 3 hypersensitivity
-confirm dx with biopsy
-advise: exercise, leg elevation
-first line: antihistamine
-colchicine, dapsone
-in children: Henoch Schonlein Purpura (usually preceded
by URTI Gr. A Strep)
Topical steroid use
-potency of steroids (ointment
> cream)
-vehicles of steroids
-location (mild if axilla,
groin)
-size
-lesion (LSC = thick = ointment)
Chronic steroid use:
1.
Acneform
2.
Steroid Purpura
3.
Telangiectasia
4.
Permanent striae
Erythematous lesions with eczema (Moist/oozing eczematous dermatitis)
Atopic dermatitis
-infants(<2): face, extensors
-childhood (2-12): antecubital
fossa, flexures, neck
-adult (>12): flexures,
lichenification
-major:pruritus, rash in
characteristic areas, chronic relapsing, family hx of atopy
-minor: xerosis, dennie morgan fold, allergic
shiners, pityriasis alba (face, powdery scales, vs tinea versicolor: back and
trunk, can be hyper/hypopigmemted) -treatment:
-Dry skin: skin hydration, emollients, avoidance of irritants,
identification and addressing of specific trigger factors
-mild to moderate AD: low-mid potency TCS (topical steroids) &/or
TCI (topical calcineurin inhibitor)
-moderate to severe AD: mid-high potency TCS and or TCI
-Recalcitrant, severe AD: systemic therapy (ex.
cyclosporine, methotrexate (do not give prednisone)) or
UVA therapy
Seborrheic dermatitis
-scalp: cradle cap
-can involve glabella,
nasolabial folds
-yellowish greasy appearance of
scales
-recalcitrant seborrheic
dermatitis: HIV
-malassezia ovalis
-treatment: mild shampoo for
babies, mineral oil
15mins before shampooing, antifungals, and if with
erythema give steroids
Psoriasis
-silvery scales
-goes beyond the hairline
Allergic contact dermatitis
-scaling
-delayed type hypersensitivity
-Allergic contact dermatitis to
hair daye
-Angioedema + erythema along the hairline
-Allergy to nickel, tattoo, rubber, cologne, fragrance
Irritant Contact Dermatitis
- due to acids
and base
Nummular eczema
-coin shaped, papules and
vesicles that coalesce
-NSS compress, antibiotic + steroids
Dyshydrotic eczema
-Tapioca like deep seated
vesicles on the lateral hands/feet
-NSS compress, steroids
Intertrigo
-circular patch in flexural
areas
-inguinal, inframammary
-candidal intertrigo: satellite pustules(tx: azole)
Inverse psoriasis
-bright red with silvery white
scales
-inguinal area + umbilicus
Breast eczema -areola
Stasis eczema
-medial lower leg
-varicosities, edema
-sign of venous insufficiency
Xerotic eczema
-elderly, pretibial
Dermatophyte infections (Papulosquamous disease) Tinea pedis
-T. Rubrum most common cause
-interdigital areas and soles of
the feet, plantar arch
(vs atopic dermatitis: NEVER
plantar arch)
-maceration, scaling, vesicles, bullae
Tinea manuum
-"1 hand, 2 feet",
check inguinal area also
-annular
Tinea capitis
-non inflammatory type: areas of alopecia with
broken of hairs (manifest as black dots) -kerion: boggy inflammatory mass
Tinea cruris
-tx: terbinafine (oral if extensive, OD for 2 weeks)
Tinea facialis
-long septated hyphae with spores
Psoriasis
-sharply marginated, raised,
red, plaque with scaly surface
-silvery white scale
-symmetry of lesions
-extensor distribution
-koebner phenomenon: lesions on
areas of trauma occurs 7-14 days on trauma or sun exposed areas -auspitz sign:
pinpoint bleeding upon removal of scales due to dilated capillaries
-pathognomonic: oil spots (nail pitting also seen in
alopecia areata)
Plaque Type: scalp, nails,
sacrum
Acute guttate: best prognosis; with preceeding strep
pharyngitis Inverse Type
Pustular psoriasis- abrupt
withdrawal of chronic corticosteriod use
Erythrodermic psoriasis: can cause exfoliative
dermatitis 90% involved Psoriatic arthritis
Cutaneous lupus erythematosus
Acute (most common, malar rash)
-localized or generalized; with systemic
symptoms
(DOPAMINE RASH)
Subacute (maculopapular rash on
sun exposed areas, annular psoriariform)
Chronic (CCLE)
-classic DLE
-red purple discoid macule and papules with
small plaques
-atrophy,
telangiectasia, hypo/hyperpigmentation, scales, keratotic plug -heals with scarring
Pityriasis rosea
-Collarette scales, herald patch
-distribution: langer lines,xmas
tree
-HHV 6&7
-heals in 4-12 weeks
Tinea versicolor
-hypo/hyper/slightly
erythematous
-malassezia furfur - short non
septated hyphae with spores
-furfuraceous scales
Syphilis
-primary: chancre
-secondary: maculopapular rash,
condyloma lata
-tertiary: gumma
-involvement of palms and soles: syphilis & EM
-great mimicker
Skin colored papules and nodules
Verruca vulgaris
-rough surface
-tiny black
dots: thrombosed dilated capillaries
-subclinical: can only be
detected by acetic acid
-autoinoculation, direct contact -fingers, palms,
periungual areas -HPV 1,2,4...
-risk factors: nail biting,
butchers, immersion in water
-treat to prevent from
multiplying
-if periungual: might have to do nail avulsion
Verruca filiformis
-Long slender upward projections
-Papillomatous
Verruca plantaris
-usually found on pressure areas
-most commonly on mid metatarsal
areas
-coalesce to form mosaic warts
-diferential dx: callus, corn (with exaggerated skin
lines, but no black dots)
Verruca plana
-flat topped
-risk factor: sun exposure,
autoinoculation by shaving
-Highest rate of spontaneous remission -koebnerization
Tx for warts
-duofilm
-electrocautery
-cryotherapy
-laser therapy
Molluscum contagiosum
-dome shaped papules with central umbilication
-usually appears in children; can be sexually transmitted -poxvirus, MCV1
-contact, immunocompromised
-can spontaneously resolve
-inclusion bodies: molluscum
bodies or henderson paterson bodies
Treatment: nick curettage, caltarithin
Milia
-white keratinous cysts
-asymptomatic
-in newborns: can resolve spontaneously in weeks -in
elderly: can be due to trauma, blistering diseases,
topical occlusive meds -incise and express the
contents
Syringoma
-sweat duct diferentiation;
skin-colored
-found on cheeks & eyelids
-familial
-recurrence after removal by
cauterization or laser therapy
-coalesce to form plaques
Sebaceous cyst/epidermoid cyst
-nodule with a central comedo like punctum -cheesy chalky pasty like foul smelling
material which represent macerated keratin -removal by: excision of capsule
Acrochordon/skin tags
-neck, axilla, groin
-can become tender, inflamed or
gangrenous when twisted
-common in obese; risk of developing DM: skin tags on top
of acanthosis nigricans velvety plaque -tx: snip excision
Pustular diseases
Primary lesion: pustule
Pus = INFECTION
Acne vulgaris
-chronic inflammatory disease
-polymorphic: closed comedone
(white head), open comedone (black head), pustules, papules, nodules
-atrophic scars
-face, upper trunk, upper back
-pathophysiology: keratin plug, sebum accumulation,
propionobacterium acnes, hormonal imbalance
Acne congoblata
-Pustules and papules coalesce that form plaques that release
serosanguinous material -tx: oral isotretinoin
Miliaria pustulosa
-non follicular pustules on
bedridden patients
-blockage of sweat duct
-areas of predilection: intertriginous areas, back
Folliculitis
-superficial inflammation of
hair follicle
-found on hair bearing areas
-multiple lesions: oral antibiotics
Furuncle
-chronic relapsing
-Deeper inflammation nodule hair
follicle --> rupture
--> nodule with or w/o central suppuration
Pyogenic Paronychia
-separation of nail fold from nail plate secondary to
frequent exposure to water; mani/pedi; nail biting
Ecthyma
-characteristic sausage shaped
ulcers
-staph or strep pyoderma
-shins/dorsal feet
-vesicle/vesiculopustules -->
rupture --> ulcer --> heals with scar
-nss compress; antibiotics
Candidal intertrigo
-secondary to maceration of
epidermal folds of the neck or intertriginous areas
-satellite pustules
-pruritic
-tx: topical azoles plus mid
strength corticosteroids
(mometasone) for rapid relief
-recommend: keep area dry, loose clothing, lose weight
Pustular psoriasis (von zumbusch)
-Pustules coalescing in lakes of
pus
-caused by rebound steroid tx (so do not give
prolonged steroids), LCD -tx: methotrexate, acitretin
Vesicular diseases
Herpes simplex viruses
A.
Primary infection: painful ulcers, vesicles
B.
Latent phase
C. Recurrence
HSV-1 trigeminal ganglion
HSV-2 sacral ganglion
Triggers: emotional stress,
illness, sun-exposure, surgey, facial cosmetic procedures, orolabial contact
Cold sores/herpetic
gingivostomatitis
-Painful grouped vesicle on an
erythematous base,
with mouth ulcers, in perioral areas Tzanck smear:
multinucleated giant cells
Varicella virus infection- "chickenpox"
-all lesions will erupt in 2
days; exposure: 10-21 days -Pruritic
-Papules, vesicles, pustules, ulcers with
crusting
(polymorphic eruption)
Herpes zoster
-Grouped vesicles, dermatomal or
unilateral; Painful, can be pruritic
-if immunocompromised:
disseminated
-chicken pox -->
latent(dorsal ganglion) --> herpes
zoster
-if no hx of chicken pox, may be
due to vaccine or varicella in utero
-herpes zoster ophthalmicus: can cause
blindness; Hutchinson's sign (tip of the
nose; involvement of the nasociliary branch of the V1) -crusting of ALL lesions
= non infectious - Ramsey Hunt (deafness, ipsilateral facial palsy;
afects facial and auditory
nerves)
-postherpetic
neuralgia (sensitization of dorsal neurons, spontaneous activity of aferent
neurons, pain in the absence of damage, more common in elderly)
-antiviral therapy: limit extent, dissemination Tx:
acyclovir 800mg/tab 1a tab q4 for 7
days; valacyclovir 500mg/tab 1 tab BID for 7days
Impetigo -honey-colored crusting
- papules, vesicles, macules, papules
-orolabial areas; Staph. aureus
Tx: cephalexin 25-50mg/kg/day in divided
dose
(every 6hrs)
250mg/5ml
Bullous Dermatoses
Bullous tinea pedis
-plantar arch and interdigital
areas
-can have id reaction: eruption distant to the primary
site of the lesion (can look like dyshidrotic eczema -- deeper vesicles)
Nikolsky sign: Lateral pressure
Asboe hansen:
Direct pressure causes extension of vesicle/blister
Intraepidermal
-flaccid
-positive nikolsky sign and
asboe-hansen's sign
-pemphigus, SJS, SSSS, erythema multiforme
Subepidermal
-tense
-negative nikolsky and
asboe-hansen
-bullous pemphigoid, insect bites, SLE
Bullous pemphigoid
-ELDERLY tense blisters;
chronic; very PRURITIC
-flexural, nuchal
-autoimmune: IgG Ab (BPAG
1&2)
-histo: eosinophil rich
subepidermal blister
-Direct immunofluorescence:
detect Ab on BM
-mgt: systemic steroids, azathioprine, dapsone
Pemphigus vulgaris
-Generalized flaccid blisters
with ulcers in the oral mucosa; PAINFUL; chronic
-rupture easily so all you see
are erosions
-trigger factors: sun-exposure,
infections -intraepidermal area is highlighted on direct immunofluorescence
-Tx: immunosuppressive agents (dapsone, azathioprine),
oral corticosteroids
Dermatitis herpetiformis
-Extremely pruritic erythematous
papules > vesicles > bullae > crust
-Nape, scapula, extensors,
buttocks
-exacerbated by wheat-rich foods
-neutrophils on the dermal
papilla
|
igA |
|
|
tx: |
dapsone & sulfapyridine |
-
deposition on the dermoepidermal junction
-
-avoid alcohol,beer, cookie crumbs, cookie dough
Bullous impetigo
-Erythematous macules > clear
filled bullae on the nostrils > seropurulent discharge > golden yellow crust
-infectious/contagious
-commonly on nose; disseminated
-staph(most common)/strep
-Tx: 1st gen cephalosporin:
cephalexin, MRSA: vancomycin, linezolid; NSS compress
-complications: AGN (grp A strep), SSSS (staph scalded
skin syndrome)
SJS
-Hx of drug intake (allopurinol,
antipsychotics)
-start as morbiliform eruption
-flaccid vesicle that rupture
easily to form erosion, crusting as they heal
-less than 10% of BSA (count
areas of detached
epidermis like bullae, vesicles,
erosions; not just erythematous areas)
-involvement of mucous
membranes: usually oral and conjunctiva (check also GI tract)
-accompanying symptoms: conjunctivitis, oral ulcers,
dysuria, dysphagia -SJS/TEN overlap: 10-30%
-TEN (toxic epidermal necrolysis): > 30%
Fixed drug eruption
-Drug use
-NSAIDS: most common ofending
drug
-Naproxen: 30-60mins lesions
come out; well-defined erythematous patch with bullae
-Recur on the same site
-50% oral and genital mucosa
TMP-SMX.
-Erythematous/dusky targetoid
lesions
-Heals with hyperpigmentation
Vitiligo
-Multiple, Well defined,
Depigmented macules and patch
-distribution: focal (often
trigeminal), unilateral, vulgaris, universal
-hands and around the mouth
("lip and any tip") are difficult to treat
-white hairs if around eyebrow(
-autoimmune (associated with
type1 DM, pernicious anemia, Hashinotos thyroid it's, Graves' disease, addisons
disease, alopecia areata)
-tx: topical steroids
Post inflammatory hypopigmentation/leukoderma
-Eythematous plaques -->
white macules
-destruction of melanocytes
during the trauma
- previous lesions/ hx of SLE
-size and shape of previous lesions
Melasma (chloasma)
-asian
-hyperpigmentation on
cheeks, sunexposed
area
-females > males, older
-OCPs, topical application of
strong chemicals
(maxipeel), sun-exposure -tx: bleaching, lasers
Freckles (Ephelis)
-fair skinned individuals
(*if darker skinned individuals = solar lentigo -
do not fade; usually in asians) -hyperpigmentation
Xanthelasma
-not all have elevated TG, can
occur with normal lipids
-most common xanthoma
-over the eyelids- xanthelasma palbebra
Xanthoma
-Firm yellow nodules arounds
elbows, knees
-Multilobulated masses
-Associated with increased
cholesterol
-tuberous xanthoma: super big, appear inflamed and
tend to coalesce -Eruptive xanthoma:
-plane xanthoma: flat
macules/slightly elevated plaques with yellowish tan coloration
-advised diet, statins, fibrins, excise if big and afect
ADLs but they will recur
Brown black papules and plaques
Benign nevus/common melanocytic nevus
-junctional: junction of
epidermis and dermis, dark
-compound: junction + dermis
-intradermal: dermis,
depigmented/skin color
-superficial = darker &
flatter bec closer to surface
-deeper = more elevated and lighter in color
-giant congenital melanocytic nevus: "wolf", appears at birth, brown
to black papules/plaque with or without hypertrichosis, increased risk of
developing melanoma, enlarges in size, any change in nodularity should warrant
investigation -biopsy
Basal cell CA
-most common skin CA;
translucent pearly
papule/nodule with telangiectasia
androlled border; friability
-malignant neoplasms from non
keratinizing cells that originate in the basal layer of the epidermis
-elderly > 60 y/o
-males, whites > asians
-sun exposed areas: head (nasal
ala) & neck (80%), back, chest, shoulders
-intermittent sun exposure
(UV-A&B) usually in childhood, ionizing radiation, environmental
carcinogens, immunosuppression, scars, burns, chronic scarring or inflammatory
dermatoses
-larger
lesion with central ulcer and crust = rodent ulcer
-no premalignant skin lesion, appear de novo -rarely
metastasizes, but with prominent tissue destruction, greatest danger is local
invasion -pathogenesis: mutation of mammalian PTCH gene →
upregulation of SMO gene -biopsy at the most indurated border
-histopathologic findings: basaloid cells, peripheral
palisading pattern, fibromyxoid stroma,
retraction space
-best tx: surgery (excision -
choice), mohs micrographic surgery
-pigmented BCC: most common type in asians -superficial BCC: trunk, erythematous patch, does not respond well
to tx, seen in HIV patients
-morpheaform BCC: aggressive, ivory white
-infiltrative
BCC: aggressive
-tx: 4mm margin for nonmorpheaform BCC smaller than 2cm in
diameter; 5mm margin if >2cm diameter; mohs micrographic surgery; curettage
for <1cm but can recur on other areas; cryotherapy; imiquimod (TLR
antagonist to boost T helper 1 immunity); 5-FU; vismodegib (hedgehog pathway
antagonist); photodynamic therapy (MAL-PDT); Radiation therapy
Squamous cell CA
-second most common form of skin CA -solitary, firm,
flash colored keratotic papule → tenderness, induration, erosion, scale, or
enlarging diameter
-intense sun exposure, burns,
wounds, ulcers, HPV
-sun exposed areas: face, back,
legs
-high chance of metastasis
-chemo and radiation is there is lesion left
ABCDs of Melanoma
Asymmetry
Borders are irregular
Color variation (brown, black,
pink, red...)
Diameter increased (>6mm) or
ugly Duckling sign
(atypical lesion)
Elevation/surface change
Acral-lentiginous melanoma
-Most common type of melanoma in
asians -hutchinson's sign: involvement of nail plate + periungual skin
-seen also on plantar surfaces
Amelanocytic melanoma
-mistaken for BCC
-pink/skin colored -biopsy
Seborrheic keratosis
-Most common benign tumor of the
skin
-Oval slightly raised
-Stuck on greasy appearance
-Occur on sunexposed areas or trunk
Sign of Leser Trelat
-Sudden eruption of multiple
seborrheic keratosis
-Indicates Adenocarcinoma Of GI tract -Parallels
the adenoCA
Dermatosis papulosis nigra
- more common in asians and
africans
-smaller version of seborrheic
keratosis
-mistaken for verruca plana, acrochordon if on the neck
Most common melanoma: superficial spreading
Highest risk for metastasis: nodular melanoma
Most common in asians: acral lentiginous
Scar
Injury > hemostasis > inflammation > remodeling
> scar
Atrophic scar:
flat, follows contour of original wound Hypertrophic
scar: elevated, erythematous if new, skin color if old, follows contour of
original wound, regresses in time
Keloid
-extension beyond borders of
initial injury
-pain, pruritus
-claw-like
-previous trauma, sites of acne,
or spontaneous
-areas of high skin tension:
chest, upper back
-does not regress, can even
become bigger
-intralesional triamcinolone: to soften lesion to reduce
pain/pruritus, can flatten but not always -emollients, silicone dressings
Skin types
1
- fairest - always burns, never tans
2
- fair - usually burns, rarely tans
3
- dark white - sometimes burns, tans slowly
4
- olive - rarely burns, tans easily
5
- dark - rarely burns, tans profusely
6 -
dark brown - never burns, tans darkly black
Blacks and whites have the same number of melanocytes, but
blacks have increased activity of melanosomes that aggregate → more melanin
Kligman's Formula
Hydroquinone
tretinoin Topical
Corticosteroid