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Involves head and body where sebaceous glands are present
Greasy appearance
All age groups
Chronic or intermittent
Scalp involvement can be minimal (dandruff) or extensive (plaques)
In children, scalp lesions are “cradle cap”
Often symmetrical
seborrhea
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seborrhea tx:
- Shampoos (selenium, ketoconazole)
- Other topicals (ketaconazole cream, terbinafine solution, corticosteroids)
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Thick, silvery-white scales
Caused by rapid turnover of dermal cells
Usually on extensor surfaces
Nails also involved (pitting)
Psoriatic arthritis involves hands and feet
Guttate form has smaller lesions
Pustular form occurs on hands and feet
women > men
Less frequent in highly pigmented skin
Can be precipitated by stress
psoriasis
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psoriasis tx:
- Control vs. cure
- Topical corticosteroids
- Coal tar
- Vitamin D preparations
- Sunshine / UVA / PUVA
- p.o. meds (Methotrexate, cyclosporine)
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what is Auspitz's sign:
punctate bleeding spots when psoriasis scales are scraped off
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Skin reaction to trauma (scratching)
May occur within days or weeks
Common in psoriasis, lichen planus
Koebner Phnomenon
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Sudden raised lesions due to minor trauma to skin
Wheal-like
Likely histamine related
Dermatographism
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Common exanthem (huge rash)
? Cause
Herald patch
Langer’s lines
Christmas (or fir) tree pattern
Lasts 5-8 weeks
Self-limiting
Easy confused with other conditions
Pityriasis Rosea (PR)
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PR tx:
- Treat pruritis
- UV therapy use with ? Results
- Reassurance of self-limiting nature
- Some evidence that erythromycin may help
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Flat-topped papules and plaques on flexor surfaces of UE, LE, genitalia, and mucous membranes
Often violaceous color
Commonly ages 30 – 60 affected
Men = Women
Self-limiting though can last up to 5 years in mucous membranes
Lichen planus
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Lichen planus tx:
- Antihistamines
- Topical steroids
- Severe cases - systemic steroids
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Autoimmune etiology
Can be fatal
Men = Women
Commonly ages 40-60
Bullous lesions start in mucous membranes then move to body
Painful lesions often interfering with eating
Weight loss, fatigue, malaise frequent
Dx made by bx
Death due to secondary infection
Pemphigus
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pemphigus tx:
- Systemic steroids
- Other agents – methotrexate, azathiopine started at the same time as steroids
- Treatment causes multiple side effects
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Vesicular lesions on hands, feet
Women 2X men
May be acute, chronic, or intermittent
Pt c/o itching or burning
Dyshydrotic eczema (Pompholyx)
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Pompholyx tx:
- High strength topical steroids- glucocorticoids
- Cool compresses
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Acute, yet self-limiting
Can be mild or severe
Target lesions
All areas potentially involved (including mucous membranes)
Categorized into Minor and Major
Minor usually resolves in 3 weeks
Major can last up to 6 weeks with 5% fatal
Men slightly more frequent
Common ages 20-40
Multiple triggers including drug rxn and infection
Erythema multiforme
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erythema multiforme tx:
- Find trigger(s) and remove
- Sxmatic tx (antihistamines,analgesics)
- Topical steroids
- Systemic steroids
- Oral lesions may require tx
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–also called palpable purpura
–triggered by drugs (penicillin), bugs (strep), tumor antigens, proteins
cutaneous vasculitis- skin only
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–Henoch-Schonlein purpura, essential mixed cryoglobulinemia, connective tissue disorders, serum sickness, hypocomplementemic urticarial vasculitis
(urticaria > 24 hours, arthritis, glomerulonephritis, gastrointestinal involvement)
Disseminated lesions
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causes of vasculitits:
pathogenesis:
complications:
- immune complexes
- –exogenous antigens - drugs (especially sulfa), food, bugs; connective tissue disease, cancer
- –rapidly progressive glomerulonephritis, GI bleed, angioneurotic edema
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testing for vasculitis:
- depends on H & P
- Bx most useful
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Tx/prognosis for vasculititis:
- steroid
- about half resolve in 6 months
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–severe febrile mucocutaneous drug reaction:
- Toxic Epidermal Necrolysis (TEN)
- also called: Lyell syndrome
- –Stevens-Johnson syndrome (SJS) less severe than toxic epidermal necrolysis (TEN), but possibly part of same disease spectrum
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types of TEN:
- Bulbous erythema multiforme
- Stevens-Johnson Syndrome
- Overlap TEN/SJS
- TEN w/ spots
- TEN w/o spots
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organ systems involved in TEN:
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causes of TEN:
- over 100 diff drugs, including:
- –sulfonamides
- –aminopenicillins
- –quinolones
- –cephalosporins
- –tetracyclines
- –imidazole antifungals
- –aromatic anticonvulsants (high risk during the first 2 months)
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Chief concern (CC): –skin lesions
symptoms may precede cutaneous manifestations by 1-3 days
–fever
–stinging eyes
–pain upon swallowing (odynophagia due to mucosal lesions)
–cough
skin lesion patterns:
–often starts on trunk–progresses to neck, face, proximal extremities
–may include entire body (including soles and palms)
TEN
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–initially erythematous, dusky-red, or purpuric macules of irregular size and shape
–progresses to gray color and flaccid blisters with full-thickness necrosis
TEN
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what is Nikolsky sign:
extension of blister with lateral traction
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wet surface (moist, glistening, exudative) characteristic of:
pemphigus vulgaris or toxic epidermal necrolysis
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dry surface characteristic:
pemphigus foliaceous or staphylococcal scalded-skin syndrome
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in TEN, what can be present on HEENT exam?
- erythema and erosions of buccal, ocular, and genital mucosa
- may have extensive involvement of mucous membranes, including:
- –lips
- –oral mucosa
- –pharynx
- –esophagus
- –conjunctiva
- –corneal ulcerations
- –uveitis
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tx for TEN:
- –treat as burn pt
- – d/c all unnecessary or suspected meds
- – bx to confirm dx
- Prognosis based on age and comorbidities
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types of contact dermatitis:
lesions are often:
- allergic (metal, plant {Rhus})
- irritant
- photo
- urticaria
- drug rxn
- lesions often vesicular
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contact derm tx:
- Removal of irritant
- Cool compresses (including cool baths/showers)
- Minimize scratching
- Antihistamines
- Topical steroids for smaller areas
- Systemic steroids for larger areas
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The itch that rashes
Itch – scratch cycle
Common in children (15%)
No specific test
-dry skin
-feels thickened
-red from scratching
Atopic dermatitis (eczema)
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atopic derm triad:
- asthma
- allergic rhinitis
- atopic dermatitis
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atopic (eczema) tx:
- Reduce itching
- Lubricants
- Topical steroids / pimecrolimus
- Antihistamines
- Cool baths / showers
- Oral steroids if severe
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Round shaped lesions
Chronic
Worse in dry, cold weather
pruritis is often intense
Nummular dermatitis
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Nummular dermatitis tx:
- Mid-high strength topical steroids
- Reduce strength as lesions improve
- Antihistamines for itching
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Lower extremities
Caused by venous insufficiency
Reddish-brown (brawny) color
Leg edema common
Condition may be precursor to others
Can become secondarily infected
Stasis dermatitis
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stasis dermatitis tx:
- Improve venous problems:
- elevation of legs
- support / compression hose
- Topical steroids
- Topical or p.o. antibiotics for infection
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fever, then lesions that start from head down, lasts 4-6 days, Koplik spots
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caused by herpes 6, rash appears after fever, often spares the face
Roseola
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caused by parvovirus, onset with fever, then lesions (slapped cheek) after fever resolves
Erythema Infectiosum (Fifth disease)
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much like rubeola but last less time
Rubella
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Erythema infectiosum (5th disease):
Rosey red cheeks
- acetaminophen and supportive therapy
- plus ibuprofen or NSAIDs
- ongoing: immunr globulin plus RBC transfusion
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most cases are irritant diaper dermatitis
–moisture
–prolonged contact with feces and urine
–bacteria
–alkaline pH
–mechanical disruption of the area
Diaper dermatitis
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Tx diaper dermatitis:
- most cases should be treated conservatively
- "diaper rash is not cured by what you put on it, but by what you take off of it"
- reduce exposure of affected skin to urine and feces
- –allow time out of diaper
- –frequent diaper changes
- –topical agents that form barrier to skin surface
- limit antifungals to rashes typical of candida dermatitis - deep, confluent redness, geographic margins, satellite lesions
- avoid combination clotrimazole and betamethasone propionate (Lotrisone), labeling states the product should not be used for diaper dermatitis
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Raised, erythematous, and edematous
Can be acute or chronic
Often challenging to find etiology
Sx range from itching to anaphylaxis
Urticaria (hives)
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urticarial tx:
- Avoid known triggers
- Oral steroids
- IM or IV steroids
- Antihistamines
- H2 blockers
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Multi – system disease
Lesions can be varied, but symmetrical if there are many
More common in Irish, Scandinavian, or African descendents
Sarcoidosis
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Sarcoidosis derm tx:
- Evaluation for systemic disease
- Lesions are challenging to treat
- Systemic steroids often useful
- Plaquenil / Methotrexate
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