Systems Plastics Derm

• -finger held in slight flexion
• -fusiform swelling
• -tenderness along sheath
• -pain with passive extension

• 1) I and D
• 2) Staph/strep abx and penicillin to cover Eikenella Corrodens
• 3)

• Phalen's (back to back)
• Tinel's (tapping)

tenosynovitis of the first dorsal compartment

Finkelstein test

• mallet: splint
• Jersey: need to operate early

Damage to the UCL

• if  incomplete tear: splint
• If complete tear: surgery

trapezium

formation of nodules and bands in palmar fascia mostly seen in northern europeans. Usually wait until it gets severe then usually do a palmar fasciotomy.

Cleft lip and cleft lip and palate are the same entity (on a spectrum)

Cleft palate alone is its own thing.

orbicularis oris (needed for speech)

• CP: 0.04, females more than males
• CL/P: 0.1, males more than females

• Plastics
• nutrition
• ENT/audiologist
• SLP
• Dentist
• Others: peds, nurses, etc

• ABCDE's
• Airways: Burned airways always swell, SO TUBE EARLY!!!
• Breathing: give 100% O2 if they have CO poisoning, low sats
• Circulation: 2 large bore IV's 
• Disability: GCS or AVPU
• Exposure: Check their whole body for extent of burn.

• 9% for head
• 18% each for chest and back
• 9% for each arm
• 18% for each leg
• 1% for groin

Tetanus immunization status

• 1st degree: epidermis only (blanches when pressed)
• 2nd degree: reaches dermis
• 3rd degree: reaches subcutaneous tissues

(2nd and third do not blanch when pressed)

4 ml of Ringer's Lactate x Kg of body weight x % burn area = how much RL to give in 1st 24 hours

Includes only 2nd and 3rd degree burns to prevent burn shock.

first half in first 8 hours (FROM TIME OF INJURY!!), 2nd half over following 16 hours.

> 15% TBSA in adults; >10% in kids and elderly

Split the fascia to allow swelling and maintain tissue perfusion

WASH, WASH, WASH!

injuries that are outside of the facial trauma

• 1) airway compromise
• 2) hemorrhage (dont forget the scalp)
• 3) brain injury
• 4) C-spine injury (most overlooked)
• 5) Ocular injury

• 1) entrapment of extra ocular muscles (there will be a firm stop)
• 2) Orbital hematoma
• 3) Damage to eye or optic nerve - ruptured globe, optic neuropathy

you MUST MUST MUST open the eye to examine it, no matter how swollen it is.

• 1) ruptured globe
• 2) decreased visual acuity
• 3) retrobulbar hematoma
• 4) concern of increased IOP
• 5) abnormal pupillary response
• 6) significant corneal injury

• 1) evidence of trapped extra ocular muscles
• 2) unstable or open fractures
• 3) hemorrhage associated with facial features

nose blowing

• 1) Plaque (most common): red, scaly plaques. Scalp, knees, elbows
• 2) Guttate (raindrop): drops on trunk and proximal extremities
• 3) Inverse: smooth and shiny, in skin folds
• 4) Pustular psoriasis (pus filled vesicles)
• 5) erythrodermic psoriasis: emergency derm consult, covers whole body, steroid withdrawl can cause it

• 1) inflammatory disease (e.g. IBD, psoriatic arthritis)
• 2) depression
• 3) CV disease (artery calc.)

• Pink papules/Papules/Pinpoint bleeding (Auspitz sign)/ Physical injury (Koebner phen.)/ pitting on nails
• Silver scale/sharp margins
• Onycholysis/Oil spots
• Rete Ridges with regular elongation
• Itching
• Autoimmune/ arthritis
• Stratum corneum with nuclei
• Immunologic
• Stratum granulosum is absent

• MD SIT
• Meds: ACEi's, beta-blockers, lithium, NSAIDS, steroid withrawl
• Dry skin
• Stress
• Infection (staph/strep)
• Trauma

• Topical treatments:
• -corticosteroids,
• -Vit D analogues,
• -retinoids (teratogenic),
• -calcineurin inhibitors,
• -tar

Systemic agents: immunosuppressants (methotrexate, acitretin, cyclosporin), biologics

+/- topical tmt or Narrow band UVB phototherapy

Chronic Hep C

• Pruritic
• Purple
• Polygonal
• Planar
• Papules
• Plaques

Toronto notes has Peripheral and Penis (i.e. mucosa) instead of planar and plaques

• Herpes-6
• herald plaque followed by lesions that look like guttate psoriasis
• Self-limited: therefore just symptomatic (itching) tmt

• TOP HAT
• Telogen effluvium, Tinea capitus
• Out of Fe, Zn
• Physical: trichotillomania, corn rolls
• Hormonal: hypothyroid, androgenic (male pattern)
• Autoimmune: SLE, alopecia areata
• Toxins: heavy metals, anticoags, chemo, vit A, SSRI's

androgenic baldness is due to long-term exposure to DHT.  

testosterone is converted to DHT by 5 alpha reductase. finasteride is a 5-alpha reductase inhibitor

• Infectious:
• -Tinea Capitus (fungal infection)
• -Folliculitis Decalvans (neutrophilic overreaction to staph infection: treat infection)
• -acne keloidalis Nuchae (acne on neck forms abscesses)
• -dissecting cellulitis of scalp

• Inflammatory:
• -Discoid Lupus Erythamatous (AI; treat with rheum drugs)

Hypertrichosis: hair all over, congenital (Edwards) or acquired (hypothyroid, etc) causes

Hirsutism: growing hair in an andregenic pattern (moustaches, etc). Look for other signs of dudification, may be due to adrenal tumor

• 1) Proximal subungual onycho...: 
• 2) white superficial onych...
• 3) Candida onycho...
• 4) distal subungual onycho...

Oral antifungals. Topical doesn't really work as monotherapy

Spontaneous appearance of a single, gradually widening, band in a fair skinned person.

• Pitting
• Oil drop
• Onycholysis (nail lifting from nail bed)
• Subungual hyperkaratosis

-Keratinization within the pilosebaceous unit blocking sebum secretion

-Androgens stimulate sebum production

-P. acnes feed on blocked sebum and bring in inflammatory cells

face washing, decreasing eating greasy food

• Mild: Topical retinoid (not in preg, decreases stickiness and proliferation of corneocytes)
• Moderate: Add topical abx (erythromycin and clindamycin) and (Benzoyl Peroxide)
• If topical isn't enough, go oral
• Severe: oral isoretinoin (SUPER TERATOGENIC!!, start low and go slow)

• Chelitis (dry lips)
• Xerosis (dry skin)
• dry eyes (PRESCRIBE DROPS)

NEED TO BE ON TWO TYPES OF BIRTH CONTROL

Oral Contraceptive Pill: decrease free testosterone (by increasing level of sex hormone binding globulin)

Spironolactone: antiandroge (teratogenic)

SEVERE acne

arthralgias, malaise, fever

neonatal acne

• 1) Erythematotelangiectic (vascular): persistent central facial erythema
• 2) Papulopustular (inflammatory): same as 1 but with transient papules/pustules
• 3) Phymatous: thickening of skin and enlargement of some facial features
• 4) Ocular: foreign body sensation in the eye

• 1) topical Metronidazole
• 2) oral Abx
• 3) once stablized, use pulsed lasers
• DO NOT USE CORTICOSTEROIDS

Perioral dermatitis: no comidones, sparing around the vermillion border of the lips

topical metronidazole or oral doxycycline

DONT USE GLUCOCORTICOIDS!!

• CAFE SPOt
• C - cafe au lait spots
• A - axillary/inguinal freckling
• F - fibroma
• E - eye: Lisch nodules
• S - skeletal dysplasia
• P - positive family history
• Ot - Optic tumour (optic nerve glioma)

• Mental retardation
• Seizures
• ash-leaf patches

Mutation in melanin synthesis. The melanocytes are there, but they are just not producing.

"white spotting"

melanocytes are absent in white patches (problem with dysfunctional melanocyte development)

• filaggrin is a keratin aggregating protein it:
• -helps keratinocytes form properly
• -forms ECM
• -maintain moisture balance

basically this mutation in filaggrin causes scaling (retention of keratinocytes)

refer to derm, this is potenitally life-threatening

• Acute (<6wks) vs chronic (>6 wks) (BUT INDIVIDUAL LESIONS ALWAYS LAST LESS THAN 24 HOURS)
• Spontaneous vs induced (known trigger)

do NOT say chronic idiopathic urticaria

the result of histamines being released by mast cells in the skin

-swelling caused by increased vasc. perm in subcutaneous tissue in skin and GI

-bradykinin is an important mediator (therefore watch out for ACEi's)

-recognize that it may be a cutaneous manifestation of anaphylaxis

-can have acquired (ACEi's) and hereditary forms

• -most common dermatosis in pregnancy
• - affects 1/130 - 1/300 pregnancies
• -frequently in first pregnancy, third trimester
• -NO FETAL OR MATERNAL COMPLICATIONS

• 1) Erythema multiforme: self limiting, target lesions, itchy, preceeding HSV infection (cold sores)
• 2) Erythema nodosum: PAINFUL red or violet subcutaneous nodules evolve into bruise like lesions with no scarring. NODOSUM mnemonic on other slide
• 3) Erythema annulare centrifugum: Annular lesions that migrate centrifugally

• NODOSUM
• NO cause (idiopathic)
• Drugs: sulfonamides, OCP, analgesics
• Other infections (GAS, TB, blasto, hilar infections)
• Sarcoidosis
• UC and Crohn's
• Malignancies (leukemia, lymphoma)

• vesicle is < 1cm
• Bullae is > 1cm

both are fluid filled

epidermis, Nikolski +ve, starts at the mouth

start with high dose steroids to put it in remission, give IVIg long term

• vulgariS: Superficial, intraepidermal, flacid lesions
• Bullous pemphigoiD: Deeper, tense lesions at dermal-epidermal layer. IgG at the BMZ

NOT HERPES! It is the bullous pemphigoid of pregnancy (IgG vs basement membrane)

IgG directed against epidermal proteins (vulgaris) or hemidesmosomes at the BMZ (pemphigoid)

• INTENSELY itchy blisters, extensor surfaces
• associated with celiac disease
• therefore, do a tissue transglutaminase test

• low cortisol increases pituitary's output of POMC, which increases ACTH and MSH
• (HYPERPIGMENTATION)

overactive pituitary (due to cancer?) causes increased release of POMC, which increases ACTH and MSH (Hyperpigment)

reduced production of POMC at the pituitary decreases ACTH (low cortisol) and MSH (hypopigment)

overactive adrenals overproduce cortisol, decreasing the release of POMC, which decreases the release of ACTH and MSH (hypopigment)

pseudomonas infection

autoimmune destruction of melanocytes causing hypopigmented patches

xanthoma = fat deposit

• all are elevated areas of skin
• Papule is <0.5 cm
• nodule is > 0.5 cm
• plaque is > 2cm

• -mab: monoclonal ab
• -cept: receptor mediated

systemic steroids

deficiency in enzyme needed for heme synthesis, heme precursors build up in the skin and react with light. results in subepidermal vesicles (these were the werewolves of old)

urticarial type pruritic plaques

immunosuppression: rarely systemic steroids, corticosteroids, UV light, calcineurin inhibitors

Sun protection

combination of candida and irritation from feces. treat with topical steroids

red background with eosinophil-filled pustules. see it at 2 days resolves in 4-5 days

blockage of exocrine sweat glands in infants

Sturge-weber syndrome

peri-ocular, nasal, facial location. Treat with propranolol or nadolol (beta blockers)

a hemangioma in the airway

derangement in the growth pattern of a normal component

rule out abuse

malar rash, discoid rash, photosens, oral ulcers

necrobiosis lipoidica

• necrobiosis lipoidica
• acanthosis nigricans
• diabetic dermopathy
• diabetic bullae
• granuloma annulare

malignancy

sebaceous adenoma

• nikolsky's sign
• blistering
• skin necrosis
• mucous membrane involvement

• -mononucleosis
• -penicillin
• -suphonamide
• -HIV

doxycycline

drug-induces vasculitis (palpable because of the BV inflammation)

one piece of skin "remembers" that drug and becomes inflammed when you take it. oval edematous patch -> sometimes bullae -> hyperpigmentation

eosinophils

• infection (90%)
• drugs (10%)

EM minor (skin only)-> EM major (+oral, genitals, ocular) -> SJS (WAYYYY more skin involvement than EM, which in mainly mucosal)

phenytoin, sulfonamides

Stop all the drugs you can. transfer them to ICU and treat them like a burn patient

• confluent erythema
• -skin pain and tenderness
• -mucous membrane erosion/ulceration
• -blistering
• -+ve nikolsky

eczema = dermatitis

• mild topical corticosteroids
• calcineurin inhibitors if steroids don't work or if you are around the eye

-thick moisurizers (ointments) to reduce keratin buildup

-reduce inflammation with corticosteroids

-control itch

irritant contact dermatitis: wet-dry lips (chapped lips)

allergic contact dermatitis

genetic tendency to dry, easily irritated skin

avoid irritants, moisturize, control itch, treat secondary infection (bleach baths), immunosuppression

• -poor adherance to the treatment regimen
• -poor treatment of close contacts

• bedbugs
• "breakfast, lunch, and dinner"

erythema migrans

cutaneous larva migrans

meningococcemia

• KOH
• cryotherapy
• Imiquimod

bacillary angiomatosis

tinea corporis

dermatophyte

Salicylic acid (cryotherapy is NOT first line)

IV penicillin

proximal subungual onychomycosis and it means that they are immunocompromised

candida. The two are married

ringworm

adherent scaly lesions on a background of solar damage. These are usually excised

malignant tumor of keratinocytes in the epidermis.

• Basal cell carcinoma. 
• -nodular
• -rodent ulcer
• -nodular-ulcerative
• -sclerosing
• -pigmented (looks like giant melanoma)
• -superficial (looks pink and splotchy)

paget's disease

Mycosis fungiodes (NOTHING TO DO WITH FUNGUS)

HHV8

SK looks stuck on and is rough to the touch

hard lesion that sits in the upper dermis, when you pinch it, it shows the pimple sign

Because it is down in the dermis, so only the blue light scatters back up

• skin "appendages" that serve a purpose.
• -hairs
• -erector pilli
• -glands
• -nails

-small (<1.5 cm): low risk, no prophylactic removal

-medium (1.5 -10 cm): not evaluated

large (giant) (>10cm): 100x melanoma risk in the main lesions, excise these by 6 months

• lentigo: many single melanocytes at the derm-epiderm junction, non palp
• junctional: many clusters of melanocytes at derm-epiderm junction, non palp
• compound: clusters penetrate to the dermis, penetrate
• dermal: clusters are now 100% below the dermal-epidermal junction, palpable, no longer brown

• unna: mostly epidermal
• Meischer: dermal (not brown)
• Spitz: red, dome shaped on face or legs in kids
• dysplastic (atypical): few progress to melanoma

like a regular mole, widespread excision of these is not the way to go!

• >50 moles
• >5 moles that are > 5mm in diameter
• >5 moles on the buttocks
• moles in unusual sites (dorsum of feet, aterior scalp, butticks)

de novo in the skin. NOT in atypical moles, although atypical moles can be a marker for elevated melanoma risk

cauterize them! ALWAYS send them for histological examination

• women: lower limbs
• men: back

• -asymmetry: one half doesn't look like the other half
• -Border: irregular, blurred, or ragged
• -Color variation
• -Diameter: lesion diameter >4mm
• -Evolution (Dr. Hull's C's!)
•   -any Change
•   -continuous growth in a new adult lesion
•   -concern in patient/relative
•   -concentrated black color
•   -curiosity - look more than 10 seconds, excise
•   -Conspicuousness (ugly duckling)

• -superficial spreading: spread on the surface
• -lentigo maligna melanoma: like a malignant lentigo
• -nodular melanoma: often in scalp and other weird places, nodular. VERTICAL GROWTH! do not follow ABCD's
• -acral lentiginous: often on the dorsum of feet

rapid vertical growth

tumor thickness. Breslow depth is gold standard

-excisional biopsy (2 mm margin)

• -definitive excision
•   <2mm thick - 1 cm margin
•   >2mm thick - 2 cm margin

melanomas > 1 mm deep

• psoriasis: extensor
• atopic dermatitis: flexor

• SJS < 10%
• TEN > 30%

• -cryotherapy
• -topical 5-FU
• -topical imiquimod

demodex