Disorders of the Skin and Subcutaneous Tissues
Aug. 26, 2009
1.
Basics
Text: Harrison’s: Chapter 52
OBJECTIVES:
The student should be able to:
1.
Describe the structure and function of the skin.
a. Protection against microorganisms
b. UV rays
c. Fluid loss
d. Mechanical stress
e. Sensory
f. Temperature regulation
g. Vit D production
2.
Skin Lesions
OBJECTIVES:
The student should be able to:
1. Recognize and differentiate the morphology of the following primary skin lesions:
1.
Macule- flat lesion that is typified by change in color example: freckle
(ephelid)
2.
Papule- raised lesion <5mm (solid) example: white head
3.
Plaque- raised w/ flat plateau like surface example: psoriasis
4.
Nodule- round lesion >5mm (larger papule)
1. Nodular Tumor Mass
 Solid raised >5cm
 Convalescence of many nodules
5.
Pustule- raised lesion that has puss- not necessarily infection
6.
Vesicle- raised lesion that has fluid, <5mm- NOT PUSS---example: allergic
contact dermatitis (poision ivy)
7.
Wheal- redish, edematous papule or plaque- normally short lived
vasodilatation or penetrability—changes quickly, last only 24-48 in
a defined area.
1
8.
9.
Bulla- raised lesion that has fluid, >5mm (big vesicle)
Cyst- Soft, raised, encapsulated lesion filled with semisolid or liquid contents
1. Sebacaeous Cyst
 Blockage of follicular canal with sebum
 Can see a hole where the canal should is
o Test- white puss can be squeezed out
10.
11.
TumorTelangiectasia- dilated superficial blood vessel—Test- blanch when tested
with diascopy
2. Recognize and differentiate the morphology of secondary skin lesions:
1.
Scale- Excessive build up of stratum cornium
2.
Erosion- loss of epidermis, no harm to dermis
3.
Ulcer- loss of epidermis and dermis, results in a scar
4.
Fissure- crack in skin or ulcer in mucous membrane
5.
Crust- Dried exudate of body fluid (yellow= serous, red=blood)
6.
Erythema7.
Excoriation- linear or angular lesion caused by scratching
8.
Atrophy- An acquired loss of substance. In the skin, this may appear as a
depression with intact epidermis or as sites of shiny, delicate, wrinkled
lesions (epidermal atrophy)
9.
Scar- change in skin secondary to trauma
10.
Edema- fluid buildup under skin
11.
Hyperpigmentation
12.
Hypopigmentation
13.
Depigmentation
14.
Lichenification- thickening of the skin, makes well defined skin wrinkles
15.
Hyperkeratosis- Hypertrophy of the horny layer of the skin, usually
associated with hypertrophy of the granular and prickle-cell layers
3. Identify information that should be obtained in all dermatological histories.
3. Dermatologic Therapy
Text:
OBJECTIVES:
The student should be able to:
1. Utilize eight guidelines that should be considered when selecting therapy for patients
1. KISS
2. Have pt. Repeat
3. Give written instructions
4. Topicals, how often, where & how much
5. Prescribe enough
2
6. If chronic, refills
7. Pregnant?
8. Warn of adverse reactions
9. “if its dry wet it, if its wet, dry it”
.
2. Identify indications for each of the following:
a. Lotions and Creams (for dryness)
i. Restore water and lipids to epidermis
ii. Creams more lubricating
iii. Creams most useful for intertriginous (areas that rub together) area
(groin, rectal area, axilla) and scalp
iv. Apply to wet skin
v. Preparations that contain urea (Carmol), or lactic acid are most
effective
vi. Menthol and phenol added to keep itching (purities) down
b. Gels
i. Are greaseless mixtures of propylene glycol and water, some contain
alcohol
ii. Useful for acute exudative inflammation (poison ivy, scalp areas)
c. Ointments (dry lesions)
i. Penetration better than creams
ii. Grease with little water
d. Wet dressings
i. Best for exudative inflammatory diseases
ii. Wet compresses suppress inflammation and debride crust and
serum
iii. Repeated cycles of wetting and drying make lesion dry
iv. Once lesion is dry, switch to emollient creams and lotions
3. Identify indications for topical, intralesional and systemic corticosteroids.
TOPICAL
a. Psoriasis, hand eczema Group 1*
Not on face, axilla, groin, under breast
Limit use to 14 day
b. Atopic dermatitis (adult) Group 2 &3
Not on face, axilla, groin or under breast
Limit use to 21 days
c. Atopic dermatitis (children) Groups 4&5
Limit use to 7-21days and intertriginous areas
d. Eyelid and diaper dermatitis Groups 6&7
Reevaluate if no response in 28days
INTRALESIONAL
• Indicated for nodulocystic (cystic acne) and large pustular lesions, alopecia
areata, keloids
• May be given at full strength or mixed with saline or xylocaine (more painful)
• May cause atrophy*, local reactions, systemic absorption, hypopigmentations,
3
telangiectasia, and sterile abscess
4. Identify contraindications and complications to systemic
a. Produces antiinflammatory response
b. Indicated when topical are unsuccessful
c. Adverse effects include suppression of hypothalamic-pituitary-adrenal
axis (HPA) and Cushing’s syndrome
4.
Diagnostic Procedures
Text:
OBJECTIVES
The student should be able to:
1. Describe indications and positive findings associated with the following diagnostic
procedures:
a. Potassium Hydroxide Prep (KOH)
i. Consider when scaling fungal lesion is suspected
ii. Dissolves keratin allowing visualization of fungal elements: hyphae,
budding yeast
b. Fungal Culture
i. Indicated for hair and nail infections
ii. Utilize cotton swab technique*
c. Scabies Test
i. Touch lesion with blue or black felt-tip pin
ii. Wait a few minutes for ink to dry
iii. Wipe of ink with alcohol pad
iv. Burrow are highlighted as a dark line
v. Scrape away with a curved #15 scapel blade and transferred to glass
microscope slide
d. Tzanck Smear
i. For herpesvirus or varicella zoster virus infections
ii. Base of vesicular lesion is scraped and placed on slide, air-dried, and
stained with Giemsa or Wright’s stain
iii. + multinucleated epithelia giant cells
e. Wood’s Lamp Examination
i. Perform in a dark room
ii. Erythrasma-coral pink (corynebacterium m.)
iii. Pseudomonas-pale blue
iv. Tinea capitis secondary to dermatophytes-pale green to yellow
4
f.
g.
h.
i.
j.
Curettage and Electrodesiccation
Shave Biopsy
Punch Biopsy
Snip Excision
Cryosurgery
Aug 28, 2009
5.
Tumors of the Skin
Text: Harrison’s Chapter 83
A.
Benign Neoplasm
OBJECTIVES:
Regarding the following, the student should be able to:
1.
Describe and identify.
2.
Establish a diagnosis.
3.
Indicate the prognosis.
4.
Establish a treatment plan.
a.
Acrochordon (Skin Tag)
b.
Callus/Chavus
c.
Cherry angiomas
d.
Nevus
e.
Seborrheic Keratosis
f.
Solar Lentigo
B.
Premalignant and Malignant Neoplasms
OBJECTIVES:
The student should be able to:
1.
Describe and identify the following.
2.
Recognize the diagnostic and therapeutic challenges associated with each.
a.
Actinic Keratosis
b.
Keratoacanthoma
c.
Melanoma
d.
Basal Cell Carcinoma
e.
Squamous Cell Carcinoma
3.
The student should relate risk factors as genetic influence and the inherent
dangers of sun exposure and tanning booths.
5
Aug.31, 2009
7. Infections of the Skin
Text: Harrison’s Chapter 53
A.
Viral Diseases
OBJECTIVES
Regarding the following, the student should be able to:
1. Recognize and define the pathogenesis.
2. Establish the diagnosis.
3. Assess and individualize the treatment.
a. Erythema Infectiosum/5ths disease/ slapped cheek
i. Red Flags
1. Prodrome of flu-like symptoms followed by “slapped cheek”
appearance 2 days later. Few days later reticulated
erythematous rash on trunk, lasting about 1 week.
2. Can recur for weeks to months
ii. Etiology
1. Parvo B-19
2. Peaks at ages 5-14
iii. Diagnosis
1. PV B19 IgG, IgM, clinical appearance
iv. Treatment
1. Symptomatic
v. ADULT
1. pruitus, arthopathy, fever, rash and adenopathy
2. hydrops fetalis
3. RBC aplastic crisis
b. Herpangina
i. Red Flags
1. Gray/White Papulovesicles with erythematous ring that
ulcerate. Commonly on tonsillar fauces, palate.
ii. Etiology
1. Coxsackievirus, Enteroviruses, echovirus
iii. Diagnosis
1. Associated with fever, HA, cervical LAD, sore throat
iv. Treatment
1. symptomatic, usually lasts 4 – 6 days
v. HAND FOOT AND MOUTH DISEASE- coxsackie
6
c. Herpes Simplex (type 1)
i. Red Flags
1. HSV 1 “cold sore” “fever blister”
 Primary gingivostomatitis
 Children and young adults (only seen about 1%)
 Fever, sore throat, painful (burning) vesicles in oral
mucosa
 Seropositive 85 – 90%; 1/3 symptomatic
2. Recurrent Herpes Labialis
 Grouped vesicles on an erythematous base
 Virus dormant in trigeminal ganglia until reactivated
 Lifetime infection
ii. Etiology
1. HSV 1
iii. Diagnosis
1. APPEARANCE
2. Tzanck smears
3. IgG antibody titer
4. culture
iv. Treatment
1. Symptomatic
2. Oral meds:
a. Acyclovir - 200 mgm 7-10 day
b. Valacyclovir – 1 Gm BID x 10 days
c. Famcyclovir – 250 mgm TID x 5 days
3. Topical: Denavir as effective
d. Herpes Zoster- Shingles
i. Red Flags- Red rash w./ papules on dermatome. Doesn’t break midline
(normally)
ii. Etiology
1. Herpesvirus varicellae (reactivated in system)
iii. Diagnosis
1. clinical, PCR, Biopsy, Culture, Tzanck smear
iv. Treatment
1. antivirals
e. Herepes Simplex (Type 2)
i. Red Flags- cold sore on the ex organs
ii. Etiology
7
iii. Diagnosis
1. : clinical, PCR, Biopsy, Culture, Tzanck smear
2. Treatment:
3. Antiviral: Valtrex, acyclovir, famcylcovir
iv. Treatment
1. Antiviral: Valtrex, acyclovir, famcylcovir
f. Roseola Infantum (6ths disease, 3 day fever)
i. Red Flags1. 3day of high fevers then as fever falls get morbilliform rash
2. 6 – 36 month old child)
ii. Etiology
1. HHV-6
iii. Diagnosis
1. clinical
iv. Treatment
1. Symptomatic, antipyretics
g. Varicella- chicken pox
i. Red Flags1. “Dew on a red rose petal” (red patche with raised vesicle in
center…several)
2. pruritus, fever, HA, malaise
ii. Etiology
1. Herpesvirus varicellae
iii. Diagnosis
1. lesions at different stages spreads centripetally, culture,
Tzanck smear
iv. Treatment
1. Acyclovir for adults or immunocomprised, cool compresses,
Sarna lotion
h. Verruca
i. Red Flags
1. Hyperkeratotic papules with black dots
ii. Etiology
1. Spread: by touch, sites of trauma
a. Human Papillomavirus, HPV
b. Verruca Vulgaris – common warts HPV-2
c. Verruca Plantaris – Plantar warts HPV-1
d. Verruca Plana – Flat wars HPV-3
e. Condyloma Acuminata – HPV 6, 11, 16, 18
8
iii. Diagnosis
1. Clinical or biopsy
iv. Treatment
1. Cryotherapy, Salicylic acid, excision, lasers, podophyllin,
cantharidin, Candida antigen, praying, aldara etc.
i. Viral exanthema
i.
ii.
iii.
iv.
B.
Red Flags- non
Etiology
Diagnosis
Treatment
specific viral rash
Bacterial Diseases
Text:
OBJECTIVES
Regarding the following, the student should be able to:
1.
Recognize and define the pathogenesis.
2.
Establish the diagnosis.
3.
Identify genetic factors
4.
Assess and individualize the treatment.
a.
Impetigo
i. Red Flags1. Contagious, acute, purulent (honey colored drainage) infection of
the skin.
ii. Etiology
1. Non-bullous (crusted) - Group A Beta-hemolytic Strep +/- Staph
2. Bullous - Staph aureus
iii. Diagnosis
1. Appearance: vesicles > pustules > crusting
2. Culture: not recommended
iv. Treatment
1. Systemic- Dicloxicillin or cephalosporin
2. Topical - (Bactroban)
3. Soaks- for debridement
b.
Erysipelas
i. Red Flags
1. Sharply demarcated erythema
usually on face or extremities
possible plaques and edema,
9
ii. Etiology
1. Group A Beta Hemolytic Strep.
iii. Diagnosis
1. appearance, poss culture: group A strep
iv. Treatment
1. antibiotics, oral or IV
c.
Folliculitis, etc
i. Red Flags
1. infection of the hair follicles- mistaken for spider bites
a. Pustule
b. Furuncle
i. acute tender fluctuant deep seated nodule
c. Carbuncle
i. multiple coalescent furuncles with multiple draining
sinuses
2. Common on buttocks, back of neck, beard, back and chest
ii. Etiology
1. - Staphylococcus aureus
2. Predisposing Factors-topical steroids, injury, abrasion or surgical
wound
iii. Diagnosis
1. Culture/apperance
iv. Treatment
1. Incision and Drainage + antibiotics, culture, warm compresses
d.
Acne vulgaris
i. Red Flags- acne-yeah
ii. Etiology
1. Proliferation of propionbacterium acnes (P. acnes) in follicles
2. Hypertrophy of sebaceous gland and increased sebum (androgen)
blocks the pilosebaceous units causing inflammation and rupture of
the follicle
iii. Diagnosis
1. Mild: papules few, more pustules, no nodules
2. Moderate: many papules and pustules, few nodules
3. Severe: several papules, pustules and nodules
iv. Treatment
1. Topical benzoyl peroxide, 5-10%, daily
2. Topical tretinoin - reverses the abnormal keratinization, 2-3 weeks
3. Topical antibiotics - Erythromycin or Clindamycin
10
4. Accutane - systemic Vit A
C. Superficial Fungal Diseases
Text:
OBJECTIVES
Regarding the following, the student should be able to:
1.
Recognize and define the pathogenesis.
2.
Establish the diagnosis.
3.
Assess and individualize the treatment.
a.
Tinea –RING WORM
– Tinea capitis – scalp
– Tinea corporis – body
– Tinea cruris – groin
– Tinea manus – hand
– Tinea pedis – feet
– Tinea unguium Onychomycosis – nail
Capitis
i. Red Flagsa. Alopecia with “black dots”. Erythema and scaling in an annular
configuration
ii. Etiology
a. 3 main types of fungus
i.Trichophyton
ii.Microsporum
iii.Epidermophyton
b. Can be transmitted by direct contact, animal exposures, and fomites
iii. Diagnosis
a. KOH of hair
b. Wood’s lamp (20%)
c. Culture (Sabouraud’s medium)
iv. Treatment
a. Systemic antifungals
11
Corporis
i. Red Flagsa. . Annular with central clearing and well defined borders.
ii. Etiology
a. Same as capitis
iii. Diagnosis
a. KOH - hyphae, culture
iv. Treatment
a. Topical (2-3 weeks) Oral (2-4 weeks)
ONYCHOMYCOSIS
i. Red Flags
a. Fungi toenails
ii. Etiology
a. Same as capitis
iii. Diagnosis
a. Need to make prior to treatment
b. KOH
iv. Treatment
a. Treatment (oral)
i.Griseofulvin
ii.Sporanox
iii.Lamisil
Manus
i. Red Flagsa.Usually unilateral with bilateral feet involvement (‘two feet one
hand disease’)
b. Appearance: hyperkeratotic
ii. Etiology
a. Same as capitis
iii. Diagnosis
a. KOH, Cx
iv. Treatment
a. may require months if nails involved
Pedís
v. Red Flagsa. Appearance - Subclinical to severe secondary infection. Varies
12
with species.
vi. Etiology
a. Same as capitis
vii. Diagnosis
a. Appearance
b. KOH
c. Culture
viii. Treatment
a. Topical
b. Oral if secondary infected
c. Burrow’s solution if macerated
d. Cotton socks, sandals, powders
Tinea versicolor
b.
i.
ii.
iii.
iv.
Red Flagsa. patches of skin that don’t tan (SUNSPOTS)
b. Usually on central upper trunk
Etiology
a. Yeast (superficial Malassezia)
Diagnosis
a. KOH shows spaghetti and meatballs look (budding yeast and hyphae)
Treatment
a. Selsun blue
b. Topical and oral
d. Candidiasis “yeast infection”
i. Red Flags
1. Erythematous papules and plaques with satellite pustules, can
involve scrotum
a. diaper area in infants
b. intertrigenous (rub together spots) areas in adults
c. Thrush- yeast infection of mucous membranes of mouth
d. Paronychia- occurs around the nails
ii. Etiology
1. Candida (type of yeast)
iii. Diagnosis
1. KOH/culture, pseudohyphae
iv. Treatment
1. local treatment to keep area dry and topical/oral antifungals
13
September 02, 2008
8. Miscellaneous Skin Disorders
Text:
A.
Arthropods
OBJECTIVES:
For the following, the student should be able to:
1. Describe the associated skin problems.
2. Identify the etiologic agent and establish the diagnosis.
3. Outline treatment and patient management.
a. Scabies
i. Red Flags
1. intense pruritus worse at night
2. Location - finger webs, flexor surf, genitals
ii. Etiology
1. Sarcoptes Scabiei (mites)
iii. Diagnosis
1. Appearance of burrow (felt pen)
2. scrapings with KOH
a. Once they start scratching hard to see burrow
b. Secondary to scratching pin point red dots
iv. Treatment
1. Eurax daily x 5 days, repeat 1 wk
2. Continued pruritus after treatment
b. Pediculosis- lice



i.
head (capitus) - children (hats, combs, etc.)
body (corporis)- unclean setting, seams of clothing
genitals (pubis) – aka crabs is sexually transmitted
Red Flags
1. Itches w/o rash
ii. Etiology
1. lice (pediculus humanus)
iii. Diagnosis
1. appearance,
2. nits (eggs) ,
3. Wood’s lamp
iv. Treatment
1. Apply Nix(permethrin)cream rinse x 10 min to dry clean hair
2. “nit comb”
3. Repeat 1 wk
14
c. Tick bites

Ticks are ectoparasites that act as vectors for
o spirochetal,
o bacterial,
o rickettsial,
o parasitic infections- Lyme, RMSP, Tularemia
i. Red Flags
1. presence of tick, FB reaction, macules and papules
ii. Etiology
1. See above
iii. Diagnosis
1. presence of tick, FB reaction, macules and papules
iv. Treatment
1. remove tick< 48 hr. decrease risk
2. prevention with tick spray
Lyme Disease
o NE, Wisconsin, Minnesota, CA
o erythema migrans- large red area, inside gets clear- “bulls eye”
o flu-like symptoms
o Serology, Elisa
 Most of the time this is false positive…if you suspect just treat
o Rx: doxycycline
 Can be given prophlatically if bite suspected
d. Fire ant bites
i. Red Flags1. really itchy,
2. pustules,
3. inflammation
ii. Etiology1. um, really, you don’t know this?
iii. Diagnosis
1. appearance
iv. Treatment
1. Steroid for bad inflammation
2. Antihistamines for itching
e. Spider bites
Black Widow
i. Red Flags
1. small local reaction
2. hours later cramps due to neurotoxin
ii. Etiology
1. Venom of black widow
15
iii. Diagnosis
1. Appearance, symptoms, and hx of exposure
iv. Treatment
1. IV opiods plus benzodiazepines,
2. antivenom antiserum,
3. PO muscle relaxant,
4. Ice
5. Tet tox
Brown recluse
i. Red Flags
a. severe local reaction, rare systemic
b. symptoms
i. fever, n/v, weakness and myalgia
c. Hemolysis
d. Necrotic ulcers
ii. Etiology
a. BR venom
iii. Diagnosis
a. Appearance, exposure
iv. Treatment
a. RICE, Antihistamines, Dapsone
b. Monitor CBC for severe bites
f. Flea bites
i. Red Flags
1. Around ankles usually
2. Macular to bolus in apperence
3. itchy
ii. Etiology
1. Again, really?
iii. Diagnosis
1. Appearance and presence of pets or indignant circumstances
iv. Treatment
1. Relieve itching
B.
Papulosquamous and Other Miscellaneous Disorders
OBJECTIVES:
In regards to the following, the student should be able to:
1.
Identify in terms of configuration and distribution and describe the
pathophysiology.
16
2.
3.
4.
Establish a diagnosis.
Recognize genetic risks
Identify treatment and outline a treatment plan.
a. Atopic Dermatitis
i. Red Flags
1. pruritic skin disorder
2. lichenification
ii. Etiology
1. Unknown, strongly familial
2. Possibly co morbid with chronic staph
iii. Diagnosis
1. Appearance
2. Family or personal history
iv. Treatment
1. Pimecrolimus cream
2. Topical steroids
3. Antibiotics
4. Tacrolimus ointment
5. Antihistamines
6. Psychological
v. Other
1. family or personal hx of hay fever, asthma, dry skin, eczema
2. Onset - early infancy, childhood or adolescence
b.
Contact Dermatitis
i. Red Flags
1. pruritic, reactionary skin disorder
2. Irritant
o nonallergic, results from chronic exposure.
o dryness, scaling, fissuring, and mild inflammation
3. Allergic
o requires sensitization, thus previous exposures.
o 1 - 4 days after exposure - presentation varies, redness, bulla,
pruritus, vesiculation, oozing, crusting, lichenification
ii. Etiology
1. Exposure to irritant or allergen
2. Long line caused by scratching
iii. Diagnosis
1. history, itching, locality
iv. Treatment
1. removal
2. symptomatic - antihistamines, soothing lotions
17
3.
4.
v. Other
1.
2.
steroids
treat with p.o. meds in by eyes
Exthanmatous drug eruption: ampicillin 
Photosensitivity drug-induced (not pictured)
a. Bacterium, ampicillin, etc
3. Posion Ivy 
a. LINEAR VESICLES
b. Does not spread by fluid in vesicles
c. Spreads by resin on hands, clothes, and pets
c. Seborrheic Dermatitis
i. Red Flags
1. GREASY, SCALY PLAQUES
2. common, chronic, scaling, erythematous, eruption
ii. Etiology
1. Pityrosporum ovale (yeast),
2. Genetic
3. environmental factors
iii. Diagnosis
1. Appearance
2. KOH…remember it can be yeast
iv. Treatment
1. Medicated shampoos frequently (Head and Shoulders)
2. Steroid lotions or solutions
3. Ketoconazole cream or shampoo if resistant
4. IF PUSTLES TREAT FOR STAPH
v. Other
1. Location - cradle cap (infants), dandruff, scalp, face, upper chest,
extent varies.
2. All ages but usually adults
d.
Pityriasis Rosea
i. Red Flags
1. lines of cleavage in Christmas tree distribution, 2-10 wks duration
2. preceded by a short lived salmon colored oval “Herald patch”
ii. Etiology
1. Unknown, may be viral
iii. Diagnosis
1. Christmas tree apperance
2. NEGATIVE yeast on KOH
iv. Treatment
1. Control itching
2. Possibly use steroids
18
3. UVB photo therapy
e.
Psoriasis
i. Red Flags
1. chronic, recurrent, hyper proliferative disease of skin
2. early - red macules covered with dry silvery scales
3. later - may coalesce
ii. Etiology
1. unknown - 1/3 have family history,
2. freq follows strep pharyngitis infection in children
iii. Diagnosis
1. Appearance
2. Family and Personal History
iv. Treatment
1. keep skin moist and lubricated
2. < 20% - topical steroid, Dovonex, coal tar preparations
3. >20% - light therapy, antimetabolites, retinoids, stress management
4. Avoid b-blockers, lithium and systemic steroids
v. Other
1. Presentation - joints, ext surfaces, lower back and buttocks
2. Course - remissions and exacerbations, freq preceded by trauma or
strept inf - STRESS!
f. Stasis Dermatitis
i. Red Flags
1. Early - hyperpigmentation
2. Late - Plaques, vesicles, bullae, cellulitis
3. Later – Ulceration, fibrotic skin
ii. Etiology
1. chronic venous insufficiency
2. Predisposing conditions: DM, obesity, familial, topical allergies
iii. Diagnosis
o Appearance and history
iv. Treatment
1. Mild
o Elevate
o support hose
o Exercise
o Steroid cream
2. Ulceration
19
o
o
o
o
Duoderm (bandage to protect wounds)
unna boot (ace wrap with calamine and other healing lotions)
Avoid steroid creams applied to ulcer
Ulcers have long healing time
v. Other
1. Location: medial malleolus
g.
Vitiligo
i. Red Flags
1. Acquired skin depigmentation due to lack of melanocytes
2. Patches of depigmented skin
ii. Etiology
1. Unknown, Autoimmune? Genetic?
iii. Diagnosis
1. clinical, Woods light
iv. Treatment
1. Sun protection
2. Look for assoc. diseases
a. Addisons Disease
b. Diabetes
c. etc
3. dermatologist
v. Other
1. 1% of population
2. Generalized (symmetrical) and segmental (nonsymmetrical)
h. Erythema Multiforme
i. Red Flags
1. target lesions that begin as macules and develop vesicles in the center
with cyanotic center
2. may have fever, malaise, or itching and burning…SELF LIMITING
ii. Etiology
1. hypersensitivity reaction
a. drugs infections
b. physical agents
c. pregnancy
d. malignancies
iii. Diagnosis
1. Clinically and history
iv. Treatment
1. 1-3 wks of prednisone 40-80mg/d
2. oral acyclovir for HSV assoc. EM
v. Other
1. Location: Backs of hands, palms, soles, extensor limbs, generalized.
20
Occur in crops for 2-3 wks
i. Stevens-Johnson Syndrome
i. Red Flags
1. vesicobullous, mucosa affecting skin, mouth, eyes, and genitals
a. trunk, palms, soles
2. Preced by cough, fever, and patchy changes on chest Xray
ii. Etiology
1. severe hypersensitivity reaction following drug reaction
a. phenytoin, phenobarbital, sulfonamides, PCN
2. May be variant of Erythema Multiforme
iii. Diagnosis
1. clinical, skin biopsy
iv. Treatment
1. systemic steroids?,
2. antihistamines for itching,
3. wet cool compresses,
4. topical steroids for plagues and papules,
5. antibiotics for infections
v. Other
1. Most often in children and young adults
j. Urticaria- hives
i. Red Flags
1. Pruritis
2. Angioedema
3. Lumps and bumps
ii. Etiology
1. histamine release
o Immunologic and non-immunological
o Physical stimulation
o Skin contact
o Small vessel vasculitis
iii. Diagnosis
iv. Treatment
1. H1 blockers (histamine blocker)
2. H2 blockers (histamine blocker)
3. Doxepin
4. Steroids
v. Other
1. Dermatographia
a. Scratching skin causes red raised line 
i. Can write name on skin
21
b. Acute uticaria /angioedema 
k. Erythema Nodosum
i. Red Flags
1. Nodular erythematous eruption limited to extensor side of extremtities
ii. Etiology
1. Hypersensitivity reaction to antigenic stimuli associated with several
diseases
a. Infections*, immunopathies, malignancies, and drug therapies
iii. Diagnosis
1. History and clinically
iv. Treatment
1. Self limiting
2. Help symptoms
a. Antinflammatory
b. Cool compress
c. elevation
v. Other
1. Fever, malaise, arthralgia (joint pain)
2. URI (upper respiratory tract infection) precede eruption by 1-3 wks
3. 55% are idiopathic
4. Familial form
5. Females> males
6.
Burns
Text:
OBJECTIVE:
1. Define first, second and third-degree burns.
a. Superficial=1st
i.
ii.
iii.
iv.
v.
b.
Epidermal layer only
Don’t blister
Red, dry, painful, blanches with pressure
Cause: UV, short flash
Heal: 3-6 d
Superficial Partial Thickness= 2nd
i. epidermis and the superficial (papillary layer) dermis are injured
ii. Blisters, appear moist, red weeping, blanches with pressure
iii. Painful to temp and air
22
c.
Deep Partial Thickness= 2nd drgree
i. All epidermal and dermal structures are destroyed including hair follicles
and glandular tissue
ii. Blisters, wet or waxy dry with variable color
iii. Doesn’t blanch
iv. Pain with pressure only
d.
Full Thickness= 3rd degree burns
i.
ii.
iii.
iv.
Extend through and destroy the dermis
Painless, usually
Skin appearance is waxy white to leathery gray to charred and black
Doesn’t blanch
2. Estimate degree of burn using (Rule of 9’s)
a.
23
3. Recognize systemic effects of burns.
1. Burn shock w/in 24-48 hrs for major burns
a. Myocardial depression
b. Increased capillary permeability
c. Intravascular volume depletion
d. Treatment: IV crystalloids such as Ringer’s lactate (LR)
2. Smoke inhalation
 Note cough, singed hair, deep facial burn or blistering of oral pharynx,
hypoxia
3. Infection
4. Mesenteric vasoconstriction
September 04, 2009, 1:00pm
10.
Office Dermatology
Macule -> Patch (same thing just bigger >5mm)
(problem is in dermal/ epidermal junction)
Papule -> Plaque (cluster of papules)
(problem is in dermis)
Vesicle ->
Bulla (same thing just bigger >5mm)
Pustule (same as vesicle just filled with puss- yellowish, etc.)
(Fluid in epidermis)
Random Tidbits











A cluster of vesicles on the face is Herpes Simplex
Linear Vesicles= Poison Ivy/Oak
Don’t call it a vesicle until you have popped one and gotten fluid
out.
Always do KOH on borders of rash where fungus is still fresh
Scaring occurs at the junction point of dermis/epidermis…SO if
they have an erosion (loss of dermis) they won’t scar. If they
have an ulcer (loss of derm and epiderm) they will.
Panniculus= subcutaneous
Crust= scab
Squamous= scale
Pimples on chest= possible steroid reaction
o Ask about steroid use
Lichenification comes from rubbing
Stria= stretch marks
o Red are early stages and can be corrected
o White are late stages and can’t be fixed
24