Dermatology

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• Presentation:
  • -usually occurs in children; onset after age 30 is rare; may be pruritic, exudative, or lichenified and located in the face, neck, trunk, wrists, hands, antecubital fossa, popliteal folds; symptoms include: itching, rough red plaques
• Pathophysiology:
  • increased T cell activation; abnormal cell-mediated immunity; overproduction of IgE
• Physical Exam:
  • -“itch-scratch cycle”; acute-erythematous papules/plaques with poorly defined border; chronic lichenification and painful fissures; excorations are common; Dennie Morgan sign
• Dx:
  • -increase in serum IgE levels; RAST allergy testing; viral cultures to rule out other infections
• Management:
  • avoiding triggers
  • topical corticosteroids
  • nonsteroidal immunomodulators (tacrolimus)
  • leukotriene inhibitors
  • acute lesions may require wet dressings
  • chronic – necessary to maintain daily hydration with unscented bath soaps and emollients

• Presentation:
  • -genital warts (HPV6&11); high risk = HPV 16, 18, 31, 33, and 45; low risk = HPV 1, 6, and 11
  • -90% of HPV infections are cleared from the body within 2 years of infection
• Transmission:
  • via skin-to-skin contact
  • 90% of people who contract HPV do not develop warts but are still contagious
  • presence of visible warts may be an indication of increased infectivity
  • vertical transmission at birth
  • sexual transmission = the most common viral STI
  • non-sexual transmission = cutaneous transmission to hands
  • sharing of clothing; incubation period = 2-3 months
• Latency:
  • possibility for virus to become latent
  • latent patients are still able to transmit the disease
  • 1/3 of patients with warts will experience recurrence
• Physical Exam:
  • -may our singly, most commonly found in clusters; papules or plaques with cleft surface; any part of oral, anal, or genital region; most common on surface, can be found internally; can be soft or firm, in a variety of colors and may bleed; possible itching, discomfort, pain
• Dx:
  • clinical dx
  • pap smear
  • biopsy to confirm
  • microscopic: enlargement of dermal papillae; parakeratosis; nuclear enlargement with perinuclear clearing; papillomatosis koilocytes

• Presentation:
  • -most commonly caused by contact with poison oak/ivy, topical antimicrobials
  • -occupational exposure is an important cause
  • -tiny vesicle formation and weepy crusted lesions; itching, burning, stinging sensation; may pattern the area of contact
• Dx:
  • clinical dx but bx if unsure
• Management:
  • immediately wash the area with soap and water
  • calamine lotion or oatmeal baths
  • oral antihistamines or topical hydrocortisone cream
  • oral corticosteroids depending on severity and area involved
  • prevention of secondary infection

• Presentation:
  • -lesion: small blisters on dusky pruritic macules (not seen in EM)
  • mucosal involvement common
  • prodrome of fever and malaise common
  • -fever (often>102F) and flu-like illness 1-3 days before mucocutaneous lesions appear
  • confluent erythema
  • facial edema or central facial involvement
  • lesions are painful
  • skin necrosis, blisters, and/or epidermal detachment
  • mucous membrane erosions/crusting, sore throat
  • visual impairment (secondary to ocular involvement)
  • rash 1-3 weeks after exposure, or days after 2nd exposure
• Steven johnson syndrome (similar in appearance to EM major):
  • • rare areas of confluence; detachment <10% BSA)
• Toxic epidermal necrolysis:
  • • confluent erythema common; outer layer of epidermis separates easily from basal layer with lateral pressure; large sheet of necrotic epidermis often present; >30% BSA involvement

• Presentation:
  • -fifth disease; slapped cheek syndrome; parvovirus B19; ages 5-15; outbreaks in close quarters
• Associated with: 
  • -arthritis: affects small joints of hands, occasionally ankles, knees, and wrists, symmetrical distribution
  • -pregnant women: infection in 1st trimester has been linked to hydrops fetalis and miscarriage
• Transmission:
  • via aerosol droplets/respiratory secretions; incubation time is 4-21 days
• Physical Exam:
  • -low grade fever, headahce, and coryza; butterfly shaped maculopapular rashes on cheeks; rash may extend across nose and around mouth; lacy red rash may appear on torso and upper arms and legs; more confluent on the extensor surfaces; rash is rarely pruritic; lasts 2-4 days
• Dx:
  • -clinical dx; PCR or ELISA for antibody testing
• Management:
  • -treatment: supportive care

• Presentation:
  • -self-limited type IV hypersensitivity reaction
  • -can be secondary to drug reactions, mycoplasma, or herpes simplex infections
  • -minor: typically post-infectious pattern, most commonly HSV
  • -major: <10% BSA involvement; commonly associated with medication use; may be associated with mycoplasma pneumonia; must involve at least two mucocutaneous surfaces; epidermal detachment; more systemic symptoms
• Physical Exam:
  • -bull’s eye papules; extremities, face, lips (usually symmetrical); accompanies by fever, malaise, and arthralgia
• Management:
  • corticosteroids
  • Tylenol

• Presentation:
  • -adolescent girls and young women;
  • strep infection, fungal infection, pregnancy, OCP, sarcoidosis (most common);
  • idiopathic
    
• Physical Exam:
  • -bilateral erythematous, tender, nodules on pretibial area; can last several weeks
    
• Management:
  • -treat cause if possible
  • rest, local heat, aspirin

• Presentation:
  • -coxsackie virus
• Transmission:
  • through nasal and pharyngeal secretions, saliva, vesicular fluid, and stool highly contagious, most infectious the first week of symptoms
• Physical Exam:
  • -fever and stomatitis, sore throat and malaise 1-2 days, LAN (cervical and submandibular)
  • oral lesions (apthae like); cutaneous lesions appear <24 hrs after oral lesions
  • -3-7 mm red macules that progress into white vesicles with erythematous rings (“square blisters”); palms, soles, dorsal toes and fingers; less likely on face, buttocks, and legs 7 days to heal
• Dx:
  • -clinical dx
  • virus culture of fluid from vesicles
  • negative tzanck smear
• Management:
  • -mild and self-limiting
  • tylenol for fever and pain control
  • acyclovir suspension for patients 9 months-5 years of age if immunocompromised

• Presentation:
  • -inflammatory and pruritic conditions with distinctive papules and insatiable pruritis
  • -predilection for flexural surfaces
  • -three cardinal features: characteristic skin lesions, mucosal lesions, infiltration of lymphocytes in the upper dermis
  • -characteristic lesion: violaceous, flat, agulated papules with very fine white streaking; mucosal lesions have a lacy/reticular pattern; bx may reveal mononuclear cells with T cell mediated cytotoxic reagant against basal keratinocytes
  • –the 5 P’s: pruritic, planar, polygonal, purple, papules
• Management:
  • -treatment: high potency topical corticosteroids if localized; systemic corticosteroids in patients with acute systemic flares
• Prognosis:
  • acute on chronic flares
  • may lead to neoplastic changes in tissues in chronic

• Presentation:
  • -chronic itching/scratching
    
  • -commonly located on wrists, ankles, anogenital region and nape of neck
    
  • -dry leathery, hypertrophic, lichenified plaques usually in a rectangular pattern
    
  • -may be hyperpigmented with exaggerated skin lines
    
• Management:
  • topical corticosteroids; cordan = highest potency

• Presentation:
  • -high fever; Koplik’s spots; malaise; loss of appetite; coryza, hacking cough, conjunctivitis
  • -rash develops 2-3 days after symptoms; starts behind ears and wraps around to the head and face, then proceeds to the rest of the body; generalized maculopapular, erythematous rash; may be pruritic; changes colors from red to dark brown before disappearing; usually lasts 6-8 days
• Dx:
  • reportable to local health department; blood and throat/nasopharyngeal swabs for detection of measles-specific IgM antibody and measles RNA by real-time polymerase chain reaction (RT-PCR)
• Management:
  • supportive care
• Prevention:
  • MMR vaccine
• Complications:
  • bacterial skin infection, otitis media, pneumonia, encephalitis, corneal ulcerations
• Risk factors:
  • immunocompromised, unvaccinated people

• Presentation:
  • -caused by poxvirus; peak age is around 3-9 years and 16-24 years; commonly affects immunocompromised patients
• Transmission
  • via contact and autoinoculation; lesions spread along inflamed skin
• Physical Exam:
  • -1-2 mm shiny, white flesh colored, dome shaped firm papules; children = upper trunk, extremities, face; young adults = usually STI; lower ab, thighs, and pubic region; papules become softer and pink in color with central umbilication
• Dx:
  • -biopsy = molluscum bodies with infected keratinocytes; curettage = express white rubbery core of papule that can be used on KOH prep
• Management:
  • -keep covered to decrease spread;
  • curettage cryosurgery
  • kids = cantharidin 0.7% solution with occlusive dressing
  • adults = topical tretinoin for 1+ month
  • untreated may last 6-9 months

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Gzzz / CC BY-SA

• Presentation:
  • -spring and winter months; outbreaks in confined populations; young adults
• Transmission:
  • via aerosol droplets, respiratory secretions, virus can survive on external surfaces
• Phsyical Exam:
  • -fever, headaches, malaise, anorexia, dry mouth and sore face/ears are prodromal sxs; painful swelling of salivary glands, specifically parotid gland (“hamster cheeks”);orchitis (15-20% of post-puberty males)/oophoritis
• Dx:
  • PCR of saliva and blood for antibody testing; serum amylase to R/O pancreatic involvement
• Management:
  • -warm compress; soft foods, saltwater gargles; pain medications
• Vaccine:
  • -MMR vaccine: live attenuated virus; two doses (12 months, 4-6 years)
• Complications:
  • infertility/subfertility in males; meningitis; pancreatitis
• Risk factors:
  • unvaccinated patients; highly populated close quarters

• Presentation:
  • -unclear etiology but secondary to chronic vasomotor instability which leads to permanent vasodilation and lesion formation; W>M, more common in celtic population; usually occurs in 30s-50s
  • -facial flushing with increase in temperature or with consumption of ETOH
• Pathophysiology:
  • increase reactivity of facial capillaries leads to flushing and development of telangectasia; dilation of superficial capillaries leads to perifollicular inflammation that causes papules and pustules
• Physical Exam:
  • -symmetric erythema of the face; telangectasia; pustules and central facial edema
• Dx:
  • skin biopsy helpful for staging
• Management:
  • topical antibiotics, systemic antibiotics
  • isotretinoin (retin A) for severe cases
  • clonidine
  • avoidance of provocative factors

• Presentation:
  • -children b/w 6 months-1 year; caused by HHV-6
  • fall and spring epidemics
  • incubation period = 5-15 days
• Transmission:
  • via respiratory droplets and oral secretions
• Physical Exam:
  • ~70% of patients are asymptomatic sudden high fever (>103F) for three days
  • after the fever subsides, a rose colored maculopapular rash appears
  • usually begins on trunk, spreading to the legs and neck/face; the rash is not itchy and may last 1-2 days
• Management:
  • supportive care
• Complications:
  • febrile seizures
  • immunocompromised (pneumonia, encephalitis)

• Presentation:
  • -malaise, fever, and anorexia are prodromal; LAN (posterior auricular, cervical, and suboccipital)
  • maculopapular rash that starts on the face and spreads down the body (lasts 3-5 days)
• Transmission:
  • via aerosol droplets; virions are present on skin and in urine and feces
• Dx:
  • can be difficult; PCR or ELISA for antibody testing
• Management:
  • supportive care
• Prevention:
  • MMR
• Associated with:
  • Pregnant women:
    • greatest risk is b/w 28 days before conception (increased risk of miscarriage) and 12 weeks after conception (congenital rubella)
  • Congenital rubella syndrome:
    • infants stay contagious for months
    • sensorineural deafness (58%)
    • eye abnormalities (43%-retinopathy, cataracts, micropthalmia)
    • CHD (50%-pulmonary stenosis, PDA)
    • microcephaly, hepatomegaly, blueberry muffin rash, autism, developmental delays, mental retardation
  • Arthritis:
    • mostly in women with fingers, wrists, and knees affected

• Presentation:
  • -IgE or complement mediated edema of the dermis and/or subcutaneous tissues
  • -may be idiopathic, hereditary, or caused by insect bites, medications, exposures to head/cold
  • -mast cells are stimulated to degranulate; histamine leads to vasodilation which leads to edema
  • -blanchable, pink, edematous papules or plaques; these lesions may colaesce; acute – typically resolves within 24 hours
• Dx:
  • -clinical dx
  • persistence may require further testing
• Management:
  •  eliminate causative factors
  • H1/H2 blockers
  • mast cell stabilizers
  • steroids topical, oral, IM, or IV depending on severity

• Presentation:
  • -virus; respiratory droplets
  • -rash begins as small red dots on the face, scalp, torso, upper arms and legs; progressing over 10-12 hours to small bumps, blisters and pustules; followed by umbilication and the formation of a scab; low grade fever; malaise; “dew drops on a rose petal
• Dx:
  • -tzank smear; IgM and IgG
• Management:
  • treat fever and supportive care
  • antivirals, vaccine, nerve block
  • narcotics