Dermatology Part 1

Dermatology Part 1

By Ken Ghis

As general internists, you will be called upon to determine the nature of skin diseases and understanding of the skin anatomy/structure is paramount .

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Fill in the Blanks

Multiple Choice

The picture shown represent the skin layers. Are you brave enough to label them?

• A- Strat. Corneum

  B- Papillary dermis

  C- Basal cell

  D- Reticularis dermis

• A- Strat. Corneum

  D- Papillary dermis

  B- Basal cell

  C- Reticularis dermis

• A- Strat. Corneum

  C- Papillary dermis

  D- Basal cell

  C- Reticularis dermis

• A- Strat. Corneum

  D- Papillary dermis

  C- Basal cell

  B- Reticularis dermis

• We don't do enough Derm- sorry I don't know 😢

​Morphology of skin lesions can be categorized as primary or secondary.

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Primary skin lesion morphology is the appearance of a rash or growth in its initial or unaltered state.

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Over time, with itching or rubbing, secondary skin changes may occur.

Multiple Choice

I am a small flat discoloration of the skin typically <1 cm in diameter

• Papule

• Macule

• Plaque

• Patch

• We don't do enough Derm- sorry I don't know 😢

Multiple Choice

I am a flat discoloration of the skin >1 cm in diameter often with surface change, such as scale

• Papule

• Macule

• Plaque

• Patch

• We don't do enough Derm- sorry I don't know 😢

Multiple Choice

I am a small <1 cm elevation of the skin, solid in nature

• Papule

• Macule

• Plaque

• Patch

• We don't do enough Derm- sorry I don't know 😢

Multiple Choice

I am a flat-topped “plateau-like” elevation of the skin >1 cm in diameter

• Papule

• Macule

• Plaque

• Patch

• We don't do enough Derm- sorry I don't know 😢

Macule--> Patch

Papule--> Plaque

​the "ule" are <1cm​

​

Multiple Choice

I am a space-occupying lesion within the dermis; larger than a papule and located deeper.

• Nodule

• Cyst

• Vesicle

• Bulla

• We don't do enough Derm- sorry I don't know 😢

Multiple Choice

I am a fluid-filled nodule containing fluid that is expressible

• Nodule

• Cyst

• Vesicle

• Bulla

• We don't do enough Derm- sorry I don't know 😢

Multiple Choice

I am a small clear fluid-filled blister <1 cm

• Nodule

• Cyst

• Vesicle

• Bulla

• We don't do enough Derm- sorry I don't know 😢

Multiple Choice

I am a larger clear fluid-filled blister >1 cm

• Nodule

• Cyst

• Vesicle

• Bulla

• We don't do enough Derm- sorry I don't know 😢

Multiple Choice

I am a vesicle filled with purulent material

• Pustule

• Wheal

• Vesicle

• Bulla

• Comedo

Multiple Choice

I am a transient edematous, erythematous papule or plaque

• Pustule

• Wheal

• Burrow

• Telangiectasia

• Comedo

Multiple Choice

I am a visibly dilated, but not palpable, blood vessel in the epidermis

• Pustule

• Wheal

• Burrow

• Telangiectasia

• Comedo

Multiple Choice

I am a serpiginous epidermal streaking/disruption caused by scabies mite

• Pustule

• Wheal

• Burrow

• Telangiectasia

• Comedo

​PRIMARY SKIN LESIONS

​

​

​​Over time, with itching or rubbing, primary skin lesions can become secondary skin lesions.

Multiple Choice

I am a dry serous fluid commonly derived from blisters or pustules; often moist and yellow or brown

• Crust

• Excoriation

• Scale

• Lichenification

• Ulcer

Multiple Choice

I am a thickened stratum corneum; often dry and white or gray

• Crust

• Excoriation

• Scale

• Lichenification

• Ulcer

Multiple Choice

I am a defect in the epidermis often caused by scratching

• Crust

• Excoriation

• Scale

• Lichenification

• Ulcer

Multiple Choice

I am a visible thickening of the stratum corneum resulting in accentuation of the normal skin lines

• Crust

• Excoriation

• Scale

• Lichenification

• Ulcer

​SECONDARY SKIN LESIONS

​

​

​​Over time, with itching or rubbing, primary skin lesions can become secondary skin lesions.

Fill in the Blanks

​The skin lesions are erythematous (discoloration) annular patches (flat (non-raised and >1cm each) with noticeable surface scale​

​

Remember

Macule (flat <1cm)--> Patch (flat >1cm)

​Papule (raised <1cm)--> Plaque (raised >1cm)

​

the "ules" are <1cm ​

COMMON RASHES

Multiple Choice

A 32-YOM is evaluated for an intermittent pruritic rash of 8 years' duration. Hx is sig. for mild persistent asthma. His only meds are an albuterol & an inhaled glucocorticoid. On PE, V/S are normal. There is mild xerosis with erythematous plaques on the bilateral antecubital fossae, volar wrists, and anterior lower legs. Lichenification is present on the dorsal hands. Linear excoriations are found within many of the erythematous plaques on the arms. Which of the following is the most appropriate treatment?

• Oral cephalexin

• Oral prednisone

• topical glucocorticoids

• topical ketoconazole

• consultation to Dermatology

Atopic Dermatitis ​

​

-Waxing and waning course

-Chronic lesions that may be lichenified and hyperkeratotic

-Involve flexures surfaces, posterior neck, antecubital fossa & popliteal fossae, wrist & ankles.

-Increased IgE​

​

Treatment: fragrance-free, non-soap based cleanser and moisturizers, hydrants, emollients, hydrocortisone​

Multiple Choice

A 29 yoF suffers a laceration, which is cleaned and sutured. An antibiotic cream applied with occlusive dressing. 3 days later presents with itching sensation and pain at the site. On exam the band-aid uncovered reveals the suture line clean, but there is surrounding erythema and eruptive vesicular lesions. What is the most likely diagnosis?

• Atopic dermatitis

• Contact dermatitis

• Strep fasciitits

• Rosacea

Multiple Choice

A 40 yo nurse has a 1 month history of vesicular eruptions on the dorsum and distal areas of her hands. Picture shown. What is the diagnosis?

• Atopic dermatitis

• Contact dermatitis

• Strep fasciitits

• Rosacea

Contact Dermatitis ​

​

Delayed type IV reaction commonly caused by:

• Nickel (found in jewerly, zippers, cells phones, medical devices

• Chromium

• Oleoresin (poison Ivy, poison oak..)

• Rubber​

​

Treatment:

• Cool compresses

• Avoid reactant​ is preventative and curative

• ​Topical steroids can be used while patient and clinician identify and eliminate the source.

• Severe allergic contact may need 2-3wks systemic steroid taper. ​

Multiple Choice

Pt presents after exposure to poison ivy within 2 hours. What do you do next?

• 7-day course of oral acyclovir

• 10-day course of oral doxycycline

• Nothing to do, patient is going to be fine.

• Showering

• topical hydrocortisone 1%

Multiple Choice

A 36-yoF is evaluated for a 3-day hx of pruritic rash on the arms, legs, and face. She is very symptomatic and cannot concentrate on her tasks or sleep due to the intense itching. She is a summer camp counselor. Medical hx is otherwise unremarkable, and she takes no meds. On PE, V/S are normal. Representative skin findings on the leg are shown.

• 7-day course of oral acyclovir

• 10-day course of oral doxycycline

• 6 day taper oral steroids

• 21 day taper of oral prednisone

• topical hydrocortisone 1%

​This patient has severe contact dermatitis from poison ivy (Toxicodendron genus), and the most appropriate treatment is a 21-day taper of oral prednisone.

​

There are two types of contact dermatitis: allergic and irritant.

Allergic contact dermatitis is a type IV delayed hypersensitivity reaction. With repeated exposure, a pruritic eczematous dermatitis develops on the exposed area.

Lichen Simplex Chronicus​

This is a condition caused by repetitive scratching or rubbing.

​

Lichen simplex chronicus manifests as thickened >1cm lesions, flat non-raised (------) with erythema and hyperpigmentation.

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Exaggerated skin markings are seen on the surface of the skin as well.

​

Lichen simplex chronicus is treated with moisturizers, high and ultrapotent topical glucocorticoids, and intralesional glucocorticoid injections.

Intertrigo

​Intertrigo is dermatitis involving adjacent skin folds (axillary, inframammary, abdominal, and inguinal).

​

Predisposing conditions include:

-Obesity

-Friction

-Occlusion

-Diabetes​

​

Treatment: drying the area and using antifungal powder​.

Multiple Choice

A 32-yoF is evaluated for a 10-month history of pruritus and scaling of both her hands. She is a child care worker and washes her hands frequently. Medical hx is unremarkable, & takes no meds. On PE, V/S are normal. Skin findings are shown. There is no scale or erythema of the feet. The remainder of the examination is normal. Results of potassium hydroxide microscopy from the scale on her hands are negative. Which of the following is the most appropriate management

• Epicutaneous patch testing

• Oral fluconazole

• Oral prednisone

• Thick emollients

• We don't do enough Derm- sorry I don't know 😢

Hand Dermatitis

Hand dermatitis results from combination of excessive hand washing, contact dermatitis or atopic dermatitis or dyshidrotic eczema (pompholyx)​

​

Commonly seen in individual who hold jobs involving frequent or prolonged hand washing,.

​

​

Treatment:

• Topical emollients such as petrolatum

• Poten topical glucocorticoids

• Avoid triggers ​

Multiple Choice

A 68-yoF is evaluated for a 12-month hx of swelling of both of her lower legs. Over the past 4 months, there was worsening edema, erythema, scaling, and itching of the lower legs. She has not used any prescription or OTC topical medications or emollients. Medical hx is sig. for HTN & T2DM. Meds are lisinopril, amlodipine, HCTZ, and metformin.

On PE, V/S are normal. BMI is 32. Skin findings are shown. There is no tenderness. Pedal pulses are strong bilaterally. Labs studies, including leukocyte ct. WNL. Which is the following is the most likely diagnosis?

• Allergic Contact dermatitis

• Cellulitis

• Leukocytoclastic vasculitis

• Psoriasis

• Stasis dermatitis

Stasis Dermatitis

​Stasis dermatitis, which can be very pruritic and erythematous, is common in patients with chronic lower extremity edema, most commonly secondary to venous stasis.

​

Symptoms can be managed topically with glucocorticoids and emollients, but the condition will not significantly improve until the edema is addressed with leg elevation and compression stockings.

​

Stasis dermatitis can be misdiagnosed as cellulitis; however, cellulitis is usually unilateral, more acute in onset, and often associated with pain, leukocytosis, and occasionally fever.

Multiple Choice

A 68-yoF is evaluated for a 12-month hx of swelling of both of her lower legs. Over the past 4 months, there was worsening edema, erythema, scaling, and itching of the lower legs. She has not used any prescription or OTC topical medications or emollients. Medical hx is sig. for HTN & T2DM. Meds are lisinopril, amlodipine, HCTZ, and metformin.

On PE, V/S are normal. BMI is 32. Skin findings are shown. There is no tenderness. Pedal pulses are strong bilaterally. Labs studies, including leukocyte ct. WNL. Which is the following is the most likely diagnosis?

• Allergic Contact dermatitis

• Cellulitis

• Leukocytoclastic vasculitis

• Psoriasis

• Stasis dermatitis

Multiple Choice

A 65-year-old man is evaluated in the ICU for a rash limited to his back that was first noticed this morning. He was admitted to the ICU for hospital-acquired pneumonia following hip replacement surgery 3 days ago. Because of deteriorating respiratory function, he was intubated and placed on mechanical ventilation. His current medications are fentanyl and piperacillin-tazobactam.

On physical examination, temperature is 38.3 °C (100.9 °F), blood pressure is 110/60 mm Hg, pulse rate is 115/min, and respiration rate is 18/min (ventilator set rate is 14/min). Pulmonary examination reveals diffuse crackles. Skin findings are shown. What is the diagnosis

• Acute generalized exanthematous pustulosis

• candida albicans infections

• miliaria

• povidone iodine contact dermatitis

Miliaria

​Miliaria (prickly heat, heat rash) is caused by the occlusion and subsequent rupture of the eccrine sweat ducts at various levels.

​

An overgrowth of Staphylococcus epidermis may contribute to the pathogenesis in miliaria.

​

Presents as numerous nonfollicular 1- to 3-mm papules or pustules that can arise with any condition causing sweating and skin occlusion

Multiple Choice

A 20 yoF is evaluated for white spots on her eyelids, hands, elbows, and knees for several months' duration. There was no previous rash. She is otherwise healthy and takes no medications.

Vital signs are normal. What is the dx?

• Pityriasis alba

• Tinea versicolor

• tuberous sclerosis

• Vitiligo

Vitiligo ​

​Vitiligo is a common acquired autoimmune condition resulting in patchy depigmentation of the skin and is characterized by the loss of function or absence of melanocytes.

Melanotic stools ---> do not say melanotic stools in your note

​

Say Melena--> Melenic Stool s​

Multiple Choice

An 18 YoM is evaluated for a 6-month hx of acne on his face, chest, and upper back. He is otherwise in good health. He has been treated with doxycycline, tretinoin cream, and topical clindamycin lotion for 6 months with minimal improvement. On exam, V/S are normal. Skin findings are shown. What is the most appropriate treatment?

• Add topical Benoyl peroxide gel

• Add topical dapsone

• Change doycycline to Bactrimn

• Discontinue current treatment and start oral isotretinoin

• Start oral prednisone

Acneiform Eruptions​

-Open and Closed Comedones--> Topical Tretinoin

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​-Papular Acne (inflammatory acne)--> Topical Benzoyl peroxide + Erythromycin

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-​Cystic and Nodular Acne--> Isotretinoin (Accutane)

Multiple Choice

A 30 yoM is evaluated for an acne flare on her face. She is 12 weeks pregnant. When she was younger, she was on a course of isotretinoin, and it cleared her acne. She is otherwise in good health and has not been on any meds other than a prenatal vitamin since she became pregnant.

On exam, V/S normal. Skin findings are shown. What do you do next?

• Topical erythromycin

• Oral Spironolactone

• Oral doycycline

• Oral isotretinoin

• No medications needed- Acne is pregnancy related

Multiple Select

Female with severe acne, wants Isotretinoin. What do you do?

• Prescribe

• Counsel patient about side effects

• Must be two forms of birth control in order to be eligible for isotretinoin therapy.

• must be on One form of birth control in order to be eligible for isotretinoin therapy.

• must be on Three forms of birth control in order to be eligible for isotretinoin therapy.

Multiple Choice

A 36YoF is evaluated for a 6-year hx of tender, foul-smelling, draining nodules in the inguinal folds. She has had occasional nodules in the axillae. She has taken multiple courses of oral clindamycin with only temporary improvement. She has a 14-pack-year smoking hx. Medical hx is negative. On exam, V/S are normal. BMI is 34. There are tender nodules, draining sinus tracts, and comedones in the inguinal folds. Scarring is present in right and left axillae. Additional inguinal skin findings are shown. What is the diagnosis?

• Chancroid

• Carbuncles

• Epidermal Inclusion cysts

• Hidradenitis suppurative

• Keloids

Fill in the Blanks

Multiple Choice

A 21-YOM is evaluated 3 wks following treatment of scabies. The patient lives alone, but his sexual partner had similar symptoms. Scabies was confirmed in both persons by microscopic examination of skin scrapings. Both were treated with two applications of 5% permethrin 2 weeks apart. Both patient and partner were adherent to the treatment protocol. The patient notes persistence of itching without the appearance of new lesions, whereas his partner is now asymptomatic. Which of the following is the most appropiate next step?

• Begin an oral antihistamine and topical glucocorticoid

• Re-treat with 5% permethrin cream

• Treat with oral ivermectin

• Treat with combination oral ivermectin and 5% permethrin cream

• Treat with 1% lindane lotion

Treatment of postscabetic pruritus

Itching can persist for several weeks following treatment of scabies and does not constitute a treatment failure; persistent itching can be treated with antihistamines, topical glucocorticoids, and, if severe, oral glucocorticoids.

​

Lindane 1% lotion has been associated with neurotoxicity and is typically reserved as third-line therapy in patients who cannot intolerant of other therapies or for treatment failures

​

Treatment of Scabies

Multiple Choice

I am a parasite that lives on walls, vents, furniture and crawl to the host to feed overnight. I do not live on the human body. My bites are characteristically linearly arranged urticarial papules (“breakfast, lunch, and dinner” bites) on exposed skin. I am called Cimex lectularius sometimes called:

• Scabies

• Lice

• Bedbug

• Consult ID for identification

• Consult Derm for identification

Bed Bugs

Bed bugs (Cimex lectularius) live in floorboards, walls, vents, or furniture and crawl to the host to feed overnight. They do not live on the human body. Bites are characteristically linearly arranged urticarial papules (“breakfast, lunch, and dinner” bites) on exposed skin

​Treatment:

LICE

​Transmission: personal contact or by fomites such as bedding, clothing, or hairbrushes.

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Body lice live in the seams of clothing and not on the skin.

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Excoriations result in crusted papules or linear petechiae on the trunk, neck, and proximal arms. Maculae ceruleae are blue-brown macules from subcutaneous hemorrhage at sites of feeding

Multiple Choice

I am a benign pigmented neoplasms of keratinocyte origin that are common in adults. I have a “stuck-on” appearance and I can occur anywhere on the body but are most common on the trunk and spare the palms, soles, and mucous membranes. A picture of myself is shown. What am I?

• Melanoma

• Squamous Cell Carcinoma

• Seborrheic keratosis

• Keloids

• Consult Derm for identification

​Seborrheic keratoses are brown, scaly, waxy papules/plaques that commonly occur in older persons.

They frequently have a “stuck-on” appearance and often have verrucous (warty) surface changes as well.

​

​They can mimic melanoma and squamous cell carcinoma, but skin biopsy confirms the diagnosis.

They may become irritated or excoriated. When seborrheic keratoses are symptomatic.

​

Treated with cryotherapy or shave removal.

Multiple Choice

A 44-year-old man is evaluated for a new lesion on the side of his face. It has been present for several months and is asymptomatic. When he shaves he cuts it, and it starts bleeding. He is otherwise healthy and takes no medications.

On physical examination, vital signs are normal. Skin findings are shown. Which of the following is the mostly likely diagnosis?

• Basal Cell Carcinoma

• Dermal Nevus

• Keratoacathoma

• Nodular Melanoma

• Squamous Cell Carcinoma

​Basal Cell Carcinoma

​BCC is the most common type of skin cancer in general

​Nodular basal cell carcinoma is the most common type of BCC.

​

It presents as a pearly or translucent nodule or papule with arborizing telangiectasias. It may have a central depression or ulceration with a rolled waxy border.

​

The term “rodent ulcer” is used to describe the ulceration. Nodular BCC is most commonly found on the face, especially the nose.

Multiple Choice

A 63-YOF is evaluated for a lesion on her nose that is slowly enlarging and nonhealing. She is otherwise in good health and takes no medications. On exam, V/S are normal. The skin exam demonstrates a 0.8 × 0.6-cm pearly ulcerated papule with arborizing telangiectasias. The remainder of the exam is normal.

Biopsy of the lesion demonstrates -------- (you know the diagnosis) with high-risk micronodular and infiltrative histologic features. What is the treatment?

• Cryotheraapy

• Electrodesication and curettage

• Mohs micrographic Surgery

• Topical 5-fluorouracil

• Vismodegib

​The most appropriate treatment for this lesion is Mohs micrographic surgery. Mohs micrographic surgery is a specialized surgical procedure that provides margin control while sparing as much normal skin as possible. Indications for Mohs micrographic surgery include tumors with aggressive histologic subtypes (micronodular, morpheaform, infiltrative, perineural involvement), high-risk and cosmetically sensitive locations (face, genitals), large tumors or tumors arising in scar tissue, and in patients who are immunosuppressed. Because this patient has a high-risk tumor that is located in a cosmetically sensitive location, Mohs surgery is the most appropriate treatment.

Multiple Choice

An 83-YOM is seen in the office for routine follow-up. He has a hx of sHTN and AFib. Meds are hydrochlorothiazide and warfarin. On exam, vital signs are normal. During lung auscultation, a 0.4 × 0.4-cm pink pearly papule with telangiectasias on his back is found. Biopsy of the lesion reveals----- (you know this diagnosis) with low-risk histology. What is the treatment?

• Cryotheraapy

• Electrodesication and curettage

• Mohs micrographic Surgery

• Radiation

• Vismodegib

Electrodesiccation and curettage (ED&C) is a widely used treatment for noninfiltrating basal cell carcinomas on low-risk anatomic sites (trunk and extremities). Treatment of basal cell carcinomas depends on many factors, including the histologic subtype, location, size, cosmetic considerations, and patient's age and comorbidities. Nodular and superficial basal cell carcinomas on the trunk and extremities are often treated with ED&C. Infiltrative and micronodular basal cell carcinomas, especially on the face, are not appropriate for ED&C. For this patient, his lesion is a small, histologically low-risk subtype of basal cell carcinoma on the back that can be treated with ED&C.

Multiple Choice

An 82-YOW is evaluated for a spot on her left cheek. Six months ago, she was diagnosed with an actinic keratosis. This lesion was treated with cryotherapy two times; however, the lesion is still persistent. On palpation, it is indurated. The lesion is shown. What is the next best step in management?

• Cryotheraapy

• Biopsy

• Topical Imiquimod

• Wide local excision

• Mohs surgery

​The most appropriate management for this lesion is biopsy. Actinic keratoses are red scaly papules and plaques that occur in sun-exposed areas, most often in those over age 50. They have a “gritty” texture, and early lesions are often easier to palpate than to see. Diagnosis is usually made clinically rather than with biopsy. Individual lesions are often treated with cryotherapy. In patients with a large number of actinic keratoses, areas with multiple lesions are best treated with topical preparations (such as 5-fluorouracil or imiquimod); photodynamic therapy may also be performed.

​Actinic keratoses are precancerous lesions of the epidermis. Approximately 1% to 5% of actinic keratoses will

Multiple Choice

A 69-year-old man is evaluated for a new lesion behind his ear. It is asymptomatic. His wife noted that it first appeared last year and is growing. The patient is a farmer and has had many sunburns over his lifetime. He has no other medical problems and takes no medications.

On physical examination, vital signs are normal. Skin findings are shown. What is the likley diagnosis?

• Junctional melanocytic nevus

• melanoma in situ, lentigo maligna

• nodula melanoma

• solar lentigo