Approach to the Patient with Skin Disorder Study

Science Medicine Dermatology

Approach to the Patient with Skin Disorder

5.0 (1 review)

Terms in this set (115)

epidermis, dermis,
subcutaneous
Layers of the skin

<2cm area of color alteration

below the epidermis
Macule

>2cm area of color alteration

below the epidermis
Patch
*same as macule*

a solid lesion of hyperplasia

above the epidermis.
Papule

larger versions of a Papule, >

1/2cm
Nodule

A solid lesion with growth

Tumor
 A raised, flat top lesion
Approach to the Patient with Skin Disorder Study
Plaque

Lesions that contain clear fluid

Vesicle

Larger sized vesicle

Bulla

Lesions that contain purulent

fluid
Pustule

a network of dilated capillaries

Telangiectasia

chronic thickening of the

epidermis
Lichenification

dryness and flaking of the

outermost layer of the skin
Scale
(stratum corneum)

Crust Dried exudate

Erosion A break in the epidermis but the dermis is intact

Ulcer A break in the dermis

Excoriation Linear erosions

Atrophy loss of dermal fibrin

Scar inflammation secondary to trauma
Approach to the Patient with Skin Disorder Study
Furuncle an infection of a single hair follicle

Carbuncle Infection of a group of hair follicles

Alopecia An area of hair loss.

Annular Ring shaped

Cystic Encapsulated lesions

Herpetiform Grouped vesicles

Milia small keratin filled papules

Morbilliform generalized, erythematous lesions

Nummular Coin shaped lesion

Pruritis Itching sensation.

Excision - scalpel or scissors

Skin biopsy techniques
Punch biopsy

Also known as "wet mount".

Potassium hydroxide
A bedside diagnostic test to confirm the diagnosis of
(KOH) Preparation
candida via the presence of hyphe.

A scraping of a suspected lesion to be placed on a

glass slide and fixed with methanol.
Tzanck smear
A positive test shows "giant cells" or "acantholytic
cells" indicative of the herpes virus.

The use of an ultraviolet (black light) to diagnose

Wood's Lamp
skin disorders

Using the process of elimination to identify specific

Patch Test
inflammatory antigens

Excising cancerous lesions via thin layers until

negative margins are achieved on frozen section.
Moh's Surgery
Achieves proper resection of margins with minimal
healthy tissue damage

Spongiosis Intercellular edema of the epidermis

 - Atopic Dermatitis
Approach to the Patient with
- Contact Skin Disorder
Dermatitis
Study

Skin disorders with a - Eczema

histology of spongiosis - Stasis Dermatitis
- Seborrheic
Dermatitis

Genetic predisposition of increased IgE synthesis.

Atopic Dermatitis
background
Most common condition is Eczema.

Pruritus, periods of exacerbation and remissions.

Located on the extensor surfaces (the front of the

Atopic Dermatitis
knee and the back of the elbow or forearm are
Presentation
extensor surfaces)

Eventually lichenification occurs.

Diagnosis of exclusion, no laboratory workup

necessary unless superimposed Staphylococcus is
Atopic Dermatitis Workup suspected.

May have a family history of asthma, allergies.

1st line - topical moisturizers

Atopic Dermatitis
2nd line - topical glucocorticoids like hydrocortisone
Treatment

3rd line - immunomodulators like tacrolimus

exogenous agent causing an inflammatory reaction

Contact Dermatitis of the skin.
Background
Ex; poison ivy, bleach, detergents, sawdust, metals.
 Pruritus, rash description depends on the agent of
Approach to the Patient with Skin Disorder
exposure.
Study

The urushiol from poison ivy causes bullous vesicular

Contact Dermatitis lesions that don't follow a dermatome (unlike other
Presentation vesicular lesions like herpes zoster).

Crusting occurs during the end of the course.

Complications of cellulitis can occur.

A proper history to identify the causative agent.

Contact Dermatitis
Workup
A patch test can be used for repetitive outbreaks.

- Avoidance of the irritant

- Removing the offending agent with soap and water
Contact Dermatitis - Antihistamines like Bendryl, Pepcid
Treatment - Topical glucocorticoids
- Oral steroids
- IV steriods; Solu-Medrol, Decadron 1mg/kg

Underlying pathology of incompetent blood flow

Stasis Dermatitis secondary to peripheral vascular disease,
Background lymphedema, congestive heart failure, deep vein
thrombosis, vasculitis.

Stasis Dermatitis Scaly, erythema, ulcerated, lichenification, oozing,

Presentation crusting, calor (hot) or pallor (cold)

1. Evaluate neuro-vascular status

2. Look for underlying cause such as echo for CHF,

Stasis Dermatitis Workup
venous duplex for DVT. Arterial ultrasound, ect.

Labs may be required for associated cellulitis.

 Treat the underlying cause such as obesity, tobacco,
Approach to the Patient with
diabetes, HTN,Skin
HLP. Disorder
Study

Stasis Dermatitis
Treatment Diuresis if heart failure.

Anticoagulants for thrombosis.

Excessive production of sebum from oil and hair

Seborrheic Dermatitis glands
Background
Termed "cradle cap" in newborns

Seborrheic Dermatitis Thick, yellow, greasy scales near hairlines such as

Presentation scalp and eyebrows.

Clinical diagnosis.
Seborrheic Dermatitis
Workup
Can be complicated with fungal infections.

- Usually resolves on its own in babies

- Can apply mineral oil before shampooing to loosen
Seborrheic Dermatitis the scales
Treatment
- Topical glucocorticoids
- Topical antifungals such as ketoconazole

Skin disorders that - Psoriasis

present as papules and - Lichen planus
scales that form plaques - Pityriasis rosea
with well defined borders - Dermatophytosis

Most common immune-mediated disease in the

Psoriasis Background
world

Erythematous plaques covered by silvery scales.

Can involve the nailbeds.

Psoriasis Presentation
Systemic arthritis can occur.

Associated with "sausage digits" of the phalanges.

 A clinical diagnosis. Exclusion of RA, gout an other
Approach
Psoriasis Workup to the Patient withdisease
autoimmune Skin may
Disorder
be required.
Study

No cure as it is an autoimmune disease

1st line - topical corticosteroids, calcipotriol

Psoriasis Treament 2nd line - UV phototherapy

3rd line - Anti-TNF agents, Methotrexate, Infliximab

4th line - Rentinoids, Acitretin

Papulosquamous disorder that doesn't have the

Lichen Planus Background systemic joint, cardiac, ect involvement that psoriasis
has

Lichen Planus "wickham's striae"- network of gray lines from

Presentation papules. Has mucosal involvement

clinical diagnosis. Associated with thiazide diuretics

Lichen Planus Workup
and phenothiazines (Compazine).

Lichen Planus Treatment topical glucocorticoids

Pityriasis Background No definitive cause but linked to viral organisms.

Annular lesion that evolves into a "herald patch"

Pityriasis Presentation
mainly on the back.

Clinical diagnosis. May rule out fungal infections with

Pityriasis Workup
a wet prep.

1st line - Oral antihistamines

Pityriasis Treatment 2nd line - Topical glucocorticoids

3rd line - UV therapy

- Cellulitis
Cutaneous Infections -
- Dermatophytosis
Skin pathology caused by
- Impetigo
bacteria, fungal or
- Candidiasis
parasites
- Tinea Versicolor
 Microbes of Staph Aureus, MRSA, pseudomonas (hot
Approach
Cellulitis to
Background the Patient with Skin
tub folliculitis), Disorder
ect penetrate the epidermis and
Study

proliferate until contained, debrided, or medicated.

Erythematous, calor, pustular lesion on skin.

Cellulitis Presentation
Associated fever, chills, nausea, vomiting, aches.

Cellulitis Workup WBC, Lactic Acid, cultures, imaging

Cellulitis Treatment Various depending on the organism

S. aureus phage type 2 that produces exfoliative

Impetigo background toxin.
(Same toxin responsible for scalded-skin syndrome.)

"honey-colored" crust mainly around the oral

Impetigo Presentation
mucosa and skin folds.

Clinical diagnosis but can be cultured and sent for

sensitivities.
Impetigo Workup
Occasional Group A- B hemolytic strep will be
found.

1st line - Mupirocin cream, Bactroban

2nd line - Oral B lactam antibiotics, Augmentin

Impetigo Treatment

3rd line - Depends on the culture such as MRSA =

bactrim

Fungal infections of the skin.

Dermatophytosis
Background Termed Tinea -corporis, cruris, unguium, capitis,
pedis.

Tinea - Pedis = foot (athletes foot)

- Corporis Corporis = full body (ringworm)
- Cruris Capitis = head
- Unguium Unguium = nails
- Capitis Cruris = groin and inner thighs ( jock itch)
- Pedis
 Erythema and annular appearance in tinea corporis
Approach to the Patient with Skin Disorder
or "ringworm".
Study

Dermatophytosis
Presentation Erythema, wet, appearance of tinea cruris and pedis.

Patients complain of itching and burning.

Dermatophytosis Workup Supported with a KOH wet prep.

1st line - Topical azoles, Fluconazole

Dermatophytosis 2nd line - Oral Azoles

Treatment
**Special note, steroids and antibiotics can
exacerbate the disease**

Tinea Versicolor M. Furfur is a normal skin pathogen but heat and

Background moisture promote an exacerbation.

Tinea Versicolor Hypopigmented lesions mainly located on the trunk.

Presentation Patients are typically asymptomatic.

KOH prep shows short hype and round spores

Tinea Versicolor Workup
(spaghetii & meatball appearance).

1st line- topical selenium sulfide.

Tinea Versicolor
Treatment
2nd line- topical azoles.

Candida albicans is a normal inhabitant of the body

Candidiasis Background but immunosuppression with HIV, diabetes, and
antibiotics.

Localized - oral "thrush", vaginitis "yeast infection",

esophagitis.
Candidiasis Presentation

Systemic - sepsis, endocarditis,

- Blood cultures
Candidiasis Workup - Biopsy
- KOH wet prep
 1st line - topical nystatin
Approach to the Patient with Skin Disorder Study

Candidiasis Treatment 2nd line- azoles

3rd- Intravenous antifungals, voriconazole.

Papillomaviruses cause skin neoplasms that is a risk

factor for future carcinomas.

HPV (condylomata) has over 100 different strains that

Warts background
occur on genitals, esophagus and anus.

Filiform warts are typical warts found on face, arms

and legs.

Sessile, dome shaped, hyperkerkeatotic lesion.

Warts Presentation
If scalped, there will be punctate bleeding spots
"seed appearing".

Acetic acid (Vinegar solution) will turn positive

lesions white.
Warts Workup
Tissue biopsy or colposcopy to evaluate for "high or
low risk" strains.

1st line- Prevention with HPV vaccine

2nd line cryotherapy with liquid nitrogen, "freeze off"

Warts Treatment 3rd line- salicylic acid plaster- a keratolytic

4th line- topical Imiquimod- TNF

5th line- surgical resection, cervical cone biopsy

A large viral genome family that synthesizes in the

Herpes Simplex (HSV)
neuronal cells. Transmitted through mucosal tissue or
Background
abraded dermis. Has latent and reactivation phases.
 - Erythematous, vesicular lesions followed by
Approach to the Patient with Skin Disorder
ulceration.
Study

Herpes Simplex (HSV) - Patient experiences intense, burning pain.

Presentation - Depends on location; bells palsy (face), genital,
finger (Herpatic Whitlow), eye (HSV conjunctivitis),
CNS encephalitis, neonatal, oral (cold sores).

Herpes Simplex (HSV) - Tzanck smear shows "dendrites".

Workup - Serologic assay. (this is expensive)

Cyclovirs -> Acyclovir

Herpes Simplex (HSV)
Treatment * Always evaluate for coinfections of HIV, syphilis, G/
C.

- A viral infection from the Herpesviridae family that

is highly contagious and affects 90% of the
population.
Herpes Zoster (VZV)
- Goes through long latency period in the dorsal
root ganglia until reactivation as zoster in later
adulthood.

Chickenpox Herpes varicella

Shingles Herpes zoster

Diffuse vesicular lesion with onset around ages 5-10.

Patients have low grade fever and flu-like symptoms.

Herpes Varicella
Superimposed Staph and MRSA can exist.
Presentation

Can be complicated with organ damage such as;

myocarditis, pneumonia, glomerulonephritis,
meningitis.