Professional Documents
Culture Documents
Skin functions
Rosacea:
➢ Chronic facial redness (forehead, nose, & cheeks), Caucasian women 30-50 yrs (most)
➢ Findings:
- Erythema, telangiectasia, papules, types (ocular, rhinophylum) (X comedones)
- Decrease by avoiding alcohol, hot drinks, extreme temp, & emotional stress
➢ Treatment:
- Topical metronidazole + tetracycline PO (maintenance), isotretinoin, laser
- Corticosteroids (PO or topical) are CI as they can cause flare up of the condition
Pityriasis rosea:
Acne vulgaris:
Isotretinoin (Roaccutane) can be used for both inflammatory & non-inflammatory – needs LFT & lipid
profile before using as it raises liver enzymes & TG – most common side effect of it is dry skin &
most serious side effect is teratogenicity
Irritant contact dermatitis Allergic contact dermatitis
Eczematic lesion → oozing + crust formation, No need for previous Requires previous exposure
exposure – not an – immune reaction – has
patient starts with itching then skin lesion appears immunologic reaction – does distant spread – not dose-
not spread – dose-related related – does not produce
Contact dermatitis: response – produce similar similar reaction if others
reaction if others exposed to exposed to same irritant
➢ Types: same irritant
- Irritant contact dermatitis: "80%" → burn symptoms
o Non immunological (no sensitization), appears soon after exposure, to any person
o Chemical or physical irritants (detergents, acids, frequent hand wash)
- Allergic contact dermatitis: "20%" → itching symptoms
o Type IV HSR, need sensitization (appear in the 2nd exposure), specific persons
o Examples of allergens: poison ivy, nickel (belt, phone, wristwatch), topical drugs
➢ Findings:
- In exposed areas, very pruritic, acute (erythematous papules & vesicles with oozing)
- Or chronic (thickening, crusting, scaling, lichenification)
➢ Diagnosis: clinically, patch test (to identify the allergen) in cases of:
- Doubt diagnosis, no response to treatment, rash reoccur
➢ Treatment: avoid allergen, emollients, topical or PO hydrocortisone
cause is - Infection:
c
k
HSV inf. (HSV 1 > HSV 2) (recurrence) or mycoplasma pneumonia
following - (was
h related to) drugs (sulfa drugs (most), penicillin, phenytoin, allopurinol)
herpes simplex ➢ Findings:
a
m
virus infection - Erythematous
s macules/papules that resemble target lesion "Bull`s/iris eye lesion"
t
➢ Types:
r major or minor (depending on sub mucosal layers involvement)
Minor → <2 mucosal
EM mostly ➢ Treatment:
i
a membranes
acrofacial - If eHSV inf.: acyclovir (prevent recurrence & deterioration & as prophylaxis)
while SJS - Symptomatic:
(
i
prednisone, antihistamines (chlorpheniramine or loratadine) Major → >2 mucosal
involved t membranes
i
trunk, face & 2. Steven-Johnson
s
syndrome (SJS) & toxic epidermal necrolysis (TEN):
neck ➢ Causes:
p drug reaction: NSAIDS, Augmentin, allopurinol, penicillin, sulfa drugs
a
➢ Findings:
i " after 7-21 days of exposure"
- Skin involvement (+ 2 mucus membrane) (+/- skin peeling) if > 30% TEN, if <10% SJS
n
f
- Systemic:
u fever, dysphagia, renal failure, sepsis, respiratory epithelium sloughs out
- Signs:
l Asboe-Hansen (increase bullae size with pressure) & Nikolsky sign
,
➢ Complication:
i alopecia, scarring, high mortality rate
➢ Treatment:
t
c
ICU admit, aggressive rehydration, give IVIG, steroids, stop offending drug
h
y
)
Skin cancer & pre-cancer lesions:
3. Melanoma:
➢ Most aggressive (mostly to metastasize), high mortality rate (1st cause of death in skin
cancer), de novo or mole
➢ RF: sun exposure, Caucasian/red hair people, family history, multi moles, age
➢ Growth:
- Linear (initial) phase: lateral growth in the epidermis, good prognosis, no metastasis
- Vertical (late) phase: extends to reticular dermis or beyond, metastasis can occur
➢ Findings: " mostly found in the back"
- ABCDE: asymmetry, border irregular, color variation, diameter > 6 mm, elevation
(raised surface)/evolution (change in the color) // +/- bleeding & itching
- Benign form is rounded, even border, color evenly spread, & constant diameter
➢ Metastasis: lymph nodes & skin (59%), lung, (36%), brain (20%- cause of death)
➢ Diagnosis: full thickness biopsy (X shave biopsy), LN dissection, c-KIT /BRAF genes
➢ Treatment: surgical removal + interferon therapy + nivolumab (if brain metastasis)
5. Kaposi sarcoma
➢ Caused by HHV-8, mostly in AIDS (sexual contact) or Mediterranean elderly
➢ Reddish/purplish lesion (vascular) that also can be found in GI tract & in the lungs
➢ Treatment:
- Treat AIDS via anti-retroviral, vincristine/interferon intra-lesion inj., chemotherapy
2. Seborrheic keratosis:
➢ Very common, mostly > 3o yrs & in elderly, hereditary (Autosomal Dominant)
➢ Not associated with sun exposure, most common benign skin tumor
➢ Findings:
- Slightly elevated plaques, hyper-pigmented, appear as "stuck on" the skin
- Found anywhere but mostly face & trunk, increase in number with time
➢ Treatment: not necessary but for cosmetic reasons: cryotherapy, surgery, or laser
3. Vitiligo:
➢ Acquired autoimmune → destruction of melanocytes by Th1
- Melanocytes are from neural crest & present in eyes, hair, skin, meninges & inner
ear (any of these sites can be affected in patient with vitiligo)
➢ Types: generalized, focal, segmental
➢ Findings: sharply demarcated patches of depigmented skin, mostly in the face
- Koebner phenomenon: appearance of skin lesion over lines of trauma
➢ Investigations: wood’s lamp, CBC, TFT, ANA, fasting blood glucose, ACTH
➢ Association: DM, hypothyroidism, pernicious anemia, Addison`s disease, SLE, RA
➢ Treatment: topical/systemic CS, topical calcineurin inhibitor, topical vitamin D analogs
& photo-chemotherapy (follicular re-pigmentation indicates pt. responsive to therapy)
➢ DDx: pityriasis alba in atopic dermatitis & tenia versicolor
6. Pyoderma gangrenosum:
➢ Painful rapidly growing ulcers, gray-violate in color, peripheral rim of erythema
➢ Necrotic borders, mostly found in lower limbs, +/- purulent base
➢ Association: acute myelogenous leukemia & Inflammatory Bowel Disease
➢ Treatment: treat underlying disease, CS (systemic, intralesional or potent topical)
7. Sarcoidosis:
➢ Granuloma formation in lungs (mostly), skin, liver, & spleen, idiopathic
➢ Skin findings: "maybe the 1st or only manifestation of the disease"
- Red-brown papule/plaque >yellowish with compression "diascopy"(the face mostly)
➢ Treatment: topical or IL: CS //oral: minocycline, methotrexate, tacrolimus
1. Androgenetic alopecia:
➢ Hair is sensitive to dihydrotestosterone (more localized)
➢ RX: topical minoxidil, finasteride (X 5-alpha reductase)(male), transplant (occipital hair) If block dots
2. Alopecia areata: present (not
IL CS:
➢ Description: bald clear patch, well defined, no scaring, +/- surrounded by broken hair clear patch) →
tenia capitis
intralesional ➢ Types: if <50%: localized, if >50%: totalis, if affect other body hair: universalis
(fungal)
corticosteroids ➢ Association: atopic dermatitis, vitiligo, any other autoimmune disease
➢ RX: potent topical or IL CS + immunosuppressant injection, minoxidil 5%
3. Telogen effluvium (comb with hair → telogen hair ↑ & anagen hair ↓):
S/E →
➢ Generalized non-scarring hair fall, causes: headache & hair
➢ Causes: surgery, post-delivery, stress, hypothyroidism, chemotherapy (3 months prior) loss aggravates
if pt. stop using
➢ Diffuse/extensive shedding or hair loss // treatment: treat the cause
4. Trichotillomania: Finasteride:
➢ Self-induced hair twirling/pulling, different lengths, psychological disorders or stress sexual
impotence in
Hair fall more than 200/day → hair pull test; +ve if more than 6 hair in around 40 pulled males &
feminization of
fetus in females
(FDA X)
Drug allergy: "occur within 1 month"
➢ Most common drugs: penicillin, NSAIDS, sulfa drugs (sulfonylurea, thiazide), insulin
➢ Systems involved:
- Dermatology: erosions (most common) e.g. urticaria, angioedema, EM, EN
- Pulmonary: asthma, pneumonitis // renal: interstitial nephritis, Nephrotic synd.
- Hematological: hemolytic anemia, thrombocytopenia, agranulocytosis
➢ Treatment: discontinue offending drug, antihistamine for symptoms
Food allergy:
➢ IgE mediated // most common food: eggs, peanuts, milk, tree nuts, shell fish, chocolate
➢ Findings:
- Skin (most common): pruritis, erythema, urticaria/angioedema
- GI (2nd): nausea, vomiting, ABD pain // anaphylaxis: respiratory, can be fatal
➢ Treatment: avoid offending agent, antihistamine, treat as anaphylaxis (if sever)
Anaphylaxis:
➢ Most severe form of allergy, type I IgE HSR, within sec to min, life-threatening
➢ Causes: food (most common), drugs, blood products, radio-contrast, latex
➢ Findings:
- Skin (most initial): rash, erythema, pruritis, urticaria, angioedema
- Respiratory: SOB & distress, wheezing // cardiac: hypotension, shock, arrhythmia
- GI: ABD pain, nausea,/vomiting, severe diarrhea // other: face/tongue/lips swelling
➢ Treatment:
- Maintain ABCs (intubation), immediate epinephrine, H1 & H2 antihistamine, CS
Infections:
1) Bacterial
2. Erysipelas:
➢ Deeper than impetigo as it involves the dermis & lymphatic, group A strept > staph.
➢ Predisposing factor: lymphatic obstruction, trauma, abscess, fungal inf., DM, & alcohol
➢ Findings:
- Well-demarcated, bright red, tender, swollen lesion mainly in lower limb & the face
- High grade fever & chills, leukocytosis
➢ Complication: sepsis, local spread, necrotizing fasciitis, GN (skin inf. doesn’t cause RH)
➢ Treatment:
- Mild: dicloxacillin > erythromycin (if penicillin allergic) > clindamycin (if MRSA) Needs RICE (rest,
- Severe (with fever): oxacillin > clindamycin (if allergic) > vancomycin (if MRSA) ice, compression
& elevation)
3. Necrotizing fasciitis:
➢ Life threatening inf. of deeper tissue, via strept. pyogenes or Clostridium perfringens
➢ RF: recent surgery, DM, IV drugs abuse, trauma
➢ Findings: pain out of proportion, fever, intense edema, violate or gray color
➢ Complications: sepsis, Toxic shock syndrome, thrombosis. discoloration, tissue necrosis
➢ Treatment: surgical debridement & broad-spectrum Antibiotics
4. Cellulitis:
➢ Skin & subcutaneous infection mostly due to group A strept. or S. aureus (gram –ve in
DM & IC) – deeper than erysipelas
➢ Routes:
- Skin break or trauma (strept.), wound, abscess, IV catheter (staph.),
- Water immersion (pseudomonas, vibrio), acute sinusitis (H. influenza)
➢ Association: DM ulcers, lymphedema, venous stasis disease
➢ Findings:
- Lesion is red, warm, tender, & swell, mainly in legs & arms (eye or face > worse)
➢ Diagnosis: inject sterile saline then take sample > culture (do Doppler to rule out DVT)
➢ Treatment:
- Mild: dicloxacillin > erythromycin (if penicillin allergic) > clindamycin (if MRSA) Needs RICE (rest,
- Severe (with fever): oxacillin > clindamycin (if allergic) > vancomycin (if MRSA) ice, compression
& elevation)
5. Scarlet fever (most common in 5-15 yrs)
➢ Bacterial illness by strept. featuring bright red rash that covers most of the body
▪ Rash begins on the face or neck and spreads to the trunk, arms and legs
▪ If pressure is applied to the reddened skin, it will turn pale
➢ Almost always accompanied by a Sore throat (URTI) and high fever
➢ Complications: can lead to rheumatic fever; heart problems & arthritis
➢ Findings → Strawberry tongue, Sand paper rash (feeling)
➢ Treatment: antibiotic covering gram +ve (erythromycin) for 2 wks, no need for topical
6. Other bacterial infections: Caused by staph
➢ Infections that involves the hair follicles // treated with surgical, drainage, RICE Treated with
- Folliculitis: single follicle, either superficial or deep, erythema topical cream, soap
- Furuncles: single follicle involve the whole hair follicle, tender, small abscess, wash & antibiotic
Type of - Carbuncles: multiple follicles (several drainages opening), more abscess, in DM
impetigo ➢ Ecthyma: superficial dermis, S. pyogenes, ulceration with hemorrhagic crusting, in DM
but deeper ➢ Pseudomonas inf.: In ecthyma → Eschar:
- Ecthyma gangrenosum: piece of dead tissue
o Caused by pseudomonas mainly & opportunistic fungi, in IC & neutropenia that is cast off from
o Sign of bacteremia or septicemia, can be found in swimming pools the surface of the skin
o Red/purple macule or patch with central necrosis +/- hemorrhagic bullae
- Hoot-foot syndrome: Tender erythematous nodules on the heel
- Treatment:
o Superficial: 5% acetic acid soaks > topical ABx (gentamicin) > PO fluoroquinolone
o Severe or systemic: piperacillin/tazobactam or doripenem if penicillin allergic
➢ Erythrasma (MCQ):
- Corny. minutissimum, wood lamp (bright red), erythromycin + aluminum chloride
➢ Pitted keratolysis:
- Kytococcus/micrococcus sedentarius or Corynebacterium, same drugs for
erythrasma
- Multiple small crater @ pressure points of plantar surfaces, foul smell feet
➢ Leprosy:
- Mycobacterium leprae, Indian or Pakistani, slowly progressive,
- Granuloma that affected the nerves & skin, no sensation in the lesion
➢ Erythema marginatum:
- Circular rash with clear center, rheumatic heart (VS. Lyme disease), group A strept.
➢ Staphylococcal scalded skin syndrome (SSSS):
- Mostly in babies & children. Features fever, a rash & sometimes blisters
- Bacteria anywhere in body release toxin that cause scalding of skin
o Culture of bullae is negative; bacteria found elsewhere, not in skin
- Nikolsky sign is positive → putting pressure will shear off epidermis, found also in:
o Pemphigus vulgaris
o Toxic epidermal necrolysis
2) Fungal:
• Tinea versicolor:
➢ Superficial fungal inf. (Malassezia group-normal flora), mostly in adolescence
➢ Findings:
- Well-demarcated lesion, mostly in trunk, hypo/hyperpigmented (can be
erythematous in white people), brown-to-white patches & macules
➢ Risk factors: hot/humid weather, oily skin, excessive sweating
➢ Diagnosis:
- KOH prep: "spaghetti & meatballs ", hyphae & yeast balls // yellow on wood lamp
➢ Treatment:
- Topical or oral antifungal that contain: selenium sulfide, or keto/fluconazole This is in clinic
Antifungal shampoo as prophylaxis because it is recurrent with hot/humid weather
In vitiligo they
appear chalky white
• Candida
➢ Nappy rash can be due to many causes: erythrasma, irritant contact dermatitis or
fungal infection; if folds involved mostly is fungal infection not irritant dermatitis
➢ Skin lesion → well-demarcated erythematous with scalding, folds involved
- Presence of satellite region in candida, NOT in dermatophytes
- Scrotum involved while in dermatophytes scrotum is spared
➢ RF → DM, immunosuppression, obesity, poor hygiene, warm weather
➢ KOH → sausage-like pseudohyphae slings
➢ Treatment → topical antifungal or oral if severe
• Dermatophytes:
History of ➢ Superficial fungal inf. that affect coetaneous epithelium, nails, & hair Well-demarcated erythema,
contact with ➢ Three main species: trichophyton, microsporum, & Epidermophyton hypopigmented in the center
animals ➢ Types: “ring worm”
- Tinea corporis "ringworm": body/trunk, all age, pinkish annular lesion
- Tinea capitis: scalp, children, scaling + hair loss +/- pruritis Nails in psoriasis only distal
- Tinea unguium "onychomycosis": nails, elderly, thick opacified nail affected while in tinea it
- Tinea pedis "athlete foot": feet, young adult, scaling + erythema + pruritis can be lateral also
- Tinea cruris "jock itch": groin/inner thigh (spares scrotum), adult, scaling +
Pseudomonas infection →
erythema
green nails
➢ Diagnosis:
- Scraping & KOH preparation: best initial, visualize hyphae // culture: most accurate
Fungal in hair & - Wood lamp: differentiate species (if fluoresce microsporum, If not trichophyton)
nail must be
➢ Treatment:
treated with and
- Topical antifungal (ketoconazole, miconazole):
oral antifungal as
o All types except tinea capitis & unguium // ketoconazole can cause gynecomastia
topical is not
- Oral antifungal (terbinafine, itraconazole, Griseofulvin): for tinea capitis & unguium
beneficial
Herpes simplex virus = human herpes virus (HHV)
Herpetic lesions: group of
HHV-1 → herpes labialis (oral) HHV-2 → genital herpes
vesicles on an erythematous HHV-3 → chickenpox & shingles HHV-4 (Epstein-Barr virus; EBV) → infectious mononucleosis
background HHV-5 (Cytomegalovirus; CMV) → infectious mononucleosis
3) Viral:
HHV-6 & HHV-7 (Roseolovirus) → sixth disease (roseola infanatum), pityriasis rosea
HHV-8 → Kaposi’s sarcoma
• Herpes zoster (shingles):
Herpes virus ➢ Reactivation of varicella-zoster virus that remains dormant in dorsal root ganglia
other ➢ Occur in times of stress, inf. illness & only for those who had chickenpox (HHV-3)
complications: ➢ Mostly > 50 yrs (< 50 yrs if patient is immune-compromised "IC")
Eczema
➢ Contagious (if open vesicles present) for those who hadn`t had chickenpox or IC
herpeticum ➢ Findings: Does not
(monomorphic - Severe pain (1st) with rash (vesicles with erythema) in dermatomal distribution cross midline
punched-up o Vesicles are found in thorax (most), CNV distribution (V1 most), arms & legs
ulcers) ➢ Complication: postherpetic neuralgia, blindness, Ramsay hunt syndrome "deafness"
Erythema
➢ Treatment:
multiforme - Keep lesion clean & dry, analgesic (acetaminophen, aspirin, or codeine) Within first
(target lesion on - Antiviral: decrease the pain & duration, + risk of postherpetic neuralgia (acyclovir) 72 hours
palm & sole) - Live vaccine: reduce number of cases, severity & duration of postherpetic neuralgia
o Indicated for all patients > 60 yrs if there is no contraindication
Chickenpox in adults: generalized all over the body, polymorphous, must be treated
• Eczema herpeticum:
➢ Mostly with atopic dermatitis // do swap (tzanck smear> multinucleated giant cells)
➢ Causes: herpes simplex virus // treatment: systemic acyclovir
➢ Finding: monomorphic bulging ulcers on atopic dermatitis background, mouth mainly
• Warts:
➢ Caused by human papilloma virus (HPV), transmitted via skin-skin contact or sexually
➢ Types:
- Common warts (verruca vulgaris): (HPV 1,2,4)
o Commonest type, found everywhere but mostly palms, fingers, elbow, knee
o Looks flesh-colored/whitish with hyper-keratotic surface
▪ Flat surface goes with skin tags rather than warts, mostly around the neck
- Flat warts (verruca plana): (HPV 3,10)
o Mainly in the chin/face, dorsum of hand, legs // hyperkeratotic, +/-flesh-colored
- Plantar warts (verruca plantaris): (HPV 1,2,4)
o Mainly in the plantar side of foot, flesh-colored with rough hyper-keratotic surface
o Differs from callus/corn in the color of the dots that appear → warts have small
black pinpoints in the center (due to blocked capillaries) while callus have white
dots
- Genital warts (condyloma acuminatum): (HPV 6,11, 16, 18) covered in the STD`s
o Female genital warts referred to Obs & Gyne to check for cervical cancer
➢ Findings:
- Mostly asymptomatic unless they bumped, +/- bleed & disfigure
- Plantar warts are painful mainly with walking or prolonged standing (pressure)
➢ Treatment:
Cryotherapy - Mostly spontaneously disappear in 1-2 yrs // 5-FU cream or retinoic acid: flat warts
kills the cell, not - Cryotherapy: freezing of the lesion with liquid nitrogen -200c, multiple sessions
the virus - Surgical excision or laser therapy // cryo S/E: pain, ulceration, secondary infection
Uses of cryo: warts, molluscum contagiosum, corns, skin tags
• Molluscum contagiosum:
➢ Self-limited viral inf. caused by poxvirus, common in sexually active young & child
➢ Transmitted via skin-skin contact (& sexually), highly contagious, child abuse??
➢ Findings: asymptomatic small papules with central umbilication, extensive in HIV +
➢ Treatment: spontaneous after 6-month, salicylic acid, podophyllin drops, cryotherapy
1. Scabies: Female
➢ Caused by human skin mite sarcoptes scabiei var hominis that lies in stratum corneum
➢ Highly contagious: transmit via skin-skin or via towels, bed linens, clothes (6 wks IP)
➢ Pathogenesis:
- Mite will tunnel via epidermis, lays egg & deposit feces (scybala) > type IV HSR Feces cause
Mainly in
the itches
warm areas ➢ Sites: fingers, inter-digital (finger web space), wrist, elbow, genital area, ankle, feet
- Head, neck, palm & soles are spared except in infant, elderly, or IC
➢ Findings:
- Severe pruritis (mostly @ night & with hot shower) + scratching (lead to excoriation)
- Burrows: represent the tunnel of the mite, female mite if dark dot @ the end
- Eczematous plaque, crusted papules, & 2ry bacterial inf. can develop
➢ Norway scabies: severe form, whitish-slivery color
➢ Diagnosis:
- Look for burrows > scrap them (via scalpel) & visualize them > mite, egg or scybala
➢ Treatment:
- Wash all clothes, towels, & bed linen & put them to dry under the sun (or use dryer)
- Permethrin 5% cream or benzyl benzoate:
o DOC, cover all the body (head-toe), apply it @ night >wash it in morning (2 days)
o Treat also the close contact even if they don`t have pruritus
- Oral ivermectin or lindane: 2nd line in case permethrin isn`t available, CI or failed
o Lindane is CI in children < 2 yrs, pregnant lady, or lactating women (seizure risk)
- Topical CS & oral antihistamine: used mainly to treat pruritis
2. Erythema migrans:
➢ Associated with Lyme disease "spirochete borrelia burgdorferi"(transmit via ticks)
➢ Large, painless, well-demarcated, target shaped lesion // in thighs, groin, & axilla
3. Leishmaniases: parasite inf. transmitted via sand fly, in exposed areas (face mainly)
Pediatrics:
1. Henoch-Schoenlein purpura:
➢ Mainly in child > 10 yrs (not always), 1-2 wks after upper respiratory tract infection
➢ Painless palpable purpura in buttocks & lower limbs // other S&S: ABD pain, diarrhea
➢ Treatment: supportive (leg raise & NSAIDS), systemic CS (for rest of S&S e.g. arthritis)
2. Salmon patch: in the central of the face (goes), & nape area "stork bite" (persistent)
3. Facial port-wine stain: persistent red-pink patches & macules, present @ birth
Kawasaki disease → strawberry tongue – fever >5 days & lymphadenopathy – do echo