Hopefully the end of rashes
1) What is Samter's Triad?
2) What is the classic triad of atopy?
1) Samter's Triad =
-Asthma
-Chronic rhinosinusitis/nasal polyps
-Aspirin sensitivity
2) Classic triad of atopy=
-Atopic dermatitis
-Asthma
-Allergies
Which tick-borne disease presents with a rash on the palms and soles?
BONUS: treatment
Rocky Mountain spotted fever!
Etiology: Rickettsia rickettsii
Tx: Doxycycline
What is the most common type of hair loss in both men and women?
Androgenetic alopecia
Tx: Minoxidil 5% if < 5 yrs since onset and minimal loss
*may also add finasteride
A 45 yo female comes into the clinic with concern that she has skin cancer. She shows you a hyperpigmented plaque that has a waxy, "stuck on" appearance on her upper back. She says it is sometimes itchy but denies any pain or bleeding from the lesion. What is the treatment for the most likely diagnosis?
Dx: seborrheic keratosis (SK)
Management: patient reassurance (extremely common & benign) + removal via cryotherapy/shave excision/curettage & cautery, either for cosmetic purposes or if lesion is irritated
What stage ulcer involves epidermis, dermis, and SQ fat?
Stage 3, does NOT involve fascia
A 6 yo male presents to the clinic with a dry, erythematous, and lichenified rash on his neck and the flexural surfaces of his arms and legs. His mother's states that he scratches at it constantly. He has a family history of asthma and seasonal allergies. What is the most likely diagnosis?
BONUS: What is the treatment?
Dx: atopic dermatitis
Tx: moisturizer + topical corticosteroids (hydrocortisone)
What is the hallmark symptom and the bacteria responsible for Cat Scratch Disease?
Hallmark: Regional lymphadenopathy
Etiology: Bartonella henselae
Tx: Azithromycin
A 30 yo F presents w/ well-defined, round patches of hair loss on her scalp. The affected areas have no scarring or inflammation, and the patient reports experiencing sudden hair loss without any other associated symptoms. On exam, you notice "exclamation point" hairs at the periphery of the patches. What is the most likely diagnosis for this type of hair loss?
a) androgenetic alopecia
b) tinea capitis
c) telogen effluvium
d) alopecia areata
Alopecia areata
*Autoimmune
Describe the appearance of actinic keratosis (AK). Is this a benign or potentially precancerous condition? If so, what type of cancer can this develop into?
Appearance: flat, scaly papules found on sun-exposed areas of the body; asymptomatic lesions; sometimes difficult to visualize but able to palpate "sandpaper" feeling
PRECANCEROUS --> Squamous cell carcinoma (SCC)
*Can perform skin bx to confirm and r/o SCC
-If > 6 mm, indurated, bleeding, ulcerated or painful --> BX!
A 60 year old male with a 20 pack year history of smoking presents to the clinic complaining of painful ulcers on his feet. He also states that his legs get quite painful with walking after a couple blocks, and he has to sit down to rest for the pain to stop. On exam he has diminished pulses and shiny skin. He has an ABI of <0.9. What is the most likely etiology for this patient's ulcers?
Arterial Insufficiency (Peripheral Artery Disease)
-Arterial ulcers usually show up on the toes, feet, and lateral malleolus
*Think lAteral is Arterial
-Venous ulcers usually show up on the medial malleolus or anterior ankle
-Diabetic ulcers will present the same as PAD, but they will not be painful
A 28 yo male presents with complaint of a pruritic rash that he has had for several weeks. The rash is mostly present around the areas of his beard and eyebrows. What is the most likely diagnosis? What is a possible treatment?
Dx: seborrheic dermatitis
Tx: shampoo or cream w/ ketoconazole 1% or selenium sulfide
- can consider topical steroids
What are you most worried about with a closed-fist human "fight bite," and what should you do about it?
Most worried about Tendon/Joint Capsule Injury
CONSULT SURGERY
Melasma is a common skin condition characterized by hyperpigmented patches on sun-exposed areas of the face. Which of the following statements regarding melasma is accurate?
a) Melasma primarily affects men and is more common in individuals with fair skin
b) It is a fungal infection caused by exposure to a specific type of dermatophyte
c) Hormonal factors, such as pregnancy and oral contraceptive use, can trigger or exacerbate melasma
d) the primary treatment of melasma involves surgical removal of affected skin areas
a) Melasma primarily affects men and is more common in individuals with fair skin - FALSE: It primarily affects females with medium to dark skin tones, rarely before puberty
b) It is a fungal infection caused by exposure to a specific type of dermatophyte- FALSE: It is not an infection
c) Hormonal factors, such as pregnancy and oral contraceptive use, can trigger or exacerbate melasma
TRUE! Thyroid disease is also a risk factor!
d) the primary treatment of melasma involves surgical removal of affected skin areas - FALSE: Primary treatment = sun avoidance, SPF, hydrochloroquine or tretinoin
What is the ABCDE mnemonic?
-used to help remember the characteristics of melanoma/evaluate for cancer
Asymmetry
Border
Color
Diameter
Evolution
A 28 yo obese female presents to the office with complaint of a 3-year history of intermittent draining boils and nodules in the axilla. Areas of involvement had previously improved with episodic antibiotic management. The patient now reports worsening redness, drainage, and pain. Flares are more frequent, more widespread, and with more severe pain. Flares now occasionally involve new areas (buttocks) and are less responsive to antibiotics. She states that the day prior she notices that she gets quite sweaty, itchy and painful before she sees the lesions appear the next day. What is the most likely diagnosis?
Dx: Hidradenitis suppurative, Hurley Stage III
Treatment is dependent on staging and may include corticosteroids, abx, hormone therapy, surgical debridement, TNF inhibitors (adalimumab)
A 20 yo male presents with a salmon-colored maculopapular rash with a large prominent central lesion. He has no past medical history and takes no medications. He denies any new exposures to irritants. What is the most likely diagnosis? What is the name of the prominent central lesion?
BONUS: Treatment
Dx: Pityriasis rosea (usually a Christmas tree pattern)
Central lesion = herald patch
Tx: supportive care
Patient presents with a one-week history of fever, fatigue, and gradually expanding, circular rash on his right thigh. He describes the rash as a red, bull's-eye patterns with a central clearing. The patient has recently gone camping in a wooded area. There was mild tenderness and swelling in his right knee joint, but no signs of joint effusion. Based on the most likely diagnosis, what is the offending bacteria, and what treatment should you recommend?
Dx: Lyme Disease
Etiology: Borrelia burgdorferi
Tx: empiric doxycycline
Prevention: early detection and removal of tick can prevent need for treatment. It takes several hours of feeding to transmit the bacteria.
An overweight female comes into your office. She is embarrassed and concerned about the skin on the back of her neck. She has noticed that the skin there is getting darker and that it feels thicker and perhaps even velvety. Name this diagnosis, the screening you must do, and how you would treat your pt.
Acanthosis nigricans, usually caused by obesity, DM, insulin resistance (so DM screen-- Hb A1C)
-Tx: tx underlying cause (lifestyle changes) or topical Tretinoin
A 65 yo male presents with a painless, shiny, pinkish nodule on his upper cheek. The lesion has a central ulceration and prominent telangiectasias. On exam, you notice rolled borders and pearly translucent areas within the lesion. The patient has a hx of significant sun exposure. That is the most likely diagnosis for this skin lesion? And what is the best treatment for this type of lesion?
a) actinic keratosis
b) basal cell carcinoma
c) melanoma
d) squamous cell carcinoma
Basal cell carcinoma (pearly + telangectasias)
Tx for nodular BCC = excision vs. MOHS
A 30 year old male presents with a sudden onset of pain in the intergluteal region that started a few days ago. He states that the pain increases with sitting and bending over. He has noticed that it has gotten quite swollen and there has been some drainage from the area. What is the treatment for the most likely diagnosis?
Dx: Pilonidal disease
Tx: I&D of abscess and wide surgical incision if there are sinus tracts & widespread disease. No antibiotics.
A 30 yo male presents with skin irritation characterized by silver scales on an erythematous base accompanied by joint pain. He has a significant medical history of liver disease. He would like to start medication to improve his condition. Which systemic immunosuppressant could you prescribe? What are the side effects of this medication?
Dx: Psoriasis
Tx: Cyclosporine
SEs: BP elevation, kidney disease
*Methotrexate is the other systemic immunosuppressant, but it is contraindicated in liver disease, cirrhosis, alcohol use disorder, active infection, immunodeficiency, pregnancy, and breastfeeding. SEs: nausea, liver disease, leukopenia, alopecia, photosensitivity
A 57 year old man cleaning out his garage earlier in the day presents to the ER with severe abdominal pain. On exam, you note normal bowel sounds, abdominal rigidity, and a target-like lesion on his leg with localized diaphoresis. What is the most likely diagnosis? And what is the treatment?
Black widow bite
Tx: wound care, analgesics, muscle relaxants for muscle spasms
An 82 year old man with a h/o DM2, alcohol use disorder, and liver cirrhosis presents to the ER with a painful, erythematous, and edematous left foot and ankle. He has a temperature of 38.8C, HR of 104 bpm, and BP of 97/63. On exam, you notice that the erythema doesn't have defined margins, and the edema goes up the leg past the area of erythema. During the exam, you notice the patient is exquisitely tender over the leg and makes it quite difficult to examine him. What is the most likely etiology for this disease?
Dx: necrotizing fasciitis
Etiology: usually polymicrobial bacterial infection (staph, strep)
Tx: Transfer to ICU, IVF for hemodynamic support, empiric abx (w/ MRSA coverage), surgical debridement ASAP
A 55 yo female presents with a scaly, erythematous 5 mm plaque on her lower lip that has been persistent for several months. The lesion is non-healing and occasionally bleeds. The patient has a hx of chronic sun exposure and tobacco use. On exam, you notice a crusted, firm, and slightly elevated area with irregular borders. What is the best tx for the most likely dx?
Dx = Squamous cell carcinoma (SCC) -- NON-HEALING W/ BLEEDING
Tx = excision vs MOHS (4-6 mm margins)
A 45 yo female presents to the ER with significant burns. The burns cover the entirety of her back, left arm, and left leg. The burns are blanchable, and the patient states that the pain is unrelenting. What is the estimated % of the body that is burned, and how would you grade her burn?
45%
Back (18%) + Arm (9%) + Leg (18%)
-Second degree (superficial partial thickness burn)