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CDM Dermatology
Skin Lesions, Cancers, and Rashes
114
Medical
Graduate
11/09/2015

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Term
Macule
Definition
Flat, circumscribed area. Change in skin color. <1cm in diameter.
Eg. Freckles, measles, scarlet fever
Term
Papule
Definition
Elevated, firm, solid circumscribed area. <1cm in diameter.
Eg. Verruca, Lichen planus, acne.
Term
Patch
Definition
Flat, non-palpable, irregular-shaped macule. >1cm in diameter.
Eg. Vitiligo, Port-Wine Stains, Cafe-au-lait spots, Mongolian Blue Spot
Term
Plaque
Definition
Elevated, firm and rough lesion with flat top. >1cm in diameter.
Eg. Psoriasis, Seborrheic keratosis, Discoid lupus.
Term
Wheal
Definition
Elevated, irregular-shaped area of cutaneous edema. Solid, transient. Variable size.
Eg. Bug bites, allergic reaction, urticaria.
Term
Nodule
Definition
Elevated, firm, solid, circumscribed. Deeper in dermis than papule. 1-2cm in diameter (larger than papule, smaller than tumor)
Term
Tumor
Definition
Elevated, solid lesion. +/- clear demarcation, deeper in dermis. >2 cm.
Eg. Neoplasms
Term
Vesicles
Definition
Elevated, circumscribed, superficial (not into the dermis). Filled with serous fluid. <1cm in diameter.
Eg. Varicella, Herpes zoster
Term
Bulla
Definition
Vesicle >1cm in diameter.
Term
Pustule
Definition
Elevated, superficial lesion. Filled with purulent fluid.
Eg. Impetigo, Acne
Term
Cyst
Definition
Elevated, circumscribed encapsulated lesion. Dermis or Subcutaneous. Liquid filled or semi-solid.
Eg. Sebaceous cyst, cystic acne.
Term
Scale
Definition
Heaped up, keratinized cells, “flakey skin”. Irregular, thick/thin, dry/oily, Various sizes.
Eg. Seborrheic dermatitis, psoriasis
Term
Lichenification
Definition
Rough, thickened epidermis secondary to persistent rubbing, scratching, or skin irritation.
Eg. Atopic dermatitis, Lichen simplex chronicus
Term
Keloid
Definition
Irregular-shaped, elevated, progressively enlarging scar. Grows beyond wound boundaries. Due to excessive collagen formation during healing. More common in African-Americans.
Term
Excoriations
Definition
Loss of epidermis. Linear, hollowed-out.
Eg. Abrasion, scratches
Term
Fissure
Definition
Linear crack/break from epidermis to the dermis.
Eg. Athlete's foot (tinea pedis)
Term
Erosion
Definition
Loss of part of the epidermis. Depressed, moist, glistening. Follows rupture of vesicle/bulla such as Herpes simplex.
Term
Ulcer
Definition
Loss of epidermis and dermis. Concave. Variable size.
Eg. Decubitus ulcers, primary syphilis, venous stasis ulcer
Term
Crust
Definition
Dried serum/blood/purulent fluids. Slightly elevated. Black/brown/red/straw-colored.
Eg. Impetigo, scabs
Term
Atrophy
Definition
Thinning of skin surface and loss of skin markings. Skin is translucent and paperlike. Aging, striae associated with obesity, scleroderma
Eg. Stretch marks
Term
Morphologic Characteristics
Definition
Distribution, Shape/Arrangement, Border/Margin, Associated Change, Pigmentation
Term
Distribution
Definition
Localized
Regional
Generalized
Term
Types of Basal Cell Carcinomas
Definition
Nodular: 60%. Pink/Flesh colored. Pearly/Translucent, Telangectasia vessel, ulceration (rolled edge)
Superficial: 30%. More common in men and on trunk. Slightly scaly macules/patches light red to pink in color.
Morpheaform: 5-10%. Most aggressive form. Smooth flesh colored papules or plaques.
Term
Basal Cell Carcinoma
Definition
Locally invasive, low metastases. Destructive to surrounding skin/structures. >40 yrs (increases w/ age). 30% more likely in men. More common in caucasians, and 70% occur on the face.
Term
Risk Factors for Basal Cell Carcinoma
Definition
Sun exposure (esp. childhood), tanning beds, therapeutic exposure to psoralen plus ultraviolet A light (PUVA), Photosensitizing drugs (Doxy, diuretics), Chronic arsenic exposure (water, fish, meds, moonshine), Ionizing radiation, Chronic immunosuppression (organ transplant, HIV), Genetic, fair-skinned people, albinos
Term
Treatment for Basal Cell Carcinoma
Definition
Identify Tumor characteristics: Size, pathology, patient preferences.
Surgical Options: ED&C, Curettage or Excision, Mohs, Cryo.
Topical Therapy: 5-Fluorouracil (5-FU) cream (chemotherapeutic)
Term
Dysplastic Nevus
Definition
Circumscribed pigmented lesions, usually irregular and often maculopapular, w/ complex colors and patterns.
Mostly on trunk, seen in adolescence. Usually >5mm.
Usually brown but can be mottled with dark brown, pink, and tan colors. Marker for a propensity to develop melanoma
Familial dysplastic nevi syndromes. Need close follow-up after excision w/ narrow margins
Term
Malignant Melanoma
Definition
Most malignant tumor of the skin. Malignant transformation of melanocytes at the dermal-epidermal junction. Responsible for 80% of skin cancer deaths. Early recognition is key (prognosis is improving. 30% arise in preexisting melanocytic lesions, 70% occur in normal skin. Can occur in unusual places (hands, feet, vulva, fundi, scalp).
Term
Risk Factors of Melanoma
Definition
Fair skin, family history of dysplastic nevi/melanoma, previous personal history of melanoma, UV irradiation esp. sunburn in childhood (intense and sporadic), large number (>50) or size (>5mm) of melanocytic nevi. Congenital nevi, more than 5 atypical (dysplastic) nevi, dysplastic melanocyte nevus syndrome.
Term
Signs of Melanoma
Definition
Asymmetry
Border
Color
Diameter
Elevation (or Evolution)
Term
Types of Melanoma
Definition
Superficial Spreading: Most common (70%), Found anywhere. Elevated flat plaque, slow growing. Delayed vertical growth.
Nodular: More common in Japanese patients (15% of total cases), found anywhere. Vertical growth phase at onset, color usually uniform. Often a "new mole".
Lentigo Maligna: Least common (<5%), usually an older patient. On face and forearm. Slow growing. Vertical growth indicates a change in growth phase and increased invasiveness.
Acral Lentigionous: 5-10% of melanomas. Arise in palms, soles, or nail beds. Most often in Asians, Africans, or AAs.
Term
Management of Melanoma
Definition
Excisional biopsy with narrow margins initially. Thickness (Breslow's Depth) is a better indicator of outcome. Prognosis can be predicted based on depth of invasion, ulceration, nodal status, patient's age, and extra-nodal extension.
Term
Seborrheic Keratosis
Definition

Presentation: Very common in elderly (esp. caucasians), variety of appearances (yellow, brown, "stuck on"). Usually asymptomatic, but can be irritated by clothing and can itch and become inflamed. Unattractive and wart-like. Benign.

 

Treatment: Topical ammonium lactate and alpha hydroxyl acids can reduce the height, cryotherapy, ED&C, Laser Surgery

Term
Actinic Keratosis
Definition
Precancerous lesions (Solar Keratosis). Can progress to Squamous Cell Carcinoma. Associated with sun exposure, more common in males/people who work outdoors. Crusty! Hyperkeratotic lesions on hands, face, scalp. Feel very rough.
Treatment: Cryo, curettage, 5-FU cream, topical imoquimod or retinoids.
Topical 5-FU is very effective but cause intense redness, ulceration and itching. Applied to the area BID until lesions peel (2-4 weeks) this is pricey! $$$
Imoquimod cream applied 2 times a week for 16 weeks, similar side effects.
Term
Cutaneous Squamous Cell Carcinoma
Definition
Malignant tumor of keratinocytes in the epidermis. Common sun exposed areas. Occurs in fair skinned people. Second most common skin cancer. Higher metastatic potential compared to BCC (esp. the lower lip and ear) Can cause local tissue destruction.
Term
Risk factors of Squamous Cell Carcinoma
Definition
UV exposure, fair skin, blond/red hair, albinism, immunosuppression, infections (hidradenitis suppurativa, chronic fungal infections, acne), sites of chronic inflammation (venous stasis ulcer, burn scars)
Term
Presentation of Squamous Cell Carcinoma
Definition
Crusting, scaly, eroded papule or plaque or non-healing ulcer. May be associated with cutaneous horn. May cause some peripheral nervous symptoms due to tumor involvement with nerve (numbness, twitching).
Term
Treatment of Squamous Cell Carcinoma
Definition
Surgical excision (tumor can be locally destructive and may require skin grafts), ED&C, Mohs for small lesions or where tissue preservation is needed (esp face), radiation (as adjuvant to surgery or primary radiation in patients unable to undergo surgery).
Term
Kaposi's Sarcoma
Definition
Spindle cell tumor, endothelial cell origin. Varies from minimal mucocutaneous disease to systemic organ involvement. Mucocutaneous lesions are asymptomatic, usually a cosmetic issue. Organ involvement causes symptoms.
Term
Four Classifications of Kaposi's Sarcoma
Definition
HIV/AIDS related
Classic (rare in US and Eastern Europeans)
Endemic (Africa)
Immunocompromised (organ transplant)
Term
Scabies: Sarcoptes scabies
Definition
Infestation, not infection. Gotten from contact with infested people/inanimate objects. 8 legged mite. Not visible unless magnified. Worldwide, across age ranges. (usually not in kids <3 mos)
Term
Scabies life-cycle
Definition
Entirely on humans. Female mite burrows into stratum corneum to stratum granulosum. Burrows up to 1cm length. Look at hands for burrows.
Term
Scabies Clinical Picture
Definition
Pruritis, characteristic lesions, epidemiological history. Excoriations/Eczematous dermatitis (web spaces, sides of fingers, volar wrists, lateral palms, elbows, axillary regions) Linear burrow is pathognomonic marking. Look at palms of hands. Crusted scabies along hairline. Infants may have diffuse scabies (fever, strep rash).
Term
Scabies Lab Studies
Definition
Clinically diagnosed, but definitive dx by scraping and microscopy. Use mineral oil drop and scrape w/ #15 blade. Skin biopsy also diagnostic.
Term
Secondary Scabies Issues
Definition
Impetiginization: Occurrence of impetigo by infection of a preexisting dermatitis.
Post-Strep: Scabies induced pyoderma?
Term
Scabies Treatment
Definition
Topical: Permethrin, Malathion, Crotamiton (less effective), Ivermectin (sometimes combined), Lindane (only used if others are not tolerated/ineffective.
Must treat household members!
Fomite Control: Wash clothes, sheets (hot heat). Dry clean. Put unwashables into plastic bags and leave in hot areas for 2 weeks.
Term
Pediculosis humanus capitis (Head Lice)
Definition
Size of sesame seed. Moves by grabbing hair laterally. Lays nits proximally (if nits are found on distal hair, it's an inactive infestation). Ova hatch over 1 week. Nymphs mature over 1 week. Female can produce 50-150 nits over 16 day lifetime.
Term
Pediculosis capitis Clinical Picture
Definition
Pruritis on scalp, back, sides. Secondary infection (scratching: likely staph aureus). Papular urticaria on back of neck! Eczema/Excoriations from scratching. Can be seen with naked eye. Nits (oval grayish-white) capsule. Creamy yellow if new. White means hatched.
Term
Pediculosis capitis Diagnosis/Treatment
Definition
Diagnosed: Finding lice. Spread from head to head contact. Use louse comb. Active infestation is indicated by nits < or = 4mm above scalp.
Treatment: Permethrin, Malathion, Pyrethrin, Piperonyl, Butoxide, Ivermectin oral
Term
Pediculus humanus humanus (Body Lice)
Definition
Larger than head lice. Female produces 270-300 over over 18 day lifespan. Ova incubate 8-10 days, mature over 2 weeks. Live in seams of clothing. Feed on human host. Able to survive 3 days between blood meals. Attach to body hair. Transmit disease!
Term
Pediculus humanus humanus Transmittable Disease
Definition
Bartonella quintana (Trench fever, endocarditis)
Rickettsia prowazekii (epidemic typhus)
Brill-Zinsser disease (louse-borne relapsing fever, after epidemic typhus)
Term
Pediculus humanus humanus clinical picture
Definition
Similar to head lice (Eczema/Excoriation from trauma, staph aureus infection, post-inflammatory hyper pigmentation)
Diagnosis: Confirmed by finding lice/eggs on clothing seams.
Term
Pediculus humanus humanus treatment
Definition
Decontamination of bed/clothes, hygiene measures, pyrethrin, permethrin, malathion
Infestations seen in war, homelessness, concentration camps, etc.
Term
Phthirus pubis (Pubic/crab lice)
Definition
0.8-1.2mm (speck sized), 14 day life span, female produces 25 ova. Nits have 7 day incubation and 14 day maturation. Adults prefer humid area. Close contact for transmission (seen with STDs)
Term
Phthirus Pubis Clinical Picture
Definition
Asymptomatic possibly, Pruritus sometimes for months, mild-moderate, Excoriation/Secondary infection possible (Staph aureus), Secondary impetiginization, regional lymphadenopathy, Pubic/crab lice may be stationary for days
Mouth embedded in skin, holding to hairs with claws
Nits (white-gray specks on hair), Pubic and Axillary areas most common, Children (eyelashes/eyebrows, no pubic involvement), Papular urticaria at sites of feeding, Maculae cerulea
Term
Phthirus Pubis Diagnosis/Treatment
Definition
Diagnosis: Live lice, nymphs, or nits. Found in pubic region indicates active infestation.
Treatment: Similar to other pediculus. Decontaminate clothes, bed. Treat sexual partners.
Term
Spider Bites
Definition
Most spiders are venomous, but unable to penetrate the skin. Most skin infections are mistaken for spider bites.
US Spiders capable of penetrating the skin include: Loxosceles (brown spider)
Latrodectus (widow spider)
Tarantulas (common name, several large spider species)
Term
Brown Recluse (Loxosceles reclusa)
Definition
Central/Southeastern US (may be seen other places due to shipping), Nocturnal hunting. Bites likely defensive.
Term
Brown Recluse Bite Clinical Picture
Definition
Pain/Burning usually around 10 minutes post bite
Mild/local/urticarial reaction. “Bull’s-Eye” type lesion over 1-12 hours (blanched ring surrounded by ring of ecchymosis)
Necrotic ulcer follows over 24-72 hours, Normally self-limiting but may be full thickness, Systemic symptoms (24-48 hours): Fever/chills, malaise, nausea, myalgias
RARE: intravascular hemolysis and DIC
Term
Brown Recluse Bite Treatment
Definition
Wound care, tetanus update, treat associated infection (cellulitis), admit patient if systemic symptoms (evaluate for and treat renal failure and hemolysis), No commercial anti-venom in the US.
Term
Latrodectus (Widow Spider)
Definition
Native to US. Female (significant invenomations, rare fatality), Disorganized web (garage, wood piles, etc), Shiny black, red hourglass shape on belly.
Term
Latrodectus (Widow Spider) clinical picture
Definition
Localized mild erythema, target lesion, central puncture site, central blanching, erythematous ring. Pain at 30-120 minutes (most bites painful). Painful cramping/muscle fasciculations: at 3-4 hours, effected extremity, progress centrally, muscle rigidity/weakness, dyspnea, headache, parenthesias, HTN, regional diaphoresis, restlessness, N/V, tachycardia. Uncommon Symptoms: Leukocytosis, fever, delirium, arrhythmia, HTN crisis, respiratory arrest.
Differential: MI, Acute Surgical Abdomen. Symptoms for 12-72 hours.
Term
Latrodectus (Widow Spider) Treatment
Definition
Monitor for >= 6-8 hours. ABCs? Treat HTN, pain, muscle cramps (relaxants, calcium IV).
Anti venom (latrodectus mactans): Effective, not widely used in US (seriously ill, elderly, peds not responding to supportive treatment) because anaphylaxis risk! Used in pregnancy to avoid pre-term labor (if sx of it).
Tetanus update, wound care, treat infection if present.
Term
Decubitus Ulcer (Pressure Ulcer)
Definition
Incidence: 2.7-9% in acute care and 2.4-23% in long-term.
Pressure on skin over boney prominence causes capillary collapse. Factors to consider: immobility, malnutrition, altered mental status.
Term
Treatment for Decubitus Ulcer
Definition
PREVENT! Surgical debridement, enzymatic debridement, topical wound treatment, VAC, remove pressure.
Term
Acne Vulgaris
Definition
Inflammation of pilosebaceous unit.
Affects 85% of adolescents. More severe in males.
Causes: Follicular keratinization and plugging prevents drainage of the sebum, Androgen stimulation of the sebaceous gland, Bacterial production of inflammatory factors (Propionibacterium acnes), Inflammation distends follicle walls which break and provoke an inflammatory response, Inflammation leads to scarring
Term
Risks/Causes of Acne
Definition
Cosmetics, mechanical trauma, sweating, clothing, humidity, familial factors, diet?, stress, HORMONAL FLUCTUATION.
Term
Skin Lesions of Acne
Definition
Non-inflammatory: Comedones (Open=Blackheads. Closed=White heads)
Inflammatory: Pustules, Papules, cysts, nodules
Term
Acne Treatment Goals
Definition
Remove follicle plugging
Reduce sebum production
Treat bacterial colonization
Prevent scarring
Term
Comedonal Acne
Definition
Topical retinoids are most effective: retinoic acid, adapalene, tazarotene
Gradually increase the concentration
Patient education to avoid side effects is important: skin irritation, overdrying, deactivation by sunlight
“Surgical” extraction
Must be properly done
Best after treatment with retinoids
Term
Mild inflammatory acne
Definition
Topical antibiotics (clindamycin or erythromycin)
Benzoyl peroxide lotions, gels, creams, washes
Topical retinoids: retinoic acid, adapalene, tazarotene
Gradually increase the concentration
Patient education to avoid side effects is important: skin irritation, deactivation by sunlight
Term
Moderate Inflammatory Acne
Definition
Topical antibiotics (clindamycin or erythromycin)
Benzoyl peroxide lotions, gels, creams, washes
Topical retinoids: retinoic acid, adapalene, tazarotene
Gradually increase the concentration
Patient education to avoid side effects is important: skin irritation, deactivation by sunlight
Oral Antibiotics: Tetracycline, doxycycline, minocycline
Term
Severe Inflammatory Acne
Definition
Nodulocystic or resistant acne, higher risk of scarring
Same topical treatments
Oral antibiotics
Oral isotretinoin
Highly effective
Highly teratogenic causing birth defects
Restricted to clinicians who register with the FDA
Serious side effects including depression, psychosis, elevated triglycerides, hearing loss, night vision loss, mucosal drying, arthragias
Term
Rosacea
Definition
Common in fair skinned middle age patients
Presents with erythema, telangiectasias, acne-like lesions on the central face
More common in women, more severe in men
Differs from acne vulgaris, there are no comedones
Patients often flush to different stimuli: alcohol, stress, spicy foods
Can result in rubbery thickening of the nose, cheeks forehead or chin due to hyperplasia, edema and fibrosis
Term
Treatment of Rosacea
Definition
Avoidance of the triggers. Topical metronidazole most effective topical antibiotic
Oral antibiotics are even more effective
Minocycline or doxycycline
Telangectasias can be treated with laser surgery
Term
Hydradenitis suppurativa
Definition
Chronic suppurativa disease of the apocrine gland-bearing skin. Usually involves the axillae and anogenital regions
Begins in puberty. More common in females
Familial component. Smoking and obesity are predisposing factors
Term
Clinical Manifestations of Hydradenitis suppurativa
Definition
Tender deep seated inflammatory nodules
Intermittent drainage of purulent to seropurulent material
Development of sinus tracts and abscesses
Most common in the axillary areas, usually bilateral but can be seen anywhere there are sebaceous glands
Upon drainage, multiple bacteria can be seen but usually are secondary colonizers
Term
Treatment of Hydradenitis suppurativa
Definition
Must be guided by disease severity, not simply an infection
Early disease: topical antibiotic clindamycin and intralesional steroids, refer to dermatology for isotretinoin or TNF inhibitors
Acute infections treat with I & D and packing
Late disease is treated with oral antibiotics
Refractory disease can be treated surgically, excisional or laser
Patient education
Smoking cessation and weight loss counseling important
Avoidance of tight synthetic clothing
Avoid deodarants (antiperspirants are ok)
Term
Dermatophytes
Definition
Microsporum, Epidermophyton, Trichophyton
Cause superficial fungal infections, infect keratinized epitheilium, hair follicles and nail apparatus
Named according to the site involved: Tinea capitis, Tinea corporis, Tinea cruris, Tinea unguium/onochomycosis, Tinea pedis
Clinical diagnosis, but can be confirmed with potassium hydroxide test (KOH)
Term
Tineas
Definition
Capitis: Most common in children. Affects African Americans more. Non scarrng alopecia from hair breakage
Corporis: Body
Cruris: Almost always associated with tinea pedis. Large, scaling well-demarcated. Often recurrent. To prevent reinfection recommend shower shoes and antifungal powders
Pedis:
Term
Treatment of Dermatophyte Infections
Definition
Most can be controlled by topical anti fungal creams (Miconazole, clotrimazole, Terbinafine (LAMISIL))
Tinea capitis and tinea unguium must be treated with oral antifungals (Grisveofulvin (scalp), Terbinafine (both), Itraconazole (both), Fluconazole (nails))
Term
Candidiasis
Definition
Most commonly caused by the yeast Candida albicans
Common cutaneous candidiasis clinical manifestations
Intertrigo, Diaper dermatitis, Follicular candidiasis, Interdigital
Risks for candida infections: Obesity, Diabetes, Any body part or situation that is moist
Term
Treatment for Candidiasis
Definition
Keep intertrigionus areas dry. Topical antifungals are the mainstay of treatment. (Nystatin cream or powder, Imidazole cream or powder). Oral antifungals for recurrence
Oral nystatin, Fluconazole, ketoconazole
Term
Cellulitis
Definition
Bacterial infection of skin and subcutaneous tissues
Infection without formation of an abscess
Usually follows a breach in the skin or port of entry for bacteria (Insect bite, puncture wound, may not be obvious/microscopic)
Without draining wounds, streptococci are the likely etiology
Cellulitis surrounding an abscess is likely staphylococci, as are pus producing wounds
Term
Clinical Presentation of Cellulitis
Definition
4 cardinal signs of a cellulite infection: Erythema, Pain, Swelling, Warmth
More severe infection shows the following findings: Malaise, chills, fever, Lymphangitic spread, Pain disproportionate to the exam, Bullae, skin sloughing, Gas in the tissue
Term
Risk Factors of Cellulitis
Definition
Elderly and diabetics are at risk for more severe disease
Peripheral arterial and venous disease, Patients with immunodeficiency, cancer or chronic kidney disease
Postvenectomy, lymph node dissections, mastectomy, Obesity
IV drug users “skin popping”, Any break in the skin: pickers, rashes, infections (chicken pox or shingles)
Term
Treatment for Cellulitis
Definition
For patient with mild local symptoms and no evidence of systemic disease, outpatient treatment with oral antibiotics is appropriate (treatment is 5-10 days depending on severity, pmh) Patients should be reassessed with a short-interval follow-up (2-3 days) Increase in erythema over first day of treatment is normal
Systemic symptoms warrant prompt reevaluation and IV antibiotic therapy (Escalating fever, Tachycardia, hypotension
Consideration of MRSA (Methicillin resistant staph aureus)
Other patients who may need IV treatment are immunosuppressed patients, patients with facial cellulitis, patients with chronic diseases like, cardiac, hepatic or renal failure
Term
Danger Sings for Cellulitis
Definition
Crepitus (gas in the tissue), Circumferential cellulitis
Necrotic-appearing skin (bronzing), Evolving bullae
Rapidly evolving cellulitis, Pain on passive motion
All point to necrotizing fasciitis, gas gangrene or compartment syndromes CALL A SURGEON!
Term
Necrotizing Fasciitis
Definition
Deep soft tissue infection involving the subcutaneous fat and fascia. There is no distinct border and can be difficult to diagnose early on. Often polymicrobial including anaerobes and seen in immunocompromised patients
Can also be cause by group A strep or MRSA and affects healthy individuals. Surgical emergency
High mortality rate even with appropriate intervention
Term
MRSA
Definition
Methicillin resistant staph aureus. Initially seen in hospitalized patients, has moved into the community
Causative agent for many skin infections especially abscesses, furuncles, carbuncles
Complicates the management of cellulitis
Treatment is usually vancomycin IV or IV Linezolid for severe infections, bacteremia and hospitalized patients. For outpatients use oral linezolid, oral TMP-SMX, oral doxycycline
Term
Bacteria
Definition
Group A Strep (B hemolytic strep) S. Pyogenes skin infections and pharyngitis
Group B Strep - S. agalactiae causes neonatal pneumonia and meningitis
Group D Strep - S. bovis GI bug causes bacteremia, endocarditis and is associated with colon cancer
Term
Cellulitis from Animals
Definition
Pasturella is the most common found organism (P. multiocida in cats). S. aureus, Bacteroides, Fusobacterium, Capnocytophaga, Porphyromonas. Assess severity and depth of wound
Drug of choice is amoxicillin-clavulante (AUGMENTIN), pen allergic patients get doxycycline or TMP-SMX or fluoroquinolone like ciprofloxacin plus clindamycin
Human bites are worse! Aerobic and anaerobic organisms
Aerobes: streptococci, S aureus, Eikenella corrodens, Anerobes: Fusobacterium, Peptostreptococcus, Prevotella, Porphyromonas
IV antibiotics is often necessary
Term
Surgical Site Infections
Definition
Rare in the first 48 hours except group A strep (S. pyogenes) and Clostridial species, they hit early
Usual agents of infection are dependent on site of surgery
For GI or GU procedures it’s a mix of GP/GN organisms
Non-intestinal sites usually Staph including MRSA, and Strep are the causes
Aim therapy at the likely cause and adjust with cultures
Term
Immunocompromised Patient
Definition
Patients with lymphoma, HIV, transplant patients,
Pseudomonas. Be aware in diabetics with leg infections
Unusual bacteria
Mycobacterium, nocardia, Viruses, Protozoa, Fungal infections
Term
Impetigo
Definition
Starts as erythematous vesicular lesions that become pustular and crusty. Honey colored crusts. Staph aureus is the most common cause, Strep pyogenes also
Treat based on number of lesions and location and to limit continued infectivity
Topical mupirocin ointment TID to small areas
Oral antibiotics aimed at S. aureus and S. pyogenes for 7 days
Dicloxacillin, cephalexin, erythromycin, clindamycin, amoxicillin-clavulante
Term
Eyrsipelas
Definition
Explosive superficial infection
Most often caused by group A streptococcus (S. pyogenes)
Spreads quickly through the skin lymphatics
Usually a clearly demarcated area of redness that is palpable
Often starts from a superficial abrasion
Term
Erysipelas Treatment
Definition
First line treatment is either IV or PO penicillin depending on the severity
PCN allergic patients receive clindamycin or erythromycin
Refractory cases may be caused by:
Unusual organism
Resistance strep or staph
More sever underlying condition (necrotizing fasciitis or myonecrosis)
Term
Molluscum Contagiosum
Definition
Poxvirus. Common in children but can be seen in sexually active teens and adults, can be overwhelming in HIV patients
Clinical Presentation: Flesh colored papules and nodules with distinctive central umbilication. Often seen in groin, thighs, lower abdomen in adults
Treatment: Self-limiting but easily auto inoculated esp. in children, usually regress in 6 months
Benign neglect, ED&C, cryotherapy, topical imoquimod 1%
Term
Verruca
Definition
Causative agents are Human Papilloma viruses. Caused by skin to skin contact and minor trauma. Multiple locations
Papules, plaques, coalesce to from larger lesions
Widespread disease can be seen in immune compromised patients. Warts heal with out scarring
Term
Verruca Presentation
Definition
Verruca vulgaris (common wart). Seen on hands especially but can be anywhere, occur at sites of trauma (fingers, knees)
Papular, hyperkeratosis, clefted surfaces with vegetations
Inoculation by scratching
Verruca plantaris (plantar warts): Plaque like with rough surface and studded with brown-black thrombosed vessels
Painful if in a pressure area such as metatarsal head
Verruca plana (flat warts): Flat papules, flesh colored, oval or polygonal. Often on the surface of hands, shins, also face and beard area
Term
Treatment of Warts
Definition
Most resolve with no treatment spontaneously (patient reassurance). Treatment can cause scarring.
Patient initiated treatments: OTC salicylic acid 10-40%, $ and effective if used consistently, Imoqimod cream, Hot water therapy, home cryotherapy
Provider initiated treatments: Cryotherapy: usually requires repetitive treatments, Electosurgery: higher chance of scarring, Laser surgery: effective for more resistant warts, Surgical excision
Term
Condyloma Accuminatum
Definition
Genital warts, most common areas: penis, vulva, vagina, cervix, perineum and perianal area. Human papilloma virus (HPV), 90% are types 6 and 11 (low neoplastic potential)
Most common STD with high prevalence in 17 to 33 year olds
Risk factors include smoking, multiple sexual partners, early age of sexual activity
Term
Clinical Manifestations of Genital Warts
Definition
Single or multiple popular eruptions that can be filiform, fungating, plaque or cauliflower like
Flesh tone in color or erythematous or hyper pigmented
Important to examine multiple sites, external lesions in women often coincide with internal lesions on the cervix or urethra, perianal lesion are common in immunosuppression and patients who have anal intercourse
Treatment involves destruction
Topical podophyllum resin or trichloroacetic acid
Cryotherapy esp. for perianal lesions, also safe in pregnancy
Electrodessication, curettage, surgical excision
HPV vaccines
Term
Herpes Simplex
Definition
DNA virus. Acute skin infections and rarely serious illness, important in pregnant patients as it can affect the fetus
HSV type 1 = oral infection
HSV type 2 = genital infection
Infection occurs with contact between an infected person who is shedding virus and a susceptible host
Invades and replicates in neurons and epidermal/dermal cells, travels to sensory dorsal root ganglion and establishes a latent infection. Infection triggers: stress, UV radiation, extremes in temperatures, hormonal changes, immunosuppression, trauma
Term
Orolabial Herpes: Cold Sores, Fever Blisters
Definition
Primary infection is typical viral infection: fever, sore throat and mouth, lymphadenopathy (viral prodrome)
Often asymptomatic in children. Gingivostomatitis with odynophagia can be observed. Painful vesicles develop on the lips, plate, gingiva, tongue and can be edematous
Lesions ulcerate and heal within 2-3 weeks.
Recurrences start as pain, burning, itching or paresthesia before the vesicles erupt, ulcerate and then crust
Usually occur in the vermillion border, symptoms last 1week, often recur at or near the same location within the distribution of a sensory nerve
Term
Genital Herpes
Definition
Primary infection occurs 2 days to 2 weeks after exposure, viral prodrome
Men: painful erythematous, vesicular lesions that ulcerate, commonly on the penis but can occur on the anus and perineum, may be a penile discharge, inguinal adenopathy, severe dysuria!
Women: lesions occur on the cervix which are asymptomatic, but may cause a vaginal discharge, painful vesicles on the external genitalia, perineum, buttocks, sacral area, females may have lumbosacral radiculopathy, severe dysuria
Recurrences are milder and preceded by the prodrome of pain, itching, tingling, burning or paresthesia
Term
Other HSV manifestations
Definition
Herpetic whitlow: Vesicular outbreak on the hands and digits, more common in children and dental and health care workers
Herpetic gladiatorum: Outbreaks on face, arms and torsos of athletes involved in close contact (wrestlers)
Eczema herpeticum: Variant infection seen in mostly children with inflammatory skin conditions like atopic dermatitis, burns
Neonatal HSV: Occurs in the first 2 weeks of life and is an HSV-2 infection transferred from the mother
Often a severe infection causing rash, eye infections, pneumonia, encephalitis and death
Term
HSV Treatment
Definition
Most are self limiting, but antiviral treatment will shorten the course of symptoms and may prevent dissemination and transmission for both primary and recurrences
Acylovir, Valacycolvir, Famciclovir
Medications are most effective is started at the onset of symptoms
Oral meds can be used for chronic suppressive therapy for frequent recurrences
Topical treatments are less effective: topical acyclovir and penciclovir (DENAVIR)
Watch for secondary bacteria infection that can lead to cellulitis
Term
HSV Patient Education
Definition
Outbreak and transmission prevention is key
Viral shedding is greatest during a clinically evident outbreak but…
Transmission to uninfected partners usually occurs during asymptomatic virus shedding
Barrier methods can confer some protection against transmission but are more effective for women that men in regard to preventing infection
Long term suppressive therapy has been shown to decrease viral shedding during asymptomatic periods (acyclovir or valacyclovir)
Prevention of neonatal transmission is paramount
May require a Cesarean section if mother has an outbreak
Suppressive therapy in the third trimester has be proven to be safe and effective (acyclovir TID)
Avoidance of a primary infection while pregnant
Term
Varicella Zoster Virus
Definition
Causative agent of chickenpox and herpes zoster (shingles)
Chickenpox (varicella) is the primary infection and is a mild, self-limiting childhood disease except in immune compromised patients
Zoster is a reactivation of the dormant virus and causes a dermatomal rash
Incidence of varicella is declining with the initiation of VZV vaccine (live attenuated)
Transmission is airborne and is highly contagious
Term
Chickenpox
Definition
Successive crops of pruritic vesicles that evolve into pustules then crusts and sometimes scars usually in children
Primary infection in adults can be complicated by pneumonia and encephalitis and the rash may be more severe
Crusted erosions heal in 1-3 weeks, some leave a punched out scar
Usually starts on the face and spreads inferiorly to trunk and extremities, palms and soles are spared, can see lesions on the palate
Immunization is 80% effective, some kids get a rash with the vaccine
Term
Chickenpox Treatment
Definition
Symptomatic
Treat itching with antihistamines, lotions,
Avoid aspirin because of the association with Reye’s syndrome??
Antiviral agents can decrease severity of course if started within 24hours, should be considered in neonates and immune compromised patients
Severe immunocompromised patients should get acyclovir IV
Term
Zoster
Definition
Acute dermatomal rash caused by the reactivation of dormant varicella-zoster virus
Starts with a prodrome: unilateral dysesthesia, pain, increased sensitivity, flu-like. Pain can mimic angina or an acute abdomen. Allodynia – heightened sensitivity to even mild stimuli, shirts, sheets. Progresses to a vesicular eruption along a sensory ganglion most common in the trunk
Vesicles rupture, erode then crust over a period of 2-4 weeks, can cover one or two dermatomes
Post herpetic neuralgia occurs in some patients which is severe, stabbing burning pain that can persists for months to years
Incidence will likely decline because of pediatric vaccination and now vaccination recommendation at age 60 for prevention in older patients
Term
Zoster Treatment
Definition
Prevention with vaccines is effective
Oral antiviral therapy for 7 to 10 days, acyclovir, valacyclovir, famciclovir
Decrease duration and prevent post herpetic neuralgia
Severely immune compromised patients or those with ophthalmologic involvement require IV acyclovir
Supportive treatment:
Pain management with narcotics is often necessary
Moist dressings for large areas of lesions, topical lotions like calamine
Treatment for Post herpetic neuralgia
Tricyclic antidepressants, gabapentin or pregabalin, capsaicin cream, lidocaine patches
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