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DERMATOLOGY
Alison Ruiz PA-C
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Molluscum Contagiosum • Pox virus • Spreads by direct skin
contact – Especially in kids – In adults usually spread
with sexual contact. • Well circumscribed, small
erythemaotus paupules with a small central indentation – Central indentation
resolves as lesions progress
• No treatment required in healthy individuals
• Can use Imiquimod cream 5% (same as used for HPV in the genital skin
• In children, freezing, curettage, topical cantharidin
Erythema Infectiosum • Fifth’s disease • Occurs in spring in children
– 5-15 yrs of age usually • Human parvovirus B19 • Abrupt onset of fiery red
rash on cheeks – Slapped cheek appearance – Closely grouped tiny papules
on erythematous base • 1-2 days later
– erythematous maculopapular rash on trunk and limbs
• Fevers, malaise, headache, Sorethroat, cough, coryza, nausea, vomiting, diarrhea and myalgia
Case Presentation
• 25 y/o M PMH Seizure Disorder recently diagnosed presents to the ED with fevers for the 4 days and URI symptoms.
• He noticed a rash for the past 72 hours to his chest and back. Rash initially itchy but now it it more painful, warm and “cracking”
• Pt feels weak, has not been eating. Fever max 103.5. States he was placed on Keppra after recent diagnosis of seizure disorder.
History
• PMH – Seizures
• PSH – None
• Meds – Keppra
• Allergies – none
• FH – Noncontributory
• SH: – smoker 5 cigaretteres
per day for 5 years – Alcohol 4 drinks per
week
Physical Exam • HEENT: PERRL, EOMi • Neck supple. No nuccal
rigidity • Lungs: CTA bilat. No
W/R/R • CV RRR s1s2 • Abd: soft NT ND NABS. • Skin: see picture • Back: see picture • Ext: small maculopapular
lesions on thighs and lower legs bilat.
Differential Diagnosis
• ??????
What labs do you want to send?
• CBC • BMG • LACTIC ACID • BLOOD CULTURES • URINALYSIS • URINE CULTURE • CXR
LAB RESULTS
• CBC – WBC: 20.4 (H) – RBC: 3.33 (L) – HEMOGLOBIN: 11.4 (L) – HCT: 28.6 (L) – MCV: 85.7 – MCH: 28.2 – MCHC: 32.9 – RDW: 16.5 (H) – PLATELET COUNT: 199
• BMG – GLUCOSE: 102 (H) – SODIUM: 140 – POTASSIUM: 3.5 – CHLORIDE: 109 (H) – CO2: 26 – BUN: 22 – CREATININE: 1.1 – CALCIUM: 8.2 (L)
LAB RESULTS
• Lactic Acid – LACTIC ACID: 3.6
• CXR – WNL
• BLOOD CULTURES PENDING
URINALYSIS • COLOR: YELLOW • APPEARANCE: CLEAR • SPECIFIC GRAVITY: 1.019 • PH: 6.0 • PROTEIN: NEGATIVE • GLUCOSE: NEGATIVE • BILIRUBIN, URINE: NEGATIVE • NITRITE: NEGATIVE • KETONES: NEGATIVE • BLOOD: NEGATIVE • UROBILINOGEN: 1.0 • LEUKOCYTE ESTERASE: NEGATIVE • SQUAMOUS EPI: 3 • HYALINE CASTS: 0 • BACTERIA: NEGATIVE • WBC, URINE: 1 • RBC: 2
48 hours later….
What is the most likely Diagnosis?
Erythema Multiforme
• ACUTE INFLAMMATORY DISEASE
• Range – Papular eruption of the
skin (EM minor) to severe multisystem illness (EM major) with
• Vesiculobullous lesions and erosions of the mucous membranes known as Stevens-Johnson syndrome
• Characterized by epidermal detachment
Epidermal Detachment EM Minor • No epidermal detachment
Stevens-Johnson Syndrome • <10% epidermal
detachment
Overlapping SJS and TEN • 10-30% epidermal
detachment
TEN • >30% epidermal
detachment
The more epidermal detachment, the higher
risk of death
Erythema Multiforme
• Affects all ages – Incidence highest 20-40
yrs
• 2:1 Males:Females • Occurs in fall and spring • Symptoms
– Malaise, fevers, myalgias, arthalgias
– Pruritus or burning from skin lesions
• Precipitating Factors – Infections
• Mycoplasma • HSV
– Drugs • Antibiotics • Anticonvulsants
– Malignancies – Unknown cause in 50%
of cases
Erythema Multiforme Lesions
Maculopapular lesions Target or Iris lesion
Management
• Hospitalize • Steroids used for localized disease and prove
sympotmatic relief • Systemic analgesics and antihistamines for
symptom relief • Ocular involvement requires optho consult
Toxic Epidermal Necrolysis
• Explosive dermatosis – Tender erythema, bullae
formation and exfoliation.
• Found in all age groups • Males=Females • Medications are most
common cause – Sulfa, PCN,
anticonvulsants, oxicam, NSAIDS
TEN
• 25%-35% mortality • Presentation
– 1-2 wk prodrome of malaise, arthalgias, fevers, anorexia
– Skin tenderness, erythema which starts with the eyes, nose, mouth and genitalia
– Nikolsky sign • Management
– Hospitalization in ICU, optimally a burn unit
Nikolsky Sign
• Slippage of the th epidermis from the dermis when slight tangential or rubbing pressure is applied to the skin.
• Seen in bullous disorders, TEN and staphlyoccocal scalded skin syndrome
Differential Diagnosis
Pemphigus
Pemphigoid
Erythema Multiforme
Exfoliative erythemoderma
Toxic Shock Syndrome
Scalded Skin Syndrome
Kawasaki’s disease in children
?????
Erythema Nodosum
Inflammatory eruption of the SQ fat.
• Fungal, bacterial, parasitic, viral, pharmacologic, sarcoidosis, inflammatory bowel disease, pregnancy, behcet syndrome, leukemia and lymphoma, idiopathic
Causes
• Tender, warm, ill-defined erythematous nodules
Clinical features
• Bed rest, leg elevation, NSAIDS • Treat underlying cause
Treatment
?????
Urticaria • Wheal • Why do we get them?
– Allergic – Idiopathic
• ID swelling in respiratory tract – Look for lip, mouth throat
swelling and listen to lungs • Treatment
– Steroids – Benadryl
?????
Pemphigus Vulgaris • Autoimmune
– Autoantibodies against part of the epidermal layer
• Primary lesions – bullae or vesicles
• Affects head, trunk, mucous membranes first
• Then blisters rupture & become painful and denuded
• Decreased fluid intake, accelerated protein, fluid and electrolyte loss through the involved skin – Leads to hypovolemia and
electrolyte disturbances • Admit • Aggressive fluid and
electrolyte administration • Steroids and
immunosuppressives to prevent death
• +/- plasmapheresis and IV immunglobulin
??????
• Diffuse infection • Caused by toxins produced by serotypes A and
B from Staph – Causes the exfoliative presentation
• Fevers, malaise, irritability and tenderness over the skin
• Most are <2 yrs old and almost all are <6 yrs old
Staphylcoccal Scalded Skin Syndrome (SSSS)
Treatment of SSSS
• Diffuse Disease – Admit
• Use burn unit if disease is extensive
– IV fluids – IV antibiotics
• Localized Disease – Outpt therapy with f/u
• Nafcillin IV • Pencillin G IV • AugmentinPO • Cefazolin IV • Cephalexin PO • If suspect MRSA, then
include Clindamycin, bactrim or Vancomycin
Case Presentation
• 7 y/o M c/o with rash and ST. Pt has had ST for 3 days. Developed fevers 2 days ago. Fever max 102.1. Pt vomited once. Drinking less because of throat pain. Rash started today. Mom unable to see the pediatrician.
• Using motrin for fevers • Kids at school are sick but mom is not sure
with what.
History
• PMH: none • Peds Vacc UTD • PSH: none • Meds: Motrin • Allergies: NKDA
Physical Exam • Vitals; 100.5 po, R: 20, HR 90, BP 101/50, Pulse ox 100% • Alert and oriented times 3 NAD. Pt is quiet but looks well
hydrated. • HEENT: PERRL EOMi • TMs clear bilat without bulging or erythema • OP: erythema, exudate. Enlarged tonsils. Uvula midline.
No petechiae • Neck: anterior cervical LAD • Lungs; CTA bilat. No W/R/R • CV RRR s1s2 • Abd: soft NT ND NABS. No HSM • Skin: see picture
Oropharynx
What to do next?
• What labs/imaging do you want?
Differential diagnosis
• Strep throat • Scarlet fever • Viral exanthems • Pharyngeal abscess
Diagnosis:
• Rapid strep: positive • STREP + RASH=?????
Scarlet Fever • Affects children • Group A B-hemolytic
strep • Fever, ST, HAs, vomiting,
abd pain • Exanthem 1-2 days later
– Sandpaper rash • Strawberry Tongue • Treatment:
– Pen VK – Amoxocilin – Macrolides for PCN allergy
?????
Contact Dermatitis • Can be caused by
allergens • More commonly caused
by irritants – Detergents, soaps,
chemicals, cold air • May be chronic exposures
or isolated accidental exposure
• Severe reactions can lead to necrosis and ulceration
Atopic Dermatitis AKA Eczema
• Atopic Triad – Dermatitis, Asthma, Hay
fever • Presentation
– Affects hands, feet antecubital and popliteal fossae, postt neck wrist and ankles
– Erythematous, pruritic, scaly patches
– Chronic atopic dermatitis • Hyperpigmentation,
lichenifications and fissuring
• Remove offending agents – antihistamines,
antibiotics and anti-itch creams (cause secondary allergy)
– Lubricate: petroleum jelly, thick ointments
?????
Psoriasis
• Palms and soles are common – Also affects elbows, knees, scalp, umbilicus and
gluteal cleft • May need biopsy to diagnosis • Treatment
– High or ultrahigh potency topical corticosteroids such as fluocinonide, clobetasol propionate or betamethason dipropionate ointment
– Topical lubricants
???????
Sebaceous Cyst
Blockage of the duct of the sebaceous gland leads to a glandular cyst
Can exist for long period of time without becoming infected
If bacterial invasion abscess formation
Erythematous, tender, fluctuant
I&D abscess (attempt to remove capsule as well)
Will help avoid recollection
REFERENCES
• Tintanilli 1599-1669, 912, 916, 1023