1.

NAIL CHANGES
LESION DERMATOPHYTE ONYCHOMYCOSIS Yellow discoloration, nail becomes brittle and separates from the nail bed resulting in the piling up of subungal keratin; breaks off, leaving an undermined black-yellow remnant to dead nail; skin of the toe & soles may be involved branny, scaling, erythematous, well-defined patches Superficial without paronychial inflammation; Chalky white spots on or in the nail plate that is easily shaved off. CANDIDAL ONYCHOMYCOSIS Pink, swollen & tender cuticle with neighboring portion of the nail becoming dark, ridged and separates from the bed. fingernails more affected AGE OF PREDILECTION AREA OF PREDILECTION HALLMARK Starts at the distal corner of the nail and involves the junction of the nail and its bed; entire maybe affected ETIOLOGY T. rubrum PREDISPOSING FACTORS

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TREATMENT Itraconazole Dose: 200mg/day, bid for 1 week/mo Fingernails: 2 mos Toenails: 3 mos Terbinafine Dose: 250mg/day Fingernails: 6 wks Toenails: 12 wks Fluconazole Dose: 150-300mg once/wk for 6-12 months Griseofulvin therapy OTHER INFO Types:
1. Distal subungal onychomycosis 2. White superficial onychomycosis 3. Proximal subungal onychomycosis

Scaling of the nail under the overhaningcuticle and remains localized to a portion of the nail, however, in time entire nail may be involved Paronychia characteristic feature; Begins on the lateral or proximal nail fold with expression of small amount of pus.

T. mentagrophytes

Candida Albicans

Common in homemakers and canners & others who have their hands mostly in water.

Griseofulvin does not treat nail disease caused by candida.

Involves all the nail plate; nail does not become friable , yellow, white

PSORIASIS

Pits on the nails, furrows or transverse depressions ( Beaus Line), crumbling nail plate or leukonychia with a smooth or rough surface; nail bed splinter hemorrhages; hyponychium yellowish green discoloration may occur in area of onycholysis.

86.5 % of patient with psoariatic arthritis Others: Reiters disease, Pityriasis rubra pilaris, Sezary syndrome & acrokeratosis paraneoplastica

Intralesional injection of triamcinolone acetonide suspension, 3-5 mg/ml Topical 1% 5-FU solution MTX, PUVA, cyclosporine or acitretin

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2A.NON-SCALY PAPULES
AREA OF PREDILECTION Antecubital and popliteal fossae, trunk, inframmary areas, abdomen (waistline), inguinal region HALLMARK ETIOLOGY Miliaria (in general) retention of sweat as a result of occlusion of eccrine sweat ducts and pores. S. epidermidis Circle of Hebra axillae, elbow, flexures, wrists, hands and crotch Mite burrows in stratum corneum Active scabies: Dull Red nodules Fierce itching at night Sarcoptes scabei Immunocompromised & institutionalized (Crusted Scabies), malnourished patients, w/ neurologic dsorders PREDISPOSING FACTORS Impedance of evaporation of moisture

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LESION MILIARIA RUBRA (Prickly Heat, Heat Rash) Dicrete, extremely pruritic, erythematous papulovesicles; may become confluent Accompanied by prickling, burning or tingling. SCABIES Pruritic popular lesions and burrows w/c house the female mite and her young

AGE OF PREDILECTION

TREATMENT

OTHER INFO Prickle cell layer site of injury and sweat escape; spongiosis

Premethrin 5% cream

Transmission: close personal contact

ACNE VULGARIS

-comedo (basic lesion) -papules, pustules, cysts, nodules, scars

-adolescents (15-18) -involution of disease before 25 years old

-face, neck, upper trunk, upper arms -oily seborrheic areas

Propionibacterium acnes (metabolize sebum to free fatty acid) -heredity, keratinous plug in lower infundibulum of hair follicle (primary defect), androgenic stimulation of sebaceous gland

TOPICAL -benzoyl peroxide -topical retionoids -clindamiycin -erythro +benzoyl peroxide -sulfur, resorcin, salicylic acid -azeleic acid SYSTEMIC (inh. formation of new lesion) -tetracycline -minocycline -doxycycline -erythromycin -clindamycin -sulfonamides -OCP -spironolactone -dexamethasone -prednisone -vitamin A -isotretinoin

1) 2) 3) 4)

atrophic papular atrophic hypertrophic

SURGICAL -comedo extractor INTRALESIONAL CORTICOSTEROID LESION PEDICULOSIS (PHTHIRIASIS) 1. PEDICUL OSIS CAPITIS Intense pruritus of scalp Affected hairs become lusterless and dry Principally in children May also occur in adults Scalp Pediculus humanus var. capitis (head louse) Permethrin Pyrethrins, combined w/ piperonyl butoxide Enzymatic egg remover (CLEAR) Generalized itching, accompanied by erythematous macules or urticarial wheals; or by excoriated papules, parallel linear scratch marks, and a pigmented thickening of skin from continued rubbing Maculae cerulae - occasional, peculiar bluish or slatecolored macules, nonpruritic, does not disappear on diascopic pressure -sides of the trunk, inner aspects of the thigh *Pls read in Andrews =) Adults Upper back; no involvement of hands and feet Dx established by generalized itching, parallel stretch marks, hyperpigtmentation, and erythematous macules. Pediculus humanus var. corporis (body louse) Px bathe thoroughly w/ soap and water Destruction of lice - laundering the bedding and clothing. Disinfection Secondary complications w/ impetigo and furunculosis are common due to itching. AGE OF PREDILECTION AREA OF PREDILECTION HALLMARK ETIOLOGY PREDISPOSING FACTORS TREATMENT OTHER INFO

PEDICULOSIS CORPORIS

Lice live in the seams of clothing, esp. wherever there is pressure (i.e. warmth) or in bedding. Dx supported by finding lice in the seams of clothing or in bedding.

3. PEDICULOSIS PUBIS (pediculosis vestimenti or vagabonds disease)

Genital region and hypogastrium Rarely, axillae or eyelashes (pediculosis palpebrarum)

Permethrin Pyrethrins combined w/ piperonyl butoxide. Enzymatic egg remover (CLEAR) *retreatment in 1 wk recommended

Transmission: sexual intercourse; not infrequently from bedding

INSECT BITES

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2B.NON-SCALY NODULES
AREA OF PREDILECTION Nape, axillae, buttocks *but may occur anywhere HALLMARK ETIOLOGY S. aureus PREDISPOSING FACTORS Impairment of skin surface integrity -irritation, pressure, friction, hyperhidrosis, dermatitis, dermatophytosis, shaving Systemic disorders - alcoholism, malnutrition, blood dyscrasias, disorders of neutrophil fxn, immunosuppresion (AIDS) Atopic dermatitis -predisposes to carrier state TREATMENT Penicillinaseresistant penicillin or 1st-gen. cephalosporin Bactobran applied to anterior nares to help prevent recurrence OTHER INFO Proximate cause is either contagion or autoinoculation from a carrier focus, usually in the nose or groin.

LESION FURUNCLE (BOIL) / CARBUNCLE Furuncle - Acute, round, tender, circumscribed perifollicular staphylococcal abscess; generally ends in central suppuration. Carbuncle- 2 or more confluent furuncles, w/ separate heads *lesions begin in hair follicles, and often continue by autoinoculation -most undergo central necrosis and rupture thru the skin, discharging purulent, necrotic debris

AGE OF PREDILECTION

Predisposing ystemic disorders, renal dialysis - often nasal carriers

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2C.NON-SCALY PLAQUES
AREA OF PREDILECTION Oral and genital mucosa HALLMARK ETIOLOGY PREDISPOSING FACTORS TREATMENT Stop taking the offending drug. OTHER INFO

LESION FIXED DRUG ERUPTION Begins as a red patch that soon evolves to an iris or target lesion identical to erythema multiforme, and may eventually blister and erode Nonpigmenting fixed drug eruption: large, tender, often symmetrical eythematous plaques ERYTHEMA MULTIFORME Begin as sharply marginated, erythematous macules, which become raised, edematous papules over 24 to 48 hours target or iris lesion with 3 zones central dusky purpura; an elevated, edematous, pale ring; and surrounding macular erythema Fiery-red swelling with characteristic raised, indurated border; distinctive features is the advancing edge of the patch Suppurative inflammation

AGE OF PREDILECTION

Young adults

dorsal hands, dorsal feet, extensor limbs, elbows and knees, and palms and soles

target or iris lesions

Usually has nondrug causes, most commonly herpes simplex infection

Prevention is cornerstone of treatment if HSV can be demonstrated as the trigger. Sunblock creams Antiherpetic antibiotic

ERYSIPELAS

Newborn, postpartum women

Face and legs

Any inflammation of the skin, especially if fissured or ulcerative, may provide an entrance for the causative streptococcus Usually follows some discernible wound

Systemic penicillin Erythromycin Locally, ice bags and cold compresses

Acute tuberculoid leprosy of the face may look exactly like erysipelas, but the absence of fever, pain, or leukocytosis is distinctive.

CELLULITIS

Intravenous penicillinaseresistant penicillins or a first-generation cephalosporin

LESION URTICARIA wheals, white or red evanescent plaques, generally surrounded by a red halo or flare

AGE OF PREDILECTION

AREA OF PREDILECTION covered areas, such as the trunk, buttocks, or chest

HALLMARK

ETIOLOGY drugs, food, food additives, infections, emotional stress, menthol, neoplasms, inhalants, viruses, parasites, alcohol

PREDISPOSING FACTORS

TREATMENT Antihistamines Avoidance of the trigger should be stressed

OTHER INFO Acute - < 6 weeks Chronic - > 6 wks

EXFOLIATIVE DERMATITIS

Erythematous plaques skin becomes scarlet and swollen and may ooze a straw-colored exudate

Face and extremities

Psoriasis; excema, neurodermatitis; drug allergy; pityriasis rubra pilaris; seborrheic dermatitis, other dermatoses, malignant lymphoma Mycobacterium leprae

topical steroid, soaks, and compresses systemic corticosteroids immunosuppressives Dapsone (cornerstone of therapy) Dapsone + Rifampin -combination therapy initially Clofazimine Ethionamide

The course of the disease may be very protracted, lasting a period of years, or it may simply persist and resist therapy.

HANSENS DISEASE (LEPROSY)

Although it occurs at all ages, there are 2 peaks of presentation: in children aged 10 to 20 years, and in adults 30 to 60 years of age. (true for all types)

1.

EARLY AND INDETERMINATE LEPROSY

Often, the first lesion is a solitary, ill-defined hypopigmented macule that merges into the surrounding normal skin

Cheeks, upper arms, thigh, and buttocks

Peripheral nerves are not enlarged, plaques and nodules do not occur.

2. TUBERCULOID LEPROSY (TT)

Typical lesion is the large, erythematous plaque with a sharply defined and elevated border that slopes

Face, limbs

The presence of palpable induration and neurologic findings distinguishes indeterminated and

down to a flattened atrophic center Lesions are solitary or few in number (usually 3 or less)

tuberculoid lesions clinically.

3. BORDERLINE TUBERCULOID LEPROSY (BT)

Typical lesion is the large, erythematous plaque with a sharply defined and elevated border that slopes down to a flattened atrophic center Smaller and more numerous (usually 310) than tuberculoid leprosy lesions. Satellite lesions around large macules or plaques are characteristic

Face, limbs

Lesion is anesthetic or hypesthetic and anhidrotic, and superficial peripheral nerves serving or proximal to the lesion are enlarged, tender, or both

4. BORDERLINE LEPROSY (BB)

Numerous (but countable) red, irregularly shaped plaques Small satellite lesions may surround larger plaques Lesions are generalized but asymmetrical

Nerves may be thicker or tender, but anesthesia is ony moderate in the lesions

5. BORDERLINE LEPROMATOUS LEPROSY (BL)

Symmetrical, numerous (too many to count), and may include macules, papules,

Nerve involvement appears later. The involvement is

plaques, and nodules

symmetrical. Sensation and sweating over individual lesions is normal.

6. LEPROMATOUS LEPROSY (LL)

Mainly pale lepromatous macules or lepromatous infiltrations, with numerous bacilli in the lesions.

There is little or no loss of sensation over the lesions, there is no nerve thickening, and there are no changes in sweating.

*HISTOID LEPROSY

Yellow-red, shiny, large papules and nodules in the dermis or subcutaneous tissue

buttocks, lower back, face, and bony prominences

may appear de novo or in patients with dapsone resistance

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2F.PAPULOSQUAMOUS DISEASE
AREA OF PREDILECTION Scalp Noninflam involve glabarous skin, eyelids and lashes HALLMARK Black dots Woods lampinfected hairs fluoresce green KOH- long septated hyphae -may be ectothrix or endothrix ETIOLOGY -All dermatophytes, except E. floccosum and T. concentricum -most caused by T. tonsurans and M.canis PREDISPOSING FACTORS more of boys in children, more women in adults TREATMENT Griseofulvin for children -10mg/kg/day for 2-4 mos steroids may be given for inflammation selenium sulfide or ketoconazole shampoo may be left on the scalp for 5 mins, 3x/wk adjuct to oral antifungals OTHER INFO Kerion celsiii boggy indurated areas exuding pus -delayed type hypersensitivity rxn Favus scalp, glabarous skin and nails -sulfur-yellow crusts form around loose hairs atrophy glossy thin, paper white patch Scutulae on glabarous skin, cupshaped crust <2cm -mousy odor nails brittle, crusted, irred thickened Fungal hyphae stained with hematoxylin

LESION TINEA CAPITIS Two types: Noninfammatory -multiple scaly lesions (gray patch), broken hair stubs Inflammatory - scaly, erythematous papupar eruptions w/ loose broken off hairs w/ inflammation

AGE OF PREDILECTION School children, city children (less commonly in infants and adults)

TINEA CORPORIS (TINEA CIRCINATA)

One or more circular, sharply circumscribed, slightly erythematous, dry, scaly, hypopigmented patches

Children adults

Neck, upper and lower extremities and trunk

-lesions slightly elevated esp at the borders, more inflammed than central area -annular outlines (ringworm)

Any of the dermatophytes T.rubrum most common M.canis cause moist type

Exposure to animals w/ ringworm (kids) Excessive perspiration (adults) Hot, humid areas

Systemic anti-fungals (griseofulvin, terbinafine, itraconazole, fluconazole) GrisPEG standard therapy 350-750mg OD, 4-6 wks

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LESION TINEA CRURIS (JOCK ITCH, CROTCH ITCH) Small erythematous and scaling or vesicular and crusted patch that spreads peripherally and partly clears the center Border may have vesicles, pustules or papules Maceration, slight scaling and occasional vesiculation and fissures between & under toes Noninflam- dull erythema pronounced scaling TINEA MANUS Dry, scaly, erythematous type or Moist, vesicular, eczematous type -salmon colored papuplar &macular -oval or circinate patches -runs parallel lines of cleavage -finely scaling, gluttate or nummular patches -yellowish to brownish on pale skin, hypopigmented on dark skin AGE OF PREDILECTION Adult men AREA OF PREDILECTION Upper, inner surface of thighs HALLMARK Curved, welldefined border, Does not involve the genitals ETIOLOGY T.rubrum, T. mentagrophytes, E.floccosum PREDISPOSING FACTORS Heat and high humidity Tight jockey shorts w/c prevent evaporation TREATMENT Keep area as dry as possible, Reduction of perspiration, enhancement of eveaporation Plain takcum powder or antifungal powders Dry toes thoroughly after bathing. Good antiseptic powder Fungicides azoles, naftifine, terbinafine, butenafine Most common fungal disease OTHER INFO Candidal infection may mimic it diff by satellite pustules

TINEA PEDIS

Younger inflam type Older noninflamm

Third toe web, most involved Mostly bilateral, may be limited to one hand, both feet Inner sole of the foot involved first Mostly one hand, two feet

Moccasin, sandal appearance Active borders, central clearing

Dermatophytes, T.rubrum most common

Sweat hyperhydrosis

Active borders, central cleraing Herald patch Christmas tree pattern on the back Woods lampfluoresce as yellow to brown lesions KOH spaghetti and meatball appearnace Furfuraceous scales

T. rubrum, T. mentagrophytes Unknown -viral infection is suggested -may be due to drug reaction Fungi Malassezia furfur

hyperhydrosis

PITYRIASIS ROSEA

15-40, mostly women

Trunk, usually sparing sun exposed areas

TINEA VERSICALOR (PYTIRIASIS VERSICALOR)

Young adults

-sternal region and sides of the chest, abdomen, back, pubis, neck and intertriginous areas

Those who perspire freely

-symptomatic -UV B to expidite the involution of the lesions -topical steroids, antihistamines topical steroids may be given Immidazoles, selenium sulfide shampoos and lotions, zinc pyrithione shampoos, sulfur prep, salicylic acid prep, propelyn lotions, benzoyl peroxide, ketokonazole

Most common during spring and autumn

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LESION PSORIASIS (REVIEW DIFFERENT TYPES) round, circumscribed, erythematous, dry scaling plaques of various sizes, covered by graying white or silvery white, imbricated and lamellar scales symmetrical, solitary macule to more than 100 macules

AGE OF PREDILECTION Mean: 27yrs Wide range (few months to seventies)

AREA OF PREDILECTION scalp, nails, extensor surfaces of the limbs (shins), elbows, knees, umbilical and sacral region

HALLMARK silvery white, imbricated and lamellar scales oil spots, nail pitting nails patho features: -abn differentiation -keratinocyte hyperproliferation -inflammation

ETIOLOGY Unknown, maybe hereditary

PREDISPOSING FACTORS

TREATMENT May disappear spontaneously, but almost certain recurrence Tx varies accdg to site, severity, duration, age Topical corticosteroids tars dihydroxyanthralin tazarotene vit D salicylic acid UV Surgery-denervation Lasers-destruction of upper dermis Systemic corticosteroids methotrexate Combination

OTHER INFO Koebners Phenomenon: appearance of typical lesions at areas of injuries (scratches and burns) Auspitzs Sign: beeding points secondary to thinning of the epidermis over the dermal papillae Woronoff Ring: concentric blanching of erythematous skin near periphery of healing psoriatic plaque

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3. SKIN COLORED PAPULES

LESION VERRUCA VULGARIS (common wart) -pinpoint 1cm, elevated, rounded papules w/ rough grayish surface (verrucous), tiny black dots (thrombosed dilated capillaries) on surface -2-4mm flat-topped papules, slightly erythematous or brown on pale skin & hyperpigmented on dark skin -smooth surfaced, firm, dome-shaped pearly papules with central umbilication AGE OF PREDILECTION -5-20 AREA OF PREDILECTION -hands (fingers & palms) -periungal (nail biters) HALLMARK -Verrucous ETIOLOGY -HPV2, less frequently 1,4,7 PREDISPOSING FACTORS -frequent immersion of hands in water -meat handlers TREATMENT -cryotherapy -immunotherapy OTHER INFO -spontaneously resolves -no dermatoglyphics (fingerprint folds) -spreads by autoinoculation

VERRUCA PLANA (flat wart)

-children & young adults

-forehead, cheeks, nose, area around mouth, back of hands -young children: face, trunk, and extremities -adults: lower abdomen, upper thighs, penile shaft in men -immunocompromised (HIV): face (esp. cheeks, neck, eyelids) , genitalia

-tendency to koebnerize forming linear, slightly raised papular lesions

-HPV3, less frequently 10,27,41

-light cryotherapy -topical salicylic acid - topical tretinoin

-autoinoculation, highest rate of spontaneous remission -Dx: Hendersonpaterson, Shellys method

MOLLUSCUM CONTAGIOSUM

-young children, sexually active adults, immunocompromised patient

-Poxvirus (MCV 1-4) -MCV 1 most common in children - MCV 2 in HIV

-young adults: dont treat or use only topical tretinoin or imiquinod cream daily -adults: cryotherapy or curettage -w/ atopic dermatitis: EMLA followed by curettage or cryotherapy -immunocompromised: combi. therapy w/ protease inh.; curettage or core removal if lesions are few; Catharine or 100% TCA applied to individual lesion; cryotherapy but used in caution

in persons of pigment; continous tretinoin cream

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4. PUSTULAR DISEASE
LESION ACNE VULGARIS -comedo (basic lesion) -papules, pustules, cysts, nodules, scars AGE OF PREDILECTION -adolescents (1518) -involution of disease before 25 years old AREA OF PREDILECTION -face, neck, upper trunk, upper arms -oily seborrheic areas HALLMARK ETIOLOGY -Propionibacterium acnes (metabolize sebum to free fatty acid) -heredity, keratinous plug in lower infundibulum of hair follicle (primary defect), androgenic stimulation of sebaceous gland PREDISPOSING FACTORS TREATMENT TOPICAL -benzoyl peroxide -topical retionoids -clindamiycin -erythro +benzoyl peroxide -sulfur, resorcin, salicylic acid -azeleic acid SYSTEMIC (inh. formation of new lesion) -tetracycline -minocycline -doxycycline -erythromycin -clindamycin -sulfonamides -OCP -spironolactone -dexamethasone -prednisone -vitamin A -isotretinoin SURGICAL -comedo extractor INTRALESIONAL CORTICOSTEROID MILIARIA PUSTULOSA -pustules: distinct, superficial & independent of hair follicle -no particular age -intertriginous area, flexure surfaces of extremities, scrotum & back -pustules are sterile & contain nonpathogenic cocci -bedridden patients -no treatment -self-limited -always preceded by some other dermatitis that has produced injury, destruction or blocking of the OTHER INFO 5) 6) 7) 8) atrophic papular atrophic hypertrophic

sweat duct

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LESION GRAM (-) FOLLICULITIS -superficial pustules 3-6mm in diameter or fluctuant, deepseated nodules AGE OF PREDILECTION -no particular age AREA OF PREDILECTION -anterior nares in patients w/ longterm antibiotic therapy HALLMARK ETIOLOGY -Enterobacter, Klebsiella, Proteus, Escherichia, Serratia PREDISPOSING FACTORS -long-term broadspectrum antibiotic therapy -patients who have moderate inflammatory acne for long period of time TREATMENT -isotretinoin -amoxicillin or trimethoprimsulfamethoxazole OTHER INFO

P.AEROGINOSA FOLLICULITIS

SUPERFICIAL PUSTULAR FOLLICULITIS

-pruritic follicular, maculopapular, vesicular or pustular lesions occurring within 14 days after bathing in hot tub -superficial folliculitis with thinwalled pustules of the follicle orifice -fragile yellowish white domed pustules develop in crops and heals in few days

-no particular age

-sides of the trunk, axillae, buttocks and proximal extremities, apocrine areas of breast & axilla

-Pseudomonas aeruginosa

-3rd gen. oral cephalosporins or fluoroquinolone in patients with fever, constitutional symptoms or prolonged disease

-no particular age

-Staphylococcus aureus

STAPHYLOCOCCAL FOLLICULITIS

-no particular age

-eyelashes, axilla, pubis & thighs

-Staphylococcus aureus

-thorough cleansing of the affected area with antibacterial soap & water tid -mupirocin ointment topically -1st gen. cephalosporin or penicillinaseresistant penicillin -anhydrous formulation of aluminum chloride for chloride folliculitis

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LESION ECTHYMA -vesicles or vesicopustules w/ an erythematous base & surrounding halo that enlarges over days & then crusted over -ulcer-punched-out appearance when the dirty yello crust & purulent materials are removed -margin of ulcerindurated, raised & violaceous & the granulating base extends deeply into the dermis -acute/chronic with purulent tender and painful swelling of the tissue AGE OF PREDILECTION -no particular age AREA OF PREDILECTION -shins, dorsal feet HALLMARK -saucer-shaped ETIOLOGY -Streptococcus -Staph. aureus PREDISPOSING FACTORS -uncleanliness, malnutrition, trauma; ; intravenous drug users and HIV pxs TREATMENT -mupirocin or bacitracin -cloxacillin -1st gen. cephalosporin -antihistamine OTHER INFO Local adenopathy may be present

PYOGENIC PARONYCHIA

-no particular age

-folds of skin surrounding fingernail

-Staph. aureus, Strep. pyogenes, Pseudomonas, Proteus, C. albicans

-separation of the eponychium from the nail plate caused by trauma as a result of frequent wetting of hands -common among bartenders, food servers, nurses, & others who frequently wet their hands

ACUTE -semisynthetic penicillin or 1st gen. cephalosporin -Augmentin CHRONIC -fungicide & bactericide (Neosporin), Castellani paint

INTERTRIGINOUS CANDIDIASIS

-pruritic, pinkish, intertriginous moist patches surrounded by a collarette scale

-no particular age

-between folds of genitals, groins, armpits, between buttocks, under large pendulous breasts, under overhanging abdominal folds, umbilicus

-satellite pustule

-Candida albicans

-topical candidal preparations -amphotericin B

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5. VESICULAR DISEASE
LESION MILIARIA CRYSTALLINE (SUDAMINA) Small, clear, and very superficial vesicles w/ no inflammatory reaction; asypmtomatic, short lived, self-limited Discrete, thin-walled vesicles that rapidly become pustular & then rupture Superficial, very weepy lesions covered by thick, bright yellow or orangec crusts with loose edges AGE OF PREDILECTION AREA OF PREDILECTION HALLMARK ETIOLOGY Increased perspiration PREDISPOSING FACTORS Increased perspiration Clothind that prevents dissipation of heat and moisture Impetigo on the scalp: pediculosis capitis Early childhood Temperate zone: summer in hot, humid weather Group A betahemolytic >>> follows >>> acute glomerulonephritis serotypes 49, 55, 57, 60 strains and strain M-type 2 childhood under 6 y/o TREATMENT Self-limited OTHER INFO Appears in bedridden patients and bundled children Mistaken for Toxidendron dermatitis Common sources of infection: Children pets, dirty fingernails and other children in school Adults barber shops, beuty parlors, meatpacking plants, swimming pools, and infected children

IMPETIGO CONTAGIOSA

Exposed body parts: face, hands, neck & extremities

Produce gyrate patterns Histopathology: extremely superficial inflammation abot the funnelshaped upper portion of the pilosebaceous follicles Subcorneal vesicopustule containing few scattered cocci, PMN leukocytes, epidermal cells Dermis: mild inflammatory reaction vascular dilation, edema & infiltration or PMN leukocytes

Stapylococcus aureus most common Streptococci spp. Group B Streptococci newborn impetigo

Systemic antiobiotics w/ topical therapy semisynthetic penicillin or firstgeneration cephalospori n bacitracin & mupirocin oitment

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LESION STEVENSJOHNSON SYNDROME Appear on the face and trunk and rapidly xtent (4 days) to their maximum extent Macular >>> desquamation >>> atypical targets with purpuric centers >>> coalesce form bullae then slough Vesicles are intraepidermal Dermis & epidermis containing infiltrates of leukocytes & serous exudates Ballooning degeneration of the epidermal cells to produce acantholysis Minute eosinophilic intranuclear bodies Recurrent Erythema Multiforme Minor: papules >>> classic target lesion AGE OF PREDILECTION AREA OF PREDILECTION Oral mucosa and conjunctiva HALLMARK Fever and influenza like symptoms precede eruption Skin biopsy: lymphocytic infiltrate at dermoepidermal junction w/ necrosis of keratinocytes Tzanck Smear: multinucleate epidermal giant cell Orolabial Herpes: Onset - high fever, regional lymphadenopath y, and malaise Presentation cold-sore or fever blister Herpetic Whitlow: tenderness & erythema of lateral nail fold Herpetic Keratoconjunctivi tis: Punctate or marginal keratitis or as a dendritic ulcer cause disciform keratits and leave scars that impair vision ETIOLOGY Medications: Trimethoprim/sulfamet hoxazole, Fansidar-R, sulfadoxone plus pyrimethamine & carbamazepine PREDISPOSING FACTORS TREATMENT Similar to patients with extensive burn Intravenous immunoglobulin OTHER INFO Involves less than 10% body surface Most common sequelae: Ocular scarring, vision loss & siccalike syndrome Herpetic Sycosis following attack of facial herpes simplex, patient who shaves; transient Herpes Gladiatorum HSV-1, wrestlers, rugby players Recurrent Erythema Multiforme Minor: recurrent SV-1 orolabial disease

HERPES SIMPLEX

Orolabial Herpes: lips near the vermilion Herpes Gladiatorum: face, sides of nec, inner arms Herpetic Whitlow: infection of pulp of fingerip Herpetic Keratoconjunctiviti s: eye Recurrent Erythema Multiforme Minor: palms, elbows, knees, and oral mucosa

HSV-1: orolabial herpes simplex, more common HSV-2: genital herpes Herpetic Whitlow: children: HSV1 adults: HSV-2

HIV patients Orolabial Herpes: UVB

Acyclovir

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LESION HERPES ZOSTER Eruption >>> ppapules and plaques of erythema in the dermatome

AGE OF PREDILECTION

AREA OF PREDILECTION Sensory dorsal root ganglion cells Ophthalmic Zoster: ophtlamic division of the 5th cranial nerve Ramsay Hunt Syndrome: facial & auditory nerves

HALLMARK Tzanck Smear: multinucleate epidermal giant cell Histopathology: intraepidermak vesicles, ballon cells, acidophilic inclusion bodies

ETIOLOGY Varicella zoster virus

PREDISPOSING FACTORS Immunosupression and age (Herpes Zoster Generalisatus): old or debilitated, lyphoreticular malignancy, AIDS

TREATMENT Bed rest, local application oh heat & gentle pressure, antiviral treatment (Acyclovir)

OTHER INFO Disseminated Herpes Zoster (Herpes Zoster Generalisatus) more than 20 lesions outside the dermatome Postherpetic Neuralgia: major complication; pain 1 month after onset Other complications: motor nerve neuropathy

SCABIES

Pruritic popular lesions and burrows w/c house the female mite and her young

Circle of Hebra axillae, elbow, flexures, wrists, hands and crotch Mite burrows in stratum corneum

Active scabies: Dull Red nodules Fierce itching at night

Sarcoptes scabei

Immunocompromised & institutionalized (Crusted Scabies), malnourished patients, w/ neurologic dsorders

Premethrin 5% cream

Transmission: close personal contact

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6. BULLOUS DERMATOSIS
LESION BULLOUS IMPETIGO -strikingly large, fragile bullae -ruptures & leaves circinate, weepy or crusted lesions (impetigo circinata) AGE OF PREDILECTION -newborn infants (4th & 5th days of life) -may occur at any age AREA OF PREDILECTION -newborn: face & hands -adults: axilla, groin, hands HALLMARK ETIOLOGY -Staphylococcus aureus PREDISPOSING FACTORS -insect bite TREATMENT -systemic antibiotics OTHER INFO -weakness, fever, diarrhea with green stools, bacteremia, pneumonia, or meningitis, fatal termination -early manifestation of HIV infection -Nonpigmented FDR: occurs occasionally; characterized by large, tender, often symmetrical erythematous lesions that resolves; normally caused by pseudoephedrine hydrochloride -Baboon Syndrome: buttocks, groin & axilla are preferentially involved

FIXED DRUG ERUPTION

-begins as an erythematous patch that soon evolves to an iris or target lesion and may eventually blister & erode -6 or fewer lesions occur but frequently single -prolonged inflammation results to hyperpigmentation

-any age

-anywhere but half occurs on oral & genital mucosa

-recur at the same site with each exposure to the medication

-medications usually taken intermittently (NSAIDS, pyrazolone derivatives, naproxen, mefenamic acid, etc.)

-persons with FDE to pyrazolone derivatives are usually HLA-B22 positive

-stop offending medication & replace with alternative drug

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LESION IRRITANT CONTACT DERMATITIS -non-allergic inflammatory reaction of the skin -erythema vesicles, erosions, crusts, scaling

AGE OF PREDILECTION -any age

AREA OF PREDILECTION -in areas that has come in contact with irritants

HALLMARK

ETIOLOGY -alkalis: soaps, detergent, ammonia, lye, toilet bowl cleaners -acids: hydrofluoric acids, HCl, nitric, sulfuric acids -Ca, Cu, Hg, Ni, Ag, Br, Cl, Fl, I -chlorinated compounds: Chloracne -dog collars: Flea Collar Dermatitis -capsaicin: Hunan hand

PREDISPOSING FACTORS -condition of skin upon contact -skin may be vulnerable by reason of maceration from excessive humidity or exposure to water, heat, cold, pressure or friction

TREATMENT -alkalis: immediate application of a weak acid (vinegar, lemon juice, 0.5% HCl) -oxalic acids: lime water -phenol: 65% EtOH or isopropyl alcohol -fluorine: magnesium oxide -periungal burns: 10% calcium gluconate solution -phosphorus burns: rinse with water & apply copper sulfate -titanium HCl: wipe away, do not rinse!

OTHER INFO

ALLERGIC CONTACT DERMATITIS

-erythema, vesicles , erosions, crusts, scaling

-any age

-in areas that has come in contact with allergen (but it has to be previously sensitized)

-previous exposure to allergen

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