2.

NAIL PSORIASIS

Anatomical structure of the nail apparatus

DERMATOLOGY REVIEWER

1. Nail and Hair Changes • onychodystrophy

NAIL • proximal matrix: pitting, beau's lines
A. Onychomycosis • distal matrix: onycholysis
4 DERMATOPHYTIC
Types of Onychomycosis
ONYCHOMYCOSIS/TINEA UNGUIUM – infection of the nail plate by fungus • nail bed: oil spots- presence of yellow spots, subungual
Distal subungual Proximal White superficial
subungual hyperkeratosis, onycholysis, splinter hemorrhages
a. PARONYCHIA – swelling of the nail folds
Most common
T. rubrum T. rubrum, T. T. rubrum, T.
• proximal
b. & lateral nail folds:
ONYCHODYSTROPHY cutaneous
– destruction psoriasis
of the nailbed
megninii mentagrophytes, 4.• Moretreatment
commonly affected: FINGERNAILS
cephalosporium,
aspergillus, 5. Microscopicofinding systemic drugs/topical/intralesional
on KOH smear: PSEUDOHYPHAE WITH SPORES
fusarium o most common- Methotrexate (check for CBC,
Distal nail bed & Nail plate from Small, chalky TREATMENT
hyponychium proximal nail fold white spots over liver enzymes, check for CXR to r/o PTB or
1. Topical antifungals: CLOTRIMAZOLE, Amorolfine
Secondary Indication of HIV
the nail plate
pneumonitis)
2. Systemic antifungals:
involvement of infection • Nailàwith
a. multiple
TERBINAFINE pits, furrows,
250mg/tab 1 tab ODtransverse
x 6-8 weeksdepressions
for fingernails and 12-16 weeks for toenails
underside of nail
plate of fingernail (Beau's
b. Line) 200mg BID x 1 week per month for 2 months
Itraconazole
and toenails
Pathophysiology:
• NailFluconazole
c. plateàcrumbling
150-300mg with a smooth
1 tab or rough
once a week surface
for 6-12 months
d. Candidal onychomycosis: AZOLES
1. T. RUBRUM: starts at the distal corner of the nail → • Nail bedà with splinter hemorrhages
yellowish discoloration → spreads proximally → e. Precaution: LIVER DISEASE
SUBUNGUAL HYPERKERATOSIS (keratin) → entire nail Hyponychium->yellowish
3.• PHOTODYNAMIC green or brown
THERAPY – phthalocyanines and discoloration
photofrin displayed a fungistatic effect, whereas p
is affected → nail becomes BRITTLE and separated from
the nail bed • causeTypical nail changes
photodynamic in the
killing of psoriasis: irregular pitting of the nail
dermatophyte
2. T. MENTAGROPHYTES: starts with scaling of the nail
under the overhanging cuticle → entire nail is affected plate, detachment of the distal nail plate from the nail bed,
Microscopic finding on KOH SMEAR: LONG SEPTATED yellow macules seen on the nail plate
NAIL PSORIASIS
HYPHAE 1. The severity of nail disease may correlate with the severity of skin and joint disease
Tx:unknown
2.• Cause: Methrotrexate, Acitretin
CANDIDAL ONYCHOMYCOSIS * Ingrown nailàonly the lateral nail fold is swollen
1.1. Etiology:
Distal
C. Subungual
ALBICANS Onychomycosis:
2. Encountered mostly in: WET WORKERS Nail segment involved Clinical signs
•
3. Associated E: T. rubrum
with: Proximal matrix PITTING – result of
• Dry, brittle, lusterless nails with yellow brown parakeratosis
BEAU’S LINES – transverse
discoloration near the hyponychium; depressions
• Distal nail beds and hyponychium are affected. Distal matrix ONYCHOLYSIS – separation
• Debris present under the nail plate of the nail from the nail bed
Nail bed OIL SPOTS – yellow areas of
• MOST common type of fungal infection of the nail subungual parakeratosis
plate from the distal matrix
2. Proximal Subungual Onychomycosis Subungual hyperkeratosis
Onycholysis
• E: T.rubrum and T.megninii SPLINTER HEMORRHAGES –
• Indication of HIV found in the nailbed with
• Involves mainly the nail plate from the proximal nail reddish discoloration of a
part or all of the nailbed
fold Proximal & lateral nail folds Cutaneous psoriasis
3. White Superficial Onychomycosis / Leukonychia
trichophytica TREATMENT - persistent and refractory to treatment
• E: T. Mentagrophytes, Cephalosporium, Aspergilllus, C. Onychomycosis
1. Topical – GLUCOCORTICOIDS, Vit D analogues, 5-FU
Fusarium oxysporum (If HIV +, T. rubrum) topical: –clotrimazole,
2.• Intralesional TRIAMCINOLONE amorolfine
• Small chalky white spots on the surface of toe nail systemic
3.• Duration antifungals
of treatment: 2-4 MONTHS FOR FINGERNAILS, 4-6 MONTHS FOR TOENAILS

plate
4. PHOTOTHERAPY o &terbinafine
radiation 250mg/day 1 tab once a day for
5. Systemic – unproven efficacy; unresponsive to topical/IL treatment; with cutaneous involvement:
finger nails- 6-8 weeks, toenails 12-16 weeks
• NO paronychia or involvement of the undersurface of METHOTREXATE, ACITRETIN
the nail plate (T. mentagrophytes -> Superficial, can (DOC for dermatophyte onychomycosis)
be scraped off) o itraconazole
o fluconazole
• Invasion of the toe nail plate on the surface of the nail
o azoles if candida
4. Candida Onychomycosis
§ precaution: liver disease (LFTs)
• E: Candida albicans
• Involves ALL the nail plate; all the finger nails are D. Bacterial paronychia
dark, ridged, and separated from its bed • swelling with pus
• non-tender swelling of proximal and lateral nail folds
• E: S. aureus
w/c exudes a small amount of fluid when pressed
• mani, pedi
• produces destruction of the nail and massive nail bed
• treat with antibiotic
hyperkeratosis
• Seen in wet workers
HAIR
• associated with Paronychia (edematous, bulky) and
• Infundibular area (hair outside to entrance into skin)
Onychodystrophy (destruction of the nailbed)
• Middle portion (upto the attachment to arrector pili)
• (+) in patients with chronic mucocutaneous
• Lower portion
candidiasis
• Phases:
• Dx: KOH – Pseudohyphae with spores
o Anagen -synthesis phase 3 yrs, hair growth
• Tx: itraconazole 200mg BID x 1 week/month for 2
o Catagen- transition or recession phase 3 weeks
mons
o Telogen- resting phase 3 mos
• Hair growth: half an inch per month, 1.25 cm/month, 6
Nail discoloration:
inches per year No hair on palms, soles, labia minora
• Trichophytonà yellow
• Normally shed hair 100-150 strands daily
• Candidaà black/brown
• Pseudomonas aeruginosaà green Alopecia areata
• Ingrown nailà no discoloration • round/oval bald spot
• association with thyroid disease, DM
B. Psoriasis
• face- alopecia areata barbae
• nail pitting >20 pits (can also be seen in alopecia areata)
• "broken exclamation mark hair" (distal end is thicker and
• oil spots/salmon patches (pathognomonic)
more pigmented)
• subungual hyperkeratosis (thickening)
• can involve scalp or facial hair
• onycholysis
• good prognosis: postpubertal onset

MJDY 1
Blue - opd lecture
 DERMATOLOGY REVIEWER

• improve with corticosteroid injections or for children: topical • do the hair pull test (at least 40 strands) count of 4-6 hairs is
corticosteroids abnormal
• poor prognosis: atopic dermatitis, childhood onset, • rule out tinea capitis, pediculosis
widespread involvement, duration longer than 5 yrs, • excessive hair loss >100-150 strands
onychodystrophy, ophiasis (loss of hair along the temporal • 3 mos after stressful event: pregnancy, fever, surgery, rapid
and occipital scalp) wt loss, drugs (ASA), allergic contact dermatitis
• hair regrowth after 3-6mos
Alopecia totalis - loss of all hair in the scalp
Alopecia universalis - loss of all hair Trichotillomania
• hair pulling disorder
Telogen effluvium • assoc with OCD
• transient falling of hair due to premature entry into telogen • hair at varying lengths
phase • Check if scarring (SLE) or non scarring (alopecia areata)
• thinning of hair

2. Erythematous Lesions
A. Non-scaly Plaques

1. Miliaria Rubra § Dull red (3-5mm) appear during

• Extremely pruritic rash on trunk, antecubital fossa, popliteal active scabies with or without
fossa itching
• Multiple pin-point papulovesicles overlying a bed of § Scrotum, penis, vulva
erythema § Tx: Intralesional steroids, tar,
• Site of injury: Prickle cell layeràwhere spongiosis is excise
produced o Crusted/Norwegian/Hyperkeratotic
• Due to occlusion of eccrine sweat glands (resolved by § Immunocompromised or debilitated
Canolin ointment), S. epidermidis patients
• The level of obstruction of the sweat glands determines the § Face, scalp. Genitalia, buttoks,
clinical type pressure bearing areas
• The disease is NOT self limiting 3. Insect Bites
• Most effective tx: place px on a cool environment • Multiple, erythematous pruritic papules with a CENTRAL
• Non follicular distribution PUNCTUM over the exposed areas of the body
o Immediate central punctum – inflammatory
o Delayed central punctum – secondary to host
2. Scabies
response
• Primary lesion: Papulovesicule
• May also present as a vesicular lesion
• E: Sarcoptes or Acarus (“uncut-table ) scabei, the itch mite
• Tx: Topical -> Intralesional steroids or excision
o Adult males are smaller than females 

o Crawl as fast as: 2.5CM/MIN 
 Bed Bug / Cimicosis
• Multiple pruritic erythematous papules scattered over the • E: Cimex lectularis (Temperate), C. hempiterus (Tropical)
trunk, finger, toe webs, extremities, genitals, buttocks • Erythematous papules or urticarial lesions grouped together
(CIRCLE OF HEBRA – imaginary circle affected scabies) in rows
• Intense pruritus at night, other family members have similar • Linear lesions
lesions
• Dx: Diascopic exam -> Hemorrhagic dot in the middle of
• May present as a vesiculobullous lesions most lesions
• Face and scalp are spared in adults • Tx: Antipruritic or topical corticosteroid, Zinc lotion, (Severe)
• Sensitization begins 2-4 weeks after onset of infection Systemic corticosteroids
•
• Dx: Microscopic view of burrows under India ink or Gentian
violet Reduviid Bites
o Burrow in the stratum corneumà characteristic • E: Trypanosoma cruzi
lesion seen in scabies • Typically PAINLESS
• TRIAD: • ROMANA’S SIGN
o Circle of Hebra o Unilateral eye swelling after a nighttime
o Nocturnal Itch encounter with the etiologic agent (T. cruzi)
o (+) in contact people at home
• Tx:
o 5% Permethrin lotionà standard tx for scabies Mosquito Bites
§ Apply from neck down. Leave on • Multiplt pruritic, often, excoriated papules
overnight for 8-10 hours and rinse • Bullous reaction -> CULICOSIS BULOSA
off in the morning. Use once a Large blisters -> PEMPHIGUS HYSTERICUS
week for 2 weeks • Drinking alcohol may attract mosquitos
o Crotamiton (Eurax cream or lotion)àrubbed
• Tx: Antipruritics, Corticosteroid creams, Oral antihistamine,
into the skin from neck to feet
Insect repellants, Protective clothing
o Lindane (Gamma benzene
• May have secondary infection (Common in children)
hexachloride)àMOST effective scabicide;
NEUROTOXIC for infants • Common cause of papular urticarial
o Ivermectrinà used as tx for nodular scabies • May play a role in latent EBV reactivation
(dull red nodules that may persist on the • Severe reaction in young children and immunocompromised
scrotum, penis)
o 6-10% Precipitated sulfur in petroleum à SAFE Flea Bites / Pulicosis
for pregnant women • Multiple, irregularly distributed wheals grouped or arranged
• May be: in zigzag lines
o Nodular • Hypersensitivity reaction results to nodules or bullae

MJDY 2
 DERMATOLOGY REVIEWER

• E: (4 species)
o Cat Flea (Ctenocephalides felis) 4. Pediculosis
o Human Flea (Pulex irritans) • Capitis
o Dog Flea (Ctenocephalides canis) o E: Pediculosis humanus var capitis
o Oriental Rat Flea (Xenopsyllacheopis) o (+) VISIBLE NITS: whitish concretions on hair
• Dx: Diascopic exam -> Central hemorrhagic bite site shaft but most common in retroauricular area
(Purupra Pulicosa) o intense pruritus of the scalp,hair becomes dry
• Tx: Topical and systemic antipruritic treatment, and lusterless
corticosteroid, pet grooming, insect repellant o rust to whitish scales that are very adherent to
the scalp
Ant Bites o Tx: 1% Permethrin Shampoo
• Painful stings with in seconds of bite with associated § Apply to DRY hair and scalp in
whealing secretions. Leave on and occlude
• May become sterile pustule with erythematous hemorrhagic for 10-15 mins. Rinse off
halo thoroughly. Use once a week for 2
• If severe, anaphylaxis, seizure, mononeuropathy weeks. Do not use any shampoo
• Tx: Ice packs, Oral antihistamines, Topical antipruritics, for 24 hours.
Corticosteroids • Corporis
• If with secondary infection, give ANTIBIOTICS o aka Pediculosis vestimenti, Vagabond's disease
o E: Pediculosis humanus var corpori
Bee Sting o erythematous macules, urticarial wheals,
• Reaction of venom (pain to local edema) excoriated papules
o Copper colored macules or urticarial wheals
• 7-10 days after sting: SERYM-LIKE SICKNESS (Fever,
and lichenification
urticarial, joint pain)
o generalized itching, parallel scratch marks
• Venom contains:
o hands and feet are spared!
o Histamine
o 2-6 weeks: Sensitization
o Mellitin
• Pubis
o Hyaluronidase
o E: Phthirus pubis
o HMW substance
o Maculae Cerulae
o Acid phosphatase
o If (+), search for other STD
o Phospholipase A
o peculiar non-pruritic bluish or slate-colored
• Tx:
macules due to altered blood pigments of the
o Local reaction: Immediate application of ice
infested humans or the excretion products of
packs, topical anesthetics
the louse’s salivary glands
o Chronic reactions: Inject Triamcinolone with
o Tx: Permethrin pythern + piperonyl butoxide for
Lidocaine
1 week
o Severe reactions Oral prednisone
o Severe systemic reaction: Epinephrine IM,
5. Acne Vulgaris (see discussion on pustular diseases)
Corticosteroids

B. Non-scaly Nodules
1. Furunculosis
• Etiology: Staphylococcus aureus
• Erythematous fluctuant swellings/perifollicular staphylococcal abscess (4cm in diameter) with CENTRAL suppuration at the upper back, nape,
axilla
• Carbuncles: 2 or more furuncles with multiple heads
• Extremely PAINFUL!
• Lesions begin around a hair follicle and continue by autoinoculation
• “Blind Boils”àwhen lesions disappear before rupture
• Brain abscessàserious complication when furuncle is within the triangle of the face around the kips and nose
• 1 or 2 exposures to x-raysà best treatment
• Avoid incisions when the lesions are incipient and acutely inflamed; Incision and draineage should only be done when the furuncles have
become localized and show definite fluctuation and when medications fail
• Tx:
o Mupirocin ointment (Bactobran)à applied to the nares for 5 days
o Cloxacillinà DOC
o Penicillinase-R penicillin
o 1st gen Cephalosporin (Oral) -> for deep lesions (Topical will not work)
• To eradicate carrier state:
o Daily chlorhexidine wash
o Rifampicin + Dicloxacillin (10days)
o Sulfa-TMP (MRSA) (10days)
o Low dose Clindamycin (3months)

C. Non-scaly Plaques

1. Fixed-Drug Eruption to medications

• Persistent hyperpigmented round patch that becomes • “Targetoid” Lesion (2 zones)
erythematous and blisters every time patient takes • Red patchàevolves into target or iris lesionàbecomes a
medications blisteràerodes!
• Usually < 6 lesions • May progress to SJS secondary to anticonvulsant use
• Prolonged / Permanent postinflammatory hyperpigmentation • If non pigmented, by PSEUDOEPINEPHRINE HCl
• “Fixed”because occur at the same site with every exposure (“Bamboo” syndrome)

MJDY 3
 DERMATOLOGY REVIEWER

• At 1st intake: • May have angioedema

o Erythema • Rarely > 12 hours (If > 24 hours, do a biopsy)
o Hyperpigmentation • Features:
o Redness + increase in size + pruritus o Mild dermal edema
• Features: o Neutrophilic margination within post capillary
o Normal stratum corneum venules
o Chronic changes in dermis o (-) karyorrhexis and fibrin deposition
§ Papillary fibrosis § If (+) karyorrhexis, vasculitis
§ Pigment incontinence • Tx: Avoid trigger, Antihistamine (If chronic, daily dosage)
o (+) Eosinophils and neutrophils
o No hyposthesia or anesthesia 5. Erythema multiforme (Erythroderma)
• Typical target or iris lesions
2. Erysipelas / St. Anthony’s Fire o 1.)central dusky purpura
• E: Streptococcus pyogenes (most common) o 2.) elevated edematous pale ring
• Fiery red hyperemic swelling w/characteristic raised o 3.)surrounding macular erythema
indurated border • Caused by
• Distinctive featureàADVANCING EDGE of the patch o Herpes Simplex Virus (Adult: 1>2)
• PAINFUL! (Spread peripherally) o Child: Mycoplasma pneumoniae
• Erythematous warm swollen plaque on the legs; plaque has • A hypersensitivity reaction presenting with various type of
well-defined borders lesion consisting of erythematous macules with dark center
• Face, legs (seen ASAP), perineum and abdomen (in
postpartum female) Erythema multiforme major
• Ddx: • multiple purpuric macules, blisters, atypical targets scattered
o Acute tuberculoid leprosy -> no prodromal all over the body
symptoms and leukocytosis • with/ painful oral ulcers, dysuria, photophobia
o Furuncle • more than 2 mucosal involvement
o Cellulitis (Spread peripherally) Erythema multiform minor
• Tx: • multiple erythematous macules and papule, some of which
o Systemic penicillin for 10 days (Response: 24- showed dark purpuric centers of 3 days duration
48 hours) • Lesions started on palms and soles accompanied by painful
o Erythromycin erosions on the oral mucosa.
o Locally: Ice bags / Cold compress • 1 mucosal involvement

6. Exfoliative Dermatitis
• Generalized erythema and scaling with >90% involvement
*Furuncle & Erysipelas • Generalized erythema, severe pruritus, extensive scaling,
• Inflammation fever and chills, lymphadenopathy
• Pain • Px has a previous hx of pre-existing dermatoses such as
• Acute onset psoriasis, atopic dermatitis, eczema, allergic contact, irritant
contact dermatitis
3. Cellulitis • Allopurinolà one of the most common drugs causing
• E: Beta Hemolytic Group A Streptococcus (most frequently exfoliative dermatitis
Strep pyogenes) and Staphylococcus aureus • Hodgkin’s diseaseà may present with generalized
• At leg via T. pedis infection exfoliative dermatitis
• Suppurative inflammation of the subcutaneous tissue • Tx: Topical steroids
WITHOUT central suppuration
• Tender, erythematous warm swollen plaque on the legs with 7. Hansen's Disease (Leprosy)
ill-defined borders (deepness) Etiology: Mycobacterium leprae
• May have fever and chills A. Early and Indeterminate
• Complications: • Solitary, ill-defined hypopigmented macule that merges w/
o Gangrene normal skin
o Mets abscess • Peripheral nerves not enlarged
o Sepsis • Biopsy:NO granulomas nor bacilli
• Tx: B. Tuberculoid Leprosy
o Systemic Penicillin (Best tx) • Anesthetic, single, large erythematous plaque with a
o Cefazolin sharply-defined elevated border and an atrophic center;
o Vancomycin lesions are solitary or few (<3 lesions); (+) Lepromin test;
o If deep, IV penicillinase-R penicillin or Oral 1st good cell-mediated immunity
gen Cephalosporin • If the smear shows NO bacilliàperform Skin Prick Test,
Skin Punch Biopsy, Check for Nerve Involvement
C. Borderline Tuberculoid Leprosy
4. Urticaria (Hives, Nettle Rash, Cnidosis) • Lesions similar to Tuberculoid Leprosy but smaller and more
• Caused by mast cell degranulation -> increased histamine numerous (3-10 lesions)
release • SATELLITE lesions around large MACULESàcharacteristic
• Food, Drugs, Infections, Emotional stressà MOST common lesion
causes D. Borderline Leprosy
• May be ACUTE (< 6 weeks) or CHRONIC (> 6 weeks) • numerous but countable red, irregular plaques;
o *Acute Urticariaà caused by dietary SATELLITE lesions around larger PLAQUES; lesions are
indiscretions, drugs such as Penicillin and generalized but symmetrical
Sulfonamides, physical allergies E. Borderline Lepromatous Leprosy
• Characterized by multiple wheals surrounded by a red halo • too many too count, includes macules, papules, plaques
or flare accompanied by severe pruritus over the face neck and nodules
and extremities F. Lepromatous Leprosy-

MJDY 4
Diascope
 DERMATOLOGY REVIEWER
-test for blanchability

• w/numerous bacilli in the lesions; mainly pale lepromatous • advise: exercise, leg elevation
-blanching (dilatation macules;ofwith BV) vsgranulomas
well-formed non on blanching
biopsy (extravasation
• of RBC)

first line: antihistamine
• colchicine, dapsone
-blanching:Tx:erythema,
For monthly multidrugsunburn, photosensitivity,
therapy for multibacillary patientsà Dapsone, urticaria,
• angioedema,
in children: Henoch Schonlein Purpura (usually preceded by
Rifampicin, Clofazimine URTI Gr. A Strep)
dermographism, morbilliform drug eruption,
For daily therapy of Hansen’s diseaseà Dapsone, Clofazimine EM, exfoliative dermatitis
-Nonblanching: purpura, vasculitis
 *Topical steroid use
* Histoid Leprosyà yellow-red, shinny, large papules and nodules in • potency of steroids (ointment > cream)

 the dermis and SQ tissue. • vehicles of steroids
Hallmark of leprosy is involvement of nerve • location (mild if axilla, groin)
Sunburn
 * Fite Faracoà special stain used in histopathologic specimens of
Hansen’s disease
• size
• lesion (LSC = thick = ointment)
-erythema, tenderness, blistering

Main side effect of rifampicinà Hepatotoxicity
Main side effect of clofazimineà blackish-red discoloration of the skin
*Chronic steroid use side effects:
-UVA: aging; UVB causes sunburn; UVC: ozone

Main side effect of dapsoneà hemolytic anemia
1. Acneform
-water resistant: 40mins;
8. Leukocytoplastic Vasculitiswater proof: 80mins

2. Skin atrophy
3. Hypopigmentation
• hallmark: Palpable Purpura (inflammation of blood vessels)
-spares suncovered•
areas

secondary to extravasation of RBC from blood vessels-
4. Steroid Purpura
5. Telangiectasia

 • type 3 hypersensitivity 6. Permanent striae
• confirm dx with biopsy

D. Non-scaly Patch
1. Phototoxic Dermatitis
• Non-immunologic; develops after exposure to light w/ greater amount of photosensitizing substance, no hx of sensitivity to a particular
substance; sunburn type of reaction; w/erythema, tenderness, blisters on sun exposed area.
• UVAà the actual spectrum of light for phototoxic drug reactions

2. Photoallergic Dermatitis
• Immunologic; pruritic eruptionàlichenificationàthick plaques; involves the neck, face, forearms, dorsum of hands, and sun-exposed areas

Phototoxicity: type 3 hypersensitivity

MJDY 5
 DERMATOLOGY REVIEWER

E. Erythematous Lesions with Eczema

Moist/Oozing Dermatitis

1. Atopic Dermatitis • Caused by worsened after immunizations & viral infections

• Areas of predilection in each age group: • Usually in 2 mos – 2 yrs of age
o Infants < 2y/o: Face, extensors • Seen in cheek, scalp, neck, forehead, wrists, extensor
§ Spares the diaper area (vs Seb extremities (areas involved correlates with capacity of child
Derm: (+) diaper area) to scratch/rub site & with baby’s activities like crawling)
§ Face: cheeks! Spares the central • Dx: Blinded food challenges Assays for food – specific IgE,
face Prick testing
§ May also have edema and • Tx:
erythema exacerbated by saliva o Partial remission during summer & relapse
o Childhood 2-12y/o: Antecubital fossa, popliteal during winter (due to therapeutic effects of UVB
fossa, flexures, neck and humidity & aggravation by wool & dry air)
o Adult >12y/o: Flexures, lichenification o Evaporation barrier immediately after bathing
(thickened with exaggerated skin markings) -> White petrolatum Aquaphor & vegetable
less exudative shortening
• Hereditary tendencies to develop allergies to food, inhalant o Protection of affected part from scratching &
substances rubbing
• Moist plaques with crust • Dry Infantile AD: associated with xerosis (dry skin),
• Multiple intensely pruritic erythematous plaques with scaling keratosis pilaris
and excoriations located on the nape, antecubital, popliteals
• With family hx of allergic rhinitis, asthma Childhood AD
• Pathology: Defective skin barrier • Less exudative
• ITCHSCRATCH CYCLE! • Often lichenified, indurated plaques
• Skin lesions appeared on the area where there was • Itch – scratch cycle:
application of diclofenac (voltaren) gel o Pruritus leads to scratching & scratching causes
• Associated with immunological imbalance secondary changes that causes itching
o IgEàsignificantly increased • Seen in antecubital & popliteal fossa, flexor wrists, eyelids,
• Temporarily improved with topical steroids face, neck
• The diagnostic criteria has been modified for young children • Scratching impulse is usually beyond control of px (itching is
and this includes: pruritus, typical facial or extensor same as lichen simplex chronicus -> compelling,
dermatitis, history of atopic disease paroxysmal) – inability to feel pain during paroxysms
• Dennie-Morganà linear transverse fold just below the edge • Severe AD (>50% body surface area involved) – associated
of the lower eyelids with growth retardation
• Tx: o Topical calcineurin inhibitors
o Moisturizer! (macrolactams)/photo therapy may allow for
o Mild to Mod: Low-Mid potent topical CS and/or rebound growth
TCI (topical calcineurin inhibitor)
o Mod to Severe: Mid-high TCS and/or TCI Adult AD
o Recalcitrant, severe: Systemic therapy (ex. • Localized, erythematous, scaly, papular, exudative, or
Cyclosporine, Methotrexate) -> DO NOT GIVE lichenified plaques
PREDNISONE, UVA therapy • Staphylococcal colonization is universal
• Hand dermatitis: most common problem for adults w/ hx of
Hanifin and Rajka Criteria AD
Must have MAJOR 3/4 and MINOR 3/23 • Caused by:
MAJOR MINOR o Wet work (Especially implicated in hand
• Pruritus • Dryness eczema)
• Rash on face and/or • Dennie-Morgan folds o After birth of 1st child
extensors in infants • Allergic shiners o Soaps
and young children • Facial pallor • Seen in: (Adolescents)
o Lichenification • Pithyriasis alba o Antecubital & popliteal fossa, front & sides of
in flexural • Keratosis pilaris neck, forehead, area around eyes
areas in older • Icthyosis vulgaris • Seen in: (Adults)
children • Hyperlinearity of palms and o Chronic hand eczema is common
• Tendency toward soles • Dermatitis is uncommon after middle life
chronic or chronically • White dermatographism • Tx:
relapsing dermatitis • Conjunctivitis o Topical corticosteroid (Mainstay)
• Personal or family • Keratoconus o Avoid extremes of cold & heat
history of atopy o Avoid overbathing
• Anterior subscapular
(Asthma, Allergic § Tepid showers, not hot
cataracts
rhinitis, AD) • Itching usually occurs in response to heat/stress, during the
• Elevated serum IgE
evening when trying to relax, or at night
• Immediate skin test
reactivity • Flares may be due to acute emotional stress (decreases itch
threshold)
Infantile AD • Mild stigmata of dry skin & irritation remain even after
recovery
• 60% present in 1st yr of life (usually >2 mos of age)
• Usually begins as erythema & scaling of cheek
2. Seborrheic Dermatitis
• Lesions may be papular or exudative
• E: Pityrosporum ovale

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• Mild form: Dandruff (E: P. sicca) trunk

• “Cradle Cap” -> seen in infants • Tx:
o yellow/brown scaling with adherent epithelial o Simple soaking & greasing w/ occlusive
debris on scalp ointment
• Area: Scalp, eyebrow, eyelashes, nasolabial fold, § NSS compress (Dissolve 2 tsp of
retroauricular area, glabella, forehead, sternal area, upper rock salt in 1L of water.
back, diaper area in infants Compress/Soak affected area for
• “Generalized Exfoliative Erythroderma / Erythroderma __ mins, __ times/day)
Desquamativum” • To repair skin barrier –
o Lesions are generalized good for open / oozing
• Scaling on erythematous base + Severe itching (More lesions
severe itching than AD) o Antibiotics + Corticosteroid
• Recurrent moist, slightly erythematous patches and plaques o Antihistamine
with chronic, superficial, inflammatory disease of the skin o If refractory to topical medications: Intralesional
• scanty, loose, moist, yellowish, greasy skin scales and crust or systemic steroids
located over the glabella, nasolabial folds, scalp o If with secondary infection (usually by Staph):
• (-) Auspitz sign (vs. Psoriasis -> (+) Auspitz sign and goes Antibiotics
beyong the hairline)
• with remissions or exacerbations *AD vs Nummular Eczema
• Falling hair may also be the complaint of patients with this • May be very similar to AD but different in site of predilection
& presentation (coin shaped). Although AD may be
inflammatory condition presenting as dry loose
whitish/yellowish scales on the scalp and eyebrows nummular in adolescents, AD is more chronic & lichenified.
• Recalcitrant seborrheic dermatitis: HIV
4. Infectious Eczematoid Dermatitis
o Malassezia ovalis and abnormal immune
• Precipitating factors:
response
o Diabetics w/ non – healing wounds
• Tx:
o Chronic otitis media, eye, nose, vaginal
o Adults: Only control because this will not go
discharge
away, Symptomatic treatment
o Topical antifungals (Ketoconazole) + Topical • Cause of the distant dermatitis is not the same as the cause
of the local one
calcinearia inhibitor (Mainstay)
o Corticosteroid (side effect: steroid rosacea) -> if • Widespread dermatitis or dermatitis distant from a local
with erythema inflammatory focus
o Mild shampoo for babies • Generalized acute vesicular eruptions associated with
o Mineral oil 15 mins before shampooing chronic eczema of the legs w/ or w/o ulceration
• Dermatitis that develops on the area macerated by the
3. Nummular Eczema discharge from an infected ulcer or sinus
• E: Unknown, Emotional stress, Alcohol, Atopy, Trauma • Pruritic, vesicular, pustular or crusted dry and scaly
(Koebner’s phenomenon) eruptions
o (+) Koebner’s phenomenon: formation of • Often in linear configuration
lesions after trauma • AUTOSENSITIZATION to the dischargeà skin becomes
• RF: Dry skin (therefore MOISTURIZE!) sensitized to bacterial or tissue chemical substances
• Discrete, round, well-circumscribed or coin-shaped • Usually develops about a:
erythematous, edematous, vesicles, papules and crusted o Discharging abscess
patches o Ulcer
• Papules -> Vesicles -> Coalesce to a plaque o Sinus
• (+) Severe, paroxysmal & nocturnal pruritus o Fistula
• A recurrent disease • Tx: Antibiotics, Oral glucocorticoids
• Old lesions expand by tiny papulovesicular satellite lesions • IMPORTANT: do antibiotic sensitivity testing to treat the
at the periphery fusing with main plaque underlying cause
• Seen in: Shin/Lower leg, dorsum of the hand, arm extensor,

MJDY 7
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5. Contact Dermatitis
CONTACT Cause / Precipitating / Age & Area of
Description Treatment
DERMATITIS Risk Factors Predilection
Irritant Contact Inflammatory reaction • Acids Hands Topical steroids This is a non –
Dermatitis to a substance that • Alkaline materials (Betamethasone, allergic inflammatory
causes eruptions in (soaps/detergents) Lesions sharply Clobetasol response. No
most people Solvents circumscribed to propionate) previous exposure
• Diaper contact area; no necessary.
Hallmark: Pain & distant lesions Effect is evident w/in
burning! Acute: direct cytotoxic mins/hrs
damage to
Lesions: necrosis & keratinocytes
ulceration
Chronic: slow damage
Includes most to cell membranes by
occupational contact CHON denaturation &
dermatitis cellular toxicity
Allergic Contact Inflammatory reaction • Poison ivy More intense in Topical Steroids Lesions appear 24 –
Dermatitis / only among people • poison oak contact areas but 72 hrs after
Dermatitis Venenata who have been • poison sumac may have distant exposure, but may
previously • Nickel/other metals lesions develop as early as 5
sensitized (delayed • Medications hrs or as late as 7
reaction) (antibiotics, Ddx: FEET (T. pedis) days after exposure
anesthetics, topical - (+) KOH
Genetics if a factor meds) - (+) interdigital Example: moist
• Rubber/latex area erythematous
Delayed type • Cosmetics patches on dorsum of
hypersensitivity, Cell- hands and wrists of
(Cologne/Fragrance)
mediated laundry woman noted
• Fabric & clothing
hypersensitivity after washing of
• Detergents
reaction clothes
• Adhesives Perfumes
Erythematous • Jewelry
papules, vesicles, • Shoes
linear & symmetrical • Hair dyes (Causes
lesions w/in scratch angioedema and
marks erythema along
hairline)
Hallmark: Itch! • Oil resins
• Insecticides
Lesions: • Products of bacteria,
Erythematous fungi, parasites
papules, vesicles, • Tattoo (due to PPD)
and linear and
symmetrical lesions
within scratch marks,
may have scaling

* Diaper/Napkin Dermatitis
• Alkaline irritative effects of ammonia formed in wet * Irritant Hand Dermatitis / Housewife’s Eczema
diaper • Causes dryness/redness of fingers
• Risk factor: frequent maceration • Chapping at back of hands, erythematous hardening
• Highest incidence: 6 – 12 mos of age of palms, fissuring
• Lower abdomen, genitals, thighs, convex surfaces of • Under rings when not removed during washing
buttocks • Tx: Betamethasone dipropionate, Clobetasol
• Use diaper w/ superabsorbent gel proprionate, Triamcinolone
• Frequent change of diaper
• Topical hydrocortisone
• Zinc oxide paste

6. Intertrigo o Candidal intertrigo (Satellite pustules. Tx:

• Superficial, inflammatory reaction caused by friction, heat, Azoles)
moisture o Inverse Psoriasis -> erythematous base with
• Well-delineated, circular, moist patch in flexural areas scaling on the umbilicus
• Occurs where to skin surfaces are in apposition • Areas of predilection:
• Result of friction, heat, moisture -> affected fold becomes o Retroauricular areas, folds of upper eyelids,
erythematous, macerated, secondarily infected creases of neck, axillae, antecubital areas,
• Precipitating factors: Hot & humid weather, Obesity, DM & finger webs, inframammary areas, umbilicus,
hyperhidrosis popliteal spaces, toe webs, gluteal folds
• May be seen in Children & elderly o Inframammary area in obese women: most
• Ddx: frequent site of intertriginous candidiasis
o Tinea cruris o Groin: fungal infection

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• Tx: o Varicosities
o Eliminate maceration Local • Usually in elderly (rarely occurs before 5th decade of life)
antibiotics/fungicides Separate apposing skin • Goal of treatment: Symptom relief
surfaces w/ gauze or other dressings • Tx of underlying venous insufficiency, Emollients – for
o Castellani paint, polysporin ointment, low pruritus & eczema, Topical corticosteroids, Support
potency topical steroid stockings

7. Stasis Eczema 9. Breast Eczema/Nipple Eczema

• Erythema/yellowish/ light brown pigmentation of lower 1/3 of • Common among nursing mothers
legs especially superior to medial malleolus (Medial lower • Occurs around the areola
leg) • Exacerbated by SALIVA and TIGHT BRA
• Hyperpigmentation due to melanin & hemosiderin • Oozing lesions with painful crusting
• Predisposing factors: • Tx: Wash area after breastfeeding
o Cutaneous marker for venous insufficiency • If unresponsive to tx, Check for mass on breast and axilla
(underlying factor for the development of the and DO BIOPSY to rule out Paget’s Disease
disease)
o Persons with heart failure, varicose veins, 10. Dyshidrotic Eczema
recent trauma of legs – greater risk • Tapioca- like deep seated vesicles on the lateral hands/feet
• Blotchy, red mottling w/yellowish or light brown pigmentation • Tx:
of the lower inner 1/3 of the legs o NSS compress
• Associated signs: § Dissolve 2 tsp of rock salt in 1L of
o Swelling/Edema may be noted late in the water. Compress/Soak affected
afternoon and spontaneously relieved in the area for __ mins, __ times/day
morning o Steroid

Dry, Chronic Eczema

1. Lichen Simplex Chronicus (Neurodermatitis Circumscripta) pruritus

• Lesions are lichenified: Exaggerated skin lines • Multiple severe itching nodules (pea – sized or larger; 3 –
o Thickened leathery skin, rough 20mm)
o exaggerated skin markings from normal skin • Chronic disease, lesions evolve slowly
markings • Symmetrical & usually linear arrangement
• most often hyperpigmented, erythematous, may be topped • itchy nodules, usually at the extensors (anterior legs)
with scaling • may be topped with excoriations and scaling
• Pathogenesis- secondary from an underlying cause, check • underlying cause- arthropod bites, xerosis (always
for atopic dermatitis investigate the cause)
• There is a habitual itch-scratch cycle • Any age but mainly in adults (20 – 60 y/o) M=F
• Paroxysmal pruritus • Areas: Anterior surfaces of thighs & legs Forearms, trunk,
• Criss – cross pattern: between is a mosaic composed of flat neck
– topped, shiny, smooth, quadrilateral facets (lichenification) • Dx:
• Circumscribed, lichenified, pruritic patches o Visual examination
• Excoriated papules (sometimes w/ bleeding), slightly scaly & o Biopsy
moist, rarely nodular o Blood tests, liver, kidney, thyroid fxn tests
• E: Chronic rubbing & scratching • Important to apply moisturizer
• Stress and anxiety are important causative factors • may give high potent corticosteroids, intralesional injection
• Associated with topic or allergic contact dermatitis, anxiety, • address underlying cause
nervousness, depression • Initial tx: intralesional or topical administration of steroids
• Areas: Nuchal area (female), scalp, ankle, lower legs, upper • Other measures:
thighs, exterior forearms, vulva, pubis, anal area, scrotum, o Keep in cool areas, avoid hot baths or showers
groin and wool clothing
• Best Tx: o Use soap only in axilla & inguinal area
o Stop scratching! o Antihistamines
o Cover affected areas at night to prevent o Antipruritic lotions/emollients
scratching while asleep o PUVA
o Topical steroids: Clobetasol propionate, o Vit D3, tacrolimus Cryotherapy
betamethasone dipropionate cream/ointment –
used initially Prurigo Mitis
o Triamcinolone suspension • Worsened after immunizations & viral infections
• Goal of treatment is the cessation of pruritus • Mild form of chronic dermatitis characterized by recurrent,
intensely itching papules & nodules
2. Prurigo Mitis/ Prurigo Nodularis • Severe itching -> excoriation, eczematisation
• Single or multiple itching nodules with excoriations situated • Age: Early childhood
chiefly on the extremities especially on the anterior surfaces • Dx:
of the thighs and legs. o Blinded food challenges Assays for food –
• Due to constant picking and scratching specific IgE
o Prick testing
Prurigo Nodularis • Initial tx: intralesional or topical administration of steroids
• E: • Other measures:
o Unknown o Keep in cool areas, avoid hot baths or showers
o Atopic dermatitis, anemia, Hep C, pregnancy, and wool clothing
stress, etc. o Use soap only in axilla & inguinal area
o Chronic renal failure: o Antihistamines
§ most common internal cause of

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o Antipruritic lotions/emollients o Vit D3, tacrolimus Cryotherapy

o PUVA
F. Papulosquamous Disease
1. Tinea Capitis in size
• Scalp ringworm • 1 or more circular, sharply circumscribed, slightly
• Etiology: Ectothrix Microsporum canis erythematous, dry, scaly, hypopigmented patches
• Most common: T tonsurans & M canis • Well-defined erythematous plaque with progressive
o T. tonsurans central clearing and whitish scales
§ Black – dot ringworm • Depth of infection usually limited to epidermis & its
§ Subtle seborrheic – like scaling appendages
§ Inflammatory lesion • See annular outlines (ringworm)
§ Large spore endothrix • May have advancing scaly borders
§ (-) fluorescence in Wood’s light • Dx:
§ Culture: granular/powdery, yellow o KOH exam of skin scrapings (get from active
to red, brown colony border of lesion -highest yield of fungal
o M. canis elements)
§ Scaly, erythematous, papular o Fungal culture
eruptions with loose & broken – off o PCR
hairs - > inflammatory o Skin biopsy (see septate branching hyphae in
§ Small spore ectothrix stratum corneum)
§ (+) fluorescence in Wood’s light • Tx includes Griseofulvin, Terbinafine, Itraconazole,
§ Culture: profuse, cottony, aerial Fluconazoles
mycelia; buff to light brown o TOPICAL: localized disease w/o fungal
• Pathogenic dermatophytes (Except: Epidermophyton folliculitis
floccosum &Trichophyton concentricum) § Sulconazole, miconazole,
• Incubation period: 2 – 4 days itraconazole (give 2 – 4 wks)
• Non inflammatory type: Areas of alopecia with broken off § Terbinafine,
hairs (Manifesting as black dots) § Ketoconazole – give for 1 wk
• (+) Hailess patch, scales, broken hairs o Combination with a potent corticosteroid may
• Erythematous papules, nodules and pustules on hairless cause widespread tinea & fungal folliculities so
patch on the scalp may be a presentation avoid using CS!
• Age of Predilection: Children (Boys > Girls) o SYSTEMIC: for extensive disease/fungal
• Seen in scalp, glabrous skin, eyelids, lashes folliculitis Griseofulvin, terbinafine, itraconazole,
• Dx: fluconazole
o Wood’s light
o Fungal fluorescence (Fluorescent substance: • Variants:
pteridine) (+) if bright green or yellow green o Fungal folliculitis (Majocchi granuloma)
o 10 – 2% KOH solution § Infection of hair follicles w/
§ Findings: pattern of endothrix/ granuloma formation
ectothrix § Usually in F who shave legs
o Culture (growth in 1 – 2 wks) § T rubrum/mentagrophyte
• Tx: o Tinea imbricate
o Drug of choice for children: Griseofulvin tablet § Concentric ring of scales, extensive
o Griseofulvin (2 – 4 mos) Terbinafine (for patches w/ polycyclic borders
tricophyton infections; 1 – 4 wks) § T concentricum
Itraconazole/fluconazole (2 – 3 wks) o Tinea incognito
o Selenium sulfide shampoo or ketoconazole § Atypical presentation due to
shampoo (adjunct) corticosteroid tx
o Kerion celsii: systemic steroids + antifungal o Tinea gladiatorum
• Kerion celsii: deep tender (Inflammatory) boggy plaques § Skin to skin contact in wrestlers
exuding pus; cause scarring & permanent alopecia
• Favus: concave, sulfur – yellow crusts around loose, wiry Tinea Cruris / Jock Itch/ Crotch Itch
hairs; atrophic scarring results to smooth, glossy, paper – • Etiology:
white patch o Trichophyton rubrum (most common),
• Scutulae: cupshaped crust on glabrous skin, < 2cm, mousy Epidermophyton floccosum, T mentagrophytes
odor o They produce keratinases that allow invasion of
cornified cell layer of epidermis
Tinea Corporis / Tinea Circinata • Risk factors:
• E: o Warm & moist areas
o T rubrum – most common o Tight – fitting clothes
o M canis – causes moist type o Autoinoculation (athlete’s foot & ringworm)
o T mentagrophytes o Direct skin-to-skin contact/fomites
• Mode of transmission: o Obesity, DM, immunocompromised
o Contact w/ infected human (most common) • Age of Predilection: Adult men
o Contact w/ contaminated household pets, farm • Areas: Upper & inner surface of thighs, Perineum & perianal
animals, fomites areas
• Widespread tinea corporis may be a presenting sign of AIDS • Pruritic erythematous patches with well-defined and
or related to the use of a topical steroid or calcineurin elevated borders containing papules or vesicles and clearing
inhibitor at the center, located in both inguinal areas
• Age of Predilection: Preadolescents F>M • Begins as small, erythematous scaling or vesicular &
• Area: Neck, extremities, trunk crusted patch that spreads peripherally and partly clears in
• History reveals that the lesion started as a pruritic circinate center
or annular erythematous macule which gradually increased • Patch: curved, well – defined border, particularly on lower

MJDY 10
 DERMATOLOGY REVIEWER

edge • Erythema, scaling,

• Dx: KOH wet mount, Growth on Mycosel/Saboraud agar maceration extend up
plates to dermis
• Ddx: Candidal infection may mimic this (difference is the • Complicated by
presence of satellite pustules in candida) secondary bacterial
• Tx: infection
o Treat all areas of active infection § White superficial onychomycosis
o Keep groin area clean & dry • Risk factors:
o Loose – fitting clothing Lose weight o Hyperhidrosis (sweat between toes and soles)
o Use plain talcum powder Hot, humid weather Occlusive footear
o Antifungal creams • Dermatophytosis of the feet
o Terbinafine • Characterized by erythema, scaling, vesicular & crusted
§ Oral if extensive, OD for 2 weeks patch spreading peripherally with partial central clearing
• Chronic w/ exacerbations in hot weather
Tinea facialis • Multiple scaling and itchy vesicles at the soles of the feet, 3rd
• Long septated hyphae with spores and 4th web of the toes
• May have maceration, scaling, vesicles, bullae
Tinea Manus • Late childhood to young adulthood
• E: • Age / Gender of predilection:
o T rubrum – more common; produces dry, scaly o Younger individualss: inflammatory
erythematous type o Older: non – inflammatory
o T mentagrophytes – dermatophytosis of hand o M>F
secondary to tinea of feet; produces vesicular • Site: usually 3rd toe web, interdigital areas and soles of the
type; both hands involved feet, plantar arch (vs AD: NEVER on the plantar arch)
• Unilateral if associated with tinea pedis & cruris o Ddx: Contact dermatitis – predilection to plantar
• Often associated with tinea unguium of fingernails (if arch
chronic) • Distribution: usually bilateral; may involve one hand, both
• Dermatophytosis of the hands feet
• Dry, scaly, erythematous type OR moist, vesicular, • Tx:
eczematous type o Dry toes thoroughly after bathing
• Annular o Good antiseptic powder
• Area: “1 hand, 2 feet”, Also check the inguinal area o Fungicides
• Dx: • May become a portal of entry for lymphangitis when
o Direct microscopic exam of scrapings (instep, pyogenic cocci infect fissures between toes & in the vesicles
heel, sides of foot, palms)
o 10 – 20% KOH solution 2. Pityriasis Rosea
o Fungal culture • E:
• Tx: Oral antifungal agents (topical don’t usually work o Unknown
because of the thick palmar stratum corneum) – o Some evidence points to a viral cause –
Griseofulvin, terbinafine, itraconazole, fluconazole reactivation of HHV7 & HHV6
• Prevention: • Usually on spring & autumn months
o Dry toes thoroughly after bathing • Age / Gender: 15-40y/o; F>M
o Good antiseptic powder between toes • Hallmark: Herald patch with Christmas tree pattern on the
(tolnaftate or zeasorb powder) back; colarrette scaling / Hanging Curtain Sign
o Plain talc, cornstarch dusted into socks o Usually begins with single 2 – 4cm thin oval
plaque w/ fine collarette of scale inside the
Tinea Pedis periphery (herald patch/mother patch)
• Most common fungal disease • Mild inflammatory exanthema characterized by salmon-
• E: colored popular and macular lesions that are at first discrete,
o T rubrum but may become confluent, covered with finely crinkled, dry
§ cause majority of infection epidermis that often desquamate
§ usually non – inflammatory type • Eruptions are usually general affecting chiefly the TRUNK
§ Moccasin type lesions and sparing the sun-exposed areas
§ non – inflammatory type w/ dull • Macules on the trunk are arranged so that the LONG AXIS
erythema & pronounced scaling runs parallel to the lines of cleavage
that may involve entire sole and • Distribution: Larger lines / Long axis runs parallel to the lines
sides of foot = moccasin/sandal of cleavage
appearance • Usually asymptomatic but may be pruritic & have
§ This type of lesion may also be constitutional symptoms
caused by E floccosum
• Lesions spontaneously resolve at around 8-12 weeks,
o T mentagrophytes
therefore NOT recurrent
§ cause inflammatory lesions
• Dx: KOH wet mount, Growth on Mycosel/Saboraud agar
§ Inflammatory/ bullous type
plates
• Plantar arch & along
• Tx:
sides of feet
o Supportive
• Burning/itching
Topical CS or antihistamines for associated pruritus
sensation
UV treatment may expedite involution of lesions
• With erosion from
ruptured vesicle 3. Tinea Versicolor
• Least common • May be hypopigmented/hyperpigmented/slightly
• Involves sole, instep, erythematous
webspaces o Hypopigmented – secondary to Azaleic acid
§ Interdigital type inhibiting tyrosinase injuring melanocytes

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 DERMATOLOGY REVIEWER

o Hyperpigmented – secondary to enlarged the appearance of the lesions

melanosomes • (+) Auzpitz Sign: bleeding points secondary to thinning of
• Hypopigmented, coalescing, scaly macules (due to epidermis over dermal papillae; bleeding upon removal of
abnormally small & poorly melanised melanosomes) in dark scales
skin o signify dilated capillaries
o Hypopigmentation may persist for wks/mos after • Woronoff ring: concentric blanching of erythematous skin
fungal disease is cured near periphery of healing psoriatic plaque
• Hyperpigmented on pale skin • Koebner Phenomenonàtypical lesions at areas of injury
• Shows dry wrinkled surface and furfuraceous thin scales • Mean age: 27 y/o
• Etiology: Malasezzia furfur (skin lesions area produced • Involves: Scalp, nails, extensor surfaces of limbs (shins),
when in hyphal phase) elbows, knees, umbilical & sacral region
o Lipophilic and dimorphic • Associated with concomitant joint pains and swelling
• Risk factors: • Tx:
o Genetic predisposition o Depends on site, severity, duration, age
o Warm, humid envt Immunosuppression o Oral immudolators such as cyclosporine and
o Malnutrition methotrexate may be needed for treatment of
o Cushing disease severe cases.
• Areas: o Oral Steroids (given only for a limited time) à
o Sterna region, sides of chest, abdomen, back, can induce lesions of Psoriasis
pubis, neck, intertriginous areas, oily areas of o Topical: (only for 2 weeks)
skin § Corticosteroids
o Face & scalp (usually in infants & § Tars
immunocompromised px) § Vit D
• Dx: § Salicylic acid
o Wood’s light exam § UV
o Culture (rarely used for dx) § Tazarotene
o KOHà short nonseptated hyphae with o Systemic
clustered spores § CS
o Tx: § Methotrexate
§ Anti – fungal agents (selenium o Chronic CS use may cause side effects –
sulfide, imidazoles, triazoles, sulfur PUSTULAR PSORIASIS (Pustule on top of
preparations, salicylic acid, benzoyl psoriatic plaque)
peroxide, etc) § DOC: Aciterin
• Most cost effective tx:
selenium sulfide & zinc Plaque – type / Psoriasis vulgaris
pyrithione soap • Most common (90%)
§ Ketoconazole: 400mg/1x a month • Typical red scaling plaque
Itraconazole: 200mg for 7 days • Symmetrical distribution (elbows, knees, scalp)
§ Terbinafine: topical
Seborrheic-like Psoriasis
*KOH • W/ prominent features of seborrheic dermatitis
• Dermatophyte – Long septated hyphae and spores • W/ minimal amount of soft & greasy micaceous scales
• M. fufur – Short nonseptated hyphae and cluster of • Flexure areas (antecubital areas, axillae, under breast)
spores
• Candida – pseudohyphae and spores Inverse Psoriasis
• “flexural psoriasis” – palms & toes, “volar psoriasis”
4. Psoriasis • Intertriginous areas
• E: Unknown • Bright red glossy, sharply demarcated lesions with silvery
• Common, chronic, recurrent, inflammatory disease of the white scales
skin • Minimal to no scaring
• A recurrent disease; may be triggered by infection, stress, • Areas:
trauma o Folds, recesses, flexor surfaces: ears, axillae,
• Round, circumscribed, erythematous, dry scaling plaques of groin, inframammary fold, palms, soles, nails
various sizes, covered by gray or silvery white imbricated o Inguinal area + Umbilicus
lamellar scales
• Multiple small plaques over a bed of erythema with white Napkin Psoriasis
silvery thick scales over the trunk and extremities • Age: Infants between 2 – 8 mos of age
• Sharply marginated, raised, red, plaque with scaly surface • Increases risk for adult psoriasis infection
(silvery white scale)
• If on the scalp, goes beyong the hairline Psoriatic Arthritis
o Ddx: T. capitis – does not go beyond the • Complication of psoriasis
hairline • 5 clinical patterns:
• Symmetrical, solitary macule to > 100 macules o asymmetrical distal interphalangeal joint
• May be accompanied by itching/burning involvement w/ nail damage
• PLAQUE TYPE: most common type; seen in scalp, nails, o arthritis mutilans w/ osteolysis of phalanges &
scarum metacarpals
• (+) Nail changes: o symmetrical polyarthritis like RA, with claw
o Nail pitting (Also seen in Alopecia areata) hands
o Oil spots (Pathognomonic) o oligoarthritis w/ swelling & tenosynovitis of 1 or
Onycholysis few hand joints – most common
o Nail discoloration o ankylosing spondylitis alone or with peripheral
o Subungal keratosis arthritis
• History revealed an upper respiratory tract infection prior to • Areas: Distal & proximal interphalangeal joints (relative

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 DERMATOLOGY REVIEWER

sparing of metacarpal & metatarsal phalangeal joints) • Presence of fever, chills

• Tx: • Tx: Acitretin
o Aspirin, NSAIDs, oral retinoids, PUVA • Plan: Admit patient
o NSAID – mainstay of therapy in concert with
physical therapy
o Methotrexate – initial choice for more severe 5. Syphillis
involvement • E: Treponema pallidum
o < 30% - Topical o Only known host: Human
o > 30% - Systemic (MTX, Cyclosporine, • Primary:
Tacrolimus) o Chancre
Guttate Psoriasis • Secondary:
• Acute onset o Maculopapular rash
• Typical lesions: Drop-like, size of water drops (2 – 5mm) o Condyloma lata
• Abrupt erosion following an infection (ex. strep pharyngitis) § Flat top papules to macules
• Self limiting but a certain percent may lead to chronic plaque § Mushroom-like
type § Ddx: Condyloma acuminata
• Usually px <30 y/o (children and adult) • Tertiary:
• Tx: Topical steroids, UVB o Gumma
• Prognosis: BEST • Involvement of palms and soles: Syphilis & EM
• Great mimicked
Generalized Pustular Psoriasis (Von Zumbusch) • Tx: IM Benzathine Penicillin
• E: infection, pregnancy, drugs (Salicylic acid), abrupt
corticosteroid withdrawal 6. Discoid Lupus Erythematous
• Pustules coalescing in lakes of pus • Acute
• Sudden onset, with formation of lakes of pus periungually, o most common
on palms & edges of psoriatic plaques o malar rash
• Erythema in flexures before eruptions appear o localized or generalized
• w/ pruritus & burning sensation o with systemic symptoms (DOPAMINE RASH)
• Presence of sterile pustules with erythematous base • Subacute
• May be due to corticosteroid withdrawal o maculopapular rash on sun exposed areas
• Px usually have hx of psoriatic arthritis o annular psoriariform
• Linked with pneumonia, CHF, ARDS • Chronic (CCLE)
• Tx: Acitretin, Methotrexate o MOST COMMON
o classic DLE
Erythrodermic Psoriasis o red purple discoid macule and papules with
• Can cause exfoliative dermatitis small plaques
• (+) generalized erythema o atrophy, telangiectasia,
hypo/hyperpigmentation, scales, keratotic plug
• Involvement of almost all the parts of the body
o heals with scarring

3. Skin-colored Papules
1. Verruca vulgaris • most commonly on mid metatarsal areas
• Common wart occurring chiefly in children and is usually • coalesce to form mosaic warts
located in hands or soles • differential dx: callus, corn (with exaggerated skin lines, but
• Etiology: Human Papilloma Virus no black dots)
• Begins as a PIN-head sized, smooth, shiny, translucent • Do not do ECT because it is prone to scarring
hyperkeratosis and grows into a PEA-sized, rough, papillary, o If with scarring on sole of foot: Pressure = Pain
dirty brown, gray or black (black dots) • Tx: Duofilm (Lactic acid and Salicylic acid -> Keratolytics),
• rough surface Curettage
• tiny black dots: thrombosed dilated capillaries
• subclinical: can only be detected by acetic acid Tx for warts
• autoinoculation, direct contact • duofilm
• fingers, palms, periungual areas but may be seen at any • electrocautery
part especially at trauma-prone areas or contaminated • cryotherapy
surfaces • laser therapy
• risk factors: nail biting, butchers, immersion in water
• treat to prevent from multiplying *Acrochordon
o if periungual: might have to do nail avulsion • Due to increase wt, obesity, DM, GH-like activity of insulin
• with filliform projection on microscopic exam
Verruca plana • may be skin colored to hyperpigmented
• Koebner Phenomenonàtypical lesions at areas of injury • smooth surface
(Linearization) • pedunculated
• flat topped and smooth surface • neck, axilla, groin
• risk factor: sun exposure, autoinoculation by shaving • can become tender, inflamed or gangrenous when twisted
• Highest rate of spontaneous remission • common in obese
• Tx: ECT • risk of developing DM: skin tags on top of acanthosis
nigricans velvety plaque
Verruca filiformis • tx: snip excision
• Long slender upward projections; Papillomatous
2. Molluscum contagiosum
Verruca plantaris • Etiology: Pox virus or Molluscum contagiosum virus
• usually found on pressure areas

MJDY 13
 DERMATOLOGY REVIEWER

• Common in immunocompromised patients occlusive meds

• Round, DOME-shaped, pink, waxy papules that are • Tx: incise and express the contents (Keratin)
umbilicated centrally and contain a caseous plug
• Central whitish or pearly gray invaginationà characteristic 4. Syringoma
lesion • Skin-colored to yellow papule
• Henderson-Patterson bodiesà eosinophilic and basophilic • Pathology: sweat ducts
inclusion bodies • found on cheeks & eyelids
• Children are most commonly affected • familial
• A self-limiting disease • recurrence after removal by cauterization or laser therapy ->
• Tx: Nick curettage and extraction of the Molluscum bodies, treatment is difficult
Calterithrin • coalesce to form plaques

5. Sebaceous cyst/epidermoid cyst

3. Milia • nodule with a central comedo like punctum
• Singular: Milium • cheesy chalky pasty like foul smelling material which
• white keratinous cysts represent macerated keratin
• asymptomatic • lined by stratified squamous cell epithelium
• in newborns: can resolve spontaneously in weeks • removal by: excision of capsule
• in elderly: can be due to trauma, blistering diseases, topical

4. Pustular Diseases
1. Acne Vulgaris scalp and each surrounding a hair
• Chronic inflammatory disease of the pilosebaceous follicles • If with multiple lesions: Oral antibiotics
characterized by COMEDONES, papules, pustules, cysts,
nodules on face, neck, upper trunk, upper arms *Furuncle
• Polymorphic: closed comedone (white head), open • chronic relapsing
comedone (black head), pustules, papules, nodules • Deeper inflammation nodule hair follicle --> rupture -->
• Erythematous papules with keratin plug nodule with or w/o central suppuration
• May present as follicular papules
• Etiology: Formation of keratinous plug in the hair follicle, 4. Ecthyma
Stimulation of sebaceous glands, Proliferation of • Multiple, thick, crusted lesions over the shins of both lower
Propionibacterium acnes (part of normal flora) legs; presence of ulcers and scarring
• Androgenà hormone responsible for Acne vulgaris • Predisposing factors: Uncleanliness, malnutrition, trauma
• Tx: • Begins as a vesicle or a vesiculopustule w/c enlarges in a
Clindamycinàexcellent antibiotic but may cause few days and becomes thickly crusted; when crust is
Pseudomembranous colitis removed, there is a superficial SAUCER-shaped ulcer
Sulfonamidesà should not be used in pregnant women; • vesicle/vesiculopustules --> rupture --> ulcer --> heals with
effective in many cases unresponsive to antibiotics scar
Tetracyclineà cheapest, safest, most effective ORAL • Due to Beta Hemolytic Streptococci (Staph or Strep
antibiotic Pyoderma)
Minocyclineà more effective than Doxycycline • Areas: Shins, dorsal feet
Estrogensàmost effective tx in postadolescent women • Tx: cleansing w/ soap and water, Antibiotics (Cefalexin,
• Benzoyl Peroxideà potent antibacterial gels or cream, kills Penicillin, Cloxacillin, Erythromycin)
P. acnes
• Isotretinoinà approved only for severe nodulocystic acne 5. Pyogenic Paronychia
and; most serious side effect is teratogenicity • Etiology: Candida albicans, Staphylococcus, Streptococcus,
Pseudomonas aeruginosa
Acne congoblata • Inflammatory reaction involving the folds of the skin
• Pustules and papules coalesce that form plaques that surrounding the nail
release serosanguinous material • separation of nail fold from nail plate secondary to frequent
• tx: oral isotretinoin exposure to water
• Predisposing factors: mani/pedi; nail biting
2. Miliaria Pustulosa • Characterized by acute or chronic purulent, tender, and
• Always preceded by some other dermatitis (contact painful swellings of the tissue around the nail caused by an
dermatitis, lichen simplex chronicus, intertrigo) abscess in the lateral nail fold
• The pustules are distinct, superficial, and independent of the • When infection is chronicàhorizontal ridges appear at the
hair follicle base of the nail
• Pustules are located most frequently on the intertriginous • Primary disorderà separation of the eponychium from the
areas, back, on the flexure sufaces of the extremities, and nail plate
on scrotum • Separation is caused by trauma as a result of moisture-
• Non follicular pustules on bedridden patients induced maceration of the nail folds from frequent wetting of
• Due to blockage of sweat galnds hands
• Tx: For chronic paronychiaàMycolog cream, Neosporin
3. Bacterial Folliculitis solution, Vioform, Castellani plant (preferred)
• Superficial inflammation of the hair follicle
• Areas: On hair bearing areas 6. Intertriginous Candidiasis
• Papules, pustules and erosions on the lower extremities • secondary to maceration of epidermal folds of the neck or
• Lesions are mostly tiny papules and superficial pustules, intertriginous areas
each surrounding a hair • pruritic
• Px may be diagnosed with pediculosis capitis and also • Cellular immunityà most common immune mechanism
presents with multiple superficial pustules scattered on the responsible for candidal infection

MJDY 14
 DERMATOLOGY REVIEWER

• Multiple pruritic erythematous macerated patches with o topical azoles plus mid strength corticosteroids
SATELLITE vesiculopustules in the inframammary area and (mometasone) for rapid relief
inguinal folds o Best Txà Topical Miconazole
• Pustules and papules on the preiphery o recommend: keep area dry, loose clothing, lose
• KOHàpseudohyphae and spores weight
• Tx:

5. Vesicular Disease
1. Vesicular Tinea Pedis o Crawl as fast as: 2.5CM/MIN
• Tinea pedis is also known as: ATHLETE’S FOOT • Pathogenesis: Hypersensitivity Type 1 and 4
• Most common fungal disease: TINEA PEDIS • Sensitization Period: 2-4 weeks after infection
• Most common cause: T. RUBRUM – produces keratinase to • HALLMARK SYMPTOM: NOCTUNAL PRURITUS
invade stratum corneum • Transmission: Skin to skin contact
• Most common cause of inflammatory type of tinea pedis: T. • Multiple pruritic erythematous papules scattered over the
MENTAGROPHYTES trunk, finger, toe webs, extremities, genitals, buttocks
• Produces NON-INFLAMMATORY type: dull erythema with (CIRCLE OF HEBRA – imaginary circle affected scabies)
silvery scaling: T. RUBRUM o Spares the scalp, face and mucosa
• Produces VESICOBULLOUS type: plantar arch, sides of • Intense pruritus at night, other family members have similar
feet and heel: T. MENTAGROPHYTES lesions
• Skin findings: WELL-DEFINED ANNULAR (CENTRAL • May present as a vesiculobullous lesions
CLEARING) PLAQUE WITH ERYTHEMATOUS • Face and scalp are spared in adults
ELEVATED SCALY BORDERS • Skin findings:
• Associated symptom: PRURITUS o Erythematous papules and burrows containing
• Complication of tinea pedis: CELLULITIS mites
• Predilection of tinea pedis: INTERDIGITS (3RD & 4TH/4TH • Dx: Microscopic view of burrows under India ink or Gentian
& 5th) violet
• Most common predisposing factor for tinea pedis: o Burrow in the stratum corneumà characteristic
HYPERHIDROSIS lesion seen in scabies
• Transmission: SKIN-TO-SKIN CONTACT • TRIAD:
• 2 FEET 1 HAND SYNDROME o Circle of Hebra
• Microscopic finding in KOH smear: LONG SEPTATED o Nocturnal Itch
HYPHAE o (+) in contact people at home
• Highest yield of fungfal elements: BORDER OF LESION • Tx:
• Treatment: ANTIFUNGALS (Terbinafine) o 5% Permethrin lotionà standard tx for scabies
§ Apply from neck down. Leave on
2. Miliaria Crystallina overnight for 8-10 hours and rinse
• Causes / Predisposing factors: off in the morning. Use once a
o Increased perspiration week for 2 weeks
o Clothing that prevents dissipation of heat & § Synthetic pyrethroid
moisture (tight fitting clothes) § Wide range of activity to many
o Bedridden px arthropods
o bundled children § Low systemic absorption
o Neonates <2 weeks § Most common scabicide
• Area: § MOA: interferes with the sodium
o Adult: Trunk transport maintaining the
o Infant: Head and Neck polarization of arthropod
• Acute onset transmembrane
§ 2 overnight applications 1 week
• Asymmtomatic and short-lived (tend to rupture with slightest
apart
trauma)
§ Approved for use in patients 2
• Normal skin with desquamation
months of age
• Small clear very superficial vesicles without inflammation § Side effect: IRRITATION
reaction § Pregnancy category: B
• Presents with flaccid clear fluid vesicles over the trunk o Crotamiton (Eurax cream or lotion)àrubbed
• Vesicles easily rupture and are non-pruritic into the skin from neck to feet
• Multiple clear vesicles on the trunk. o Lindane (Gamma benzene
• Px may have high grade fever prior to the appearance of the hexachloride)àMOST effective scabicide;
vesicles. NEUROTOXIC for infants
• The lesions are asymptomatic and would rupture at the o Ivermectrin
slightest trauma. § used as tx for nodular scabies (dull
red nodules that may persist on the
3. Scabies scrotum, penis)
• May have vesicles § Effective oral agent
• Features: § MOA: increase permeability of cell
o Pruritic membrane to chloride ions →
o No target lesions death
o No mucosal involvement § Dosage: 200ug/kg single dose
o Px usually comes to you the lesion has been repeated in a week to 10 days
there for several weeks duration o 6-10% Precipitated sulfur in petroleum
• Primary lesion: Papulovesicule § SAFE for pregnant women
• E: Sarcoptes or Acarus (“uncut-table ) scabei, the itch mite § MOA: toxin formation (hydrogen
o Adult males are smaller than females sulfide and polythionic acid)

MJDY 15
 DERMATOLOGY REVIEWER

§ Adverse effects: ALLERGIC o NON-BULLOUS

CONTACT DERMATITIS, o BULLOUS – fragile bullae
OFFENSIVE ODOR • Papules, vesicles, macules, pustules and erosions
o Supportive management: • There is rapid spread of the pustules and erosions with thick
§ Treat the infection first yellowish brown or honey-colored crust
§ Synchronous topical treatment of • Acute Glomerulonephritis
all contacts with or without skin o MOST frequent complication of recurrent
lesions Impetigo Contagiosa
§ Wash all clothing, linens, towels in o Especially in <6 years old
hot water o Absent in staph impetigo
§ Clip nails, brush subungual fold • Px may have hx of atopic dermatitis and presents with
with scabicides pustules, erosions with thick yellowish brown crusts along
v. Antihistamines the perinasal area
• May be: • If (+) on scalp -> complication of pediculosis capitis
o Nodular • Very weepy lesions
§ Dull red (3-5mm) appear during o Discrete, thin-walled vesicles that become
active scabies with or without pustular and rupture
itching • Gyrate Pattern / Erythema
§ Scrotum, penis, vulva o Round, ring-like, polycyclic or arcuate
§ Tx: Intralesional steroids, tar, • NO ERYTHEMA (Most important)
excise
• NO TARGET LESION
o Crusted/Norwegian/Hyperkeratotic
• NO MUCOSAL INVOLVEMENT
§ Immunocompromised or debilitated
patients • Histopathology:
§ Face, scalp. Genitalia, buttoks, o Superficial inflammation in upper part of
pressure bearing areas pilosebacoues follicles
o Subcorneal vesicopustule
4. Insect Bites o Middermis inflammation (PMN & edema)
• May have fluid-filled vesicles • Self limited, No treatment
• Multiple, erythematous pruritic papules with a CENTRAL • Symptomatic relief: Keep cool
PUNCTUM over the exposed areas of the body • Management:
o Immediate central punctum – inflammatory o Clean area before meds
o Delayed central punctum – secondary to host o Systemic with topical
response § Semisynthetic Penicillin or 1st gen
• May also present as a vesicular lesion Ceph + topical bacitracin or
mupirocin
• Tx: Topical -> Intralesional steroids or excision
o Cephalexin 25-50mg/kg/day in divided dose
• Onset: any age
(every 6hrs) 250mg/5ml
• Skin findings: URTICARIAL PAPULES WITH CENTRAL o If recurs, Rifampicin 600 mg/day for 10 days
PUNCTUM, papulovesicles or bullae, BREAKFAST-LUNCH- o Drug of choice for skin and soft tissue
DINNER SIGN (linear configuration)
infections: CLOXACILLIN
• Areas of predilection: EXPOSED AREAS of the body
• Associated symptoms: PRURITUS at the bite sites 6. Herpes Simplex
• Pathophysiology: INFLAMMATORY REACTION at the site • E: HSV -> ds DNA virus
of the punctured skin to the bite, saliva or venom of o HSV I (TRIGEMINAL GANGLION) à Orofacial
insects Herpes Simplex (more common)
• Predisposing factors: POOR HOUSING CONDITIONS o HSV II (DORSAL ROOT GANGLION S2-S4) à
• DIASCOPY: pressing the lesion with the use of glass slide Genital Herpes Simplex
• ROMANA’S SIGN: unilateral eye swelling after a nighttime • Risk factors:
encounter with Trypanosoma cruzi 20. Complication: o Immunocompromised
• CHAGA’S DISEASE: bed bug o Prior infection
• FEVER & JOINT PAIN: bee sting o Occupation (esp in herpetic whitlow)
• Treatment: TOPICAL STEROIDS o Minor trauma & sun exposure
• Prevention: insect repellants (DIETHYL TOLUAMIDE), • Transmission: intimate skin to skin contact, bodily fluids
insecticides, pet grooming • 30%-50% of adults are sero-positive
o Most are asymptomatic
5. Impetigo Contagiosa o All persons infected are potentially infectious
• Etiology: Streptococcus pyogenes (group B strep – Newborn even when asymptomatic
impetigo), Staph aureus (most common) o Spread by asymptomatic shedding which
o Exclusively Staph in origin: Bullous impetigo occurs: 2-3 DAYS AFTER LESIONS APPEAR
• More common in children and in exposed body parts • Painful intraepidermal vesicles and bullae
• Areas: • Skin findings:
o Adult: Trunk o MULTIPLE, CLUSTERED VESICLES AND
o Infants: Head, neck, upper trunk ULCERS WITH ERYTHEMATOUS EDGE +
o May be seen in Orolabial areas FIRM, TENDER, BILATERAL
• Predisposing factors: LYMPHADENOPATHY
o Temperate zones • The lesions have been recurrent over the angle of the mouth
o Pediculosis capitis and lower cheeks, spontaneously resolving after 1-2 weeks
• Sources of infection: but recurring once a month
o Kids: pets, dirty fingernails, other kids • Viremia occurs in seronegative primary herpes simplex
o Adults: barber shops, beauty parlors, swimming infected patients
pools, etc • Features:
• More common in PEDIATRIC AGE GROUP o Acute
• 2 clinical patterns: o Clustered lesions (In SJS, not clustered)

MJDY 16
 Genital Vesicles in erythematous HSV2 Labia, vulva,
Herpes base that ulcerate & crust perineum, perianal
Spread by skin-to-skin areas, shaft, glans
Grouped blisters & contact during sexual penis
erosions w/ continued intercourse
DERMATOLOGY REVIEWER
development of new
blisters over 7 – 14 days
o Can have mucosal involvement Course:
• Types of infection:
o Primary infection
§ virus replicates in site of infection
§ usually resides in trigeminal
ganglion
§ with painful ulcers, vesicles
o Nonprimary initial episode
§ initial clinical lesion in a person
previously infected w/ the virus
o Recurrent infection
§ Within 6 months
• Workup: • E: HSV2
o TZANCK SMEAR • Spread by skin-to-skin contact during sexual intercourse
§ Most common procedure • Area: Labia, vulva, perineum, perianal areas, shaft, glans
§ Non specific (HSV, VZV) penis
§ used to confirm diagnosis of herpes • Usually resolves in 21 days
simplex syndrome • Asymptomatic shedding may occur between outbreaks
§ see MULTINUCLEATED GIANT • Can present as severe systemic illness
CELLS o Fever & flulike illness
o DIRECT FLUORESCENT ANTIBODY TEST o Vaginal pain & dysuria (herpetic vulvovaginitis)
§ most accurate
o VIRAL CULTURE Other manifestations:
§ Accurate and rapid (results in 48-72 Herpetic whitlow
hours) • Infection of digits
o POLYMERASE CHAIN REACTION (PCR) • Tenderness & erythema of lateral nail fold
§ monitor response to treatment
o URINALYSIS Herpetic Gingivostomatosis
§ initial laboratory procedure • Infection in the oral mucosa, tongue and tonsils
requested for herpes genitalis
• Acantholysis (ballooning degeneration of epidermal cells) Herpetic keratoconjunctivitis
• Other procedures: • Punctate/marginal keratitis
o Skin biopsy • May impair vision
o Serolog
• Goals of Tx: Herpes gladiatorum
o Reduces duration of ulcerative lesions • HSV 1
o Minimal toxicity • Seen in wrestlers, rugby players
o Stop after 12 months to determine recurrence • Face, sides of neck, inner arms
• Drug of choice: ACYCLOVIR 200MG/TAB 1 TAB Q4H X 5
DOSES/DAY FOR 1 WEEK Herpes Sycosis
• Indications for oral meds: • Infection of the hair follicle
o Recurrence • Close razor shaving
§ Give treatment within 24 hours
o Dissemination (in immunocompro mised) Recurrent Ecthyma Multiforme
• DO NOT GIVE STEROIDS!!! Because of reactivation • Presents with papules later become target lesions in palms,
elbows, knees and oral mucosa
OROLABIAL HERPES
• Infection in the oral mucosa and lips near the vermillion Neonatal Herpes
border • Passage through birth canal
• Lesions in mouth: broken vesicles that appear as erosions • Skin lesions, microphthalmos, encephalitis, chorioretinitis,
or ulcers covered w/ white membrane intracerebral calcifications
• Frequent manifestation:
o cold sore or fever blister HSV Encephalitis/Meningitis
• 95%: recurrent HSV1 infection • Headache, fever, mild photophobia, autonomic dysfunction
• Frequent trigger: UVB exposure
• Area: Lips near vermillion border 7. Herpes Zoster / Shingles
• If untreated, may last 1 – 2 wks • E: Reactivation of VZV
• Upon onset: high fever, lymphadenopathy, malaise • Risk factors: Age and immunocompromised
• More common in > 10 years old
GENITAL HERPES • Gender: F>M
• Genital ulcer which is recurrent and incurable • Remains latent in the SENSORY DORSAL ROOT
• Vesicles in erythematous base that ulcerate & crust GANGLION USUALLY THORACIC and affects ANTERIOR
• Grouped blisters & erosions w/ continued development of ROOT GANGLION
new blisters over 7 – 14 days • Usually not recurrent
• Course: • May be dermatomal or unilateral
• Cutaneous eruptions frequently preceded by one to several
days of pain in affected area
• Papule & plaques of erythema -> blisters
• Grouped vesicles on an erythematous base located on the
right scapular area accompanied by severe pain
• Associated with dermatomes
o Usual sites:
o Thoracic (55%)

MJDY 17
 DERMATOLOGY REVIEWER

o Cranial – trigeminal (20%)
 • Confers LIFELONG IMMUNITY

o Lumbar – 15% • Most common complication of varicella: PNEUMONIA
o Sacral – 5% • Treatment: ANTIVIRAL (WITHIN 24 HOURS)
o Thoracic dermatomes are most commonly o Children: complications are infrequent, antivirals
affected are infrequently indicated
o affects trigeminal nerve o Atopic dermatitis, Darier’s disease, diabetes,
• Features: cystic fibrosis, steroid therapy
o More painful than simplex o Recommended for adults and adolescents
o Dermatomal o Required number of doses of Varicella vaccine
o Not recurrent in adults: 2 DOSES
o Unilateral w/in distribution of cranial/spinal • Antiviral prophylaxis: VARICELLA IMMUNOGLOBULIN
nerve • CD4 count of HIV-infected patients which can still be given
o Neuralgic Varicella and MMR: >200 CELLS/UL
• Multiple tender grouped vesicles with LINEAR configurations
• Age and Immunosuppression are factors that reactivate the 8. Steven Johnson's Syndrome
disease • aka Ectodermosis erosive pluriorificialis, Erythema
o Immunocompromised patients may have multiforme exudativum
disseminated lesions (> 20 lesions outside • Usually a drug-induced disease
dermatomal level) o Drug allergy (1day – 3 wks latent period)
• Post-herpetic Neuralgia o antibiotics, NSAIDs, allopurinol, anticonvulsants
o Due to sensitization of dorsal neurons • Precipitating factors:
o Tendency to have persistent pain o Drugs: NSAIDS, SULFONAMIDES,
o Major complication of herpes zoster anticonvulsants, antibiotics
o Major cause of persistent pain is age dependent o Bacterial infection: MYCOPLASMA
(more painful in elderly) PNEUMONIAE, Yersinia, M. tuberculosis, T.
o Occurs 1 month after onset of zoster infection pallidum, Chlamydia
• Ophthalmic zoster / Herpes zoster ophthalmicus o Fungal infections: Coccidiodomycosis,
o involvement of ophthalmic division of 5th CN Histoplasmosis
o can cause blindness o Viral infections: Enterovirus, Adenovirus,
• Hutchinson’s Sign Measles, Mumps, Influenza
o external division of the nasociliary branch of CN o Irradiation
V1 (ophthalmic division) is affected with vesicles o Inflammatory Bowel Disease
on the side and tip of the nose o Vaccines
• Ramsay Hunt Syndrome o BCC
o involvement of the facial and auditory nerves by • Clinical features of Stevens-Johnson syndrome:
the varicella zoster virus o FEVER
o caused by herpetic inflammation of geniculate o PURULENT CONJUNCTIVITIS, photophobia
ganglion o Difficulty swallowing
o zoster of the external ear, ipsilateral facial o Dehydration
paralysis and auditory symptoms (tinnitus, o Stomatitis, hemorrhagic crusts, ulceration of
deafness and vertigo) buccal mucosa
• Herpes zoster oticus o Less common: nasal esophageal and
o Vesicular eruptions of the ear canal, otalgia pulmonary involvement
• Dx: Tzank smear o Hepatomegaly, hepatitis
• Main benefit of therapy for Herpes Zosterà reduction of the o Lymphadenopathy
duration of zoster associated pain o GENITAL LESIONS, erythema and erosions on
• Therapy should be started w/in 3-4 days for rapid resolution labia, penis, and perianal region
of the skin lesions o SLAUGHING OF SKIN
• Tx • History reveals intake of allopurinol and/or cotrimoxazole
o Oral acyclovir 800mg/tab 5x/day for 7days (Best prior to appearance of multiple generalized papules,
treatment) vesicles, bullae, erythematous macules and patches, some
o valacyclovir 1000mg/tab 1tab TID for 7days with dark centers
o within 24-72 hours is the best time to give • Non pruritic skin lesions
the meds • Starts as a morbilliform eruption
• Indications for treatment: • Flaccid vesicle that rupture easily to form erosion, crusting
o Immunocompromised px as they heal
o To prevent complications in elderly (give 1st 3 • Flat, erythematous, purpuric macules that form incomplete
days) “atypical targets” that may blister centrally
o Ophthalmic involvement o (Erythema multiforme minor may also appear as
• Sequence of infection: chicken pox infectionà virus target lesions, may be drug induced, and may
remains dormant in the sensory gangliaà exposure to a have the same areas of predilection. Difference
predisposing factorà virus travels back to the skin causing is in Nikolsky sign)
an inflammation of a dermatome • (+) Nikolsky sign: application of very slight pressure causes
the skin to slough off; usually seen in vesicular lesions (due
Varicella virus infection- "chickenpox" to weakening of intercellular attachments)
• all lesions will erupt in 2 days; exposure: 10-21 days o This is absent in erythema multiforme minor
• Pruritic because lesions here are more popular
• Papules, vesicles, pustules, ulcers with crusting • Evolution of lesions: Macules -> vesicles & bullae
(polymorphic eruption) • Vesicles and bullae are seen all over the trunk, upper and
• Transmission: RESPIRATORY, DIRECT CONTACT (less lower extremities with concomitant conjunctivitis with matted
common) eyelids, tender erosions on the buccal mucosa and genital
• Infectious from 5 DAYS before eruption and most infectious areas and hemorrhagic crusts over lips
1-2 DAYS before eruption • Fever and flu-like symptoms precede eruption of skin

MJDY 18
 DERMATOLOGY REVIEWER

lesions (rapidly spreads within 4 days) • Lesions:

• Mucosal involvement (>2 mucosal surfaces eroded – oral or o Recur on the same site
conjunctiva) (check also GI tract) o Erythematous/dusky targetoid lesions
• Dx: Skin biopsy o Heals with hyperpigmentation
o Lymphocytic infiltrate at dermoepidermal • 50% oral and genital mucosa
junction w/ necrosis of keratinocytes
• Complications: 3. Contact Dermatitis (See above)
o SEPTICEMIA
o SSSS 4. Bullous tinea pedis
o PNEUMONIA • plantar arch and interdigital areas
o MENINGITIS • can have id reaction:
• Tx: Similar to px with extensive burn o eruption distant to the primary site of the lesion
o IV immunoglobulin (can look like dyshidrotic eczema -- deeper
o Systemic corticosteroids (dexamethasone, vesicles)
methylprednisolone)
§ commonly indicated in the early 5. Bullous pemphigoid
stage of this condition • ELDERLY tense blisters
o Stops spread & skin loss • Chronic
o ICU • very PRURITIC
o Increase caloric enteral intake • flexural, nuchal
• Cause of mortality in dermatology • autoimmune: IgG Ab (BPAG 1&2)
• Px usually go to the hospital because of pain • Dx:
• 2 causes of mortality in SJS: o Histopathology:
o Sepsis § Eosinophil rich subepidermal blister
o Electrolyte imbalance o Direct immunofluorescence:
• SJS involves less than 10% body surface § detect Ab on BM
o count areas of detached epidermis like bullae, • Management:
vesicles, erosions; not just erythematous areas o systemic steroids
3. Complications: o azathioprine
Toxica.epidermal
SEPTICEMIA
necrolysis o dapsone
b.• SSSS
involves >30% body surface § side effect: Hemolytic anemia
c. PNEUMONIA
• it’s a more severe SJS
d. MENINGITIS
4. Classification: 6. Pemphigus vulgaris
SJS/TEN overlap
a. SJS: <10% BSA • Generalized flaccid blisters with ulcers in the oral mucosa
10-30%
b.• SJS-TEN: BSA BSA
10-30% • PAINFUL; chronic
c. TOXIC EPIDERMAL NECROLYSIS: >30% BSA • rupture easily so all you see are erosions
5. SCORTEN
SCORTEN • trigger factors: sun-exposure, infections
PROGNOSTIC FACTORS POINTS • intraepidermal area is highlighted on direct
Age >40 years old 1 Mortality rate: immunofluorescence
HR >120 beats/min 1 0-1: 3.2% • Tx:
CA or hematologic malignancy 1 2: 12% o immunosuppressive agents (dapsone,
BSA >10% 1 3: 35.8% azathioprine)
Serum urea >10mM 1 4: 58.3% o oral corticosteroids
Serum bicarbonate <20mM 1 >5: 90%
Serum glucose level >14mM 1
7. Dermatitis herpetiformis
Mortality rate:
• Extremely pruritic erythematous papules > vesicles > bullae
6.0-1: 3.2% Dermatosis
Bullous > crust
2: 12%
Intraepidermal
3: 35.8% • Seen on the nape, scapula, extensors, buttocks
• flaccid
4: 58.3% • Exacerbated by wheat-rich foods
•
>5: 90% positive nikolsky sign and asboe-hansen's sign • Neutrophils on the dermal papilla
• pemphigus, SJS, SSSS, erythema multiforme
• IgA deposition on the dermoepidermal junction
BULLOUS PEMPHIGOID • Tx:
1. Subepidermal
Side effects of dapsone: HEMOLYTIC ANEMIA o Dapsone & Sulfapyridine
• tense o avoid alcohol,beer, cookie crumbs, cookie
• negative nikolsky and asboe-hansen dough
• bullous pemphigoid, insect bites, SLE

1. Bullous Impetigo
• Etiology: Staphylococcus aureus (most common cause of
pyogenic skin and soft tissue infection)
• Predisposing factor:
o Insect botes
o Cuts
• Honey-colored crust
• Best Tx: Cloxacillin
o Drug of choice for skin and soft tissue
infections: CLOXACILLIN

2. Fixed- Drug Eruption

• Due to drug use
o NSAIDS: most common offending drug
o Naproxen: 30-60mins lesions come out; well-
defined erythematous patch with bullae

MJDY 19
 DERMATOLOGY REVIEWER

6. Hypo/Depigmented – Hyperpigmented Lesions

VITILIGO COMPOUND
• Acquired pigmentary anomaly of the skin: VITILIGO 
 § junction + dermis
• Depigmented lesion INTRADERMAL 

• Autoimmune destruction of melanocytes 
 § dermis, depigmented/skin color
• autoimmune (associated with type1 DM, pernicious • superficial = darker & flatter bec closer to surface
anemia, Hashinotos thyroiditis, Graves' disease, addisons • deeper = more elevated and lighter in color
disease, alopecia areata) • giant congenital melanocytic nevus: "wolf", appears at
• Frequently associated with other autoimmune diseases birth, brown to black papules/plaque with or without
o THYROID DISEASE – most common 
 hypertrichosis, increased risk of developing melanoma,
o TYPE 1 DM 
 enlarges in size, any change in nodularity should warrant
investigation
o ALOPECIA AREATA 

• Onset at birth but may develop within first 10 years of life 

• Multiple, Well defined, Depigmented macules and patch
• LINES OF BLASCHKO 
- lines of normal cell
• distribution: focal (often trigeminal), unilateral, vulgaris,
universal development
• hands and around the mouth ("lip and any tip") are difficult • Dx: Biopsy
to treat • Treatment:
• white hairs if around eyebrow o CO2 LASER or ER:YAG LASER 

• Treatment:
o TOPICAL CORTICOSTEROIDS: first line for GIANT / CONGENITAL MELANOCYTIC NEVUS
pediatric cases and facial involvement 
 • May increase in size as the patient grows
o Topical calcineurin inhibitors 

MELANOMA
o 8-methoxypsoralen 

o NBUVB 
 BROWN, BLACK, YELLOW PAPULES
• Features:
o Asymmetry 

o MONOBENZYL ETHER OF o Borders are irregular
HYDROQUINONE: 50-80% involvement 
 46. NEVUSo Color variation (brown, black, pink, red...)
• First line tx: 47. MELANOMAo Diameter increased (1/4 inch or >6mm) or
o Topical: Corticosteroids, Calcineurin 48. SEBORRHEIC UGLY DUCKLING SIGN (Atypical sign)
KERATOSIS
o Physical: NB-UVB, Systemic Psoralen and 49. DERMATOSIS
o PAPULOSA NIGRA
Elevation/surface change OR Evolves over
UVA 50. SQUAMOUS CELL CARCINOMA
time
• Second line tx: •51. BASAL CELL CARCINOMA
Skin findings: surface change, satellite pigmentation,
o Topical: Calcipotriol 52. XANTHOMAS
symptomatic 

o Physical: Topical Psoralen and UVA, Excimer
laser (308 nm) NEVUS
1. Types: melanoma


Acral-lentiginous
o Systemic: Corticosteroids (Pulse therapy)
• Mosta.common type of melanoma in Asians
JUNCTIONAL
o Surgical: Crafting, Melanocyte transplant
• seenb.alsoCOMPOUND
on plantar surfaces 


c. INTRADERMAL
POST INFLAMMATORY HYPOPIGMENTATION / LEUKODERMA 2. Onset at birth but may develop within first 10 years of life
• Acquired, depigmented dermatosis caused by repeated Subungal melanoma
3. LINES OF BLASCHKO
exposure to chemicals: LEUKODERMA 
 • HUTCHINSON SIGN: involvement of nail plate +
4. Treatment: CO2 LASER, ER:YAG LASER
periungual skin

• Exposure to aromatic or aliphatic derivatives of phenols
and catechols 
 Melanocytic
MELANOMA melanoma
mistaken for BCC
•1. Features:
• Eythematous plaques --> white macules 

• pink/skin colored
a. ASYMMETRY
• destruction of melanocytes during the trauma 


• biopsy
b. IRREGULAR BORDER
• Diagnostic criteria: c. VARIATION IN COLOR
o Acquired vitiligo-like lesions 
 d. INCREASE
Most common melanoma: IN DIAMETER
superficial spreading >6MM
o History of REPEATED EXPOSURE TO A 2. Skin findings: surface change, satellite pigmentation, symptomatic

Highest risk for metastasis: nodular melanoma 

SPECIFIC CHEMICAL COMPOUND 
 3. HUTCHINSON SIGN
Most common
4. UGLY in asians: acral lentiginous
DUCKLING SIGN 


o Patterned vitiligo-like macules conforming to
site of exposure 
 SKIN
SKINCARCINOMA
CARCINOMA
o CONFETTI MACULES 
 BCC SCC
• Ddx: Vitiligo Sites of Face > dorsum Dorsum of hands
predilection of hands > face
MELASMA Sun exposure Intermittent Chronic long term
Metastasis Rare Common
• more common in asian 
 Characteristic Yes No
• hyperpigmentation on cheeks and sunexposed area ROLLED BORDER
• females > males, older 
 Necrotic border +
• Unknown pathogenesis XANTHOMAS
Telangiectasia +
• Triggers: 1. Deposits of LIPIDS in tissues (skin, tendon, eyes)
Premalignant
2. Appearskin - abnormalities
when there are • SCC inin situ
lipid amount of processing
o Sun exposure: primary 
 lesion
3. Important markers for underlying(Bowen’s Dx) and potentially increase
dyslipidemia
o Topical application of strong chemicals • Actinic Keratosis
(Maxipeel)
o Female hormones (OCP)
o Other medications, cosmetics, etc. Basal cell CA
• Tx: • most common skin CA; translucent pearly papule/nodule
o Use sunscreen everyday with telangiectasia and rolled border; friability
• malignant neoplasms from non keratinizing cells that
BENIGN NEVUS / COMMON MELANOCYTIC NEVUS
originate in the basal layer of the epidermis

• Types:
• elderly > 60 y/o
JUNCTIONAL
• males, whites > asians 

§ junction of epidermis and dermis, dark

MJDY 20
 DERMATOLOGY REVIEWER

• sun exposed areas: head (nasal ala) & neck (80%) – most
common area: NOSE, back, chest, shoulders XANTHOMA
• intermittent sun exposure (UV-A&B) • Firm yellow nodules arounds elbows, knees 

• usually in childhood, ionizing radiation, environmental • Multilobulated masses 

carcinogens, immunosuppression, scars, burns, chronic • Associated with increased cholesterol 

scarring or inflammatory dermatoses 
 • Deposits of LIPIDS in tissues (skin, tendon, eyes) 

• from 1-4 irregular nodules forming a central • Appear when there are abnormalities in lipid amount of
depression with a characteristic rolled border processing 

• larger lesion with central ulcer and crust = rodent ulcer 
 • Important markers for underlying dyslipidemia and
• no premalignant skin lesion, appear de novo 
 potentially increased cardiovascular disease 

• rarely metastasizes, but with prominent tissue • Work up: LIPID PROFILE
destruction, greatest danger is local invasion

• pathogenesis: mutation of mammalian PTCH gene → tuberous xanthoma
upregulation of SMO gene
 • super big, appear inflamed and tend to coalesce
• biopsy at the most indurated border

• histopathologic findings: basaloid cells, peripheral Eruptive xanthoma
palisading pattern, fibromyxoid stroma, retraction space 

• best tx: surgery (excision - choice), mohs micrographic plane xanthoma
surgery • flat macules/slightly elevated plaques with yellowish tan
• tx: coloration 

o 4mm margin for nonmorpheaform BCC • advised diet, statins, fibrins
smaller than 2cm in diameter • excise if big and affect ADLs but they will recur
o 5mm margin if >2cm diameter
o mohs micrographic surgery
o curettage for <1cm but can recur on other XANTHELASMA
areas • not all have elevated TG
o cryotherapy; imiquimod (TLR antagonist to • can occur with normal lipids

boost T helper 1 immunity) • appear as yellowish nodules
o 5-FU; vismodegib (hedgehog pathway • most common xanthoma 


antagonist); photodynamic therapy (MAL-PDT) • Areas: upper and lower eyelid
o Radiation therapy • Work up: LIPID PROFILE
pigmented BCC: EPHELIS / FRECKLES
• most common type in asians
 • fair skinned individuals 

• if darker skinned individuals = solar lentigo –do not fade;
superficial BCC:
usually in asians
• trunk, erythematous patch
• hyperpigmentation
• does not respond well to tx


Seborrheic keratosis
morpheaform BCC:
• Most common benign tumor of the skin 

• aggressive
• ivory white
 • Oval slightly raised 

• Stuck on greasy appearance 

infiltrative BCC: • Occur on sunexposed areas or trunk 


• aggressive • Spares the palms, soles, mucous membranes
• Dx: (+) comedo-like cyst in dermoscopy

Squamous cell CA
• second most common form of skin CA Sign of Leser Trelat 

• solitary, firm, flesh colored keratotic papule → tenderness, • Sudden eruption if multiple seborrheic keratosis 

induration, erosion, scale, or enlarging diameter 
 • Indicates Adenocarcinoma Of GI tract 

• intense sun exposure, burns, wounds, ulcers, HPV • Parallels the adenoCA 


• sun exposed areas: face, back, legs 

• high chance of metastasis 
 DERMATOSIS PAPULOSIS NIGRA
• chemo and radiation is there is lesion left • more common in asians and africans

• smaller version of seborrheic keratosis 

• mistaken for verruca plana, acrochordon if on the neck 


• genetic in 40-50%

MJDY 21
 DERMATOLOGY REVIEWER

SCAR
• 
Injury > hemostasis > inflammation > remodeling > scar
contour of Complication:
original• wound, regresses in time

o Contractures which may cause difficulty of breathing


Keloid
 

Atrophic scar
-extension beyond• bordersflat, follows
ofcontour
initialof injury

original wound 

-pain, pruritus

Hypertrophic scar
-claw-like
 • elevated, erythematous if new, skin color if old
-previous trauma,•sites of acne,
follows contour ofor spontaneous

original wound
• regresses in time
-areas of high skin tension: chest, upper back

-does not regress,
KELOIDcan even become bigger

-intralesional triamcinolone:
• to soften
extension beyond borderslesion to reduce pain/pruritus, can
of initial injury
flatten but not always

• symptoms: pain, pruritus 

claw-like
• dressings

-emollients, silicone
• previous trauma, sites of acne, or spontaneous 

• areas of high skin tension: chest, upper back
• does not regress, can even become bigger 

• Tx:
o intralesional triamcinolone
§ to soften lesion to reduce pain/pruritus, can flatten but not always 

o emollients, silicone dressings

Skin types
1. fairest - always burns, never tans
2. fair - usually burns, rarely tans
3. dark white - sometimes burns, tans slowly
4. olive - rarely burns, tans easily

5. dark - rarely burns, tans profusely

Skin types 6. dark brown - never burns, tans darkly black
1 - fairest - always burns, never tans
Blacks and whites have the same number of melanocytes, but blacks have increased activity of melanosomes that aggregate → more melanin
2 - fair - usually burns, rarely tans

MJDY 22