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146 Cards in this Set
- Front
- Back
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Amount of topical medication for one application:
- hands, face, head - arm - leg - entire body |
2 g
3g 6g 30-60g |
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Where is the greatest rate of absorption from topical medication
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face, axillae, genital
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Which form of topical medication has the maximum absorption
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ointment
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Which form of topical medication has the least absorption
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gel or lotion
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What is the effect of topical corticosteroids?
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vasocontriction - used for inflammatory and allergic disorders.
Have immunosuppressive and inflammatory properties |
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What effect does high does topical steroids have?
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More vasocontrctive activity
The more potent, the more vasocontriction action |
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What is the most most potent topical steroid?
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Betametashone 0.05%
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What are the low potency topical steroids?
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Hydrocortisone
Triamcinolone Fluocinolone |
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Why are antihistamines used for symptoms of itching and allergy?
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Anticholingergic effects
Block activity at histamine receptor sites |
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What are the first generation antihistamines
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Diphenhydramine (Benadryl)
Chlorpheniramine (Chlor-Trimeton) |
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What are the second generation antihistamines?
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Loratadine (Claritin)
Deslaratadine (Clarinex) Cetirizine (Zyrtec) fexofenadine (Allegra) Levocetirizine (Xyal) |
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Caution with first generation antihistamines
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anticholingergic effects - visual changes, sedation, urinary retention (esp. older men with BPH)
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Impetigo
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contagious skin infections consisting of purulent draingage; honey crusted lesions
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Peak age of occurrence for impetigo
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2-5 years
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Bacteria that causes impetigo
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group A streptococci
Staphylococcus auereus |
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Bullous impetigo causative agent
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cased by straings of Staphylococcus auereus that produce a toxin causing cleavage on superficial skin layer - usually present in nose before outbreak
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Bullous impetigo lesions
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superficial vesicles that rapidly enlarge to form a bulla or blister that is often filled with dark or purulent liquids; lesion ruptures and think, lacquer-like crust forms
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Nonbullous impetigo
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Begins as papules that rapidly turn into vesicles surrounded by area of erythema; pustules increase then break down over 4-6 days forming characteristic thick crusts
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Most common form of impetigo
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Nonbullous (70%)
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Most common cause of nonbullous impetigo
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Staphylococci or combo with streptococci
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Primary treatment of impetigo
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topical antibiotic - mupirocin (Bactroban)
I |
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Treatment of impetigo with numerous lesions or no response to Bactroban
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Oral antibiotic
Dicloxacillin Cephalosporin Azithromycin Clarithromycin |
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What is the implications for chosing the antibiotic used to treat impetigo?
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Antimicrobials with a gram+ spectrum of coverage and stability in the presence of beta-lactamase
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What is the next step for treating impetigo if there is no response to the first line antibiotic?
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High dose trimethoprim-sulfamethoxazole (Bactrim)
Clindamycin Mniocycline and doxycline (tetracyclines) - but not in children <11 |
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How long should children with impetigo be kept out of school?
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24 hrs after starting antibiotic therapy
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Clinical features of impetigo
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vesicular lesions
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Likely causative organism of nonbullos impetigo in a 6 yo
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group A streptococcus and Staph auereus
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The spectrum of antimicrobial activity of mupirocin (Bactrim) includes
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select gram + organisms
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Oral antibiotic commonly used for MRSA cutaneous infection
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trimethoprim-sulfamethoxazole (Bactrim)
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Acne vulgaris
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Pustular inflammatory disorder caused by increase in sebaceous activity that causes plugging of folicles and retention of sebum leading to lesions, open (blackheads)and closed comedones (whiteheads), cysts and pustules
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Species that causes acne vulgaris
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propionbacterium
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First line therapy for acne vulgaris with closed comedones
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benzoyl peroxide (lower strength as effective as higher strength and causes less skin irritation)
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Treatment of acne vulgaris that presents with mild to moderate inflammatory lesions
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topical antibiotics
clindamycin, erythromycin, tetracycline, metronidazale (often given in combo w/benzoyl peroxide) |
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How long does it take to see results for oral antibiotics used to treat acne vulgaris?
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6-8 weeks
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Therapy for cystic acne
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Isotretinoin (Accutane)
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What is typical length of treatment with Isotretinoin (Accutane)?
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4-6 months; disconue when 70% reduction is achieved
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Advserse reactions of Isotrentinoin (Accutane)
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cheilitis, conjunctivitis, hypertriglyceridemia
photosensitivity, potent teratogenicity mood destablization, suicidal thoughts |
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Use of birth control while on Isotrentinoin (Accutane)
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2 methods of high effective contraception; monthly pregnancy test
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Why is birth control used for acne and what type of birth control pills are used to treat acne vulgaris?
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- Reduces ovarian androgen production leading to decreased sebum production
- Combined estrogen-progestin (BCP, ring, patch) |
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Mild acne vulgaris description and tx
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few papules/pustules, no nodules
tx: topical retinoid + topical antimicrobial first-line tx |
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Moderate acne vulgars description and tx
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papules/pustules, comodones
tx: add oral antibiotic |
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Severe acne vulgaris and tx
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cyctis lesions
tx: add isotretinoin (Accutane) |
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Topical retinoids (keratinolytic agents) used to treat acne vulgaris and for prophylaxis
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Tretinoin (Retin-A)
Azelaic acid |
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Caution regarding Retin-A or other topical retinoids
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Photosensivity. Instruct pt to use sunscreen.
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Labs to monitor for pt on Isotretinoin (Accutane)
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pregnancy, CBC, lipids, LFTs
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Acne rosacea
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facial flushing, telangiectases, papules, pustules (resembles acne vulgaris)
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Treatment of acne rosacea
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metronidiazole gel (metroGel)
Zaelaic acid (Finacea) + oral doxycycline |
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Which bite is more infective - dog or cat?
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Cat
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Common infective agent in domestic pet bites
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pasteurella multocida
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Initial treatment for all bite wounds
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All bites should be considered to have significant infection risk. Vigorous cleaing with antimicrobial agent and debridement is needed. Start short-term antibiotic prophylactic tx w/in 12 hrs. Tetanus if needed.
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Antibiotic most frequently used for bites
Primary Alternative |
Amoxicillin with clavulanate (Augmentin) 875/125 mg Bid
Doxycyline Clindamycin, Bactrim, cipro |
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Type of wounds that can be treated in outpatient setting
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Mild less than 10% of body surface
Burns that do not involve a high function area or minimal cosmetic consequence Hands/feet to specialty care |
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Treatment of burns
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Silver sulfadiazine (Silvadene)
Mafenide acetate (Sulfamylon) |
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First degree burn
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erythema and pain
skin blanches |
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Second degree burn
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blisters with raw, moist surface
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Third degree burn
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minimal pain, white and leathery
burns usually surrounded by areas of painful firth and second degree burns |
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Estimating body surface area - rule of 9's
palm head/arm leg trunk |
palm 1%
head/arm 4.5% leg 9% trunk 18% |
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Atopic dermatitis (eczema)
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Most common in peds; familial risk factor
type 1 hypersensitivity rx from IgE antibodies causing mast cell to release histamine - causes vasodilation, tissue swelling, skin eruptions |
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Three criteria needed for dx of atopic dermatitis (eczema)
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red or inflamed rash
presence of excessive dryness/scaling location in skin folds of arms or legs |
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Most common complaint of atopic dermatitis (eczema)
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Pruritis - most common symptom
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Where is pruritis rash found:
infants children |
trunks, face, flexural surfaces - diaper area spared
antecubital and popliteal surfaces |
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Non-prescription first line treatment of atopic dermatitis (eczema)
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Avoid offending agent, minimize skin dryness by limiting soap and water exposure, consistent use of lubricants (Eucerine, Vaseline)
Cool, wet dressings with Burow's solution applied x 30 min |
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Treatment of atopic dermatitis (eczema) - steroid
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Intermediate potency steroid for acute (Betamethasone dipropionate 0.05% cream)
Lowest dose steroid after control obtained (hydrocortisone) |
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Steriod potency tips
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gel = Most potent steroids (Betamethasone)
cream = less potent (hydrocortisone) using plastic wrap = increased potency |
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Immunomodulators used for atopic dermatitis (eczema)
warnings MOA |
age>2; black box risk of cancer
block T-cell stimulation and inhibit mast cell activation Use only if other tx has not worked |
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Immunomodulator topical drugs
"-crolimus" |
Pimecrolimus (Elidel) and tracrolimus (Protopic)
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PO steroid use for atopic dermatitis (eczema)
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For severe cases - Prednisone tapered over 7-14 days
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Immune modifiers used in tx of severe atopic dermatitis (eczema)
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Methotrexate, azathioprine cyclosporine
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Tx for pruritis associated with atopic dermatitis (eczema)
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Antihistamines - Hydroxyzine (Atarax) at HS
Cetirizine (Zyrtec) - less sedating metabolite of hydroxyzine |
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Common triggers for contact dermatitis
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nickel, rubber additives in shoes and gloves, toiletries and topical medications
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Common site for atopic dermatitis (eczema) in:
infant adult |
infant: face
adult: flexor surfaces |
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Onychomycosis (dermatophytosis of nail)
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chronic fungal infection of fingernails and toenails
Toenails more common |
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Presentation of onychomycosis
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nails dull, thick, lusterless with pithy consistency; nails often break off; nails yellow-brown appearance
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Onychomycosis diagnosis
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Microscopic examination of nail scraping mixed with KOH for hyphae or culture
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Onychomycosis treatment (antifungals)
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itraconazole (sporanox)-
terbinafine (lamisil) - PREFERRED fluconazole (diflucan) Topical treatment of little value |
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Duration of treatment for onchymycosis
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6wk fingernails
3 mo toenails |
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Describe pulse cycle treatment of onychomycosis
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Take med first week of month for 2 months for fingernails or 3 months for toenails - produces less systemic effects
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Caution when prescribing itraconazole (sporanox) and fluconazole (Diflucan)
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Inhibits cytochrome P450, 3A4 pathyway
caution: hepatic disease, hx of CHF (itraconazole) |
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When prescribing pulse dosing with itraconazole for tx of onchomychosis, the NP can expect a transient increase in which lab
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hepatic enzymes
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Transmission of scabies
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parasitic infection of skin spread by skin-to-skin contact requiring close personal contact (sexual relations) or contact with bedding of infected person
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Treatment of bedding following scabies infection
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Wash in hot water or place in clothes dryer for a normal cycle or place items in plastic storage bags for at least 1 week
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Presentation of scabies
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Burrows (thin curvy elevated lines in upper dermies) with clustering lesions in areas of warmth - finger webs, axillary folds, belt line, areola, scrotum. Progresses to vescular or papular rash with excoriation caused by scratching
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Treatment of patient infected with scabies
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Permethrin (Elimite) 5% lotion. Must be left on for 8-14 hrs. May need to repeat in 1 week.
Adult dose 30g. alt: Kwell |
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Pruritis associated with scabies
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Related to dead mites and waste trapped under skin; can last several weeks. Tx w/ antihistamines or topical/oral corticosteroids
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Potential adverse effects of long-term high potency corticosteroid use
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telangiectasia, skin atrophy, adrenal suppression, striae, acne
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Psoriasis vulgaris
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chronic T cell autoimmune skin disorder caused by accelerated mitosis and rapid cell turnover
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Presentation of psoriasis vulgaris
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silvery scales with underlying red plaque; typically found in extension surfaces (trunk, limbs); plaques over elbows and knees; scalp occasionally involved
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Risk factors for psoriasis vulgaris
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genetic; trauma, sunburns, stress, HIV, folic/b12 deficiency, alcohol use, smoking, diabetes, obesity
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Treatment of psioriasis vulgaris: acute, maintenance
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Medium potency topical corticosteroids until plaques resolve followed by lower potency 3-4 X week to maintain remission
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Nonsterioidal tx of psioriasis vulgaris
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Tar preparations, Vitamin D (calcipotriene), psoralen with UV light
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Treatment of recalcitrant psoriasis
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methotrexate, cyclosporine, systemic retinoid(acitretin), infliximab (Remicade), Entanercept (Enbrel)
other "-mab" biological agents |
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What is the cause of psoriatic lesions
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rapid skil cell turnover leading to decreased maturation and keratinization
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What is Auspitz sign?
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appearance of punctate bleeding spots when psoriasis scales are scraped off
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Seborrheic dermatitis (ie cradle cap)
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chronic, recurrent inflammatory rash affecting areas with high concentration of sebaceous glans - scalp, eyebrows, eye lid, nasolabial folds, ears, upper trunk
waxing and waning-worse during winter |
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Presentation of seborrheic dermatitis
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red, greasy, scaling consisting of patches and plaques with indistinct margins; red smooth glazed appearance in skin folds, minimal pruritis
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Treatment of seborrheic dermatitis on scalp (cradle cap)
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Shampoos: Ketaconazole (Nizoral), coal tar; selenium sulfide, zinc pyrithione
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Treatment of seborrheic dermatitis on skin
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topical antifungals - ketazonazole or topical corticosteroids starting with hydrocortisone 1%
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General measures for cradle cap, esp infant
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Frequenc shamppoing with mild, nonmedicated shampoo
Remove thick scale with mineral oil left on x 1 hr and then washed off with mild soap and soft bristle toothbrush or washcloth (usually resolves by 6-8 months) |
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Malignant melanoma
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-malignancy that arises from melanocytes-cells that make pigment melanin
-Most common form of FATAL dermatologic malignancy |
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ABCDE for assessing malignant melanoma
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Asymmetric, irregular Borders, Color not uniform (brown, glack, red, white, blue) - variable pigmentation, Diameter >6mm (size of pencil eraser), Evolving (new or changing)
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In office removal of suspicious nevi
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fully excision lesion with 2mm rim of normal skin; send for biopsy
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Basal cell carcinoma
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- most common form of cancer
- rarely metastasizes - painless, pearly ulcerated nodule; may have overying telangiectasis |
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Risk factor for basal cell carcinoma
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chronic sun exposure (use sunscreen and avoid sunlight from 10a.m. to 4 p.m.), long sleeve shirts, wide brim hats
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Pnemonic for basal cell carcinoma
'PUT ON' sunscreen |
Pearly painless papule, Ulcerating, Telangioectasia, On: face, scalp pinnae, Nodule (slow growing)
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Sqammous cell carcinoma
"NO SUN" |
Nodular, Opaque, Sun-exposed area, Ulcerating, Nondistict borders
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Squammous cell carcinoma
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- second most common form of skin cancer
- most arise in solar keratoses - slow growing, minimally invasive, not agressive, good prognosis |
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Virus that can cause squammous cell carcinoma
(verruccous carcinoma) |
HPV
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Actinic keratosis (aka solar keratosis)
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Premalignant UV inducted skin lesions that can evolve into squamous cell carcinoma
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Actinic keratosis presentation
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Small red, pink, brown macules - small rough spots that are easier to feel than see; sandpaper-like quality
- may itch or burn - may see yellow or brown scale on top of the lesion |
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Most common treatment of actinic keratoses (solar keratoses)
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Cryotherapy with liquid nitrogen
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Alternative treatment for actinic keratoses
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Fluorouracil cream
imiquimod cream Diclofenac Chemical peel or laster tx |
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Urticaria
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eruption of groups of intensely itchy wheals or hives in response to allergen exposure; lesions usually last 2-4 hrs and no more than 24 hrs
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Cause of urticaria
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IgE anibodies on receptor sites of mast cells causing degradation and release of histamine, vasodilation, mucous gland stimulation and tissue swelling
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What dod you expect to find elevated in person with urticaria?
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eosinophilia
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Treatment of urticaria
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Avoid trigger, antihistamines, topical corticosteroids, leukotriene modifiers (zafirlukast, montelukast)
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verruca vulgaris
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warts caused by HPV types 1,2,4
spread by person to person contact resolves spontaneously over 12-24 mo w/o treatment |
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Cellulitis
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Bacterial infection caused by break in the skin; presents with pain, erythema, warmth and swelling
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Pt presentation with cellulitis
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localized pain, tenderness, itch or burning; fever, chills, malaise, regional lymphadenopathy, purulent drainage
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Treatment of cellulitis when risk of MRSA is low
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Dicloxacillin or macrolide (azithromycin, clarithromycin)
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Treatment of cellulitis with risk of MRSA
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TMP/SMX (Bactrim), doxycycline, minocycline or clindamycin
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Most common causative organisms in cellulitis
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group A beta hemolytic streptococci and S. aureus
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Treatment of skin lesion based on size:
<5 cm, afebrile; >5cm |
<5cm = I&D, C&S, warm dressing soaks
>5 cm = previous interventions + Bactrim DS |
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Foliculitis
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inflammation of hair follicle caused by infection, physical or chemical irritation or injury
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Presentation of folicullitis
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mutiple small macules and papules <5mm ; papular/pustular rash on hair-bearing skin (esp face, limbs, scalp); often pruritic
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Most common pathogen in folliculitis
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Staph aureus (gram +) or
Pseudomonas aeruginosa (hot tub folliculitis) |
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Risk factors for folliculitis
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hair removal, eczema, acne, occlusive clothing, obesity, immunosupression, DM, use of hot tubs or saunas, exposure to MRSA
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Treatment of folliculitis
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Topical mupirocin (Bactroban) 2-5 x day - preferred
Cephalosporin or Diclocacillin PO |
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Furuncle (boil)
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acute bacterial abscess of hair folicle; often caused by Staph aureus; infection spreads from hair folicle to surrounding dermis
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Furuncle presentation
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painful, erythematous papules/nodes (1-5cm); tender, red, perifollicular swelling, pus and necrotic plug; may be solitary or clusters
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Treatment of furuncle
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Abx directed at Staph aureus (gram +) x 10-14 days
Dicloxacillin, cephalexin or clindamycin |
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Pityriasis Rosacea rash
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salmon-colored to light brown oval plaques with fine scales centrally and loose scales along borders;
lesions 1-2 cm diameter and spare face, hands and feet Form along skin lesion in "christmas tree" pattern |
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Pityriasis Rosacea herald patch
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2-10 cm salmon colored patch or plaque present 40-75%; appears before onset of rash
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Treatment of pityriasis rosacea
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Symptomatic tx as needed:
Topical steroid to reduce itching - Triamcinolone oral antihistamine - Diphenhydramine, Chlorpheniramine lukewarm oatmeal bath (not HOT-can make increase itching) |
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Pityriasis rosacea course
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self-limiting, usually resolves in 2-6 wks
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Anthrax - cutaneous
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highly infectious disease; bioterristic threat; caused by B. anthracis
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Anthrax skin presentation
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PAINLESS pruritic spot followed by red-brown papule that enlarges into BLACK eschar with massive edema within 7-10 days of initial lesion. May have fever, malaise and HA.
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Treatment of cutaneous anthrax
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Ciprofloxacin or doxycycline
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Corn (heloma)
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circumscribed hyperkeratotic lesion with central conical core of keratin that causes PAIN and inflammation; flat, slightly elevated
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Callus (tyloma)
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superficial hyperkeratosis; usually NOT PAINFUL; result of exposure to repetitive fricture or mechanical pressure - tend to occur on palms of hands and soles of feet; thickening of skin without distinct borders
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Cafe au lait spots - caution
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Coffee colored patches - present at birth or develop a few years later. Presence of several cafe-au-lait spots larger than a quarter may occur in neurofibromatosis (a genetic disorder that causes abnormal cell growth of nerve tissues).
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Molluscum contagiosum
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Viral Poxviridae skin infection; highly contangious via skin-to-skin ; esp. in immunocompromised (HIV, chemo, corticosteroids, transplant)
Resolves spontaneously in healthy people |
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Molluscum contagiosum presentation
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dome shaped pearly white or flesh-colored papules with central umbilication
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Molluscum contagiosum treatment
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Cantharidin solution (from blister beatle); Podofilox, Podophyllin
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Woods lamp (black light)
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used to evaluate hypo for hyperpigmented skin
hypo = white = vitiligo hyper - purple - cafe-au-lait fungus - yellow - tinea versicolor |
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tinea versicolor
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macules that are hypopigmented white or hyperpigmented light brown or salmon colored - caused by saprophytic yeast; lesions usually white in sun exposed areas
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tinea versicolor treatment
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Ketoconazole shampoo for 5 minutes or selenium sulfide;
topical clotrimazole (Lotrimin), miconazole (monistat), terbinafine (Lamisil). Repeat each spring prior to sun exposure |
