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How do you differentiate erythema multiforme from Steven Johnson Syndrome (SJS)? EM may appear similar to Steven Johnson Syndrome (SJS) but SJS has a more generalized distribution of lesions; concentrated on the trunk (EM extremities and mouth), an absence of raised typical target lesions and atypical flat (not raised) target lesions or macules with the coalescence of lesions Does erythema multiforme have a negative or positive Nikolsky sign? Negative Nikolsky sign (as opposed to SJS/TEN) What is the treatment for erythema multiforme? Symptomatic treatment with oral antihistamines and topical corticosteroids for mild cases; mouthwashes or topical steroid gels for oral disease. A 9-year-old male on antibiotics for a UTI has a cough, aching, headache, fever, a red rash across the face and trunk, and oral mucosal lesions. What is your diagnosis? Stevens-Johnson Syndrome (SJS) What is Stevens-Johnson syndrome? Stevens-Johnson syndrome (SJS) is a milder form of toxic epidermal necrolysis (TEN) with LESS THAN 10% of body surface area detachment
SJS vs. TEN? Stevens-Johnson syndrome and toxic epidermal necrolysis are considered variations of the same skin condition. If 10% of the body surface is affected, it's generally considered Stevens-Johnson syndrome; if 10-30% is affected, it's considered an overlap between Stevens-Johnson syndrome and toxic epidermal necrolysis; and if more than 30% is affected, it's considered toxic epidermal necrolysis. What is the cause of Stevens-Johnson syndrome? Most common with drug eruptions: Over 100 medications have been implicated in causing SJS especially sulfa and anticonvulsant medications What are two distinguishing symptoms of Stevens-Johnson syndrome and toxic epidermal necrolysis that differ from other similar conditions? Two distinguishing symptoms of Stevens-Johnson syndrome and toxic epidermal necrolysis from other similar conditions are that both mucosal linings and skin are affected Name two infections that can also be a trigger of SJS? In addition, some types of infections, like Mycoplasma pneumoniae or cytomegalovirus, can also be a trigger. How is SJS diagnosed?
Stevens-Johnson syndrome and toxic epidermal necrolysis are considered variations of the same skin condition. If 10% of the body surface is affected, it's generally considered Stevens-Johnson syndrome; if 10-30% is affected, it's considered an overlap between Stevens-Johnson syndrome and toxic epidermal necrolysis; and if more than 30% is affected, it's considered toxic epidermal necrolysis. What's a good way to remember the body surface area affected in TEN? A good way to remember the body surface area affected in TEN is "T hree x T en = Thirty percent in Toxic Epidermal Necrolysis Triggers for toxic epidermal necrolysis? Triggers for toxic epidermal necrolysis are typically certain kinds of medications! Which medications can cause toxic epidermal necrolysis? Medications such as lamotrigine, carbamazepine, allopurinol, sulfonamide antibiotics, and nevirapine can cause toxic epidermal necrolysis. A virus that can cause toxic epidermal necrolysis? A virus that can cause toxic epidermal necrolysis is cytomegalovirus.
The bacteria most-commonly associated with toxic epidermal necrolysis? The bacteria most-commonly associated with toxic epidermal necrolysis is Mycoplasma pneumoniae. Nearly all patients with toxic epidermal necrolysis appear with lesions where? Nearly all patients with toxic epidermal necrolysis appear with oral, ocular, or genital mucositis, which helps to diagnose the condition How is the diagnosis of TEN confirmed? The diagnosis of TEN is confirmed by biopsy (showing necrotic epithelium). What sign describes the separation of papillary dermis from basal layer when gentle lateral pressure is applied? The Nikolsky sign is the separation of papillary dermis from basal layer when gentle lateral pressure is applied; this is a helpful diagnostic feature of toxic epidermal necrolysis.
Alopecia areata What is alopecia? Alopecia refers to a loss of hair from part of the head or body and it can occur in a wide variety of disorders. What is the "hair pull test?" Assessment of activity on the scalp may be done with a hair pull test, done by gripping about 20 hairs and gently pulling upward and away from the skin What defines a positive hair pull test? Normally, about three hairs may fall out with each pull, while if more than 10 hairs are removed, the test is considered positive What is trichoscopy?
Trichoscopy is a noninvasive method of examining hair and scalp which is performed with the use of a dermatoscope. This traditionally consists of a magnifier, a non- polarised light source, a transparent plate, and a liquid medium between the instrument and the skin. What is a pluck test? The pluck test is conducted by pulling hair out by the roots. The root of the plucked hair is then examined under a microscope to determine the phase of growth, and is used to diagnose if there’s a defect of anagen or telogen. These hairs have sheaths attached to their roots and is consistent with a long (2- to 6- year) growing phase Anagen: A long (2- to 6-year) growing phase. Anagen hairs have sheaths attached to their roots These hairs have tiny bulbs without sheaths at their roots and is consistent with a short (2- to 3-month) resting phase Telogen: A short (2- to 3-month) resting phase. Telogen hairs have tiny bulbs without sheaths at their roots
What are secondary cicatricial alopecias? Secondary cicatricial alopecia always has a known cause. Causes include tinea capitis, radiation therapy, and surgical or injury scars. Diagnosis of cicatricial alopecia? A scalp biopsy is necessary to diagnose the type of cicatricial alopecia, to determine the degree of activity, and to select appropriate therapy. Treatment of tinea capitis? Treatment involves systemic antifungals like griseofulvin, terbinafine, fluconazole, or itraconazole. Adjunctive interventions for tinea capitis include using a shampoo with antifungal properties to reduce risk of spread of infection to other individuals. What is alopecia areata? Alopecia areata is a relatively common form of nonscarring alopecia in which an autoimmune process leads to the spontaneous loss of hair on the scalp or other areas.
Presentation of alopecia areata? Most often, alopecia areata presents with smooth circular patches of complete hair loss that develop over a period of a few weeks. Trichoscopy findings in alopecia areata? Trichoscopy findings include yellow dots, short vellus hairs, black dots, tapering hairs, and broken hairs Treatment of alopecia areata? In most cases, there’s spontaneous regrowth of hair. Individuals who want additional treatment may get topical or intralesional injections of corticosteroids if alopecia is limited; while individuals with extensive alopecia may get topical immunotherapy with diphenylcyclopropenone or squaric acid dibutyl ester. ● Systemic glucocorticoids are occasionally prescribed as a temporary measure to slow hair loss in individuals with rapidly progressing and extensive hair loss. What is traction alopecia?
Treatment of androgenic alopecia? For men with androgenetic alopecia, oral finasteride is suggested as first-line therapy, while topical minoxidil is an alternative therapy for male individuals that prefer to avoid systemic therapy. ● For women who want treatment, topical minoxidil is suggested as first-line therapy. This is a psychiatric disorder that lies on the obsessive-compulsive spectrum, in which individuals repeatedly pull out hairs, most often from the scalp, creating areas of alopecia that may have irregular, bizarre shapes? Trichotillomania (Hair-Pulling Disorder) Treatment of trichotillomania? Initial treatment usually involves behavioral psychotherapy, learning to recognize the impulse to pull, and also teaching them to redirect this impulse. ● Some individuals whose severity interferes with daily functioning may get medications like tricyclic antidepressants or selective serotonin reuptake inhibitors. And abrupt hair thinning caused by an abundance of hair follicles entering the resting phase at the same time. Can be due to stress-induced factors such as hormonal changes, surgery, severe emotional trauma, or crash dieting?
Telogen effluvium (TE) Hair loss occurs as a result of an acute interruption of the anagen phase, which may be caused by chemotherapeutic agents? Anagen Effluvium Alopecia - Chemotherapeutic agents are a major cause of anagen effluvium since most chemotherapy drugs work by attacking rapidly dividing cells like hair follicle cells. A 29-year-old field worker with a rash on his nails. The patient has a history of tinea pedis and tinea manuum and thought that this might be related. On physical exam, mild paronychia, loss of the cuticle of some nails, dirt-like yellowish-green nail pigmentation, subungual debris, and dystrophy of some nails is seen. What's the dx? Onychomycosis What is onychomycosis? Onychomycosis is a fungal infection of the nails that causes discoloration, thickening, and separation from the nail bed
What is an alternative systemic treatment for patients who cannot tolerate terbinafine or fail to respond to terbinafine. Itraconazole is an alternative systemic treatment for patients who cannot tolerate terbinafine or fail to respond to terbinafine. Terbinafine SE? Hepatotoxicity A 32-year-old female with a painful index finger. She obtains regular manicures, changing colors every 2 weeks. She recently had one a week ago and started feeling pain near the nail on her left index finger. A physical exam reveals redness, warmth, and pain along the nail margin of the index finger. When applying pressure to the nail plate, some pus drains from the nail. She is prescribed frequent warm soaks with chlorhexidine and oral antibiotics. What's the dx? Paronychia What is paronychia?
Inflammation/infection of the nail fold Most common cause of acute paronychia? Staph aureus Most common cause of chronic paronychia? Candida albicans Diagnosis of paronychia Diagnosis is by inspection Treatment of acute paronychia? Warm soaks, I&D, antibiotics (for staph coverage; Keflex, Bactrim, Clindamycin, etc.)
6 weeks What is the length of treatment for onychomycosis of toenails? 12 weeks What is the most common bacterial cause of paronychia? Staph aureus Immune system attack against the hair follicles? Alopecia areata Hair loss secondary to fungal infection of scalp? Tinea capitis This condition is caused primarily by pulling force being applied to the hair Traction alopecia
A scalp disorder characterized by the thinning or shedding of hair resulting from the early entry of hair in the telogen phase (the resting phase of the hair follicle) Telogen effluvium Lab testing required while on oral antifungal medications? LFT's Necrotic wound - > Local tissue reaction causes local burning at the site for 3-4 hours → blanched area (due to vasoconstriction) → central necrosis erythematous margin around an ischemic center "red halo" → 24-7 hours after hemorrhagic bullae that undergo eschar formation → necrosis Brown recluse spider bite Neurologic manifestations - > May not see much at bite site: toxic reaction: nausea, vomiting, HA, fever, syncope, and convulsions Black widow spider bite Describe the management of animal bites?
- Stop the bleeding
