Derm 2

Question 1

Acute Skin Wounds: Referral

Answer 1

• Foreign matter post irrigation
• Chronic wounds
• Animal/human bites
• Infected
• Face, mm’s (mucous membrane), genitalia
• Deep (closure needed)
• Tetanus status(?)

Don’t suture in wild, close in bacteria

Question 2

What would you treat these wounds with and why?

1. H2O2, 3% - efferescent cleansing action, strong bactericidal effect
2. Neosporin ointment (Triple antibotic) – prevent wound infections
3. Iodine treated lake/creek water-irrigation removal of debris, antisepsis
4. Betadine solution-safe i.e., not absorbed systemically.

Answer 2

• H202: weakly bactericidal, releases oxygen to have weak bactericidal effect, bubble and get gunk out
• Neosporin: prevent infection, won’t treat infection, barrier (can use Vaseline), don’t like because resistance issues, out in the woods might be good
• Irrigating to get the big chunk out. 1 tab per liter for clean water. 2 tab per liter of dirty water. Iodine very effective at cleaning water. Iodine not cause probably
• Betadine: bactericidal, well tolerated, probably won’t be carrying when hiking
  ​

Question 3

Ferral Cat Wound

Answer 3

• Pasteurella multocida
• The hot water most important part, but not Epsom salt
• Refer for antibiotics
  
  • Cats have dirty mouths
  • P. multocida sensitive to augmentin
  • Little cut can streak up arm because of tendon sheath, infection all up arm, infection on hands really risky
• Cut on leg not as risky, no “highway” tendon sheath

Question 4

Acute Skin Wounds: Treatment

Answer 4

• Cleanse with irrigation (saline)
  
  • saline better than water because less irritating
• Antiseptics
  
  • hydrogen peroxide
    
    • enzymatic release of oxygen, effervscent cleansing action, short acting (O2 release), not in abcess, limited cidal effect, risk of tissue toxicity – little benefit over soapy water
  • ETOH
    
    • Good cidal activity in 20-70% range; tissue irritation; flammable;
  • isopropyl alcohol
    
    • 70% stronger cidal; cytotoxic effects; drying; flammable
  • iodine
    
    • broad spectrum; oxidizes microbial protoplasm; Water base preferable to alcohol base – less irritating; stains, irritates tissue, allergic sensitization (used with chlorhexidine allergy)
  • povidone-iodine
    
    • Better than iodine
    • AKA: Betadine
    • nonirritating; absorbed sysemically;
• Antibiotics
  
  • neomycin, Gm+/-
  • bacitracin, Gm-
  • polymyxin B, Gm-
  • tetracycline, DON’T USE
  • Use one Gm+ and -, don’t need to double up, so triple antibiotic ointment is bad, can cause sensitization

Question 5

Insect Bites

Answer 5

• Mosquito: West Nile, malaria
  
  • Malaria: fever, malaise, swollen spleen, from typical area
  • West Nile: same sort of symptoms, horses
• Fleas: annoying, bubonic plague, endemic typhus, itching problem
• Scabies: “the itch”
  
  • Takes physical contact
  • Common reaction sites: interdigital spaces, flexor wrists, external male genitalia, buttocks, anterior axillary folds
  • Don’t jump across pharmacy counter
• Spiders: black widow, brown recluse, hobo
• Chiggers: (red bugs) brushy areas
• DEET: Sunscreen first, then DEET
• Bees, YJ’s, wasps: Local to allergy/anaphylaxis; infections 3-5 days, cold, prednisone, NSAID, H1RB, top steroids
  
  • Anaphylactic shock: red, swollen, lightheaded, dizziness have already developed antibodies
    
    • Benadryl too slow, only block reaction, but reaction still going. Need epinephrine.
  • Remove stinger immediately (if wait, already empty) get off with credit card
  • They have dirty mouths too, infection
    
    • Slower, 3-5 days, redness, swelling
• How deal with local inflammatory reaction
  
  • 1 dose prednisone
  • Topical steroid
  • NSAID
  • H1RB
  • Cold compress

Question 6

Inset Bites: Treatment

Answer 6

• LAs: Pramoxine less cross sensitivity; temporary blockade of transmission of nerve impulses
• Phenol conc >2% irritating, avoid in Pg, children depresses sensory receptors
• Topical antihistamines: use systemic
• Camphor, menthol: Depresses cutaneous receptors; camphor – dangerous if ingested.
• Hydrocortisone:
• Spider Bites: big red blob, necrosis in the middle, normally don’t see spider that bit you
• Local anesthetics: only last short time, sensitizer
• Counterirritants:
  
  • **Sarna **lotion, camphor, menthol
• Systemic antihistamine, need to be sedating
  
  • cetirazine might be okay

Question 7

Ticks

Answer 7

• RM spotted fever
  
  • HA, fever, fatigue, palmar rash
• Remove intact
  
  • tweezers at base
  • Not w/ mineral oil, vaseline – induces salivation
• Lyme’s
  
  • skin rash, flu
  • Untreated: neurological, HA, stiff neck, cardiac, rhem BAD
  • If treat quickly, okay
    
    • treatment effective, chronic if not treated
  • Target rash 2-3 weeks after bite
    
    • See picture

Question 8

Pediculosis

Answer 8

• AKA: Lice (head, body, pubic)
• Kids share hats, have sleepovers, put heads together, lay together
• Nurses tend to go overkill and see it as the “black-mark”
  
  • Don’t keep kids out of school
• Leads to overtreatment, leads to expense, resistance, toxicity
• Only treat Sam, not the other kids
• Seizure not caused by pyrethrins
  
  • Seizure caused by Quell, Lindane, neurotoxic to humans, keep away from children, tendency to overtreat
  • BE CAREFULL with refills
• Side note: Febrile fits, fever, treat kid for fever because more serious
  
  • Mayo and dippity-doo to get the nits (“empty treehouses”) off hair shaft. Don’t comb obsessively
• # 4: Permethrin is a cream rinse, not a shampoo
  • Shampoo doesn’t stay on hair, let sit on hair for 10 minutes with cap.
  • Pass on instructions to patients ​

Question 9

Pediculosis: Treatment

Answer 9

• Physical (comb)
• Pediculicides
  
  • Pyrethrins
    
    • Shampoo
  • Permethrin
    
    • Nix
    • cream rinse
  • Lindane
  • Malathion
  • Spinosad
  • Benzoyl alcohol
  • Ivermectin
    
    • Last chance drug
• Tea tree oil
• mayo, Dippity-Do, Vaseline

Question 10

Fungal Skin Infections:

• Tinea pedis
• Tinea corporis
• Tinea cruris
• Tinea capitus

Answer 10

• Common
• Yeast fungal infections, under breast, vagina, mouth
• Dermatophite causes majority of infection
• Named by where it occurs ​
  
  • Pedis: Athletes foot
  • Corporis: Ringworm
  • Cruris: Jock’s Itch
  • Capitus: Head

Question 11

What is this?

Answer 11

• Tinea corporis
  
  • Vesicular on borders and clearing in middle
• Hydrocortisone making fungi worse
  
  • Tinea incognito, when doesn’t look like “typical” ringworm
  • Steroids putting a mask on it

Question 12

Fungal Skin Infections: Treatments

Answer 12

• Antifungals
  
  • Treat it long enough
  • Apply sparingly
  • Generous area
  • Put it on until done, and then a couple days longer
• Clotrimazole
• Turbinafine
• Butenafine
• Miconazole
  
  • Not as good against microsporin
  • Microsporin found in kids and hair
  • If kids and hair, think about using something different
• Tolnaftate
  
  • Dermatophites ONLY
• Undecylenic acid
  
  • Dermatophites ONLY
  • Very weak
  • Only good use as prophylactic in boots

Question 13

Tinea unguium
onychomycosis

Answer 13

• Get after dose of athlete’s foot first
• Get between toes 4 and 5 first
• Big toes always get infected at nail base
• 6-12 months to treat
• Cannot treat nails topically
  
  • Lousy cure rates topically
• Potential liver toxicity with systemic
• Try to not get it in first place
• Diabetes with fissures with athletes foot, entrance for bacteria
  
  • Not feel toes
  • Diabetic, careful to treat feet
  • Only if can’t feel feet, normal feet treat like everybody else
  • Soak in hot water, burn foot example

Question 14

Tinea Capitis

Answer 14

• Patch of hairloss
• Patch, circumferential, spreading out, broken hair shafts
• Cannot treat OTC
  
  • Cannot self treat because on head
• Use turbenafine oral, flucanzol oral, grinesefol oral

Question 15

Don’t treat hair and nails with topical products!

Answer 15

Only treat systemically

Question 16

What is this?

Answer 16

• ID reaction
• Looks like eczema of hands
• New cosmetics, handling soaps, ask those questions
• Rashes anywhere else, no
• Athletes foot between 4-5
  
  • Treat it and hand rash go away
  • Id reaction means reacting to herself

Question 17

Acne: Grades

Answer 17

• Grade I: comedones only
• Grade II: papular acne
• Grade III: pustular acne
• Grade IV: Nodules/cysts, scarring
• Grade 3 and 4 causes scarring
• Grade 1: keep comedones open
• Grade 2: Kill bacteria
• Grade 3: Definitely need to kill bacteria

Question 18

Acne: Etiology

Answer 18

• Rapid cell turnover
• Increased sebum
• P. acnes
• Inflammation
• Like rush hour, all plugged up
• Closed comedone: expose to sunlight, blackhead
• Papule: when explode under skin and causes irritation (zit)

Question 19

Acne: Treatments

Answer 19

• Cleansing
  
  • washes away the oils
  • Don’t use moisturizing soap, use sensitive soap, need to be squeaky clean with no oil
• Benzoyl peroxide
  
  • (soln, cr)
  • Antibacterial drug, 30-40% efficacy is this reason
  • Mostly a ketorylytic, unplug comedone
    
    • Prevent papules from forming
  • Water base, cream, not as drying
  • Alcohol, more drying
  • Bigger dose more redness and peeling
    
    • Sensitive skin, use lower dose
    • Dripping in oil, alcohol base and higher dose
    • Good dose shows that after putting on skin a little dry and red, stiff face, DON’T COUNTERTREAT WITH LOTION
  • Takes 21 days
• Antibiotics
• Retinoids
• Diet is not a factor

Question 20

Diagnose

Answer 20

• Really bad, probably 3 or 4, needs to go to doctor
• Antibiotics

Question 21

(Acne) Rosacea

Adult Acne

Answer 21

• Disorder of blood vessels
  
  • Vascular, not sebaceous
• No endocrine relationships
• Differs from acne
  
  • Sensitive to touch
  • reddening of the face
  • enlarged blood vessels (telangiectasias)
  • solid papules
  • central face
  • no comedones
• Worsened by alcohol, spicy foods, steroids
• Treatment:
  
  • Oral antibiotics
  • Topical metronidazole, clindamycin (gels), mosturizing gels

Question 22

Diagnose and Treat

Answer 22

• Planter Warts
• Corn and calluses tell you that shoes don’t fit
  
  • Corn and calluses don’t lie
  • Retain footprint
  • Corn on top of foot and calluses on the bottom
• He has way too many warts for salicylic acid
  
  • Apply patch directly to wart, eats away at wart until crater left
  • Can’t put on whole heel because will form a red ulcerated square on foot
• Volatile, painted on salicylic acid
  
  • 4 drops on wart each night
  • Take a long time and the guy is already limping
• Can freeze at home, but can only treat a little wart, this guy would need like 40 bottles
• Referal needed because of extense/quantity

Question 23

Warts

Answer 23

•Verruca vulgaris (common)
•Verruca planaus (flat, juvenile)
•Condyloma lata, acuminata (venereal)
•Verruca plantaris (plantar)**
Tender, disrupts the footprint pattern

Question 24

Warts: Exclusions

Answer 24

• Face, toenails, fingernails, anus, genitalia
• Extensive – one site
• Painful plantar warts
• Chronic, debilitating disease (DM, PVD)
• Physical, mentally impaired

Question 25

Warts: Rx

Answer 25

* Salicylic acid * Liquid, plaster * Cryotherapy * Liquid nitrogen * Dimethyl ether (DMEP/propane) * Duct tape

Question 26

What is this?

Answer 26

* **Androgenetic Alopecia** * male pattern baldness * **finesteride** * **​**inhibits the 5-alpha-reductase type 2, inhibits conversion of testosterone to DHT * **minoxidal** * **​** 5% vs 2%; Foam – no propylene glycol irritant * have to do continious * take months to work

Question 27

What is this?

Answer 27

* **Alopecia areata** * treated with injectable steroids * smooth, discrete * explanation point hairs at margins * nail involvement * thyroid, rheum, autoimmune * Rx: intralesional steroids

Question 28

What is this?

Answer 28

* **Telogen effluvium** * diffuse, nonscarring, noninflammatory hair loss post trauma * Regrows, reassure patient * diffuse hair loss (all over), no spots, no broken hairs, usually emotional or medical problems