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Dermatology

Dermatology. …or “Is this a boil?” Dan Cushman. Intro to Dermatology. What is the most common skin diagnosis for non-dermatologists?. Dermatitis > Pyoderma > Warts. Primary. Are nevi primary or secondary lesions?. Acne vulgaris > Dermatitis > Actinic keratosis. The dermis.

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Dermatology

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  1. Dermatology …or “Is this a boil?” Dan Cushman

  2. Intro to Dermatology What is the most common skin diagnosis for non-dermatologists? Dermatitis > Pyoderma > Warts Primary Are nevi primary or secondary lesions? Acne vulgaris > Dermatitis > Actinic keratosis The dermis What is the most common skin diagnosis for dermatologists? Which portion of the skin is damaged in scar formation? Benign Are nevi benign or malignant? 03/10/2008 13:00

  3. Intro to Dermatology General lesion type Flat or raised? Flat Macule What is the larger sized version called? Patch What size are they? <1cm 03/10/2008 13:00

  4. Intro to Dermatology General lesion type Flat or raised? Raised Papule What is the larger sized version called? Plaque What size are they? <1cm 03/10/2008 13:00

  5. Intro to Dermatology General lesion type Flat or raised? Raised Nodule What is the larger sized version called? Tumor What size are they? >1cm 03/10/2008 13:00

  6. Intro to Dermatology General lesion type How do they differ from papules? Fluid-filled Vesicle What is the larger sized version called? Bullae What size are they? >1cm 03/10/2008 13:00

  7. Intro to Dermatology General lesion type What are the flakes? Compacted desquamated layers of stratum corneum Scale 03/10/2008 13:00

  8. Intro to Dermatology General lesion type What causes excoriation? Mechanical means (e.g. scratching) Excoriation 03/10/2008 13:00

  9. Intro to Dermatology General lesion type Which portion of the skin is affected? Epidermis + dermis Ulcer 03/10/2008 13:00

  10. Intro to Dermatology Name of lesion Benign or malignant? Benign Nevi Congenital or developed? Either Similar to which animal? The shrew 03/10/2008 13:00

  11. Intro to Dermatology Name of lesion Benign or malignant? Benign SeborrheicKeratosis Younger or older patients? Older Where are they commonly found? Face and trunk 03/10/2008 13:00

  12. Intro to Dermatology Name of lesion Benign or malignant? Benign Skin Tags Where are they commonly found? Neck, groin, axilla 03/10/2008 13:00

  13. Intro to Dermatology Name of lesion Benign or malignant? Benign Cyst What is contained inside? Keratin Do they affect the sebaceous glands? Nope 03/10/2008 13:00

  14. Intro to Dermatology Name of lesion Benign or malignant? Benign Solar Lentigo Cause? Sun exposure 03/10/2008 13:00

  15. Intro to Dermatology Name of lesion Benign or malignant? Malignant Basal Cell Carcinoma Common or Rare? Common Is it aggressive? Very rarely metastasizes From which layer of skin do they derive? Basal layer of epidermis 03/10/2008 13:00

  16. Intro to Dermatology Name of lesion Benign or malignant? Precancerous Actinic Keratosis To which type of cancer can they transform? Squamous cell carcinoma 03/10/2008 13:00

  17. Intro to Dermatology Name of lesion Benign or malignant? Malignant Squamous Cell Carcinoma Common or rare? 2nd-most common form of skin cancer Aggressive? 2-3% risk of metastasis 03/10/2008 13:00

  18. Intro to Dermatology Name of lesion Benign or malignant? Benign Dysplastic Nevi Clinical relevance? People who have them are at an increased risk of melanoma 03/10/2008 13:00

  19. Intro to Dermatology Name of lesion Benign or malignant? Malignant Melanoma Originates from…? Melanocytes Is it aggressive? High risk of metastasis Prognosis correlates with…? Depth 03/10/2008 13:00

  20. Intro to Dermatology • A • B • C • D • E • symmetry • order: irregular • olor: multiple colors • iameter • volution 03/10/2008 13:00

  21. Intro to Dermatology Name of lesion Patho-physiology? Autoimmune Psoriasis Common sites? Knees & elbows 03/10/2008 13:00

  22. Intro to Dermatology Name of lesion Patho-physiology? Fungus TineaCorporis Name that fungus Trichophytonrubrum 03/10/2008 13:00

  23. Intro to Dermatology Name of lesion Patho-physiology? Fungus TineaVersicolor Name that fungus Pityrosporumovale 03/10/2008 13:00

  24. Intro to Dermatology Name of lesion Patho-physiology? Strep or Staph Impetigo Common in which age group? Children 03/10/2008 13:00

  25. Intro to Dermatology Name of lesion Patho-physiology? Usually medications Toxic Epidermal Necrolysis Treatment? IV Ig 03/10/2008 13:00

  26. Intro to Dermatology Name of lesion Also known as…? Inflammatory dermatitis Atopic dermatitis 03/10/2008 13:00

  27. Intro to Dermatology Name of lesion Polar Bear Cutitis 03/10/2008 13:00

  28. Function & Structure of Skin Hair Skin Nails What makes up the integumentary system? Mesoderm From which embryonic layer does the dermis derive? Ectoderm Stratum Basale From which emybronic layer does the epidermis derive? Which is the deepest epidermal layer? Stem cells What types of cells mostly make up the stratum basale? Stratified squamous epithelium What type of tissue makes up the epidermis? 03/10/2008 14:00

  29. Function & Structure of Skin • What are the four layers of the skin from the surface down? • Stratum corneum • Stratum granulosum • Stratum spinosum • Stratum basale 03/10/2008 14:00

  30. Function & Structure of Skin Desmosomes, Osland bodies What structures are present in high amounts within the stratum spinosum? Palms & Soles Where is the stratum lucidum found? They crosslink the layer Dead ones What is the purpose of the keratohyalin granules in the stratum granulosum? What type of cells are present in the stratum corneum? 28 days How long is the maturation period for a keratinocyte? Keratin What molecule is present in high amounts in the stratum corneum? 03/10/2008 14:00

  31. Function & Structure of Skin Basal cell layer Where are melanocytes found? Caucasian – smaller melanosomes only in the mid-epidermal layer What is the difference in melanocytes between caucasian and africanskin-types? Keratinocytes (10x) Immune System Are there more keratinocytes or melanocytes? With which body system are Langerhans cells associated? They are the first cells in antigen detection What do Langerhans cells do? Above the basal cell layer Where are Langerhans cells found? 03/10/2008 14:00

  32. Function & Structure of Skin Neuroendocrine cells with unknown function What are Merkel cells? Des = cell-cell; Hemi = cell-basement membrane What is the difference between desmosomes and hemi-desmosomes? Merkel Cell Carcinoma Fibroblasts What is the clinical relevance to Merkel Cells? What is the main cell present in the dermis? Reticular > papillary What are the two sections of the dermis? Which is bigger? The epidermis receives no blood flow (it’s indirect from the dermis) What is the main source of blood vessels to the epidermis? 03/10/2008 14:00

  33. Function & Structure of Skin Pacinian Which is a pressure receptor – Pacinian or Meissner’s Corpuscle? Papillary dermis In which layer are Meissner’s Corpuscles found? External genitalia, mammary glands, internal organs Fingertips and lips Where in the body are Pacinian Corpuscles found? Where are Meissner’s Corpuscles abundant? Anagen In which phase are most hairs? Anagen Catagen Telogen What are the three phases of hair growth? 03/10/2008 14:00

  34. Fingernails = 3mm/month Toenails = 1mm/month How fast do fingernails grow? …Toenails? Function & Structure of Skin Lubricates hair ↓ Water evaporation Kills bacteria What is the purpose of sebum? Apocrine Which sweat glands respond to emotional stress? Everywhere except for palms & soles Axillae Groin Perianal region Where on the body are sebaceous glands found? Where are apocrine sweat glands found mostly? Keratin What are nails made from? Produce sweat in response to heat and humidity What do eccrine glands do? 03/10/2008 14:00

  35. Clinical Pathological Correlation At the junction of the epidermis and dermis Where do junctional nevi sit in the skin? Below the umbilicus, usually Where on the body are spider angiomas not found? In the dermis Comma-shaped nuclei; pink appearance Where does a blue nevus sit? What is the histological presentation of a neurofibroma? Are seborrheic keratoses well- or poorly-defined? Well-defined The upper trunk, thighs, and neck Where on the body are lipomas usually found? 03/11/2008 09:00

  36. Clinical Pathological Correlation Stay away from girls with psoriatic knees Purple (lots of chromaffin) What color is predominant under the microscope in basal cell carcinoma? What type of immune cell is present in allergic contact dermatitis? Eosinophils CENSORED (Joke about psoriatic knees) Squamous Cell Carcinoma In Situ Type IV What is Bowen’s Disease? What type of hypersensitivity takes place in allergic contact dermatitis? What is missing histologically in psoriasis? A granular layer Elbows Knees Where on the body does psoriasis normally occur? 03/11/2008 09:00

  37. Clinical Pathological Correlation Pemphigus = suprabasal Pemphigoid = subepidermal What is the histologic difference between pemphigus and pemphigoid lesions? Pemphigus Which of the two often has oral mucosa blisters? Pemphigoid Pemphigus Which of the two has eosinophilia? Which of the two is more severe? Plasma cells What type of immune cell is found in syphilis? Tinea versicolor Spaghetti & Meatballs! What is the histologic appearance of Malassezia furfur? What is the name of the skin lesion it causes? 03/11/2008 09:00

  38. Clinical Pathological Correlation A poxvirus What is the causative agent for Molluscum Comtagiosum? Purple What color are the lesions associated with Kaposi’s Sarcoma? Inverted (umbilicated) dome-shaped papules HHV-8 What do Molluscum Contagiosum lesions look like? What is the causative agent of Kaposi’s Sarcoma? Allergic contact dermatitis Where is spongiosis commonly seen? 03/11/2008 09:00

  39. Viral exanthems Rubeola First Disease Causative Agent Paramyxovirus Virus type ssRNA Type of exanthem Morbiliform Centrifugally Direction of spread Enanthem present? Koplik’s spots Significant labs Leukopenia, ↑ hemagglutination inhibition Ab’s Pneumonia Encephalitis What are the main complications of rubeola? Clinical presentation Cough, coryza, conjunctivitis, Koplik’s spots Special Treatment Vit A 03/11/2008 10:00

  40. Viral exanthems Scarlet Fever Second Disease Causative Agent Streptococcus Type of exanthem Pinpoint papules, Pastia’s lines Neck  trunk Direction of spread Enanthem present? Strawberry tongue Clinical presentation Pharyngitis, palatal petechia, strawberry tongue 48h before rash Prodrome present? Special Treatment Penicillin, erythromycin, cloxacillin 03/11/2008 10:00

  41. Viral exanthems German Measles Third Disease Causative Agent Togavirus Virus type ssRNA Type of exanthem Dark pink macules and papules Face  centrifugal spread Direction of spread Enanthem present? Soft palate petechiae Significant labs Neutropenia Congenital rubella (low birth weight, extramedullary hematopoiesis, etc.) What are the main complications of rubella? Clinical presentation Malaise, sore throat, cough, fever, lymphadenopathy Prodrome present? No 03/11/2008 10:00

  42. Viral exanthems Erythema Infectiosum Fifth Disease Causative Agent Parvovirus B19 ssDNA Virus type Type of exanthem Lacy erythema Face  centrifugal spread Direction of spread Enanthem present? No Significant labs Can lead to aplastic crisis or hydrops fetalis Rash is not contagious Clinical presentation No Prodrome present? 03/11/2008 10:00

  43. Viral exanthems Roseola Sixth Disease Causative Agent HHV6 and 7 Virus type dsDNA Non-pruritic rose pink macules Type of exanthem Enanthem present? No Significant labs Trophism for CD4+ T-cells High fever, heavy eyelids + periorbital edema Clinical presentation Prodrome present? Abrupt onset of rash after fever 03/11/2008 10:00

  44. Viral exanthems Pityriasis Rosea Causative Agent HHV6 and 7 Virus type dsDNA Type of exanthem Salmon-colored papules & plaques; plaques run parallel to line of cleavage Usually starts as herald patch Direction of spread Enanthem present? No Spares sun-exposed skin Clinical presentation Prodrome present? No UVB, antihistamines Special Treatment 03/11/2008 10:00

  45. Viral exanthems Varicella Zoster Causative Agent HHV3 Virus type dsDNA Pruritic macules, papules, vesicles, and crusts Type of exanthem Shingles Hepatitis Varicella pneumonitis What are the main complications of varicella zoster? Enanthem present? No Contagious period 4 days pre-exanthem until all lesions crust Virus migrates to sensory nerves Post-exanthem pathology Yes Vaccine available? 03/11/2008 10:00

  46. Viral exanthems HSV Drugs Idiopathic What is the causative agent of Erythema Multiforme (EM)? CD8+ cells in epidermis CD4+ cells in dermis What immune cells are involved? Target or iris lesion No – they add to the moribidity! What do the lesions of EM look like? Should immuno-suppressive agents be used? High dose aspirin + IVIg What is the treatment for Kawasaki’s Disease? Increased toxic granulations, vacuoles in PMNs What histological presentations are present in Kawasaki’s Disease? 03/11/2008 10:00

  47. Viral exanthems Lymph nodes Hands/feet Which portions of the body are swollen in Kawasaki’s disease? Mucosal injection Fissured lips What is the enanthem associated with Kawasaki’s Disease? Very high Generalized macular erythema Is the fever high, low, or normal in Kawasaki’s disease? What is the exanthem associated with Kawasaki’s Disease? 03/11/2008 10:00

  48. Viral exanthems Coxsackievirus (picorna) What is the causative agent of Hand, Foot, and Mouth Disease? Pregnant women  spontaneous abortion possible during first trimester Which patients are especially at risk for serious complications? Tongue, hard palate, buccal mucosa, hands, feet Kidsor immuno-suppressed patients Where do the lesions appear? Who gets Molluscum Contagiosum (MC)? Cryosurgery, curettage, etc. What is the treatment for MC? 03/11/2008 10:00

  49. Benign Neoplasms of the Skin Increased keratinocytes at the epidermal base What is the pathophysiology of solar lentigo? All layers In which layers are keratinocytes increased in seborrheic keratosis? Seborrheic Keratosis Uniform To what lesion can solar lentigo progress? What are the borders like in junctional nevi? Dermal-epidermal junction and the dermis Where are melanocytes present in compound nevi? Raised Are intradermal nevi raised or flat? 03/11/2008 11:00

  50. Benign Neoplasms of the Skin Large nevi (>20cm) increase one’s risk for melanoma What is the relationship between congenital nevi and melanoma? Spindle-cell melanocytes What histology is seen in blue nevi? An immunologic event where lymphocytes attempt to destroy a nevus No, but their presence increases one’s risk of other melanomas What is the pathophysiology of halo nevi? Are dysplastic nevi premalignant? No, most spontaneously regress Will hemangiomas continue to increase in size? The superficial plexus Which blood vessels are increased in spider angiomas? 03/11/2008 11:00

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