Infections & Infestations Part 2 Steven J. Sager, MPAS, PA-C Clinical Medicine & Surgery I
Objectives <ul><li>At the completion of the Dermatology lectures and in conjunction with the textbook, lecture handouts, a...
Objectives <ul><ul><li>Identify  diagnostic and laboratory tests utilized in dermatology clinical practice </li></ul></ul>...
Objectives <ul><ul><li>Identify  common dermatology signs and symptoms while recognizing potential systemic implications <...
Dermatophytoses <ul><li>Etiology </li></ul><ul><ul><li>Superficial fungal infections </li></ul></ul><ul><ul><li>Caused by ...
Dermatophytoses <ul><li>Etiology </li></ul><ul><ul><li>Genera: </li></ul></ul><ul><ul><ul><li>Trichophyton </li></ul></ul>...
Dermatophytoses <ul><li>Epidemiology </li></ul><ul><ul><li>Worldwide distribution </li></ul></ul><ul><ul><li>Affects all a...
Dermatophyoses <ul><li>Evaluation: </li></ul><ul><ul><li>KOH – diagnostic </li></ul></ul><ul><ul><li>Wood’s lamp </li></ul...
Topical antifungals <ul><li>Imidazoles </li></ul><ul><ul><li>miconazole (Micatin) </li></ul></ul><ul><ul><li>clotrimazole ...
Oral antifungals <ul><li>Imidazoles </li></ul><ul><ul><li>clotrimazole (Lotrimin) </li></ul></ul><ul><ul><li>ketoconazole ...
Tinea capitis <ul><li>Epidemiology </li></ul><ul><ul><li>primarily affects 6-10 year olds </li></ul></ul><ul><ul><li>typic...
Tinea capitis <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>+/- pain and tenderness </li></ul></ul><ul><ul><li>alopecia ...
Kerion <ul><li>Boggy inflammatory plaques </li></ul><ul><li>Purulent, inflamed nodules </li></ul><ul><li>Extremely painful...
Tinea capitis <ul><li>DDx: </li></ul><ul><ul><li>Atopic dermatitis </li></ul></ul><ul><ul><li>Psoriasis </li></ul></ul><ul...
Tinea capitis <ul><li>Lab: </li></ul><ul><ul><li>KOH </li></ul></ul><ul><ul><li>direct microscopy of hairshaft </li></ul><...
 
Tinea facialis <ul><li>Infection of the glabrous facial skin </li></ul><ul><li>More common in children </li></ul><ul><li>T...
 
Tinea corporis <ul><li>Dermatophyte infection involving: </li></ul><ul><ul><li>neck </li></ul></ul><ul><ul><li>trunk </li>...
Tinea corporis <ul><li>Symptoms </li></ul><ul><ul><li>+/- pruritus </li></ul></ul><ul><ul><li>scaly, annular patches </li>...
 
Tinea cruris <ul><li>Infection of the inguinal/pubic regions and thighs </li></ul><ul><li>Etiology – T. rubrum </li></ul><...
Tinea cruris <ul><li>Symptoms </li></ul><ul><ul><li>pruritus (moderate to severe) </li></ul></ul><ul><li>P.E. </li></ul><u...
 
Tinea pedis (Athlete's foot) <ul><li>Dermatophyte infection of the feet </li></ul><ul><li>Often spreads to: </li></ul><ul>...
Tinea pedis (Athlete's foot) <ul><li>Etiology </li></ul><ul><ul><li>T. rubrum </li></ul></ul><ul><ul><li>T. mentagrophytes...
Tinea pedis (Athlete's foot) <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>pruritus </li></ul></ul><ul><ul><li>erythema ...
Tinea pedis (Athlete's foot) <ul><li>Treatment: </li></ul><ul><ul><li>counsel patient: </li></ul></ul><ul><ul><ul><li>prev...
 
Onychomycosis <ul><li>Chronic progressive infection of the nail apparatus </li></ul><ul><li>Usually associated with tinea ...
Onychomycosis <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>discoloration </li></ul></ul><ul><ul><li>brittle, thickened ...
 
Pityriasis (Tinea) versicolor <ul><li>Chronic, asymptomatic scaling eruption </li></ul><ul><li>Caused by the Pityrosporum ...
Pityriasis (Tinea) versicolor <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>sharply marginated macules </li></ul></ul><u...
 
Candidiasis <ul><li>Etiology </li></ul><ul><ul><li>primarily caused by the yeast Candida albicans </li></ul></ul><ul><ul><...
Candidiasis <ul><li>Host factors: </li></ul><ul><ul><li>diabetes </li></ul></ul><ul><ul><li>obesity </li></ul></ul><ul><ul...
“ Diaper Dermatitis” <ul><li>Etiology </li></ul><ul><ul><li>common in infants </li></ul></ul><ul><ul><li>NOT generally due...
“ Diaper Dermatitis” <ul><li>Lab: </li></ul><ul><ul><li>KOH </li></ul></ul><ul><ul><li>fungal culture </li></ul></ul><ul><...
Candidiasis (Cutaneous) <ul><li>Typically occurs in the intertriginous areas </li></ul><ul><li>Symptoms </li></ul><ul><ul>...
Candidiasis <ul><li>Treatment options </li></ul><ul><ul><li>Topical antifungals </li></ul></ul><ul><ul><ul><li>miconazole ...
Candidiasis (Oropharyngeal) <ul><li>Resident flora of the mouth </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>odynophag...
Candidiasis (Genital) <ul><li>Resident flora of the vagina (~20%) </li></ul><ul><li>Onset usually 1 week before menses </l...
Candidiasis (Genital) <ul><li>Dx: </li></ul><ul><ul><li>KOH </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Topica...
 
HSV <ul><li>Etiology </li></ul><ul><ul><li>Human herpesvirus (HHV) </li></ul></ul><ul><ul><ul><li>DNA virus </li></ul></ul...
HSV <ul><li>Labialis </li></ul><ul><ul><li>80-90% HSV-1 </li></ul></ul><ul><li>Genitalis </li></ul><ul><ul><li>70-90% HSV-...
HSV <ul><li>Epidemiology </li></ul><ul><ul><li>reoccurs when immunocompromised </li></ul></ul><ul><ul><ul><li>stress </li>...
HSV <ul><li>Symptoms </li></ul><ul><ul><li>primary infections are usually asymptomatic </li></ul></ul><ul><ul><li>vesicles...
HSV <ul><li>P.E. </li></ul><ul><ul><li>lesions occur on epidermis & mucous membranes </li></ul></ul><ul><ul><li>grouped ve...
HSV <ul><li>DDx: </li></ul><ul><ul><li>aphthous stomatitis </li></ul></ul><ul><ul><li>hand-foot-and-mouth disease </li></u...
HSV <ul><li>Lab: </li></ul><ul><ul><li>Tzanck smear </li></ul></ul><ul><ul><ul><li>Optimally, fluid from an intact vesicle...
HSV <ul><li>Treatment options: </li></ul><ul><ul><li>heal spontaneously in 2-4 weeks </li></ul></ul><ul><ul><li>topical an...
 
 
Varicella-Zoster virus <ul><li>Etiology </li></ul><ul><ul><li>DNA virus </li></ul></ul><ul><ul><li>primary infection </li>...
Varicella-Zoster virus <ul><li>Etiology </li></ul><ul><ul><li>persists in the sensory ganglia for life </li></ul></ul><ul>...
VZV <ul><li>Symptoms & P.E. </li></ul><ul><ul><li>primary is almost always symptomatic </li></ul></ul><ul><ul><ul><li>diss...
VZV <ul><li>Dx: </li></ul><ul><ul><li>VZV antigen smear </li></ul></ul><ul><ul><li>viral cultures </li></ul></ul><ul><ul><...
 
 
Human Papillomavirus <ul><li>Etiology </li></ul><ul><ul><li>ubiquitous </li></ul></ul><ul><ul><li>DNA virus </li></ul></ul...
Verrucae <ul><li>V. vulgaris </li></ul><ul><ul><li>~70% of all cutaneous warts </li></ul></ul><ul><ul><li>~20% of all scho...
Conylomata accuminata <ul><li>Etiology </li></ul><ul><ul><li>Caused by the human papilloma virus (HPV) </li></ul></ul><ul>...
Conylomata accuminata
Conylomata accuminata
Conylomata accuminata
Human Papillomavirus <ul><li>transmitted by skin-to-skin contact </li></ul><ul><li>occur at sites of trauma </li></ul><ul>...
Human Papillomavirus <ul><li>Symptoms: </li></ul><ul><ul><li>tenderness </li></ul></ul><ul><ul><li>bleeding </li></ul></ul...
Human Papillomavirus <ul><li>DDx: </li></ul><ul><ul><li>Molluscum contagiosum </li></ul></ul><ul><ul><li>SK </li></ul></ul...
Human Papillomavirus <ul><li>Bx is usually not necessary </li></ul><ul><li>Treatment options: </li></ul><ul><ul><li>kerato...
 
 
 
 
Molluscum contagiosum <ul><li>Etiology </li></ul><ul><ul><li>self-limiting viral infection (6-12 months) </li></ul></ul><u...
Molluscum contagiosum <ul><li>DDx: </li></ul><ul><ul><li>Verrucae </li></ul></ul><ul><ul><li>Keratoacanthoma </li></ul></u...
 
Pediculosis <ul><li>Etiology </li></ul><ul><ul><li>Pediculus humanus </li></ul></ul><ul><ul><ul><li>corporis </li></ul></u...
Pediculosis capitis <ul><li>~10 million cases in U.S. annually </li></ul><ul><li>most common in 3-11 years old </li></ul><...
Pediculosis corporis <ul><li>Associated with poor socioeconomic conditions </li></ul><ul><ul><li>clothing is not changed o...
Pediculosis pubis (Phthiriasis) <ul><li>Primarily affects young adults </li></ul><ul><li>Typically transmitted sexually </...
 
 
Infections associated with Pediculoses <ul><li>Cellulitis/lymphangitis/bacteremia </li></ul><ul><ul><li>S. aureus </li></u...
Pediculoses <ul><li>Symptoms </li></ul><ul><ul><li>moderate to intense pruritus </li></ul></ul><ul><ul><li>children are “d...
Pediculoses <ul><li>Treatment: </li></ul><ul><ul><li>Topical pediculocides </li></ul></ul><ul><ul><ul><li>should be active...
Pediculocides <ul><li>Permethrins </li></ul><ul><ul><li>Nix </li></ul></ul><ul><ul><ul><li>treats head lice </li></ul></ul...
Scabies <ul><li>Etiology </li></ul><ul><ul><li>infestation by Sarcoptes scabiei (Itch mite) </li></ul></ul><ul><ul><li>usu...
Scabies <ul><li>Symptoms </li></ul><ul><ul><li>intractable, widespread pruritus </li></ul></ul><ul><ul><li>burrows in the ...
Scabies <ul><li>P.E. </li></ul><ul><ul><li>easily missed </li></ul></ul><ul><ul><li>visible burrows </li></ul></ul><ul><ul...
 
References <ul><li>Harrison’s Principles of Internal Medicine; 16 th  Ed. </li></ul><ul><li>Fitzpatrick TB, Johnson RA, Wo...
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Derm Infections Portfolio

  1. 1. Infections & Infestations Part 2 Steven J. Sager, MPAS, PA-C Clinical Medicine & Surgery I
  2. 2. Objectives <ul><li>At the completion of the Dermatology lectures and in conjunction with the textbook, lecture handouts, and any recommended Internet web sites, the student will be able to: </li></ul><ul><ul><li>Define the anatomy and function of the skin </li></ul></ul><ul><ul><li>Identify the appendages of the skin and their functions </li></ul></ul><ul><ul><li>Apply the basic concepts of the approach to dermatology patients </li></ul></ul><ul><ul><li>Describe the morphology of the skin and related structures </li></ul></ul><ul><ul><li>Define common terminology, signs, and symptoms used in dermatology practice </li></ul></ul><ul><ul><li>Differentiate primary from secondary skin lesions </li></ul></ul><ul><ul><li>Accurately identify skin lesions when given a picture </li></ul></ul>
  3. 3. Objectives <ul><ul><li>Identify diagnostic and laboratory tests utilized in dermatology clinical practice </li></ul></ul><ul><ul><ul><li>Magnification </li></ul></ul></ul><ul><ul><ul><li>Transillumination </li></ul></ul></ul><ul><ul><ul><li>Diascopy </li></ul></ul></ul><ul><ul><ul><li>Wood’s light examination </li></ul></ul></ul><ul><ul><ul><li>patch tests </li></ul></ul></ul><ul><ul><ul><li>physical contact testing </li></ul></ul></ul><ul><ul><ul><li>gram stain </li></ul></ul></ul><ul><ul><ul><li>fungal and bacterial cultures </li></ul></ul></ul><ul><ul><ul><li>Tzanck smear </li></ul></ul></ul><ul><ul><ul><li>skin biopsy. </li></ul></ul></ul><ul><ul><li>Describe the clinical situation in which, diagnostic or laboratory tests are important. </li></ul></ul>
  4. 4. Objectives <ul><ul><li>Identify common dermatology signs and symptoms while recognizing potential systemic implications </li></ul></ul><ul><ul><li>Compare and contrast the diagnostic work-up for the dermatology patient </li></ul></ul><ul><ul><li>Define cream, ointment, gel, solution and lotion; and then indicate the appropriate clinical use </li></ul></ul><ul><ul><li>Identify the basic concept for use of wet and dry dressing for skin lesions </li></ul></ul><ul><ul><li>List the indications for the use of cryosurgery, incisions, excisions, electrocautery, and chemical treatment of skin lesions </li></ul></ul>
  5. 5. Dermatophytoses <ul><li>Etiology </li></ul><ul><ul><li>Superficial fungal infections </li></ul></ul><ul><ul><li>Caused by an overgrowth of transient or resident flora </li></ul></ul><ul><ul><ul><li>Change in microenvironment of the skin </li></ul></ul></ul><ul><ul><li>Infects </li></ul></ul><ul><ul><ul><li>Keratinized epithelium (epidermomycosis) </li></ul></ul></ul><ul><ul><ul><li>Hair follicles (trichomycosis) </li></ul></ul></ul><ul><ul><ul><li>Nails (onychomycosis) </li></ul></ul></ul>
  6. 6. Dermatophytoses <ul><li>Etiology </li></ul><ul><ul><li>Genera: </li></ul></ul><ul><ul><ul><li>Trichophyton </li></ul></ul></ul><ul><ul><ul><ul><li>T. rubrum </li></ul></ul></ul></ul><ul><ul><ul><ul><li>T. tonsurans </li></ul></ul></ul></ul><ul><ul><ul><li>Microsporum </li></ul></ul></ul><ul><ul><ul><ul><li>M. canis </li></ul></ul></ul></ul><ul><ul><ul><li>Epidermophyton </li></ul></ul></ul>
  7. 7. Dermatophytoses <ul><li>Epidemiology </li></ul><ul><ul><li>Worldwide distribution </li></ul></ul><ul><ul><li>Affects all ages </li></ul></ul><ul><ul><ul><li>Location is more age dependent </li></ul></ul></ul><ul><ul><li>Transmission: </li></ul></ul><ul><ul><ul><li>Anthrophilic (fomites or direct contact) </li></ul></ul></ul><ul><ul><ul><li>Zoophilic (animals) </li></ul></ul></ul><ul><ul><ul><li>Geophilic (soil) </li></ul></ul></ul>
  8. 8. Dermatophyoses <ul><li>Evaluation: </li></ul><ul><ul><li>KOH – diagnostic </li></ul></ul><ul><ul><li>Wood’s lamp </li></ul></ul><ul><ul><li>Fungal cultures </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Topical antifungals </li></ul></ul><ul><ul><ul><li>Not effective for infection of hair or nails </li></ul></ul></ul><ul><ul><li>Oral (systemic) antifungals </li></ul></ul>
  9. 9. Topical antifungals <ul><li>Imidazoles </li></ul><ul><ul><li>miconazole (Micatin) </li></ul></ul><ul><ul><li>clotrimazole (Lotrimin) </li></ul></ul><ul><ul><li>ketoconazole (Nizoral) </li></ul></ul><ul><li>Allylamines </li></ul><ul><ul><li>terbinafine (Lamisil) </li></ul></ul><ul><li>Naphthiomates </li></ul><ul><ul><li>tolnaftate (Tinactin) </li></ul></ul><ul><li>Ciclopirox (Penlac) </li></ul>
  10. 10. Oral antifungals <ul><li>Imidazoles </li></ul><ul><ul><li>clotrimazole (Lotrimin) </li></ul></ul><ul><ul><li>ketoconazole (Nizoral) </li></ul></ul><ul><ul><li>itraconazole (Sporanox) </li></ul></ul><ul><ul><li>fluconazole (Diflucan) </li></ul></ul><ul><li>Allylamines </li></ul><ul><ul><li>terbinafine (Lamisil) </li></ul></ul><ul><li>Griseofulvin </li></ul>
  11. 11. Tinea capitis <ul><li>Epidemiology </li></ul><ul><ul><li>primarily affects 6-10 year olds </li></ul></ul><ul><ul><li>typically spread by fomites </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>T. tonsurans (90%) </li></ul></ul><ul><ul><li>fungus invades the hair shaft </li></ul></ul>
  12. 12. Tinea capitis <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>+/- pain and tenderness </li></ul></ul><ul><ul><li>alopecia </li></ul></ul><ul><ul><li>pruritus </li></ul></ul><ul><ul><li>annular, scaly patches </li></ul></ul><ul><ul><li>broken hairs </li></ul></ul>
  13. 13. Kerion <ul><li>Boggy inflammatory plaques </li></ul><ul><li>Purulent, inflamed nodules </li></ul><ul><li>Extremely painful </li></ul><ul><li>Drains pus from multiple locations </li></ul><ul><li>Hair falls out (vs. breaking) </li></ul>
  14. 14. Tinea capitis <ul><li>DDx: </li></ul><ul><ul><li>Atopic dermatitis </li></ul></ul><ul><ul><li>Psoriasis </li></ul></ul><ul><ul><li>Lichen simplex chronicus </li></ul></ul><ul><ul><li>Seborrheic dermatitis </li></ul></ul>
  15. 15. Tinea capitis <ul><li>Lab: </li></ul><ul><ul><li>KOH </li></ul></ul><ul><ul><li>direct microscopy of hairshaft </li></ul></ul><ul><ul><li>Wood’s lamp green fluorescence with M. canis </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>oral antifungals </li></ul></ul><ul><ul><ul><li>topical preparations are not usually effective </li></ul></ul></ul>
  16. 17. Tinea facialis <ul><li>Infection of the glabrous facial skin </li></ul><ul><li>More common in children </li></ul><ul><li>T. tonsurans and T. rubrum </li></ul><ul><li>Predisposing factor </li></ul><ul><ul><li>animal contact </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>+/- pruritus </li></ul></ul><ul><ul><li>scaly patches </li></ul></ul><ul><li>Lab - KOH </li></ul><ul><li>Treatment – </li></ul><ul><ul><li>topical (localized) or oral (diffuse) antifungals </li></ul></ul>
  17. 19. Tinea corporis <ul><li>Dermatophyte infection involving: </li></ul><ul><ul><li>neck </li></ul></ul><ul><ul><li>trunk </li></ul></ul><ul><ul><li>arms </li></ul></ul><ul><ul><li>legs </li></ul></ul><ul><li>Etiology </li></ul><ul><ul><li>T. rubrum, T. tonsurans, M. canis </li></ul></ul><ul><ul><li>spread by autoinoculation </li></ul></ul><ul><ul><ul><li>Most commonly spread from feet </li></ul></ul></ul><ul><ul><li>increased incidence in tropical/subtropical </li></ul></ul>
  18. 20. Tinea corporis <ul><li>Symptoms </li></ul><ul><ul><li>+/- pruritus </li></ul></ul><ul><ul><li>scaly, annular patches </li></ul></ul><ul><ul><ul><li>well-defined margins </li></ul></ul></ul><ul><ul><ul><li>marginal erythema </li></ul></ul></ul><ul><ul><ul><li>central clearing </li></ul></ul></ul><ul><ul><li>+/- vesicles/pustules </li></ul></ul><ul><li>Lab - KOH </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>topical (localized) or oral (diffuse) antifungals </li></ul></ul>
  19. 22. Tinea cruris <ul><li>Infection of the inguinal/pubic regions and thighs </li></ul><ul><li>Etiology – T. rubrum </li></ul><ul><li>M > F </li></ul><ul><li>Predisposing factors: </li></ul><ul><ul><li>warm, humid environment </li></ul></ul><ul><ul><li>tight clothing </li></ul></ul><ul><ul><li>obesity </li></ul></ul>
  20. 23. Tinea cruris <ul><li>Symptoms </li></ul><ul><ul><li>pruritus (moderate to severe) </li></ul></ul><ul><li>P.E. </li></ul><ul><ul><li>large, scaly dull red/tan/brown plaques </li></ul></ul><ul><ul><li>well-demarcated margins </li></ul></ul><ul><li>Treatment options </li></ul><ul><ul><li>topical antifungals </li></ul></ul>
  21. 25. Tinea pedis (Athlete's foot) <ul><li>Dermatophyte infection of the feet </li></ul><ul><li>Often spreads to: </li></ul><ul><ul><li>inguinal region </li></ul></ul><ul><ul><li>trunk </li></ul></ul><ul><ul><li>hands (tinea manuum) </li></ul></ul><ul><li>Transmitted by walking barefoot on a contaminated floor </li></ul><ul><li>Tends to be chronic </li></ul><ul><li>May develop a secondary infection by S. aureus and GAS </li></ul>
  22. 26. Tinea pedis (Athlete's foot) <ul><li>Etiology </li></ul><ul><ul><li>T. rubrum </li></ul></ul><ul><ul><li>T. mentagrophytes </li></ul></ul><ul><li>Predisposing factors: </li></ul><ul><ul><li>hot, humid weather </li></ul></ul><ul><ul><li>occlusive footwear </li></ul></ul><ul><ul><li>hyperhydrosis </li></ul></ul>
  23. 27. Tinea pedis (Athlete's foot) <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>pruritus </li></ul></ul><ul><ul><li>erythema </li></ul></ul><ul><ul><li>scaling </li></ul></ul><ul><ul><li>maceration </li></ul></ul><ul><ul><li>hyperkeratosis </li></ul></ul><ul><ul><li>+/- vesicles/bullae/pustules formation </li></ul></ul><ul><li>Lab: </li></ul><ul><ul><li>KOH </li></ul></ul><ul><ul><li>+/- fungal culture </li></ul></ul><ul><li>Treatment options </li></ul>
  24. 28. Tinea pedis (Athlete's foot) <ul><li>Treatment: </li></ul><ul><ul><li>counsel patient: </li></ul></ul><ul><ul><ul><li>preventive measures </li></ul></ul></ul><ul><ul><ul><li>footwear </li></ul></ul></ul><ul><ul><li>wash feet with benzoyl peroxide </li></ul></ul><ul><ul><li>Burrow's dressings </li></ul></ul><ul><ul><li>Drysol </li></ul></ul><ul><ul><li>topical or oral antifungals prn </li></ul></ul>
  25. 30. Onychomycosis <ul><li>Chronic progressive infection of the nail apparatus </li></ul><ul><li>Usually associated with tinea pedis </li></ul><ul><li>Etiology </li></ul><ul><ul><li>dermatophytes (~95%), Candida, or molds </li></ul></ul><ul><ul><li>T. rubrum </li></ul></ul><ul><li>Epidemiology </li></ul><ul><ul><li>incidence increasing with age </li></ul></ul><ul><ul><li>M > F </li></ul></ul><ul><ul><li>primarily affects big toe </li></ul></ul>
  26. 31. Onychomycosis <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>discoloration </li></ul></ul><ul><ul><li>brittle, thickened nails </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>counsel on foot care/footwear </li></ul></ul><ul><ul><li>trim dystrophic nails </li></ul></ul><ul><ul><li>Ciclopirox (Penlac) </li></ul></ul><ul><ul><li>oral antifungals </li></ul></ul>
  27. 33. Pityriasis (Tinea) versicolor <ul><li>Chronic, asymptomatic scaling eruption </li></ul><ul><li>Caused by the Pityrosporum ovale yeast </li></ul><ul><li>Primarily affects young adults </li></ul><ul><li>Not contagious </li></ul><ul><li>Predisposing factors: </li></ul><ul><ul><li>high humidity </li></ul></ul><ul><ul><li>increased oil (sebum) production </li></ul></ul>
  28. 34. Pityriasis (Tinea) versicolor <ul><li>Symptoms and P.E. </li></ul><ul><ul><li>sharply marginated macules </li></ul></ul><ul><ul><ul><li>appear hypopigmented </li></ul></ul></ul><ul><ul><li>fine scaling </li></ul></ul><ul><li>Lab – KOH </li></ul><ul><li>Treatment: </li></ul><ul><ul><li>Topical </li></ul></ul><ul><ul><ul><li>selenium sulfide </li></ul></ul></ul><ul><ul><ul><li>azole creams and shampoos </li></ul></ul></ul>
  29. 36. Candidiasis <ul><li>Etiology </li></ul><ul><ul><li>primarily caused by the yeast Candida albicans </li></ul></ul><ul><ul><ul><li>frequently colonizes the GI tract </li></ul></ul></ul><ul><ul><ul><ul><li>oropharyngeal ~20% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>fecal ~40-70% </li></ul></ul></ul></ul><ul><ul><ul><ul><li>vaginal ~20% </li></ul></ul></ul></ul><ul><ul><ul><li>Increased occurrence with antimicrobial therapy </li></ul></ul></ul><ul><ul><li>superficial infections of the mucosal surface are common </li></ul></ul><ul><ul><li>cutaneous involvement occurs at moist occluded skin </li></ul></ul><ul><ul><li>affects young and old </li></ul></ul>
  30. 37. Candidiasis <ul><li>Host factors: </li></ul><ul><ul><li>diabetes </li></ul></ul><ul><ul><li>obesity </li></ul></ul><ul><ul><li>hyperhydrosis </li></ul></ul><ul><ul><li>hot climate </li></ul></ul><ul><ul><li>corticosteroids </li></ul></ul><ul><ul><li>chronic debilitation </li></ul></ul>
  31. 38. “ Diaper Dermatitis” <ul><li>Etiology </li></ul><ul><ul><li>common in infants </li></ul></ul><ul><ul><li>NOT generally due to poor hygiene </li></ul></ul><ul><li>Symptoms </li></ul><ul><ul><li>inflamed, erythematous eroded patches </li></ul></ul><ul><ul><li>small peripheral (“satellite”) pustular lesions </li></ul></ul><ul><ul><li>edema </li></ul></ul><ul><ul><li>involves the perigenital/perianal skin, the buttocks, and the inner aspects of the thighs </li></ul></ul>
  32. 39. “ Diaper Dermatitis” <ul><li>Lab: </li></ul><ul><ul><li>KOH </li></ul></ul><ul><ul><li>fungal culture </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>topical antifungals </li></ul></ul><ul><ul><li>keep area as dry as possible </li></ul></ul><ul><ul><li>talc </li></ul></ul><ul><ul><li>miconazole powder </li></ul></ul><ul><ul><li>desitin or A&D ointment (OTC) </li></ul></ul>
  33. 40. Candidiasis (Cutaneous) <ul><li>Typically occurs in the intertriginous areas </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>pustules on an erythematous base </li></ul></ul><ul><ul><li>become eroded and confluent </li></ul></ul><ul><ul><li>satellite lesions </li></ul></ul>
  34. 41. Candidiasis <ul><li>Treatment options </li></ul><ul><ul><li>Topical antifungals </li></ul></ul><ul><ul><ul><li>miconazole powder </li></ul></ul></ul><ul><ul><ul><li>nystatin </li></ul></ul></ul><ul><ul><ul><li>clotrimazole </li></ul></ul></ul><ul><ul><li>Oral antifungals </li></ul></ul><ul><ul><ul><li>fluconazole </li></ul></ul></ul><ul><ul><ul><li>itraconazole </li></ul></ul></ul><ul><ul><ul><li>ketoconazole </li></ul></ul></ul>
  35. 42. Candidiasis (Oropharyngeal) <ul><li>Resident flora of the mouth </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>odynophagia </li></ul></ul><ul><ul><li>“ burning” or pain when eating spicy/acidic foods </li></ul></ul><ul><ul><li>“ white curds” on tongue </li></ul></ul><ul><li>Tx: </li></ul><ul><ul><li>nystatin oral rinse or troches </li></ul></ul><ul><ul><li>clotrimazole troches </li></ul></ul><ul><ul><li>oral antifungals </li></ul></ul>
  36. 43. Candidiasis (Genital) <ul><li>Resident flora of the vagina (~20%) </li></ul><ul><li>Onset usually 1 week before menses </li></ul><ul><li>Symptoms </li></ul><ul><ul><li>pruritus </li></ul></ul><ul><ul><li>vaginal discharge </li></ul></ul><ul><ul><li>dyspareunia </li></ul></ul><ul><ul><li>dysuria </li></ul></ul><ul><li>P.E.: </li></ul><ul><ul><li>erythema and edema of vulva </li></ul></ul><ul><ul><li>white, curd-like vaginal discharge </li></ul></ul>
  37. 44. Candidiasis (Genital) <ul><li>Dx: </li></ul><ul><ul><li>KOH </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>Topical antifungals </li></ul></ul><ul><ul><ul><li>butoconazole (Gynazole-1) </li></ul></ul></ul><ul><ul><ul><li>clotrimazole </li></ul></ul></ul><ul><ul><ul><li>miconazole (Monistat) </li></ul></ul></ul><ul><ul><ul><li>terconazole (Terazol) </li></ul></ul></ul><ul><ul><ul><li>fluconazole </li></ul></ul></ul>
  38. 46. HSV <ul><li>Etiology </li></ul><ul><ul><li>Human herpesvirus (HHV) </li></ul></ul><ul><ul><ul><li>DNA virus </li></ul></ul></ul><ul><ul><ul><li>8 serotypes </li></ul></ul></ul><ul><ul><ul><ul><li>HSV-1 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HSV-2 </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HZV (VZV) </li></ul></ul></ul></ul><ul><ul><ul><ul><li>EBV </li></ul></ul></ul></ul><ul><ul><ul><ul><li>CMV </li></ul></ul></ul></ul><ul><ul><ul><ul><li>HHV-6, HHV-7, & HHV-8 </li></ul></ul></ul></ul><ul><ul><li>persists in the sensory ganglia for life </li></ul></ul>
  39. 47. HSV <ul><li>Labialis </li></ul><ul><ul><li>80-90% HSV-1 </li></ul></ul><ul><li>Genitalis </li></ul><ul><ul><li>70-90% HSV-2 </li></ul></ul><ul><li>Herpetic whitlow </li></ul><ul><ul><li><20y.o. ~ HSV-1 </li></ul></ul><ul><ul><li>>20y.o. ~ HSV-2 </li></ul></ul>
  40. 48. HSV <ul><li>Epidemiology </li></ul><ul><ul><li>reoccurs when immunocompromised </li></ul></ul><ul><ul><ul><li>stress </li></ul></ul></ul><ul><ul><ul><li>menses </li></ul></ul></ul><ul><ul><ul><li>UV radiation </li></ul></ul></ul><ul><ul><ul><li>illness </li></ul></ul></ul><ul><ul><li>any age </li></ul></ul><ul><ul><li>spread by direct contact when shedding virus </li></ul></ul><ul><ul><li>2-20 day incubation period </li></ul></ul><ul><ul><li>usually reoccurs in the vicinity of the primary infection </li></ul></ul>
  41. 49. HSV <ul><li>Symptoms </li></ul><ul><ul><li>primary infections are usually asymptomatic </li></ul></ul><ul><ul><li>vesicles at the site of inoculation </li></ul></ul><ul><ul><li>gingivostomatitis </li></ul></ul><ul><ul><li>regional lymphadenopathy </li></ul></ul><ul><ul><li>fever </li></ul></ul><ul><ul><li>headache </li></ul></ul><ul><ul><li>malaise </li></ul></ul><ul><ul><li>myalgia </li></ul></ul><ul><ul><li>“ tingling”, “burning” or “itchy” sensation </li></ul></ul><ul><ul><ul><li>precedes visible skin changes by ~24 hours </li></ul></ul></ul>
  42. 50. HSV <ul><li>P.E. </li></ul><ul><ul><li>lesions occur on epidermis & mucous membranes </li></ul></ul><ul><ul><li>grouped vesicles arising on an erythematous base </li></ul></ul><ul><ul><ul><li>may evolve to pustules </li></ul></ul></ul><ul><ul><ul><li>often umbilicated </li></ul></ul></ul><ul><ul><li>erode due to sloughing of epidermis </li></ul></ul><ul><ul><ul><li>may enlarge to ulcerations </li></ul></ul></ul><ul><ul><li>may be crusted or moist </li></ul></ul>
  43. 51. HSV <ul><li>DDx: </li></ul><ul><ul><li>aphthous stomatitis </li></ul></ul><ul><ul><li>hand-foot-and-mouth disease </li></ul></ul><ul><ul><li>erythema multiforme </li></ul></ul><ul><ul><li>fixed drug eruption </li></ul></ul>
  44. 52. HSV <ul><li>Lab: </li></ul><ul><ul><li>Tzanck smear </li></ul></ul><ul><ul><ul><li>Optimally, fluid from an intact vesicle </li></ul></ul></ul><ul><ul><li>viral culture </li></ul></ul><ul><ul><li>antigen smear </li></ul></ul><ul><ul><li>serology for antibodies </li></ul></ul>
  45. 53. HSV <ul><li>Treatment options: </li></ul><ul><ul><li>heal spontaneously in 2-4 weeks </li></ul></ul><ul><ul><li>topical antivirals </li></ul></ul><ul><ul><ul><li>acyclovir </li></ul></ul></ul><ul><ul><ul><li>penciclovir </li></ul></ul></ul><ul><ul><li>oral antivirals </li></ul></ul><ul><ul><ul><li>acyclovir </li></ul></ul></ul><ul><ul><ul><li>valacyclovir </li></ul></ul></ul><ul><ul><ul><li>famciclovir </li></ul></ul></ul>
  46. 56. Varicella-Zoster virus <ul><li>Etiology </li></ul><ul><ul><li>DNA virus </li></ul></ul><ul><ul><li>primary infection </li></ul></ul><ul><ul><ul><li>chickenpox (Varicella) </li></ul></ul></ul><ul><ul><ul><li>90% of cases occur in children < 10 years old </li></ul></ul></ul><ul><ul><ul><li>3-4 million cases annually in U.S. </li></ul></ul></ul><ul><ul><ul><li>~14 day incubation period </li></ul></ul></ul><ul><ul><li>infects 98% of adult population </li></ul></ul>
  47. 57. Varicella-Zoster virus <ul><li>Etiology </li></ul><ul><ul><li>persists in the sensory ganglia for life </li></ul></ul><ul><ul><li>reactivation occurs in a dermatomal pattern </li></ul></ul><ul><ul><li>transmitted via airborne droplets and direct contact </li></ul></ul><ul><ul><li>contagion: </li></ul></ul><ul><ul><ul><li>several days before exanthem appears until last crop of vesicles </li></ul></ul></ul>
  48. 58. VZV <ul><li>Symptoms & P.E. </li></ul><ul><ul><li>primary is almost always symptomatic </li></ul></ul><ul><ul><ul><li>disseminated pruritic vesicles </li></ul></ul></ul><ul><ul><ul><li>“ cropping” rash </li></ul></ul></ul><ul><ul><ul><ul><li>macules, papules, and vesicles +/- pustules </li></ul></ul></ul></ul><ul><ul><ul><ul><li>develop over 8-12 hours </li></ul></ul></ul></ul><ul><ul><li>vesicles rupture and crusts form </li></ul></ul><ul><ul><ul><li>fall off in 1-3 weeks leaving a pink, depressed base </li></ul></ul></ul><ul><ul><li>+/- prodromal/constitutional symptoms </li></ul></ul><ul><ul><li>dermatomal pain prior to rash </li></ul></ul><ul><ul><li>post-herpetic neuralgia </li></ul></ul>
  49. 59. VZV <ul><li>Dx: </li></ul><ul><ul><li>VZV antigen smear </li></ul></ul><ul><ul><li>viral cultures </li></ul></ul><ul><ul><li>Tzanck smear </li></ul></ul><ul><ul><li>serology </li></ul></ul><ul><li>Treatment options </li></ul><ul><ul><li>VZV immunization (Varivax) </li></ul></ul><ul><ul><li>antipruritics (topical or systemic) </li></ul></ul><ul><ul><li>antivirals (if started within 24 hours of rash) </li></ul></ul><ul><ul><li>ASA is CONTRAINDICATED!!! </li></ul></ul>
  50. 62. Human Papillomavirus <ul><li>Etiology </li></ul><ul><ul><li>ubiquitous </li></ul></ul><ul><ul><li>DNA virus </li></ul></ul><ul><ul><li>causes a variety of benign lesions </li></ul></ul><ul><ul><ul><li>discrete epithelial hyperplasia/hyperkeratosis </li></ul></ul></ul><ul><ul><ul><li>extent of involvement is determines by immune status of the host </li></ul></ul></ul><ul><ul><li>affects the skin and mucous membranes </li></ul></ul><ul><ul><li>has a role in oncogenesis </li></ul></ul><ul><ul><li>>150 types </li></ul></ul>
  51. 63. Verrucae <ul><li>V. vulgaris </li></ul><ul><ul><li>~70% of all cutaneous warts </li></ul></ul><ul><ul><li>~20% of all school-aged children are affected </li></ul></ul><ul><li>V. plantaris (~30%) </li></ul><ul><ul><li>affect older children and young adults </li></ul></ul><ul><li>V. plana (~4%) </li></ul><ul><ul><li>occur on face, beard area, dorsum of hands, shins </li></ul></ul><ul><li>Filiform warts </li></ul><ul><li>Periungual warts </li></ul><ul><li>Mosaic warts </li></ul>
  52. 64. Conylomata accuminata <ul><li>Etiology </li></ul><ul><ul><li>Caused by the human papilloma virus (HPV) </li></ul></ul><ul><ul><li>Significant role in pathogenesis of invasive SCC of the anogenital region </li></ul></ul><ul><li>Symptoms = usually asymptomatic </li></ul><ul><li>P.E. </li></ul><ul><ul><li>Papillomatous plaques or nodules with a granular surface on the mucosa </li></ul></ul><ul><ul><li>Early lesions turn white when 5% acetic acid is applied </li></ul></ul>
  53. 65. Conylomata accuminata
  54. 66. Conylomata accuminata
  55. 67. Conylomata accuminata
  56. 68. Human Papillomavirus <ul><li>transmitted by skin-to-skin contact </li></ul><ul><li>occur at sites of trauma </li></ul><ul><li>autoinoculation </li></ul><ul><li>higher incidence in immunocompromised </li></ul><ul><li>~60% resolve in <2 years untreated </li></ul>
  57. 69. Human Papillomavirus <ul><li>Symptoms: </li></ul><ul><ul><li>tenderness </li></ul></ul><ul><ul><li>bleeding </li></ul></ul><ul><li>P.E. </li></ul><ul><ul><li>firm 1-10mm papules </li></ul></ul><ul><ul><li>irregular surface </li></ul></ul><ul><ul><li>capillary “seeds” </li></ul></ul>
  58. 70. Human Papillomavirus <ul><li>DDx: </li></ul><ul><ul><li>Molluscum contagiosum </li></ul></ul><ul><ul><li>SK </li></ul></ul><ul><ul><li>AK </li></ul></ul><ul><ul><li>Keratoacanthomas </li></ul></ul><ul><ul><li>SCC (in situ or invasive) </li></ul></ul><ul><ul><li>heloma </li></ul></ul><ul><ul><li>callus </li></ul></ul>
  59. 71. Human Papillomavirus <ul><li>Bx is usually not necessary </li></ul><ul><li>Treatment options: </li></ul><ul><ul><li>keratolytics </li></ul></ul><ul><ul><li>cryosurgery </li></ul></ul><ul><ul><li>electrodessication </li></ul></ul><ul><ul><li>CO 2 laser surgery </li></ul></ul><ul><li>DON’T excise </li></ul><ul><li>DON’T be too aggressive! </li></ul>
  60. 76. Molluscum contagiosum <ul><li>Etiology </li></ul><ul><ul><li>self-limiting viral infection (6-12 months) </li></ul></ul><ul><ul><ul><li>usually resolves completely </li></ul></ul></ul><ul><ul><li>affects children and sexually active adults </li></ul></ul><ul><ul><li>M > F </li></ul></ul><ul><ul><li>can be spread by autoinoculation </li></ul></ul><ul><li>Symptoms - none </li></ul><ul><li>P.E. </li></ul><ul><ul><li>pearly-white or flesh-colored papules (1-5 mm) in diameter </li></ul></ul><ul><ul><ul><li>children – exposed skin </li></ul></ul></ul><ul><ul><ul><li>adults – anogenital region </li></ul></ul></ul><ul><ul><li>often have an umbilicated center (central keratotic plug) </li></ul></ul><ul><ul><li>variable distribution </li></ul></ul>
  61. 77. Molluscum contagiosum <ul><li>DDx: </li></ul><ul><ul><li>Verrucae </li></ul></ul><ul><ul><li>Keratoacanthoma </li></ul></ul><ul><ul><li>Syringoma </li></ul></ul><ul><ul><li>Sebaceous hyperplasia </li></ul></ul><ul><ul><li>BCC </li></ul></ul><ul><ul><li>SCC </li></ul></ul><ul><ul><li>EIC </li></ul></ul><ul><li>Treatment options </li></ul><ul><ul><li>curettage </li></ul></ul><ul><ul><li>imiquimod </li></ul></ul><ul><ul><li>cryosurgery </li></ul></ul><ul><ul><li>electrodessication </li></ul></ul>
  62. 79. Pediculosis <ul><li>Etiology </li></ul><ul><ul><li>Pediculus humanus </li></ul></ul><ul><ul><ul><li>corporis </li></ul></ul></ul><ul><ul><ul><ul><li>body louse </li></ul></ul></ul></ul><ul><ul><ul><ul><li>live in clothing </li></ul></ul></ul></ul><ul><ul><ul><li>capitis - head louse </li></ul></ul></ul><ul><ul><li>Phthirius pubis </li></ul></ul><ul><ul><ul><li>live in the pubic area and other hear-bearing areas </li></ul></ul></ul><ul><ul><li>spread by: </li></ul></ul><ul><ul><ul><li>direct or indirect contact </li></ul></ul></ul><ul><ul><li>may coexist with scabies </li></ul></ul>
  63. 80. Pediculosis capitis <ul><li>~10 million cases in U.S. annually </li></ul><ul><li>most common in 3-11 years old </li></ul><ul><li>lice are not typically a vector of infection </li></ul><ul><li>more common in summer/warm climates </li></ul><ul><li>transmitted by fomites or head-to-head </li></ul>
  64. 81. Pediculosis corporis <ul><li>Associated with poor socioeconomic conditions </li></ul><ul><ul><li>clothing is not changed or washed frequently </li></ul></ul><ul><ul><ul><li>indigent </li></ul></ul></ul><ul><ul><ul><li>homeless </li></ul></ul></ul><ul><ul><ul><li>refugee camps </li></ul></ul></ul>
  65. 82. Pediculosis pubis (Phthiriasis) <ul><li>Primarily affects young adults </li></ul><ul><li>Typically transmitted sexually </li></ul><ul><li>Life cycle of louse is ~20 days </li></ul><ul><li>Frequently coexists with another STD </li></ul><ul><li>Most common in pubic and axillary areas </li></ul><ul><li>Children = non-sexual contact with an infected parent </li></ul>
  66. 85. Infections associated with Pediculoses <ul><li>Cellulitis/lymphangitis/bacteremia </li></ul><ul><ul><li>S. aureus </li></ul></ul><ul><ul><li>Group A strep </li></ul></ul><ul><li>Trench fever </li></ul><ul><li>Typhus </li></ul>
  67. 86. Pediculoses <ul><li>Symptoms </li></ul><ul><ul><li>moderate to intense pruritus </li></ul></ul><ul><ul><li>children are “distracted” and “restless” </li></ul></ul><ul><li>P.E. </li></ul><ul><ul><li>visible lice or nits (Wood’s lamp) </li></ul></ul><ul><ul><ul><li>examine hairs carefully </li></ul></ul></ul><ul><ul><ul><li>examine clothing </li></ul></ul></ul><ul><ul><li>excoriations </li></ul></ul><ul><ul><li>papular urticaria </li></ul></ul>
  68. 87. Pediculoses <ul><li>Treatment: </li></ul><ul><ul><li>Topical pediculocides </li></ul></ul><ul><ul><ul><li>should be active against adults and eggs </li></ul></ul></ul><ul><ul><li>wash all clothing and linens </li></ul></ul><ul><ul><li>treat contacts/family members prn </li></ul></ul><ul><ul><li>repeat in 7-10 days prn </li></ul></ul>
  69. 88. Pediculocides <ul><li>Permethrins </li></ul><ul><ul><li>Nix </li></ul></ul><ul><ul><ul><li>treats head lice </li></ul></ul></ul><ul><ul><ul><li>apply to washed and towel-dried hair x 10 minutes </li></ul></ul></ul><ul><ul><ul><li>remove nits with comb </li></ul></ul></ul><ul><ul><li>Elimite </li></ul></ul><ul><ul><ul><li>treats scabies </li></ul></ul></ul><ul><ul><ul><li>apply from head to soles x 8-14 hours </li></ul></ul></ul><ul><li>Pyrethrins (Rid) </li></ul><ul><ul><li>treats all lice </li></ul></ul><ul><li>Crotamiton (Eurax) </li></ul><ul><ul><li>apply from chin to soles & repeat in 24 hours </li></ul></ul><ul><ul><li>bathe after 48 hours </li></ul></ul>
  70. 89. Scabies <ul><li>Etiology </li></ul><ul><ul><li>infestation by Sarcoptes scabiei (Itch mite) </li></ul></ul><ul><ul><li>usually spread by skin-to-skin contact </li></ul></ul><ul><ul><li>any age </li></ul></ul><ul><ul><li>300 million cases in the world annually </li></ul></ul><ul><ul><li>mites burrow into epidermis shortly after contact </li></ul></ul><ul><ul><ul><li>2-3mm daily </li></ul></ul></ul><ul><ul><ul><li>burrow during the night; lay eggs during the day </li></ul></ul></ul><ul><ul><ul><li>female lives 4-6 weeks </li></ul></ul></ul><ul><ul><ul><li>deposits 40-50 eggs </li></ul></ul></ul><ul><ul><ul><li>can live 2+ days off host </li></ul></ul></ul>
  71. 90. Scabies <ul><li>Symptoms </li></ul><ul><ul><li>intractable, widespread pruritus </li></ul></ul><ul><ul><li>burrows in the non-hairy areas </li></ul></ul><ul><ul><ul><li>finger webs, wrists, genitalia, beltline, & buttocks </li></ul></ul></ul><ul><ul><ul><li>grey or flesh-colored ridges </li></ul></ul></ul><ul><ul><ul><li>small vesicle or papule at the end of the tunnel </li></ul></ul></ul><ul><ul><li>similar symptoms in family members or sexual partners </li></ul></ul><ul><ul><li>+/- rash (erythroderma) </li></ul></ul>
  72. 91. Scabies <ul><li>P.E. </li></ul><ul><ul><li>easily missed </li></ul></ul><ul><ul><li>visible burrows </li></ul></ul><ul><ul><li>“ Id” reaction </li></ul></ul><ul><ul><li>various lesions </li></ul></ul><ul><li>Treatment: </li></ul><ul><ul><li>antipruritics </li></ul></ul><ul><ul><li>scabicides </li></ul></ul><ul><ul><ul><li>permethrins </li></ul></ul></ul><ul><ul><ul><li>crotamiton </li></ul></ul></ul><ul><ul><ul><li>lindane </li></ul></ul></ul><ul><ul><li>treat all contacts!! </li></ul></ul>
  73. 93. References <ul><li>Harrison’s Principles of Internal Medicine; 16 th Ed. </li></ul><ul><li>Fitzpatrick TB, Johnson RA, Wolff K: Color Atlas & Synopsis of Clinical Dermatology </li></ul><ul><li>Habif TP: Clinical Dermatology </li></ul><ul><li>Lawrence CM, Cox NH: Physical Signs in Dermatology </li></ul>
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