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Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
Derm Infections Portfolio
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Derm Infections Portfolio

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  • 1. Infections & Infestations Part 2 Steven J. Sager, MPAS, PA-C Clinical Medicine & Surgery I
  • 2. Objectives
    • 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:
      • Define the anatomy and function of the skin
      • Identify the appendages of the skin and their functions
      • Apply the basic concepts of the approach to dermatology patients
      • Describe the morphology of the skin and related structures
      • Define common terminology, signs, and symptoms used in dermatology practice
      • Differentiate primary from secondary skin lesions
      • Accurately identify skin lesions when given a picture
  • 3. Objectives
      • Identify diagnostic and laboratory tests utilized in dermatology clinical practice
        • Magnification
        • Transillumination
        • Diascopy
        • Wood’s light examination
        • patch tests
        • physical contact testing
        • gram stain
        • fungal and bacterial cultures
        • Tzanck smear
        • skin biopsy.
      • Describe the clinical situation in which, diagnostic or laboratory tests are important.
  • 4. Objectives
      • Identify common dermatology signs and symptoms while recognizing potential systemic implications
      • Compare and contrast the diagnostic work-up for the dermatology patient
      • Define cream, ointment, gel, solution and lotion; and then indicate the appropriate clinical use
      • Identify the basic concept for use of wet and dry dressing for skin lesions
      • List the indications for the use of cryosurgery, incisions, excisions, electrocautery, and chemical treatment of skin lesions
  • 5. Dermatophytoses
    • Etiology
      • Superficial fungal infections
      • Caused by an overgrowth of transient or resident flora
        • Change in microenvironment of the skin
      • Infects
        • Keratinized epithelium (epidermomycosis)
        • Hair follicles (trichomycosis)
        • Nails (onychomycosis)
  • 6. Dermatophytoses
    • Etiology
      • Genera:
        • Trichophyton
          • T. rubrum
          • T. tonsurans
        • Microsporum
          • M. canis
        • Epidermophyton
  • 7. Dermatophytoses
    • Epidemiology
      • Worldwide distribution
      • Affects all ages
        • Location is more age dependent
      • Transmission:
        • Anthrophilic (fomites or direct contact)
        • Zoophilic (animals)
        • Geophilic (soil)
  • 8. Dermatophyoses
    • Evaluation:
      • KOH – diagnostic
      • Wood’s lamp
      • Fungal cultures
    • Treatment:
      • Topical antifungals
        • Not effective for infection of hair or nails
      • Oral (systemic) antifungals
  • 9. Topical antifungals
    • Imidazoles
      • miconazole (Micatin)
      • clotrimazole (Lotrimin)
      • ketoconazole (Nizoral)
    • Allylamines
      • terbinafine (Lamisil)
    • Naphthiomates
      • tolnaftate (Tinactin)
    • Ciclopirox (Penlac)
  • 10. Oral antifungals
    • Imidazoles
      • clotrimazole (Lotrimin)
      • ketoconazole (Nizoral)
      • itraconazole (Sporanox)
      • fluconazole (Diflucan)
    • Allylamines
      • terbinafine (Lamisil)
    • Griseofulvin
  • 11. Tinea capitis
    • Epidemiology
      • primarily affects 6-10 year olds
      • typically spread by fomites
    • Etiology
      • T. tonsurans (90%)
      • fungus invades the hair shaft
  • 12. Tinea capitis
    • Symptoms and P.E.
      • +/- pain and tenderness
      • alopecia
      • pruritus
      • annular, scaly patches
      • broken hairs
  • 13. Kerion
    • Boggy inflammatory plaques
    • Purulent, inflamed nodules
    • Extremely painful
    • Drains pus from multiple locations
    • Hair falls out (vs. breaking)
  • 14. Tinea capitis
    • DDx:
      • Atopic dermatitis
      • Psoriasis
      • Lichen simplex chronicus
      • Seborrheic dermatitis
  • 15. Tinea capitis
    • Lab:
      • KOH
      • direct microscopy of hairshaft
      • Wood’s lamp green fluorescence with M. canis
    • Treatment
      • oral antifungals
        • topical preparations are not usually effective
  • 16.  
  • 17. Tinea facialis
    • Infection of the glabrous facial skin
    • More common in children
    • T. tonsurans and T. rubrum
    • Predisposing factor
      • animal contact
    • Symptoms
      • +/- pruritus
      • scaly patches
    • Lab - KOH
    • Treatment –
      • topical (localized) or oral (diffuse) antifungals
  • 18.  
  • 19. Tinea corporis
    • Dermatophyte infection involving:
      • neck
      • trunk
      • arms
      • legs
    • Etiology
      • T. rubrum, T. tonsurans, M. canis
      • spread by autoinoculation
        • Most commonly spread from feet
      • increased incidence in tropical/subtropical
  • 20. Tinea corporis
    • Symptoms
      • +/- pruritus
      • scaly, annular patches
        • well-defined margins
        • marginal erythema
        • central clearing
      • +/- vesicles/pustules
    • Lab - KOH
    • Treatment:
      • topical (localized) or oral (diffuse) antifungals
  • 21.  
  • 22. Tinea cruris
    • Infection of the inguinal/pubic regions and thighs
    • Etiology – T. rubrum
    • M > F
    • Predisposing factors:
      • warm, humid environment
      • tight clothing
      • obesity
  • 23. Tinea cruris
    • Symptoms
      • pruritus (moderate to severe)
    • P.E.
      • large, scaly dull red/tan/brown plaques
      • well-demarcated margins
    • Treatment options
      • topical antifungals
  • 24.  
  • 25. Tinea pedis (Athlete's foot)
    • Dermatophyte infection of the feet
    • Often spreads to:
      • inguinal region
      • trunk
      • hands (tinea manuum)
    • Transmitted by walking barefoot on a contaminated floor
    • Tends to be chronic
    • May develop a secondary infection by S. aureus and GAS
  • 26. Tinea pedis (Athlete's foot)
    • Etiology
      • T. rubrum
      • T. mentagrophytes
    • Predisposing factors:
      • hot, humid weather
      • occlusive footwear
      • hyperhydrosis
  • 27. Tinea pedis (Athlete's foot)
    • Symptoms and P.E.
      • pruritus
      • erythema
      • scaling
      • maceration
      • hyperkeratosis
      • +/- vesicles/bullae/pustules formation
    • Lab:
      • KOH
      • +/- fungal culture
    • Treatment options
  • 28. Tinea pedis (Athlete's foot)
    • Treatment:
      • counsel patient:
        • preventive measures
        • footwear
      • wash feet with benzoyl peroxide
      • Burrow's dressings
      • Drysol
      • topical or oral antifungals prn
  • 29.  
  • 30. Onychomycosis
    • Chronic progressive infection of the nail apparatus
    • Usually associated with tinea pedis
    • Etiology
      • dermatophytes (~95%), Candida, or molds
      • T. rubrum
    • Epidemiology
      • incidence increasing with age
      • M > F
      • primarily affects big toe
  • 31. Onychomycosis
    • Symptoms and P.E.
      • discoloration
      • brittle, thickened nails
    • Treatment:
      • counsel on foot care/footwear
      • trim dystrophic nails
      • Ciclopirox (Penlac)
      • oral antifungals
  • 32.  
  • 33. Pityriasis (Tinea) versicolor
    • Chronic, asymptomatic scaling eruption
    • Caused by the Pityrosporum ovale yeast
    • Primarily affects young adults
    • Not contagious
    • Predisposing factors:
      • high humidity
      • increased oil (sebum) production
  • 34. Pityriasis (Tinea) versicolor
    • Symptoms and P.E.
      • sharply marginated macules
        • appear hypopigmented
      • fine scaling
    • Lab – KOH
    • Treatment:
      • Topical
        • selenium sulfide
        • azole creams and shampoos
  • 35.  
  • 36. Candidiasis
    • Etiology
      • primarily caused by the yeast Candida albicans
        • frequently colonizes the GI tract
          • oropharyngeal ~20%
          • fecal ~40-70%
          • vaginal ~20%
        • Increased occurrence with antimicrobial therapy
      • superficial infections of the mucosal surface are common
      • cutaneous involvement occurs at moist occluded skin
      • affects young and old
  • 37. Candidiasis
    • Host factors:
      • diabetes
      • obesity
      • hyperhydrosis
      • hot climate
      • corticosteroids
      • chronic debilitation
  • 38. “ Diaper Dermatitis”
    • Etiology
      • common in infants
      • NOT generally due to poor hygiene
    • Symptoms
      • inflamed, erythematous eroded patches
      • small peripheral (“satellite”) pustular lesions
      • edema
      • involves the perigenital/perianal skin, the buttocks, and the inner aspects of the thighs
  • 39. “ Diaper Dermatitis”
    • Lab:
      • KOH
      • fungal culture
    • Tx:
      • topical antifungals
      • keep area as dry as possible
      • talc
      • miconazole powder
      • desitin or A&D ointment (OTC)
  • 40. Candidiasis (Cutaneous)
    • Typically occurs in the intertriginous areas
    • Symptoms
      • pustules on an erythematous base
      • become eroded and confluent
      • satellite lesions
  • 41. Candidiasis
    • Treatment options
      • Topical antifungals
        • miconazole powder
        • nystatin
        • clotrimazole
      • Oral antifungals
        • fluconazole
        • itraconazole
        • ketoconazole
  • 42. Candidiasis (Oropharyngeal)
    • Resident flora of the mouth
    • Symptoms
      • odynophagia
      • “ burning” or pain when eating spicy/acidic foods
      • “ white curds” on tongue
    • Tx:
      • nystatin oral rinse or troches
      • clotrimazole troches
      • oral antifungals
  • 43. Candidiasis (Genital)
    • Resident flora of the vagina (~20%)
    • Onset usually 1 week before menses
    • Symptoms
      • pruritus
      • vaginal discharge
      • dyspareunia
      • dysuria
    • P.E.:
      • erythema and edema of vulva
      • white, curd-like vaginal discharge
  • 44. Candidiasis (Genital)
    • Dx:
      • KOH
    • Treatment:
      • Topical antifungals
        • butoconazole (Gynazole-1)
        • clotrimazole
        • miconazole (Monistat)
        • terconazole (Terazol)
        • fluconazole
  • 45.  
  • 46. HSV
    • Etiology
      • Human herpesvirus (HHV)
        • DNA virus
        • 8 serotypes
          • HSV-1
          • HSV-2
          • HZV (VZV)
          • EBV
          • CMV
          • HHV-6, HHV-7, & HHV-8
      • persists in the sensory ganglia for life
  • 47. HSV
    • Labialis
      • 80-90% HSV-1
    • Genitalis
      • 70-90% HSV-2
    • Herpetic whitlow
      • <20y.o. ~ HSV-1
      • >20y.o. ~ HSV-2
  • 48. HSV
    • Epidemiology
      • reoccurs when immunocompromised
        • stress
        • menses
        • UV radiation
        • illness
      • any age
      • spread by direct contact when shedding virus
      • 2-20 day incubation period
      • usually reoccurs in the vicinity of the primary infection
  • 49. HSV
    • Symptoms
      • primary infections are usually asymptomatic
      • vesicles at the site of inoculation
      • gingivostomatitis
      • regional lymphadenopathy
      • fever
      • headache
      • malaise
      • myalgia
      • “ tingling”, “burning” or “itchy” sensation
        • precedes visible skin changes by ~24 hours
  • 50. HSV
    • P.E.
      • lesions occur on epidermis & mucous membranes
      • grouped vesicles arising on an erythematous base
        • may evolve to pustules
        • often umbilicated
      • erode due to sloughing of epidermis
        • may enlarge to ulcerations
      • may be crusted or moist
  • 51. HSV
    • DDx:
      • aphthous stomatitis
      • hand-foot-and-mouth disease
      • erythema multiforme
      • fixed drug eruption
  • 52. HSV
    • Lab:
      • Tzanck smear
        • Optimally, fluid from an intact vesicle
      • viral culture
      • antigen smear
      • serology for antibodies
  • 53. HSV
    • Treatment options:
      • heal spontaneously in 2-4 weeks
      • topical antivirals
        • acyclovir
        • penciclovir
      • oral antivirals
        • acyclovir
        • valacyclovir
        • famciclovir
  • 54.  
  • 55.  
  • 56. Varicella-Zoster virus
    • Etiology
      • DNA virus
      • primary infection
        • chickenpox (Varicella)
        • 90% of cases occur in children < 10 years old
        • 3-4 million cases annually in U.S.
        • ~14 day incubation period
      • infects 98% of adult population
  • 57. Varicella-Zoster virus
    • Etiology
      • persists in the sensory ganglia for life
      • reactivation occurs in a dermatomal pattern
      • transmitted via airborne droplets and direct contact
      • contagion:
        • several days before exanthem appears until last crop of vesicles
  • 58. VZV
    • Symptoms & P.E.
      • primary is almost always symptomatic
        • disseminated pruritic vesicles
        • “ cropping” rash
          • macules, papules, and vesicles +/- pustules
          • develop over 8-12 hours
      • vesicles rupture and crusts form
        • fall off in 1-3 weeks leaving a pink, depressed base
      • +/- prodromal/constitutional symptoms
      • dermatomal pain prior to rash
      • post-herpetic neuralgia
  • 59. VZV
    • Dx:
      • VZV antigen smear
      • viral cultures
      • Tzanck smear
      • serology
    • Treatment options
      • VZV immunization (Varivax)
      • antipruritics (topical or systemic)
      • antivirals (if started within 24 hours of rash)
      • ASA is CONTRAINDICATED!!!
  • 60.  
  • 61.  
  • 62. Human Papillomavirus
    • Etiology
      • ubiquitous
      • DNA virus
      • causes a variety of benign lesions
        • discrete epithelial hyperplasia/hyperkeratosis
        • extent of involvement is determines by immune status of the host
      • affects the skin and mucous membranes
      • has a role in oncogenesis
      • >150 types
  • 63. Verrucae
    • V. vulgaris
      • ~70% of all cutaneous warts
      • ~20% of all school-aged children are affected
    • V. plantaris (~30%)
      • affect older children and young adults
    • V. plana (~4%)
      • occur on face, beard area, dorsum of hands, shins
    • Filiform warts
    • Periungual warts
    • Mosaic warts
  • 64. Conylomata accuminata
    • Etiology
      • Caused by the human papilloma virus (HPV)
      • Significant role in pathogenesis of invasive SCC of the anogenital region
    • Symptoms = usually asymptomatic
    • P.E.
      • Papillomatous plaques or nodules with a granular surface on the mucosa
      • Early lesions turn white when 5% acetic acid is applied
  • 65. Conylomata accuminata
  • 66. Conylomata accuminata
  • 67. Conylomata accuminata
  • 68. Human Papillomavirus
    • transmitted by skin-to-skin contact
    • occur at sites of trauma
    • autoinoculation
    • higher incidence in immunocompromised
    • ~60% resolve in <2 years untreated
  • 69. Human Papillomavirus
    • Symptoms:
      • tenderness
      • bleeding
    • P.E.
      • firm 1-10mm papules
      • irregular surface
      • capillary “seeds”
  • 70. Human Papillomavirus
    • DDx:
      • Molluscum contagiosum
      • SK
      • AK
      • Keratoacanthomas
      • SCC (in situ or invasive)
      • heloma
      • callus
  • 71. Human Papillomavirus
    • Bx is usually not necessary
    • Treatment options:
      • keratolytics
      • cryosurgery
      • electrodessication
      • CO 2 laser surgery
    • DON’T excise
    • DON’T be too aggressive!
  • 72.  
  • 73.  
  • 74.  
  • 75.  
  • 76. Molluscum contagiosum
    • Etiology
      • self-limiting viral infection (6-12 months)
        • usually resolves completely
      • affects children and sexually active adults
      • M > F
      • can be spread by autoinoculation
    • Symptoms - none
    • P.E.
      • pearly-white or flesh-colored papules (1-5 mm) in diameter
        • children – exposed skin
        • adults – anogenital region
      • often have an umbilicated center (central keratotic plug)
      • variable distribution
  • 77. Molluscum contagiosum
    • DDx:
      • Verrucae
      • Keratoacanthoma
      • Syringoma
      • Sebaceous hyperplasia
      • BCC
      • SCC
      • EIC
    • Treatment options
      • curettage
      • imiquimod
      • cryosurgery
      • electrodessication
  • 78.  
  • 79. Pediculosis
    • Etiology
      • Pediculus humanus
        • corporis
          • body louse
          • live in clothing
        • capitis - head louse
      • Phthirius pubis
        • live in the pubic area and other hear-bearing areas
      • spread by:
        • direct or indirect contact
      • may coexist with scabies
  • 80. Pediculosis capitis
    • ~10 million cases in U.S. annually
    • most common in 3-11 years old
    • lice are not typically a vector of infection
    • more common in summer/warm climates
    • transmitted by fomites or head-to-head
  • 81. Pediculosis corporis
    • Associated with poor socioeconomic conditions
      • clothing is not changed or washed frequently
        • indigent
        • homeless
        • refugee camps
  • 82. Pediculosis pubis (Phthiriasis)
    • Primarily affects young adults
    • Typically transmitted sexually
    • Life cycle of louse is ~20 days
    • Frequently coexists with another STD
    • Most common in pubic and axillary areas
    • Children = non-sexual contact with an infected parent
  • 83.  
  • 84.  
  • 85. Infections associated with Pediculoses
    • Cellulitis/lymphangitis/bacteremia
      • S. aureus
      • Group A strep
    • Trench fever
    • Typhus
  • 86. Pediculoses
    • Symptoms
      • moderate to intense pruritus
      • children are “distracted” and “restless”
    • P.E.
      • visible lice or nits (Wood’s lamp)
        • examine hairs carefully
        • examine clothing
      • excoriations
      • papular urticaria
  • 87. Pediculoses
    • Treatment:
      • Topical pediculocides
        • should be active against adults and eggs
      • wash all clothing and linens
      • treat contacts/family members prn
      • repeat in 7-10 days prn
  • 88. Pediculocides
    • Permethrins
      • Nix
        • treats head lice
        • apply to washed and towel-dried hair x 10 minutes
        • remove nits with comb
      • Elimite
        • treats scabies
        • apply from head to soles x 8-14 hours
    • Pyrethrins (Rid)
      • treats all lice
    • Crotamiton (Eurax)
      • apply from chin to soles & repeat in 24 hours
      • bathe after 48 hours
  • 89. Scabies
    • Etiology
      • infestation by Sarcoptes scabiei (Itch mite)
      • usually spread by skin-to-skin contact
      • any age
      • 300 million cases in the world annually
      • mites burrow into epidermis shortly after contact
        • 2-3mm daily
        • burrow during the night; lay eggs during the day
        • female lives 4-6 weeks
        • deposits 40-50 eggs
        • can live 2+ days off host
  • 90. Scabies
    • Symptoms
      • intractable, widespread pruritus
      • burrows in the non-hairy areas
        • finger webs, wrists, genitalia, beltline, & buttocks
        • grey or flesh-colored ridges
        • small vesicle or papule at the end of the tunnel
      • similar symptoms in family members or sexual partners
      • +/- rash (erythroderma)
  • 91. Scabies
    • P.E.
      • easily missed
      • visible burrows
      • “ Id” reaction
      • various lesions
    • Treatment:
      • antipruritics
      • scabicides
        • permethrins
        • crotamiton
        • lindane
      • treat all contacts!!
  • 92.  
  • 93. References
    • Harrison’s Principles of Internal Medicine; 16 th Ed.
    • Fitzpatrick TB, Johnson RA, Wolff K: Color Atlas & Synopsis of Clinical Dermatology
    • Habif TP: Clinical Dermatology
    • Lawrence CM, Cox NH: Physical Signs in Dermatology

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