Dermatology from Physical Diagnosis MS II Block IV
Terms
undefined, object
copy deck
- Question
- Answer
- What is alopecia?
- hair loss
- stress-induced alopecia?
- telogen effluvium
- Most common diffuse alopecias?
- telogen effluvium and androgenetic alopecia
- What causes scarring scalps?
- trauma (such as excessive braiding or hot comb), burns, lupus erythematosus, or folliculitis
- Non-scarring alopecia?
- telogen effluvium, anagen effluvium (chemotherapy, for example), androgenetic alopecia, alopecia areata, thyroid disease, secondary syphilis (“moth-eaten alopeciaâ€), and drug-induced.
- Trichotillomania
- Patient pulls out hair or twists it. Hair shaft breakage. Emotional problems. Can be diffuse, patchy, scarring or nonscarring depending upon how vigorous and aggressive the patient is.
- Traction alopecia
- breakage to hair shaft occur from trauma (hot combs, permanent waves, braiding, etc).
- Genetic syndromes
- (trichorrhexis nodosa, trichothiodystrophy, etc). Most cause hair shaft breakage
- Stress induced alopecia (telogen effluvium).
- This is a molting phenomenon where active growing anagen hairs cycle synchronously into telogen (resting phase). Then they all molt at once (like some animals). Typically 3 months or so after delivery of a child, high fever, illness, or major surgery. Excellent prognosis for regrowth. Nonscarring.
- Androgenetic alopecia.
- Due to androgen excess or hair follicle excessive sensitivity to androgens. Also genetic. Often called male pattern baldness, but since not only males and not always go bald, it's more politically correct to call it androgenetic. Castration often prevents it (not recommended). Typical distribution in frontal area and crown of head. Nonscarring. Can be treated now with topical minoxidil (Rogaine OTC), or finasteride (Propecia) orally.
- Alopecia areata
- Circular non-scarring smooth patches. More in children and young adults. May spontaneously regrow. Regrowth faster with intralesional corticosteroid injections. Autoimmune disease. Associated with thyroid disease. Broken off hairs taper proximally (exclamation point hairs). May occasionally progress to alopecia totalis (all of scalp hair) or alopecia universalis (all body hair everywhere).
- Discoid lupus erythematosus.
- Scarring reddish patches in scalp. Autoimmune. Often no systemic disease but needs workup. Usually will scar. Folliculitis of scalp can be nonbacterial due to follicular plugging (more common in black skin, so-called folliculitis decalvans), bacterial (Staph, etc), or fungal (see below). All of these scar in later stages.
- Tinea capitis
- fungus in scalp (usually > 90% Trichophyton tonsurans from other children or < 10% Microsporum canis from cats or dogs). Other fungi more common in other parts of the world. Rare in adults. Varies from nearly non-inflammatory dry scaly area like seborrheic dermatitis (dandruff) on up to very red inflamed plaques, with or without pustules. Hairs often broken off (black dots) because of fungus in the hair shaft. Diagnosis by plucking out hairs and doing KOH, or by fungus culture. Can be scarring or non-scarring depending upon inflammation or severity.
- Proximal nail groove
- groove at base of nail
- Cuticle
- stratum corneum only (a web at base of nail, often "pushed back in the nail salons, sometimes allowing bacterial entry).
- Lateral nail groove
- groove at sides of nail; often the site of inflammation and "ingrown nail."
- Eponychium
- (skin around base of nail)
- Matrix
- tissue at base of nail from which nail originates. Whitish fibrous tissue (lunula is over part of it).
- Nail bed
- tissue on which the nail plate lies
- Lunula
- whitish half moon at base of nail, is pale because part of matrix is beneath it.
- Avulsion (total or partial)
- removal of nail plate. [X] of lateral edges of nails is a common procedure for ingrown nails. Nail often grows back because matrix not destroyed.
- Matrixectomy
- (surgical or with caustic phenol application) removal of nail plate and the matrix from which it originates. Nail should not grow back but often nail spicule formation occurs.
- Onychomycosis
- tinea unguium = fungus nail infection, usually by Trichophyton rubrum, other Trichophyton species or Epidermophyton. Very common; oral antifungal treatments now popular, such as griseofulvin, terbinafine, itraconazole. Multimillion dollar drug market with "direct to consumer" ads in magazines such as "kick toenail fungus." Not all thick nails are fungus! Culture of nail plate is scientific approach, so as to save on expensive antifungal meds, but culture technique takes experience (must scrape lots of material from deep under nail and inoculate plate). KOH (potassium hydroxide preparation) to look for hyphae in nail might be difficult for average physician. Biopsy of nail to look for fungus with PAS or GMS stains is possible, but less popular than culture or KOH prep. Psoriasis, eczema, trauma, and artificial nails often cause nail dystrophy, so not all of this is fungus!
- Psoriasis
- causes nail pits, dystrophy, onycholysis with oil-drop appearance under nail
- Anonychia
- absence of nail; often congenital or genetic due to syndrome
- Koilonychia
- spoon nail (iron deficiency, congenital anomaly, hereditary)\
- Onychauxis
- thick or hypertrophied nails (usually trauma or fungus)
- Onychogryphosis
- ram's horn nails, due to trauma or fungus
- Onycholysis
- separation of nail from its bed (thyroid disease, psoriasis, tinea trauma, and other causes)
- Onychomadesis
- nail shedding starting from the base (such as chemotherapy)
- Onychophagia
- nail biting
- Onychorrhexis
- longitudinal striation or splitting. Many causes. Sometimes a normal variation.
- Onychoschizia
- splitting of nail into layers. Trauma, thyroid disease.
- Paronychia
- inflammation of tissue around nail, often from infection (usually infection with Candida or Staphylococcus). Look for damage to cuticle or lateral nail fold. Abscess (accumulation of pus) may occur if severe, then it is sometimes called a felon.
- Trachyonychia
- rough nails. Often a normal variant or hereditary.
- Unguis incarnatus
- ingrown nail.
- Pitting of nails
- psoriasis, tinea, alopecia areata, trauma
- Mee's lines
- longitudinal white or brown stripes from inorganic arsenic
- Beau's lines
- transverse depressions in nail from severe illness; grows out with nail
- Muehrcke's nails
- transverse white bands with hypoalbuminemia. It is not a true "leukonychia" because it does not grow out with nail
- Transverse leukonychia
- white bands that grow out with nail. Usually means trauma (such as car door).
- Clubbing
- Hippocratic nails = Lovabond's angle between proximal skin and nail plate should be <180 degrees. There is clubbing if >180 degrees. Usually indicates pulmonary or cardiac disease, poor oxygenation (cyanosis).
- Yellow nail syndrome
- pulmonary disease, AIDS, nail grows slowly, edema
- Blue nails
- Wilson's disease, antimalarial medicines, argyria (silver)
- Green nails
- Pseudomonas infection under onycholytic nail
- Lindsay's nails
- half and half nails = proximal half is white, distal is red or brown. Not a true leukonychia because it is a nail bed (not plate) problem. Usually means renal disease.
- Terry's nails
- total white nails = nearly all white, but there is a red rim distally. Not a leukonychia. Mostly liver disease.
- Splinter hemorrhages
- subacute bacterial endocarditis (SBE): bacterial emboli (often originating from heart valves) lodge in skin under nails, often with fever
- Pincer nails
- claw-like nails ingrow at sides (very pinched)
- HISTORY At a minimum, ask the following 3 things:
- How long has the lesion(s) been present? Does the lesion(s) bother you? (itching, burning, etc). Previous treatment and results?
- Other questions that are often necessary:
- Family history? Associated constitutional ("systemic") symptoms, such as chills, fever, weakness, etc.? Relationship of lesion(s) to heat, cold, medications, hobbies, occupation, sun exposure, travel?
- The following areas are commonly overlooked by the inexperienced:
- palms, soles, nails, genitalia, scalp, oral mucosa.
- herpetiform
- arranged in a group or cluster
- PAPULE
- Raised lesion less than 5 - 10 mm (I prefer 10 mm, but some authorities use 5 mm as the cut-off between papule and plaque
- MACULE
- flat lesion. Some people use this term when the lesion is less than 5-10 mm and use PATCH when it is larger, while others use macule for all flat lesions. Macules can be any color: red, brown, white, etc.
- PLAQUE
- Raised lesion greater than 5-10 mm (larger than papule).
- NODULE
- Similar to papule or plaque, but deeper and more solid.
- VESICLE
- Elevated blister containing clear fluid, less than 5-10 mm.
- BULLA (pl. BULLAE)
- Elevated blister containing clear fluid, larger than 5-10 mm (larger than vesicle). We can use “blister†collectively for vesicles and bullae.
- PUSTULE
- Same as vesicle, except that it contains pus instead of clear serous fluid.
- SCALES
- Desquamating masses of laminated keratin.
- ECZEMATOUS
- Manifested by scaling and erythema, along with vesicles if acute, dry if chronic. Sometimes the erythema is minimal and scaling is the main finding.
- PAPULOSQUAMOUS
- Made up of papules and plaques with scale, usually thicker than eczematous.
- WHEAL
- Evanescent, pink, slightly elevated lesion due to edema. Also called URTICARIA or HIVES. Lesions will blanch (unlike purpura). In very hypersensitive patients, you can write on their skin and make wheals (“dermatographismâ€).
- PURPURA
- Bleeding into the skin (red blood cells are extravasated = out of blood vessels). Lesions will not blanch because the red cells are outside the vessels and do not move down the vessel when pressure is applied. Petechiae and ecchymoses are types of purpura. Most other red lesions on the skin are related to dilated blood vessels which WILL blanch (become less red when pressure applied, sometimes called diascopy).
- PETECHIA (pl. PETECHIAE)
- Pinpoint purpura.
- ECCHYMOSIS (pl. ECCHYMOSES)
- Large purpura; a bruise.
- EROSION
- Superficial defect in skin, not all the way through the epidermis.
- ULCER
- Defect or excavation of the skin, deeper than erosion; extends at least into the dermis.
- CRUST
- A scab, dried blood, or serum. Not the same as scales. A black crust is called eschar.
- CYST
- A circumscribed walled process, usually in the dermis or subcutaneous tissue.
- INDURATED
- Thickened or hard firm skin; also called SCLEROTIC.
- LICHENIFICATION
- Thickening of the skin, usually by repeated chronic rubbing or scratching. Differs from sclerosis in that lichenification usually implies more epidermal change with scaling.
- TUMOR
- Similar to nodule; implies neoplastic. More of a diagnosis than a legal descriptive term.
- EXCORIATION
- An ulcer obviously dug by fingernails.
- FISSURE
- Linear crack in the skin, usually due to extreme dryness.
- ATROPHY
- Thinning of the skin. Epidermal atrophy often exhibits "cigarette paper" wrinkling when skin is compressed.
- TELANGIECTASIA
- Dilated capillary visible with naked eye. Blanches.
- INFILTRATED
- Same as indurated (firm); implies infiltration of skin with neoplastic or inflammatory cells, or some substance.
- ERYTHEMATOUS
- Red, like an erythrocyte.
- PEDUNCULATED
- - A nodule or papule on a thin stalk.
- VERRUCOUS
- Very jagged, irregular surface like a wart.
- ANNULAR
- Ring-shaped lesions; also called CIRCINATE. There are about 40 skin diseases that can be annular, but most docs automatically think only of tinea (“ring-worm†fungus), like a horse wearing blinders. Dermatologists think of the other 39, and miss the common tinea!
- RETICULATED
- - Net-like pattern.
- SERPIGINOUS
- Creeping or enlarging in a linear fashion, like a snake.
- GYRATE
- - Round concentric circles, often would up like a coil.
- UMBILICATED
- Central depression in lesion, like the umbilicus.
- MACULOPAPULAR (EXANTHEMATOUS, MORBILLIFORM)
- Combination of macules and papules. Usually used for non-specific drug rashes and viral exanthems (and secondary syphilis) – those are the main 3 things that present this way. Usually used when there is no scale. The term maculopapular is often misused (since macular and papular covers most rashes) and used for everything by some docs who don’t know how to describe skin lesions.
- ALOPECIA
- Hairloss
- PAPULOSQUAMOUS DISEASES
- Psoriasis, Lichen planus, Pityriasis rosea, Syphilis (secondary), Lichen simplex chronicus
- VESICULOBULLOUS DISEASES
- Dermatitis herpetiformis (not the same as herpes), Pemphigus, Pemphigoid, Acute contact dermatitis (like poison ivy), Bullous impetigo, Herpes simplex, Herpes zoster-varicella, Erythema multiforme, Miliaria ("heat rash")
- ECZEMATOUS DISEASES (sometimes called dermatitis)
- Atopic eczema, Seborrheic dermatitis, Stasis dermatitis, Nummular dermatitis, Tinea, Candidiasis, Asteatotic eczema = xerosis = dry skin, Ichthyosis, Contact dermatitis, Dyshidrotic eczema, Neurodermatitis, Mycosis fungoides
- BLANCHING MACULOPAPULAR ERUPTIONS (little or no scaling)
- Most drug eruptions (reactions to medication), Most viral rashes except herpes viruses, Urticaria, Erythema multiforme, Erythema nodosum (blanching nodules or shins), Syphilis (secondary)
- PURPURIC ERUPTIONS
- Bruises, Vasculitis (usually palpable), Schamberg's disease (usually non-palpable), Meningococcemia, gonococcemia
- PUSTULAR ERUPTIONS
- Folliculitis, Acne, Furunculosis, Candidiasis
- TUMORS
- Basal cell carcinoma, Squamous cell carcinoma, Malignant melanoma, Dermatofibroma, Seborrheic keratosis