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Dermatology - Lichen Simplex Chronicus
Lichen simplex chronicus is a specific, localized manifestation of lichenification that occurs in distinct plaques as a result of continuous rubbing and scratching. This condition manifests in persons who are at least 20 years old and is more prevalent among women. If rubbing or scratching is not ceased, this condition can persist for several decades.
The skin exhibits heightened sensitivity to tactile stimuli and experiences itching in reaction to even the slightest external triggers. The symptoms include pruritus, which commonly occurs in paroxysms. The skin that has become lichenified elicits a pleasurable sensation when scratched, and stroking it becomes a habitual and reflexive response.
A dense layer of lichenification, resulting from the merging of tiny papules, is noticeably thicker; skin patterns (barely discernible in healthy skin) are intensified and easily evident. Individuals with deeply pigmented skin may exhibit hyperpigmented excoriations that initially appear as dull red and gradually turn brown or black. Lesions can be either solitary or present in several plaques, and are commonly found in the nuchal region (in women), scalp, ankles, lower legs, upper thighs, outer forearms, vulva, pubis, anal area, scrotum, and groin. Lichenification in individuals with dark skin may have a distinctive "follicular" pattern.
The diagnosis is made based on clinical examination, and the differential diagnosis includes chronic pruritic plaque of psoriasis vulgaris, early stages of mycosis fungoides, contact dermatitis, and epidermal dermatophytosis.
Inform the patient that they must cease the act of rubbing and scratching. Topical glucocorticoid treatments or tar preparations, when applied with occlusive dressings, are beneficial for treating the legs and arms. The efficacy of including glucocorticoid in adhesive plastic tape is maintained while left for a duration of 24 hours.
A gauze roll dressing containing zinc oxide paste can be applied to a significant area of thickened skin, such as the calf, known as lichenification. This dressing, also known as an Unna boot, can be left in place for a maximum of one week. Intralesional administration of triamcinolone is frequently highly efficacious in treating minor lesions (3 mg/mL); however, using greater dosages may lead to the development of atrophy. Administering oral hydroxyzine, at a dosage of 25-50 grams before bedtime, may provide assistance.
Lichen simplex chronicus is a specific, localized manifestation of lichenification that occurs in distinct plaques as a result of continuous rubbing and scratching. This condition manifests in persons who are at least 20 years old and is more prevalent among women. If rubbing or scratching is not ceased, this condition can persist for several decades.
The skin exhibits heightened sensitivity to tactile stimuli and experiences itching in reaction to even the slightest external triggers. The symptoms include pruritus, which commonly occurs in paroxysms. The skin that has become lichenified elicits a pleasurable sensation when scratched, and stroking it becomes a habitual and reflexive response.
A dense layer of lichenification, resulting from the merging of tiny papules, is noticeably thicker; skin patterns (barely discernible in healthy skin) are intensified and easily evident. Individuals with deeply pigmented skin may exhibit hyperpigmented excoriations that initially appear as dull red and gradually turn brown or black. Lesions can be either solitary or present in several plaques, and are commonly found in the nuchal region (in women), scalp, ankles, lower legs, upper thighs, outer forearms, vulva, pubis, anal area, scrotum, and groin. Lichenification in individuals with dark skin may have a distinctive "follicular" pattern.
The diagnosis is made based on clinical examination, and the differential diagnosis includes chronic pruritic plaque of psoriasis vulgaris, early stages of mycosis fungoides, contact dermatitis, and epidermal dermatophytosis.
Inform the patient that they must cease the act of rubbing and scratching. Topical glucocorticoid treatments or tar preparations, when applied with occlusive dressings, are beneficial for treating the legs and arms. The efficacy of including glucocorticoid in adhesive plastic tape is maintained while left for a duration of 24 hours.
A gauze roll dressing containing zinc oxide paste can be applied to a significant area of thickened skin, such as the calf, known as lichenification. This dressing, also known as an Unna boot, can be left in place for a maximum of one week. Intralesional administration of triamcinolone is frequently highly efficacious in treating minor lesions (3 mg/mL); however, using greater dosages may lead to the development of atrophy. Administering oral hydroxyzine, at a dosage of 25-50 grams before bedtime, may provide assistance.
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Dermatology - Perioral Dermatitis
Perioral dermatitis primarily affects females and typically starts between the ages of 16 and 45, however it can also occur in infants and the elderly. The exact etiology is uncertain, although outbreaks are significantly worsened by the use of strong topical (fluorinated) glucocorticoids.
The lesions persist for a duration of weeks to months and are frequently seen as a form of cosmetic deformity. Intermittent stinging, burning, or sensation of constriction may occur.
Abnormalities
The individual has small, raised, red bumps with pus-filled centers, about 1 to 2 millimeters in diameter. These bumps are located on a red backdrop and are arranged in an irregular and symmetrical pattern. The number of plaques increases when they merge together at a central point and form satellites. Confluent plaques may have an eczematous appearance with small scales. No comedones are present. There is a possibility of a narrow region of unaffected skin around the red border of the lips, and sores may also develop in the areas surrounding the nose and eyes.
The diagnosis is made based on clinical examination, and the possible conditions to consider are allergic contact dermatitis, atopic dermatitis, seborrheic dermatitis, rosacea, acne vulgaris, and steroid acne.
Apply Topical Metronidazole, 0.75% gel twice daily or 1% gel once daily. Apply erythromycin, 2% gel twice daily. Do not use glucocorticoids.
Administer systemic Minocycline or doxycycline at a dosage of 100 mg per day until the condition is resolved, followed by a dosage of 50 mg per day for an additional 2 months. Please note that doxycycline is a medicine that increases sensitivity to sunlight. The recommended dosage for Tetracycline is 500 mg taken twice daily until the symptoms clear up. After that, the dosage should be reduced to 500 mg taken once daily for a duration of 1 month. Following this, the dosage should be further reduced to 250 mg taken once daily for an extra month.
Perioral dermatitis primarily affects females and typically starts between the ages of 16 and 45, however it can also occur in infants and the elderly. The exact etiology is uncertain, although outbreaks are significantly worsened by the use of strong topical (fluorinated) glucocorticoids.
The lesions persist for a duration of weeks to months and are frequently seen as a form of cosmetic deformity. Intermittent stinging, burning, or sensation of constriction may occur.
Abnormalities
The individual has small, raised, red bumps with pus-filled centers, about 1 to 2 millimeters in diameter. These bumps are located on a red backdrop and are arranged in an irregular and symmetrical pattern. The number of plaques increases when they merge together at a central point and form satellites. Confluent plaques may have an eczematous appearance with small scales. No comedones are present. There is a possibility of a narrow region of unaffected skin around the red border of the lips, and sores may also develop in the areas surrounding the nose and eyes.
The diagnosis is made based on clinical examination, and the possible conditions to consider are allergic contact dermatitis, atopic dermatitis, seborrheic dermatitis, rosacea, acne vulgaris, and steroid acne.
Apply Topical Metronidazole, 0.75% gel twice daily or 1% gel once daily. Apply erythromycin, 2% gel twice daily. Do not use glucocorticoids.
Administer systemic Minocycline or doxycycline at a dosage of 100 mg per day until the condition is resolved, followed by a dosage of 50 mg per day for an additional 2 months. Please note that doxycycline is a medicine that increases sensitivity to sunlight. The recommended dosage for Tetracycline is 500 mg taken twice daily until the symptoms clear up. After that, the dosage should be reduced to 500 mg taken once daily for a duration of 1 month. Following this, the dosage should be further reduced to 250 mg taken once daily for an extra month.
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Dermatology - Tinea Capitis
Tinea is a fungal infection that affects the outer layers of the skin, nails, and hair. It is caused by a specific type of fungus called dermatophytes. The spores of these fungi, known as arthrospores, can remain viable in skin flakes for a period of up to 12 months.
Transmission primarily occurs through interpersonal contact, followed by transmission from animals, and least frequently, from soil. Tinea capitis is a fungal infection of the scalp and hair that mainly affects youngsters.
Tinea capitis can manifest as noninflammatory patches of scaling, broken-off hairs, or as acute and painful inflammation accompanied by painful, swollen nodules that release pus (known as kerion) and can lead to permanent hair loss due to scarring, particularly if there is a subsequent infection. Typically, hair regrowth ensues following the administration of antifungal treatments.
Abnormalities
Alopecia can manifest as either broad or restricted hair loss without any signs of inflammation, and is accompanied with scaling. The "gray patch" is a form of partial hair loss that typically takes on a circular shape with well-defined edges and a fine layer of scales. It is characterized by the presence of many damaged hairs and appears dull gray due to the accumulation of arthrospores. Small patches merge together, creating larger patches. "Black dot" lesions refer to damaged hairs located near the scalp that provide the appearance of "dots" or enlarged hair shafts in individuals with dark hair. The lesion typically has a widespread and indistinct appearance, and there may be a presence of mild inflammation of the hair follicles.
Kerion and favus are inflammatory masses distinguished by swollen, pus-filled, inflamed nodules and patches that typically cause discomfort and discharge pus from many apertures, resembling a honeycomb. Hair strands do not fracture but rather shed naturally and can be extracted without causing discomfort. Follicles can release pus, leading to the formation of sinuses and the presence of mycetoma-like grains. There is a dense formation of crusts with tangled nearby hairs. Typically, there is only one plaque, although it is possible to have several lesions that affect the entire scalp. Often, there is concurrent lymphadenopathy.
Utilize direct microscopy of the hair shaft (obtained by plucking) and scalp scales collected using a brush coated with a small amount of potassium hydroxide (KOH) to demonstrate the existence of fungal hyphae. The differential diagnosis comprises seborrheic dermatitis, psoriasis, atopic dermatitis, lichen simplex chronicus, alopecia areata, and chronic cutaneous lupus erythematosus. In cases of kerion or favus, impetigo, ecthyma, and crusted scabies should also be considered.
The 250-mg tablet of Terbinafine is a systemic allylamine that serves as the most potent oral antidermophytic medication. Other options consist of itraconazole capsules with a strength of 100 mg or an oral solution with a concentration of 10 mg/mL. Additionally, fluconazole tablets are available in strengths of 100 mg, 150 mg, and 200 mg, as well as an oral suspension with concentrations of 10 mg/mL or 40 mg/mL.
Tinea is a fungal infection that affects the outer layers of the skin, nails, and hair. It is caused by a specific type of fungus called dermatophytes. The spores of these fungi, known as arthrospores, can remain viable in skin flakes for a period of up to 12 months.
Transmission primarily occurs through interpersonal contact, followed by transmission from animals, and least frequently, from soil. Tinea capitis is a fungal infection of the scalp and hair that mainly affects youngsters.
Tinea capitis can manifest as noninflammatory patches of scaling, broken-off hairs, or as acute and painful inflammation accompanied by painful, swollen nodules that release pus (known as kerion) and can lead to permanent hair loss due to scarring, particularly if there is a subsequent infection. Typically, hair regrowth ensues following the administration of antifungal treatments.
Abnormalities
Alopecia can manifest as either broad or restricted hair loss without any signs of inflammation, and is accompanied with scaling. The "gray patch" is a form of partial hair loss that typically takes on a circular shape with well-defined edges and a fine layer of scales. It is characterized by the presence of many damaged hairs and appears dull gray due to the accumulation of arthrospores. Small patches merge together, creating larger patches. "Black dot" lesions refer to damaged hairs located near the scalp that provide the appearance of "dots" or enlarged hair shafts in individuals with dark hair. The lesion typically has a widespread and indistinct appearance, and there may be a presence of mild inflammation of the hair follicles.
Kerion and favus are inflammatory masses distinguished by swollen, pus-filled, inflamed nodules and patches that typically cause discomfort and discharge pus from many apertures, resembling a honeycomb. Hair strands do not fracture but rather shed naturally and can be extracted without causing discomfort. Follicles can release pus, leading to the formation of sinuses and the presence of mycetoma-like grains. There is a dense formation of crusts with tangled nearby hairs. Typically, there is only one plaque, although it is possible to have several lesions that affect the entire scalp. Often, there is concurrent lymphadenopathy.
Utilize direct microscopy of the hair shaft (obtained by plucking) and scalp scales collected using a brush coated with a small amount of potassium hydroxide (KOH) to demonstrate the existence of fungal hyphae. The differential diagnosis comprises seborrheic dermatitis, psoriasis, atopic dermatitis, lichen simplex chronicus, alopecia areata, and chronic cutaneous lupus erythematosus. In cases of kerion or favus, impetigo, ecthyma, and crusted scabies should also be considered.
The 250-mg tablet of Terbinafine is a systemic allylamine that serves as the most potent oral antidermophytic medication. Other options consist of itraconazole capsules with a strength of 100 mg or an oral solution with a concentration of 10 mg/mL. Additionally, fluconazole tablets are available in strengths of 100 mg, 150 mg, and 200 mg, as well as an oral suspension with concentrations of 10 mg/mL or 40 mg/mL.
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Symptoms and Signs – Differential Diagnosis of Colorectal Cancer
• Strictures
• Metastatic carcinoma (prostate, sarcoma)
• Inflammatory bowel disease (IBD)
• Infectious or inflammatory lesions
• Extrinsic masses (cysts, abscesses)
• Diverticular disease
• Arteriovenous malformations
• Adhesions
• Strictures
• Metastatic carcinoma (prostate, sarcoma)
• Inflammatory bowel disease (IBD)
• Infectious or inflammatory lesions
• Extrinsic masses (cysts, abscesses)
• Diverticular disease
• Arteriovenous malformations
• Adhesions
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Symptoms and Signs – Differential Diagnosis of Coma
• Vascular: hemorrhage, thrombosis, embolism
• Uremia
• Postictal
• Metabolic disturbances
• Ingestion or inhalation of toxins: carbon monoxide (CO), alcohol, lead
• Hypoxia
• Hypothyroidism
• Hypothermia, hyperthermia
• Hypotension, malignant hypertension
• Hypoglycemia, hyperglycemia
• Hepatic failure
• Head injury: subdural hematoma, cerebral concussion, cerebral contusion
• Electrolyte disorders
• Drugs: narcotics, sedatives, hypnotics
• CNS infections: meningitis, encephalitis, cerebral abscess
• Cerebral neoplasms with herniation
• Acid-base disorders
• Vascular: hemorrhage, thrombosis, embolism
• Uremia
• Postictal
• Metabolic disturbances
• Ingestion or inhalation of toxins: carbon monoxide (CO), alcohol, lead
• Hypoxia
• Hypothyroidism
• Hypothermia, hyperthermia
• Hypotension, malignant hypertension
• Hypoglycemia, hyperglycemia
• Hepatic failure
• Head injury: subdural hematoma, cerebral concussion, cerebral contusion
• Electrolyte disorders
• Drugs: narcotics, sedatives, hypnotics
• CNS infections: meningitis, encephalitis, cerebral abscess
• Cerebral neoplasms with herniation
• Acid-base disorders
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Symptoms and Signs – Differential Diagnosis of Coma with Normal Computed Tomography
MENINGEAL DISORDERS
• Subarachnoid hemorrhage (uncommon)
• Bacterial meningitis
• Encephalitis
• Subdural empyema
EXOGENOUS TOXINS
• Sedative drugs and barbiturates
• Anesthetics and γ-hydroxybutyrate*
• Alcohols
• Stimulants
• Phencyclidine†
• Cocaine and amphetamine‡
• Psychotropic drugs
• Cyclic antidepressants
• Phenothiazines
• Lithium
• Anticonvulsants
• Opioids
• Clonidine§
• Penicillins
• Salicylates
• Anticholinergics
• Carbon monoxide (CO), cyanide, and methemoglobinemia
ENDOGENOUS TOXINS, DEFICIENCIES, OR
DERANGEMENTS
• Hypoxia and ischemia
• Hypoglycemia
• Hypercalcemia
• Osmolar
• Hyperglycemia
• Hyponatremia
• Hypernatremia
• Organ system failure
• Hepatic encephalopathy
• Uremic encephalopathy
• Pulmonary insufficiency (carbon dioxide narcosis)
SEIZURES
• Prolonged postictal state
• Spike-wave stupor
HYPOTHERMIA OR HYPERTHERMIA
• Brainstem ischemia
• Basilar artery stroke
• Brainstem or cerebellar hemorrhage
• Conversion or malingering
MENINGEAL DISORDERS
• Subarachnoid hemorrhage (uncommon)
• Bacterial meningitis
• Encephalitis
• Subdural empyema
EXOGENOUS TOXINS
• Sedative drugs and barbiturates
• Anesthetics and γ-hydroxybutyrate*
• Alcohols
• Stimulants
• Phencyclidine†
• Cocaine and amphetamine‡
• Psychotropic drugs
• Cyclic antidepressants
• Phenothiazines
• Lithium
• Anticonvulsants
• Opioids
• Clonidine§
• Penicillins
• Salicylates
• Anticholinergics
• Carbon monoxide (CO), cyanide, and methemoglobinemia
ENDOGENOUS TOXINS, DEFICIENCIES, OR
DERANGEMENTS
• Hypoxia and ischemia
• Hypoglycemia
• Hypercalcemia
• Osmolar
• Hyperglycemia
• Hyponatremia
• Hypernatremia
• Organ system failure
• Hepatic encephalopathy
• Uremic encephalopathy
• Pulmonary insufficiency (carbon dioxide narcosis)
SEIZURES
• Prolonged postictal state
• Spike-wave stupor
HYPOTHERMIA OR HYPERTHERMIA
• Brainstem ischemia
• Basilar artery stroke
• Brainstem or cerebellar hemorrhage
• Conversion or malingering
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Symptoms and Signs – Differential Diagnosis of Coma in Pediatric Cases
ANOXIA
• Birth asphyxia
• Carbon monoxide (CO) poisoning
• Croup/epiglottitis
• Meconium aspiration
INFECTION
• Hemolysis
• Blood loss
• Hydrops fetalis
• Meningoencephalitis
• Sepsis
• Postimmunization encephalitis
INCREASED INTRACRANIAL PRESSURE
• Anoxia
• Inborn metabolic errors
• Toxic encephalopathy
• Reye’s syndrome
• Head trauma/intracranial bleed
• Hydrocephalus
• Posterior fossa tumors
HYPERTENSIVE ENCEPHALOPATHY
• Coarctation of aorta
• Nephritis
• Vasculitis
• Pheochromocytoma
ISCHEMIA
• Hypoplastic left side of heart
• Shunting lesions
• Aortic stenosis
• Cardiovascular collapse (any cause)
PURPURIC CAUSES
• Disseminated intravascular coagulation
• Hemolytic-uremic syndrome
• Leukemia
• Thrombotic purpura
HYPERCAPNIA
• Cystic fibrosis
• Bronchopulmonary dysplasia
• Congenital lung anomalies
NEOPLASM
• Medulloblastoma
• Glioma of brainstem
• Posterior fossa tumors
DRUGS/TOXINS
• Maternal sedation
• Alcohol
• Any drug
• Lead
• Salicylism
• Arsenic
• Pesticides
ELECTROLYTE ABNORMALITIES
• Hypernatremia (diarrhea, dehydration, salt poisoning)
• Hyponatremia (syndrome of inappropriate antidiuretic hormone [SIADH], androgenital syndrome, gastroenteritis)
• Hyperkalemia (renal failure, salicylism, androgenitalism)
• Hypokalemia (diarrhea, hyperaldosteronism, salicylism, diabetic ketoacidosis [DKA])
• Hypocalcemia (vitamin D deficiency, hyperparathyroidism)
• Severe acidosis (sepsis, cold injury, salicylism, DKA)
HYPOGLYCEMIA
• Birth injury or stress
• Diabetes
• Alcohol
• Salicylism
• Hyperinsulinemia
• Iatrogenic
POSTSEIZURE
• Renal causes: nephritis, hypoplastic kidneys
• Hepatic causes: acute hepatitis, fulminant hepatic failure, inborn metabolic errors, bile duct atresia
ANOXIA
• Birth asphyxia
• Carbon monoxide (CO) poisoning
• Croup/epiglottitis
• Meconium aspiration
INFECTION
• Hemolysis
• Blood loss
• Hydrops fetalis
• Meningoencephalitis
• Sepsis
• Postimmunization encephalitis
INCREASED INTRACRANIAL PRESSURE
• Anoxia
• Inborn metabolic errors
• Toxic encephalopathy
• Reye’s syndrome
• Head trauma/intracranial bleed
• Hydrocephalus
• Posterior fossa tumors
HYPERTENSIVE ENCEPHALOPATHY
• Coarctation of aorta
• Nephritis
• Vasculitis
• Pheochromocytoma
ISCHEMIA
• Hypoplastic left side of heart
• Shunting lesions
• Aortic stenosis
• Cardiovascular collapse (any cause)
PURPURIC CAUSES
• Disseminated intravascular coagulation
• Hemolytic-uremic syndrome
• Leukemia
• Thrombotic purpura
HYPERCAPNIA
• Cystic fibrosis
• Bronchopulmonary dysplasia
• Congenital lung anomalies
NEOPLASM
• Medulloblastoma
• Glioma of brainstem
• Posterior fossa tumors
DRUGS/TOXINS
• Maternal sedation
• Alcohol
• Any drug
• Lead
• Salicylism
• Arsenic
• Pesticides
ELECTROLYTE ABNORMALITIES
• Hypernatremia (diarrhea, dehydration, salt poisoning)
• Hyponatremia (syndrome of inappropriate antidiuretic hormone [SIADH], androgenital syndrome, gastroenteritis)
• Hyperkalemia (renal failure, salicylism, androgenitalism)
• Hypokalemia (diarrhea, hyperaldosteronism, salicylism, diabetic ketoacidosis [DKA])
• Hypocalcemia (vitamin D deficiency, hyperparathyroidism)
• Severe acidosis (sepsis, cold injury, salicylism, DKA)
HYPOGLYCEMIA
• Birth injury or stress
• Diabetes
• Alcohol
• Salicylism
• Hyperinsulinemia
• Iatrogenic
POSTSEIZURE
• Renal causes: nephritis, hypoplastic kidneys
• Hepatic causes: acute hepatitis, fulminant hepatic failure, inborn metabolic errors, bile duct atresia
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Symptoms and Signs – Differential Diagnosis of Condyloma Acuminatum
• Verrucous carcinoma
• Syphilis
• Seborrheic keratosis
• Lichen planus
• Erythroplasia of Queyrat
• Dysplastic warts
• Bowenoid papulosis
• Abnormal anatomic variants or skin tags around labia minora and introitus, pearly penile papules
• Verrucous carcinoma
• Syphilis
• Seborrheic keratosis
• Lichen planus
• Erythroplasia of Queyrat
• Dysplastic warts
• Bowenoid papulosis
• Abnormal anatomic variants or skin tags around labia minora and introitus, pearly penile papules
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Symptoms and Signs – Differential Diagnosis of Congenital Adrenal Hyperplasia
• Addison’s disease
• Adrenocortical carcinoma
• Androgen resistance syndromes
• Leydig cell tumors
• Mixed gonadal dysgenesis
• Pituitary adenoma
• Polycystic ovary syndrome
• Precocious puberty
• Pseudohermaphroditism
• Testicular carcinoma
• Addison’s disease
• Adrenocortical carcinoma
• Androgen resistance syndromes
• Leydig cell tumors
• Mixed gonadal dysgenesis
• Pituitary adenoma
• Polycystic ovary syndrome
• Precocious puberty
• Pseudohermaphroditism
• Testicular carcinoma
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Symptoms and Signs – Differential Diagnosis of Congestive Heart Failure
• Venous occlusive disease
• Pulmonary embolism
• Pneumonia
• Nephrotic syndrome
• Hypothyroidism
• Heroin overdose
• Cirrhosis
• Chronic obstructive pulmonary disease (COPD), asthma
• Acute respiratory distress syndrome (ARDS)
• Venous occlusive disease
• Pulmonary embolism
• Pneumonia
• Nephrotic syndrome
• Hypothyroidism
• Heroin overdose
• Cirrhosis
• Chronic obstructive pulmonary disease (COPD), asthma
• Acute respiratory distress syndrome (ARDS)
