Condition

Morphology/Distribution    

Management

Candida

Mucous membrane:

- Thrush (white adherent exudate)

- Chronic atrophic (erythematous patch)

Cutaneous:

- Usually in intertriginous areas

- Erythematous, erosive patch with satellite pustules

Nails:

- Can affect periungual areas and nails

- Prolonged water exposure is a risk factor

Topicals:

- Nystatin

- Azole antifungals

- Note: terbinafine does not cover candida

Systemic:

- Fluconazole

- Itraconazole

Eczema

(atopic dermatitis)

Associated features:

- Asthma

- Allergic rhinitis

- Early-onset

- Family history

Infants/children:

- Face, neck, extensor surfaces

Adults:

- Flexural surfaces

Acute lesions:

- Erythematous, ill-defined patches and plaques with serous crust

Chronic lesions:

- Hyperpigmented plaques with accentuated skin markings (lichenification)

Gentle skincare:

- Short, lukewarm showers

- Pat dry gently

- Immediate moisturization with Vaseline or Aquaphor while damp

Topical steroids:

- Choice of potency depends on the age of the patient, anatomic site, the severity of the lesion

- Refer to the steroids section for choices

Oral immunosuppressants:

- For disease resistant to topical treatments

Herpes simplex

Prodrome:

- Lesions may be asymptomatic or may sting/itch

- Preceding SxS include fever, LAD, anorexia

Skin lesions:

- Can be primary or recurrent

- Mouth and lips most common sites

- Also affects the vulva, vagina, cervix, glans penis, perineum, buttocks

- Grouped vesicles on an erythematous base

- Quick progression to erosions and crust (may not see vesicles on an exam)

- Scalloped borders

Genital Primary Infection:

- Acyclovir 200 mg 5x/d x10d or 400 mg po tid x 10d

- Famciclovir 250 mg po tid x 10d

- Valacyclovir 1g po bid x 10d

Genital Recurrent infection:

- Acyclovir 200 mg 5x/d x 5d or 400 mg po tid x5d

- Famciclovir 1g po bid x 1d or 125 mg po bid x5d

- Valacyclovir 500 mg po bid x 3-5d

Suppressive:

- Acyclovir 400 mg po bid

- Famciclovir 250 mg po bid

- Valacyclovir 500 mg po daily

Immunocompromised +/- disseminated:

- Acyclovir 5-8 mg/kg IV q8h x 7-10d

Herpes zoster

- Due to reactivation of VZV after primary varicella infection

- Prodrome of intense pain, pruritus, hyperesthesia

- Distributed along sensory dermatome; respects the midline

- Trunk, face, neck, extremities

- Crops of grouped vesicles or crusted papules

Complications:

- Postherpetic neuralgia

- Ophthalmic zoster

- Ramsay-Hunt syndrome

Disseminated zoster:

- >20 lesions outside primary and two contiguous dermatomes

- Occurs in 10% of immunocompromised patients

Immunocompetent:

- Acyclovir 800 mg po 5x/d x 7-10d

- Famciclovir 500 mg po tid x 7d

- Valacyclovir 1 g po tid x 7d

Immunocompromised +/- disseminated:

- Acyclovir 10-12 mg/kg IV q8h x 7-10d

Zoster Vaccine

- One-time dose for people older than 60, whether or not they have a history of herpes zoster infection

- Reduces zoster incidence, severity, and post-herpetic neuralgia

Paronychia

- Swelling, erythema, and pain of nail folds

- Acute: most commonly due to Staph aureus or GAS

- Recurrent episodes: suspect HSV

- Chronic: suspect Candida

Acute:

- Warm compresses

- Drainage of abscess

- Oral abx according to culture results

- Systemic antivirals if HSV present

Chronic:

- Topical steroids +/- antifungal

Pityriasis

rosea

- Herald patch on trunk

- Annular papules and plaques with central fine scaling and collarette of trailing scale

- Christmas-tree distribution on the posterior trunk (follows Langer’s lines)

- Spontaneous remission

- Sunlight

- Symptomatic treatment with topical steroids

- Remember to rule out secondary syphilis

Condition

Description

Management

Rosacea

Four major subtypes:

Erythematotelangiectatic:

- Central facial erythema

- Recurrent skin flushing

- Dryness, sensitivity

- Telangiectasias

Papulopustular (inflammatory):

- Central facial erythema

- Erythematous papules and pustules

Phymatous:

- Thickening of skin over nose, chin, forehead, ears

Ocular:

- Can present as multiple eye symptoms (eg foreign body, burning, stinging, dryness, blurred vision)

Prevention:

- Avoid triggers (e.g., EtOH, spicy foods, sunlight, extreme temperatures, vasodilatory meds)

Topical therapy (first-line in bold):

- Metronidazole 0.75% or 1% daily or bid

- Azelaic acid 15-20% bid

- Ivermectin 1% cream daily

- Benzoyl peroxide/clindamycin daily

- Tretinoin 0.025% to 0.1% daily

Systemic therapy (trial 4-12 weeks):

- Tetracycline 250-500 mg bid

- Doxycycline 50-100 mg bid

- Minocycline 50-100 mg bid

- If resistant to oral antibiotics, can refer to dermatology for consideration of isotretinoin

For telangiectasias:

- Topical and oral therapies mostly ineffective

- Vascular-targeted lasers or light therapy effective

For rhinophyma:

- Ablative laser or electrosurgery

For ocular:

- Refer to ophtho

Seborrheic dermatitis

- Limited to periods of life when sebaceous glands are active (infantile and adult forms; rare in prepubertal children)

- Distributed over areas rich in sebaceous glands-scalp, face, nasolabial folds, eyebrows, ears, chest, intertriginous areas

- Erythematous patches with greasy, diffuse scale

- Can rarely be erythrodermic

- More common in HIV (can be more extensive and severe) and Parkinson’s

- First-line: antifungal shampoos ketoconazole 2% or ciclopirox 1% Alternative fungal shampoos include zinc pyrithione 1% or selenium sulfide 2.5%.

- Use daily or at least two or three times per week for several weeks until remission achieved; rotate among classes

-

- Topical Ketoconazole 2% daily or bid x 4 weeks

- Topical low dose steroids, calcineurin inhibitors

- Severe/refractory: oral itraconazole 200mg qD x 7d

Tinea versicolor

- Distributed over seborrheic areas (neck, trunk, upper arms)

- Annular hypo- or hyperpigmented macules with overlying fine scale

- KOH prep: “spaghetti and meatballs” representing fungal hyphae & yeast (Malassezia furfur)

Topicals (first-line):

- Selenium sulfide 2.5% shampoo daily for 1 week; leave on for 10 min

- Ketoconazole 2% cream daily for 2weeks

Systemic (severe disease):

- Itraconazole 200 mg daily x 5 days

- Fluconazole 300mg x1; repeat at 1 week

Verrucae (warts)

- ~100 different HPV genotypes can cause warts

Cutaneous infection

- Common, plantar, palmar, flat, mosaic, and butcher’s warts

- Classified by morphology and anatomic location

Mucosal infection

- Condyloma acuminata (genital warts) found on the external genitalia, perineum, perianal region

- Usually caused by HPV types 6 and 11

- Persistent infection by HPV types 16 and 18 can lead to cervical, vaginal, vulvar, penile, anal cancer

Verrucous carcinomas

- Caused by HPV 6 and 11

- Locally invasive and rarely metastasize

- Buschke-Lowenstein tumor: giant condyloma acuminata

- Oral florid papillomatosis

- Epithelioma cuniculatum of the sole

Overview

- Broadly categorize as destructive or immunomodulatory

- Everything works about 20% of the time

- There is no evidence that treatment prevents subsequent sexual transmission of genital warts

- Tools used for paring down warts (eg, nail file, pumice stone, etc.) should not be used on normal skin or nails to avoid spreading the virus

Destructive (first-line in bold)

- Cryotherapy

- Salicylic acid 20-50% daily x 12 weeks

- Bleomycin- refractory (refer to derm)

- 5-fluorouracil- refractory

- Cantharidin

- Laser

- Excision

Immunomodulatory

- Works poorly in immunosuppressed patients

- Squaric acid

- DNCB

- High dose cimetidine and other H2 antagonists

- Imiquimod (genital warts only)

Condition

Description

Management

Rosacea

Four major subtypes:

Erythematotelangiectatic:

- Central facial erythema

- Recurrent skin flushing

- Dryness, sensitivity

- Telangiectasias

Papulopustular (inflammatory):

- Central facial erythema

- Erythematous papules and pustules

Phymatous:

- Thickening of skin over nose, chin, forehead, ears

Ocular:

- Can present as multiple eye symptoms (eg foreign body, burning, stinging, dryness, blurred vision)

Prevention:

- Avoid triggers (e.g., EtOH, spicy foods, sunlight, extreme temperatures, vasodilatory meds)

Topical therapy (first-line in bold):

- Metronidazole 0.75% or 1% daily or bid

- Azelaic acid 15-20% bid

- Ivermectin 1% cream daily

- Benzoyl peroxide/clindamycin daily

- Tretinoin 0.025% to 0.1% daily

Systemic therapy (trial 4-12 weeks):

- Tetracycline 250-500 mg bid

- Doxycycline 50-100 mg bid

- Minocycline 50-100 mg bid

- If resistant to oral antibiotics, can refer to dermatology for consideration of isotretinoin

For telangiectasias:

- Topical and oral therapies mostly ineffective

- Vascular-targeted lasers or light therapy effective

For rhinophyma:

- Ablative laser or electrosurgery

For ocular:

- Refer to ophtho

Seborrheic dermatitis

- Limited to periods of life when sebaceous glands are active (infantile and adult forms; rare in prepubertal children)

- Distributed over areas rich in sebaceous glands-scalp, face, nasolabial folds, eyebrows, ears, chest, intertriginous areas

- Erythematous patches with greasy, diffuse scale

- Can rarely be erythrodermic

- More common in HIV (can be more extensive and severe) and Parkinson’s

- First-line: antifungal shampoos ketoconazole 2% or ciclopirox 1% Alternative fungal shampoos include zinc pyrithione 1% or selenium sulfide 2.5%.

- Use daily or at least two or three times per week for several weeks until remission achieved; rotate among classes

-

- Topical Ketoconazole 2% daily or bid x 4 weeks

- Topical low dose steroids, calcineurin inhibitors

- Severe/refractory: oral itraconazole 200mg qD x 7d

Tinea versicolor

- Distributed over seborrheic areas (neck, trunk, upper arms)

- Annular hypo- or hyperpigmented macules with overlying fine scale

- KOH prep: “spaghetti and meatballs” representing fungal hyphae & yeast (Malassezia furfur)

Topicals (first-line):

- Selenium sulfide 2.5% shampoo daily for 1 week; leave on for 10 min

- Ketoconazole 2% cream daily for 2weeks

Systemic (severe disease):

- Itraconazole 200 mg daily x 5 days

- Fluconazole 300mg x1; repeat at 1 week

Verrucae (warts)

- ~100 different HPV genotypes can cause warts

Cutaneous infection

- Common, plantar, palmar, flat, mosaic, and butcher’s warts

- Classified by morphology and anatomic location

Mucosal infection

- Condyloma acuminata (genital warts) found on the external genitalia, perineum, perianal region

- Usually caused by HPV types 6 and 11

- Persistent infection by HPV types 16 and 18 can lead to cervical, vaginal, vulvar, penile, anal cancer

Verrucous carcinomas

- Caused by HPV 6 and 11

- Locally invasive and rarely metastasize

- Buschke-Lowenstein tumor: giant condyloma acuminata

- Oral florid papillomatosis

- Epithelioma cuniculatum of the sole

Overview

- Broadly categorize as destructive or immunomodulatory

- Everything works about 20% of the time

- There is no evidence that treatment prevents subsequent sexual transmission of genital warts

- Tools used for paring down warts (eg, nail file, pumice stone, etc.) should not be used on normal skin or nails to avoid spreading the virus

Destructive (first-line in bold)

- Cryotherapy

- Salicylic acid 20-50% daily x 12 weeks

- Bleomycin- refractory (refer to derm)

- 5-fluorouracil- refractory

- Cantharidin

- Laser

- Excision

Immunomodulatory

- Works poorly in immunosuppressed patients

- Squaric acid

- DNCB

- High dose cimetidine and other H2 antagonists

- Imiquimod (genital warts only)