Other

-Acanthosis Nigricans-

-diffuse thickening and hyperpigmentation of the skin
-usually the axillae or body folds
-can be associated with hereditary, obesity, endocrine problems, meds, or malignancy
-caused by hyper secretion of pituitary peptide or non specific growth effect of hyperinsulinemia
-treatment is targeted at treating underlying disorder


-Burns-

-Rule of 9's-

-9% for the head and neck
-18% for the front torso
-18% for the back torso and buttocks
-9% for each lower extremity on front
-9% for each lower extremity on back portion
-9% for each arm
-1% for genitals



-Parkland Formula- to determine fluid needs for the first 24 hours in a burn victim

4 x weight in kg x TBSA burn = fluid requirements for the first 24 hours.

Give first half over the first 8 hours and give the second half over the last 16 hours.  Simple divide the total over the amount of hours necessary to give the fluids and that gives you the hourly rate.


-Classification of Burns-

-First degree Burn:

-Includes only the outer layer of skin, the epidermis

-Skin is usually red and very painful
-Equivalent to superficial sunburn without blisters
-Dry in appearance
-Healing occurs in 3-5 days, injured epithelium peels away from the healthy skin




-Second degree: Can be classified as partial or full thickness.

-Partial thickness
-Blisters can be present
-Involve the entire epidermis and upper layers of the dermis
-Wound will be pink, red in color, painful and wet appearing
-Wound will blanch when pressure is applied
-Should heal in several weeks (10-21 days) without grafting, scarring is usually minimal

-Full thickness
-Can be red or white in appearance, but will appear dry.
-Involves the destruction of the entire epidermis and most of the dermis
-Sensation can be present, but diminished
-Blanching is sluggish or absent
-Full thickness will most likely need excision & skin grafting to heal

-Third degree:

-All layers of the skin is destroyed
-Extend into the subcutaneous tissues
-Areas can appear, black or white and will be dry
-Can appear leathery in texture
-Will not blanch when pressure is applied
-No pain


-Fourth degree: Full thickness that extends into muscle and bone.

-Hidradenitis Suppurativa-

-chronic suppurativa often cicatricial disease of the apocrine gland axillae and the anogenital regain
-sometimes associated with nodulocystic acne and pilonidal sinuses
-unknown cause
-there is keratinous plugging of the apocrine duct, dilation of the hair follicle, and severe inflammatory changes of the single apocrine gland.
-Bacterial growth causes dilated duct
-ruptured duct or gland causes extension of inflammation or infection which cause tissue destruction and then this leads to ulceration, fibrosis and sinus tract formation
-treatment is incision and drainage and to excise recurrent fibrotic nodules and tracts


-Lipoma-

-benign subcutaneous tumors that are rounded, lobulated, and moveable over the overlying skin
-many are small but can be greater than 6 cm
-occur mainly on the neck, trunk and extremities
-most of the time just observe.  Rarely excise unless causing pain or discomfort


-Epithelial Inclusion Cyst-

-occurs secondary to traumatic implantation of the epidermis within the dermis.
-traumatically grafted epidermis grows in the dermis with accumulation of keratin within the cyst cavity
-treatment is excision



-Melasma-

-an acquired light or dark brown hyperpigmentation that occurs in the exposed areas to sunlight
-can be associated with pregnancy, oral contraceptives, or idiopathic
-pathogenesis is unknown
-treatment 3% hydroquinone solution in combination of tretinoin gel or 4% hydroquinone solution and glycolic acid
-need to use high SPF sunblock


-Pilonidal Disease-

-Pilonidal disease is a chronic infection of the skin in the region of the buttock crease
-The condition results from a reaction to hairs embedded in the skin, commonly occurring in the cleft between the buttocks.
-The disease is more common in men than women and frequently occurs between puberty and age 40. -It is also common in obese people and those with thick, stiff body hair.
-Treatment is incision and drainage with antibiotics.  Usually poly-microbial
-Definitive treatment is excision


-Pressure Ulcers-

-develop over body support surfaces over bony prominences as a result of the external compression of the skin, shear forces, or friction which produce ischemic changes or necrosis
-treatment is prevention.  Reposition patient every 2 hours.  Pad ulcer prone areas and massage them
-clean areas and keep free of urine and feces
-mobilize patient if possible

-Stages of Pressure Ulcers-
Stage I: Non-blanchable erythema
Intact skin with non-blanchable redness of a localized area usually over a bony prominence. Darkly pigmented skin may not have visible blanching; its color may differ from the surrounding area. The area may be painful, firm, soft, warmer or cooler as compared to adjacent tissue. Category I may be difficult to detect in individuals with dark skin tones.

Stage II: Partial thickness
Partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough. May also present as an intact or open/ruptured serum-filled or sero-sanginous filled blister.Presents as a shiny or dry shallow ulcer without slough or bruising. This category should not be used to describe skin tears, tape burns, incontinence associated dermatitis, maceration or excoriation.

Stage III: Full thickness skin loss
Full thickness tissue loss. Subcutaneous fat may be visible but bone, tendon or muscle are not exposed. Slough may be present but does not obscure the depth of tissue loss. May include undermining and tunneling. The depth of a Stage III pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and Stage III ulcers can be shallow. In contrast, areas of significant adiposity can develop extremely deep Stage III pressure ulcers. Bone/tendon is not visible or directly palpable.

Stage IV: Full thickness tissue loss
Full thickness tissue loss with exposed bone, tendon or muscle. Slough or eschar may be present. Often includes undermining and tunneling. The depth of a Stage IV pressure ulcer varies by anatomical location. The bridge of the nose, ear, occiput and malleolus do not have (adipose) subcutaneous tissue and these ulcers can be shallow. Stage IV ulcers can extend into muscle and/or supporting structures (e.g., fascia, tendon or joint capsule) making osteomyelitis or osteitis likely to occur. Exposed bone/muscle is visible or directly palpable.


-Urticaria-

-IgE mediated complement mediated to physical stimuli
-acute urticaria is less than 30 days.
-chronic urticaria-greater than 30 days
-management is steroids, H1 and H2 blockers.  Subcutaneous epinephrine for hypotension, airway compromise.  Albuterol for bronchospasm.  Consider observation for severe systemic symptoms


-Vitiligo-

-characterized by development of totally white macules and the complete absence of melanocytes
-associated with thyroid disease and many other medical conditions
-management sunscreens and cosmetic coverup
-Regimentation-  topical steroids, UVA, systemic UVA