1. JEOPARDY Visual Diagnosis
Pennsylvania Coalition of Nurse Practitioners
8th Annual Conference
November 12-13, 2010

2. 100 200 300 400 500 Baby Bummers Describe This Rash Rings and Things
The Dark Side
Fingers and Toes
Potpourri
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200
300
400
500

3. Baby Bummers 100
Answer

4. Baby Bummers 100 Answer
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5. Babby Bummers 100 Neonatal Acne Erythematous papules or pustules
Resembles acne vulgaris as seen in adolescents
May be present at birth or develop in early infancy
Usually on cheeks, occasionally affects chin and forehead
Etiology not clearly defined – may be due to hormonal stimulation of sebaceous glands that have not yet involuted
No treatment necessary in most cases

6. Baby Bummers 200
Answer

7. Seborrheic Dermatitis
Baby Bummers 200 Answer
Seborrheic Dermatitis
In newborns and infants often begins in 1st 12 weeks of life
May start with scaly dermatitis of scalp (cradle cap)
May spread over face including the forehead, ears, eyebrows, nose and back of head
Erythematous, greasy, salmon colored, and sharply marginated oval scaly lesions may involve other parts of the body
Prognosis is good – some clear in 3 to 4 weeks, even without treatment and most clear spontaneously by 8 to 12 months of age
Rx: apply baby or mineral oil to scalp, leave on overnight, remove scales with soft baby brush or tooth brush in am and wash off
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8. Baby Bummers 300
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9. Eczema/Atopic Dermatitis
Baby Bummers 300 Answer
Eczema/Atopic Dermatitis
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10. Baby Bummers 400
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11. Baby Bummers 400 Answer Intertrigo Question
Erythematous rash in neck folds (or other intertriginous areas) characterized by superficial inflammation
Can become secondarily infected by yeast or bacteria
Treat like diaper rash
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12. Baby Bummers 500
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13. Erythema Toxicum Neonatorum
Baby Bummers 500 Answer
Erythema Toxicum Neonatorum
Benign, self-limited condition, etiology unknown
Blotchy, evanescent erythematous macules, sometimes with associated small papules, vesicles and pustules on erythematous base
Lesions disappear and reappear at different locations
Peak onset at 48 hours after birth, generally resolves by 5-14 days of life
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14. Describe This Rash 100
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15. Describe This Rash 100 Answer
Vesicular exanthem, “teardrop” vesicles on an erythematous base =
Varicella
All stages and sizes of lesions may be found at the same time and in the same vicinity
Eruption usually begins abruptly on the trunk, face and scalp, with successive crops of pruritic lesions – minimal involvement of distal aspect of extremities
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16. Describe This Rash 200
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17. Describe This Rash 200 Answer
Erythematous maculopapular rash
Roseola Infantum (exanthem subitum = sixth disease)
Eruption characterized by discrete rose pink macules or maculopapules 2-3 mm in diameter that fade on pressure and rarely coalesce.
Usually appears on trunk and may spread to neck, upper and lower extremities
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18. Describe This Rash 300
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19. Describe This Rash 300 Answer
Erythematous raised oval/round papules and macules, (wheals) some with central clearing, some with coalescence=
Urticaria (hives)
Typical lesions have a white palpable center of edema with a variable halo of erythema.
Vary from pinpoint sized papules to large lesions several cms in diameter
Central clearing, peripheral extension and coalescence of individual lesions result in oval, annular or bizarre serpiginous configurations
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20. Describe This Rash 400
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21. Describe This Rash 400 Answer
Small smooth topped papules around corona of penis=
Pearly Penile Papules
Lesions are located on the corona of the penis and occur in 15% of adolescent males;
Lesions are 1-3 mm in diameter; occurring in 1-5 rows
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22. Describe This Rash 500
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23. Describe This Rash 500 Answer
Greyish or yellowish white small specks on shafts of hair and erythematous papules with scabs = Lice
Pediculosis capitis (head lice) and pediculosis pubis (pubic lice)
Can have impetigo of scalp, postoccipital lymphadenopathy, dermatitis of neck, shoulders and posterior auricular areas.
Nits are small, oval whitish and measure about 0.5 mm in length
Can have erythematous papules with scabs or superinfection in GU area
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24. Rings and Things 100
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25. Rings and Things 100 Answer
Pityriasis Rosea
Acute self limited disorder-not contagious
Typically affects teens
Usually lasts 4-14 weeks
Herald patch followed by Christmas tree distribution
Symptomatic treatment for itch
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26. Rings and Things 200
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27. Rings and Things 200 Answer
Granuloma Annulare
Papules or nodules in a ring typically on the dorsum of hands and feet 1-5cm
Can occur at any age
Disappear spontaneously months to 2 years
Steroids topically not recommended because of dermal atrophy
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28. Rings and Things 300
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29. Rings and Things 300 Answer
Tinea Corporis
Annular sharply demarkated scaly patches with clear center, often pruritic
Usually 1-2 lesions
All ages
Treat with topical antifungal clotrimazole for 2-3 weeks
Organism microsporum or trichophyton
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30. Rings and Things 400
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31. Rings and Things 400 Answer
Tinea Versicolor
Multiple scaling oval patchy lesions hyper- or hypopigmented
Typically occurs in adolescents
Generally asymptomatic
Treat with selenium sulfide shampoo
Persistent lesions treat with oral ketoconazole
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32. Rings and Things 500
Answer

33. Rings and Things 500 Answer
Erythema Multiforme
Symmetric eruption on extensor surfaces of arms and legs, backs of hands and feet
Target lesions macular, urticarial, and vesiculobullous (sharply marginated)
Often preceded by herpes simplex (history of cold sores)
More severe form: Stevens Johnsons involves mucous membranes
Treatment: supportive care antihistamines
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34. The Dark Side 100
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35. The Dark Side 100 Answer Acanthosis Nigricans Question
Light brown to black verrucous hypertrophic lesions, classically on the neck, axillae and groin
Familial tendency, obese individuals
May be related to risk diabetes, insulin resistance states
Lac-hydrin and Retin A, periodic abrasion with Buff Puff
Weight loss also can help
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36. The Dark Side 200
Answer

37. The Dark Side 200 Answer Mongolian Spot Question
Deep brown to slate gray or blue-black large macular lesions
Typically over lumbosacral areas, buttocks and lower limbs
Seen in over 90% of African American infants, 81% of Asians, 70% of Hispanics, 9.6% of Whites
Usually fade by age 2 – occasionally persist into adulthood but usually disappear by age 7-13 years
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38. The Dark Side 300
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39. Congenital Pigmented Nevus
The Dark Side 300 Answer
Congenital Pigmented Nevus
Most are small (less than 1.5cm diameter) or medium (15 to 20cm) sized
Flat pale hyperpigmented macules or papules, well circumscribed lesions
Risk of developing malignant melanoma over lifetime (2.5-5%) in medium size nevus (uncertain)
REFER: very large, irregular pigment, red or blue (different colors), irregular shape, irregular surface characteristics
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40. The Dark Side 400
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41. The Dark Side 400 Answer Café au Lait Spot Question
Large round or oval, flat lesions of light brown pigmentation found in 10-20% of normal individuals
May be a sign of neurofibromatosis: 6 or more spots greater than 1.5cm in diameter
Look for axillary freckling early sign of NF- freckling called Crowe’s sign
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42. The Dark Side 500
Answer

43. Linear Epidermal Nevus
The Dark Side 500 Answer
Linear Epidermal Nevus
Linear arrangement of hypertrophic warty papules
Usually present at birth can appear during early childhood, pruritic
Chronic course resistant to therapy, may need excision if irritating
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44. Fingers and Toes 100
Answer

45. Fingers and Toes 100 Answer
Onychomycosis
Primarily caused by Trichophyton rubrans and T mentagrophytes
Topical therapy often ineffective, especially as monotherapy; may help prevent recurrence
Oral therapy with terbinafine (Lamisil), itraconazole (Sporanox); Terbinafine has pediatric dosing; treat for months, until disease-free nail is seen
All oral therapy requires periodic (q4-6 week) monitoring of CBC and LFTs
Consider referral if diagnosis unclear or for possible surgery
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46. Fingers and Toes 200
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47. Fingers and Toes 200 Answer
Plantar Wart
Black dots often visible
Caused by HPV
Seen in 7-10% of the population, highest incidence ages years of age
Warts can be spread from one person to another and auto-inoculation also can occur
Duration ranges from a few months to 5 years or more. 25% disappear spontaneously in 3-6 months
Treatment: OTC salicylic acid, duct tape?, freezing
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48. Fingers and Toes 300
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49. Fingers and Toes 300 Answer
Herpetic Whitlow
Caused by HSV-1 or HSV-2
Often associated with thumb-sucking, or occupational exposure
Primary infection can be associated with systemic symptoms
Topical acyclovir can help primary infection; oral acyclovir can decrease recurrence in patients with frequent recurrence
Can do scraping for diagnosis, avoid deep incision; always consider whitlow before incising a paronychia
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50. Fingers and Toes 400
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51. Fingers and Toes 400 Answer
Trachyonychia or Twenty-Nail Dystrophy
Longitudinal ridging and roughness of nails
Does not necessarily involve all twenty nails
Associated with psoriasis, lichen planus, alopecia areata, and eczema; Can also be genetic and unassociated with other skin disease
No treatment; treatment of skin disease does not help nail appearance; will often improve with age
Can also see nail pitting with psoriasis
Question
Nail Pitting
Lichen Planus

52. Fingers and Toes 500
Answer

53. Fingers and Toes 500 Answer
Melanonychia Striata or Longitudinal Melanonychia
Longitudinal hyperpigmentation of nail matrix
Very common in dark-skinned people, often on multiple nails (77% of blacks by age 20 years, and it is seen in 90% of blacks by the fifth decade of life)
Refer to dermatology for evaluation for melanoma if: light-skinned patient, found on single nail, pigmentation of proximal nail fold
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54. Potpourri 100
Answer

55. Potpourri 100 Answer Papular Urticaria Question
Chronic or recurrent papular eruption caused by sensitivity reaction to the bites of mosquitoes, fleas, bedbugs and other insects
Primarily seen in children between 2 and 7 years old
Lesions occur on any part of the body but tend to be grouped in clusters on exposed areas, particularly the extensor surfaces of extremities
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56. Potpourri 200
Answer

57. Potpourri 200 Answer Keratosis Pilaris Question
Chicken-skin appearance typically on outer aspect of arms and legs but also on the trunk, buttocks and cheeks
Often seen in association with atopic dermatitis
Treatment with Eucerin Plus, emollients, 5-10% salicylic acid in a moisturizing cream such as Aquaphor
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58. Potpourri 300
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59. Erythema Infectiousum =Fifth Disease
Potpourri 300 Answer
Erythema Infectiousum =Fifth Disease
Caused by human parvovirus B19 which is associated with aplastic crisis in sickle cell patients and risk for hydrops fetalis
Peak incidence: age 3-12 years of age
Three stages:
Erythematous malar blush “slapped cheek”: contagious stage
Erythematous maculopapular eruption on the extensor surfaces of extremities next day
Rash fades with central clearing creating a reticulated pattern which lasts 3-24 days
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60. Potpourri 400
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61. Potpourri 400 Answer Scarlet Fever Question
Diffuse punctuate erythematous eruption with a sandpaper-like texture
Etiology: group A Beta hemolytic strep and other bacteria
Peak incidence: ages 1- to 10- years
Associated symptoms; sore throat, fever, headaches, vomiting and malaise
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62. Potpourri 500
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63. Potpourri 500 Answer Measles Question
“morbilliform” rash – erythematous maculopapular eruption, first on the scalp and hairline, the forehead, the area behind the ear lobes and then upper part of the neck. Then it spreads downward to involve the face, neck, upper extremities and trunk and continues until it reaches the feet by the 3rd day. Rash fades in same order that is appeared
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