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Intertrigo:
A 68 year old female adult with pendulous breasts complains of
burning under her right breast. The nurse practitioner observes
a malodorous discharge with mild maceration under both
breasts. What is this? Intertrigo.
This is not unusual in adults of any age. This is common in areas
between skin folds, under the breasts, between the scrotum and
inner thigh, or between the toes. These are moist lesions with
maceration and possible skin loss. It is easily treated if the skin
can be separated from touching the adjoining skin and the area
can be kept dry. A topical powder with an antifungal would likely
resolve this if used twice daily for 7-14 days. A diagnosis of
diabetes should be considered if this is resistant to treatment or
if it recurs.
Lyme Disease:
Many factors must be present for a patient to develop Lyme
Disease from a tick bite. First, the tick must belong to Ixodes
species. The tick must have been attached for at least 48-72
hours before disease can be spread. Time of year, stage of
organism's development, and others all affect transmission.
There is no need for prophylactic treatment in this case because
the tick has not been present long enough, though, many
patients will feel antibiotics are necessary.
The first serologic test for Lyme disease is the ELISA. If this is
positive, it should be confirmed. In this case, it was confirmed by
a Western blot and it is positive. This patient can be diagnosed
with Lyme disease. The appropriate treatment for treatment of
erythema migrans is doxycycline, amoxicillin, or cefuroxime for
21 days. All three medications were found to be of equal efficacy.
A detailed history should always precede testing for Lyme
Disease. The red circle with the white center is likely erythema
migrans (EM). EM is the characteristic skin lesion of Lyme
Disease (and other illnesses) and usually occurs within one
month following the tick bite. Many learned authorities including
the Infectious Diseases Society of America conclude that
individuals should not be screened/tested for Lyme disease
unless they have a high probability of having Lyme disease. In
this case, historical features coupled with physical exam support
the diagnosis, and thus screening. The most common initial
serologic test for screening is an ELISA. If it is positive, it should
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Shingles:
This patient has been diagnosed with shingles[vesicular rash that
burns & itches]. This can be a painful neuritis. Shingles is treated
with an oral antiviral agent preferably within 72 hours of onset of
the symptoms. Treating shingles with an oral antiviral shortens
the severity and duration of shingles. It may also help decrease
the incidence of a post-herpetic neuralgia.
Pt Dx: shinglesRx: oral antiviral agent; An oral antiviral
agent such as acyclovir, famciclovir, valacyclovir should be
prescribed, especially if it can be initiated within 72 hours after
the onset of symptoms. The addition of oral corticosteroids to
oral antiviral therapy demonstrates only modest benefit. Adverse
events to therapy are more commonly reported in patients
receiving oral corticosteroids. There is no evidence that
corticosteroid therapy decreased the incidence or duration of
post-herpetic neuralgia or improved quality of life.
Corticosteroids should be limited to use in patients with acute
neuritis who have not derived benefit from opioid analgesics.
Characterizes shinglesunilateral dermatomal rash.
i. Shingles is herpes zoster. It characteristically affects a
single dermatome. Grouped vesicles on an erythematous
base can be seen in some patients with shingles, but this is
not unique to shingles. In fact, it is typical in many viral
infections. Crusting may be seen with shingles, chicken
pox, or impetigo. Pain, burning, and itching describes the
symptoms that some patients have with shingles, but not
all patients report itching with shingles.
Herpes viruses are the causative agents in shingles, chickenpox,
genital herpes, and oral fever blisters. Diagnosis is usually made
on clinical presentation. However, in questionable cases, lab
tests may be employed. A Tzanck preparation is a rapid test used
to diagnose infections due to herpes viruses. Cells taken from a
blisters fluid are smeared on a slide and stained with a Wrights
stain or the fluid can be used for other methods of testing. DFA is
the most common test employed for shingles diagnosis because
it can be rapidly performed and offers results in about 90
minutes. PCR may be performed on skin scrapings, serum or
blood for herpetic diagnosis. CBC may indicate a patient with a
viral infection, but is non-specific for herpetic infections.
Dx: ShinglesTx with oral antivial & pain medication
i. The primary goal of antiviral therapy in a patient diagnosed
with shingles is to reduce the risk of, or severity of post-
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Main difference between cellulitis and erysipelas is the: layer of
skin involvement.
a. Erysipelas and cellulitis both cause skin erythema, edema,
warmth. However, erysipelas involves the upper dermis and
superficial lymphatics; cellulitis involves the deeper dermis and
subcutaneous fat. Erysipelas is usually caused by Streptococcus;
cellulitis may be caused by Staphylococcus and less commonly
by Streptococcus.
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Cellulitis:
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