Dermatology Skin Conditions

Acne Vulgaris

RF: m/c dx in America
teenagers (puberty)
severe→male
more common→female

E: propionibacterium acnes
inflammation
androgen+receptors
excess sebum
plugging of follicle

CM:
sebaceous gland activity areas:
face
chest
back
shoulders

comedonal:
whiteheads (closed comedones)
blackheads (open comedones)

inflammatory:
papules
pustules

nodulocystic:
comedones/inflammatory lesions+large nodules with/without scarring

TX:
topical
comedonal+inflammatory→retinoids:
andapalene (weak)
tretinoin
tazarotene (weak)

inflammatory acne+p. acnes→abx:
clindamycin
erythromycin
dapsone

p. acnes:
benzoyl peroxide

oral
inflammatory+p. acnes→abx:
doxycycline
minocycline

androgen-receptors→hormonal tx:
contraceptive pills
spironolactone

excess sebum:
isotretinoin
-teratogenic
-monthly pregnancy tests
-Ipledge registration
-monthly bloodwork
-not for hormonal acne
-15+ y/o (fully developed skin glands)

P: POC→post-inflammatory hyperpigmentation→tx aggressively

Hiradentitis Suppurativa

E: chronic
puberty
apocrine gland sites
-axillae
-groin

CM: tender+recurrent inflammatory nodules/abscesses
open comedomes
sinus tracts
purulent drainage

DX: bx culture

TX:
NP:
decrease weight
stop smoking
incision+drainage
excision+laser surgery

MX:
1st line: topical tetracycline
chlorhexidine
IL triamcinolone
prednisone
humira
cosentyx

Folliculitis

PP: inflamed hair follicles
-superficial
-deep
anywhere there are hairs

E: infection
occlusion
irritation
s. aureus
malassezia

CM: tender red perifollicular papule
with surface pustule

TX:
s. aureus:
PO cephalexin
PO cefadroxin
topical mupirocin

malassezia:
econazole
ketoconazole
selenium sulfide

systemic: fluconazole

Hot Tub Folliculitis

RF: hot tub use

E: p. aeruginosa

CM: red papules on lower body/lower regions

TX: PO ciprofloxacin
topical gentamicin

Rosacea

PP: persistent erythema of convex surfaces of face
includes nasolabial fold

E: unknown
steroids (too long/strong on face)

CM:
phymatous (nose)
ocular (eye)
papulopustular (papules/pustules)
erythematotelangioetic (flushing)

DX: biopsy
ANA

TX:

NP:
avoid spicy foods
avoid alcohol
gentle skin care regimen
blood vessels→laser surgery
rhinophyma→surgery+CO2 laser

MX:
topical:
1st line: metronidazole
azelaic acid
sulfacetamide
ivermectin

systemic:
doxycycline 20mg BID
doxycycline 40 mg QD

Seborrheic Dermatitis

PP: abnormal inflammatory reaction to malassezia in sebum-rich areas

E: malassezia
sebum rich areas
-scalp
-central face

CM: greasy scale on erythematous base
dandruff
peds: “cradle cap”
POC: lighter in color+no redness

TX:
peds:
NP: reassurance
outgrow by 6 months

MX: aquaphor
coconut oil

adults:
short term: hydrocortisone cream
long term: ketoconazole cream

Erythema Multiforme/SJS/TEN

EM minor:
PP: sharply marginated erythematous macules→raised+edematous over 1-2 days
ring of erythema forms→target shape

E: m. pneumonia

CM: orolabial herpetic outbreak 3-14 days before rash
no prodromal/flu-like sx

P: self-limited
1-2 weeks
common recurrence

EM major:
PP: sharply marginated erythematous macules→raised+edematous over 1-2 days
ring of erythema forms→target shape

E: m. pneumonia

CM: influenza-like sx 1-2 weeks before cutaneous lesions

P: 5% mortality rate
uncommon recurrence

SJS:
PP: EM like skin lesions
cover 10% BSA or less
mucosal involvement
-oral
-occular
-genital

E: adverse reaction to mx
-sulfonamides
-anticonvulsants

TEN:
PP: cover 30% or greater BSA
skin sloughs off body

E: adverse reaction to mx
-sulfonamides
-anticonvulsants

DX: clinical assessment
biopsy→does not distinguish
neutropenia
BUN (high→bad prognosis)

TX:
EM:
NP:
stop mx
tx underlying cause

MX:
antihistamines
mild topical steroids

SJS/TEN:
admit to hospital
TEN→burn unit

Alopecia Etiology

good hx needed

non-scarring:
hormonal
tight hair buns
immune system (alopecia areata)
telogen effluvium (systemic cause)
-pregnancy
-COVID
-mx
-nutrition deficiency

scarring:
follicles destroyed by inflammation
-ex: discoid lupus

Alopecia Areata

E: autoimmune dx
-totalis (scalp)
-universalis (whole body)

CM: non-scarring
1+ round/oval patches (1-5 cm)
exclamation point hairs

TX:
localized:
intralesional/topical triamcinolone

extensive:
topical immunotherapy
PO JAK inhibitors
off-label tx

Androgenic Alopecia

E: genetics
sensitivity to DHT (dihydrotestosterone)

CM:
male:
front temporal areas+vertex of scalp

female:
crown of head
retaining frontal hairline

TX:
male:
topical/PO minoxidil
PO spironolactone

female:
topical minoxidil
PO finasteride

Paronychia

PP: inflammation of the nail fold

E: bx
secondary candida colonization

CM: erythema
swelling
throbbing pain
pustular drainage

TX: topical+systemic abx

Tinea Unguim/Onchymycosis

PP: fungal infection of nails

E: dermatophytes

CM: subungual hyperkeratosis
scaling
yellow discoloration
onycholysis (end of nail lifts up)

DX: clinical
KOH
culture
nail plate biopsy

TX:
topical ciclopirox QD x 1 year
terbinafine QD x 3 months
-mx interactions
-mtr liver enzymes

Erythema Infectiosum (5th Disease)

E: parvovirus B19

CM: mild fever+headache→red slapped cheeks x 2-4 days→reticulated/lacy patch on limbs/trunk

TX: none

C: spontaneous abortion
polyarhtorpathy

Hand Foot and Mouth Disease

E: coxsackie virus
common
mild
short-lasting

contagious:
direct contact
nasal
oral secretions
fecal contamination

CM: flat pink patches→blisters on hands+feet
peel off in a week
small+painful vesicles in mouth
red macules+papules on butt/arms/genitals

TX:
don’t pop blisters
antiseptic mouthwash
maintain fluid intake
poor PO→IV fluids
painful oral ulcer→topical/PO analgesics

Rubeola/Measles

E: measles virus/morbillivirus

highly contagious:
airborne
respiratory droplets

CM: cough
coryza
conjunctivitis
gray-white papules
buccal mucosa (koplik’s spots)

high fever:
nonpruitic morbilliform rash on face→24-36 hrs→entire trunk+extremities (no palms+soles)

TX: none
prophx: measles vaccine

Cellulitis

PP: acute spreading inflammation of dermis+subcutaneous tissue

E: h. influenzae
streptococcus
staphylococcus

DX: drainage bx culture

TX:
PO dicloxacillin
PO cephalosporins
severe→IV 1st gen cephalosporin
surgery

Erysipelas

PP: superficial cellulitis of the upper dermis that extends to superficial cutaneous lymphatics

E: abrupt onset
rapid progression

CM: painful macular rash
well-defined margins
fiery red rash
face→progression to extremities

TX:
PO penicillin x 10-14 days
IV penicillin x 10-14 days
desquamates x 5-10 days

Impetigo

PP: gram-positive bx infxn

E: s. aureus
10% of peds derm
warm/humid environment
highly contagious
face
extremities

spreads:
cutaneously
systematically (rare)

CM:
bullous:
-m/c peds
-blisters (enlarge+rupture)

nonbullous:
small+easily ruptured vesicles→honey-covered crusts

DX: bx culture

TX:
NP: proper hand washing

MX: cephalexin
cefadroxil
topical mupirocin

Syphillis

PP: skin/mucous membranes→circulatory system (tertiary/late)→CNS (neurosyphillis)

E: trepodema pallidium
sexual contact
congenital

CM:
primary:
painless/indurated macule/papule
highly infectious
heals in 3-6 weeks

secondary:
several weeks after primary syphillis
persists for weeks-months
highly infectious
rough/red/non-itching papules/patches on trunk+palms+soles

latent:
asx
only shows with positive serologic test

tertiary/late:
widespread abx→rare
gummatous lesions
CV sx

neurosyphillis:
asx
or
acute syphilit meningitis
ocular involvement

congenital:
deafness
deformities
neuro impairment

DX: treponemal qualitative+nontreponemal qualitative
HIV testing
report to state department

TX: IM penicillin
doxycycline
tetracycline

C:
congenital:
stillbirth
neonatal death
infant disorders

Candidiasis

E: yeast
abx
diabetes
obesity
poor hygiene
oral infxn (1st sx of HIV)
warm/moist areas

CM:
oral: whitish plaques on erythematous base of buccal mucosa (thrush)

body:
beefy/red papules/plaques in skin folds (interigo)
satellite lesions
thick “cheesy” discharge

TX:
oral:
nystatin suspension
fluconazole
breastfeeding→tx mother’s nipples

body:
keep area dry+clean
stop mx
topical/PO antifungals

Tinea Capitis

PP: fungal infection of scalp

E: dermatophytes

CM: dry scaling
moth-eaten hair loss
inflamed mass/abscess (kerion)→untx→permanent scarring/baldness

DX: bx culture

TX:
NP: throw out hairbrush
adjunctive therapy

MX: ketoconazole shampoo
selenium sulfide shampoo
PO griseofulvin x 6 weeks-6 months

P: swollen lymph glands at sides/back of neck

Tinea Corporis/Ringworm

PP: fungal infection of body

E: dermatophytes

CM: well-demarcated annular plaque
central clearing+peripheral scale
contagious

DX: KOH prep

TX: topical econazole
topical ketoconazole

P: swollen lymph glands at sides/back of neck

Tinea Incognito

PP: potent topical/non-antifungal steroid→drives fungus deep into skin→affects hair follicles

E: dermatophytes

CM: irregular/red/scaly plaque
follicular papules
pustules→more severe→majocchi’s granuloma

TX: PO griseofulvin x 4-6 weeks

Tinea Cruris/Jock Itch

PP: fungal infection of groin+gluteal cleft

E: dermatophytes
contaminated towels/sheets
autoinnoculation

CM: scaly plaque with widespread erythema
intensely pruritic

TX:
NP: keep groin dry
weight loss

MX: topical azoles x 2-4 weeks

Tinea Manuum

PP: fungal infection of palms on hands

E: dermatophytes
primary infection→rare

CM: blisters on palms/fingers→single scale patch→infected nails

TX: topical antifungals
PO antifungals

Tinea Pedis/Athlete’s Foot

PP: fungal infection of feet

E: dermatophytes

CM: macerated scale on feet

DX: KOH
bx culture
biopsy (rare)

TX:
NP: wear protective footwear in communal areas
minimize foot moisture

MX: topical antifungals
mocacsin-type/chronic→PO antifungals

Tinea Versicolor

PP: superficial malassezia infection
not contagious

E: malassezia furfur

CM: hyper/hypopigmented oval macules
fine scale on chest+back

TX: topical ketoconazole
topical selenium sulfide

P: 1-2 months for pigment to return to normal

Pediculosis Capitis/Head Lice

PP: scalp infestation

E: head lice

CM: intense itching
posterior cervical lymphadenopathy
excoriations on scalp
nits/ova on hair

TX:
NP: remove lice+ova
nit combing (not on topical spinosad 0.9% suspension)

MX: permethrin
malathion 0.5% lotion

Scabies

PP: female mites burrow into skin+lay eggs

eruption conditions:

• length of infestation

• climate

• host’s immune status

E: sarcoptes scabiei mites
personal contact
contaminated linens+clothing

CM: pruruitic papular lesions
excoriations
s-shaped burrows

common sites:

• finger webs

• wrists

• axillae

• lower abdomen

• genitals

• buttocks

adults: scalp
face

infants: entire body

DX: surgical blade→scrape burrow→place on slide+mineral oil→examine under microscope

TX:
NP: clothing+bed lines changed+laundered thoroughly

MX:
topical permethrin 5% cream

• neck to feet

• wash over 8-10 hours later

• repeat x 1 week

PO ivermectin

• take on day 1

• repeat x 1 week

Bed Bugs

PP/E: blood-sucking human parasite
cimex lectularius
survive without eating for 1 year

RF: warmth
night
mattresses
furniture
luggage
clothing

CM:
papular urticaria:

• upon awakening

• bites in groups of 2-3

TX:
NP: extermination

MX: topical steroids
antihistamines
secondary infections→abx

Verucca Infections/Warts

PP: benign viral tumor
wart

E: HPV 16
HPV 18

CM:
common wart (verrucous vulgaris):

• solitary papule

• irregular

• scaly surface

plantar wart (verrucous plantaris):

• weight-bearing areas on feet

flat wart (verruca plana):

• multiple papules

• flat-topped

• broad-skin

• colored

veneral wart (candyloma acuminata):

• multiple/confluent papules

• irregular surface

• on genital mucosa

TX:
NP:
1st line: cryotherapy
laser surgery

MX:
1st line: topical salicylic acid
intralesional bleomycin
topical fluorouracil
topical immunotherapy

Candyloma Acuminatum/Veneral Warts

PP: benign viral tumor
genital wart

E:
cervical:
HPV 16
HPV 18
RF for dysplasia→cervical cancer

genital:
sexual contact

CM: multiple/confluent papules
irregular surface
on genital mucosa

TX:
NP:
1st line: cryotherapy
HPV vaccine
laser surgery

MX:
1st line: topical salicylic acid
topical imiquimod
intralesional bleomycin
topical fluorouracil
topical immunotherapy

Herpes Simplex

E:
HSV-1:
oral herpes
more common

HSV-2:
genital herpes
multiple sexual partners
monogamy→5-10% risk of transmission

CM:
grouped vesicles on erythematous base
recurrent cases→tingling or pain

triggers:
UV light exposure
dental procedures

HSV-1:
cold sore
high fever
leukocyte adhesion deficiency (LAD)
malaise
duration: 1-2 weeks untxd
-oral mucosa
-tongue
-tonsils
-lips

HSV-2:
asx shedding→no clinical lesions/sx→still infectious with sexual contact
painful
dysuria
fever
flu-like sx
leukocyte adhesion deficiency (LAD)
duration: 3+ weeks untxd
-vagina
-rectum
-penis
-buttock

DX: viral culture
specific for acute lesions
not in older/crusted lesions

TX:
HSV-1:
NP:
daily sunblock on lips

MX:
prodrome→valacyclovir BID x 1 day
dental/laser procedures prophx→ valacyclovir BID x 14 days (start 24 hours before surgery)
topical acyclovir crm
topical pencyclovir
topical tetracaine
inflammatory rxn prophx→fluocinonide gel 0.05% TID+systemic tx

HSV-2:
NP:
condom use
active lesions→avoid sexual exposure

MX:
PO valacyclovir BID x 7-10 days
6-12 outbreaks/year→PO valacyclovir QD (reduces shedding by 95%)

Herpes Zoster/Shingles

PP: reactivation of varicella-zoster virus

E: varicella-zoster virus (VZV)/chicken pox

CM: pain→red papules+plaques→blisters
UL on a dermatome
leukocyte adhesion deficiency (LAD)
elderly→scar
immunocompromised→scar

TX:
NP:
immunocompromised→inpatient tx
varicella-zoster vaccine (recommended for 60+ y/o)

MX:
acyclovir

post-herpetic neuralgia:
PO gabapentin
topical capsaicin

P: eye→temporary/permanent blindness (hutchinson’s sign)
ear→hearing loss (ramsay-hunt syndrome)
20+ lesions outside dermatome→disseminated

Molluscum Contagiosum

PP: benign contagious viral infection
incubation→2-7 weeks

E: pox virus

CM: white/flesh-colored papules
central umbilication

TX: nothing→goes away on its own
cryotherapy
topical cantharadin

Actinic Keratosis

E: 2nd most common derm dx
sun exposed areas

leukoplakia:
sun
smoking
chronic irritation

CM: firm+rough keratotic papule
erythematous base

leukoplakia:
white patch on mucous membranes (mouth)
more aggressive

DX: unsure+r/o SCC→biopsy

TX:
NP: cryotherapy
photodynamic therapy (PDT)
laser
chemical peel
electrodessication+curettage (ED&C)

MX: topical 5-fluorouracil
imiquimod

P: precursor to squamous cell carcinoma/SCC
normal→30%
leukoplakia→20-40%

Seborrheic Keratosis

E: very common

CM: papule
-dry
-raised
-“stuck on”
-tan/brown/black
-sharply demarcated

Lesar Trelat sign: sudder appearance of multiple SKs→internal malignancy

TX: cryotherapy
curettage

Benign Nevus

mole/freckle

benign

symmetric/evenly-pigmented macule/papule

new nevi after 30 minutes in sun→suspicious

blue nevus: melanocytes in dermis

becker’s nevus:
present at birth
appear with puberty
males

Atypical/Dysplastic Nevi DX

5-10% has at least 1 atypical nevus

increased number→increased melanoma risk

ABCDE rule:
Asymmetry
Border irregularity
Color variation
Diameter (greater than 6mm+)
Evolution

history:
especially past bleeding/ulceration hx
single most historical reason for close eval/referral

biopsy:
shave biopsy
punch biopsy
moderately atypical→normal removal/monitoring
severely atypical→remove with 5mm margins

Ephelides/Freckles

E: sun-exposed areas
young children
genetics

CM: flat brown macules

Lentigines/Sun Spots

E: sun-exposed areas
adults
photoaging

CM: flat brown macules
don’t fade with no sun exposure

Basal Cell Cancer

PP: locally invasive
rarely metastasizes

RF: sun-exposed/damaged areas
elderly
males
fair skin
previous skin injury
thermal burn

CM: “lesion that won’t heal+keeps bleeding”

nodular (most common)

superficial (least aggressive)

sclerosing (most aggressive)

pigmented (confused with melanoma)

TX:
NP:
surgical excision
electrodessication+curettage (ED&C)
moh’s surgery
radiation

MX:
imiquimod cream
PO vismodegib x lifelong

Merkel Cell Carcinoma

PP: pink nodule
solitary
rapidly growing

E: extensive actinic damage
older
head
neck

DX: sentinel lymph node biopsy (SLNB)

TX: wide excision
radiation

P:
40%→distant metastases→18% survival
under 2 cm+no metastases→70% 5+ years survival

Mammary vs Extramammary Paget Disease

mammary:

• unilateral

• hyperpigmented in beginning→nipple eczema-like

extramammary:

• genitalia

• starts from intraepidermal carcinoma/GI cancer

• eczema-like

Squamous Cell Cancer

RF: sun exposure
fair skin
HPV infection
radiation exposure
sunburns

E: 2nd most common skin cancer
actinic keratosis
sun-exposed areas
chronic trauma
inflammation
genitalia
oral mucosa

CM:

bowen’s disease: SCC in situ

keratoacanthoma (KA):
appears suddenly
grows rapidly

TX:
mohs surgery
surgical excision
in-situ→electrodessication and curretage (ED&C)
no surgery→radiation therapy

P: 45%→metastasis
early intervention→high cure rate

Melanoma

PP: malignancy of melanocytes in skin
half-develop from pre-existing nevi in normal-appearing skin

RF: atypical nevi
fair skin
family hx
sunburns (5+/1 blistering→2x risk)

E: women
25-29 y/o

CM:

lentigo maligna

• older patients

• heavily sun-damaged skin

• tan macule→spreads+darkens

• 5+ years→invasive

superficial spreading

• most common

• any form of skin

• upper back

• multicolored

acral-lentiginous

• dark skin+asian

• periungual hyperpigmentation (dark pigment under nails)

• hutchinson’s sign (pigmented streak+black color on proximal nail fold)

nodular

• smooth+dome shaped tumors

• sun-exposed areas

• bleeding→late sign

amelanotic:

• non-pigmented

• pink/erythematous/flesh-colored

DX:
ABCDE
asymmetry
border irregularity
color variation
diameter over 6mm
evolution (metastasis)

1mm+ thickness→sentinel lymph biopsy

TX:
early (5-20mm)→surgical excision

metastatic
NP: radiation
chemotherapy

MX: ipilimunab+nivolumab

P: deadliest skin cancer
deeper→worse prognosis
metastatic→6-9 months
metastatic 5 year survival rate→under 20%

Melanoma Histopathology

breslow depth+ulceration→tumor stage

ulceration
top layer breaks/pulls apart→poor prognosis

mitosis
increased mitosis rate→decreased survival rate

margin status
surgeon gets/doesn’t get clear margins

Melanoma Prophylaxis+Patient Education

lab work not effective
many dysplastic nevi→full body photography

skin checks:
1st year→every 3 months
after 1st year→every 6 months
all 1st degree relatives
melanoma risk→ +0.5% every year

pt education:
risk+prevention (spf protection)
monthly skin exam

Kaposi Sarcoma

PP: malignancy of vascular endothelial cells

E: AIDS-associated
skin
mucosa
lymph nodes
GI tract

CM: reddish/blue-black macules/patches→spread+coalesce→nodules/plaques+edema

TX: surgical excision
radiation therapy
laser ablation
injected chemotherapy

P: slow progression
deaths due to other causes
AIDS→intercurrent/secondary infection→death

Mycosis Fungoides

PP/E: cutaneous T-cell lymphoma
skin→dormant for years (or)→progresses to systemic disease

CM: scaly patches/plaques on trunk
itchy
localized/systemic
erythematous

DX: multiple punch biopsies

TX: topical chemotherapy
UV light phototherapy
systemic chemotherapy
immunotherapy
topical steroids

commonly mistaken for eczema/tinea/psoriasis

Contact Dermatitis

PP/E: direct skin contact with irritant/allergen

irritant
nonspecific inflammatory skin reaction
bleach

allergic
hypersensitivity to allergy
poison ivy

TX: discontinue contact with offending agent+topical steroids

Dermatitis Medicamentosa

PP: adverse skin reaction to medication

E: NSAIDS
antimicrobials
cytokines
anticonvulsants
psychotropic agents
chemotherapeutic agents

CM: symmetric drug rash

morbiliform
pustules
urticaria
pruritus
dysethesia (pain to light touch)
arthralgia
fever
headache
malaise

DX: histology
skin biopsy

P: discontinue mx→resolves on own
mild+self-limiting

Atopic Dermatitis PP/E/CM

PP: chronic inflammatory skin disease

RF: asthma
allergic rhinoconjunctivitis
atopic disorders
food allergy (35%)
2+ household smoker
cats

E: genetic
unknown
1st world country kids→30%
1 y/o→50%

CM: pruritis
chronic exacerbations+remissions

acute: plaques
red
thin
scaly

chronic: plaques+excoriations
thick
scaly

infants
face
extensor surfaces

children
flexor surfaces

adults
localized

POC
lichenification
prurigo-like lesions
hyperpigmentation

Atopic Dermatitis TX

NP
pt education
repair skin barrier→prevent outbreaks
moisturizer after baths
decrease number+length+temperature of baths
allergen-free detergents
cotton clothing
humidifier
no food restriction diet
severe→allergist referral

MX

mild-moderate:
mild
topical hydrocortisone 2.5% BID x up to 2 weeks

moderate
topical triamcinolone 0.1% BID x up to 2 weeks

topical tacrolimus QD x up to 6 weeks
topical pimecrolimus QD x up to 6 weeks
topical ruxolitinib
cetirizine
hydroxyzine

infection
topical abx
PO abx

moderate-severe:
1st line→SQ duplimab x 2-4 weeks

2nd line:
baricitinib
abrocitinib
upadacitinib

PO prednisone
narrow band UVB x 3x/week
PO cyclosporine

Dyshidrosis/Dyshidrotic Eczema

PP: recurrent vesicular hand eczema
thick acral skin→edema→vesicles

E: stress
allergy
irritants

CM: firm+pruitic vesicles on palms (more common)+soles (less common) on medial/lateral aspects of digits
“tapioca pudding”

DX: rule out contact dermatitis

TX:
NP
pt education
repair skin barrier→prevent outbreaks
moisturizer after baths
decrease number+length+temperature of baths
allergen-free detergents
cotton clothing
humidifier
no food restriction diet
severe→allergist referral

MX

mild-moderate:
mild
topical hydrocortisone 2.5% BID x up to 2 weeks

moderate
topical triamcinolone 0.1% BID x up to 2 weeks

topical tacrolimus QD x up to 6 weeks
topical pimecrolimus QD x up to 6 weeks
topical ruxolitinib
cetirizine
hydroxyzine

infection
topical abx
PO abx

moderate-severe:
1st line→SQ duplimab x 2-4 weeks

2nd line:
baricitinib
abrocitinib
upadacitinib

PO prednisone
narrow band UVB x 3x/week
PO cyclosporine

Lichen Simplex Chronicus

PP: chronic rubbing+scratching→beyond normal pain threshold→thick+leathery skin+exaggerated skin markings

E: neck (back+sides)
wrists
ankles
gradual insidious onset
skin site of another condition

CM: thick+leathery skin
exaggerated skin markings→lichenification

TX:
high potency topical steroid + temporary
steroid tape
intra-lesional kenalog

Lichen Planus

PP: inflammatory disease of skin+mucous membranes+hair follicles
mucous membranes→malignancy risk

E: T-cell mediated immune reaction
acute or chronic
Hepatitis C infection

CM: white lines→whickam striae

DX: 4 P’s
purple
polygonal
pruritic
papules

TX:
NP:
self-limiting x 8-12 months
phototherapy

MX:
superpotent topical steroids
superpotent intralesional steroids

mouth→benzocaine

systemic: isotretinoin
acitretin
cyclosporines

Pityriasis Rosea

PP/E: subclinical viral infection/adverse mx reaction→mild inflammatory exanthem

CM: salmon-colored+fine scale papules+macules
singular herald patch→more appear
“christmas tree” distribution pattern

TX: none
itch→topical steroid
self-limiting x after 3-8 weeks

Psoriasis (General)

PP: chronic/recurrent inflammatory disease

E: common
scalp
nails
extensor surfaces
umbilical region
sacrum
1-3% of population

TX:
topical:
1st line→topical steroids
topical calcipotriene
anthralin+coal tar
narrow band UV x 3x/week

systemic:
methotrexate
acute→cyclosporine+taper off
PO acitretin
apremilast

Biologics:
TNF alpha inhibitors:
-entanercept
-adalimumab

interleukin 12+23 inhibitor:
-ustekinumab

interleukin 17 inhibitors:
-ixekizumab
-secukinumab

interleukin 23 inhibitor:
-guselkumab
-risankizumab
-tildrakizumab

Koebner Phenomenon (Psoriasis)

PP: post-traumatic psoriatic phenomenon

E: trauma

CM: trauma to skin→plaque

TX:
topical:
1st line→topical steroids
topical calcipotriene
anthralin+coal tar
narrow band UV x 3x/week

systemic:
methotrexate
acute→cyclosporine+taper off
PO acitretin
apremilast

Biologics:
TNF alpha inhibitors:
-entanercept
-adalimumab

interleukin 12+23 inhibitor:
-ustekinumab

interleukin 17 inhibitors:
-ixekizumab
-secukinumab

interleukin 23 inhibitor:
-guselkumab
-risankizumab
-tildrakizumab

Psoriatic Arthritis

PP: arthritis+psoriasis

E: distal interphalangeal joint (DIPJ)

DX:
Xray→“pencil in a cup” deformity

TX:
topical:
1st line→topical steroids
topical calcipotriene
anthralin+coal tar
narrow band UV x 3x/week

systemic:
methotrexate
acute→cyclosporine+taper off
PO acitretin
apremilast

Biologics:
TNF alpha inhibitors:
-entanercept
-adalimumab

interleukin 12+23 inhibitor:
-ustekinumab

interleukin 17 inhibitors:
-ixekizumab
-secukinumab

interleukin 23 inhibitor:
-guselkumab
-risankizumab
-tildrakizumab

Psoriasis Guttate

PP: post group A strep pharyngitis infection→abrupt eruption

E: group A strep pharyngitis

CM:
numerous salmon pink papules+fine scale
“drop-like”

TX:
topical:
1st line→topical steroids
topical calcipotriene
anthralin+coal tar
narrow band UV x 3x/week

systemic:
methotrexate
acute→cyclosporine+taper off
PO acitretin
apremilast

Biologics:
TNF alpha inhibitors:
-entanercept
-adalimumab

interleukin 12+23 inhibitor:
-ustekinumab

interleukin 17 inhibitors:
-ixekizumab
-secukinumab

interleukin 23 inhibitor:
-guselkumab
-risankizumab
-tildrakizumab

Inverse Psoriasis

PP: psoriasis under folds

E: folds
-ears
-axillae
-groin
-intergluteal crease
-penis

CM: mimics candida infection

Dx: KOH→negative

TX:
topical:
1st line→topical steroids
topical calcipotriene
anthralin+coal tar
narrow band UV x 3x/week

systemic:
methotrexate
acute→cyclosporine+taper off
PO acitretin
apremilast

Biologics:
TNF alpha inhibitors:
-entanercept
-adalimumab

interleukin 12+23 inhibitor:
-ustekinumab

interleukin 17 inhibitors:
-ixekizumab
-secukinumab

interleukin 23 inhibitor:
-guselkumab
-risankizumab
-tildrakizumab

Pustular Psoriasis

PP: psoriasis+pustules

E: tobacco

CM:
sterile+red+scaly pustules
-palms
-soles
-nails

DX: “oil-drop” sign

TX:
topical:
1st line→topical steroids
topical calcipotriene
anthralin+coal tar
narrow band UV x 3x/week

systemic:
methotrexate
acute→cyclosporine+taper off
PO acitretin
apremilast

Biologics:
TNF alpha inhibitors:
-entanercept
-adalimumab

interleukin 12+23 inhibitor:
-ustekinumab

interleukin 17 inhibitors:
-ixekizumab
-secukinumab

interleukin 23 inhibitor:
-guselkumab
-risankizumab
-tildrakizumab

Chronic Plaque Psoriasis

E: most common type of psoriasis

CM: “silvery” scaling plaques
circumscribed
erythematous
dry

extensor surfaces:
-elbows
-knees
-scalp
-sacrum

auspitz sign:
pick at silver scales→blood

TX:
topical:
1st line→topical steroids
topical calcipotriene
anthralin+coal tar
narrow band UV x 3x/week

systemic:
methotrexate
acute→cyclosporine+taper off
PO acitretin
apremilast

Biologics:
TNF alpha inhibitors:
-entanercept
-adalimumab

interleukin 12+23 inhibitor:
-ustekinumab

interleukin 17 inhibitors:
-ixekizumab
-secukinumab

interleukin 23 inhibitor:
-guselkumab
-risankizumab
-tildrakizumab

Melasma

PP: acquired symmetric hyperpigmentation

E: hormone sensitivity
birth control
pregnancy (“mask of pregnancy”)
face
sun exposure→worsens sx

TX: difficult
peels
lasers
topical hydroquinone
topical tretinoin

prophx/prevention of worsening sx→spf sun protection

Vitiligo/“Michael Jackson’s Skin Condition”

PP: acquired pigmentary anomaly

E: childhood
mx-induced

CM: depigmented white patches surrounded by normal/hyperpigmented border

DX: wood’s lamp

TX:
nontreatment option→fitzpatrick 1-2 only
NP:
narrow band UVB x 2x/week

MX:
topical pimecrolimus
topical tacrolimus
calcipotriene
topical ruxolitinib
PO baricitinib
total depigmentation (50-80% BSA gone)→monobenzone

P: psychological effect
spontaneous repigmentation→15-25% of cases

1st Degree Burn

PP: minor epidermal damage

E: m/c→scalding

CM: erythema
tenderness
no bullae

DX: hematocrit
electrolytes
BUN
creatine
urinalysis
chest radiography
arterial blood gas
EKG

electrical energy levels on the skin do not match how severe the actual injury is

TX:
NP:
chemical→stop burning
maintain ABCs
estimate % of burn
-palm of hand=1%BSA

manage shock:
aggressive fluid resuscitation
NG tube
foley catheter

MX: topical sulfadiazine

C: inhalation injury
hypovolemic shock
neurogenic shock
renal failure
multiorgan system dysfunction
infection
chronic healing wounds→malignancy to SCC

2nd Degree Burn

E: superficial partial-thickness→papillary dermis
deep superficial→reticular dermis

CM:
partial-thickness:

• extends to papillary dermis

• thin-walled blisters

• moist

• blanching

• pain

deep:

• extends to reticular dermis

• thicker-walled blisters→rupture

• erythema

• pallor

• pressure→pain

DX: hematocrit
electrolytes
BUN
creatine
urinalysis
chest radiography
arterial blood gas
EKG

electrical energy levels on the skin do not match how severe the actual injury is

TX:
NP:
chemical→stop burning
maintain ABCs
estimate % of burn
-palm of hand=1%BSA

manage shock:
aggressive fluid resuscitation
NG tube
foley catheter

MX: topical sulfadiazine

C: inhalation injury
hypovolemic shock
neurogenic shock
renal failure
multiorgan system dysfunction
infection
chronic healing wounds→malignancy to SCC

3rd Degree Burn

PP: full thickness
destroys epidermis+dermis

CM: white
leathery
or
charred
dry without sensation

DX: hematocrit
electrolytes
BUN
creatine
urinalysis
chest radiography
arterial blood gas
EKG

electrical energy levels on the skin do not match how severe the actual injury is

TX:
NP:
chemical→stop burning
maintain ABCs
estimate % of burn
-palm of hand=1%BSA

manage shock:
aggressive fluid resuscitation
NG tube
foley catheter

MX: topical sulfadiazine

C: inhalation injury
hypovolemic shock
neurogenic shock
renal failure
multiorgan system dysfunction
infection
chronic healing wounds→malignancy to SCC

4th Degree Burn

PP: destroys skin+subcutaneous tissue
fascia/muscles/bone exposed

CM: significant charring
exposure of muscle/bone
extensive damage to nerves
little to no pain/sensation

DX: hematocrit
electrolytes
BUN
creatine
urinalysis
chest radiography
arterial blood gas
EKG

electrical energy levels on the skin do not match how severe the actual injury is

TX:
NP:
chemical→stop burning
maintain ABCs
estimate % of burn
-palm of hand=1%BSA

manage shock:
aggressive fluid resuscitation
NG tube
foley catheter

MX: topical sulfadiazine

C: inhalation injury
hypovolemic shock
neurogenic shock
renal failure
multiorgan system dysfunction
infection
chronic healing wounds→malignancy to SCC

C: inhalation injury
hypovolemic shock
neurogenic shock
renal failure
multiorgan system dysfunction
infection
chronic healing wounds→malignancy to SCC

Lacerations

PP: damage penetrating under the skin

E:
laceration:
tearing of soft body tissue
irregular+jagged
often contaminated

puncture:
sharp pointy object (nail/teeth/etc.)
prone to infection

TX: stop bleeding
clean sutures

Pressure Ulcers

PP: areas of pressure+limited mobility→decubitus ulcers

E: localized pressure→impaired blood supply
sacrum
lip

CM/DX:
stage 1: nonblanching erythema of intact skin

stage 2:
necrosis
superficial/partial thickness
epidermis
±dermis
shallow ulcer

stage 3:
deep necrosis
crater ulcer
full thickness skin loss
damage/necrosis
no fascia involvement

stage 4:
full-thickness ulceration
extensive damage+necrosis to muscle/bone/supporting structures

TX:
NP: prophx
repositioning
massaging
minimize friction

ulcer:
moist sterile gauze
surgical debridement

MX: only if sx of infection are present
topical abx
PO abx

C: osteomyelitis
bacteremia

Stasis Dermatitis

PP/E: chronic venous insufficiency→edema→stasis dermatitis

CM: hyperpigmentation
ulcerations
prophx→varicose veins

PE:
heaviness+aching in legs
increased→standing
decreased→leg elevation

TX:
NP: compression stockings
vascular surgery
ulcers→chronic tx

MX: topical triamcinolone BID x 2 weeks on/off

Cherry Angioma

PP: benign vascular papule

E: proliferating endothelial cells
lines the inside of blood vessels
unknown

CM: bright red papule

TX: none

Infantile Hemangioma/Large Cherry Angioma

PP: benign vascular tumor

CM: large red papule/patch

TX:
NP:
serial observation
surgery
laser
embolization

MX:
topical timolol
PO propanolol x after feeding

Purpura

PP: hemorrhagic lesions

E: bleeding in skin
bleeding in small blood vessels

CM:
petechiae:
pinpoint macules
1-2 mm in size

ecchymosis:
bruise
larger

Telangiectasia

PP: small+linear broken capillaries

E: injury
topical steroids
skin cancer

CM: web-like veins

TX: none
sclerotherapy
laser treatment

Pemphigus Vulgaris

PP: chronic autoimmune disorder
appear first in mouth+malodorous

E: unknown

CM: mucosal erosions
thin-walled bullae
easily rupture→crusts→hyperpigmented patches+no scarring

DX:
nikolsky sign:
push blister→further separation of the dermis

paraneoplastic:
non-hodgkin lymphoma
chronic lymphocytic leukemia
sarcoma

TX: high-dose PO prednisone

P: paraneoplastic→death from underlying cancer

Bullous Pemphigoid

PP/E: autoimmune disorder
adverse mx reaction

RF: elderly
groin
axillae
trunk
thighs
flexor forearms

CM:
urticaria: large+tense subepidermal bullae
can persist for months.years

DX: immunofluorescence of normal skin
blister edge biopsy

nikolsky sign:
push blister→further separation of the dermis

TX: high-dose prednisone x slow taper
azathioprine
topical steroids

Acanthosis Nigricans

E: diabetes mellitus
non-obese aged pt over 40→GI carcinoma

CM: plaque
hyperpigmented
velvet-textured
-posterior neck
-axillae

TX:
NP: weight loss
tx underlying disorder

MX: topical retinoids

Dermatitis Herpetiformis

E: gluten
celiac disease (90% of pts)

CM: itchy papules/vesicles
-elbows
-knees
-buttock
-posterior neck
-scalp

DX: punch biopsy
celiac dx→tissue transglutamase

TX: strict gluten-free diet
PO dapsone

Xanthoma

PP: deposits of lipids in tissue

E: underlying dyslipidemia

DX: full lipid profile
biopsy

TX: surgery
laser

P: increased CV risk

Lipoma

PP: benign subcutaneous fatty tumor

E: m/c→trunk

TX: none
surgical excision

Epidermal Inclusion/Sebaceous Cyst

E: unknown
adults
men
-face
-neck
-trunk

CM: benign/round/dome-shaped/encapsulated lesion+central pore/punctum

TX: none
surgery
inflammation→intralesional kenalog

Urticaria/”Hives”

PP: histamine reaction

E: idiopathic (50%)
mx
cold/heat
foods
stress
infections
menthol
wine (sulfites)

CM: wheal (localized edema)
never lasts more than 24 hours

severe itching/sticking/prickling sensation
angioedema
anaphylaxis
hypotension

dermatographism: post scratching→raised wheal

DX: detailed hx

chronic:
CBC
LFT
ANA
thyroid screening
hepatitis screening

TX:
acute→within 6 weeks
self-relieving
antihistamines PRN

chronic→over 6+ weeks
NP: allergist referral

MX: injectable omalizumab x 1 month
antihistamines x daily (linked to dementia)
no topical steroids

Pilonidal Disease

PP: hair follicles become blocked→chronic infection of the skin in the cleft between the buttocks near the tailbone
associated with a sinus tract

E: men

CM: cyst in upper gluteal cleft
fragments of hairs

TX: colorectal surgery

Hyperhidrosis

E: primary cortex (waking hours only)
thyroid

CM: excessive sweating
symmetric
bilateral
waking hours only→primary cortical
-axillae
-palms
-soles
-face (rare)

DX: thyroid panel

TX: aluminum chloride antiperspirants
aluminum chloride hexahydrate
PO glycopyrrolate (long term use→dementia)
botulinum toxin injections x 3-6 months