Dermatology Study Notes

Introduction to Dermatology

  • Focused on acute and chronic conditions in primary care for adults.

  • Instructor: Whitny Schluter, DNP, FNP-BC.

Course Objectives

  • Skin Cancer Identification: Identify possible skin cancers and pre-cancers through patient history and physical examination, including understanding in-office biopsy techniques for primary care providers.

  • Differential Diagnosis: Differentiate between various conditions like psoriasis, herpes zoster, common tinea infections, pediculosis, scabies, and acne rosacea based on a thorough patient history and physical examination.

  • Patient-Centered Management: Develop comprehensive management plans that include both pharmacologic and non-pharmacologic therapies for the aforementioned conditions.

  • Prevention Strategies: Suggest strategies for preventing dermatological conditions such as skin cancer and herpes zoster.

  • Cellulitis Management: Identify and manage cellulitis and its differential diagnoses appropriately.

  • Assessing Red Flag Symptoms: Assess patients for significant red flag symptoms that may indicate more serious underlying conditions.

Resources

  • VisualDx: Access via HSC account. Important resource for diagnostic imaging and dermatological conditions.

  • DermNet NZ: Free educational resource offering information on dermatology.

  • UNM's Inclusive Dermatology Gallery: A resource focusing on diverse dermatological presentations.

Skin Structure Review

  • Largest Organ: Skin is the largest organ in the human body.

  • Components:

    • Epidermis

    • Dermis

    • Subcutaneous tissues

    • Hair

    • Nails

    • Sebaceous glands

    • Sweat glands

  • Functions:

    • Protects against damage/injury

    • Regulates body temperature

    • Provides sensation

    • Synthesizes Vitamin D

    • Immune surveillance

    • Protects against fluid loss

Health History and Examination Techniques
History of Present Illness (HPI)

  • Details to gather include:

    • Patient Demographics: Age, gender, ancestry.

    • Onset of Rash: Abrupt or gradual, any precipitating factors (prodrome, exposure).

    • Location: Where the rash began and its current state.

    • Duration: Length of time the rash has been present.

    • Evolution: Changes in the appearance or spread over time; recurrence history.

    • Characteristics: Morphology, texture, color of lesions.

    • Aggravating/Alleviating Factors: Environmental triggers such as sun exposure, stress, hormonal changes, home remedies, OTCs.

    • Associated Symptoms: Pain, burning, itching, bleeding, systemic signs.

    • Timing: Seasonal variations or daily patterns.

    • Severity: Impact on daily activities or emotional state.

Comprehensive History Taking
Past Medical History

  • Include chronic diseases: allergies, autoimmune disorders, cardiovascular diseases, infections, psychiatric history, and substance use.

  • Medications: Always inquire about any recent medication changes or new prescriptions.

Family History

  • Document family history of relevant skin conditions and other pertinent diseases.

Social History

  • Consider occupational exposures, travel, outdoor activity, exposure to children or pets, and usage of personal care products.

Review of Systems (ROS)

  • It is essential to cover a full systems review while focusing on constitutional, dermatological, and related systems.

Physical Examination Review
Inspection Techniques

  • Visual Inspection: Observe for:

    • Distribution: Localized, generalized, unilateral, bilateral, etc.

    • Color: Variations in skin hues, including erythema, pigmentation.

    • Morphology: Primary and secondary lesions characterized by type, size, configuration, and texture.

    • Borders: Defined or undefined edges, presence of halos or collarettes.

Palpation Techniques

  • Wear gloves and assess:

    • Texture (hard, soft).

    • Edema and induration.

    • Temperature.

    • Pain or pruritus response.

Differential Diagnosis Techniques

  • VINDICATE: A mnemonic to categorize differential diagnoses based on mechanisms (Vascular, Infectious, Neoplastic, Degenerative, Intoxication, Congenital, Autoimmune, Traumatic, Endocrine).

  • Be thorough in examining morphology and distribution data to produce accurate diagnoses.

Common Rashes Overview

  • Understanding that not all symptoms are unique to a condition. For example:

    • Psoriasis vs. eczema: Both may present with scaling.

    • Cellulitis vs. venous stasis: Features may overlap but differ in treatment approaches.

Infestations
Scabies

  • Caused by Sarcoptes scabiei: can infest all demographics.

  • Transmission through direct, prolonged skin contact.

  • Presenting features: Intensely pruritic lesions often worse at night, characteristic burrows on skin.

Lice (Pediculosis)

  • Types: Pubic lice, body lice, head lice, each with unique presentations and treatments.

  • Commonly presents with itching and nits in hair, body, or pubic areas.

Skin Cancer Screening

  • Melanoma Indicators:

    • Recognize the ABCDEs (Asymmetry, Border irregularity, Color variation, Diameter > 6mm, Evolution of a lesion).

    • Distinguish between different skin cancers: Basal Cell Carcinoma (BCC), Squamous Cell Carcinoma (cSCC), and Melanoma.

Treatment and Referral Protocols

  • Determine treatment based on severity and type of condition, utilizing both pharmacologic and preventive measures.

  • Consider referral to specialists as necessary, especially for chronic and complex cases.

Conclusion

  • A systematic approach in diagnosis and management of dermatological conditions is critical for effective patient care. Regular follow-up and education on conditions and prevention reinforce good practice.