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265 Cards in this Set

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  • Back
5 layers of epidermis
Stratum corneum, lucidum, granulosum, spinosum, basale

(Can Liza grow seven babies?)
Fingerprints are made from this layer.
Simply a change in skin color 1 cm or less, without any elevation or depression in relation to the adjacent skin
Freckles, tattoos, hyperpigmentation, purpura

Large macules greater than 1 cm in size, without any elevation or depression in relation to the adjacent skin
Vilitigo, vascular nevus (“salmon patch”), nevus flammeus

A solid lesion elevated above the adjacent skin less than 1 cm in diameter
Warts, molluscum contagiosum, nevi

A solid lesion elevated above the adjacent skin greater than 1 cm in diameter
Eczema, psoriasis, tinea corporis

A solid palpable lesion greater than 1 cm in diameter, frequently centered in the dermis or subcutaneous fat

(Small blisters) A circumscribed fluid-filled lesion less than 0.5 cm in diameter

(Large blisters) A circumscribed fluid-filled lesion greater than 0.5 cm in diameter

Raised flesh-colored or erythematous papules or plaques that are transient lesions; they generally last less than 24 hours and may change shape and size

(desquamation) abnormal
accumulation or shedding of visible epidermis

Shallow losses of tissue involving only the epidermis; heals without a scar

Scab: hard, rough surface formed by dried sebum, exudate, blood or necrotic skin

Honey-colored crusts (usually a sign of superficial infection)

Linear ulcers or cracks in the skin

Thickened skin with accentuated skin lines

Due to extravasation of red blood cells into the skin (does not blanch)

Visibly enlarged or dilated small blood vessels on the skin surface

(Scratch marks) linear or punctate erosions induced by scratching

A pebbly epidermal surface cause by a tight grouping or confluence of papules

excessive hair growth

(Defect deeper than erosions), involve the dermis or deeper layers and usually heal with scarring

Swollen and softened by an increase in water content; the appearance skin gets when left in water too long

Irregular, rough and convolutes surfaces

A many-colored lesion
of concentric rings

Round like a ring

Shaped like a net

Occur in proximity to one another to form a distinct larger entity

Resembling a cluster of flowers

Describe this.
5 cm sharply marginated erythematous annular plaque with scale on the left proximal superior medial leg
Describe this.
Oval, salmon-red, 2 cm plaque with a fine collarette of scale at periphery with scattered salmon-red papules and plaques on the superior chest
Rubbing a lesion causes a urticarial flair
Darier's Sign
Pinpoint bleeding after scale is removed
Auspitz's Sign
Pushing a blister causes further separation of the dermis
Nikolsky's Sign
Demonstrates hypersensitivity reaction
Patch Test
Minor trauma leads to new lesions at site of trauma
Koebner's Phenomenon
Labs and special exams review
Primary lesions include: discrete, skin-colored or pearly-white, raised or dome-shaped, waxy-appearing, firm papules 1 mm to 5 mm in diameter with a central keratotic plug which gives an umbilicated surface (looks like a belly button)

Molluscum Contagiosum
What is the secondary lesions of molluscum contagiosum?
Secondary lesions include: crust formation on involuting lesions, excoriations on some papules, and mild scarring
What is the distribution of Molluscum Contagiosum?
MC has a macrodistribution
They are found alone or in clusters on the face, trunk, lower abdomen, pubis, inner things, axilla, and genitalia
What is the configuration of Molluscum Contagiosum?
Configuration is grouped, usually within the region of onset
The number of lesions varies from 1 to 20 up to hundreds
What is the differential diagnosis for Molluscum Contagiosum?
Molluscum Contagiosum
Flat Warts
Condylomata Acuminata
Sebaceous Hyperplasia
Invasive Fungal Infection i.e. cryptococcosis, histoplasmosis, coccidioidomycosis
How do you diagnose Molluscum Contagiosum?
Diagnosis can be confirmed by incising one of the papules, smearing the contents from the center of a papule between two glass slides, staining (with Wright’s, Giemsa’s or Gram’s stain), and then viewing diagnostic anucleate homogeneous ovoid “molluscum bodies” under low magnification.
When the clinical findings are confusing and the smear is negative, do a biopsy.
How do you treat Molluscum Contagiosum?
Children: conservative, non-scarring methods
Adults: genital lesions should be treated definitively to prevent spread by sexual contact
New lesions that are too tiny for detection may appear after treatment and may require additional treatment.
How is molluscum contagiosum spread?
Lesions are spread by autoinoculation from picking or rubbing or shaving
Advise patients against such things while lesions are present
Veruca Vulgaris
What pertinent history questions do you want to ask about warts?
Ask if the patient is taking a mediation that may decrease cell-mediated immunity (i.e. prednisone, cyclosporine, chemotherapeutic agents)
Ask if the patient is a transplant recipient (these patients have warts that can be very resistant to treatment)
Ask if the patient handles raw meat, fish, or other types of animal matter in one’s occupation (i.e. butcher). This increases susceptibility.
What is the primary lesion of a wart?
Primary lesions include: tiny firm flesh-colored papules that interrupt skin lines or dermatoglyphic lines when on palms or soles. Can also see filiform (threadlike) papules, especially on the eyelid and facial areas.
What are the secondary lesions of warts?
Secondary lesions include: grey-white scaling and “black dots” or thrombosed capillaries
What is the distribution for warts?
VV have a macrodistribution
What is the scientific name for warts?
Veruca Vulgaris
What is the configuration for Veruca Vulgaris?
VV have a grouped or corymbiform configuration
May coalesce into clusters that can be up to 5 cm in diameter
What is the differential diagnosis for Veruca Vulgaris?
Verruca vulgaris
Verrucous carcinoma of skin
Squamous cell carcinoma
How is veruca vulgaris transmitted?
By touch
How is veruca vulgaris diagnosed?
Warts are diagnosed on their clinical appearance, but a biopsy can be performed if the diagnosis is in doubt. A skin biopsy will distinguish VV from other tumors and growths.
VV displaces the skin lines.
How is veruca vulgaris treated?
Keratolytic therapy (salicylic acid)
Imiquimod (Aldara)
5-fluorouracil (Carac)
Suggestive therapy
Dinitrochlorobenzene (DNCB)
Cantharone: Tends to produce doughnut warts, a wart with a central clear zone at the site of the original wart
Intralesional bleomycin sulfate
Seborrheic Dermatitis
What pertinent history questions would you ask someone with Seborrheic Dermatitis?
How frequently does she shampoo?
With what does she shampoo her hair?
Does she frequently wear wigs?

Infrequent shampooing, inadequate body
hygiene, and climate conditions, especially
long spells of wet weather, exacerbate existing
cases and precipitate conditions
What are the primary lesions of Seborrheic Dermatitis?
Primary lesions: dull, sharply demarcated red patches
What are the secondary lesions of Seborrheic Dermatitis?
Secondary lesions: loose, easily dislodged yellow or white scale
Where does Seborrheic Dermatitis manifest?
Post-auricular folds
Concha of the ears
Perinasal, nasolabial, and mental creases of the face
Mid-chest and inframammary creases
Upper back
How do you treat Seborrheic Dermatitis?
Medicated Shampoo
Topical Antifungal Agents
Thick crusts can be removed by applying overnight corticosteroid oil (Dermasmooth) and washing in AM
Short-term topical steroids
What is the prognosis for Seborrheic Dermatitis?
SD can be chronic. It is important to frequently reinforce treatment and maintenance regimens with patients. After the initial visit have patients RTC after 4 weeks.
What is the presentation of Pityriasis Rosea?
Rash abruptly begins with a single 2 to 10 cm round to oval lesion (the herald patch), which is usually salmon colored
The complaint of “ring worm” and the use of OTC antifungal creams.
Within a few days to several weeks (average, 7 to 14 days) the disease enters the eruptive phase. Smaller lesions appear and reach their maximum number in 1 to 2 weeks. This phase tends to resolve over 6 weeks, but variability is common.
*Only one occurance. If reoccurance, think eczema*
What are the primary lesions of Pityriasis Rosea?
Primary lesions include: an erythematous to salmon-colored plaque measuring 1-2 cm in diameter. The first appearing lesion is called the “herald patch.”
What are the secondary lesions of Pityriasis Rosea?
Secondary lesions include: a collarette (or ring) of scale on the papules or plaques
What is the distribution of Pityriasis Rosea?
PR has a macrodistibution and includes the neck, chest, back, abdomen, arms, hips, and proximal thighs

PR has a “Christmas tree” distribution (this means that the lesions appear as a linear descending pattern much like the dropping branches of a pine tree)
How do you differentiate Pityriasis Rosea from Tinea Corporis?
How do you treat Pityriasis Rosea?
There is no specific therapy. PR is a benign self-limiting disease that resolves on its own in a 6 to 12 week time period. It heals without permanent scars or marks, and recurrence is rare.
The following treatments can be suggested if patients are distressed with extensive lesions:
Medium potency group IV or V steroid cream (triamcinalone cream) used BID x 3 weeks, avoiding face, axilla, and groin, when there is significant itching
UV light
Avoid hot showers, overheating or activity that raises body temperatures. This can increase itching.
What are the primary lesions of Psoriasis Vulgaris?
Primary lesions include: sharply marginated erythematous papules or plaques
What are the secondary lesions of Psoriasis Vulgaris?
Secondary lesions include: silver-white scale Scales are loose and easily removed by scratching. Removal of scale results in the appearance of minute blood droplets and this is called Auspitz’ sign.
What factors adversely influence Psoriasis Vulgaris?
Drugs (antimalarials, beta-blockers, ACE-I, indomethacin, interferon, lithium carbonate)
Physical trauma
Other factors: smoking, obesity, dyslipidemia
What is the distribution of Psoriasis Vulgaris?
PV has a macrodistribution and can occur on any skin surface.
Scattered, discrete lesions, like a rash, are generally concentrated on the trunk and scalp, less on the face, and usually spare the palms and soles.
EXTENSOR surfaces
What are the physical findings of Psoriasis Vulgaris?
Nail changes include pitting, subungal hyperkaratosis, onycholysis, and yellowish-brown spots under the nail plate. (This is called oil spots. Oil spots are is pathognomonic for psoriasis).
Arthritis (in 10% of cases)
How do you diagnose Psoriasis Vulgaris?
The diagnosis of psoriasis is made on clinical grounds. However, a skin biopsy or fungal study may be performed to rule in or rule out other possible diagnosis.
Antistreptolysin titer is increased in acute guttate psoriasis.
How do you treat Psoriasis Vulgaris?
Topical agents
Phototherapy (narrow band UVB 3x/week)
Systemic agents (chemotherapy drugs, hard on liver)
A rash on limbs and trunk that is often preceeded by strep throat.
Guttate psoriasis

Antistreptolysin titer is increased in acute guttate psoriasis
Onset can be acute (days) or insidious (over 2-16 weeks)
Begins as tiny papules that are geometric or polygonal in shape and can evolve into plaques

Lichen Planus
What are the primary lesions of Lichen Planus?
Primary lesions include: red to deep violet, flat-topped, 1 to 10 mm, sharply defined, shiny papules. These papules may be separate or tightly grouped. Thse primary lesions can have Wickham’s striae (white lines), seen best with hand lens after application of mineral oil.
What are the secondary lesions of Lichen Planus?
Secondary lesions include: scale, excoriations (due to itching), or hyperpigmentation as lesions resolve.
Erosions are common with mucosal LP. Atrophy and scarring is common with LP of the scalp.
What is the distribution of Lichen Planus?
LP has a macrodistrubution
Lesions are distributed to the flexural surfaces of joints and forearms, dorsal hands, extensor shins, lateral neck, buttocks, lumbar region, glans penis, and mouth
The face, scalp, palms, and soles are only rarely involved
What is the configuration of Lichen Planus?
What is the differential for Lichen Planus?
Lichen Planus
Cutaneous Lupus Erythematosus
Eczematous Dermatitis
Lichen Simplex Chronicus
Pityriasis Rosea
How do you diagnose Lichen Planus?
Biopsy! Lichen planus has a characteristic histology on biopsy
How does Lichen Planus present?
Severely itchy rash, often accompanied with sores in the mouth, in adults in their fourth, fifth, and sixth decades of life

Papulosquamous disease    
What 2 diseases is Lichen Planus associated with?
There is a strong association of LP with chronic liver disease and hepatitis
How do you treat Lichen Planus?
If drug-induced, eliminate suspect medication
Superpotent topical steroids
Intralesional steroid injections
Systemic corticosteroids (1 mg/kg/day x 7 days, 40 for 7 days, 20 mg x 7 days, and then slowly tapering at a rate of 2.5mg/week)     
Narrow-band UVB     
Course, without treatment, 6-36 months     
Kids will usually outgrow LP of nails, but for all nail dystrophies: biotin 2.5 mg/day, AmLactin above matrix, and nail strengthening coating (Dermanail)
A 16-year-old female comes to your office complaining of a pruritic generalized eruption of gradually increasing intensity over the prior 4 months

What are the primary lesions of scabies?
Primary lesions include: tiny discrete vesicles and erythematous papules, some of which evolve into burrows (the classic telltale lesions of scabies) in the interdigital webs of the hands, wrists, antecubital fossae, points of the elbows, nipples, umbilicus, lower abdomen, genitalia, and gluteal cleft
What are the secondary lesions of scabies?
Secondary lesions include: excoriations, ulcerations, hemorrhagic crusts and lichenification (these may replace the primary lesions due to the intense itch)
Where is scabies found?
Lesions are found on the finger webs, finger margins, flexor surface of the wrists, elbows, axillary folds and ankles
What are the symptoms of Scabies?
Itching (especially at night) that progressively worsens over 2-3 weeks and can persist indefinitely, thus the appellation, “the seven year itch”
Rash on hands, feet, wrists umbilicus, waistband area, axillae, ankles, buttocks, or groin
Symptoms (rash and itching) in several members in the same family
How do you diagnose scabies?
Diagnosis is made by identifying scabies mites, eggs, egg casings (hatched eggs) or feces (scybala) under the microscope. This is called a ectoparasite examination.
What is Ectoparasite Examination?
A drop of mineral oil is applied to the most likely lesion (usually a vesicle on the finger web or wrist is chosen). The site is then scraped with a 15-surgical blade. (Remember, to scrape con gusto! No bleeding, no bug). The scrapings are placed on a glass slide, a cover slip is applied, and examinated on low power under the microscope.
How do you treat Scabies?
After a warm bath apply permethrin (Elimite cream, Acticin cream) or lindane (Kwell) cream or lotion (only used if other agents fail or are not tolerated) to skin from “head to toe” and wash off 12 hours later, usually overnight. Repeat 1 week later.
Nails should be cut short and medication should be applied under nails vigorously with a toothbrush.
If indicated, other family members and contacts should be treated simultaneously
All bed linen and undergarments should be washed in hot water after treatment is completed
What kind of follow-up should you do with Scabies?
Because of resistance, careful follow-up and a possible second treatment should be considered. Have patients RTC 2 to 4 weeks after treatment. Remember, symptoms or nodules may persist for weeks or months after the mites have been eradicated on the buttocks, groin, scrotum, penis, and axillae.

It is normal to itch for up to 2 months after treatment
Erythema with scale-forming yellowish plaques on the eyebrows, nasolabial folds, glabella, and presternal area best describes:
Seborrheic Dermatitis
An acute eruption of violaceous, pruritic, polygonal, shiny, flat-topped papules involving the flexor surfaces is suggestive of which of the following?
Lichen Planus
Which of the following diseae can affect the skin, nails, and joints?
A 19-year-old presents with a minimally pruritic rash as seen on the other side.

The lesion on the right arm
was the first to appear
followed a week later by the
remaining lesions.
What is the most likely diagnosis?

Pityriasis Rosea
Thickening of the epidermis secondary to scratching best describes:
Lichen Simplex Chronicus
Oil spots is pathognomonic for:
What are the 4 key ingredients for acne?
Follicular hyperkeratinization
P. acnes
Sebum overproduction
What is the most common cause of acne?
Hormones and Stress
What's the scientific name for clogged pores?
What are white heads?
Closed comedones
What are black heads?
Open comedones
What are 3 inflammatory lesions of acne?
Red papules
What is your differential diagnosis for acne?
Acne Vulgaris
Perioral Dermatitis
Acne-like Drug Eruptions
Gram Negative Folliculitis
Pseudofolliculitis Barbae
“Hot-tub” Pseudomonas Folliculitis
What labs are required to diagnose acne?
No laboratory examinations required. However, if there is a suspicion of endocrine disorder free testosterone, follicle-stimulating hormone, luteinizing hormone, and DHEAS should be tested to exclude hyperandrogenism and polycystic ovary syndrome. (Note: In the overwhelming majority of acne patients, hormonal levels are normal).
What would you expect to see on physical exam of Grade I: Superficial, non-inflammatory?
Open/Closed comedones.
What would you expec to see on physical exam of Grade II: Superficial Inflammation
Comedones, mild to moderate papules/pustules
What would you expect to see on physical exam of Grade III: Deep Inflammatory
Moderate papules/pustules, few nodules
What would you expect to see on physical exam of Grade IV: Severe Nodulystic
Papules, pustules, multiple nodules, cysts
What grade of acne?
Grade I-II: Comedonal Acne
What grade of acne?
Grade III: papulo/papulopustular acne.
What grade of acne?
Grade IV: Nodulocystic Acne
How do you treat Grade I acne?
First Line
Topical retinoids
Benzoyl peroxide
Comedone extraction

Second Line
Alpha hydroxy acid products
Salicylic acid products
How do you treat Grade II acne?
First Line
Topical retinoids
Benzoyl peroxide
Topical antibiotics

Second Line
Azelaic acid
How do you treat Grade III acne?
First Line
Topical retinoids
Topical benzoyl peroxide
Oral antibiotics

Second Line
Intralesional steroid injections
Hormonal therapies
How do you treat Grade IV acne?
First Line
Isotretinoin, isotretinoin, isotretinoin…
Oral contraceptives

Second Line
Intralesional steroid injections
Incision and drainage of cysts
Short courses of Prednisone
How do Comedolytics work?
Combat clumping of cells and follicular plugging, anti-inflammatory.
How does Benzoyl Peroxide work?
Anti-inflammatory, antimicrobial to P. acnes (prevents development of antibiotic resistant P. acnes strains).
How do oral antibiotics work for treating acne?
Target P. acnes, anti-inflammatory
How do hormonal therapies work for treating acne?
Hormonal Therapies: Reduce circulating androgens
What antibiotic could cause Steven-Johnson Syndrome?
SMX/TMP (Bactrim)
How does Isotretinoin (Accutane) work?
*Oral retinoid (isotretinoin): Decreases sebum, corrects epidermal desquamation, anti-inflammatory, antimicrobial
Usually 20-week therapy

Metabolized in liver, thus liver disease/cirrhosis is contraindicated.
What precautions must you follow when prescribing Isotretinoin?
Baseline labs
2 forms birth control (abstinence is one)
Labs each month: LFT, lipids, hcg
30 days of pills, no refills
Office visit each month
What are the standards in treating acne?
Combination therapy is standard of care for mild-moderate acne
Discontinue antibiotics when inflammatory lesions resolve (2-4 months)
Continue topical retinoids to maintain remission
Hormonal therapy is useful in androgen-driven acne
Isotretinoin is standard of care for severe acne
Acne, hirsutism, and irregular periods may be a sign of what disorders?
Hyperandrogenism and/or polycystic ovarian disease
"I leak."

"I have acne in my axilla."
Hidradenitis Suppurativa
What is Hidradenitis Suppurativa?
Acne in the axilla
Painful red papules and/or nodules
Inflamed discharging papules and/or nodules
Thighs, vulva, axilla
Double or bridged comedone
How do you treat Hidradenitis Suppurativa?
Incision and drainage
Weight loss
Intralesional injections (Kenalog 2.5 to 10 mg/ml)
Antibiotics (Minocycline 100 mg BID)
Isotretinoin (1mg/kg/day x 20 weeks)
Surgical excision
Presents with a localized papular and eczematous eruption (scaly) with tiny pinpoint pustules in the perioral, perinasal, or periocular areas of the face
Lacks comedones, nodules and cysts
Topical acne medications will exacerbate the condition
The disease steroids made famous

Perioral Dermatitis
How do you treat Perioral Dermatits?
Simplify topical regimens (avoid routine use of moisturizers unless absolutely necessary)
Stop BPO or steroids
Mild to moderate cases use one or more of the following:
Metronidazole cream (MetroGel 1% or 0.75%) q d
Sodium sulfacetamide 10% (Klaron) qd
Clindamycin lotion qd
Erythromycin solution q d
Pimecrolimus cream 1% (Elidel), and tacrolimus 0.03%, 0.1% ointment (Protopic) may by helpful
Severe cases: Use a topical medication with an oral antibiotic for 4 to 6 weeks*
Doxycycline 100 mg BID
Tetracycline 500 mg BID
Minocycline 100 mg BID

*Once the condition is resolved, the antibiotic is stopped or tapered
45 yo female with history of flushing and red face, worse over past 5-6 years, now getting “pimples” and nose looks like “Rudolph’s” in family photos.

How does Rosacea present?
Complaining of episodic flushing, redness, and pimples on the face
Dry or red eyes, scratchiness, burning or tearing, and a sense of a foreign body being in the eye (ocular rosacea may precede skin manifestations in up to 20% of people)
Enlarged blood vessels on the cheeks
What precipitating factors can exacerbate rosacea?
Exposure to sun, stress, spicy foods, alcohol, hot drinks such as coffee, excessive washing of the face, or irritating cosmetics.
What would you expect to see on physical exam with Rosacea?
Papules and papulopustules on the central third of the face (forehead, nose, cheeks, and chin- the so called “flush/blush” areas)
Telangiestases and marked sebaceous hyperplasia
Blepharoconjunctivitis (red, scratchy eyes)
Rhinophyma (enlarged nose)
What serious disease can develop secondary to rosacea?
Corneal ulcers
How do you treat Rosacea?
Patients should be advised to avoid significant environmental triggers
Apply a daily sunscreen
Topical medications such as Metrogel 1% qd or Finacea gel qd are the most frequently prescribed first line therapy. Sodium sulfacetamide and sulfur topicals such as Klaron, Rosac, Plexion are also effective and used BID.
How do you treat Rosacea if topical treatment is ineffective?
If topical treatment is ineffective, an oral antibiotic can be prescribed. Tetracycline 500 mg BID or doxycycline 100 mg BID noticeably improves rosacea within 3 weeks. Oracea, an anti-inflammatory low-dose doxycycline, is also effective and taken 40 mg qd.
How do you treat Rosacea if tetracycline and doxycycline are ineffective?
If tetracycline or doxycycline is not effective there are alternative antibiotics that can be used such as amoxicillin, azithromycin, or clarithromycin
Pulse Dye Lasers and Intense Pulsed Light are light treatments that can be used to destroy larger telangiectatic vessels
Pimples and pustules in hair-bearing areas such as the face, scalp, thighs, chest and body folds. The patient usually describes them as “razor bumps” or “ingrown hairs”.
Sore on the distal nose, near the tip of the nose, or involving an eyelash
Papules may be itchy
Clean gym-strict about cleaning equipment
Treadmill, weight machines
Takes a shower at gym after soaking in hot tub

Folliculitis caused by Pseudomonas aeruginosa
What is the differential diagnosis for folliculitis?
Insect bites
Folliculitis/Hot tub folliculitis
Acne vulgaris
Transient acantholytic disease (Grover’s disease)
What are the lesions associated with folliculitis?
Follicular papules, vesicles, pustules, may be crusted
How do you diagnose folliculitis?
In cases that are resistant to treatment, a bacterial culture should be done
Culturing and treating of family members should be considered in cases of chronic bacterial folliculitis
How do you treat folliculitis?
Encourage good personal hygiene, including bathing, hand washing, and keeping nails short and clean
Wash with an antibacterial soap such as a benzoyl peroxide preparation (Benzac AC 5% gel or wash)
Apply mupirocin 2% (Bactroban) to the NASAL vestibule TID x 5 days to eliminate the S. aureus carrier state
Treat with Dicloxacillin 250-500 mg QID or a cephalosporin, such as Cephalexin 1-4 g/day in two divided does. Minocycline 100 mg BID or Septra DS BID can be used for MRSA.
How do you treat Hot Tub Folliculitis?
Symptomatic relief-mild to mod topical steroid
Acetic acid compresses 20 minutes 2-4 times a day
If systemic involvement, persistent infections, or immunosuppressed consider oral fluoroquinolone- such as ciprofloxacin (ex: 500-750mg po bid x 7-14 days)
Prevention is preferred
Very common inherited condition
Benign hyperkertinization of hair follicles
Triceps, thighs, buttocks, and cheeks
Characteristic look and feel
rough small bumps-sandpaper texture
sometimes inflamed, excoriated, hyperpigmented
Asymptomatic to slightly pruritic
Treatment often prompted by cosmetic concerns
Often improves in adulthood

Keratosis Pilaris
How do you treat Keratosis Pilaris?
Soapless cleansers
Emollients and Keratolytics
Lactic acid lotions- AmLactin, Lac-Hydrin
Alpha-hydroxy acid lotions- Glytone, glycolic body lotions
Urea cream- Carmol
Salicylic acid- Salex
Topical steroid creams (short period only)
Topical retinoids
Onset is heralded by an aura of itching and burning 12 hours before a visible lesion
Lesions have recurred at approximately the same site each time
The patient clearly describes an evolution from a red welt to bump, blister, and crust
Evolution of each lesion is about 10 days from start to finish

Herpes Simplex Virus
What are the physical findings of herpes?
Vesicular lesions that can ulcerate or form a crust
Infrequently, regional lymphadenopathy occurs
How do you diagnose herpes?
The diagnosis of HSV is usually based on clinical appearance and history. When necessary, however, a Tzanck preparation can be done to determine the presence of HSV or VZV (it does not distinguish between these two viruses).
How do you treat herpes?
Options include one of the following:
Valacyclovir (Valtrex) 2 g twice daily for 1 day taken 12 hours apart
Famciclovir (Famvir) 500 mg, Single dose of 1500 mg
Acyclovir 400mg TID x 5 days

When should oral antivirals be prescribed for an HSV outbreak?
Oral antivirals must be administered during the prodromal stage (first 48 hours) for optimal results.
Not contagious.
Sharply demarcated rash on hands, elbows, knees.
Blister (HSV) is often aura to EM, but does not cause EM.
Tender, red rash on the face, particularly in and around the nose and mouth
Small bumps with honey-colored crusts or blisters

Describe the rash/lesions that are associated with impetigo.
Rash that spreads quickly and is poor to heal
Lesions are usually asymptomatic; however occasionally they itch and are painful
What kind of primary and secondary lesions make up impetigo?
Bullae or vesicles with clear contents
Plaques with peripheral scale
Crusts, typically honey-colored, but sometimes brown or hemorrhagic
Begins as a crust or thin-roofed, fragile vesicle or bulla that ruptures, leaving a oozing eruption capped with a thick, “honey-crusted” lesion that appears “stuck on”
What non-lesion physical findings are associated with Impetigo?
Regional lymphadenopathy
The face is commonly involved, particularly in and around the nose and mouth
Loose white peripheral scale
Hypopigmentation once rash is resolved
Hyperpigmentation once rash is resolved
How do you diagnose Impetigo?
Diagnosis is based on history and clinical appearance
Bacterial culture and sensitivity testing are recommended if standard topical or oral treatment does not result in improvement
50% of patients may have an increased white blood count
How do you treat Impetigo?
Use antibacterial soaps twice daily
Use a warm washcloth and antibacterial soap to gently remove the crusts. Crusts should be removed because they block the penetration of antibacterial ointments. Lesions can also be soaked in warm water TID to help soften crusting and ease debridement.
Apply Mupirocin 2% (Bactroban) ointment or cream TID to lesions and INSIDE OF NOSTRILS until lesions are cleared, usually 10 days. Once clear, mupirocin 2% ointment can also be applied inside the nostrils TID x 5 days each month to reduce bacterial colonization in the nares.
Use an oral antibiotic, such as cephalosporin (Keflex) 250 to 500 mg QID x 7 days or dicloxacillin 500 mg BID x 7 days in conjunction with topical antibiotics in those patients with widespread involvement. If bacterial cultures reveal MRSA tetracyclines, trimethoprim/sulfamethoxazole (Bactrim), clindamycin, or linezolid are effective oral antibiotics.
Good hygiene and hand washing should be encouraged. Household spread is common otherwise. If skin care is not reviewed with the patient, the chance of re-infection or persistent infection is high. Skin care details should include adjuvants to topical antibiotics. The easiest adjuvants to use for patients are the bleach bath (1 cup of bleach in a bathtub of 12 inches water and with supervision), mixing vinegar and water at a 1:4 ratio for rinsing the area, and chlorhexidine scrubs.
Acute phase: poorly defined erythematous patches, papules, and plaques with scale
Chronic phase: lichenification (thickening of the skin with accentuation of skin markings)

Atopic Dermatitis
What two diseases are associated with atopic dermatitis?
Asthma and allergic rhinitis

Triad of ectopy
1. Eczema (atopic dermatitis)
2. Allergies
3. Asthma
What are some physical findings you'd expect to see in atopic dermatitis?
*Allergic shiners
Morgan-Dennie lines
*Pityriasis alba
*Atopic palms
Keratosis Pilaris

*Most helpful findings in adult cases
How do you diagnose Atopic Dermatitis?
If there is a question of tinea, perform a KOH to differentiate between tinea and eczema
How do you treat Atopic Dermatitis (Nummular Eczema)?
Lubricate the skin with an emollient (Cetaphil cream, CeraVe cream) TID and immediately after bathing
Eliminate excessive lengthy bathing, hand washing, and abrasive washcloths. Use a gentle soap (Cetaphil) while bathing.
Do not scratch
Use Group V steroid creams of ointments for red, scaling skin BID x 2 weeks. Use I or II creams or ointments for lichenified skin BID x 2 weeks. When the condition is under control, the frequency and potency of the topical steroid is reduced and discontinued.
Antibiotics may be used to suppress S. aureus. Use cephalexin (Keflex) 500 mg BID x 10 days or Dicloxacillin 500 mg BID x 10 days.
Minimize airborne allergens and dust
Antihistamines are useful in treating children with coexistent allergies, hives or allergic rhinoconjunctivitis
In severe cases, use Prednisone 1mg/kg x 10-14 days
Phototherapy can induce remission in patients with recalcitrant chronic atopic dermatitis
How does the sliding scale treatment work for atopic dermatitis?
Ask the patient to point out pink, red, and white spots:
Basic Rules:
Short nails, short bath (3 min), cotton clothing, and cool environment; laundry- hypoallergenic detergent with no bleach or fabric softener
Bath care:
Antibacterial soap to skin from the neck down (do not use on face) for three minutes
Bath with one ounce of emollient bath oil for 3 minutes
After bath, pat dry. Do not rub. Apply emollient to entire body.
Emollient to entire body, even if no inflammation (nothing red or pink).
Medium strength topical steroid to red areas on body
Lower strength topical steroid to slightly red or pink areas on body
Lower strength topical steroid to pink or red areas on face
Emollient to all skin.
Emollient to entire body, even if no inflammation (nothing red or pink on body).
Medium strength topical steroid to red areas on body.
Lower strength topical steroid to slightly red or pink areas on body.
Lower strength topical steroid to pink or red areas on face.
Why wouldn't you use Triamcinalone for eczema?
Too potent for face
Not potent enough for body
Overwhelms antifungal properties in combo
Wrong vehicle in wrong place
Wrong medicine for wrong diagnosis
Too many large tubes with too many refills
Patients use it for other problems when not often indicated
What are three adverse effects of topical corticosteroids?
Atrophic Changes:
Skin Fragility
Masking or promotion of infections
Steroid exacerbated acne and acne-like conditions
What are three key differential features of allergic contact dermatitis (to differentiate between atopic dermatitis?)
More localized distribution
Varied spectrum of pruritis
No family history of atopy
What are the differential features of Dyshidrotic Eczema/Pompholyx?
>5% of all hand eczema cases
Recurrent vesicles and fissures
Symmetric over hands and feet
Regular hand barrier therapy important
Annular patch with distinctive raised, red, scaling, snake-like border, clearing areas in the center.
Lesions are annular, single or multiple, with central clearing, and a scaly “active border”

Tinea Corporis
Inflamed, scaly patches with areas of hair loss or hairs that are broken off close to the surface of the scalp (often called “black dot”). Tender pustular nodules or plaques called kerions may occur.
Tinea Capitis
lesions are bilateral, fan-shaped, or annular plaques with a slightly elevated scaly “active border”. It generally involves the upper thighs, the crural folds, and pubic area and buttocks but spare the scrotum and penis.
Tinea Cruris
Scale, maceration, and fissures on the foot.
Tinea Pedis
Thickened, crumbly nails, scale buildup under nails, nail discoloration.
Tinea Unguium (nail)
How do you diagnose fungus?
Do KOH: “If it scales, scrape it!”
Quick, easy to diagnose in office
Only 2 times KOH required:
1. Absolutely sure not fungus
2. Absolutely sure is fungus
How do you treat Tinea Corporis?
Use topical antifungal such as ketoconazole (Nizoral), econazole (Spectazole), oxiconazole (Oxistat) BID x 4 weeks or until lesions resolve
Use systemic antifungal agents, such as terbinafine (Lamisil) 250 mg po qd x 2-4 weeks when multiple lesions are present
How do you treat Tinea Capitis?
Topical therapy is INEFFECTIVE
Use micronized griseofluvin 20 to 25 mg/kg/day in divided doses with milk or food until clinically cured, generally 2 to 4 months
How do you treat Tinea Cruris?
Use broad spectrum antifungal agents such as ketoconazole (Nizoral), econazole (Spectazole), oxiconazole (Oxistat) BID x 4 weeks or until lesions resolve
Use a moderate strength steroid (Westcort 0.2% cream) BID x 10 days in combination with a topical antifungal
How do you treat Tinea Pedis?
Use broad-spectrum antifungal agents such as ketoconazole (Nizoral), ciclopirox (Loprox), or clotrimazole (Lotrimin) applied BID x 1 month, then qd x 1 month
Use Burrow’s solution compresses TID x 10 min for oozing and maceration
Keep feet dry (especially between the toes), frequently change socks, and decrease wetness by airing shoes out regularly
How do you treat Tinea Unguium?
Topical therapy is ineffective
Use terbinafine (Lamisil) 250 mg/day x 6 weeks for fingernails and 250 mg/day x 12 weeks for toenails
The main symptoms are reddish-brown slightly scaly patches with sharp borders. The patches occur in moist areas such as the groin, armpit, and skin folds. They may itch slightly and often look like patches associated with other fungal infections, such as ringworm.

What bacteria causes erythrasma?
Corynebacterium minutissimum
How do you diagnose Erythrasma?
Examination with a Wood’s lamp will usually produce a pink or coral-red fluorescence
KOH is negative
How do you treat erythrasma?
Topical antibacterials
Azole-group antifungals (clotrimazole, econazole, miconazole, oxiconazole, tioconazole)
Clindamycin lotion, erythromycin lotion
Systemic therapy
Erythromycin, azithromycin
Posttreatment prophylaxis
Cleansing with antibacterial soap, loose clothing, proper aeration of intertriginous ski
A common superficial YEAST caused by the hyphal form of Malassezia furfur (previously known as Pityrosporum ovale and Pityrosporum orbiculare)

Patients present because of cosmetic concerns about their “blotchy pigmention” otherwise seen as hypopigmented or hyperpimented macules on the upper back, chest, arms, face, and legs
Occasionally, mild pruritis

Tinea Vesicolor
What's the distribution of Tinea Vesicolor?
Distributed to central regions: upper trunk, upper arms, neck, abdomen, axillae (spares creases or intertriginous areas)
How do you diagnose Tinea Vesicolor?
KOH examination is positive, which have been described as having the appearance of “spaghetti and meatballs”
Wood’s light examination is used to demonstrate the extent of the infection and my help to confirm the diagnosis, because lesions often fluoresce an orange-mustard color when the Wood’s light is help close to lesions in a dark room
How do you treat Tinea Vesicolor?
Topical treatment includes: Ketoconazole 2% shampoo applied for 10 minutes daily, followed by a shower, or selenium sulfide suspension 2.5% applied for 10 minutes, followed by a shower, every day for 7 consecutive days
Oral treatment may be used in patients with extensive disease and those who do not respond to convention treatment or have frequent recurrences. Options include a single dose of Ketoconazole (Nizoral) 400 mg and repeated in 7 days if needed or Fluconazole (Diflucan) 300-400 mg given as a single dose and repeated if needed after 2 weeks.
Prophylactic application of ketoconazole cream or shampoo once or twice weekly may prevent recurrences
Idiopathic, asymptomatic, ring shaped grouping of dermal papules
Lesions are skin-colored or red firm papules, with no epidermal change (scale)
Although any part of the cutaneous surface may be involved, lesions are most often symmetrically distributed on dorsal surfaces of hands, fingers, feet

Graunuloma Annular
How do you treat Granuloma Annular?
The patient should be reassured of the benign nature of this condition
Potent topical steroids
Intralesional triamcinolone acetonide (Kenalog) in a dose of 2 to 4 mg/mL with a 30-gauge needle. This may be repeated in 4 to 6 week intervals.

Sometimes with a punch biopsy, the GA will go away.
Itching is produced by sensory nerve irritation as it turns sharply and enters the spinal canal
No cutaneous manifestations in acute cases
Lichenified and hyperpigmentation seen in chronic cases
Treatment: Inexpensive back scratcher!

Nostalgia Paresthetica
A Tzank smear demonstrating multinucleated giant cells indicates which condition?

Tinea Versicolor
Herpes Simplex Virus (HSV)
Mupirocin (Bactroban) ointment is indicated for the treatment of a localized case of:

Atopic Dermatitis
Tinea Pedis
Which of the following does NOT exacerbate the flushing of rosacea:

Cigarette smoking
Spicy foods
Cigarette Smoking
Comedonal acne is best treated with:

Benzoyl peroxide
Topical antibiotics
Oral antibiotics
How do you know if a lesion is worrisome?
First, know what normal looks like!
Second, ask questions
Is it changing in size, color, or shape?
Is it bleeding?
Does it “come and go” or does it stay?
How long has it been there?
Generally flat (macule) brown with melanocytic nests at the junction of the dermis and epidermis
Junctional Nevus
Brown papule with combined histiologic features of junctional and dermal nevi
Compound Nevus
Skin colored or light brown (pinkish) raised (papule) with nests of melanocytes in the dermis
Dermal Nevus
Well circumscribed, round or ovoid lesions
2-6 mm in diameter
Lesions vary greatly in size, histologic characteristic overlap, surface appearance, hair or no hair
Blue, red, gray and black are not usually seen in these nevi

Can look like "fried egg"
Benign Melanocytic Nevi
Subcutaneous squamous epithelial lining (sac wall) with contained keratinous debris
Scalp variant known as pilar cyst
Scrotal lesions often multiple
Favored sites are head region, neck and trunk
Variable clinical course
Inflammation when contents “leak” into dermis
Multiple lesions in children or in adults
Epidermal Cyst
Epidermal Cyst

If fixed, worry about carcinoma.
Pilar Cyst

Not fixed. Get bigger with time. SEND TO PATHOLOGY!
Halo Nevus
Sebhorreic Keratosis
Most common macules, papules, plaques over the age of 30
Verrucous, waxy, velvety- tan black
“Stuck On”
Face, neck, trunk not palms, soles, or mucous membranes
Single, but often multiple
Not true moles
Thickened epidermis basaloid or squamous cells
Various colors white, pink, brown, black and all in between
Sebhorreic Keratosis
Sudden outbreak of multiple SKs can signal underlying visceral cancer (most commmon Stomach Adenoma)
Sign of Leser Trelat
SK Treatment
If there is any question regarding the clinical diagnosis, shave biopsy (removal) is imperative
Some will describe irritation, itching… when removing, important to note irritated seborrheic keratoses and method of removal for insurance purposes
Cryotherapy is appropriate, with immediate follow-up if the lesion has not resolved in 30 days
Fibrous growth found on the distal limbs and upper back
Irregular tan pigmentation and a fuzzy border
Palpation will reveal a firm button-like tumor in the dermis and, with lateral compression, the lesion will depress downward (a positive “pucker” sign)
Usually bright red
May be multiple
Middle-age to elderly
Trunk> extremities

Can remove with cauterization
Cherry Angioma
Very common in persons will oily complexions
Rasied papules with a central dell 3 to 7 mm in size
White or yellowish in color
Central face > trunk
May mimic basal cell carcinoma (BCC)
Sebaceous Hyperplasia
Dark red-violaceous
On the lips and ears
Venous Lake
Venous Lake
Caused by inflammed cartilage secondary to sun exposure

Chondrodermatitis nodularis chronicua helicus (CNH)
Most common form of skin cancer
Pearly boder with telangestasia on outer rim, not in center.
Metastasis is rare and usually associated only with tumors that have been neglected
Treatment is needed to prevent local destruction of normal tissue
A suspected BCC should be biopsied both to establish the diagnosis and treatment
Basal Cell Carcinoma
What are the 5 types of basal cell carcinoma?
Nodular (most common): smooth, translucent gray to gray-pink papule or nodule
Ulcerating: central punched-out ulcer and a raised translucent border
Pigmented: papules or nodules with flecks of brown pigmentation interspersed with gray translucent areas
Morpheiform: yellow papules or plaques with dilated surface vessels
Superficial: shallow plaque with a pearly border
How do you treat basal cell carcinoma?
Electrodessication and
Imiquimod (Aldara)
MOHS micrographic surgery

*Most appropriate therapy depends on size, location, histologic subtype of tumor
Basal Call Carcinoma
Basal Cell Carcinoma
Skin Tags
Cherry Angioma
Sebaceous Hyperplasia
Earliest lesions of squamous cell carcinoma (SCC) in sun damaged skin
More easily palpated than seen
Rough texture like sandpaper
Pinkish color: varying sizes
Sometimes will be tender or pruritic; most often asymptomatic
Usually multiple
If untreated, these lesions may progress into a squamous cell carcinoma
Actinic Keratosis

(If a presumed actinic keratosis has recurred after 2 treatments, a biopsy is warranted to rule out squamous cell carcinoma.)
Treating Actinic Keratosis (AK)
Liquid nitrogen: “freezing” or “burning”, causes focal ‘frost bite’ destroying the abnormal tissue, allowing the area to heal with healthy epidermis
Topical chemotherapy: application of a topical agent, usually over 3-6 weeks, that will destroy the trouble spots. This is useful when it is difficult to determine the borders of the lesion or when there are too many lesions to destroy individually.
Erythematous keratotic papule
Sun-damaged skin
Slow or rapid growth
May bleed or ulcerate
May metastasize
Malignant neoplasm of keratinocytes derived from the epidermis in which tumor cells have invaded the dermis
May invade locally into fat, muscle, bone or cartilage
Can metastasize to regional nodes and distant sites
Is generally slow growing
Squamous Cell Carcinoma
Keratotic, crusted nodule in sun-exposed area
Most frequent risk factor is chronic UV damage
Treatment similar to BCC
Most common skin cancer in immunosuppressed patients
Squamous Cell Carcinoma
Arise quickly
Middle-aged to elderly
Sun-exposed surfaces
Dome shaped
Hyperkeratotic center
Frequently SCC
Frequently seen in children
Pink to red-brown
Papule/ Nodule
Bleed very easily
Head, Neck > trunk
Treat as melanoma...can be preursor.
Spitz Nevi
Melanoma ABCs
A- Asymmetry
B-Border Irregularity
C- Color
D- Diameter > 6mm
E- Evolution

Itching can also be early symtom (may be tenderness)
Melanoma Risk Factors
Red or blond hair
Marked freckling on the upper back
Family history of melanoma
Actinic keratosis
Outdoor teen summer job
What to tell patients with melanoma, or those at high risk.
Avoid unnecessary sun exposure.
Seek the shade.
Cover with clothing.
Wear a broad-spectrum sunscreen with SPF 30 or higher.
Avoid tanning parlors.
Examine skin every month, professionaly every year.
Treatming Melanoma
Adjuvant medical treatment
High-dose Interferon only FDA approved therapy
Some prolongation of relapse-free survival, unclear if overall survival is improved
No other treatment: chemotherapy, radiation, vaccines, proven yet to improve survival
A 1-cm pearly papule with central umbilication and telangiectasias on the left temple of a 67-year-old male is most likely:

Basal Cell Carcinoma
Sebaceous gland hyperplasia
Basal Cell Carcinoma
Spitz Nevi
Spitz Nevus
Squamous Cell Carcinoma
Squamous Cell carcinoma
Basal Cell Carcinoma
Basal Cell Carcinoma
The use of cold temperature to treat disease
Cause epidermal-dermal separation above the basement membrane
Stinging, burning pain that peaks during thawing (about 2 minutes after treatment is over)
Intense edema or a blister forms 3 to 6 hours later, flattens in 2 to 3 days, and sloughs off in 2 to 4 weeks
Treatment of choice for verruca vulgaris
Treatment of choice for Actinic Keratosis
Proper method of biopsy for Acrochordan (skin tag)
Lesions appropriate to shave for biopsy
Basal cell carcinoma
Squamous cell carcinoma
Hypertrophic actinic keratosis
Lesions apprpriate to punch for biopsy
Basal cell carcinoma
Squamous cell carcinoma
Proper method to biopsy a rash or inflammatory condition
Punch a new lesion and one not excoriated
Proper method to biopsy a blister or bullous.
Punch straddles the blister edge and normal skin
Areas to discuss before performing biopsy.
Patient medication allergies
Is patient anti-coagulated (Coumadin, Plavix, ASA)
Does patient have a pacemaker?
Previous vasovagal reactions
Informed patient consent
Discuss the actual procedure and anticipated diagnosis
Scar, Bleeding, Infection, Recurrence
Discuss potential complications
Methods to making a less painful injection
Inject needle quickly and smoothly
Infiltrate slowly
Use small needle (30 gauge)
Use topical anesthesia-cryo or cream
Distract patient
Verbal distraction (talk about puppies)
Mechanical distraction (pinch)
Sodium Bicarbonate reduces pain
Biopsy Techniques
Signs and symptoms of analgesic overdose
Perioral and digital numbness
Lightheadedness, tinnitus, visual disturbances
Fine twitching and seizures
CV symptoms- hypotension, arrhythmias, respiratory and cardiac arrest
Used to remove lesion in total
Used to sample some of large lesion
Best biopsy for blistering or inflammatory conditions
Usually sutured or left to granulate
Anesthesia need to be deeper in skin
Punch biopsy
Allows pathologist to see entire lesion
Used to remove entire lesion
Deeper anesthesia
Usually performed with sterile technique
Always closed with sutures
Try to orient with skin tension lines
Shape of the incision made during excision
Suture Removal Timetable