PANCE Blueprint Dermatology (5%)

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PANCE Blueprint Dermatology (5%)

PANCE Blueprint Dermatology (5%)

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Follow along with the NCCPA™ PANCE AND PANRE Dermatology Content Blueprint

Lessons

  4. Dermatology 77 Question Comprehensive Exam

    Comprehensive PANCE/PANRE Dermatology Blueprint Exam

  5. Smarty PANCE Dermatology Flashcards and Cheat Sheet

    Flashcards covering all Dermatology PANCE/PANRE NCCPA Content Blueprint topics. Download and print the flashcard cheat sheet and access our premium Quizlet flashcard sets.

    1. Additional Dermatology Flashcards

  6. Acneiform Eruptions (PEARLS)

    1. Acne vulgaris (ReelDx)

      Characterized by areas of open comedones (blackheads) incomplete blockage, closed comedones (whiteheads) complete blockage, papules, pustules, nodules, or cysts. May result in scarring.

    2. Folliculitis

      Folliculitis is an infection of one or more of the hair follicles (pockets from which hair grows) characterized by papules and pustules
      • The lesions are erythematous papules or pustules. They are usually not painful but may burn
      • Commonly caused by S. aureus but can be caused by other organisms. Pseudomonas folliculitis is seen in hot tub users
      • Mupirocin ointment and topical benzoyl peroxide cream are first-line
      • In more extensive cases, oral antibiotics may be necessary - dicloxacillin and cephalexin. If methicillin-resistant S. aureus is suspected, patients should be treated with trimethoprim/sulfamethoxazole, clindamycin, or doxycycline

    3. Perioral dermatitis

    4. Rosacea

      Rosacea - women aged 30-50, facial erythema, telangiectasias, and papules, may cause rhinophyma. Triggers include heat, alcohol, spicy foods.
      • Differentiate from acne by lack of comedones (blackheads)
      • Treatment is topical metronidazole

  7. Desquamation (PEARLS)

    1. Erythema multiforme (ReelDx)

      Erythema multiforme (EM) is an acute, self-limited skin condition that is considered to be a type IV hypersensitivity reaction associated with certain infections - most commonly herpes simplex virus (HSV), medications (sulfa drugs), and other various triggers.
      • Skin lesions predominantly involving the extremities (hands, feet, and mucosa). Target-like shape, raised, blanching and lack of itchiness help characterize this rash.

    2. Stevens-Johnson syndrome

      SJS is 3-10% of the body - a rare, serious hypersensitivity complex that affects the skin and mucous membranes. It's usually a reaction to a medication or an infection commonly caused by anticonvulsants and sulfa drugs.
      • It begins with a prodrome of flu-like symptoms, followed by a painful red or purplish rash that spreads and blisters. Layers of skin peel away in sheets (+) Nikolsky's sign (pushing blister causes further separation from the dermis)

    3. Toxic epidermal necrolysis

      Toxic epidermal necrolysis (TEN) is > 30% of the body surface area - is a more severe form of Stevens-Johnson syndrome. More common in adults.

  8. Disorders of the Hair and Nails (PEARLS)

    1. Alopecia (ReelDx)

    2. Onychomycosis

      Onychomycosis: Thick, yellow, brittle nails. Treat 6 weeks for fingernails and 12 weeks for toenails. LFT monitoring is necessary for most oral antifungal regimens.

    3. Paronychia (ReelDx)

      Paronychia: Superficial inflammation of the lateral and posterior folds of skin surrounding the fingernail or toenail. Caused by candida if chronic and staph aureus if acute

  9. Envenomation and arthropod bite reactions (ReelDx)

    • Brown Recluse spider bites (necrotic wound) tend to cause pain, erythema, ecchymosis, and bleb formation, sometimes with surrounding ulceration and necrosis
    • Black Widow spider bites (neurologic manifestations) generalized muscle pain, spasms, and rigidity. May not see much at the bite site.
    Black Widow Spider BiteBrown Recluse Spider Bite

    2. Hand Foot and Mouth Disease (ReelDx)

      Children < 10 years old caused by coxsackievirus type A virus producing sores in the mouth and a rash on the hands, feet, mouth, and buttocks (watch video)
      • The virus usually clears up on its own within 10 days
      • Treatment is supportive, anti-inflammatories
      Hand Foot and Mouth Disease

    3. Measles (Rubeola)

      Measles is caused by a paramyxovirus and is transmitted by respiratory droplets. It has a 10-12 day incubation period. It progresses in three phases characterized by a prodrome, enanthem, and exanthem.
      • Prodrome: 1-3 days of "the three C's" - cough, coryza, conjunctivitis, as well as fever.
      • Enanthem (48 hours prior to exanthem) - Koplik spots - are pathognomonic for measles and present as small red spots with a blue-white center on the buccal mucosa.
      • Exanthem (2-4 days after onset of fever): consists of a morbilliform, brick red erythematous, maculopapular, blanching rash, which classically begins on the face and spreads cephalocaudally and centrifugally to involve the neck, upper trunk, lower trunk, and extremities.
      • Treatment is supportive with anti-inflammatories.
      Rubeola (Measles)

  11. Dermatologic Infectious diseases (PEARLS)

      1. Cellulitis (ReelDx)

        Cellulitis is an acute bacterial skin and skin structure infection of the dermis and subcutaneous tissue characterized by pain, erythema, warmth, and swelling. Margins are flat and not well demarcated. It is caused by Staphylococcus and Streptococcus in adults and H. influenzae or strep pneumonia in children.
        Cellulitis

      2. Erysipelas

        Erysipelas is a distinct form of cellulitis notable for acute, well-demarcated, raised superficial bacterial skin infection with lymphatic involvement
        • Almost always caused by streptococcus pyogenes
        • Treated with Penicillin G
        Erysipelas

      3. Impetigo (ReelDx)

        • Nonbullous impetigo: the most common form of impetigo caused by staphylococcus aureus or streptococcus pyogenes, characterized by golden honey-colored crusts around the nose, mouth, and extremities.
        • Bullous impetigo: staphylococcus aureus impetigo that progresses rapidly from small to large flaccid bullae (newborns/young children) caused by epidermolytic toxin release; less lymphadenopathy; trunk more often affected; < 30% of patients.
        • Mupirocin and retapamulin are first-line topical treatments. Cephalexin and dicloxacillin are appropriate first-line oral treatments.
        Impetigo

    2. Fungal Infections (PEARLS)

      1. Candidiasis (ReelDx)

        Beefy red, sharp, bordered rash with pinpoint satellite pustules at the edge of erythema. Potassium hydroxide wet mount of skin scrapings - budding yeast, hyphae, and pseudohyphae. Favors skinfolds/creases (axillae, groin, below breasts, and, in infants, diaper area). They are commonly associated with immunocompromising conditions in adults.
        • Oropharyngeal candidiasis causes white plaques on oral mucous membranes that may bleed when scraped and DO SCRAPE OFF (unlike oral leukoplakia, which does not scrape off) - Remember, oral candidiasis scrapes off
        • Vulvovaginal candidiasis: A yeast infection of the vagina and tissues at the opening of the vagina (vulva)
        • Candidiasis of skin and nails: An infection of the skin and nails caused by the candida fungus
        • Candida of the esophagus: Causes pain with swallowing
        • Oral thrush: An infection in which the fungus Candida albicans accumulates in the mouth
        • Diaper dermatitis: Candida can affect the diaper region of babies, causing a diaper rash with redness surrounded by scattered red spots that are called satellite lesions

      2. Dermatophyte Infections (ReelDx)

        KOH - long, branching fungal hyphae with septations
        • Tinea corporis: (ringworm): usually seen in younger children or in young adolescents with close physical contact with others (i.e., wrestlers)
        • Tinea Pedis: Athlete's Foot: pruritic scaly eruptions between toes. Trichophyton rubrum is the most common dermatophyte causing athlete’s foot  Mgmt: Topical antifungals
        • Tinea Cruris: “Jock Itch” diffusely red rash in the groin or on the scrotum.
        • Tinea capitis: The most common fungal infection in the pediatric population. Occurs mainly in prepubescent children (between ages 3 and 7 years). Asymptomatic carriers are common and contribute to the spread
        • Tinea manuum - Infection of the hand
        • Tinea Barbae: papules pustules, around hair follicles
        • Tinea versicolor: is caused by Malassezia furfur, a yeast found on the skin of humans. Lesions consist of hypo or hyperpigmented macules that do not tan
        • Tinea unguium (dermatophyte onychomycosis) – Infection of the nail

      1. Lice (ReelDx)

        Pruritic scalp, body, or groin. Nits are observed as small white specs on the hair shaft. Body (corporis), scalp (capitus), pubic (pubis). Launder potential fomites such as sheets in hot water (> 131 F or 55 C)

      2. Scabies (ReelDx)

        Pruritic papules, s-shaped, or linear burrows on the skin. Often located in web spaces of hands, wrists, waist with severe itching (worse at night), treated with topical permethrin, all clothing bedding, towels washed and dried using heat and have no contact with body for at least 72 hours.
        Scabies

    4. Viral Dermatologic Diseases (PEARLS)

      1. Condyloma acuminatum (genital warts)

        Genital warts - flesh-colored, cauliflower appearance  caused by HPV types 6 and 11
        • The HPV quadrivalent vaccine (Gardasil) protects against 6 and 11, and the 2 most cancer-promoting types, 16 and 18, indicated for females and males ages 9–26 years

      2. Herpes simplex (ReelDx)

        There are eight types of herpes viruses known to affect humans. They are called the Herpes Human Viruses (HHV). There are two types of Herpes Simplex viruses: HSV 1- Oral lesions and HSV 2 - Genital lesions.

      3. Molluscum contagiosum (ReelDx)

        Molluscum contagiosum: caused by the poxvirus, pearly papules with central umbilication

      4. Varicella-zoster virus infections (Lecture + ReelDx)

        • Chickenpox: Vesicular lesions in different stages of development. Dewdrop on rose petal
        • Shingles: Pain precedes rash groups of vesicles in a unilateral dermatomal pattern - Tzanck prep is positive for multinucleated giant cells. Hutchinson’s sign - lesion on the nose. Concern for eye involvement

      5. Verrucae (ReelDx)

        Warts: all warts are caused by the Human Papillomavirus (HPV)

        • Verruca vulgaris (common warts): skin colored papillomatous papules. Hands
        • Verruca plana (flat warts): face, arms, legs
        • Verrucae plantaris (plantar warts): bottom of the foot. Rough surface. Dark spot (thrombosed capillaries)
        • Condyloma acuminatum (venereal warts): flesh-colored, cauliflower appearance genital warts caused by HPV types 6 and 11

  12. Keratotic disorders (PEARLS)

    1. Actinic keratosis

      Actinic Keratosis - flesh-colored, pink or yellow-brown lesion with rough sandpaper feel, occurs on sun-exposed surfaces and is a precursor to squamous cell carcinoma

    2. Seborrheic keratosis

      Seborrheic keratosis - most common benign skin tumor seen in fair-skinned elderly patients with prolonged sun exposure, brown-black plaques with waxy, “stuck on” appearance, commonly referred to as barnacles of old age

  13. Dermatologic Neoplasms (PEARLS)

    1. Basal cell carcinoma

      Basal cell carcinoma (BCC) is the most common type of skin cancer and accounts for 90% of skin cancers in the U.S. It is common in fair-skinned individuals with a history of sun exposure
      • Classically presents as raised, pearly, rolled borders, telangiectasis, central ulcer, erythematous patch > 6 mm, or nonhealing ulcer in sun-exposed areas (face, trunk, lower legs)

    2. Kaposi sarcoma

      KS is a violaceous papular lesion associated with human herpesvirus 8 and is an AIDS-defining cancer
      • Kaposi sarcoma is most common when the CD4 count is below 100 in HIV patients

    3. Melanoma

      Melanoma is a tumor arising from malignant transformation of cells from the melanocytic system

      • ABCDE: Asymmetry, Border is irregular, Color variability (blue, red, white), Diameter (increasing or > 6 mm),  elevation (raised)
      • Prognosis of a melanoma is most strongly associated with the depth of the lesion, uses Clark Classification System of microstaging

    4. Squamous cell carcinoma

      Cutaneous SCC presents as enlarging hyperkeratotic macule, scaly, or crusted lumps. They often arise within pre-existing actinic keratosis.

  14. Papulosquamous Disorders (PEARLS)

    1. Dermatitis (ReelDx)

      Dermatitis, commonly known as eczema, is an inflammatory skin condition characterized by itchy, red, and inflamed patches of skin. The condition can be triggered by a variety of factors, including allergens, irritants, and stress. The terms dermatitis and eczema are often used interchangeably. Dermatitis can be acute, chronic, or both.

    2. Drug eruptions (ReelDx)

      An adverse cutaneous reaction in response to administration of a drug. Skin reactions are the most common adverse drug reactions. Severity can range from mild eruptions that resolve after the removal of the inciting agent to severe skin damage with multiorgan involvement.

    3. Lichen planus

      Lichen planus (LP) is a chronic papulosquamous inflammatory dermatosis of unknown etiology, probably autoimmune in origin
      • Clinically characterized by 5Ps - purple, papule, polygonal, pruritis, and planar
      • Wickham striae: whitish lines visible in the papules of lichen planus and other dermatoses

    4. Pityriasis rosea (ReelDx)

      Pityriasis rosea typically occurs in children and young adults. It is characterized by an initial herald patch, followed by the development of a diffuse papulosquamous rash.
      • Pityriasis rosea is easier to identify when the general eruption appears with smaller secondary lesions that follow Langer’s lines (cleavage lines) in a Christmas tree-like pattern.
      Pityriasis rosea

    5. Psoriasis (ReelDx)

      The classic clinical appearance is a well-demarcated, erythematous plaque with silver scaling. Patients may also present with no rash and only joint symptoms - pain in both hands and nail changes such as pitting and onycholysis.

  15. Pigment disorders (Pearls)

    1. Melasma

      Melasma: a hyperpigmented macules in sun-exposed areas, also known as chloasma, or the mask of pregnancy when present in pregnant women.

    1. Burns (ReelDx)

      Body percentage:
      • Rule of 9’s: Head 9%, Each arm 9%, Chest 9%, Abdomen 9%, Each anterior leg 9%, Each posterior leg 9%, Upper back 9%, Lower back 9%, Genitals 1%
      • Palmar method: Patient’s palm equates to 1%
      Degree involvement:

    2. Lacerations

      Suture removal — The timing of suture removal varies with the anatomic site
      • Eyelids – Three days
      • Neck – Three to four days
      • Face – Five days
      • Scalp – 7 to 14 days
      • Trunk and upper extremities – Seven days
      • Lower extremities – 8 to 10 days

    3. Pressure ulcers

      Sacrum and hip most often affected, reposition every 2 hours
      • Stage 1: erythema of localized area, usually non-blanching over bony surface
      • Stage 2: partial loss of dermal layer, resulting in pink ulceration
      • Stage 3: full dermal loss often exposing subcutaneous tissue and fat
      • Stage 4: full thickness ulceration exposing bone, tendon, or muscle. Osteomyelitis may be present

    4. Stasis dermatitis

      Stasis dermatitis is caused by fluid buildup due to varicose veins, poor circulation, or heart disease
      • Skin discoloration of the ankles or shins, itching, thickened skin, and open sores (ulcers) are symptoms
      • Treatments may include compression stockings and corticosteroid creams as well as treating the underlying condition
      • Systemic antibiotics for patients with more extensive infection and signs of cellulitis

  17. Vascular abnormalities (PEARLS)

    1. Cherry angioma

      Red moles, or cherry angiomas, are common skin growths that can develop on most areas of the body. The collection of small blood vessels inside a cherry angioma give them a reddish appearance
      • They're also known as senile angiomas or Campbell de Morgan spots
      • They're usually found on people aged 30 and older
      • These lesions generally do not require treatment
      • If they are cosmetically unappealing or are subject to bleeding angiomas may be removed by electrocautery or pulsed dye laser treatment

    2. Telangiectasia

      Dilated small blood vessels on the skin or mucous membranes anywhere in the body

  18. Vesiculobullous disease (PEARLS)

    1. Bullous pemphigoid

      Bullous pemphigoid is a rare, chronic acquired autoimmune subepidermal blistering skin disorder caused by linear deposition of autoantibodies against the epithelial basal membrane zone: IgG produced against the basement membrane.
      • Large bullae and crusts located on axillae, thighs, groin, and abdomen. More tense, less fragile, and deeper than pemphigus vulgaris.

    2. Pemphigus Vulgaris

      Pemphigus vulgaris (PV) is a potentially fatal autoimmune blistering disease characterized by painful mucocutaneous lesions and a positive Nikolsky sign (extension of blister or sloughing of skin with blunt pressure or lateral traction of skin)
      • Autoantibodies (IgG) against desmosome, which  disrupts keratinocyte adhesion and separation of the epidermis
      • Nonhealing and nonscarring ulcers persisting for at least 1 month, extremely painful, fragile blisters from mouth to elsewhere
      • Most common in those of Mediterranean or Jewish descent 40-60 years of age
      • Immunofluorescence of serum or blister material highlights intercellular deposition of IgG or C3 in a net-like (reticular) pattern
        • Biopsy proves acantholysis (separation of epidermal cells)
      • Systemic therapy is required. Start with oral prednisone, and then add immunosuppressive agents, azathioprine, and/ or methotrexate as needed

  19. Other Dermatological Disorders (PEARLS)

    1. Acanthosis nigricans (ReelDx)

      Acanthosis nigricans: Thick velvety hyperpigmentation and accentuated skin lines at skin folds - around the neck, armpits, and groin. Associated with insulin resistance - control blood sugars, weight loss, smoking cessation, Metformin.

    2. Hidradenitis suppurativa

      Hidradenitis suppurativa is a chronic follicular occlusive disease manifested as recurrent, tender, inflammatory nodules, abscesses, sinus tracts, and complex scar formation in the axilla and groin. Predominantly affecting women aged 20-30 and African Americans, the condition is often mistaken for bacterial folliculitis. HS is a progressive disease that can cause substantial emotional distress.

    3. Lipomas/epithelial inclusion cysts

      • Lipomas are benign growths of fat cells that are usually soft, homogeneous, oval, and nontender, with a rubbery or doughy consistency; if hard, suspect another diagnosis.
      • Epidermoid cysts, also called epidermal cysts, epidermal inclusion cysts, or, improperly, "sebaceous cysts," are the most common cutaneous cysts. They can occur anywhere on the body and typically present as asymptomatic, skin-colored dermal nodules, often with a clinically visible central punctum.

    4. Photosensitivity reactions

      Photosensitivity reactions include solar urticaria, chemical photosensitization, and polymorphous light eruption
      • Solar urticaria develops at a site of sun exposure within a few minutes. Lesions generally resolve within 24 hours
      • Chemical photosensitivity is a cutaneous reactions after sun exposure after ingestion or topical application substance (ex. isotretinoin and amiodarone)
      • Polymorphous light eruption is a common photosensitive reaction to UV and sometimes visible light not associated with systemic disease or drugs
      • Phototesting can help confirm the diagnosis
      • Avoid overexposure to sun, wear protective clothing, use sunscreens (prevention), topical corticosteroids, H1 blockers
      • Stop drugs or chemicals that cause photosensitivity
      • For polymorphous light eruption, other specific treatments include immunosuppressive therapy such as prednisone, azathioprine, cyclosporine, or hydroxychloroquine
      Photosensitivity reactions

    5. Pilonidal disease

      Pilonidal disease: A teenager with pain, discomfort, and swelling above the anus or near the tailbone (sacrococcygeal cleft) that comes and goes.
      Pilonidal disease

    6. Urticaria (ReelDx)

      Urticaria (hives): Pt will present with blanchable, edematous pink papules, wheels, or plaques
      • (+) Darier's sign: localized urticaria appearing where the skin is rubbed (histamine release)
      • Angioedema: a painless, deeper form of urticaria affecting the lips, tongue, eyelids, hand and genital
      • If anaphylaxis: Epinephrine: 0.3–0.5 mg; use 1:1,000 dilution for IM route and 1:10,000 for IV route (peds: epinephrine 0.01 mg/kg SC/IV)
      Urticaria (HIVES)

    1. Dyshidrosis (ReelDx)

      Tapioca vesicles on the lateral aspects of fingers, the central palm, and plantar surfaces following stress or hot, humid weather.

    2. Lichen simplex chronicus

      Lichen simplex chronicus (LSC) is a chronic dermatitis resulting from chronic, repeated rubbing or scratching of the skin. Skin becomes thickened with accentuated lines (“lichenification”). The constant scratching causes thick, leathery, brownish skin.

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