PANCE Blueprint Dermatology (4%)

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PANCE Blueprint Dermatology (4%)

PANCE Blueprint Dermatology (4%)

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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 (Lecture)

      Perioral Dermatitis is a chronic inflammatory facial rash that commonly affects the perioral region, often triggered by topical corticosteroid use or irritants.
      • Most commonly affects women aged 16-45 years, though it can occur in children and men
      • Symptoms include clusters of erythematous papules and pustules around the mouth, sparing the vermilion border of the lips; may extend to the nasolabial folds and chin
      • Associated with itching, burning, or tightness, but systemic symptoms are absent
      • Triggers include prolonged use of topical corticosteroids, heavy face creams, fluorinated toothpaste, or hormonal changes
      • Diagnosis is clinical, based on the characteristic appearance and history of topical irritant exposure
      • Management involves discontinuing topical corticosteroids and irritants:
        • Topical treatments: First-line therapy includes metronidazole, clindamycin, or pimecrolimus
        • Oral antibiotics (e.g., tetracyclines such as doxycycline or minocycline) may be required for moderate to severe cases
      • Avoidance of heavy moisturizers, makeup, and irritants is essential during treatment

    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.

    4. Staphylococcal scalded skin syndrome (SSSS)

      Staphylococcal Scalded Skin Syndrome (SSSS) is a serious skin condition caused by exfoliative toxins from Staphylococcus aureus, leading to widespread epidermal blistering and desquamation.
      • Primarily affects infants and young children, but can also occur in immunocompromised adults
      • Caused by toxin-producing strains of S. aureus (exfoliative toxins A and B), which target desmoglein-1 in the epidermis, leading to intraepidermal splitting
      • Symptoms:
        • Fever, irritability, and tender erythema that rapidly spreads
        • Flaccid bullae and skin peeling resembling scalding, typically beginning around the mouth, eyes, and diaper area
        • Positive Nikolsky sign: Gentle pressure causes the skin to slough off
        • Mucous membranes are spared (helps differentiate from Stevens-Johnson syndrome)
      • Diagnosis:
        • Primarily clinical, based on presentation
        • Cultures from possible primary infection sites (e.g., nasopharynx, conjunctiva) may identify S. aureus, but skin lesions are sterile
        • Biopsy (if done) shows intraepidermal cleavage at the stratum granulosum without inflammation
      • Management:
        • Hospitalization, especially in infants or widespread disease
        • IV antistaphylococcal antibiotics (e.g., nafcillin, oxacillin, or vancomycin if MRSA is suspected)
        • Supportive care: Fluid and electrolyte replacement, wound care, and pain management similar to burn treatment
      • Prognosis: Excellent in children with early treatment; higher mortality in adults due to underlying comorbidities

  8. Diseases/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

    4. Felon

      Felon is an infection of the fingertip pulp space usually involving the thumb and index finger, typically caused by bacterial invasion, leading to a closed-space abscess
      • Penetrating trauma (e.g., splinters, nail biting) is the most common cause, but it can also be a complication of untreated раrοոyсhia
      • Most cases are caused by Staphylococcus aureus, including MRSA
      • Symptoms include severe throbbing pain, swelling, warmth, and erythema localized to the distal fingertip; may also exhibit tense pressure and fluctuation if an abscess has formed
      • Diagnosis is clinical, based on characteristic symptoms and physical findings; imaging (e.g., X-ray) may be needed to rule out osteomyelitis or foreign bodies
      • Early cases can be managed with warm soaks, elevation, and oral antibiotics (e.g., cephalexin or clindamycin/TMP-SMX for MRSA coverage)
      • Abscess formation requires surgical drainage via a lateral incision to avoid damage to the flexor tendon sheath

  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

  10. Dermatologic Infectious diseases (PEARLS)

      1. Abscess (ReelDx)

        Abscesses are localized collections of pus caused by infection, typically resulting from bacteria such as Staphylococcus aureus, including MRSA
        • Presents with pain, redness, swelling, and fluctuance over the affected area; may also cause fever if severe or systemic
        • Common locations include the skin (cutaneous abscesses), perianal region, or internal organs (e.g., liver, brain, lungs)
        • Diagnosis is primarily clinical, but imaging (e.g., ultrasound or CT scan) may be required for deeper abscesses to confirm location and size
        • Management involves:
          • Incision and drainage (I&D) as the mainstay of treatment for cutaneous abscesses
          • Antibiotic therapy for severe cases, systemic symptoms, or abscesses in high-risk patients; empiric coverage for MRSA is often necessary (e.g., clindamycin, trimethoprim-sulfamethoxazole, or vancomycin)
          • Percutaneous drainage under imaging guidance for deep abscesses
          • Surgical drainage for abscesses that do not respond to less invasive treatments or those with complications
        • Complications include spread of infection, sepsis, or chronic sinus formation if not adequately treated
        • Prevention involves addressing underlying risk factors (e.g., hygiene, immune suppression, or chronic wounds)

      2. 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

      3. 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

      4. 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. 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)

      3. Hand Foot and Mouth Disease (ReelDx)

        Hand, Foot, and Mouth Disease (HFMD) is a common, highly contagious viral illness caused primarily by coxsackievirus A16 and enterovirus 71, most frequently affecting children under 5 years
        • Presents with fever, followed by the development of painful oral ulcers, and a vesicular rash on the hands, feet, and buttocks (watch video)
        • Oral lesions typically begin as erythematous macules that evolve into vesicles, then ulcers, commonly on the tongue, buccal mucosa, and soft palate
        • Skin lesions are small, grayish vesicles on an erythematous base, usually located on the palms, soles, and buttocks
        • Transmission occurs via fecal-oral, respiratory droplets, or direct contact with infected secretions; highly contagious, especially in daycare settings
        • Diagnosis is clinical, based on characteristic symptoms and physical exam findings
        • Treatment is supportive: antipyretics for fever, hydration, and topical/oral analgesics for pain relief
        • Most cases resolve spontaneously within 7–10 days
        • Complications are rare but may include viral meningitis, encephalitis, or nail shedding (onychomadesis)
        • Preventive measures include good hand hygiene and disinfection of contaminated surfaces
        Hand Foot and Mouth Disease

      4. 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.

      5. Molluscum contagiosum (ReelDx)

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

      6. 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

      7. 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

  11. 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

  12. Dermatologic Neoplasms (PEARLS)

    1. Basal cell carcinoma

      Basal Cell Carcinoma (BCC) is the most common skin cancer, arising from basal cells in the epidermis, and is typically slow-growing with a very low risk of metastasis.
      • Strongly associated with chronic sun exposure, especially in fair-skinned individuals and those with a history of sunburns or tanning bed use
      • Most commonly found on sun-exposed areas: head, neck, face, and upper trunk
      • Classic presentation is a pearly papule or nodule with rolled borders, telangiectasia, and possible central ulceration (“rodent ulcer”)
      • Superficial BCC appears as a scaly, erythematous patch, often on the trunk
      • Pigmented BCC may mimic melanoma, appearing darker due to melanin
      • Diagnosis is confirmed with skin biopsy (shave or punch), showing characteristic basaloid cells with palisading nuclei
      • Treatment options include:
        • Surgical excision with clear margins (standard treatment)
        • Mohs micrographic surgery for cosmetically sensitive areas or recurrent lesions
        • Topical therapies (e.g., imiquimod, 5-FU) or curettage and electrodessication for superficial or low-risk lesions
        • Radiation therapy may be considered for non-surgical candidates
      • Prognosis is excellent, but local recurrence is common if not completely excised; regular follow-up and skin exams are recommended

    2. Kaposi sarcoma

      Kaposi Sarcoma is a vascular tumor associated with Human Herpesvirus-8 (HHV-8), commonly seen in immunocompromised patients, especially those with AIDS.
      • Presents as violaceous (purple), red, or brown macules, plaques, or nodules, commonly on the skin, oral mucosa, GI tract, or lungs
      • Most common sites include the lower extremities, face, oral cavity, and genitalia
      • Lesions may be painless or tender, and can ulcerate or bleed; visceral involvement can cause GI bleeding or respiratory symptoms
      • Strongly associated with HIV/AIDS, particularly when CD4 count <200 cells/mm³
      • Diagnosis is clinical and confirmed by skin biopsy, showing spindle cells, vascular proliferation, and HHV-8 positivity
      • Treatment depends on disease severity:
        • HAART (highly active antiretroviral therapy) is first-line in HIV-positive patients and often leads to regression of lesions
        • Local therapy (e.g., intralesional chemotherapy, radiation, cryotherapy) for isolated cutaneous lesions
        • Systemic chemotherapy (e.g., liposomal doxorubicin) for widespread or visceral involvement
      • Prognosis improves significantly with immune reconstitution in HIV-positive 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.

  13. Papulosquamous Disorders (PEARLS)

    1. Atopic dermatitis (ReelDx)

      Atopic Dermatitis is a chronic, relapsing inflammatory skin condition characterized by itchy, dry, and scaly skin, commonly associated with asthma, allergic rhinitis, and a family history of atopy.
      • Most common in children, but may persist or recur in adulthood
      • Triggered by allergens, irritants, heat, sweating, stress, and infection
        • Pruritus (itching) is the hallmark symptom
        • Dry, erythematous, scaly patches often affecting flexural areas in children and adults (e.g., elbows, knees, neck) and cheeks, scalp, and extensor surfaces in infants
        • Lichenification (thickening of skin from chronic scratching) and excoriations in chronic cases
      • DX is clinical based on history and distribution of skin lesions; no definitive diagnostic test
      • Complications include secondary bacterial infections (e.g., Staphylococcus aureus), eczema herpeticum, and sleep disturbances from severe itching
      • TX: Moisturizers/emollients are  the cornerstone of therapy to restore the skin barrier
        • Topical corticosteroids for acute flares (low potency on face, high potency on thick skin)
        • Topical calcineurin inhibitors (e.g., tacrolimus) as steroid-sparing agents
        • Antihistamines for itching (limited efficacy, more useful for sleep)
        • Systemic therapies (e.g., dupilumab, cyclosporine) for severe, refractory cases
        • Avoid triggers, use gentle skin care products, and maintain consistent skin hydration
      • Many children outgrow the condition, but some experience persistent or recurrent flares throughout life

    2. Contact dermatitis (ReelDx)

      Contact Dermatitis is a localized inflammatory skin reaction caused by direct contact with an irritant or allergen, leading to itching, redness, and rash
      • Two types:
        • Irritant (more common): Caused by soaps, solvents, chemicals, moisture
        • Allergic: Type IV hypersensitivity to nickel, poison ivy, latex, fragrances
      • Symptoms include itching, burning, erythema, vesicles, crusting, and scaling in areas of direct exposure
      • DX: clinical, based on history and rash pattern
        • Patch testing (GOLD STANDARD) for allergen identification (if allergic type suspected)
      • TX: Avoid triggers, topical corticosteroids (first-line), oral steroids for severe/widespread cases, antihistamines for itch, moisturizers/barrier creams for skin repair and prevention
      • Complications include secondary infection (e.g., impetigo), chronic thickened skin

    3. 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.

    4. Eczema

      Eczema, commonly known as dermatitis, 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.
      • Contact Dermatitis: Triggered by irritants (e.g., soaps) or allergens (e.g., nickel). Look for well-demarcated erythema and vesicles. Remove offending agent; use topical steroids.
      • Atopic Dermatitis: Chronic, itchy, flexural rashes, often in kids. Linked to genetics and allergens. Treat with emollients, topical steroids, or calcineurin inhibitors; severe cases may need phototherapy.
      • Seborrheic Dermatitis: Scaly, greasy patches on scalp/face/chest. Yeast-related. Use antifungal shampoos (ketoconazole) for scalp; low-potency steroids for face.
      • Perioral Dermatitis: Papulopustules around mouth, common in young women. Avoid topical steroids; use metronidazole or erythromycin; systemic antibiotics if persistent.
      • Nummular Eczema: Coin-shaped plaques on arms/legs. Mimics ringworm (KOH negative). High-potency steroids; consider phototherapy for severe cases.
      • Dyshidrotic Eczema: Itchy, “tapioca-like” vesicles on hands/feet. Common in adults <40. High-potency steroids; manage triggers like stress.
      • Stasis Dermatitis: Lower leg eczema with edema, hemosiderin staining. Tied to venous insufficiency. Compression therapy key; mid-potency steroids for inflammation.
      • Neurodermatitis (Lichen Simplex Chronicus): Thick, leathery skin from chronic scratching (e.g., neck, ankles). Break itch-scratch cycle with high-potency steroids, antihistamines.

    5. 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

    6. 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

    7. 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.

    8. Seborrheic dermatitis

      Seborrheic Dermatitis is a chronic inflammatory skin condition affecting sebaceous (oil-rich) areas, associated with Malassezia yeast overgrowth.
      • Commonly affects the scalp, face (nasolabial folds, eyebrows), ears, and chest
      • Presents with greasy, yellow scales overlying erythematous patches
      • Cradle cap is the infantile form, typically benign and self-limited
      • Pruritus may be present, especially in adults
      • More severe in patients with Parkinson disease and HIV
      • Diagnosis is clinical based on characteristic distribution and appearance
      • Treatment includes antifungal shampoos (ketoconazole, selenium sulfide), topical antifungals, and low-potency topical corticosteroids for flares
      • For cradle cap treatment involves mild shampooing and removal of scales with a soft brush
      • Chronic and relapsing course, but symptoms are controllable with maintenance therapy

  14. 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. Diabetic ulcers

      Diabetic ulcers are chronic, non-healing wounds, typically on the feet, caused by neuropathy, poor circulation, and impaired immunity in diabetic patients
      • Plantar surface, metatarsal heads, heels, and pressure points are common sites
      • Risk factors include peripheral neuropathy, PAD, foot deformities, poor footwear, prior ulcers, and poor glycemic control
      • Often painless, with surrounding callus, erythema, swelling; may show infection (purulence, odor) or signs of osteomyelitis
      • DX: Clinical exam, probe-to-bone, monofilament testing, cultures if infected, X-ray/MRI for osteomyelitis, ABI (may need toe pressures if falsely elevated)
      • Management:
        • Wound care: Debridement, moist dressings
        • Offloading: Total contact cast or protective footwear
        • Antibiotics: Empiric, then culture-directed
        • Glycemic control: Essential for healing
        • Revascularization: If PAD is severe
        • Surgery: For deep infection, gangrene, or nonresponse
      • Complications: Osteomyelitis, cellulitis, gangrene, amputation
      • Prevention: Daily foot checks, podiatric care, proper shoes, tight glucose control

  16. 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. Hemangioma

      Hemangiomas are benign vascular tumors caused by abnormal blood vessel proliferation, most common in infants
      • Infantile hemangioma (most common): Appears within weeks, grows rapidly, and involutes by age 5–10
      • Congenital hemangioma: Present at birth, may regress (rapidly involuting) or persist (non-involuting)
      • Common locations include the head, neck, trunk, and extremities; they may affect internal organs (e.g., liver)
        • Superficial: Bright red, raised, well-demarcated lesions (strawberry hemangiomas)
        • Deep: Blue or skin-colored subcutaneous masses
      • Complications include ulceration, bleeding, airway obstruction, high-output heart failure (large hepatic hemangiomas)
      • Diagnosis is clinical; ultrasound or MRI for deep/atypical lesions
      • Management:
        • Observation: Most involute spontaneously
        • Beta-blockers (propranolol): First-line for large or complicated hemangiomas
        • Topical timolol: For small, superficial lesions
        • Systemic corticosteroids/laser therapy: For resistant cases
        • Surgical excision: For symptomatic or persistent lesions (e.g., vision obstruction)
      • Prognosis: Excellent—most resolved by childhood without intervention

    3. Purpura

      Purpura is the appearance of purple, non-blanching skin lesions caused by bleeding into the skin or mucous membranes.
      • Results from capillary fragility, platelet disorders, coagulation abnormalities, or vasculitis
      • Lesions are non-blanching and larger than petechiae (>3 mm)
      • Palpable purpura suggests vasculitis (e.g., IgA vasculitis / Henoch–Schönlein purpura)
      • Non-palpable purpura is commonly due to thrombocytopenia or coagulation disorders
      • Common causes include immune thrombocytopenic purpura (ITP), DIC, scurvy, steroid use, aging (senile purpura), and anticoagulant therapy
      DX: Diagnosis is guided by CBC with platelets, coagulation studies (PT/INR, aPTT), and inflammatory markers; skin biopsy may be needed if vasculitis is suspected TX: Management depends on the underlying cause and may include treating platelet disorders, addressing coagulation defects, or immunosuppression for vasculitis
      • Presence of purpura with systemic symptoms (fever, hypotension, renal involvement) is concerning and requires urgent evaluation

    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

    5. Telangiectasia

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

  17. 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

  18. Other Dermatological Disorders (PEARLS)

    1. Acanthosis nigricans (ReelDx)

      Acanthosis Nigricans is a skin condition characterized by velvety, hyperpigmented, thickened plaques, typically occurring in intertriginous areas.
      • Most commonly found on the neck, axillae, groin, and under the breasts
      • Strongly associated with insulin resistance, especially in obesity, type 2 diabetes, and polycystic ovary syndrome (PCOS)
      • May also be a paraneoplastic sign, especially when sudden in onset, extensive, or occurring in non-obese individuals—most commonly linked to gastric adenocarcinoma
      • Diagnosis is clinical, based on characteristic skin findings and relevant history; a workup for underlying metabolic or malignant disease may be indicated depending on presentation
      • Management focuses on treating the underlying cause, particularly by controlling blood sugar levels, promoting weight loss, facilitating smoking cessation, and using Metformin
      • Topical treatments (e.g., keratolytics, retinoids) may improve appearance but are secondary to systemic management
      • Screening for malignancy is warranted in atypical or rapidly progressive cases, especially in older adults without obvious metabolic risk factors

    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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