Dermatology PANCE and PANRE Blueprint PEARLS

Eczematous Eruptions (PEARLS)

Papulosquamous Diseases (PEARLS)

Many diseases can mimic pityriasis rosea including drug exanthems, but the most worrisome condition to be ruled out is secondary syphilis. Topical or systemic steroids and antihistamines are often used to relieve itching. Asymptomatic lesions do not require treatment.

pityriasis rosea

Patients may also present with no rash and only joint symptoms - pain in both hands and nail changes such as pitting and onycholysis

Psoriasis

Desquamation (PEARLS)

Vesicular Bullae (PEARLS)

Diagnosis is made by skin biopsy with direct immunofluorescence exam shows deposition of IgG and C3 basement membrane, treat with corticosteroids (topical or oral)

Bullous Pemphigoid

Acneiform Lesions (PEARLS)

1. Mild: comedones (+/- small amounts of papules and pustules)
2. Moderate: comedones, larger amounts of papules and pustules
3. Severe: nodular or cystic acne

Grade 4 Nodulocystic Acne

Verrucous Lesions (PEARLS)

Insects/Parasites (PEARLS)

Permethrin topical is the drug of choice:

• Capitis: shampoo x 10 minutes
• Pubis: permethrin lotion x 8 hours.

Lice and nits on the scalp

Widow spider bites (may not see much at bite site) cause generalized muscle pain, spasms and rigidity

Two painful superficial ulcers with necrotic centers and red borders involved the lower abdomen and upper thigh of two days duration. The patient gave history of a spider sting one day before the appearance of the lesions.

Dermatologic Neoplasms (PEARLS)

A = asymmetry, B= border (irregular), C= color (varied), D=diameter (increasing or > 6mm), E= elevation (raised), Prognosis of a melanoma is most strongly associated with the depth of the lesion

Clark Classification System of Microstaging

1. Level I: Confined to the epidermis (in situ)
2. Level II: Invasion into the papillary dermis
3. Level III: Penetration to the papillary-reticular interface
4. Level IV: Invasion into the reticular dermis
5. Level V: Penetration into subcutaneous fat

Melanoma

Cutaneous SCCs present as enlarging scaly or crusted lumps. They usually arise within pre-existing actinic keratosis or intraepidermal carcinoma.

• They grow over weeks to months
• They may ulcerate
• They are often tender or painful
• Located on sun-exposed sites, particularly the face, lips, ears, hands, forearms and lower legs
• Size varies from a few millimetres to several centimetres in diameter.

Squamous cell carcinoma

Hair and Nails (PEARLS)

• Tinea capitis: hair loss secondary to fungal infection of scalp.
• Alopecia areata: immune system attack against hair follicles
• Traction alopecia: caused primarily by pulling force being applied to the hair.
• Telogen effluvium: a scalp disorder characterized by the thinning or shedding of hair resulting from the early entry of hair in the telogen phase (the resting phase of the hair follicle)
  • Alopecia is preceded by a psychologically or physically stressful event 6–16 weeks prior to the onset of hair loss.
  • Growing hairs convert rapidly to resting hairs.

alopecia areata

Incision and drainage of abscess, if present. Tetanus booster if indicated. Candida in chronic and staph aureus in acute.

Acute paronychia. Visible swelling, erythema, and discharge along the nail fold, yet the nail itself is intact.

Viral Diseases (PEARLS)

The HPV quadrivalent vaccine (Gardasil) protects against 6 and 11 and the 2 most cancer-promoting types, 16 and 18, treated with Imiquimod (Aldara), Podofilox, Cryotherapy, surgery, or TCA

Condyloma acuminatum of the penis. Raised, circumscribed, cauliflower-like lesions are seen on the shaft of the penis.

Roseola

Coxsackie virus: HAND FOOT and MOUTH DISEASE, part of enterovirus family, MC in children < 5, vesicular lesions on a reddened base, herpangina causing sudden onset of high fevers and stomatitis (see rashes that affects the palms and soles)

coxsackievirus A-16

Rubeola (measles): 3 C's: cough, coryza, conjunctivitis along with Koplik spots (small red spots in buccal mucosa with blue white pale center) precedes rash by 24-48 hours - morbilliform (maculopapular_ brick red rash on face beginning at hairline then progressing to palms and soles last - rash lasts 7 days

Rubeola

Rubella (german measles): "3 day rash" lymphadenopathy (posterior cervical, posterior auricular) - pink light-red spotted maculopapular rash on face (lasts 3 days)

• Distribution is similar to measles but lesions are less intensely red
• Teratogenic in 1'st trimester - congenital syndrome - deafness, cataracts, TTP, mental retardation

Rubella (German Measles)

Erythema infectiosum (fifth disease): Parvovirus B-19 - "slapped cheek" rash on face - lacy reticular rash on extremities, spares palms and soles resolves in 2-3 weeks

Erythema infectiosum - Symmetrical bright red cheeks, the rash does not extend over the bridge of the nose or around the mouth

Herpes Zoster (shingles) - groups of vesicles in a unilateral dermatomal pattern - Tzanck prep + for multinucleated giant cells

• Genital herpes is treated with antiviral drugs.
  • Acyclovir 800 mg po 2 times/day for 5 days, valacyclovir 1 g po q 12 h for 10 days, or famciclovir 250 mg po tid for 7 to 10 days can be used for primary eruptions
• Recurrent herpes labialis: Famciclovir 1,500 mg as one dose or valacyclovir 2 g po q 12 h for 1 day
• Patients with frequent eruptions (eg, >6 eruptions/yr) may receive suppressive antiviral therapy
  • acyclovir 400 mg po q 12 h, valacyclovir 500 to 1000 mg po once/day, or famciclovir 250 mg po q 12 h
• Herpes Zoster: Famciclovir 500 mg po tid for 7 days and valacyclovir 1 g po tid for 7 days

Genital Herpes Simplex

• Warts (verrucae) are benign growths that are confined to the epidermis.
• All warts are caused by the human papillomavirus (HPV) types 1, 2, 4, 27, and 29

Multiple warts on the hands

Bacterial Infections (PEARLS)

• Caused by S. aureus, group A strep, or in children H. influenzae or strep pneumonia.

Treat MRSA with:

• Clindamycin 300–450 mg PO
• Trimethoprim-sulfamethoxazole (TMP-SMZ) 1 DS tab PO BID
• Doxycycline 100 mg PO BID
• IV: Vancomycin Or Linezolid

Cellulitis with erythematous tender swelling of the left lower extremity

• Mild disease can be treated with Penicillin G

Erysipelas. This patient has large, confluent erythematous plaques. A bulla is present near the angle of her jaw.

Fungal Infections (PEARLS)

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.

• case example: A 20-year-old male with no significant past medical history presents complaining of patchy tanning. He states that he has been out in the sun without a shirt several times. Areas on his chest and back just don’t tan, and he is becoming self-conscious.

Tinea Versicolor (pityriasis versicolor)

Other Dermatological Conditions (PEARLS)

• Intralesional triamcinolone is 1'st line treatment

Hidradenitis suppurativa: axilla

• Look for sinus tract, treated with surgical repair

Pilonidal cyst

1. Stage I: erythema of localized area, usually non blanching over bony surface
2. Stage II: partial loss of dermal layer, resulting in pink ulceration
3. Stage III: full dermal loss often exposing subcutaneous tissue and fat
4. Stage IV: full thickness ulceration exposing bone, tendon, or muscle. Osteomyelitis may be present

Wound management by stage of ulcer

• Stage I: aggressive preventive measures, thin film dressings for protection
• Stage II: occlusive dressing to maintain healing, transparent films, hydrocolloids
• Stages III–IV: Débridement of necrotic tissue. Exudative ulcers will benefit from absorptive dressings such as calcium alginates, foams, hydrofibers. Dry ulcers require occlusive dressing to maintain moisture, including hydrocolloids, and hydrogels.

Pressure ulcer staging. (A) Stage I, erythema; (B) Stage II, breakdown of the dermis; (C) Stage III, full thickness skin breakdown; (D) Stage IV, bone, muscle, and supporting tissue involved.

(+) Darier's sign: localized urticaria appearing where the skin is rubbed (histamine release).

May have angioedema: painless, deeper form of urticaria affecting the lips, tongue, eyelids hand and genital. Anaphylaxis may occur (see treatment below).

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