General Surgery Rotation

General Surgery: Dermatology (PEARLS)

The General Surgery End of Rotation Blueprint dermatology section covers eleven topics and represents 5% of your General Surgery EOR exam

Basal cell carcinoma A type of cancer that begins in the basal cells

  • Basal cells produce new skin cells as old ones die. Limiting sun exposure can help prevent these cells from becoming cancerous
  • Typically appears as a white waxy lump or a brown scaly patch, raised pearly and rolled borders, telangiectasis, central ulcer on sun-exposed areas, such as the face and neck
Treatments include prescription creams fluorouracil (FU) and imiquimodphotodynamic therapy (PDT), and surgical excision with clear margins

Basal Cell Carcinoma

Basal Cell Carcinoma

Burns 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:

Treatment: Monitor ABCs, fluid replacement, sulfadiazine. Children with > 10% total body surface area and adults with > 15% total body surface area burns need formal fluid resuscitation

rule9_lg

Cellulitis 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.

  • Caused by Staphylococcus and Streptococcus in adults
  • H. influenzae or strep pneumonia in children

TX:

Treat mild cellulitis (MSSA) with Cephalexin or Dicloxacillin

Treat methicillin-resistant Staphylococcus aureus infection (MRSA) with

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

Cellulitis with erythematous tender swelling of the left lower extremity

Cellulitis with erythematous tender swelling of the left lower extremity

Discharge Breast/nipple discharge

GU 

Other skin conditions

  • Abscess: pain, redness, with or without discharge
Drug eruptions (postoperative) Drug-induced exanthems are the most common cutaneous reactions to drugs, responsible for approximately 90 percent of all drug rashes

  • The most commonly prescribed medications (eg, antibiotics, sulfonamides) are implicated in most cases

Clinical evaluation and skin biopsy  - shows necrotic epithelium

  • Diagnosis is often obvious from the appearance of lesions and rapid progression of symptoms. Histologic examination of sloughed skin shows necrotic epithelium, a distinguishing feature.
  • Differential diagnosis in SJS and early TEN include erythema multiformeviral exanthems, and other drug rashes

Stop all potentially offending medications

  • Early admission to burn unit or pediatric intensive care unit for initial stabilization and management of fluid, electrolytes, and nutrition; airway stability; and eye care
  • Prompt ophthalmology and dermatology consultation
  • Intravenous immunoglobulin (IVIG)
  • Steroids used to be the treatment of choice are now thought to be an increased risk for sepsis
Melanoma Usually a pigmented lesion with an irregular border, irregular surface, or irregular coloration

Melanoma occurs when the pigment-producing cells that give color to the skin (melanocytes) become cancerous

  • Symptoms might include a new, unusual growth or a change in an existing mole. Melanomas can occur anywhere on the body
  • Asymmetrical, unevenly pigmented patch/plaque with a nodule and an irregular border

ABCDE: A symmetry, B order is irregular, C olor variability (blue, red, white), D iameter (increasing or > 6 mm), E levation (raised)

  • Prognosis of melanoma is most strongly associated with the depth of the lesion, based on the Clark Classification System of Microstaging

Clark Classification System of Microstaging

  • Level I: Confined to the epidermis (in situ)
  • Level II: Invasion into the papillary dermis
  • Level III: Penetration to the papillary-reticular interface
  • Level IV: Invasion into the reticular dermis
  • Level V: Penetration into the subcutaneous fat

Treatment may involve Mohs surgery, radiation, medications, or in some cases chemotherapy

Melanoma

Melanoma

Pressure ulcers Sacrum and hip most often affected, reposition every 2 hours

  • Stage 1: erythema of localized area, usually non-blanching over the 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

Wound management by stage of the 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.

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.

Rash Differential diagnosis:

  • Antibiotics Side Effects: Adverse antibiotic reactions may occasionally mimic infection by causing fever, skin rashes, and mental status changes
  • Zinc deficiency is characterized by a perioral pustular rash
  • Paget disease is a rare condition characterized by an intraepithelial adenocarcinoma of the perianal skin. The most common presenting complaint is intolerable pruritus and examination typically reveals a well-demarcated, erythematous, eczematous rash
  • Herpes zoster presents with classic vesicular lesions which develop unilaterally in a dermatomal distribution
  • Herpes simplex presents with clear vesicles on an erythematous base; crusting
  • Systemic rheumatoid disease (Still’s disease) usually presents with multiple (more than five) involved joints, fever, lymphadenopathy, hepatosplenomegaly, rash, subcutaneous nodules, and pericarditis.
  • Fat emboli from long bone fractures cause a syndrome characterized by respiratory insufficiency, coagulopathy, encephalopathy, and an upper body petechial rash

Decide whether to observe and treat empirically, perform diagnostic testing, or refer to dermatology for workup

Redness/erythema Redness and erythema can be caused by infection (cellulitis), massage, electrical treatment, acne medication, allergies, exercise, solar radiation (sunburn), photosensitization, cutaneous radiation syndrome, mercury toxicity, blister agents, niacin administration, or waxing and tweezing of the hairs—any of which can cause the capillaries to dilate, resulting in redness.

Erythema is a common side effect of radiotherapy treatment due to patient exposure to ionizing radiation.

Differential Diagnosis

Squamous cell carcinoma Raised, slightly pigmented skin lesion; ulceration/exudate; chronic scab; itching

Cutaneous SCC present as enlarging hyperkeratotic macule, 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 millimeters to several centimeters in diameter
  • On the exam, you will need to differentiate this from Basal Cell Carcinoma (look for telangiectasia of basal cell carcinoma central ulceration and rolled border) vs. scaly papules of SCC

Treatment may involve Mohs surgery, radiation, medications, or in some cases chemotherapy

Squamous cell carcinoma

Squamous cell carcinoma

Urticaria (postoperative) Urticaria (hives) is a skin rash triggered by a reaction to certain foods, medications, stress, or other irritants

  • Symptoms include blanchable, pruritic, raised, red, or skin-colored papules, wheels or plaques on the skin's surface
  • (+) Darier's sign: localized urticaria appearing where the skin is rubbed (histamine release)
  • Angioedema: painless, deeper form of urticaria affecting the lips, tongue, eyelids hand and genital

Hives usually go away without treatment, but antihistamine medications are often helpful in improving symptoms

  • If anaphylaxis give 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

Urticaria/Hives

 

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