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 imiquimod, photodynamic therapy (PDT), and surgical excision with clear margins 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: 1st degree (sunburn): Erythema of involved tissue, skin blanches with pressure, the skin may be tender 2nd degree (partial thickness): Skin is red and blistered, skin is very tender 3rd degree (full thickness): Burned skin is tough and leathery, skin non-tender 4th degree: Into the bone and muscle 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
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
Discharge	Breast/nipple discharge Mastitis/Breast abscess: nipple discharge, redness, warm skin Breast Cancer: nipple discharge, breast discomfort, breast mass Gynecomastia: nipple discharge, breast enlargement, overweight Inflammatory breast cancer: nipple discharge, breast enlargement, redness Hypogonadism: nipple discharge, sexual dysfunction, reduced sex drive GU Infections of the vagina, such as a yeast infection, bacterial vaginosis, trichomoniasis, human papillomavirus (HPV), or herpes Infection of the cervix (cervicitis) An object in the vagina, such as a forgotten tampon Sexually transmitted infections (STIs), such as chlamydia or gonorrhea Various sex practices, such as oral-to-vaginal and anal-to-vaginal contact Vaginal medicines or douching Menopause: vaginal discharge, an absence of menstruation, anxiety 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 multiforme, viral 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
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.
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 Ulcer Eczema Stasis and contact dermatitis Drug allergy Cellulitis, MRSA Erysipelas Chemical burns Angioedema and urticaria Venous insufficiency Impetigo Herpes zoster Scarlet fever Tinea infections Psoriasis Acne Polycythemia Vera Paronychia Osteomyelitis Abscess Autonomic hyperreflexia Lymphadenitis Carbuncle Neutropenia
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
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