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DERMATOLOGY

Dr. N. Shear
Blaise Clarkson and Elana Lavine, chapter editors
Harriette Van Spall, associate editor

APPROACH TO THE DERMATOLOGY

PATIENT

History

Physical Exam

DEFINITIONS

Primary Morphological Lesions
Secondary Morphological Lesions
Other Morphological Lesions

USEFUL DIFFERENTIAL DIAGNOSES

Differential Diagnosis by Morphology

Differential Diagnosis by Location

COMMON SKIN LESIONS. . . . . . . . . . . . . . . . . . 5

Hyperkeratotic
Fibrous
Cysts
Vascular
Melanocytic Nevi
Miscellaneous

ACNEIFORM ERUPTIONS. . . . . . . . . . . . . . . . . . 11

Acne Vulgaris/Common Acne
Rosacea
Perioral Dermatitis

DERMATITIS (ECZEMA). . . . . . . . . . . . . . . . . . . 13

Contact Dermatitis
Atopic Dermatitis
Seborrheic Dermatitis
Stasis Dermatitis
Nummular Dermatitis
Dyshydrotic Dermatitis
Diaper Dermatitis

INFECTIONS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16

Bacterial

Superficial Skin (Epidermal)
Deeper Skin (Dermal)
Hair Follicles
Periungual Region
Sexually Transmitted Infections

Viral Infections

Dermatophytosis

Yeast

Parasitic

PAPULOSQUAMOUS DISEASES. . . . . . . . . . . . 25

Psoriasis
Psoriasis Arthritis
Lichen Planus
Pityriasis Rosea

VESICULOBULLOUS DISEASES. . . . . . . . . . . . . 28

Pemphigus Vulgaris
Bullous Pemphigoid
Dermatitis Herpetiformis (DH)
Porphyria Cutanea Tarda
Differential of Primary Bullous Disorder

MCCQE 2002 Review Notes

Dermatology \u2013 D1

DRUG ERUPTIONS. . . . . . . . . . . . . . . . . . . . . . . . 30

Exanthematous Eruptions
Urticaria
Fixed Drug Eruption
Delayed Hypersensitivity Syndrome
Photosensitivity Eruptions
Serum Sickness - Like Reaction

ERYTHEMA MULTIFORME (EM),. . . . . . . . . . . 32
STEVENS-JOHNSON SYNDROME (SJS) AND
TOXIC EPIDERMAL NECROLYSIS (TEN)

ERYTHEMA NODOSUM. . . . . . . . . . . . . . . . . . . . 33

MALIGNANT SKIN TUMOURS. . . . . . . . . . . . . . 33

Basal Cell Carcinoma (BCC)
Squamous Cell Carcinoma (SCC)
Malignant Melanoma
Others

HERITABLE DISORDERS. . . . . . . . . . . . . . . . . . 36

Ichthyosis Vulgaris
Neurofibromatosis (NF)
Vitiligo

SKIN MANIFESTATIONS OF INTERNAL. . . . . 37

CONDITIONS

Autoimmune Disorders
Endocrine Disorders
HIV
Malignancy
Others
Pruritus

WOUNDS AND ULCERS. . . . . . . . . . . . . . . . . . . 39

ALOPECIA (HAIR LOSS). . . . . . . . . . . . . . . . . . . 39

Non-Scarring (Non-Cicatricial) Alopecia

Scarring (Cicatricial) Alopecia

NAILS. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41

TOPICAL THERAPY. . . . . . . . . . . . . . . . . . . . . . . .41

Vehicles
Topical Steroids
Dry Skin Therapy

COSMETIC DERMATOLOGY. . . . . . . . . . . . . . .43

Chemical Peel

Laser Therapy

SUNSCREENS AND PREVENTIVE. . . . . . . . . . .43

THERAPY

REFERENCES. . . . . . . . . . . . . . . . . . . . . . . . . . . . .44

D2 \u2013 Dermatology

MCCQE 2002 Review Notes

APPROACH TO THE DERMATOLOGY PATIENT

HISTORY

\u274fage, race, occupation (especially exposures), hobbies

\u274fdetails of skin eruption should include:

\u2022 location, onset, duration (persistent versus intermittent eruption)

\u2022 alleviating and aggravating factors (plant contact, cosmetic/jewellery use,

exposure to heat/cold/sunlight, relationship to foods/spices)

\u2022 associated skin symptoms
\u2022 changes in sensation (itchiness, burning, pain)
\u2022 changes in surface (dryness versus discharge)

\u2022 past history including investigations and therapy

\u274fassociated systemic symptoms (weight loss, malaise, fever, diarrhea, arthralgias, muscle weakness)
\u274fmedications and allergies
\u274fpast dermatological history
\u274ffamily history of atopy, skin cancer, psoriasis

PHYSICAL EXAM(How to describe a Lesion)

\u274fSize
\u274fColour (e.g. hyperpigmented, hypopigmented, erythematous)
\u274fArrangement (e.g. solitary, linear, reticulated, grouped, herpetiform)
\u274fLesion morphology (see Table 2)
\u274fDistribution (e.g. dermatomal, intertriginous, symmetrical/asymmetrical, follicular)
\u274fAlways check hair, nails, mucous membranes and intertriginous areas

Table 1. Skin Phototypes

Phototypes

Colour of Skin Without

Skin\u2019s Response to Sun Exposure

Sun Exposure

White

Always burns, never tans

White

Always burns, little tan

III

White

Slight burn, slow tan

Pale Brown

Slight burn, faster tan

Brown

Rarely burns, dark tan

Dark brown/black

Never burns, dark tan

DEFINITIONS

PRIMARY MORPHOLOGICAL LESIONS

Table 2. Types of Lesions

< 1 cm Diameter

\u22651 cm Diameter

Raised Superficial Lesion

Papule (e.g. wart)

Plaque (e.g. psoriasis)

Palpable Deep (dermal)

Nodule (e.g. dermatofibroma)

Tumour (e.g. lipoma)

Lesion (not necessarily raised)

Flat Lesion

Macule (e.g. freckle)

Patch (e.g. vitiligo)

Elevated Fluid-filled Lesions

Vesicle (e.g. herpes simplex virus (HSV))

Bulla (e.g. bullous pemphigoid)

\u274fprimary lesion: an initial lesion that has not been altered by trauma or manipulation, and has

not regressed

\u274fpustule: a vesicle containing purulent exudate (white, yellow, green)
\u274fcyst: a nodule containing semisolid or fluid material
\u274ferosion: a disruption of the skin involving the epidermis alone
\u274fulcer: a disruption of the skin that extends into the dermis or deeper
\u274fwheal: a special form of papule or plaque that is blanchable and

transient, formed by edema in the dermis (e.g. urticaria)

\u274fscar: replacement fibrosis of dermis and subcutaneous tissue

SECONDARY MORPHOLOGICAL LESIONS

\u274fdevelop during the evolutionary process of skin disease, or are created by manipulation

or complication of primary lesion lesion (e.g. rubbing, scratching, infection)

\u274fcrust: dried serum, blood, or purulent exudate originating from a lesion (e.g. impetigo)

\u274fscale: excess keratin (e.g. seborrheic dermatitis)

MCCQE 2002 Review Notes

Dermatology \u2013 D3

DEFINITIONS. . . CONT.

\u274ffissure: a linear slit-like cleavage of the skin
\u274fexcoriation: a scratch mark
\u274flichenification: thickening of the skin and accentuation of normal

skin markings (e.g. chronic atopic dermatitis)

\u274fxerosis: dryness of skin, eyes and mouth

\u274fatrophy: histological decrease in size and number of cells or tissues

resulting in thinning or depression of the skin

OTHER MORPHOLOGICAL LESIONS

\u274fcomedones: collection of sebum and keratin

\u2022 open comedone (blackhead)

\u2022 closed comedone (whitehead)

\u274fpurpura: extravasation of blood into dermis resulting in

hemorrhagic lesions
\u2022petechiae: small pinpoint purpura
\u2022ecchymoses: large flat purpura

\u274ftelangiectasia: dilated superficial blood vessels; blanchable

USEFUL DIFFERENTIAL DIAGNOSES

Table 3. Differential Diagnosis by Morphology

Dermatitis

Nondermatitis

Red Scaling Lesions

Atopic Dermatitis (flexural folds)

Psoriasis (elbows/knees/scalp,

(epidermal cells produced

Contact Dermatitis (history)

nail pits, Koebner\u2019s)

from excessive and

Nummular Eczema (coin-like, isolated)

Discoid Lupus (don\u2019t see hair follicles)

abnormal keratinization

Seborrheic Dermatitis (scalp/nasolabial folds/chest) Drug reaction (e.g. gold)

and shedding)

Lichen Planus (flat surface, lacy lines

on surface)
Mycosis Fungoides (girdle area, leonine facies)
Pityriasis Rosea (Christmas-tree distribution)
Secondary Syphilis (palms + soles,

copper coloured)

Tinea (well demarcated, raised border)

Inflammatory

Proliferative

Discrete Red Papules

Acne (teenager, face/chest/back)

Dermatofibroma (\u201cdimple sign\u201d)

(elevated/solid lesion < 1 cm)

Bites/Stings (history of outdoors, central punctum)

Hemangioma (blanching)

Folliculitis (in hair follicle)

Psoriasis
Furuncle (very painful, central plug)
Hives (whitish border, pruritic)
Inflamed Epidermal Cyst (mobile under skin)
Inflamed Seborrheic Keratosis (stuck-on appearance)
Lichen Planus (purple, polygonal papules with flat surface)
Miliaria Rubra (heat/overbundling of child)
Pyogenic Granuloma (bleeds easily)
Scabies (burrow, interdigital/groin, family members)
Urticaria

Flat Brown Macule

Actinic/Solar Lentigo (sun-damaged area)

(circumsrcibed flat and

Congenital Nevus (contain hair)

discoloured area)

Cafe-au-Lait (present in childhood, very light brown)
Hyper/hypopigmentation (e.g. posttraumatic, Addison\u2019s)
Freckle (sun-exposed areas, disappears in winter)
Junctional Nevus (regular shape)
Lentigines associated with underlying disorders (LEOPARD, LAMB, Peutz-Jegher\u2019s)
Lentigo Maligna (irregular, varied pigmentation)
Malignant Melanoma (characteristic atypia)
Pigmented Basal Cell Carcinoma
Simple Lentigo (non-sun exposed area, irregular)
Stasis Dermatitis

Viral

Nonviral

Vesicles

Viral

Acute Contact Dermatitis (e.g. poison ivy)

(circumscribed collection

\u2022 HSV (mouth, genitals)

(exposure history)

of free fluid > 1 cm)

\u2022 Zoster (dermatomal,painful)

Cat-Scratch Disease

\u2022 Varicella (generalized, itchy)

Dyshydrotic Eczema (sides of fingers/palms/soles)

\u2022 Molluscum (umbilicated)

Dermatitis Herpetiformis (VERY itchy, gluten history)

\u2022 Coxsackie

Impetigo

(painful, hand-foot-mouth, summer) Porphyria Cutanea Tarda
(hypertrichosis, heliotrope lesion around eyes,
alcohol ingestion)

Scabies

Bullae

Bullous Impetigo (children, other family members)

(circumscribed collection

Bullous Pemphigoid (tense, lower limb)

of free fluid > 1 cm)

Drug eruption
EM/SJS/TEN (target lesions)
Lupus Erythematosus (American Rheumatology Association (ARA) criteria)
Pemphigus Vulgaris (flaccid, easy bleeding)
Poyphyria Cutanea Tarda (photodistribution, fragile skin, hyperpigmentation)
Dermatitis Herpetiforms (extensor surfaces, symmetrically grouped)
Acute dermatitis