DERMATOLOGY REVIEWER

Pruritus
-Unmyelinated C fibers
-Stimuli: light touch, temperature changes, emotional stress
-Pruritoceptive itch: inflammation, dryness
-Neuropathic itch: post herpetic
-Central neurogenic itch: liver cirrhosis
-Psychogenic itch: parasitophobia
-Itch caused by systemic /internal disease: Chronic kidney disease (most common)
-Internal causes: liver disease, renal failure, hypo/hyperthyroidism, IDA, PV, malignancy
(lymphoma), neuropsychiatric

Xerosis (dry skin)

causes: old age, dry scented soaps, scrubbing, vigorous washing, frequent bathing

Xerotic eczema
-background of xerosis
-pruritus occurs before lesions appear
-erythematous patch with accompanying scaling

Pruritus ani
-secondary to contact dermatitis
-hemorrhoids, anal tags

Pruritus scroti
-lichen simplex chronicus
-Pyschogevnic pruritus is the most frequent type
-low potency steroids

Pruritus vulvae
-vaginal candidiasis
-unspecified dermatitis
-lichen sclerosus, lichen planus, psoriasis

DRY CHRONIC ECZEMA

Lichen simplex chronicus
a. Thickened leathery skin
b. exaggerated skin markings
-most often hyperpigmented

Prurigo nodularis
-itchy nodules, usually at the extensors.
-anterior legs
-multiple hyperpigmented nodules topped with excoriations and scaling
Nail
Distal subungual onychomycosis
-most common
-t. Rubrum
-distal nail bed & hyponychium
-secondary involvement of underside of nail plate of fingernails and toenails

Proximal subungal onychomycosis

-associated with HIV
-t.rubrum & t.megninii
-nail plate from proximal nail

White superficial
-can be scraped off
-t.rubrum & t.metangrophytes, cephalosporium, aspergillus, fusarium
-small chalky white spots on nail plate

Candidal onychomycosis
-candida albicans
-"wet workers" (water --> destroy cuticle --> fungi enter)
-paronychia
-fingernails affected

Onychomycosis
-topical: clotrimazole, amorolfine
-systemic antifungals (terbinafine (DOC for dermatophyte onychomycosis), itraconazole,
fluconazole, azoles if candidal)
-precaution: liver disease (LFTs)

Bacterial paronychia
-swelling with pus
-s. Aureus
-mani, pedi

Nail Psoriasis (psoriatic onychomycosis)

-nail pitting (can also be seen in alopecia areata)
-oil spots/salmon patches (pathognomonic)
-subungual hyperkeratosis (thickening)
-onycholysis (separation of nail plate from the nail bed)
-onychodystrophy
-proximal matrix: pitting, beau's lines
-distal matrix: onycholysis
-nail bed: oil spots, subungual hyperkeratosis, onycholysis, splinter hemorrhages
-proximal & lateral nail folds: cutaneous psoriasis
Hair
Infundibular area (hair outside to entrance into skin)
Middle portion (upto the attachment to arrector pili)
Lower portion
a. Anagen -synthesis phase 3 yrs
b. Catagen- transition phase 3 weeks
c. Telogen- resting phase 3 mos
Hair growth: half an inch per month
6 inches per year
No hair on palms, soles, labia minora
normal hair loss - 100-150 strands per day

Alopecia areata
-round/oval bald spot
-"broken exclamation mark hair" (distal end is thicker and more pigmented)
-can involve scalp or facial hair
-good prognosis: postpubertal onset
-improve with corticosteroid injections
-poor prognosis: atopic dermatitis, childhood onset, widespread involvement, duration
longer than 5 yrs, onychodystrophy, ophiasis (loss of hair along the temporal and
occipital scalp)

Alopecia areata barbae - beard

Alopecia areata totalis - loss of all hair in the scalp
Alopecia areata universalis - loss of all hair

Telogen effluvium
-transient falling of hair due to premature entry into telogen phase
-3 mos after stressful event: pregnancy, fever, surgery, rapid wt loss, drugs
-hair regrowth after 3-6mos

Trichotillomania
-hair pulling disorder
-assoc with OCD
-hair at varying lengths

Non scaly inflammatory nodules

Folliculitis
-Infection inflammation of hair follicle usually caused by s. Aureus

S. Barbae
-Autoinoculation
-Pustules are superficial

Furuncle
-Nodule with central suppuration, tenderness
-Nape, axilla, buttocks
-DM, atopic dermatitis, any form of immunosuppression
-Tx: warm compress, penicillinase resistant penicillin, I & D if fluctuant

Recurrent Furunculosis
-3 or more episodes per year
-Secondary to staphylococcal carrier state
-Intranasal mupirocin BID for one week every month
-rifampicin 600mg/day  dicloxacillin (MSSA) or TMP-SMX (MRSA) × 10 days
-clindamycin 150mg/day x 3 mos

Carbuncle 
-2 or more furuncles together

Hansen's dx
*missed slide
Fite faraco stain

Ridley Jopling classification system

TT: polar tuberculoid
BT: borderline tuberculoid
BB: borderline leprosy
BL: borderline lepromatous
LL: lepromatous leprosy
Borderline: unstable phases
Skin prick test (test for numbness)

Indeterminate leprosy
-Early lesion
-Appears before host make definitive immunologic
-Hypopigmented

TT
-Cell mediated immunity is strong
-Saucer shaped (annular, periphery is elevated)
-Can spontaneously cure

BT
-Immunity is strong enough to restrain infection but insufficient for self-cure.
-No hope for cure
-Satellite lesion or pseudopods

BB
-borderline immunity
-Most unstable
-Swiss cheese appearance
BL
-Inverted saucer shaped

LL
-No cell mediated immunity
-Unrestricted bacillary replication
-Diffuse dermal infiltration
-Widespread nodules or plaques
-Madarosis, saddle nose

Multibacillary: dapsone, rifampicin, clofazimine.

Day 2 onwards: dapsone, clofazimine
Paucibacillary: rifampicin, clofazimine

Adverse effects of drugs:

Dapsone
-hemolytic anemia
-methemoglobinemia
-psychiatric problems (psychosis) rarely
Clofazimine
-red brown discoloration of the skin, conjunctiva
-red urine, stools, sputum, sweat, tears
-drynes of skin

Rifampicin
-red urine
-hepatitis
-thrombocytopenia
-psychosis
-decrease effectiveness of systemic steroids

Scrofuloderma
-nodules secondary to direct extension from cervical lymph node
-characteristic cord like scars
-anti-kochs tx

Cellulitis
-ill defined plaque
-staph. aureus or Strep. pyogenes

Bullous cellulitis
-tinea pedis

Erysipelas
-well defined plaque
-grp A strep

Fixed drug eruption

-NSAIDS most common cause
-targetoid lesion always on the same area
-lips, genital area

Miliaria rubra
-Hot humid climates
-Back, intertriginous areas, popliteal areas

Miliaria crystallina
-Clear superficial vesicles with no inflammatory reaction
-Tight clothing
-No tx, just cold compress

Miliaria pustulosa
-Non follicular pustules (vs folliculitis) bec eccrine sweat glands do no exit thru the pores
Scabies
-Intensely pruritic papular lesion, can come with excoriation, contain mites, eggs or
feces
-Finger webs, axilla, popliteal, axilla, extremities, inguinal
-Sarcoptes scabei var hominis
        Obligate human parasitic mite
        Burrows in stratum corneum
        Live in human for 3 days only
        Close contacts
        Humans are the only reservoir
        Contaminated clothes and beddings
        Sensitization: 2-4 wks after onset of infestation
        If reinfection: days
-IMPT: nocturnal pruritus, close personal contact, circle of hebra
-Tx: permethrin 5% lotion, sulfur (if pregnant, apply everyday), lindane (with cytotoxicity)

-Prevention: soak linens in very hot water for 15mins or more then dry under the sun,
vacuum all rugs, carpets, furniture, ALL personal contacts should be treated at the same
time, regardless if symptomatic or not, if patient is poor: can pack clothing in garbage
bag for a week (since mites only live for 3 days)
Arthropod bites
-Central punctum

Bed bugs
-Bites in rows

Pediculosis capitis/corporis/pubis
Capitis
-Children
-Secondary inflammation,
-Most common: retroauricular
-Permethrin 1% shampoo, use a fine toothed comb for grooming (use only once), do not
shampoo 24hrs after application, not ovicidal (so repeat after 1 wk)
-secondary impetigo is common.

Corporis
-Mite lays eggs in seams of clothing
-Homeless people with poor hygiene

Acne
-Propionibacterium acne
-Hallmark lesion: Comedone
-can have papules, pustules, nodules, cysts...
-4 features: hyperkeratosis of follicular infundibulum, sebum, propionobacterium acnes,
androgen
A. Microcomedone
B. Comedone
C. Inflammatory papule/ pustule
D. Nodule
First choice in mgt:
*consider physical removal of comedones
Comedonal (blackhead/whiteheads): Topical retinoid: tretinoin, adapalene
Papular/pustular (mild): Topical retinoid + topical antimicrobial: benzoyl peroxide
Papular/pustular (moderate): oral antibiotic + topical retinoid +/- BPO
Nodular (0.5-1 cm, moderate): oral antibiotic + topical retinoid + BPO
Nodular/conglobate (severe): oral isotretinoin

Acneiform
-monomorphic follicular papules/acne
-cause: steroids (oral and topical)

Vascular disorders
Diascope
-test for blanchability
-blanching (dilatation of BV-erythema) vs non blanching (extravasation of RBC-purpura)
-blanching: erythema, sunburn, photosensitivity, urticaria, angioedema,
dermographism, morbilliform drug eruption, EM, exfoliative dermatitis
-Nonblanching: purpura, vasculitis
Sunburn
-erythema, tenderness, blistering
-UVA: aging; UVB causes sunburn; UVC: ozone
-water resistant: 40mins; water proof: 80mins
-spares suncovered areas

Phototoxicity: type 3 hypersensitivity

Photoallergy: type 4 delayed hypersensitivity; photopatch test
Contact dermatitis: patch test

Urticaria
-wheals (evanescent: doesn't last >24hrs)
-acute (<6 weeks: food, drugs, infection); chronic (>6 weeks: parasitism, dental caries,
thyroid dx, autoimmune diseases)
-mast cell degradation--> release of histamine

Angioedema
-swelling of subcutaneous layer
-common cause: ACE inhibitors
-ask if there is dyspnea (might have swelling in respiratory passages)
- treatment: epinephrine

Dermatographism
-drawing hehe

Morbilliform reaction
-also called maculopapular rash/exanthem
-most common causes: adverse drug eruption and viral infection

Erythema multiforme
-Dusky center, pale ring, erythematous surrounding (3 layers)
-adult:HSV (1>2)
-child: mycoplasma pneumonia
-minor: 1 mucosal surface
-major: involvement of more than 2 mucosal surfaces

Exfoliative dermatitis
-Generalized erythema and scaling
-psoriasis, atopic dermatitis, eczema, allergic contact, irritant contact dermatitis

Purpura
-flat macule/patch
-petechiae --> purpura --> ecchymoses
-vascular dysfunction, trauma, coagulation disorders, thrombocytopenia

Vasculitis
-hallmark: Palpable Purpura (inflammation of blood vessels)
-secondary to extravasation of RBC from blood vessels
-type 3 hypersensitivity
-confirm dx with biopsy
-advise: exercise, leg elevation
-first line: antihistamine
-colchicine, dapsone
-in children: Henoch Schonlein Purpura (usually preceded by URTI Gr. A Strep)

Topical steroid use

-potency of steroids (ointment > cream)
-vehicles of steroids
-location (mild if axilla, groin)
-size
-lesion (LSC = thick = ointment)

Chronic steroid use:

1. Acneform
2. Steroid Purpura
3. Telangiectasia
 4. Permanent striae

Erythematous lesions with eczema

(Moist/oozing eczematous dermatitis)
Atopic dermatitis
-infants(<2): face, extensors
-childhood (2-12): antecubital fossa, flexures, neck
-adult (>12): flexures, lichenification
-major:pruritus, rash in characteristic areas, chronic relapsing, family hx of atopy
-minor: xerosis, dennie morgan fold, allergic shiners, pityriasis alba (face, powdery
scales, vs tinea versicolor: back and trunk, can be hyper/hypopigmemted)
-treatment:
  -Dry skin: skin hydration, emollients, avoidance of irritants, identification and
addressing of specific trigger factors
  -mild to moderate AD: low-mid potency TCS (topical steroids) &/or TCI (topical
calcineurin inhibitor)
  -moderate to severe AD: mid-high potency TCS and or TCI
  -Recalcitrant, severe AD: systemic therapy (ex. cyclosporine, methotrexate (do not
give prednisone)) or UVA therapy

Seborrheic dermatitis
-scalp: cradle cap
-can involve glabella, nasolabial folds
-yellowish greasy appearance of scales
-recalcitrant seborrheic dermatitis: HIV
-malassezia ovalis
-treatment: mild shampoo for babies, mineral oil 15mins before shampooing,
antifungals, and if with erythema give steroids

Psoriasis
-silvery scales
-goes beyond the hairline

Allergic contact dermatitis

-scaling
-delayed type hypersensitivity
-Allergic contact dermatitis to hair daye
     -Angioedema + erythema along the hairline
-Allergy to nickel, tattoo, rubber, cologne, fragrance

Irritant Contact Dermatitis

- due to acids and base

Nummular eczema
-coin shaped, papules and vesicles that coalesce
-NSS compress, antibiotic + steroids

Dyshydrotic eczema
-Tapioca like deep seated vesicles on the lateral hands/feet
-NSS compress, steroids

Intertrigo
-circular patch in flexural areas
-inguinal, inframammary
-candidal intertrigo: satellite pustules(tx: azole)

Inverse psoriasis
-bright red with silvery white scales
-inguinal area + umbilicus

Breast eczema
-areola

Stasis eczema
-medial lower leg
-varicosities, edema
-sign of venous insufficiency
Xerotic eczema
-elderly, pretibial

Dermatophyte infections (Papulosquamous disease)

Tinea pedis
-T. Rubrum most common cause
-interdigital areas and soles of the feet, plantar arch (vs atopic dermatitis: NEVER
plantar arch)
-maceration, scaling, vesicles, bullae

Tinea manuum
-"1 hand, 2 feet", check inguinal area also
-annular

Tinea capitis
-non inflammatory type: areas of alopecia with broken off hairs (manifest as black dots)
-kerion: boggy inflammatory mass

Tinea cruris
-tx: terbinafine (oral if extensive, OD for 2 weeks)

Tinea facialis
-long septated hyphae with spores

Psoriasis
-sharply marginated, raised, red, plaque with scaly surface
-silvery white scale
-symmetry of lesions
-extensor distribution
-koebner phenomenon: lesions on areas of trauma
-auspitz sign: bleeding upon removal of scales due to dilated capillaries
-pathognomonic: oil spots (nail pitting also seen in alopecia areata)
Plaque Type: scalp, nails, sacrum
Acute guttate: best prognosis; with preceeding strep pharyngitis
Inverse Type
Pustular psoriasis
Erythrodermic psoriasis: can cause exfoliative dermatitis
Psoriatic arthritis

Cutaneous lupus erythematosus

Acute (most common, malar rash)
  -localized or generalized; with systemic symptoms (DOPAMINE RASH)
Subacute (maculopapular rash on sun exposed areas, annular psoriariform)
Chronic (CCLE)
 -classic DLE
 -red purple discoid macule and papules with small plaques
 -atrophy, telangiectasia, hypo/hyperpigmentation, scales, keratotic plug
 -heals with scarring

Pityriasis rosea
-Collarette scales, herald patch
-distribution: langer lines,xmas tree
-HHV 6&7
-heals in 4-12 weeks

Tinea versicolor
-hypo/hyper/slightly erythematous
-malassezia furfur
-furfuraceous scales

Syphilis
-primary: chancre
-secondary: maculopapular rash, condyloma lata
-tertiary: gumma
-involvement of palms and soles: syphilis & EM
-great mimicker

Skin colored papules and nodules

Verruca vulgaris
-rough surface
-tiny black dots: thrombosed dilated capillaries
-subclinical: can only be detected by acetic acid
-autoinoculation, direct contact
-fingers, palms, periungual areas
-HPV 1,2,4...
-risk factors: nail biting, butchers, immersion in water
-treat to prevent from multiplying
-if periungual: might have to do nail avulsion

Verruca filiformis
-Long slender upward projections
-Papillomatous

Verruca plantaris
-usually found on pressure areas
-most commonly on mid metatarsal areas
-coalesce to form mosaic warts
-differential dx: callus, corn (with exaggerated skin lines, but no black dots)

Verruca plana
-flat topped
-risk factor: sun exposure, autoinoculation by shaving
-Highest rate of spontaneous remission
-koebnerization

Tx for warts
-duofilm
-electrocautery
-cryotherapy
-laser therapy

Molluscum contagiosum
-dome shaped papules with central umbilication
-usually appears in children; can be sexually transmitted
-poxvirus, MCV1
-contact, immunocompromised
-can spontaneously resolve
-inclusion bodies: molluscum bodies or henderson paterson bodies
Treatment: nick curettage, caltarithin

Milia
-white keratinous cysts
-asymptomatic
-in newborns: can resolve spontaneously in weeks
-in elderly: can be due to trauma, blistering diseases, topical occlusive meds
-incise and express the contents

Syringoma
-sweat duct differentiation; skin-colored
-found on cheeks & eyelids
-familial
-recurrence after removal by cauterization or laser therapy
-coalesce to form plaques

Sebaceous cyst/epidermoid cyst

-nodule with a central comedo like punctum
-cheesy chalky pasty like foul smelling material which represent macerated keratin
-removal by: excision of capsule

Acrochordon/skin tags
-neck, axilla, groin
-can become tender, inflamed or gangrenous when twisted
-common in obese; risk of developing DM: skin tags on top of acanthosis nigricans
velvety plaque
-tx: snip excision

Pustular diseases
Primary lesion: pustule
Pus = INFECTION

Acne vulgaris
-chronic inflammatory disease
-polymorphic: closed comedone (white head), open comedone (black head), pustules,
papules, nodules
-atrophic scars
-face, upper trunk, upper back
-pathophysiology: keratin plug, sebum accumulation, propionobacterium acnes,
hormonal imbalance

Acne congoblata
-Pustules and papules coalesce that form plaques that release serosanguinous material
-tx: oral isotretinoin

Miliaria pustulosa
-non follicular pustules on bedridden patients
-blockage of sweat duct
-areas of predilection: intertriginous areas, back

Folliculitis
-superficial inflammation of hair follicle
-found on hair bearing areas
-multiple lesions: oral antibiotics

Furuncle
-chronic relapsing
-Deeper inflammation nodule hair follicle --> rupture --> nodule with or w/o central
suppuration

Pyogenic Paronychia
-separation of nail fold from nail plate secondary to frequent exposure to water; mani/
pedi; nail biting

Ecthyma
-characteristic sausage shaped ulcers
-staph or strep pyoderma
-shins/dorsal feet
-vesicle/vesiculopustules --> rupture --> ulcer --> heals with scar
-nss compress; antibiotics

Candidal intertrigo
-secondary to maceration of epidermal folds of the neck or intertriginous areas
-satellite pustules
-pruritic
-tx: topical azoles plus mid strength corticosteroids (mometasone) for rapid relief
-recommend: keep area dry, loose clothing, lose weight

Pustular psoriasis (von zumbusch)

-Pustules coalescing in lakes of pus
-caused by rebound steroid tx (so do not give prolonged steroids), LCD
-tx: methotrexate, acitretin

Vesicular diseases
Herpes simplex viruses
A. Primary infection: painful ulcers, vesicles
B. Latent phase
C. Recurrence

HSV-1 trigeminal ganglion

HSV-2 sacral ganglion
Triggers: emotional stress, illness, sun-exposure
Cold sores/herpetic gingivostomatitis
-Painful grouped vesicle on an erythematous base, with mouth ulcers, in perioral areas
Tzanck smear: multinucleated giant cells

Varicella virus infection- "chickenpox"

-all lesions will erupt in 2 days; exposure: 10-21 days
-Pruritic
-Papules, vesicles, pustules, ulcers with crusting (polymorphic eruption)

Herpes zoster
-Grouped vesicles, dermatomal or unilateral; Painful, can be pruritic
-if immunocompromised: disseminated
-chicken pox --> latent(dorsal ganglion) --> herpes zoster
-if no hx of chicken pox, may be due to vaccine or varicella in utero
-herpes zoster ophthalmicus: can cause blindness; Hutchinson's sign (tip of the nose;
involvement of the nasociliary branch of the V1)
-crusting of ALL lesions = non infectious
-Ramsey Hunt (deafness, ipsilateral facial palsy; affects facial and auditory nerves)
-postherpetic neuralgia (sensitization of dorsal neurons, spontaneous activity of afferent
neurons, pain in the absence of damage, more common in elderly)
-antiviral therapy: limit extent, dissemination, prevent post herpetic neuralgia
Tx: acyclovir 800mg/tab 2tab every4hrs for 7days (5 times); valacyclovir 1000mg/tab
1tab TID for 7days

Impetigo -honey-colored crusting

- papules, vesicles, macules, papules
-orolabial areas; Staph. aureus
Tx: cephalexin 25-50mg/kg/day in divided dose (every 6hrs) 250mg/5ml
Bullous Dermatoses
Bullous tinea pedis
-plantar arch and interdigital areas
-can have id reaction: eruption distant to the primary site of the lesion (can look like
dyshidrotic eczema -- deeper vesicles)  

Nikolsky sign: Lateral pressure

Asboe hansen: Direct pressure causes extension of vesicle/blister

Intraepidermal
-flaccid
-positive nikolsky sign and asboe-hansen's sign
-pemphigus, SJS, SSSS, erythema multiforme

Subepidermal
-tense
-negative nikolsky and asboe-hansen
-bullous pemphigoid, insect bites, SLE

Bullous pemphigoid
-ELDERLY tense blisters; chronic; very PRURITIC
-flexural, nuchal
-autoimmune: IgG Ab (BPAG 1&2)
-histo: eosinophil rich subepidermal blister
-Direct immunofluorescence: detect Ab on BM
-mgt: systemic steroids, azathioprine, dapsone

Pemphigus vulgaris
-Generalized flaccid blisters with ulcers in the oral mucosa; PAINFUL; chronic
-rupture easily so all you see are erosions
-trigger factors: sun-exposure, infections
-intraepidermal area is highlighted on direct immunofluorescence
-Tx: immunosuppressive agents (dapsone, azathioprine), oral corticosteroids

Dermatitis herpetiformis
-Extremely pruritic erythematous papules > vesicles > bullae > crust
-Nape, scapula, extensors, buttocks
-exacerbated by wheat-rich foods
-neutrophils on the dermal papilla
-igA deposition on the dermoepidermal junction
-tx: dapsone & sulfapyridine
-avoid alcohol,beer, cookie crumbs, cookie dough

Bullous impetigo
-Erythematous macules > clear filled bullae on the nostrils > seropurulent discharge >
golden yellow crust
-infectious/contagious
-commonly on nose; disseminated
-staph(most common)/strep
-Tx: 1st gen cephalosporin: cephalexin, MRSA: vancomycin, linezolid; NSS compress
-complications: AGN (grp A strep), SSSS (staph scalded skin syndrome)

SJS
-Hx of drug intake (allopurinol, antipsychotics)
-start as morbiliform eruption
-flaccid vesicle that rupture easily to form erosion, crusting as they heal
-less than 10% of BSA (count areas of detached epidermis like bullae, vesicles,
erosions; not just erythematous areas)
-involvement of mucous membranes: usually oral and conjunctiva (check also GI tract)
-accompanying symptoms: conjunctivitis, oral ulcers, dysuria, dysphagia
-SJS/TEN overlap: 10-30%
-TEN (toxic epidermal necrolysis): > 30%

Fixed drug eruption

-Drug use
-NSAIDS: most common offending drug
-Naproxen: 30-60mins lesions come out; well-defined erythematous patch with bullae
-Recur on the same site
-50% oral and genital mucosa.
-Erythematous/dusky targetoid lesions
-Heals with hyperpigmentation

Vitiligo
-Multiple, Well defined, Depigmented macules and patch
-distribution: focal (often trigeminal), unilateral, vulgaris, universal
-hands and around the mouth ("lip and any tip") are difficult to treat
-white hairs if around eyebrow(
-autoimmune (associated with type1 DM, pernicious anemia, Hashinotos thyroid it's,
Graves' disease, addisons disease, alopecia areata)
-tx: topical steroids
Post inflammatory hypopigmentation/leukoderma
-Eythematous plaques --> white macules
-destruction of melanocytes during the trauma

Melasma (chloasma)
- asian
-hyperpigmentation on cheeks, sunexposed area
-females > males, older
-OCPs, topical application of strong chemicals (maxipeel), sun-exposure

Freckles (Ephelis)
-fair skinned individuals
(*if darker skinned individuals = solar lentigo - do not fade; usually in asians)
-hyperpigmentation

Xanthelasma
-not all have elevated TG, can occur with normal lipids
-most common xanthoma

Xanthoma
-Firm yellow nodules arounds elbows, knees
-Multilobulated masses
-Associated with increased cholesterol
-tuberous xanthoma: super big, appear inflamed and tend to coalesce
-Eruptive xanthoma:
-plane xanthoma: flat macules/slightly elevated plaques with yellowish tan coloration
-advised diet, statins, fibrins, excise if big and affect ADLs but they will recur

Brown black papules and plaques

Benign nevus/common melanocytic nevus
-junctional: junction of epidermis and dermis, dark
-compound: junction + dermis
-intradermal: dermis, depigmented/skin color
-superficial = darker & flatter bec closer to surface
-deeper = more elevated and lighter in color
-giant congenital melanocytic nevus: "wolf", appears at birth, brown to black papules/
plaque with or without hypertrichosis, increased risk of developing melanoma, enlarges
in size, any change in nodularity should warrant investigation
-biopsy

Basal cell CA
-most common skin CA; translucent pearly papule/nodule with telangiectasia and rolled
border; friability
-malignant neoplasms from non keratinizing cells that originate in the basal layer of the
epidermis
-elderly > 60 y/o
-males, whites > asians
-sun exposed areas: head (nasal ala) & neck (80%), back, chest, shoulders
-intermittent sun exposure (UV-A&B) usually in childhood, ionizing radiation,
environmental carcinogens, immunosuppression, scars, burns, chronic scarring or
inflammatory dermatoses
-larger lesion with central ulcer and crust = rodent ulcer
-no premalignant skin lesion, appear de novo
-rarely metastasizes, but with prominent tissue destruction, greatest danger is local
invasion
-pathogenesis: mutation of mammalian PTCH gene upregulation of SMO gene
-biopsy at the most indurated border
-histopathologic findings: basaloid cells, peripheral palisading pattern, fibromyxoid
stroma, retraction space
-best tx: surgery (excision - choice), mohs micrographic surgery
-pigmented BCC: most common type in asians
-superficial BCC: trunk, erythematous patch, does not respond well to tx
-morpheaform BCC: aggressive, ivory white
-infiltrative BCC: aggressive
-tx: 4mm margin for nonmorpheaform BCC smaller than 2cm in diameter; 5mm margin if
>2cm diameter; mohs micrographic surgery; curettage for <1cm but can recur on other
areas; cryotherapy; imiquimod (TLR antagonist to boost T helper 1 immunity); 5-FU;
vismodegib (hedgehog pathway antagonist); photodynamic therapy (MAL-PDT);
Radiation therapy

Squamous cell CA
-second most common form of skin CA
-solitary, firm, flash colored keratotic papule tenderness, induration, erosion, scale, or
enlarging diameter
-intense sun exposure, burns, wounds, ulcers, HPV
-sun exposed areas: face, back, legs
-high chance of metastasis
-chemo and radiation is there is lesion left

ABCDs of Melanoma
Asymmetry
Borders are irregular
Color variation (brown, black, pink, red...)
Diameter increased (>6mm) or ugly Duckling sign (atypical lesion)
Elevation/surface change
 Acral-lentiginous melanoma
-Most common type of melanoma in asians
-hutchinson's sign: involvement of nail plate + periungual skin
-seen also on plantar surfaces

Amelanocytic melanoma
-mistaken for BCC
-pink/skin colored
-biopsy

Seborrheic keratosis
-Most common benign tumor of the skin
-Oval slightly raised
-Stuck on greasy appearance
-Occur on sunexposed areas or trunk

Sign of Leser Trelat

-Sudden eruption if multiple seborrheic keratosis
-Indicates Adenocarcinoma Of GI tract
-Parallels the adenoCA

Dermatosis papulosis nigra

- more common in asians and africans
-smaller version of seborrheic keratosis
-mistaken for verruca plana, acrochordon if on the neck

Most common melanoma: superficial spreading

Highest risk for metastasis: nodular melanoma
Most common in asians: acral lentiginous

Scar
Injury > hemostasis > inflammation > remodeling > scar

Atrophic scar: flat, follows contour of original wound

Hypertrophic scar: elevated, erythematous if new, skin color if old, follows contour of
original wound, regresses in time

Keloid
-extension beyond borders of initial injury
-pain, pruritus
-claw-like
-previous trauma, sites of acne, or spontaneous
-areas of high skin tension: chest, upper back
-does not regress, can even become bigger
-intralesional triamcinolone: to soften lesion to reduce pain/pruritus, can flatten but not
always
-emollients, silicone dressings

Skin types
1 - fairest - always burns, never tans
2 - fair - usually burns, rarely tans
3 - dark white - sometimes burns, tans slowly
4 - olive - rarely burns, tans easily
5 - dark - rarely burns, tans profusely
6 - dark brown - never burns, tans darkly black

Blacks and whites have the same number of melanocytes, but blacks have increased
activity of melanosomes that aggregate more melanin