Student Selective Dermatology Rotation: Schedule/ Responsibilities

Student Selective Dermatology Rotation
Schedule/ responsibilities
1) Please check with the chief resident as to clinic & conference schedules. Students are welcome, but
not required, to attend the lectures at the dermatology department (check with the chief resident for the
schedule). rand rounds (at the !" at # am each $hursday) are mandatory.
%) Please dress appropriately for patient care
&) '(cused absences are permitted with ad)anced notice to the !" chief resident, mainly to allow for
residency inter)iews. $o achie)e a passing grade, a ma(imum of & e(cused absences are allowed.
*ote+ to achie)e honors, no absences are allowed.
Evaluation
Average score determined by the residents and director
1 ,ail -
% Pass
& .igh Pass
/ .onors --
- to pass a student must ha)e no more than & e(cused absences (arranged with !" chief resident).
-- to obtain .onors a student must not ha)e any absences.
Resident score based on interaction during clinic. 0e on time, efficient, intelligent and helpful.
Directors score based on the oral e(amination during the second week (usually 1ed "2)
34/ points+ 5ral session score
1 points each+ identify a Rash & Infection slide (1 point)
identify a Neoplasm & Hamartoma slide (1 point)
answer a question about each from the handout (1 point each).
1 optional point if you bring an article to discuss prior to the e(am relating to+
6ermatology & either your future field or an interesting patient.
1
Rashes & Infections
Acne
Description and Symptoms
7omedones and inflammatory papules common in teenagers and young adults. 2ostly distributed on the
face, chest and back.
Diagnosis
7linical appearance.
athology
5bstructed hair follicle leading to inflammation. 2any underlying factors+ Propionobacter acnes infection,
hormones, follicular cornification, sebum production.
rinciples of !herapy
" plethora of agents a)ailable. 7ommon topicals include ben8oyl pero(ide, antibiotics and retinoids.
Systemic antibiotics (especially tetracycline deri)ati)es) for more se)ere acne. 9sotretinoin ("ccutane
$2
)
is an e(cellent option for recalcitrant acne. "A formulary# $en%oyl ero&ide' (lindamycin' Retin A
Alopecia Areata
Patchy, non4scarring hair loss in normal looking skin. 2ost patients ha)e small, locali8ed patches. Some
ha)e widespread in)ol)ement. 7an be associated with hypothyroidism.
Diagnosis
7linical appearance. 0iopsy confirmatory.
athology
:ymphocytic attack on the hair follicle (;swarm of bee<s= appearance on path) of unknown etiology.
$opical or intralesional steroids are first line treatments.
Atopic Dermatitis )Ec%ema*
7ommon itchy eruption that affects (13> of children), especially those with an atopic diathesis (seasonal
allergies, asthma). 9n)ol)ement can be mild to se)ere. "ssociated increased risk of skin infection. *o
cure a)ailable, though decreased se)erity with age.
Diagnosis
"cute ec8ema consists of red plaques. 7hronically inflamed skin has more prominent skin markings and
scale. 9t is )ery unusual for ec8ema to affect the a(illa or groin. *o diagnostic test a)ailable.
athology
?nknown.
6aily moisturi8er. P@* topical steroids, antihistamines and antibiotics. *ew drugs include topical
tacrolimus and pimecrolimus. (lobetasol )strong*' !riamcinolone )mod+*' Hydrocortisone )mild*+
(andidiasis
5ften seen either as white cheesy plaques in the mucosa or red papules and pustules in the inguinal
region.
Diagnosis
7linical. Skin scraping will demonstrate psuedohyphae.
athology
9nfection with Candida Albicans (usually)
*ystatin cream or "8ole based antifungal medications. 9t is helpful to minimi8e precipitating factors
(uncontrolled diabetes, antibiotic therapy, moist en)ironment). (lotrima%ole' ,etocona%ole
(ontact Dermatitis
%
9tchy red plaques often in a line or geometric distribution depending on the type of offending substance.
"cutely, the skin may ha)e )esicles or blisters. 7hronically, there may be thickened skin (lichenification)
and scale. % types+ allergic and irritant. 2ost common causes of allergic contact dermatitis include poison
i)y and nickel. 9rritant contact dermatitis is often seen on the hands due to o)er hand4washing.
Diagnosis
7areful history picks up ob)ious e(posures. Patch testing for difficult to diagnose allergic causes.
athology
9nflammation in the skin due to an irritating en)ironment or contact with an allergen.
rinciples of therapy
")oid precipitating factors. $opical -clobetasol )strong*' triamcinolone )mod+*' hydrocortisone
)mild*., or systemic steroids )prednisone*+
/olliculitis / /uruncle / (arbuncle
,olliculits presents as one or many red papules (and pustules) originating from a hair follicles. :arger,
tender nodules are termed furuncles. 2ultiple follicles may be in)ol)ed (carbuncle).
Diagnosis
7linical suspicion. 0acterial culture of the e(udates may be helpful.
athology
9nfection, usually by Staph aureus, of a hair follicle.
"ntibacterial soap, antibiotics topical )mupirocin' clindamycin* or systemic )diclo&acillin' cephale&in'
erythromycin*+ P@* 9&6. 1arm compresses.
Herpes Simple&
@ecurrent self4limited tender )esicular eruption most often found on the lips and genitalia. Prior to the
recurrence, a tingling or burning sensation is usually felt.
Diagnosis
"ppropriate history and clinical appearance. 7ulture or P7@ may be used.
athology
.erpes Simple( !irus 1 4 mostly oral.
.erpes Simple( !irus % 4 mostly genital.
"nti)irals (famcyclo)ir, acyclovir, valacyclovir) taken at the first sign of recurrence may abort or shorten
an episode.
Impetigo
@ed papules and plaques that form superficial )esicles leading to a characteristic ;honey colored= or
;golden= crust. $he lesions are often asymptomatic, but may be pruritic.
Diagnosis
7linical suspicion. 0acterial culture can be helpful
athology
Superficial infection of the skin with Strep. Pyogenes or Staph. aureus. 5ften occurs after minor skin
trauma.
$opical mupirocin or systemic antibiotics )diclo&acillin' cephale&in' erythromycin*+
0entigo
0rown well demarcated macules in areas of chronic sun damage (often the face, neck, upper chest,
forearms and hands). 7ommonly referred to as ;li)er spots= or ;age spots=.
Diagnosis
7linical. 0iopsy is occasionally needed to e(clude skin cancer.
athology
9ncreased pigmentation & number of melanocytes in the epidermis. ?nlike ne)i, no nests are seen.
*o treatment needed unless for cosmetic purposes. :aser or :*% may be used.
&

0eu1ocytoclastic vasculitis )palpable purpura*
Purpuric papules most often on the lower e(tremities usually lasting se)eral weeks. 7ommonly
associated with fe)er, arthralgias and other systemic symptoms including renal in)ol)ement. 2ay be
idiopathic or associated with a )ariety of triggering factors (medications, infections, connecti)e tissue
disorders).
Diagnosis
7linical suspicion confirmed by biopsy.
athology
9mmune comple( deposition in the cutaneous )essels leading to )ascular destruction and e(tra)asation
of @07<s.
9f possible, treatment of the precipitating e)ent or disorder. " )ariety of medications can be helpful+
NSAIDS' Dapsone' (olchicine or rednisone.
0ichen lanus )0++*
7hronic eruption that affect the mucous membranes, skin and nails. $he buccual mucosa often has a
lacy white appearance. $he skin has itchy reddish4purple flat topped papules with an o)erlying fine white
lacy scale (1ickham<s striae) most commonly seen on the wrists, genitalia and ankles. $he nails may be
normal, but may be se)erely dystrophic.
Diagnosis
7linical suspicion confirmed by biopsy.
athology
?nknown. Some drug eruptions can mimic rash. 9n addition, some studies indicate an association
between :.P. and .epatitis 7.
$opical steroids -(lobetasol )strong*' !riamcinolone )mod+*' Hydrocortisone )mild*. and
antihistamines. 6rug history and .epatitis screen may be helpful.
ityriasis Rosea )+R+*
$ransient eruption that tends to occur on the trunk of young adults. $he first sign is usually a large red
scaly plaque (.erald patch), followed later by smaller o)al scaly plaques. $he eruption lasts &4# weeks.
Diagnosis
7linical, howe)er may be mimicked by syphilis (check @P@).
athology
?nknown etiology.
*o therapy needed. 9f symptomatic, topical steroids or ?! light may be helpful.
orphyria (utanea !arda )+(+!+*
Photodistributed blisters, crusts and erosions that lead to scars and pigmentary changes. 2ay be
associated with milia, hypertrichosis and sclerodermoid changes.
Diagnosis
7linical suspicion confirmed by urine or serum porphyrins.
athology
2ay be associated with )iral hepatitis, hormonal therapies, hemodialysis or alcohol intake. 'tiology is a
defect in the uroporphyrinogen decarbo(ylase en8yme used in the production of heme.
7omplete sun protection e(tremely important. $reatment of underlying disorder. Phlebotomy and low4
dose antimalarials )hydro&ychloro2uine* are treatment options.
soriasis
/
Scaly, red plaques that tend to affect the knees, elbows, scalp and sacrum. 2ost patients ha)e a few
small asymptomatic plaques, howe)er some ha)e widespread lesions & Aor pruritus. 1> incidence.
Possible autosomal dominant inheritance with )ariable penetrance.
Diagnosis
7linical appearance, though may confirm with a biopsy.
athology
"n inflammatory reaction in the skin altered by en)ironmental and genetic factors.
"ggressi)eness of therapy must be tailored to clinical situation. 2any options a)ailable# topical
)steroids' calcipotriene' retinoids*' ultraviolet light )A&$*' and systemic )methotre&ate' retinoids'
cyclosporine, $*,4alpha inhibitors).
Rosacea
,acial acne like pimples along with redness, telangiectases and flushing in adults. ?sually asymptomatic,
though eye in)ol)ement may be irritating. Bey diagnostic feature is the lack of comedones.
Diagnosis
7linical.
athology
?nknown cause, but higher predisposition in fair skinned female patients. !ery common.
")oid triggers (stress, heat, alcohol). 3etronida%ole gel or the tetracycline class of antibiotics.
Stasis Dermatitis
'c8ematous plaques on the bilateral lower legsAankles accompanied by purple, hyperpigmented
edematous skin. $he skin may be itchy. 9n)ol)ed skin may easily ulcerate, heal slowly and become
superinfected.
Diagnosis
7linical history and appearance.
athology
Poor )enous return leading to chronic edema & stasis changes.
9t is important to minimi8e leg swelling by combining leg ele)ation, compression and perhaps medication
(diuretics if needed). $he ec8ematous plaques may be treated with moderate potency topical steroids
)triamcinolone*. ?lcers need good wound care and careful antibiotic therapy when infected.
?nfortunately, this tends to be a chronic problem without cure.
!inea (orporis/(apitis/(ruris/edis
@ed scaly plaques that may be asymptomatic or itchy. ,requent cause of hair loss on the scalp. 5n the
body, the lesions often ha)e an annular (ring4shaped) appearance. 5n the feet, often seen between the
toes and along the plantar portion of the foot. 7ommonly referred to by patients as athletes foot, jungle
rot, ringwor or joc!"itch.
Diagnosis
7linical. Skin scraping with B5. will demonstrate hyphae
athology
7aused by a )ariety of dermatophyte fungi.
$opical or systemic antifungal medications. Naftin' ,etocona%ole
!inea "ersicolor
Scaly thin plaques mostly on the trunk and pro(imal e(tremities. $he lesions can be darker or lighter than
the surrounding skin, hence ;)ersicolor=. 5ften asymptomatic.
Diagnosis
7linical. Skin scraping with B5. will demonstrate ;spaghetti & meatball= appearance of short hyphae and
spores.
athology
7aused by #alesse$ia %urfur &P. 'vale)
C
$opical or P5 antifungals. ,etocona%ole )4 or cream* and Selenium shampoo.

"aricella 5oster "irus
9nitial airborne infection leads to the common childhood e(anthem chickenpo( (self4limited diffuse pruritic
)esicular eruption). @ecurrence later in life as )esicular plaques in a dermatomal distribution is termed
8oster (shingles).
Diagnosis
"ppropriate history and clinical appearance. 7ulture or P7@ may be used.
athology
!aricella Doster !irus infection
9solation from une(posed or immunocompromised adults (including pregnancy). "nti)iral and
symptomatic therapy. 'ncephalitis or pneumonia may be rare but dangerous complications. "altre& &
Acyclovir+
"erruca )6arts*
1arts can occur on any skin surface included the oral mucosa. 9n the genital region they are termed
condyloma and may be se(ually transmitted. ?sually asymptomatic, larger lesions may become tender
with trauma or pressure.
Diagnosis
7linical. 0iopsy can confirm.
athology
.uman papilloma )irus infection.
Salicylic acid, li2uid nitrogen, cantharidin, podophyllin' imi2umod )Aldara), laser and surgery all can
be used to treat warts depending on location and patient preference. *o treatment yet can pre)ent
recurrence. ,emale partners of men with condyloma should ha)e routine pap smears (certain .P! types
lead to cer)ical cancer).
7rticaria )hives*
$ransient itchy non4scaly red plaques each present less than %/ hours. 6i)ided into acute and chronic if
present less or more than E weeks duration. @arely associated with angioedema, which can be fatal.
Diagnosis
7linical diagnosis.
athology
'ither idiopathic or triggered by e(posure to a causati)e factor. 7ommon causes include medications,
food (shellfish, nuts, etc), pressure, temperature, infection, and bee stings.
6isco)er offending agent and a)oid e(posure. "ntihistamines are the mainstay of therapy.
Diphenhydramine )$enadryl*' Hydro&y%ine )Atara&* & 0oratidine )(laritin*+
!umors & Hamartomas
Achrochordon )S1in !ags*
Pedunculated flesh colored papules often found on the eyelids, neck and a(illa.
Diagnosis
7linical
athology
*ormal skin
*o treatment needed unless for irritation or cosmetic reasons. 'lectrocautery, scissor e(cision or :*%.
E
Actinic ,eratosis )A+,+*
$hin rough scaly plaques that are more easily felt than seen. 2ostly seen in a photodistribution in a
setting of sun damaged skin.
Diagnosis
athology
" )ery small percentage of these sun4induced lesions will degenerate into squamous cell carcinoma.
,requently treated during routine skin checks in sun damaged patients. $reatments include liquid
nitrogen and topical products (8 fluoururacil and diclofenac).
Angiomas )(herry angiomas*
Small red or purple papules commonly found in 7aucasian patients. 2ore frequent with age.
Diagnosis
7linical. 0iopsy is almost ne)er needed.
athology
7omposed of blood )essels.
@eassurance. 9f treatment desired for cosmetic appearance, irritation or bleeding electrocautery or laser
therapy works well.
$asal (ell (arcinoma )$((*
Pearly pink cancerous plaque with telangiectases on sun damaged skin. Prone to bleeding and
ulceration. "lmost 8ero risk of metastasis. 2ost common malignancy.
Diagnosis
7linical confirmed by biopsy.
athology
Sun damage induced skin cancer.
@emo)al necessary )ia e(cisional surgery, 2ohs surgery, desiccation and curettage, topical medications
(imiquimod, C4fluourouracil). ,Au skin checks needed as patient at higher risk for other skin cancers.
(utaneous !9(ell 0ymphoma )(!(0' 3ycosis /ungoides*
2alignant patches progressing to plaques, tumors and ulcers on the skin. ?sually )ery slow course and
delayed diagnosis (E4# years after onset). Se8ary syndrome is more aggressi)e and manifested by
diffuse erythema.
Diagnosis
.igh inde( of clinical suspicion. 2any biopsies often needed. C4F year delay from onset to diagnosis is
typical.
athology
'pidermal attack by malignant $ 7ell clones.
Skin in)ol)ement often treated with P?!", *itrogen 2ustard &Aor @etinoids.

Dermatosis apulosa Nigra )D++N+*
6ark papules mainly on the cheeks on patients with dark skin. $he actor, 2organ ,reeman has many.
Diagnosis
7linical.
athology
@esembles a seborrheic keratosis.
F
@eassurance. 9f bothersome for cosmetic reasons, curretage or light electrocautery can be helpful. 0e
)ery careful with the use of :*% on dark skin as hypopigmentation is common.
Epidermoid (yst )Epidermal inclusion cyst*
Small to large subcutaneous nodules with an o)erlying plugged follicular opening (punctum) almost
anywhere on the body. 5ccasionally inflamed due to traumatic rupture of the cyst sack or superinfection.
Diagnosis
7linical diagnosis
athology
0locked follicular opening leading to accumulation of degenerated hair in the follicle (like a balloon)
*o therapy indicated unless for cosmetically bothersome or symptomatic (repeatedly inflamedAtender).
Surgical remo)al is the only option.
,eloid
,irm protuberant scar that e(tends beyond the boundary of the inGury. Beloids can be itchy or painful and
often occur in certain locations (chest & shoulders) and racial groups (black, asian, etc).
Diagnosis
6iagnosis is clinical and usually not difficult.
athology
"ltered wound healing and collagen synthesis.
2ay be difficult as keloids tend to recur. 5cclusi)e dressing, intralesional steroids and pulsed dye laser
are treatment options.
3elanoma
6angerous skin cancer that often appears as an irregular changing mole. 1arning signs+ " (asymmetry),
0 (Gagged border), 7 (multiple colors) and 6 (diameter H Emm).
Diagnosis
athology
@isk factors include many unusual moles, positi)e family history, sunburns as a child.
Sunprotection starting early in life. Self monitoring of moles and periodic skin checks by a dermatologist.
Prognosis with surgical e(cision e(cellent if caught early. "d)anced (deep) melanoma that has
metastasi8ed responds poorly to treatment.
Nevi )3oles*
7ommon skin colored to brown macules and papules anywhere on the body. 9f present as an infant they
are called congenital ne)i. *e)i with irregular pigmentation, Gagged border, asymmetry andAor large
diameter are often biopsied to rule out melanoma.
Diagnosis
7linical. 7onfirmed by biopsy if needed.
athology
*ests (groups) of melanocytes in the epidermis andAor upper dermis.
Patients should be ad)ised on sun protection and to report moles that change or de)elop atypical
features. Some are remo)ed for cosmetic reasons.
Seborrheic ,eratosis )S+,+*
$an to brown scaly plaques that ha)e a ;stuck4on= appearance. 5ften occurs more with age.
Diagnosis
athology
#
?nknown etiology.
9f irritated or cosmetically bothersome, these can be remo)ed with liquid nitrogen or curettage.
S2uamous (ell (arcinoma )S((*
7rusted, keratotic or ulcerated tumors. "lthough most are low grade malignancies, some areas carry a
higher risk (lip, mucosa, ears and mid face) of metastasis.
Diagnosis
athology
$umors induced by either sun damage, arsenic e(posure or chronic wounds.
Surgical e(cision, 2ohs surgery or radiation therapy.
!reatments
Antimicrobials4 " )ariety of antibiotics, antifungals and anti)iral medication can be used to treat skin infections. $here is
an increasing problem with drug resistance, especially with antibiotics. "n abnormal skin barrier becomes more susceptible
to infection, one reason ec8ema flares may also impro)e with antibiotic therapy to treat super4infection.
Antineoplastic agents4 $opical C4fluourouracil is used for many "Bs o)er large areas. 9miquimod cream may be used for
warts, 077, S77 and others. 9nGectable bleomycin for recalcitrant warts. 5ral methotre(ate can help treat se)ere psoriasis.
(ryotherapy I "pplication of :iquid *itrogen can destructi)ely free8e lesions. Side effects include+ pain & discoloration.
Electrodessication and (urettage9 " curette is used to ;scoop out= the soft cancerous tissue (usually 077) and the base
of the lesion is treated with electrocautery. 7ure rates in appropriate tumors approaches JC>.
,eratolytics9 ?rea, lactic acid and salicylic acids are all products that dissol)e thick or e(tensi)e e(cessi)e scale.
0asers I 7oncentrated monochromatic focused beams of light can selecti)ely destroy targets in the skin. " )ariety are
a)ailable with different wa)elengths, energy le)els and pulse duration settings.
3oisturi%ers4 9n many skin disorders, such as "topic 6ermatitis, it is )ery important to lubricate the skin. 6ry skin
diminishes the barrier function and can be )ery itchy. 9n general ointments are better emollients than creams which in turn
are better than lotions. 'qually important is the use of a gentle soap and short lukewarm showers or baths.
Retinoids4 5ften used for acne, psoriasis and other skin disorders. $opical formulations are safe, but may cause skin
irritation. Systemic retinoids are more effecti)e, howe)er carry potential for serious side effects including+ high triglycerides,
teratogenicity, possible psychiatric alterations and li)er to(icity.
Steroids 4 $opical and systemic steroids are e(cellent anti4inflammatory agents and can be used to treat a wide )ariety of
inflammatory skin conditions from ec8ema to lupus. $opical steroids are categori8ed 1 I F (1 being the strongest). Steroid
side effects include+ acne, atrophic skin, striae and increased susceptibility to infection.
Sunscreen4 Suncreen & sunblock forms a topical defense from ?!" and ?!0 light, which o)er years may lead to wrinkles,
pigmentary changes and skin cancer. "n SP, (sun protection factor) of 1C indicates the ability to stay out 1C times longer
with protection than without to achie)e the same le)el of sun damage from ?!0.
Surgery9 '(cisional surgery is still the gold standard for remo)al of many skin lesions, especially skin cancer. 2oh<s
surgery is a speciali8ed surgical technique using microscopic inspection of 133> of the surgical margin, thereby eliminating
the need to take wide margins. 2oh<s is often used for facial skin cancers (high cure rate & tissue sparing).
7" 0ight : :ight in the ultra)iolet part of the spectrum can impro)e a )ariety of inflammatory and itchy skin disorders such
as psoriasis and atopic dermatitis. ?!0 is less aggressi)e but less effecti)e. P?!" (Psoralen pill gi)en prior to ?!"
treatment) is more effecti)e but has more side effects (higher risk of skin cancer, burn and photosensiti)ity).
J

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