Dermatology

Test Interpretation
Diagnostic Test Measures Indications Other
Result Parameters
Examination of skin lesions using a
device made up of a magnifier,
Dermoscopy non-polarised light source, and a
Any skin lesion

transplarent plate
A Asymmetry Asymmetric
ABCDE's of Process for inspecting
pre-existing or new
B
C
Borders
Color Melanoma
Irregular borders
Various colors
Dermatology moles D
E
Diameter
Elevation / Evolve
Larger than a pencil
Elevated
Find the newest lesion
to sample
Timing Timing is not important
for basal cell carcinoma
or dysplastic nevi
Histologic analysis of
Skin Biopsy skin tissue
Most characteristic area
of the lesion
Go for advancing
Site Selection borders
Avoid hyperkeratotic,
scarred, excoriated, or
denuded areas
Procedure
Squamous cell
Basal cell carcinoma Clean biopsy site with alcohol
Skin lesion and a thin carcinoma
Mark site (if needed)
layer of surrounding skin Anesthetize
Shave Biopsy are removed with a small
Actinic keratosis Verrucae
Shave lesion
Perform wound care
blade Molluscum contagiosum Dysplastic nevi Send to pathology

Procedure
Malignant melanoma Granuloma annulare Clean biopsy site with alcohol
Mark site (if needed)
Multiple dermal layers Anesthetize
Punch Biopsy are removed
Erythema nodosum Vasculitis
Punch lesion
Remove specimen w/ tissue scissors
Depth of lesion is
Dermal pathology Close with suture
needed for staging
Perform wound care
Elliptical excision usually with layered

Excisional Complete removal of

lesion and surrounding Melanoma
Thought to be in the
deep dermis of
closure

Biopsy skin subcutaneous fat

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

 Dermatology
Test Interpretation
Diagnostic Test Measures Indications Other
Result Parameters
HSV I HSV II
Study of antibodies in plasma
Serology serum or other body fluids Lyme disease Autoimmune diseases
Lesion is cut. > 98% cure rate
Microscopically controlled surgery
Tissue micrscopically analyzed.
Mohs Surgery used to treat common types of
skin cancer
Tissue repeatedly cut and analyzed until the tissue
is cleared of cancer cells.
Erythrasma Coral fluorescence
TV lesion Vitiligo
Tinea Capitus No fluorescence
Wood's Lamp Black light
Tinea cruris Erythrasma Vitiligo
Hypopigmentation
visible
Quick, inexpensive fungal test to Scale is collected by scraping the
Tinea versicolor Dermatophytes
differentiate dermatophytes and advancing border of the lesion with a
KOH Prep Candida albicans from other skin
Candida albicans Yeast
Tinea Versicolor Spaghetti and meatballs
#15 blade or glass slide. Allow scale
disorders to fall onto second glass slide
Blanching Inflammation
Test for blanchability by Angiomas
applying pressure with a Purpura
Diascopy glass slide and observing
Erythematous lesions
Non-Blanching Ecchymosis
Portwine stain
color changes
Vasculitis
Procedure
Select a fresh lesion
Vesicles
Vesicle Viral Determines presence of
Herpes zoster
Use a #11 blade or swab to unroof
the vesicle
a viral infection Roll swab over lesion to collect fluid
Culture Herpes simplex
and place in viral culture medium.
Send to lab

Procedure

Tzanck Alternative testing

modality for viral Vesicular infections Pemphigus Viral Infection
Multinucleated giant
Blister is opened along side.
Roof is folded back.
cells Underside scraped.
Preparation infections Material collected is smeared onto a
microscope slide.
Procedure

Pustule Bacterial culture of a

Select a fresh lesion.
Use a #11 blade to gently nick the surface of the
pustule pustule
Culture Use a bacterial culture swab to collect content.
Send for culture and sensitivity.

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

 Dermatology
Test Interpretation
Diagnostic Test Measures Indications Other
Result Parameters
Select a linear burrow or intact papule. Mite
Scabies Test to diagnosis scabies
Thin shave biopsy is performed
POSITIVE Eggs
Specimens placed on a microscope slide and
Preparation covered with immersion oil.
Feces
Look under low power
Patients avoids antihistamines or any
Allergic contact dermatitis
steroid preparations for > 2 weeks
Neomycin before testing.
Determines sensitivities Black rubber
Patch Testing to specific allergens Examples of Testable Fragrance
Allergens Propylene glycol
Nickel
Wool alcohols

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Flat Patch
(nonpalpable) Large macule (> 1 cm)

Macule Primary lesion ≤ 1 cm

Alteration in color

Raised Plaque
(palpable) Large papule (> 1 cm)

Papule Primary lesion ≤ 1 cm

Variable color

Bulla
Raised
Large vesicle (> 1 cm)

Vesicle Primary lesion Filled with clear fluid

≤ 1 cm

Raised
(palpable)

Pustule Primary lesion Circumscribed collection

of inflammatory cells
Varable size and free fluid

Raised

Nodule Primary lesion Round and solid

Deeper than papule ≤ 1 cm

Firm, edematous papule

Wheal Primary lesion seen in or plaque

type I hypersnesitivity Unbound fluid

(Hive) reaction Flat-topped elevations Transient

Very common in fungal skin

infections.

Scale Secondary lesion

Crust Secondary lesion

Collection of serum,
blood, or pus
(Scab)
Focal loss of epidermis

Erosion Secondary lesion

Heals without scarring

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result

Focal loss of epidermis

and dermis
Ulcer Secondary lesion
Heals with scaring

Fissure Secondary lesion Linear "crack"

Atrophy Secondary lesion

Excoriation Lesion from scratching

Comedo Blackhead or whitehead

Small, superficial keratin

Milia cyst

Closed sac that has a

distinct membrane and Visible opening is often
Cyst devision compared to the seen

nearby tissue

Narrow, elebated tunnel

Burrow due to a parasite

Linchenification Thickening of the skin

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result

Telangectasia Dilated superficial vessels

Purpura
Nonblanchable Large petechaie (> 1 cm)

Petechiae Blood deposit

≤ 1 cm

Non-Bullous Impetigo Very common in child but adults can

Bactroban also be infected
Small pustules or
Pre-Disposing Factors
"Scabbing eruption" vesticles that erode and Topical Antibiotics
Trauma
curst (honey-colored) Altabax
caused by group A (MSSA only)
Underlying dermatoses
Usually inflammed Poor hygiene
Impetigo β-hemolytic Bullous Impetigo Previous antibiotic therapy
Streptococcus pyogenes Vesicles or bullae Cephalosporins Warm temperatures and high
containing clear or Systemic humidity
or S. aureus
turbid fluid Antibiotics Ecthyma
Surrounding skin can Dicloxacillin Impetigo that extends into dermis
be normal
Plaques with more Can be confused with inflammatory
defined borders dermatoses such as psoriasis,
seborrheic dermatitis, or atopic
No satellite lesions
dermatitis

Bacterial Non-specific bacterial Odor

Topical antibiotics
The role of topical steroids is
controversial.
infection of opposed skin Group A and B Neck-fold intertrigo in babies is due
Intertrigo Streptococci to Strep.
Non-dpihtheroid species
Etiologies
of Corynebacterium
P. aeurginosa

Commonly seen in Benzoyl peroxide

Chronic superficial skin intertriginous skin Topical Antibiotics
Mupirocin
Erythrasma infection by
Appears bright red with
± Imidazoles
C. minutissimum Wood's lamp
Systemic Doxycycline
Antibiotics Macrolides
Dermal ulceration
Yellowish-gray crust
Impetigo that extends
Ecthyma into dermis Crust is thicker and
harder than seen in
impetigo

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Incision and drainage
Abscess
Localized, walled-off
Abscess collection of pus Systemic antibiotic

Furuncle
Warm compresses

Antibacterial
Deep-seated
Furuncle erythematous nodule
Carbuncle soaps
Monthly Betadine
Pre-Disposing Factors
or Hibiclens
Trauma Chronic carriage of S. Prevention
showers
Diabetes aureus
Large area of coalescing
Carbuncle abscesses or furuncles
Obesity
Minor Immunologic
Poor hygiene
Bactericidal defects
Control of any
predisposing
Deficits Chemotactic defects conditions
At-Risk Populations
Culture and sensitivity Sulfamethoxazole
Native Americans
Abscess, furuncle, or / Trimethoprim
CA-MRSA Skin Most common clinical carbuncle
Incision and drainage
(large abscesses)
Clindamycin
African Americans
Homeless
manifestion of MRSA Populations in close quarters
Infection Risk Factors
Surveillence (small abscesses)
Competitive atheltes
Skin trauma Cosmetic body shaving Linezolid
Antibiotics (adjunctive therapy)
Sharing equipment not washed between uses
Acute, diffuse Warmth
inflammation Tenderness
Lack of systemic symptoms (common) Penicillinase-
Pre-Disposing Factors resistant synthetic
Trauma Surgery penicillins
Mucosal infection
Immunologic deficiency
Underlying dermatoses
Systemic
Cellulitis
Antibiotics
Extends into
Cephalosporins
subcutaneous tissue

Soft Tissue Infection of the skin and Indistinct borders

the soft tissue below it Group A Strep Macrolides

Infections Etiologies
S. aureus (if PCN allergic)
Others (in special clinical
settings)
Erysipelas Rest
Superficial cellulitis
Supportive
Raised borders with Elevation
Treatment
clear demarcation
Lower extremities and Etiologies
face most commonly Group A Strep Warm compresses
affected S. aureus (rare)

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Begins with soft-tissue Progression into Common Infection Sites
infection multi-organ failure Perineum
Pain out of proportion to physical findings Extremities
Etiologies Trunk

Necrotizing Infection of the skin and

Clostridium
Peptostreptococcus
Bacteroides
Enterobacter
Proteus Pseudomonas
Soft-Tissue soft tissue that leads to Risk Factors
necrosis PAD Impaired cellular
Infection IVDU immunity
Smoking Alcoholism
Hypertension CAD
Chronic steroid use Lymphedema
Varicella lesions Genital trauma
EMERGENCY
Fulminant NSTI of the
10 ♂ : 1 ♀
Type of necrotizing perineum and genitalia
Fournier's infection or gangrene Complicates GU or
usualy affecting the anorectal surgery
Gangrene perineum
Etiologies
E. coli Klebsiella
Proteus Bacteroides
Single, scatteed papules No tenderness Can evolve into a pyoderma
PRSPs
or pustules No pruritis Bacterial Agents
Pre-Disposing Factors Oral Antibiotics First gen. S. aureus
Shaving (7 - 10 days) cephalosporins Gram (-) bacteria

Infectious Infection of the upper

Friction / occlusion of
hair-covered areas
Macrolides
(if PCN allergic)
Pseudomonas
Special Types of IF
portion of the hair follicle Immunosuppression Pseudofolliculitis barbae
Folliculitis Topical corticosteroids Correct any predispoing condition Keloidal folliculititis
Sites of Prediliction "Hot tub" folliculitis
Face Scalp
Neck Legs Encourage antibacterial soaps
Trunk Buttocks
Small curly hairs become ingrown
Shaving cessation resulting in foreign-body reaction to
Pseudofolliculitis Common in shaved areas the hair.
Barber's itch of the face
Barbae Antibiotic therapy

Papules that coalesce

Keloidal Chronic folliculitis found into nodular masses
Antibiotic therapy
at the nape of the neck (cyclic administration common)
Folliculitis Develops over slowly
over months or years

Far less common than S. aureus

Occurs on the trunk
folliculitis
Pseudomonas after bathing in tubs
Very alarming to patients
"Hot tub" folliculitis Resolves spontaneously in 1 - 2 weeks
Folliculitis Incubation period of
1 - 5 days

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Erythematous linear
streaks extending from

Acute Infection of the wound / skin break

Antibiotic coverage for Strep and
subcutaneous lymphatic Etiologies
Staph
Lymphangitis channels Group A Strep S. aureus
P. multocida
Subacute Etiologies
Mycobacteria
(rare)
Sporothrix
Starts as macular area
that develops into
Cellulitis due a Gram bullous lesions
negative bacteria found Occupation with fish and
Vibro Cellulitis in marine animals that seafood

inhabit warm water Common In… Brackish water exposure

Immunocompromised
↑ Serum iron levels
Anti-TB drugs are not helpful
Single nodule that
Resolve spontaneously Suspect M. marinum in patients with
Mycobacterial Infrequent cause of skin ulcerates or crusts
frequent aquatic exposure

Skin Infection infection Joined by satellite

Excision may hasten resolution
lesions

Papulovesicular lesion Usually acquired via contact with

Cutaneous Very rare infection of the ↓
Necrosis
7 - 10 day course of ciprofloxacin or
infected animals, animal products,
feed, or soil contaminated with
skin doxycycline
Anthrax ↓
Eschar-covered ulcer
spores of the bacillus

Etiologies
Predisposing Factors
Microsporum
Skin infection by a unique Trichophyton
Dermatophytic Atopy Occulsion
KOH Wet Epidermophyton
group of fungi that infect Mount
Diagnostic
Routes of Transmission
Infections keratinized epithelium Steroid use ↑ Humidity
Person-to-person
Animal-to-human
Dry skin
Environmental
Erythema Predisposing Factors Ulcerative Type
Topical Imidazoles
Scaling ↑ Sweating Interdigital infection spreads to
Antifungals
Vesicles Occulsion (by shoes) plantar and lateral surfaces of foot
(2 - 4 weeks) Allylamines
Maceration Contaminated public
Dermatophytic infection
Involvement of toe nails floors For severe or
of the feet Interdigital Type refractory cases
Scaling
Imidazole
Maceration (between
4th and 5th toes) Oral Antifungals
Tinea Pedis Moccasin Type (2 - 6 weeks)
Allylamines

Erythema
Monitor liver
Scale and papules on
function if therapy
heels, soles, and lateral
to exceed 4 weeks
"Athlete's foot" foot borders
Inflammatory / Bullous
Treat any secondary infection
Type
Fluid-filled vesicles that
Open infection to air
erupt into erosions

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Risk Factors
Erythematous, scaling,
Subacute or chronic infection Obesity
and well-demarcated
of the groin / medial thighs Tight clothing
Tinea Cruris plaques Topical antifungals

"Jock itch" Dull red, tan, or brown

Subacute infection of
Tinea Corporis neck, trunk, and/or
Plaques with sharp
borders
Smaller pustules or
vesicles within borders
Topical antifungals

extremities Enlarge peripherally

Central clearing
Most common in African-American
Griseofulvin children between 6 - 10 years old.
Ectothrix
Asymptomatic
Systemic Infection is outside hair shaft
Antifungals Imidazoles Endothrix
(6 - 12 weeks) Infection is inside hair shaft
"Black Dot"
Dermatophtyic infection Terbinafine Broken-off hairs resemble dots
Tinea Capitus of the scalp
Black Dot
"Gray Patch"
Arthrosporse give gray appearance
Antibiotics for any secondary
and circular areas of alopecia
infections
Kerion
Infection accompanied by swollen,
Kerion
Topical ketoconazole or selenium painful nodule
sulfide (reduces transmissibility)

Any type of tinea in which the Less demarcated Flatter borders

Tinea appearance of the lesion has been
altered by inappropriate Lack scaling Larger lesions
Incognito treatment (usually a topical
steroid) More pustular in appearance

Predisposing Factors
Nystatin Obesity
Diabetes
Infection involving sites
Intertriginous where maceration and Imidazoles
Hyperhydrosis
Steroid use
occulsion create a warm, Infection in the small body folds is
Candidiasis moist environment
more common in cooks, bartenders,
health-care workers, or others that
Glucocorticoids (used sparingly)
keep their hands frequently in water.

Asymptomatic
Selenium sulfide
Multiple well-
Yeast
demarcated macules Topical Works only in

Tinea Chronic skin infection by Hyper- or hypo-

pigmenting
Antifungals limited disease
Imidazoles
the opportunistic Fine scaling Microscopic
(Pityriasis) pathogen Common Sites Study
Pseudohyphae
Ketoconazole
Upper trunk Axillae
Versicolor Malasezzia furfur Groin Thighs
Oral Antifungals Fluconazole
Neck "Spaghetti and
Sites of Oil / Grease
Face meatballs"
Applications Itraconazole
Scalp

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Usually acquired by
Outdoor occupations
trauma
Subcutaneous Rare and slow progressing Persistent lesions that are poorly responsive to
antibiotics
Fungal subcutaneous infection by Etiologies
saprophytes found in soil Sporothrix Exophila
Infections Fonsecaea madurella
Pseudallescheria
Rash preceded by Scarlatinform Type
Self-limiting
prodrome Generalized erythema
Oral lesions (possible) Worse in body creases
Generalized skin eruption Common Childhood Viral Exanthems Morbiliform Type
Viral Exanthem secondary to systemic Rubeola
(measles)
Rubella
(German measles)
Maculopapular
Vesicular Type
viral infection Varicella Roseola Vesicles → papules → pustules →
(chicken pox) (sixth disease) erosions
Erythema infectiosum (fifth disease)

Hand-Foot-Mouth Systemic Coxsackie Oral lesions (erosions) Vesciualr exanthem

limited to the distal
viral infection Outbreaks every
Disease 3 years
extremtriteis

Complications
Perioral infection by Group vesicles on Penciclovir (topical) Systemic symptoms
HSV-1 or HSV-2 erythematous base Conjunctival/corneal autoinoculation
Bell's palsy
Herpes Labialis Acyclovir
Erythema multiforme
"Cold sore" or Preceded by prodrome Eczema herpeticum
"fever blister" of sensory complaints Valacyclovir Severe, diffuse infection (in
immunocompromised)
HSV-1 > HSV-2
Fever
Eczema Rare but severe disseminated HSV
infection that generally occurs at Malaise

Herpeticum sits of skin damage

Possible secondary
infection by S. aureus
Eruptions may take Necrosis (possible) ↑ Dose acyclovir, valacyclovir, Post-herpetic neuralgia (PHN) is the
Primary infection 1 week to compeletely Single dermatome famciclovir, or foscarnet most worrisome complication. Oral

Varicella- (varicella) permanent evolve distribution (acyclovir-resistant strains)

Prednisone (if ≥ 50 years old)
steroids may help prevent.
Thoracic > trigeminal > lumbosacral
infection and latency Analgesics > cervical
Zoster Virus until reactivation that Gabapentin Zosatvax is a live vaccine for the
Pregabalin prevention of shingles.
Infection results in zoster Post-Herpetic
Neuralgia
Tricyclics
(shingles) Capsaicin
Lidocaine
Very common in children and

Molluscum Viral skin infection Distinct flesh-colord or

pearly white papules Spontaneous resolution
sexually active adults
Transmission is through skin-to-skin
caused by pox virus contact
Contagiosum with umbilicated centers

Oncogenic potential
Keratinocyte and Cutaneous Warts
Wart mecusous membrane Common
Filiform
infection by HPV Flat

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Environmental agents are
Contact Eczematous dermatitis
caused by exposure to
Papules Vesicles
characterized as irratants or
allergens.
Dermatitis environmental agents Pruritus

Burning Pain Slight improvement over weekend is

Stinging Discomfort unlikely with allergens
Irritant Contact Most common Pruritus Clears within 2 - 3 break
Patch Test Diagnostic
Identify and remove the offending
occupational skin disease from work agent
Dermatitis Recurs within days of
return to work Chronic lip licking

Erythema
Acute Irritant ↓
Bizarre configuration Wet dressings with Burrow's solution
Acute damage to Vesciulation
Contact keratinocytes ↓
Lesions do not spread Patch Testing
beyond area of contact
NEGATIVE Potent topical steroids

Crusting
Dermatitis Sharp borders
Oral steroids (in severe cases)

Dryness Chapping
Chronic Irritant Erythema Scaling Potent topical steroids + lubrication
Seen particularly in frequent hand-
washers
Disruption of normal skin ↓ ↓
Contact barriers Hyperkeratosis Crusting
Barrier creams
Dermatitis Fissuring Hands (most common)

Occupations

ICD Chrome Ulcers caused by the Tanning

corrosive necrotizing
Ulcers effects of chromates Electroplating

Chrome production

Test only known Scalp, plams, and soles are relatively

Intense pruritus Phytodermatitis Wet dressings
substances resistant.
Macules Concentrations Mucous membrane involvement is
Potent topical steroids
Papules predetermined uncommon.
Acute
Allergic Sensitized T-lymphocytes Vesicles
Bullae
Avoid testing with Systemic steroids
See PowerPoints for specific antigen
reactions
acute dermatitis (if widespread involvement)
respond to a recognized Erythematous plaques
Contact antigen to produce Subacute
with scale
Patch Test
Test site should be Oral antihistamines

Dermatitis inflammation Firm papules with scale free of dermatitis

Phototherapy or cyclosporine
Lichenified plaques Patches applied
(in more severe cases)
Scaling for 48 hours
Chronic
Fissured lesions Read 72 - 120
Allergen avoidance
Excoriation hours later
Co-existing atopic Sites of Predilection
Dry skin Moisturizers (emollients only)
manifestations Flexual surfaces
Mechanical Ill-defined papules
Tacrolimus
Face
Disruption of the epidermal Topical steroids
Plaques and patches Wrist
barrier
Atopic Acute
Erythematic
(± edematous)
Topical immune modulators
Pimecrolimus
Dorsal feet
Infantile, child, adult, hand, and
underlying skin follicular variants
Dermatitis Immunologic ± Linear excoriations
Oral antihistamines
Exacerbating Factors
T cells and Langerhans cells trigger Secondary Infection with Pustules
Phototherapy
Specific autoallergens
IgE-mediated inflammatory S. aureus Crusting and oozing Winter season
Cyclosporine
response Lichenification Manage secondary infection with Wool clothing
Chronic
Fissuring systemic therapy Emotional stress

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Atopic dermatitis
Lichen Simplex associated disorder due Localized area of
to repetitive scratching lichenification
Chronicus
and rubbing
Deep, tapioca-like

Dyshidrotic Vesicular eruption on

vesicles
Bullae
↑ potency topical steroids

hands and feet

Eczema Fissuring
Oral steroids (severe cases)

More common in winter months

Coin-shaped papuless
Nummular Also known as discoid and vesicles grouped in a
plaque
Moisturizers More commonly found on
extremities
dermatitis
Eczema Underlying skin may be
Intensely pruritic
Topical steroids
erythematous
Chronic plaque Anthralin Peak incidence in 20s.
Dovonex
Acute guttate Steroids Associations
Psoriais Vulgaris
Palmoplantar Tars Cardiovascular disease
Tazarotene
Inverse Topical Therapy Depression
Vitamin D analogs
Erythroderma Pustular Lymphoma
Cyclosporine
Shortened keratinocyte Trigger Factors Retinoids
Streptococcal infection Injury / trauma Taclonex
cell cycle with increased Drugs ↓ Humidity UVB Adalimumab
Psoriasis CD8 cells causues Emotional stress
Overtreatment with
steroids
Phototherapy Narrowband UVB
epidermal Lithium PUVA
Alefacept
hyperproliferation β blockers
Retinoids Etanercept
CCBs
Exacerbating Drugs ACE inhibitors Methotrexate
Systemic Therapy Infliximab
Antimalarials Immune-
NSAIDs modulating
Ustekinamab
Systemic steroids therapy
Months to years
Plaque distribution Palms / soles / scalp may
Chronic Plaque somewhat symmetrical be the only sites
Chronic type of psoriasis affected
Psoriasis Nail involvement (10 - 25%)

Relatively rare form

Small papules of short Streptococcal URI within
Psoriasis usually seen in
Guttate Psoriasis children and young adults
duration
(weeks to months)
1 - 2 weeks of
presentation
Spontaneous resolution

Erythematous plaques
Marcerated scales
Psoriasis that affects with shiny appearance
Inverse Psoriasis intertriginous areas Can co-exist with chronic plaque psoriasis

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Guttate Lesions
Salmon-pink papules
Loose scales
Scales not readily visible

(+) Auspitz sign

Psoriasis Most common form of Chronic Stable Lesions

psoriasis Well-demarcated
Vulgaris erythematous plaques
with silvery white scale
Plaques coalesce to form
variable patterns
More common in scalp
Variable pruritus
and anogential areas
EMERGENCY
Diffuse erythema
Extremely dangerous Serious Underlying Illnesses
Erythrodermic Hypo- / hyperthermia
form of exfoliative Skin thickening
Protein loss
Psoriasis dermatitis in adults Scale
Dehydration
Renal / cardiac failure
Pustules
(instead of papules)
Surrounding skin

Uncommon form of ± Erythema

Pustular psoriasis consisting of Chronic pustules limited

Palmoplantar
widespread pustules on to palms and soles
Psoriasis an erythematous Rare
Pustules develop in
background
waves over entire body
Generalized Acute
"Lakes" of pus
(Von Zumbusch)
Systematic symptoms
Can precede or follow
psoriasis vulgaris
M. furfur may be a possible causative
Erythema Scaling In infants…
factor.
Genetic and environmental factors
Seen in areas with ↑ sebaceous gland activity Scale removal Triamcinolone
influence onset and course.
Infants (Cradle Cap)
Treat infection
Greasy adherent scale
on vertex
Reduce inflammation
Accumlations of scales
Seborrheic Common, chronic, and and inflammation
Frequent washing of all involved areas Acetonide
inflammatory dermatitis 2⁰ Infection may occur
Dermatitis Adults
Topical steroids
Erythematous / grayish
plaques with greasy or
white scale Change shampoo
May appear as severe Betamethasone
dandruff Valerate
Blepharitis Maintenance therapy
Variable pruritus

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Scaling flat plaque on Appears as salmon pink in whites and
Abrupt onset
trunk or proximal hyperigmented in African-Americans.
Oral antihistamines
extremities
Papules and smaller
scaling plaques
(7 - 14 days after onset) Topical steroids

Pityriasis Common, benign, and Collarete scale

self-limiting dermatoses
Rosea "Christmas tree"
arrangement
10 - 35 years old (75%) Acyclovir

Pruritus worse at night

Asymptomatic and with heat
(if present)
Oral prednisone ± UVB phototherapy
Recent history of acute infection with fatigue,
(in severe cases)
headache, sore throat, lymphadenitis, and fever
(20%)
Topical Triggers
40 - 50 years old
Steroids Intralesional Drugs
Systemic Chemical exposure
1 - 10 mm flat-topped
Bacterial infection
papule with an irregular Cyclosporine
Inflammatory dermatitis angulated border
Post-bone marrow transplants

Lichen Planus of skin and/or mucous Wickham's striae on

Pruritis
Retinoids

membranes papules
Methotrexate
Pruritic
Polygonal
4 P's of Lichen Planus PUVA
Purple
Papule Antihistamines
Associations
Typically on the neck and
Acanthosis Hyperpigmentation of other body folds
Obesity
Endocrine abnormalities
the skin Certain drugs
Nigricans "Velvety" appearance Malignancy (onset is rapid)

Vesicles Lesions frequently become colonized

Rare genetic disorder
Hailey-Hailey characterized by chronic oozing
lesions that fissure and crack
↓
Erosions
Topical / oral antibiotics with S. aureus ± Candida

Disease Familial Benign Pemphigus

Occur in body folds Topical steroids

Dermatitis Chronic blistering skin Papules and vesicles

condition near the elbow
Herpetiformis
Serous-filled vesicles and
bullae Aggressive systemic steroid treatment
On scalp, axillae, face,
Autoimmune bullous groin, and trunk
Pemphigus disease that leads to (+) Nikolsky sign
Immunosuppressive therapies

acantholysis
Initial lesions start on Skin lesions typically
Correct any electrolyte discrepancies
oral mucosa develop months later

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Generalized
erythematous papules

Bullous Most common Urticarial lesions

autoimmune bullous Systemic steroids ± azothioprine
Pemphigoid disease
Bullae

60 - 80 years old

Behavioral Modiciation Most common in adolescents

No picking Flaring Elements
Follicular plugging and dilatation No mechanical exofoliation Sweating
Mild, gentle cleansing twice a day Chocolate
Oil-free, non-comedogenic products Cell phones
Topical Comedolytics Hands on face
↑ Cell turnover Cosmetics
Affects face, neck, upper trunk, and arms Prevent new Complications
Retinoids
comedones Scarring
(Vitamin A)
Chemically Keloids
exfoliate Psychological impact
Azelaic acid Pyogenic granulomas
± Inflammation and pustules
Glycolic acid preparations
Salicyclic acid preparation
Common inflammatory Benzoyl peroxide
disease of the hair Possible cyst formation
Clindamycin For specific details
Topical Erythromycin on acne
Acne Vulgaris follicles and Antibacterials Sulfur-containing medications, see
sebum-producing glands preparations PowerPoint slides.
Metronidazole
of the skin May lead to scarring or keloid formation
Dapsone (inflammatory acne)
Oral antibiotics
Severe, nodular-
cystic acne
Isotretinoin Inflammatory,
recalcitrant acne
Teratogenic
Oral
Hormone Therapy contraceptives
Spironolactone
Comedo extraction
Photodynamic therapy
Laser therapy
Chemical peels

Comedonal Acne with a high number

Blackheads Whiteheads
of comedones
Acne
Cysts
Fissures

Acne Severe, chronic, and

Abscess formation
Deep scaring
cystic acne High inflammation
Conglobata Begins in puberty Worsens with time

Flourishes on trunk Not as severe on face

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Oral / topical antibiotics
Sinus tract formation possibly Deep undermining cysts
Intralesional triamcinolone
caused by obstruction and
Hidradenitis infection of an apocrine duct
Fistulas
Scarring
Oral prednisone (14 days)

Incision and drainage

Suppurativa Double comedone
(simple cases)
"Acne Inversa" Occurs in the axillae, inguinal folds, perianal, and Excision by surgery
scalp (rare) (complex cases)
Mostly ♀
Lingering erythema Avoidance of triggers
30 - 50 years old; peak 40 - 50
Chronic condition Papules
Metronidazole Triggers
Sulfacetamide / Hot / spicy food or drink
characterized by facial Topical
Rosacea erythema and sometimes Pustules Treatments
sulfur
Azelaic acid
Sun
Alcohol
pimples No comedones Flushing Brimonidine Exercise
Telangiectasia Occurs on cheeck and Oracea
Rhinophyma nose Laser therapy
Grouped 1 - 2 mm Triggers

Perioral Unknown inflammatory

erythematous papules
Symmetrical around
etiology border of mouth
Dermatitis No comedones
Pain
Mobility limitations
Small, rough growth due
Wart to human papilloma virus Malignant degeneration
Occur in sites of skin
Necrotic capillaries
Avoidance of triggers Cinnamon products
Tartar control toothpastes
Metronidazole Whitening agents
Topical Therapy Erythromycin Heavy facial moisturizers
Clindamycin Topical steroids
Spontaneous resolution Cantharadrin HPVs can cause both benign and
Tenderness
(if immune-competent) Podophyllin malignant lesions.
Cryotherapy Retinoids Regression of warts is dependent on
Cosmesis
Duct tape occlusion Salicylic Acid cell-mediated immunity.
Obscure skin lines
Laser therapy or cautery 5-FU Warts occur more often in
Excision Imiquimod immunosuppressed individuals.
Chemical destruction Cimetidine
trauma Immunodulation Sinecatechins
5% prevalence in children
Verrucous surface

Verruca Common wart

Thrombosed capillaries

Vuglaris Dermatoglyhic loss

Prefers hands or places

5 - 20 years old
of trauma

Periungual Difficult-to-treat wart

Around the nail bed
near the nail matrix
Warts
Flat-topped surface

Pink to brown

Multiple
Verruca Plana Flat Wart
Prefers the face, dorsal hands, wrists, neck, and
legs
Flat warts frequently
Koebner's Phenomenon occur in a linear
formation

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Verrucous surface

Verruca Plantar wart

Thrombosed capillaries
Multiple and coalescent
Plantaris ("mosaic warts")
"Kissing lesions" on adjacent toes are common

Most common STD

Lobulated surface
High risk lesions are often

Condyloma Genital wart

Cauliflower-like
hyperpigmented
Caused by HPV 6, 11, 16, and 18

Acuminata Gray or pink

Can occur on cervix, vulvovaginal skin, anus, penis,

and perianal skin
Worse prognosis with acute onset of
hair loss, extensive hair loss, or hair
No treatment (regrowth < 1 year)
"Exclamation loss beginning over the ears.
point" hairs Associated Diseases

Alopecia Hair is lost from some or Patchy, nonscarring May involve entire scap
Scalp Biopsy Topical / intralesional corticosteroids
Thyroid disease
Stress
all areas of the body alopecia or body Vitiligo
Areata Autoimune disease
↑ Lymphocytes Diabetes
around hair bulb Atopic dermatitis
Systemic steroids (severe cases)
Nail pitting

Starts with recession of
Increased 5-α reducatase
causes testosterone
Androgenetic conversion to DHT
♂ ♀ Inherited condition
Later onset Minoxidill (Rogaine)
frontal hairline Less progressive
↓ Shaft length and
Advance loss or male
thickness
pattern is associated Finasteride (Propecia)
Castration prevents
alopecia
with hirsutism

resulting in hair
Alopecia miniaturization on scalp Hair transplantation
but increased hair on
other body areas
Wigs, hairpieces, or "comb over"

Rapidly dividing hair

Anagen Hair loss due to follicles
Hair regrows after offending agent is
chemotherapy or removed
Effluvium radiation therapy High metabolism in hair
follicles

Can occur 3 months

Beau's lines in the nails
Diffuse hair shedding as after events
Telogen more follicles are shifted Occurs After "System Shock"
Stressful event Surgery
Surveillence
from anagen to telogen (hair loss is temporary)
Effluvium phase
Childbirth
Massive blood loss
Thyroid disease
Crash dieting
High fever Car accident

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Irregular pattern of 7x more common in children and
Pigment casts Referral to child psychiatry
alopecia 2.5x more common in ♀
Broken and variable
Pleasure / relief from Achordion
Trichotillomania pulling hair out
length hair in affected
areas
Scalp Biopsy Treat underlying psychiatric disorders

Stretching of
Usually occurs with
epithelium Pharmacotherapy
psychosocial stress
↑ Incidence in African Americans
Most common in
Constant pulling or traction on
Traction hair follicles from wearing tight
frontotemporal scalp
Get a new hairstyle
braids and cornrows leads to hair
Alopecia loss
Can lead to scarring
alopecia if ignored

Nail Pitting
Nail
Nail changes seen in
Manifestations patients with psoriasis
of Psoriasis Discoloration

Alternating white and May be caused by cirrhosis or

Nonspecific nail
Muercke's manifestation that associated
pink lines
Blanchable
nephrotic syndrome

with decreased protein

Lines synthesis Located in the nail bed

Usually Staph
Acute
Affects proximal nail fold

Usually Candida
Inflammation of the Chronic
Paronychia nail folds
Affects lateral nail folds

Common in diabetics,
waitstaff, bartenders,
and food handlers

Nail growth arrest caused

Horizontal grooves in
Beau's Lines by severe illness, high nail plate
fever, or pregnancy

Nail changes seen in chronic

Half and Half renal disease
White proximal nail

Nails "Lindsey's Nails"

Red-brown distal nail

Nail color change due to

Blue Nails Wilson's disease, argyria,
and ochronosis

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result

Pseudomonas Infection of the nail by

Green discoloration
Nail Infection Pseudomonas

Translucent papule at
Benign ganglion cysts of proximal nail fold
Digital Mucous the digits Clear, viscous, jelly-like
substance at DIP joint
Cyst space
Myxoid Cyst Longitudinal ridge or indentation in the nail plate
distal to growth
Common and normal in African
Dark brown or black Americans. May be a sign of
Longitudinal Nail discoloration due to pigmentation at the melanoma in caucasians.
melanoma proximal nail fold
Melanonychia (Hutchnson's sign)

Squamous Cell May mimic a wart

Neoplasm around the
Carcinoma of nail bed
located around the nail
folds
Biopsy Confirm diagnosis

the Nail
Alopecia Oral ulcers Sun exposure may trigger acute
Photosensitivity lesions.
Acute Cutaneous LE Non-Specific Lesions / Rashes
Lupus profundus
Malar or butterfly rash
Vasculitic lesions (purpura)
Papules / papular Livedo reticularis
urticaria Urticaria
Scaly plaques
Discoid lesions
Bullae Palmar erythema
Subacute Cutaneous LE

Annular / papular lesions

Start as small
Systemic Lupus > 85% of SLE patients erythematous papules
have skin manifecstions with scale
Erythematosus Associated with anti-Ro
Resembles erythema
multiforme
and anti-La antibodies
(less common)
Seen on shoulders, forearms, neck, and trunk
Chronic Cutaneous LE
Discoid lesions

Start as well-defined
scaling plaques that
extend into hair follicles

Expand slowly Heal with scarring

Dyspigmentation ± Seen on face, neck, and
atrophy scalp

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Gottron's Papules
Slightly raised pink,
dusky red, or violaceous
papuls over the dorsal
sides of MCP/PIP
± DIP joints
Gottron's Sign

Macular rash in the

same areas as Gottron's
papules
Connective-tissue disease No papules
related to polymyositis Shawl Sign

Dermatomyositis that is characterized by Macular rash over

inflammation of muscles posterior shoulders and
neck
and skin
Poikiloderma

Mottled red or brown

discoloration that
develops from old DM
lesions

Calcifications
Linear erythema over
Periungual erythema
extensor surfaces of
Telangiectasias
joints
Cuticle overgrowth
Raynaud's phenomenon
Sclerodactyly (95%)
(79%)
Sclerosis of face, scalp, Periungual and mat-like
and trunk telangiectasia
Systemic Chronic autoimmune Pigmentation
Calcinosis cutis
disease that primarily abnormalities
Scleroderma affects the skin

Flaring Factors
Palpable purpura
Infections
Well-defined raised Drugs
Inflammation of blood petechaie and macules Connective tissue disease
Vasculitis vessels ± central area of
hemorrhage
Primarily on lower Can become ulcerative
extremities or necrotic

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Skin infection
Acanthosis nigricans
manifestations
Diabetic Dermopathy
Atrophic, small (< 1 cm),
brown lesions on lower
extremities
Asymptomatic
Last 18 - 24 months
Topical / intralesional steroids (NLD)
Diabetic Bullae
Appear spontaneously
on hands or feet
Sterile (no scarring)
Hemorrhagic

Diabetes Endocrine disorder that Non-scarring (triggered

by sun exposure)
leads to multiple skin Necrobiosis Lipodica Diabeticorum
Mellitus manifestions Flesh-colored or reddish-
brown plaques that
evolve into waxy plaques
May become ulcerative
or necrotic
Diabetic Ulcers
Ulcer prevention
Result from neuropathic
or ischemic causes
Often surrounded by
callus formation
Secondary to loss of
protective sensation
Generalized granuloma annulare has
Papules and plaques in
been associated with systemic
annular distribution
Granuloma Uncommon benign skin
Self-limiting
disease.

disorder
Annulare Localized
Variants Generalized
Perforating
50% of cases are associated with ↑
Yellow plaques occuring
Reduction of serum lipids lipid levels.
near medial canthus of
Non-painful skin lesion of
Xanthelasma the eyelid
eyelid

Upper lid > lower lid Surgical excision

Soft lesions
Wheal CBC H-1 and H-2 blockers Up to 20% of the population will have
Edematous papule or LFT (synergistic effect) an acute episode.
plaque Thyroid Tests Doxepin
Localized swelling of the Transient Glucocorticoids
Renal
skin and mucous Very pruritic
Function Tests Evaluation
Epinephrine (Epi-Pen)
Occurs once Allergist or rheumatologist referral
Urticaria membranes with
Acute
Individual lesions resolve ESR / CRP Avoid systemic
immunologic and non- < 24 hours Hepatitis corticosteroids
Lasts days to 6 weeks Serologies Chronic Identify causative
immunologic etiologies
Recurrent or constant ANA Management factors
Chronic > 6 week duration In cases of Constant
Biopsy
Undetermined trigger vasculitis antihistamines

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
≈ ⅓ of patients with venous
Pitting edema Varicose vein
insufficiency will develop ulcers.
Compression
Hyperpigmentation
Multiple skin Atrophie blanche
(mottled blue or purple)
manifestations secondary Skin fibrosis
Venous to decreased or absent (lipodermatosclerosis)
Venous ulcers
Stasis Dermatitis Stasis Dermatitis Oral antibiotics
return of venous blood
Insufficiency and increased capillary
Erythematous papules
Scale
Erosion
pressure Excoriation
Topical steroids
Occurs on lower legs and
ankles
Asymptomatic

Most common
Brown, yellow, or purple
Macules / Papules
Occur on face and
extremities
Annular or serpiginous
Chronic multisystem Possibly scaly
Sarcoidosis granulomatous disease
Plaques
Occurs on buttock,
trunk, and extremities
Lupus Pernio

Infiltrating violaceous
plaque

Occurs on nose, cheeks,

ears, and lips

Macule Stevens-Johnson Syndrome and Toxic

↓ Epidermal Necrolysis are considered
Analgesics
Papule with vesicle or separate clinical entities.
bulla in center
Mild
Symmetric
Pain ± pruritic
Topical steroids
Occurs on hands, forearms, feet, face, and possibly
Erythema Cutaneous immunologic mucous membranes
response to varied No bullae
Multiforme antigens
Mild Lesions on upper
extremities and face
Severe EM Discontinue any
≥ 1 mucous membranes Major offending drugs /
involved factors
Major
Epidermal detachement
< 10% of total body
surface area
EMERGENCY
Steven-Johnson Monitor fluid / electrolytes
Syndrome / Toxic Occurs on trunk, face,
Widespread bullae and mucous membrane
Epidermal
Systemic steroids
Necrolysis
Compiled by Drew Murphy, Duke Physician Assistant of 2015
 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Triggers
Erythematous nodules
Infections

Erythema Cutaneous reaction to Limited to extensor

surfaces of lower
Drugs
Systemic disease
antigenic stimuli
Nodosum extremities

Associated systemic
Very painful
symptoms

Infective Osler nodes Janeway lesions

Infection of endocardium
Endocarditis Subungual hemorrhages

Gram (-) blood infection that can Petchiae

Meningococcemia cause disseminated intravascular Purpura
coagulation Necrosis

Infectious disease caused

Lyme Disease Skin Erythema migrans Lymphocytoma cutis
by bites from
Manifestations Borrelia tick Acrodermatitis chronica Atrophicans

Dermatologic reaction Pruritis

Allergic reaction Inflammatory reaction

Transient erythema
Arthropod Bite Bite from a bug or spider Papular urticaria
Bullae
Lesions ↓
Erosions
Hemorrhagic ulcers
Necrotic
Most Common Biters
2 - 8 mm erythematous, Fleas

Papular Hallmark lesion of

papulovesicular lesions Mosquitoes
Bedbugs
arthropod bite
Urticaria Children > adults
Arranged in clusters

Seen in exposed areas

Possible secondary infections
Extremely toxic venom
Systemic symptoms RICE

Black Widow Potent neurotoxin whose Muscle cramping Update tetanus immunization
site of action is Analgesics
Spider neuromuscular junction
Hypertension
Antibiotics (if needed)
Tachycardia Dark, dry places Antivenom

RICE Found in the southeast US

Dermal necrosis
Toxic effect caused by a protein
Brown Recluse that stimulates platelet
Systemic symptoms
Update tetanus immunization

aggregation and infiltration of site Analgesics

Spider by neutrophils Dark, quiet places
Found in clothing and
Antibiotics (if needed)
shoes

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
At Risk Populations
Tunnels 5% Permethrin cream
Young, sexually active adults
Excoriated papules and Bed-ridden patients
1% Lindane lotion
pustules Care-givers of bed-ridden patients
Hypersensitivity Oral ivermectin
Highly contagious mites
Finger webs
Scabies that are spread by direct Flexor aspects of wrist
Treat family members
(even if asymptomatic)
or sexual contact Elbows
Axillae
Sites of Predilection Wash bedding / clothing in hot water
Penis
External genitalia
Sedating antihistamines
Feet
(at bedtime)
Ankles

Severe crusting

Norwegian Crusted scabies

Limited number of
papules and burrows
Scabies Variable pruritus Can infest head, neck,
and genital and perianal
Usually underlying
(homosexual ♂)
immunodeficiency
Prevention
Dermatitis
Avoid brush
Immediate bath in hot soapy water
Proper clothing
Papules / hives
Repellant (DEET)
Known as bedbugs or
Chiggers jiggers
Severe pruritis
Antihistamines
Ankles
Back of knees
Sites of Predilection
Groin Topical steroids
Axillae
Rosacea (possibly)
Mite found in hair Nose
Demodex Mite follicles and sebaceous
Sites of Predilection
Cheeks
Forehead
glands Neck
Chest
Oral antihistamines ± medium to high Attracted by the smell of sweat, body
Papules Local edema
potency topical corticosteroids heat, and color white
Arthropods that are Local erythema
Induration Intralesional steroids (if severely Advise patients that local raections
(after a few days) symptomatic) may persist for 3 - 4 weeks
Ticks frequently vectors of Nodular
Pruritus ± tenderness Excision (if severely symptomatic)
human disease (after a few days)
Granulomatous reaction (rare) Permethrin and DEET

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Erythema Migrans Erythema Chronicum Migrans
Erythema migrans lasting longer than
Bull's eye lesion
4 weeks
4 day - 3 week onset
Occurs ≈ 50% of cases
Vesicles
Malar rash
Variants
Urticaria
Nodules
Lymphocytoma Cutis
Single 1 - 5 cm bluish
nodule
Infectious disease caused
Lyme Disease by bites from Borrelia tick Develops in response to
See Ticks treatment section
antigenic stimulation

Site of bite
Earlobe
Sites
Areola
Neck
Acrodermatitis Chronica Atrophicans
Bluish erythema
+ edema
Can lead to atrophy of
all layers of skin if
untreated
Small erythematous Hemorrhagic puncta Pediculicides are not ovicidal, and
papules Linear excoriations Removal of nits patients need to be re-treated in 1
Bluish-brown or gray Permethrin week.
Maculae Ceruleae macules at the site of
the bite
Wash all bedding,
Secondary infection
Vesicles clothing, hats, and
possible Head Lice
combs
Body Lice Malathion
Infect clothing Lay eggs on seam fibers
Not seen on skin except
Reemerging in US in Pediculicides
when feeding
homeless
± Pruritus
Sklice
Pediculosis Infestation of lice
Scalp pruritus
Head Lice
Excoriations
Ivermectin

Cervical adenopathy Pubic Lice

Major problem in school Rare in African-
children Americans
Lindane lotion
Transmission through Sklice
Diagnosis made by
direct contact or
observing nits in scalp 5% permethrin
formites
Public Lice
Manual removal
Small erythematous 1 - 2 mm lice are often
papules visible Eyelashes Lindane
Petroleum jelly
Inguinal adenopathy Can infest eyelashes
TID for 5 days
Moderate pruritus (worse at night)
Prophylactic Allergic response to irritating salivary
Flies and Pruritic wheals and
Possibly vesicular,
antihistamine secretions
Blight upon humanity papules
eczematous, or Prevention
Mosquitoes Bite granulomatous lesions Insecticide

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Spread by travelers in clothing and
Papular urticaria
baggage
Flat bugs that feed at May be vesicular /
Bedbugs night eczematous lesions

Linear arrangement

Erythematous macules
Destroy fleas at home
Urticarial-like papules
Fleas Blood-sucking insects
Excoriations
Oral prednisone (for severe)

Secondary infections are Antibiotics for secondary infections

Grouped lesions
common
Erythema Stinger removal ≈ 4% of US population is sensitized.
Pain RICE
Potentially fatal insect Diffuse urticaria Antihistamines (questionable)
Bee Sting sting Anaphylaxis Oral steroids (if severe)
Angioedema Epi-Pen
Shock Medic-Alert bracelets
Lesion
Local cleansing
↓
Vesicle
Ice
↓
Worst creatures in
Fire Ants existence
Itchy pustule
↓
Oral histamine

Crusting Immediate pain

Oral steroids
Flare reaction
Update tetanus (if needed)
Can be seen anywhere
on the body
Cryotherapy
Smooth, velvety,
verrucous, or
hyperkeratotic
White, pink, tan, light Shave removal
Seborrheic Very common, benign,
Age > 30
Appear "stuck-on" but
and dark brown, or black

epidermal growths can come off Multiple keratin cysts

Keratosis Single or multiple
imbedded within surface
Light electrocautery
of lesion
Sign of Leser-Trelat
Sudden eruption of
Maybe a cutaneous sign
many seborrheic Curettage
of internal malignancy
keratosies

Most common in ♀ and obese

Fleshy filiform or
Surveillence (asymptomatic)
pedunculated papules
Flesh-colored, pink, or
Cryotherapy
Acrochordon Skin tag brown
Occur in the axilla, neck, groin, eyelids, antecubital Scissors-snip removal
and popliteal fossa, inframammary folds, beltline,
and other friction areas Electrodessication

Compiled by Drew Murphy, Duke Physician Assistant of 2015


Condition / Disease Cause
Very common, benign,
Dermatofibroma firm dermal papule
Arise spontaneously or secondary to insect bites or
Subcutaneous, benign
Lipoma fatty tumors
Clinical Medicine
Laboratory
Signs and Symptoms Treatment Medications Other
Test Result
Dimple Sign
Most common in legs
Pinching surrounding skin between 2
but can occur on trunk
fingers cause the lesion to dimple
and arms
Button Sign
Flesh-colored, brown, Slightly to very raised or Pinching surrounding skin between 2
pink, red, or tan slightly depressed
Excision (if symptomatic)
fingers cause the lesion to raise
Pruritus Tenderness
Dimple sign Button sign
trauma when shaving legs
Single or multiple
Variable size Excision (if needed)

Palpable Overlying skin is mobile

Epidermoid Cyst
Filled with keratin
Epidermal Inclusion Cyst Treatment is not indicated unless
symptomatic or on the face
Sebaceous Cyst Cheesy consistency
Epidermal Cyst Infundibular Cyst
when ruptured or
manually expressed
Incision and drainage
Pilar Cyst Nasty odor Firm and mobile
Wen Possible visible opening
Be suspicious of new moles
Can appear, grow,
appearing or moles that are growing,
Asymptomatic darken, lighten, and
changing shape, or changing colors in
disappear during lifespan
adults.
Junctional Nevus
Flat or slightly raised
Tan or brown
Round or oval
Benign lesions composed Most on palms, soles, genitals, and mucosa, but
they can occur anywhere.
of organized clusters of
Compound Nevus
melanocyte-derived Slightly to markedly
nevus cells raised
Exicision
Tan, brown, or black
Nevus Center may be more
(if symptomatic or concerned about
malignancy)
elevated and pigmented
Common on face, scalp,
Found at both the DEJ
trunk, and extremities
and in the dermis
Intradermal Nevus

Raised and soft papules

Flesh-colored, tan, or
brown
Mole Course hairs may grow

Common on the face, scalp, and neck, but can be

seen on trunk and extremities

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Blue Nevus
Cells located within the
deeper dermis
Tyndall effect

Macules or papules Blue, gray, or black

Common on head, neck, buttock, and
dorsal hands / feet
Halo Nevus

Surrounded by a rim of
depigmentation
Autoimmune
phenomena preceding
its disappearance
Area usually repigments
Spitz Nevus
Dome-shaped smooth
papules
Pink, tan, or brown
History of rapid growth
Nevus Mole
Common on face, scalp, neck, and legs
Nevus Spilus

Continued… Sharply-defined tan to

brown patch with
multiple
hyperpigmented
macules ± papules
Can occur anywhere
Becker's Nevus
Brown patch, a patch of
hair, or both
Vary in size
May enlarge
Not a true nevus
because it lacks nevus
No malignant potential
cells
Congenital Melanocytic Nevus
Verrucous surface
Dark brown and raised
Greatly vary in size
Present at birth of
during infancy ↑ Risk of malignant
Recommend excision melanoma in lesions
after puberty > 20 cm
1 - 2 mm
Well-defined
Red, tan, or brown-
Ephilides Freckles colored macules
Appear in childhood Darken with sun
Fade in winter exposure

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result

Multiple lesions are

Age Spots referred to as lentigines

Juvenile Lentigines
Lentigo Liver Spots Appear in childhood Do not darken in sun and
Part of several fade is absence of
hereditary syndromes sunlight
Solar Lentigines
Wisdom Spots Occur on sun-exposed ↑ Size and number with
caucasians ↑ age
1 - 3 mm elevated
papules
Common and benign
Sebaceous enlargement of the
Flesh-colored or yellow
May have central
subaceous glands on the
Hyperplasia face
umbilication
Could be solitary but common occur in multiples
on the forehead, nose, cheeks, and eyelids

Ectopically-located Small, pinpoint macules

± papules
sebaceous glands on the
Fordyce Spots buccal mucosa and
No treatment

Orange or yellow
vermillion of lips
Single or multiple Eruptive onset of hundreds of these
0.5 - 5 mm may be seen with the sign of Leser-
Extremely common,
Cherry benign proliferation of
Smooth and dome-
shaped, flat, or polypoid
Trelat.

dilated superficial papules

Angioma capillaries
Cherry red to purple
May occur anywhere but more common on the
trunk
2 - 10 mm papule on sun-
exposed skin
Dilated blood-filled Single or multiple
Venous Lake vascular channel
Soft and usually
compressible
Common on the lower lip and ears, but almost
always on the face
In both children and adults
Composed of an
Those appearing during pregnancy
Spider Common, benign, arteriole (body)
and in childhood tend to disappear
perpendicular to the skin Electrocautery or laser
dilatation of superficial Diascopy Blanching
(risk of scarring)
spontaeously.
Angioma bleed vessels Multiple radiating
capillaries parallel to
Common on face and
hands, but also occurs
skin surface on trunk and arms

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Slow growing Locally destructive Risk Factors
ED&C
Most common on the Usually > 40 years old Cumulative sun exposure
face, scalp, ears, and ♂>♀ White-skinned patients with poor
Excision
Nodular BCC Nodular BCC tanning
Most common variant MMS Albinos
Dome-shaped papule (for recurrent or Sunburns prior to age 14
with overlying random high risk) Arsenic ingestion
telangectasias Prior XRT
ED&C
Center becomes flattens Borders become raised
Superficial BCC
or ulcerates or rolled
Excision
Frequently bleed and develop crust ± scale
Superficial BCC
ED&C
Least aggressive variant

Basal Cell Most common skin Erythematous and scaly

plaques ± rolled border
Pigment BCC
Excision
Vismodegib
cancer MMS
Carcinoma More common on the trunk and extremities (for recurrent or
Pigmented BCC high risk)
Morpheaform BCC MMS
May resemble
melanoma Metastatic BCC

Common, persistent,
Actinic keratotic growth with
malignant potential
Keratosis caused by cumulative sun
exposure
plaques, or nodules with
Potentially invasive,
Squamous Cell primary cutaneous
malignancy of
Carcinoma keratinocytes in the skin
or muscous membranes
Locally-advanced
Morpheaform BCC
disease not
Least common varient
Vismodegib amenable to
White to yellow patch
surgery or
with poorly-defined
radiation
borders
Tumor may extend beyond borders of clinical
Gorlin syndrome
lesion
Cutaneous horns should always be Actinic Cheilitis
Scaly, hyperkeratotic, or
biopsied. Actinic keratosis on the lower lip
rough-textured papules
Palpate lesions for induration and if
5-FU (Efudex) and imiquimod (Aldara)
Flesh-colored, yellow, present, the lesion should be
brown, pink, or red biopsied to rule out SCC.
Most commonly seen on
Cryotherapy
May present as sun-exposed skin of fair-
Photodynamic therapy
cutaneous horns skinned patients
Usually occur on face, scalp, neck, ears, dorsal
ED&C
hands, and forearms
Risk Factors
Indurated papules, ED&C
Ultraviolet radiation (causative)
Radiation
scale Excision
Chemicals (arsenic and hydrocarbons)
Tobacco
Flesh-colored, pink, MMS
Chronic infection
yellow, or red
Chemotherapy (if metastatic)
Chronic inflammation
Burns
May be ulcerated or Face, scalp, neck, and
HPV infection
eroded hands of older patients 5-FU
Accounts for approximately 20% of
Bowens Disease Bowens Disease Cryotherapy all skin cancers
(dependent on Palpate regional LNs for mets,
SCC in situ ED&C
location, patient, especially for lesions on the ear,
Slow-growing, slightly and size of lesion) Excision scalp, lips, and temples
raised, red plaque with Erythroplasia of Queyrat
MMS
scale SCC in situ of the penis

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Rapidly growing Most commonly occurs on sun
Cannot be clinically Solitary, firm, and red exposed skin of caucasians
nodule with a central
Keratochanthoma distinguished from an keratotic plug or
Biopsy Diagnostic Excision

invasive SCC cutaneous horn

♂>♀ > 50 years old
Solitary lesions appear Observation Multiple lesions are thought to be of
Mild Atypia
sporadically and are Excision autosomal dominant inheritance and
common are uncommon.
Dysplastic nevus May start in childhood
Moderate Atypia Excision
but more common in Treated as if it is
Severe Atypia
Atypical Nevus A
adults
Asymmetry
Biopsy Grade atypia melanoma
Mole mapping
B Border irregularity
Clarks Melanocytic (multiple atypical nevi)
C Color
Nevus D Diameter
Deramatology referral
E Evolving
Breslow Level
Flat, raised, nodular, or
Depth of lesion (in mm) from the top
ulcerated
of the clinical lesion to the bottom of
Punch Biopsy Early detection
of the lesion in the tissue specimen
Variable color
Most important prognostic indicator
Malignant Malignancy of Any new mole presenting in adulthood or any
mole changing in size, shape, or color Diagnostic
Clark Level
Level of anatomic invasion
melanocytes
Melanoma PMH or FMH
Risk Factors
Fair skin
Important in areas of thinner skin
May appear anywhere in the body
Incisional
Blue eyes Blond or red hair Excision and exam should include LN
Biopsy
Many moles palpation for mets
UV exposure from both
History of blistering
sun and tanning beds
sunburns
Most common metastatic site is the skin, but any Lentigo maligna represent 5 - 10% of
organ can be involved. CNS mets are most all melanoma.
common cause of death IL-2 IL-2 70 - 80% of all melanoma is
Lentigo Maligna superficial spreading MM
Melanoma in situ
Usually seen in older
caucasians
Commonly seend on Ipilimumab Ipilimumab
face, neck, and arms
Superficial Spreading MM

Metastatic Deadly form of skin

Most common type of
MM
cancer Asymmetric and flat BRAF inhibitors Vemurafenib
Melanoma > 6 mm
Variable color
Most common in Usually seen on the
caucasians trunk and extremities
Spread laterally but may develop deeper MEK inhibitor Dabrafenib
Nodular MM
Very rapid growth
Most common on the
Treatments only halt or delay
extremities
progression of the disease and are Trametinib
10 - 15% of all MM
rarely curative.
Grow vertically

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Clinical Medicine
Laboratory
Condition / Disease Cause Signs and Symptoms Treatment Medications Other
Test Result
Least common type of MM in
Acral Lentiginous Most common type of Primarily occurs on the caucasians.
metastatic melanom in hands, feet, and nails ≈ 7% of all MM
Metastatic Asian-Americans and
Melanoma African-Americans ♂>♀

Pink to red colored Scares the crap out of all

Amelanotic Nonpigmented papules dermatologists
Metastatic melanoma of any ↓ ≈ 2% of all MM
Enlarged plaques and
Melanoma subtype nodules

Compiled by Drew Murphy, Duke Physician Assistant of 2015

 Pharmacology
Generic Examples /
Drug Mechanism of Action Indications Pharmacokinetics Contraindications Adverse Effects Monitoring / Other
Brand Name
Inhibit macrophage A: After bathing when Bacterial infection Skin drying / cracking / thinning Discontinuation of Therapy
Potency
skin is moist Viral infection Skin atrophy Depends upon dose, duration,
accumulation in D: "Fingertip unit" Fungal infection Purpura and disease
inflamed areas Formulation
Topical ↓ Capillary permeability Factors for Absorption Use with dressings
Onset: 1 - 2 days Tolerance / tachyphylaxis
Adrenal suppression
Risk of rebound flare when
discontinued

Steroids and edema formation

Frequency of application

Histamine antagonist % of total dose absorbed

through skin
Face Genitals

Armpits Skin folds

Low Potency hydrocortisone
Children Chronic use

Occlusive dressings Large body areas

Generally choose non-

HC butyrate Trunk Arms
Medium HC valerate Legs Face (limited)
fluorinated products

Potency clocortolone Chronic eczema Radiation dermatitis

halcinonide Face Use with caution in occlusive

triamcinolone Intertriginous areas dressings
High Potency augmented
betamethasone
Severe psoriasis Eczema

dipropionate
D: Should not exceed Occlusive dressings Do not use more than 2
Very High clobetasol
Skin conditions where steriod will not be
50 grams/week Face
Groin
weeks.
Be aware of symptoms of
discontinued abruptly
Potency halobetasol Armpit
Skin folds
adrenal suppression

Most skin areas Mostly absorbed

Cream Drying effect Opaque

Hairy areas
Skin that needs
Ointment Dry, scaly lesions
protection

Therapeutic advantage of ointment + cosmetic

advantage of cream
Gel Can have cooling effect

Weeping lesions in areas

Evaporates quickly
subject to chafing
Lotion Penetrates easily
Drying effect
(if contains alcohol)
High potency steroids Increases adverse effects of steroid Do not use for > 12 hours /
Occulsive ↑ Skin penetration by
↑ moisture content of
Beneficial in resistant day
cases
Dressings stratum corneum

Hand 1 fingertip unit 1 fingertip unit = 500 mg of

Amount of steroid squeezed Foot 2 fingertip unit cream or ointment
out of tube that covers from Face and Neck 2.5 fingertip unit
Fingertip Unit the tip to the first crease of Arm 3 fingertip unit
the finger Leg 6 fingertip unit
Front or Back Trunk 7 fingertip unit

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

 Pharmacology
Generic Examples /
Drug Mechanism of Action Indications Pharmacokinetics Contraindications Adverse Effects Monitoring / Other
Brand Name
D: Daily Stinging / burning Directions for Use
Free-radical oxidation Effect: 4 - 6 weeks Dryness Wash skin

Benzoyl Acne
Irritation
Peeling
Apply thin layer
Avoid eyes, mouth, lips, and
Mild keratolytic with Redness nose
Peroxide drying and desqamative Contact dermatitis
actions Bleach hair / towels / carpeting
↑ Sun sensitivity
D: Daily Diabetes (use caution) Stinging / burning
Removes excess
Clearasil Poor circulation Confusion
keratin Infants Headache
Salicyclic Acid Desquamation of the
Acne Nongential warts
Pregnancy (category C) Dizziness
Stridex Peeling
horny layer
D: Daily Ophthalmic irritation Gels are the most effective
Sulfur / Clearasil
Keratolytic
Acne
Noticeable color and odor formulation
Increases horny cell Dark brown scale (reversible)
Resorcinol adhesion
D: Q evening Benzoyl peroxide use Peeling / dry skin
Reduces the adhesiveness of Effect: 2 - 3 weeks with Stinging / burning
follicular epithelial cells optimal > 6 weeks Erythema
Pruruitis
Tretinoin Acne
Photosensitivity
Stimulates mitosis and Changes in skin pigment
turnover in epithelial Edema
Blistering
D: Q evening Peeling / dry skin
Modulates cell Stinging / burning
differentation, Pruruitis
Photosensitivity
Adapalene keratinization, and Acne
Blistering
inflammatory Dermatitis
processes Eczema

Pregnancy Peeling / dry skin Second-line retinoid

Modulates Stinging / burning
differentiation and Irritation
proliferation of Pruritis
Pain
Tazarotene epithelial tissue Acne
Discoloration
Edema
Photosensitivity
Anti-inflammatory Contact dermatitis
Fissuring
A: Foam or gel Peeling / dry skin
D: Daily (Clindagel and Stinging / burning
foam) or BID Irritation
50S ribsome subunit Pruritis
Clindamycin Clindagel
inhibitors
P. acnes Acne
Oiliness
Folliculitis
Photosensitivity
Nausea / vomiting / diarrhea
D: Daily or BID Peeling / dry skin Resistance is increasing.
Burning
50S ribosome Erythema
Erythromycin subunit inhibitor
P. acnes
Pruritis
Oiliness
Eye irritation

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

 Pharmacology
Generic Examples /
Drug Mechanism of Action Indications Pharmacokinetics Contraindications Adverse Effects Monitoring / Other
Brand Name
D: BID Irritation
Sodium Inhibits bacterial
dihydrofolic acid Acne
Hypersensitivity

Sulfacetamide synthesis
Microbial cellular D: BID Stinging / burning Patients with dark complexions
Azelex Cream Effect: 4 weeks Pruritus should be monitored for early
protein synthesis Erythema signs of hypopigmentation.
Azelaic Acid inhibitor Acne
Peeling / dry skin
Finacea Gel Contact dermatitis
Oxygen radical scavenger
Hypersensitivity
A: Oral on empty Photosensitivity Monitor LFTs and CBC for long-
stomach Rash term treatment
Inhibits bacterial D: Q6 hours for 1 - 2 Nausea / vomiting / diarrhea
Tetracycline protein synthesis
Acne
weeks Tooth discoloration
↑ Intracranial pressure (rare)

A: Oral Dizziness / vertigo Monitor LFTs, renal function,

D: BID Hypersensitivity and CBC for long-term
30S and (possibly) SLE treatment
Minocycline 50S ribosomal Acne Bulging fontanelle
Pseudotumor cerebri (rare)
Do not take calcium, iron,
magnesium, or aluminum
subunit inhibitor antacids or supplements
≤ 4 hours.
A: Oral Photosensitivity Monitor LFTs, renal function,
GI disturbance and CBC for long-term
30S and (possibly) ↑ BUN treatment
Doxycycline 50S ribosomal Acne Bulging fontanelle Do not take calcium, iron,
magnesium, or aluminum
subunit inhibitor antacids or supplements
≤ 4 hours
Inhibits bacterial A: Topical (safer) or oral Peeling / dry skin
D: BID for 12 weeks Erythema
Dapsone dihydrofolic acid Acne
Oiliness
synthesis

Oral norethinodrone Decrease circulating androgen

Acne
Contraceptives norgestimate Decreases sebum production

D: BID Pregancy (category X) Severe birth defects Under restricted distribution

Peeling / dry skin and mucous Monitor for depression or
membranes aggressive behavior, LFTs,
Inhibits sebaceous Lip inflammation lipids, CBC, and hearing
Hypertriglyceridemia changes.
Isotretinoin gland function and Acne
Myalgia
keratinization Anemia
Conjunctiviitis
Various skin conditions

Bacterial isoleucyl A: Topical or nasal Burning / pruritis High level resistance has been
D: TID Headache reported in S. aureus and
Mupirocin t-RNA synthetase Bacterial infection
Rhinitis coagulase (-) staphylococci
inhibitor Nasal congestion
butenafine Short time to cure
naftifine Interfere with
Allylamines terbenafine cellular permability
Fungal infection

tolnaftate

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015

 Pharmacology
Generic Examples /
Drug Mechanism of Action Indications Pharmacokinetics Contraindications Adverse Effects Monitoring / Other
Brand Name
clotrimazole Requires skin turnover for
econazole complete effect
ketoconazole
Azoles miconazole
oxiconazole
Fungistatic Dermatophyte infection Yeast skin infection

sulconazole
sertaconazole
Seizures Discolors light-colored hair
Loprox Polyvalent cation chelator Dermatophyte infection
Immunosuppression
Ciclopirox Penlac
Inhibits metal-dependent
Yeast skin infection
fungal enzymes

Alters membrane
Nystatin permability
Fungal infections

A: Cream or oral Headache

D: 5x a day for 4 days Nausea / diarrhea
(cream) or 5 days (oral) Malaise
Acyclovir Zovirax Antiviral HSV-1 infection
E: Renal Mild pain / burning / stinging
Neutropenia
↑ LFTs
D: 2 g Q12 hours for 1 See Acyclovir
day or 1 g TID for 7 days
Valacyclovir Valtrex Antiviral HSV-1 infection Shingles
(shingles)
E: Renal
D: 500 mg Q8 hours for Breastfeeding See Acyclovir Penciclovir
HSV-1 infection
7 days Active metabolite of
Famcyclovir Famvir Antiviral
Shingles
E: Renal famcyclovir

D: 5x a day Decreases healing time

Docosanol Abreva
Interferes with viral
HSV-1 infection
entry into target cell
10% Cream
Prevention of May be used in patients
Avoid antivirals for 1 day
before and 14 days after
Shingles Vaccine Zostavax shingles in patients Shingles with previous shingles
episodes
vaccination.
> 60 years old

Compiled by Drew Murphy, Duke Physician Assistant Class of 2015