Introduction to Dermatology

A review of the basic science of the skin, morphology, general examination, and
therapeutics.

Essentials of Clinical Reasoning -2, Fall 2013

Jim Carlson, PhD, PA-C

Acknowledgements

Content and images for this slide set were

provided in part by the American Academy
of Dermatology.

How to approach this module and

review.

1. Go through the slides with the goal of being able

to apply the content to dermatologic case studies.

2. Review the ECR-1 Slides (especially) part 2 of the

series on Dermatology given last year.

3. Once you complete reviewing the slides take the

quiz in D2L.

4. You may use all the information in this ppt and

any other resources you find to assist you with the
D2L quiz.

Lesson Objectives
Recognize pertinent history for a patient who presents with a dermatologic

problem.
Utilize the descriptors and definitions of morphology for primary and

secondary skin lesions.

Apply a systematic approach to describing skin eruptions to include history,

primary and secondary lesion descriptions, other descriptors (color,

pigmentation, vascular), arrangement, and distribution of lesions.
Recognize different classifications for rashes and skin lesions.
Recognize the indications for cryotherapy, KOH preparation, shave biopsy, and

punch biopsy.
Apply basic management principles for:
Use of topical steroids
Acne
Fungal skin infections

Functions of the Skin:

Barrier function
The skin regulates water loss and protects against
insults from the external environment.
Dysfunction leads to injury, dehydration, infection and
inflammation.

This child has atopic

dermatitis, a chronic skin
condition associated with
barrier dysfunction.
5

Functions of the skin:

Immunologic function
As an immunologic barrier, the skin both senses
and responds to pathogens.
Dysfunction of the immunologic barrier leads to
infection, skin cancer, inflammatory skin
conditions and allergy.
This HIV-positive man has
molluscum contagiosum, a skin
infection caused by a virus.

Functions of the skin:

Temperature regulation

The skin helps maintain a constant body

temperature with the insulating properties of fat
and hair and through accelerating heat loss with
sweat production and a dense superficial
microvasculature.

Functions of the skin:

Protection from radiation

The dark pigment melanin in the epidermis protects cells against

ultraviolet radiation.

Dysfunction of melanin production causes the patient to be more

susceptible to skin cancer.

This patient with albinism

has a skin cancer on the
back.

Functions of the skin:

Nerve sensation

Sensory receptors allow the skin to constantly monitor

the environment.

Dysfunction leads to pruritus (itch), dysesthesia

(abnormal sensation), and insensitivity to injury (e.g.
diabetes, leprosy).
This photo is of a chronic
ulcer on the foot of a patient
with peripheral neuropathy
related to diabetes.

Functions of the skin:

Injury repair

Loss of ability to repair injury (e.g. post-radiation

treatment) leads to delayed wound healing.

This patient has a chronic ulcer

following trauma on the scalp in
a site previously irradiated as
part of treatment for
squamous cell carcinoma.

10

Layers of the skin

Skin is composed of three layers:

Epidermis
Dermis
Subcutis

11

Layers of the skin

The epidermis is the topmost layer, and consists
primarily of keratinocytes.
The dermis lies below the epidermis, and
consists primarily of fibroblasts, collagen, and
elastic fibers.
Epidermis
Dermis

12

Layers of the skin

Below the
dermis lies fat,
also called
subcutis,
panniculus, or
hypodermis.

Epidermis
Dermis

Subcutis

13

The four major layers of the epidermis

Stratum corneum

Stratum granulosum
(granular cell layer)
Stratum spinosum
(spiny layer)
Stratum basale
(basal cell layer)

14

Diseases related to dysfunction of the

epidermal layers loss of adhesion
Bullous pemphigoid: an autoimmune blistering disease,
typically affects older patients. Autoantibodies form to
antigens directly beneath the basal layer of the
epidermis. Clinically, presents as tense blister with redness
(erythema)

15

Diseases related to dysfunction of the

epidermal layers

In psoriasis, the rate of

epidermal turnover is
increased (thickening).

The accelerated rate of

movement through the
epidermis doesnt allow
adequate time for differentiation,
which is recognized as scale.

16

Epidermis: Types of Cells

Three main types of cells make up the epidermis:

Keratinocytes
Melanocytes
Langerhans cells

17

Keratinocytes

Keratinocytes make up the majority of

cells.

Keratinocytes are held together by

macromolecular structures that look like
stripes (or spines) between cells, called
desmosomes (primarily visible in the
spinous layer).

Provide structure and protection.

18

Melanocytes

Melanocytes are staggered

along the basal layer at around
one in every 10 keratinocytes.

They are the pigmentproducing cells, and transfer

their pigment, called melanin,
to the keratinocytes in the
basal cell layer.

19

Nevi and Melanoma

Melanocytic nevi, or moles, are benign

collections of melanocytes.
Melanoma, shown below, is a malignancy of
melanocytes.

20

Langerhans Cells

Provide for the recognition, uptake, processing, and

presentation of antigens to sensitized T-lymphocytes, and
are important in the induction of delayed-type
hypersensitivity immune response.

A common skin disease in which

Langerhans cells play a
prominent role is allergic
contact dermatitis, such as
poison oak

21

21

Layers of the skin

The dermis lies below the epidermis, and
consists primarily of fibroblasts, collagen, and
elastic fibers.

Epidermis
Dermis

22

Cells of the dermis

Fibroblasts are responsible for the synthesis and

degradation of connective tissue proteins.

They are instrumental in wound healing and

scaring
Keloids (abnormal scars) result
from uncontrolled synthesis and
excessive deposition of collagen
at sites of prior dermal injury and
wound repair

23

Cells of the dermis

Mast cells are specialized cells that are

responsible for immediate-type
hypersensitivity reactions in the skin
The mast cell is the major
effector cell in urticaria,
which is a vascular reaction
of the skin characterized by
wheals (hives) surrounded by
a red halo or flare.
24

The Subcutis

The subcutis is the fat layer which separates the

dermis from deeper underlying structures such as
fascia and muscles.

The subcutis insulates the body, serves as an

energy supply, cushions and protects the skin,
and allows for its mobility over underlying
structures

25

The pilosebaceous (hair/oil gland) unit

Adnexal structures include the

pilosebaceous unit and eccrine
gland
Pilosebaceous unit consists of:
1.
2.
3.
4.

A hair follicle
Sebaceous (oil) glands
Apocrine* sweat glands
An arrector pili muscle (when these
contract you get goosebumps)

Apocrine glands are found in the axillary and

anogenital areas, which is why we do not see them
on this biopsy of the scalp. These glands open
directly in to the hair follicle.

26

Disorder of pilosebaceous unit

Acne vulgaris is a disorder of the

pilosebaceous unit.

It is caused by 4 factors:
Presence of hormones (androgens)
Sebaceous gland activity (increased in the
presence of androgens)
Plugging of the hair follicle/abnormal
keratinization-(comedones)
P. acnes (bacteria) which breaks down
oils to free fatty acids and leads to
inflammation)

27

General Examination and Morphology:

How to describe what you see

28

Dermatologic Differential Diagnosis: The Challenge

Approx 2000 named diseases in Dermatology.
Organize and narrow in terms of importance:

Most common
Most dangerous
Most curable
Most contagious

This brings the list down to around 50 dermatologic

diagnoses you should know something about.

A general approach dermatologic diagnosis

Both history and physical are important.
However, visual inspection of the lesion often takes some

precedence when diagnosing dermatologic problems.

The physical is often performed early in the encounter to identify a general DDx

Pattern of recognition.
The history is then used to further narrow the DDx.

A methodological and systematic approach to diagnosis

History
Distribution (Where is the location on the body?)
Localized
Widespread and systemic
Examine and DESCRIBE the lesion(s).
Arrangement and shape of lesions (Morphology)
Primary Lesions
Secondary Lesions
Color
Arrangement

A methodological and systematic approach to diagnosis

When possible, classify the lesion into a diagnostic group based on
distribution and morphology.
-Eczematous disorders (erythematous patches)
-Maculopapular disorders and pigmented lesions
-Vesicular and Bullous Diseases
-Psoriasis and papularsquamous disorders.
-Hair and nail disorders
-Vascular disorders
Order testing if appropriate, but many Dermatologic diagnoses are clinical,

based on symptoms and signs.

Treatment: Sometimes treatment is diagnostic.

Pattern of Recognition: Distribution

Localized

Extensor/ flexor surfaces

Dermatomal
Sun exposed
Intertiginal areas
Contact vs. Non-Contact Areas
Palms/ Soles

Regional (trunk, extremities, etc.)

Generalized/ Systemic

Dermatologic conditions affecting a high %of skin area.

Skin findings indicating systemic health problems.

Pattern of recognition: Distribution

Pattern of Recognition:
Morphology

The word morphology is used by dermatologists to accurately

characterize and document skin lesions.
Primary Lesions
Secondary Lesions
Vascular Patterns
Color

The morphologic characteristics of skin lesions are key elements

in establishing the diagnosis and communicating skin findings.

There are two steps in establishing the morphology of any given

skin condition:
1. Careful visual inspection
2. Application of correct descriptors
35

Visual Inspection

Visual inspection at its core is

much like analyzing a painting or
looking at any object for the first
time.

36

Morphology: Primary Lesions

Macule
Patch
Papule
Plaque
Wheal
Nodule
Vesicle
Bulla
Pustule
Cyst

Morphology allows
healthcare providers
to communicate skin
findings succinctly.
Dermatologists
attempt to identify the
primary lesion of
any skin eruption.

Primary lesion: Macule

A macule is flat; if you can feel it, then

its not a macule.

< 1.0 cm

Usually caused by color changes in

the epidermis or upper dermis

38

Examples of Macules

39

Macules

Presence of a macule indicates that the

process is confined to the epidermis.

Macules do not contain fluid and are not

raised.

Macules can have secondary changes

such as scale or crust

If a flat lesion is over 1 cm it is called a

patch
40

Primary lesion: Patch

Patches are flat but

larger than
macules.

If its flat and larger

than 1 cm, call it a
patch

41

Examples of Patches

42

Macules and Patches

MACULE (<1cm)
PATCH (>1cm)

43

Primary lesion: Papule

(L. papula, pimple)

Papules are raised
lesions less than 1
cm
A proliferation of cells
in epidermis or
superficial dermis

44

Examples of Papules

45

Primary lesions: Plaque

Plaques are raised

lesions larger than 1
cm
You can feel them
Cast a shadow with side
lighting

A proliferation of cells
in epidermis or
superficial dermis
46

Examples of Plaques

47

Papule and Plaque

PAPULE (<1cm)
PLAQUE (>1cm)

48

Nodule

A larger deep papule

A proliferation of cells
down to the middermis.

49

Nodule
A raised area in the
skin where the
overlying epidermis
looks and feels
normal, but there is a
proliferation of cells
in deeper tissues is
called a nodule.

50

Primary lesion: Vesicle

Vesicles are fluidfilled papules

(small blisters < 1
cm)

A large (> 1cm)

blister is called a
bulla
vesicle

bulla
51

Examples of Vesicles

52

Pustule

Pus is made up of
leukocyte.

53

Wheal
Elevated, palpable
Irregular shaped area of

cutaneous edema
Solid, transient, changing
Variable diameter
Pale pink with lighter
center
Examples: Urticaria,

insect bites,
Dermatographism

Cyst
Elevated, palpable,

but deep.
Circumscribed,

encapsulated
Filled with liquid or

semi-solid material
Example: Epidermoid

cyst

Classifying Primary Lesions

Secondary Lesions
Scale
Crust
Excoriation
Erosion
Ulcer
Atrophy
Lichenification
Scar Keloid
Fissure
Striae

Changes in an area of

primary pathology due to

secondary events:
(scratching, infection,

trauma, inappropriate
treatments, natural
progression of the
disease etc.)

Secondary Lesions
Scale-small, thin dry
exfoliation shed from the
upper layers of skin

Crust-scab; dry serous or

seropurulent exudation

Secondary Lesions
Excoriation-abrasion of the
epidermis

Erosion-external or internal
destruction of a surface layer

Secondary Lesions
Ulcer-an open sore or lesion
of the skin or mucous
membrane accompanied by
sloughing of inflamed necrotic
tissue

Atrophy-a wasting or
decrease in size of a tissue

Secondary Lesions
Lichenification-cutaneous
thickening and hardening from
continued irritation

Scar/ Keloid-mark left by

healing of a wound due to
replacement of the injured
tissue by connective tissue

Secondary Lesions
Fissure-an ulcer or crack-like
sore

Striae-a line or band differing

in color and texture

Vascular Findings
Ecchymoses
Petechiae
Purpura
Hemangioma
Telangiectasia

Ecchymoses (bruising)
Red-purple

nonblanchable
discoloration of variable
size
Cause: Vascular wall

destruction, trauma,

Petechiae
Red-purple

nonblanchable
discoloration less than
0.5 cm in diameter
Cause: Intravascular

defects, infection,
meningococcemia

Purpura
Red-purple

nonblanchable
discoloration greater
than 0.5 cm in
diameter
Cause: Intravascular

deficit, infection,
vasculitis

Hemangioma
Red, irregular macules or

patches
Cause: Collection/

dilation of dermal
capillaries

Telangiectasia
Fine, irregular lines
Cause: Dilation of the

capillaries,
inflammation, Rosacea

Spider Angioma
Red, central body with

radiating spider like legs

Blanches with pressure
to the central body
Cause: Liver disease,
vitamin B deficiency,
Idiopathic

Other descriptive terms

Flat toped vs.

Pedunculated (stalk)
Verrucous (wart-like)
Umbilicated
Size

Abnormal Skin Colors

Cyanosis
1. Acrocyanosis ( in palms and soles of feet)
2. Peripheral cyanosis ( in arms and legs)
3. Central cyanosis (in mouth and tongue)

Erythema (Redness)
Jaundice/Scleral icterus (yellow
skin/yellow sclera
Localized Pigmentary changes

Cyanosis

Jaundice

Erythema

Pigmentary changes
Hypopigmentation

Hyperpigmentation

Classifying Primary Lesions

In summary
-For each lesion, try and identify:
-History of lesion(s)
-The DISTRUBUTION (is the lesion present in a
classic pattern?).
- PRIMARY lesion
-Any associated SECONDARY lesions
-The ARRANGEMENT of the lesions
-Other descriptors (vascular, pigment, etc)

Next
Classify the lesion into a diagnostic category.
Examples inlcude:
-Eczematous disorders (erythematous patches)
-Maculopapular disorders and pigmented lesions
-Vesicular and Bullous Diseases
-Psoriasis and papularsquamous disorders.
-Hair and nail disorders
-Vascular disorders

Dermatologic Procedures

There are a number of Dermatologic

procedures that are useful for both
diagnosis and treatment. These include,
but are not limited to:

Cryotherapy
KOH preparation
Shave Biopsy
Punch Biopsy

Dermatologic Procedures

Go to
http://www.aad.org/education/medical-student-core-curriculum/derm
atology-skills-videos
Review Cryotherapy
Review KOH Preparations
Both can be found under the Cryotherapy, KOH, and local anesthesia section

Go to
http://www.aad.org/education/medical-student-core-curriculum/derm
atology-skills-videos
Review How to perform a SHAVE Biopsy
Review How to perform a PUNCH Biopsy
Both can be found under the Biopsy and Pathology section

Dermatologic Procedures

Lesions of vitiligo are wellcircumscribed depigmented

macules and patches.

The Woods light exam

distinguishes hypopigmented and
depigmented lesions by showing
up WHITE.

Very few rashes other than vitiligo

are completely depigmented.
81

General Treatment
Principles

Do no harm! (sometimes no treatment is necessary).

Biopsy or culture suspicious lesions (suspected cancer, etc.)

Simple/ common treatments:

Inflammatory (usually topical or oral steroids caution,
antihistamines, etc.).
Infectious (antiviral, antibacterial, antifungal, etc).
Cancerous (remove: Cryotherapy, Surgical, pharmacologic).
Cosmetic (remove or reassure)
Dressings/ occlusions accelerates topical treatment.

Patient Education and managing expectations is very important.

Dermatologic
Therapies

83

Principles of Dermatologic Therapy

The efficacy of any topical medication is

related to:
The active ingredient (inherent strength)
Anatomic location
The vehicle (the mode in which it is
transported)
The concentration of the medication

84

Vehicles
Foams
Gels

Creams

Sprays
Oils

Solutions
Ointments
85

Vehicles

Ointments (e.g. Vaseline): lubricating, occlusive; greasy

USE for smooth, non-hairy skin; dry, thick, or hyperkeratotic lesions
AVOID on hairy and intertriginous (when skin is in contact with skin, e.g. armpits,
groin, pannus) areas

Creams (vanish when rubbed in): less greasy, drying effects; not
occlusive, can sting, more likely to cause irritation
(preservatives/fragrances)
USE for acute exudative inflammation, intertriginous areas

Lotion (pourable liquid): less greasy, less occlusive; may contain

alcohol (drying effect on oozing lesion); penetrate easily, little residue
USE for hairy areas
86

Vehicles (cont.)

Oils: less stinging than lotions or solutions

USE for the scalp, especially for people with coarse or very curly hair

Gel (jelly-like): may contain alcohol, greaseless, least occlusive; dry

quickly
USE for acne, exudative inflammation (e.g. acute contact dermatitis); on
scalp/hairy areas without matting

Foams (cosmetically elegant): spread readily, easier to apply; more

expensive
USE for hairy areas; inflammation

Sprays: Aerosols (rarely used), pump sprays

87

What goes into a topical

prescription?

88

Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area
(face) BID PRN for scaling #15 Grams RF3

89

Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area
(face) BID PRN for scaling #15 Grams RF3
Generic name

90

Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area
(face) BID PRN for scaling #15 Grams RF3
Generic name
Vehicle

91

Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area (face)
BID PRN for scaling #15 Grams RF3
Generic name
Vehicle
Concentration

92

Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area (face)
BID PRN for scaling #15 Grams RF3
Generic name
Vehicle
Concentration
Sig (directions)

93

Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area (face)
BID PRN for scaling #15 Grams RF3
Generic name
Vehicle
Concentration
Sig
Amount

94

Topical prescriptions

What goes into a prescription?

Desonide cream 0.05% apply to affected area (face)

BID PRN for scaling #15 Grams RF3

Generic name

Vehicle

Concentration

Sig

Amount

Refills
95

Now Lets Review Some

Common Types of Medications
Used by Dermatologists
96

Topical Corticosteroids

Topical steroids produce an anti-inflammatory

response in the skin.

They are effective for conditions that are

characterized by hyperproliferation, inflammation,
and immunologic involvement.

They can also provide symptomatic relief for burning

and pruritic lesions
97

Topical Corticosteroids

Corticosteroids are organized into classes based

on their strength (potency)
Therefore, steroids within any class are equivalent in
strength

Strength is inherent to the molecule, not the

concentration
Know one steroid from each class that would be
available to the majority of your patients (the
generic in that class)

98

Topical Steroid Strength

Potency

Class

Example Agent

Super high I

Clobetasol propionate 0.05%

High

II

Fluocinonide 0.05%

III V

Triamcinolone acetonide ointment 0.1%

Triamcinolone acetonide cream 0.1%
Triamcinolone acetonide lotion 0.1%

VI VII

Fluocinolone acetonide 0.01%

Desonide 0.05%
Hydrocortisone 1%

Medium

Low

99

Topical Steroid Strength

Remember to look at the

class not the percentage
Note that clobetasol
0.05% is stronger than
hydrocortisone 1%.

When several are listed,

they are listed in order of
strength
Note that triamcinolone
ointment is stronger than
triamcinolone cream or
lotion because of the
nature of the vehicle

Potency

Class

Super
high

Clobetasol 0.05%

High

II

Fluocinonide 0.05%

III V

Triamcinolone ointment 0.1%

Triamcinolone cream 0.1%
Triamcinolone lotion 0.1%

VI
VII

Fluocinolone 0.01%
Desonide 0.05%
Hydrocortisone 1%

Medium

Low

Example Agent

100

Corticosteroid Selection
Super high potency (Class I) are used for severe
dermatoses over nonfacial and nonintertriginous areas
Scalp, palms, soles, and thick plaques on extensor surfaces

Medium to high potency steroids (Classes II-V) are

appropriate for mild to moderate nonfacial and
nonintertriginous areas
Okay to use on flexural surfaces for limited periods

Low potency steroids (Classes VI, VII) can be used for

large areas and on thinner skin
Face, eyelid, genital and intertriginous areas
101

Local Side Effects of

Topical Steroids

Local side effects of topical steroids

Acne
include:
Skin atrophy
Telangiectasias
Striae

Steroid Rosacea
Hypopigmentatio
n

The higher the potency the more likely

side effects are to occur.
To reduce risk, the least potent steroid
should be used for the shortest time, while
still maintaining effectiveness
102

Local Corticosteroid Skin Side Effects

Skin Atrophy

Striae

103

Local Corticosteroid Skin Side Effects

Hypopigmentation

104

Systemic Side Effects of

Topical Steroids

Systemic side effects are rare due to low

absorption
They can include:

Glaucoma (when steroid applied to the eyelid)

Hypothalamic pituitary axis suppression
Cushings syndrome
Hypertension
Hyperglycemia

The higher the potency the more likely side effects

are to occur
To reduce risk, the least potent steroid should be
used for the shortest time, while still maintaining
effectiveness

105

Duration of Treatment

Duration of treatment is limited by side effects.

In general:
Super high potency: treat for <3 weeks
High and Medium potency: <6-8 weeks
Low potency: side effects are rare. Treat facial,
intertriginous, and genital dermatoses for 1-2 week
intervals to avoid skin atrophy, telangiectasia, and
steroid-induced acne

Stop treatment when skin condition resolves

106

Directions to patients and prescribing information.

Apply in thin layer only

Generally, only BID is necessary, more than that does
not increase efficacy, only the risk of side effects.

Estimation for amount needed:

Generally (15g, 30g, 60g, 120g)

15g = enough for the face x 1 mo
30g = enough for larger area (extremity) x 1 mo
60 -120g may be necessary for larger body areas.

How To treat ACNE

Ask the patient what type of Acne they get.
A combination of medications will be helpful
to treat each type of Acne
Surface Red
Bumps
and Papules

Deep Cystic
Acne
Non
hormonal
Oral ABx
or
Accutane
Amoxicillin 500mg BID
Minocycline 100mg
BID
Septra DS BID
If Abx Fail:
Accutane
1mg/kg/day
up to
2 mg/kg/day

Hormonal
(Women
Only)

Topical
Antibiotics

Spiranolactone
100mg q day

Clindamycin
Solution
Lotion or Gel
BID

and/or
Low Estrogen
Oral
Contraceptive:
Ortho-Tri-Cyclen
If Abx and
Hormonal
Approaches fail
Consider
Accutane

Benzoyl
Peroxide,
Benzaclin,
qhs or qohs

Comedones
(Black Heads and White
Heads)
Exfoliating/
Keratolytic
Agents
Retin A,
Tazorac,
Differin,
qhs to qohs

Benzoyl peroxide

Benzoyl peroxide is a topical medication with both

antibacterial and comedolytic (breaks up
comedones) properties.

Available as a prescription and over-the-counter,

as well as in combinations with topical antibiotics
Patients should be warned of common adverse
effects:

Bleaching of hair, colored fabric, or carpet

May irritate skin; discontinue if severe

Topical Antibiotics

Used to reduce the number of P. acnes and

reduce inflammation in inflammatory acne.
Erythromycin 2% (solution, gel)
Clindamycin 1% (lotion, solution, gel, foam)

Metronidazole 0.75%, 1% (cream, gel) is used in

the treatment of rosacea
110

Topical Retinoids
(tretinoin, all trans retinoic acid)

Patients should be warned of common adverse

effects:
Dryness, pruritus, erythema, scaling
Photosensitivity

Available as a cream or gel

Do not apply at the same time as benzoyl peroxide

because benzoyl peroxide oxidizes tretinoin
111

Oral Antibiotics
Use for moderate to severe acne

Tetracycline, doxycycline, minocycline

Are contraindicated in pregnancy and children age
<8 years
May cause GI upset (epigastric burning, nausea,
vomiting and diarrhea can occur)
Can cause photosensitivity (patients may burn
easier, which can be easily managed with better
sun protection). Recommend sun block with UVA
coverage for all acne patients on tetracyclines
112

Oral Isotretinoin

Oral isotretinoin, a retinoic acid derivative, is indicated in

severe, nodulocystic acne failing other therapies

Should be prescribed by physicians with experience using

this medication

Typically given in a single 5-6 month course

Isotretinoin is teratogenic and therefore absolutely

contraindicated in pregnancy
Female patients must be enrolled in a FDA-mandated prescribing
program in order to use this medication
Two forms of contraception must be used during isotretinoin
therapy and for one month after treatment has ended
113

Isotretinoin Side Effects

Common side effects of isotretinoin include:

Xerosis (dry skin)

Cheilitis (chapped lips)
Elevated liver enzymes
Hypertriglyceridemia

Individuals with severe acne may suffer mood

changes and depression and should be monitored
Severe headache can be a manifestation of the
uncommon side effect pseudotumor cerebri
114

Topical Antifungals

The following are some examples of topical antifungals:

Imidazoles (fungistatic): Ketoconazole (Rx & OTC),
Econazole, Oxiconazole, Sulconazole, Clotrimazole (Rx &
OTC), Miconazole (OTC)
Useful to treat candida and dermatophytes

Allylamines and benzylamines (fungicidal): Naftifine,

Terbinafine (OTC), Butenafine
Better for dermatophytes, but not candida

Polyenes (fungistatic in low concentrations): Nystatin

Better for candida, but not dermatophytes
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Antihistamines

The following are examples of H1 antihistamines:

2nd Generation
1st Generation
Diphenhydramine (OTC)

Cetirizine (OTC)

Hydroxyzine (Rx, generic)

Loratadine (OTC)

Chlorpheniramine (OTC)

Fexofenadine (OTC)

For most pruritic dermatoses that are not

urticaria, 1st generation H1 antihistamines
primarily work through their sedative effect rather
than their anti-histaminic properties
116

Acknowledgements

This module was developed by the American

Academy of Dermatology Medical Student Core
Curriculum Workgroup from 2008-2012.

Primary authors: Alina Markova, Sarah D. Cipriano,

MD, MPH; Timothy G. Berger, MD, FAAD; Patrick
McCleskey, MD, FAAD.

Peer reviewers: Peter A. Lio, MD, FAAD; Ron

Birnbaum, MD.

Revisions: Sarah D. Cipriano, MD, MPH. Last revised

June, 2011.
117

References

Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The WebBased Illustrated Clinical Dermatology Glossary. MedEdPORTAL;
2007. Available from: www.mededportal.org/publication/462.

Drake LA, Dinehart SM, Farmer ER, et al. Guidelines of care for the
use of topical glucocorticosteroids. American Academy of
Dermatology. J Am Acad Dermatol 1996; 35:615.

Ference J, Last A. Choosing Topical Corticosteroids. Am Fam

Physician 2009;79 (2):135-140.

Goldstein B, Goldstein A. General principles of dermatologic therapy and

topical corticosteroid use. In: UpToDate, Basow, DS (Ed), UpToDate,
Waltham, MA, 2011.

Hettiaratchy S, Papini R. ABC of burns. Initial management of a

major burn: II assessment and resuscitation. BMJ. 2004;329:101103.

118

References

High Whitney A, Fitzpatrick James E, "Chapter 219. Topical

Antifungal Agents" (Chapter). Wolff K, Goldsmith LA, Katz SI,
Gilchrest B, Paller AS, Leffell DJ: Fitzpatrick's Dermatology in
General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2969866.

Limb Susan L, Wood Robert A, "Chapter 230. Antihistamines"

(Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS,
Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=3003116.

Nelson A, Miller A, Fleischer A, Balkrishnan R, Feldman S. How

much of a topical agent should be prescribed for children of
different sizes? J Derm Treat 2006; 17:224-228.

Weller R, Hunter J, Dahl M. Clinical Dermatology. 2008; 55.

Wolff K, Johnson R. Fitzpatricks Atlas of & Synopsis of Clinical

Dermatology. 2009; Sixth Ed.
119

Acknowledgements

This module was developed by the American Academy

of Dermatologys Medical Student Core Curriculum
Workgroup from 2008-2012.

Primary authors: Patrick McCleskey, MD, FAAD; Peter A.

Lio, MD, FAAD; Jacqueline C. Dolev, MD, FAAD; Amit
Garg, MD, FAAD.

Peer reviewers: Heather Woodworth Wickless, MD, MPH;

Ron Birnbaum, MD; Timothy G. Berger, MD, FAAD.

Revisions: Sarah D. Cipriano, MD, MPH. Last revised

June 2011.

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Acknowledgements

This module was developed by the American Academy

of Dermatologys Medical Student Core Curriculum
Workgroup from 2008-2012.
Primary author: Elizabeth Buzney, MD.
Contributors: Sarah D. Cipriano, MD, MPH; Ron
Birnbaum, MD.
Peer reviewers: Susan Burgin, MD, FAAD; Peter A. Lio,
MD, FAAD.
Revisions: Sarah D. Cipriano, MD, MPH. Last revised
March, 2011.
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References

Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The WebBased Illustrated Clinical Dermatology Glossary. MedEdPORTAL;
2007. Available from: www.mededportal.org/publication/462.
Morphology illustrations are from the Dermatology Lexicon
Project, which is now maintained by the American Academy of
Dermatology as DermLex.
Dolev JC, Friedlaender JK, Braverman, IM. Use of fine art to
enhance visual diagnostic skills. JAMA 2001; 286(9), 100-2.
Habif TP. Clinical Dermatology: a color guide to diagnosis and
therapy, 4th ed. New York, NY: Mosby; 2004.
Marks Jr JG, Miller JJ. Lookingbill and Marks Principles of
Dermatology, 4th ed. Elsevier; 2006.
Review primary lesions and other morphologic terms at
http://www.logicalimages.com/educationalTools/learnDerm.htm.

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References

Berger T, Hong J, Saeed S, Colaco S, Tsang M, Kasper R. The

Web-Based Illustrated Clinical Dermatology Glossary.
MedEdPORTAL; 2007. Available from:
www.mededportal.org/publication/462.
Bolognia JL, Jorizzo JL, Rapini RP. Dermatology, 2003, Elsevier
Limited.
Chu David H, "Chapter 7. Development and Structure of Skin"
(Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B, Paller AS, Leffell
DJ: Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2950881.
Proksch Ehrhardt, Jensen Jens-Michael, "Chapter 45. Skin as an Organ
of Protection" (Chapter). Wolff K, Goldsmith LA, Katz SI, Gilchrest B,
Paller AS, Leffell DJ: Fitzpatrick's Dermatology in General Medicine, 7e:
http://www.accessmedicine.com/content.aspx?aID=2977622.

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