A Review of Skin Conditions for the Physician Assistant Exam

There are multiple skin conditions you will need to be aware of for the Physician Assistant Exam (PANCE). Although there are several more that should be studied, make sure you familiarize yourself with these basics.

Keratosis lesions

You need to be aware of two types of keratosis lesions:

  • Actinic keratosis: This skin lesion is caused by excessive exposure to the sun or UV light. It can take many years to develop. Unlike squamous cell carcinoma, actinic keratosis isn’t a malignancy, although a small percentage of the lesions can develop into squamous cell carcinoma.

    Some of the most common areas to find actinic keratosis are the face and hands. The risk factors are the same as the ones for squamous cell carcinoma: long-term daily sun over-exposure or exposure to ultraviolet light. Older adults, especially people who are fair-skinned, are more at risk. The lesion is scaly. You can diagnose actinic keratosis by skin biopsy, and the treatment can include topical creams like imiquimod.

  • Seborrheic keratosis: This condition is neither cancerous nor precancerous. It’s a benign lesion that occurs on many areas of the body, including the face and back. The lesions are multicolored, raised, and papular.

    Seborrheic keratosis is associated with Leser-Trélat syndrome, a paraneoplastic sign that colon cancer may be present. The skin condition is also associated with Parkinson’s disease. Seborrheic keratosis is usually treated with topical therapy to try to reduce the size of the lesions.

Blistering bullous pemphigoid

Bullous pemphigoid is a dermatologic disorder in which large blisters are on the body, usually on the extremities and on the truncal areas. They can itch, especially early on, and they almost resemble an urticarial-type process.

Later, they form bullae/blistering lesions. Experts think the condition is autoimmune. The treatment depends on the severity of the bullous pemphigoid. In minor cases, you can use doxycycline. In more severe cases, immunosuppressive medication may be necessary. Usually a biopsy is required to confirm the diagnosis.

Hidradenitis

Hidradenitis suppurativa, which can affect the axillary and groin areas, is a clogging of the sweat glands, causing infection. Ask someone with hidradenitis to show you his or her armpits, and you’ll likely see small, pus-filled, cyst-like structures that over time can become scarred. The treatment is varied. It includes identifying and alleviating risk factors, using antibiotics, and maybe using immunosuppressive agents.

Lipomas

A lipoma is a benign fatty growth that’s freely movable and painless. You can find it anywhere, but it’s often in the extremities. The basic advice is to leave lipomas alone because they’re benign. When lipomas affect movement or the nerve of a particular area, they’re usually removed surgically.

Hives

Urticaria is a skin condition usually triggered by some sort of allergic condition. You can see a coalescing area of small, erythematous lumps that can itch a lot. They’re raised and can resemble a wheal.

Think of a wheal like the wheal you had under your skin after you received a purified protein derivative test, which you had to do as a medical professional. Unlike the wheals made by the PPD, the wheals of urticaria are smaller, and there can be a lot of them.

Urticaria has many causes: allergy-mediated, stress, and medication-induced. The treatment is identifying and eliminating the offending cause. Contributors can include the use of antihistamines. Steroids can also be used.

Dermatographia is a type of physical hives or physical urticaria. Here, the skin becomes acutely red and inflamed when the skin is either rubbed or touched. The cause is unknown. Stress may play a role. In pressure hives, the pressure of touching the skin itself can invoke an urticarial reaction. In most cases, physical urticaria resolves on its own over time. Antihistamines are also needed.

Pilonidal cyst

A pilonidal cyst is an abscess or hair-filled collection of fluid located at the sacral/coccyx area, although these abscesses can occur anywhere in the body. The most common initial presenting symptom is pain. They can hurt like the dickens. The usual treatment is incision and drainage.

Bedsores

In a hospital rotation, you’ve likely been exposed to the sacrum, a major body area where decubitus ulcers occur. The pressure sore/ulcer is an injury to the skin on a dependent area. The sacrum is especially affected because it’s a large bony prominence and most people lie in bed on their backs.

The most common clinical presentation is an older patient who is nonambulatory, usually bedridden. He or she may not be able to move or may even be unable to ask to be moved; this may be secondary to advanced dementia or a history of a cerebrovascular accident, where the person can’t verbalize or vocalize his or her wishes.

When someone comes into a hospital, look at the backside to examine for pressure ulcers. You may need to take a picture of the area and put it in the hospital record to demonstrate that the pressure ulcer didn’t occur in the hospital. In addition to measuring the diameter of the skin lesion, pay attention to the depth of the pressure ulcer. Be aware of the stages of pressure ulcers:

  • Stage I: You see a little erythema over the affected area and no evidence of skin breakdown.

  • Stage II: You can see the other layers of the skin affected. There’s a break in the integrity of the skin, but it isn’t deep.

  • Stage III: The injury to the skin has gone beyond the skin layers and now affects the subcutaneous fascia.

  • Stage IV: You can see the bone in the setting of a sacral decubitus. You also need to worry about a possible osteomyelitis.

Prevention of pressure ulcers includes promoting ambulation and turning people every 2 hours or so in bed, especially when they’re sleeping. The active management of a pressure sore includes constant monitoring for signs of infection, including wound weeping, angry-looking erythema, and skin necrosis. In addition, surgical debridement or intravenous systemic antibiotics may be necessary.

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