DIP Episode 242 - USMLE Dermatology (Part 1 of 3) + 2CK, 10 hr Course (6/27/20)

Okay, welcome. My name is Divine, I'm a resident. This is episode 242 of the Divine Intervention Podcast. And in this podcast I'm going to be studying a three-part series. Initially I thought to, and it's going to be on dermatology. Initially my idea was to make it one part, but I'm beginning to realize that dermatology is quite a huge topic. And the thing is this is classically a very difficult topic for people to study for the USMLE exams. So I figured I'll just cover it, would be very comprehensive and make it in three parts. So that each podcast is short. And my apologies I chose to not make a Power Point for this. I'll encourage you as you're going through each diagnosis, pause the podcast and look up a picture. Because to be quite honest with you, I really cannot, many of these things really gross me out. So I really do not, my body does not really enjoy going through the process of kind of looking up pictures of most of this stuff. So my sincere apologies on that. Okay. And just real quick, I have my next step to CK class on the 27th of this month. Again, just email me if you want some more information, but basically it's the same format as I've done for other classes. But you know, I'm trying to make modifications. So actually I'll be making fairly. I've it has got in very good reviews, but I plan to make some mild modifications for the next iteration or coming up in two weeks.

So if you want to register spots are limited to just send me an email and I will point you in the right direction. Okay. Now what if they give you a question about a patient and they tell you that this patient has like dry skin and they tell you that this patient has like intense parrhoidus and then detail you on physical exam. You notice a lot of erythematos like papules and vesicles and detail you that there's a lot of question and using. And let's say it's a person that has a family history of asthma. What are you thinking about for that question? I would really hope you're telling me that that person has a topic dermatitis or exam. Right. And it is actually very high you to know some associations with exam are here with regards to kids versus adults. It's high you to know that in adults exam attend to shop on flexural surfaces. But when people are super young kids the exam attend to shop on extensor surfaces first before it then manifests to the flexural surfaces. So basically like if you look at your antichybidophosa that's your flexural surface for your pre-extremely right. That's where exam attend to shop in older adults right. And then the thing is on an in-bimmy exam, what is the classic finding in a person that has had chronic a topic dermatitis. Well you want to think about the term known as like-kinification right. Like-kinification. Basically these people have each each each for like a ton right. So the skin is now like looks really looks very fissured.

That's like characteristic of like chronic exam. And if they give you a question you may say which of the following is the most likely infectious complication of a person has in having a topic dermatitis. You want to think about a staff-oreal super-infection right. And remember that exam is a kind of type 1 hypersensitivity reaction. I'll talk about the treatment of a X-ima in a bit. Now what if they give you a question about a patient and they tell you that you know this patient acquired new jewelry and this patient has like a lot of itching around their wrists. What are you thinking about there? Well I would hope you're really thinking about contact dermatitis right. Contact dermatitis there's like the type that's called like a allergic contact dermatitis. Probably you know this person has like some kind of nickel in the jewelry that recently acquired and that's causing a lot of problems for them. Now one thing I would also say because you know your friends at the MBM again they are trying to find new ways of testing old information right. So again they know that many people have memorized nickel right. So you want to begin to think about some other things that potentially cause contact dermatitis. And by the way contact dermatitis is a type 4 hypersensitivity reaction. You want to think along the lines of like you know like all these medication patches those things classically can cause contact dermatitis right. Poison, no poison ivy right.

Those things can absolutely cause contact dermatitis right. Again remember the hallmark of poison ivy is usually they will show you like a picture right. And you'll see like you know like all these like vesicular lesions they'll be like vesicles they'll be they'll be grouped and usually they'll be in a linear distribution. That's classic for poison ivy on MBM exams right. And again remember at topic dermatitis, flexural surfaces. The reason that I'm mentioning that is when a person has like psoriasis psoriasis would be on the extensor surfaces. The thing is many times on MBM questions they may not even give you the picture of the dermatologic condition they'll just describe it to you right. They'll give you some buzzwords. So it's those buzzwords that I'm going to try to focus on in this podcast. Now what if they give you a question about like a 79 year old female you know the tell you that she presents to a dermatologist because you know she has had like really dry skin especially like on her left shin right like a left you know like a left-low extremity like her entire shin and they tell you that oh physical exam the skin is red it's dry all these net-like features right. And again let's say this person presents in December you know this stuff I'm talking about now it's really bad in cold weather really bad in dry like dry weather.

If you see this you want to think about a kind of exema known as exerotic exema XEROTIC exema right that's a classic thing and we present on MBM exams and again remember it tends to present in old people not young people on exams old people right old people right so again you have red skin you'll be dry you'll be cracked and again you'll look net-like. And it's usually on the lower extremities it's almost like they have like it's almost like I've almost looked at it as like a tree bark appearance of the lower extremities especially around the shins if you see that you absolutely want to think about exerotic dermatitis sometimes they call it ST-atotic so like AST-E-A-T-O-T-I-C dermatitis right. And the thing is in general like for bursi has like a topic dermatitis or even any kind of dermatitis right you generally want to just you know select the answer that says to use them all in right but don't forget that's typically you want to use topical glucocoricoids right topical glucocoricoids work really well for the treatment of most kinds of exema or most kinds of dermatitis although you actually want to be careful especially if you're dealing with like dermatitis of the face right if a person has exema on their face you don't want to use like these high potency glucocoricoids remember those steroids can cause atrophy of the skin you don't want that right.

And those steroids can also cause acne remember one of the common causes of acne and inbim exempt is actually the use of topical corticosterids right.

Now what if they give you a question about a patient and they tell you that you know these are 36 year old Mexican male and they tell you that you know on his elbows right you know like the extension of his elbows you are finding like thick erythematous blocks and they tell you that he has the same risk skill right if you see the what are you thinking about or really hope you're thinking about like plaxorises right plaxorises remember right again typically when people have psoriasis right they will have like you know the area will be red right and again you will be on an extension surface and the classic area as it tends to show up on on inbim exempt is you can show up around the elbows you can show up on the knees right so basically extensor surfaces can show up on the scalp can show up on the ears can show up in the genitalia right and the thing is one classic physical exam finding on inbim using people that have psoriasis is that they will have like very thick nails like their nails will be thick you'll be yellow they'll have a lot of like nail peed in if you see that you want to think about psoriasis especially in his in a in a his panic person on inbim exempts and there are some key things that can actually make psoriasis worse right so for a person sticking like a bit of blocker or an n-set or like another pro like an is inhibitor right or if one like again like these oral steroids or if one tetracycline these things can actually all trigger psoriasis they can actually worse in a person's psoriasis or make the person have like more flares so those are things to keep in mind on exempts and then there is one kind of psoriasis that occasionally you know you see the kind of shows up on exempts and people are like what in the world are they talking about right so what if they give you a question about a patient and they tell you that oh this patient has like a lot of

poppules and plucks on their trunk and they tell you that it looks like tiny like drops like tiny tiny tiny drops right and they tell you that oh this person was recently recently developed like a like a group A strep skin infection if you see so like strep hygiene is a skin infection if you see that you want to think about something known as gotate psoriasis so g-u-w-t-a-t-e gotate psoriasis right and again in general for psoriasis if you're trying to think of treatment on an in-bim exam you want to go ahead and give those people like like a like a topical vitamin D analog right so like the classic one you may see on your exam is something known as calcipo-train so C-A-L-C-I-P-O-T-R-I-E-N-E right so typical calcipo-train or you can use a like a topical right noise or you can use like topical and thralin right or like a tar preparation right really is it the right answer to use like a topical steroid on in-bim exams for psoriasis and let me tell you one thing right of the but please never never never never never do this never give oral steroids or IV steroids for psoriasis if you do that I promise you you'll get that question wrong on exams right you'll get that question wrong on exams so you really want to be careful with that you really want to be careful with that because the thing is like systemic steroids can actually worsen a presence of psoriasis in fact sometimes some people can get a very dangerous complication the quality of erythroderma where like the skin just turns really red especially when they have a history of psoriasis and they are taking like oral steroids that erythroderma this is actually one of the furies and so why you consult dermatology at night right because these people like when they get that erythroderma they begin to have all these electrolyte abnormalities from like just losing a ton of fluid and they have like very very high risk of li

ke a skin super infection right so those are again things you want to watch out for on an in-bim exam so again systemic steroids those are terrible idea in a person that has psoriasis right again those are terrible ideas ever ever give steroids systemic steroids for a person that has psoriasis on endymies okay now what if they give you a question about a patient and they tell you that this patient you know they have noticed over the last three days they've been having a lot of paritis on their on their a lot of paritis like on their wrists and they've also noticed it on the ankles and then they tell you that on physical exam you notice like some purple papules and they tell you that all these lesions are shaped like polygons and again notice the distribution rest ankles rest ankles and they are purple they are paritic they are shaped like polygons if you see that you want to think about the diagnosis of likened planus you want to think about the likened planus and the way you treat likened planus is with a topical steric now what if they give you a question about a patient that again over the last two weeks they have a lot of paritis and then they tell you that oh this person had like the notice like a like a like a circular or sometimes it can be like a rectangular like lesion on their trunk usually this is what's called the heral patch and then they tell you that you know these leaders they studied notice no these red paritic like patches like on their trunk on their backs, on their axilla and all that stuff and this is really last for weeks if you see this you want to think about paritisis or zia you want to think about a peterosis or zia and the way you treat peterosis or zia there's really no great treatment but if you are trying to get you to select something on an embankment exam you can give those people topical steroids or you can also give them like anti-his

tamines to help with the paritis now what if they give you a question about a patient and they tell you that this patient tell you that this patient has like these like oily scaly lesions on their eyebrows I mean this thing can also show up on like on the scalp it can also show up like it can show up on the nezolibio folds, it can show up on the chin it can show up in the perinium in some rechesis if you see something like this what are you thinking about well I would really hope you're thinking about seborrheika dermatitis right you want to think about seborrheika dermatitis and the way you treat seborrheika dermatitis on embankment exams is actually with like a shampoo of usually like selenium sulfide although you could also potentially use like a condo-zol but first learn on your test should be like a selenium sulfide or shampoo right and there are some weird bizarre associations you want to keep at the back of your mind with seborrheika dermatitis and the first thing is if they tell you that oh a young person that sexually active develops like just explosive like just tons and tons and tons of lesions that are seborrheika dermatitis you want to go ahead and screen that person for HIV that classic presentation of HIV on exams right and also don't forget seborrheika dermatitis classically an embium is maybe seen in a person that has Parkinson's disease okay so again that's something you want to keep at the back of your mind for exams now one thing I guess one concept that should talk about is what if they give you a question about the 35-year-old female right and they tell you that you know she has had like redness of like her cheeks of her nose right and you know they tell you that she has like whenever she eats spicy foods she has like a lot of like facial flushing whenever she takes alcohol she has like facial flushing if you see that you absolutely want to think

about a rosicia right you want to think about a rosicia on your test you want to think about a rosicia on your test and remember rosicia on mbm is almost certainly that person will have that person will be more than 30 years old you'll shop in a woman and that will be more than 30 years old on your mbm exam right if you see that you absolutely want to think about a rosicia and the thing is sometimes on your test right they will like to try to like mess with your head you know like the way the mbm does they will try to mess with your head by trying to get you to think that oh this person has lupus they may try to present like that's the presentation of rosicia they may try to make it look like the Miller rash of lupus here's one key thing I think that will help you actually two key things one the rash of lupus spares the lizzolibial folds the Miller rash of rosicia does not spare the nizolibial folds that's one two people that have lupus they will not have these flushing episodes they will not have any papioles they will not have any pussioles on their face but people that have rosicia will okay so again those are all high-yield things you want to keep at the back of your mind for for exams right and one thing I guess I want to say is if they give you a question about like a woman right and they tell you that you know this woman suddenly develops like severe acne I'll talk about acne in a bit but you know woman just develops like this sudden onset severe acne and they tell you that man you've tried all these acne medications nothing is working and they tell you that this woman has her sirtism or she has like menstrual problems or she has like signs of virulization right if you see that you want to think about a person that potentially has like some kind of tumor either in the adrenal glands that's making DGS or in the testic in her not testic groups in her go on out r

ight like a sort of totally lady exelt tumor that's making testosterone right so those are all high-yield things you want to keep in mind for exams now what if they give you a question about a patient they tell you that oh this patient has a his show diabetes and they tell you that they've had these chronic lesions like on the the axilla on the the breasts right and they tell you that in fact they even have this like in their like in the gluteal cleft and they tell you that oh this person has been having um um this person have been having having like just um a lot of like they tell you on physical exam you'll see like a lot of like nodules a lot of cysts like a lot of comedones and they tell you that you see a lot of scarring again notice the distribution here under the axilla right under the breasts in the inguinal folds right along around the gluteal region if you see this this is hydrodynamic is a superativa right this is hydrodynamic is a superativa remember this affects epocrine sweat glands right remember acne itself affects a sebaceous glands sebaceous follicles what hydrodynamic is a superativa effect um epocrine or sweat glands right uh it's you know it's pretty bad and really the way you treat hydrodynamic superativa in your test um if you're trying to get you to pick a drug you can either pick uh percent you can either pick the combination of clindamycin and rifampin or you can pick a tnf inhibitor actually like inflicts him up but for the most part the definitive treatment for hydrodynamic is a superativa is uh to go ahead and uh excise those lesions right so those people need some kind of a surgical excision right and then we all know how acne presents acne right to present like again being a woman on a test right and you'll see buzzwords you'll see in the question of be like oh there's open and close comedones there's papules there's pustules there's noz

ila lesions and for the most part on nbm is the distribution will be the face the neck or like the upper trunk if you see that right that's acne vulgaris right and again remember it's sebaceous follicle sebaceous sweat glands that are affected and acne on nbm exams right the way you typically want to treat it is first line you want to either start with a topical agent right like a topical retinoid or topical salicylic acid or topical benzoyl peroxide right if that's not cutting it you then switch second line or not switch actually you add on you add on a topical antibiotic like topical retromycin topical aclyndomycin if that's not working you add on a third line thin right you want to add on like an oral anti-biotic you can use like tetracycline remember tetracycline if they give you a question about the person that's you know taking like tetracycline for acne and then this person has like many weeks short of like headaches visual difficulty that's worse in the mornings right you want to think about idiopathic intra-creational hypertension on that those are circumstances right and then if all those things are not working obviously where you want to go ahead and give those people an isotrate knowing remember isotrate knowing you need to make sure that those people's liver work well and they need to be on two forms of birth control and if the woman is pregnant she should not be on isotrate knowing if she's pregnant she should also not be on an oral tetracycline that be a bad idea remember those things are all are those things are all um uh teradogins right so you want to keep that at the back of your mind for exams and actually if you get a question about a woman that has like PCOS for example and she has acne your drug of choice right because she has signs of hyperindrogenism your drug of choice day is actually an ocp is actually very effective at relieving acne in tha

t specific kind of patient population and then what if they give you a question about an athlete right and they tell you that this athlete um you know like on their scalp on their buttocks on their thighs they have all these like uh postures and papules right and they tell you that they are centered around like hair follicles right basically where that has hair notice this will be an athlete on a test if you see that you want to think about bacterial folliculitis right and remember the most common cause of bacterial folliculitis is actually stuff stuff for you and typically these things you can try to treat it with like a topical like a topical you purer say for example right and then don't forget another kind of folliculitis right you see a person that uses like a community pole or a hot tub that's you know been inadequately chlorine needed you want to think about hot tub folliculitis right and remember that's classically caused by a pseudomonas species okay and then don't forget right the buzzword hot tub long i think i have talked about in a different podcast remember that's actually caused by mycobacteria my evoma complex right so mycobacteria my evoma that's a lary on mbim exams okay so this is 20 minutes already okay i'm gonna try and stop this soon but any kind of shuffling these are them out of fight skin infections right so they are basically these things are our tiniens and the thing is the most common cause to the list common cause are three organisms the most common cause of any kind of tiniya is trichofightin especially trichofightin transurants on mbim exams that's number one number two will be micro sporen species so micro sporen and the number three will be the epidermal fighting species epidermal fighting species right and remember all these things are referred to as the modified infections for the most part right and the big thing you want to think a

bout you know like there's tiniya pides right this is what's called an like at least foot right so basically you see like all the scaling and featuring between the tools although one on usual we didn't be presented on the exam maybe like it's almost like in a like all the scaling all around from like the presence tools all the way back to around the area of the Achilles if you see that that's tiniya pides right tiniya corpus is probably the most common one on the exam right those people they'll have a circular lesion right and they will tell you that it will be like a circle of red so it will be like around the circle it's red right so they will have like an erythematos circle right and that thing will have like like like vesicles right some vesicles some skills around it but the center of it will be clear right the buzzword there is central clearing that's tiniya corpus right that's ringworm right and then right like you know jock it right usually will be like a very itchy itchy person they will just have a lot of red around like their inguinal folds right and then nail fungus right those people have like thick nails it'll be yellow it'll be or it'll be like really white right and then they'll tell you that the the distal edge right like so basically like the part that's like farthest away from your skin right they'll tell you that it's elevated and it's almost like separate it from the nail cleat if you see that you want to think about a kind of sometimes they call it tiniya own guayem but the classic term on envy makes them is onikomaicosis right onikomaicosis and one thing that i guess is closely related that should maybe try to slot in here is like candida right like people can have like cutinia acandidaeus right usually these people have like red itchy skin right and then you will find satellite lesions red satellite lesions right that's characteristic of a cand

idaeus right that's characteristic of candidaeus right and again typically these dramatic fighting factions the way you make the diagnosis right is you go ahead and like you know you may script some part of the lesion and do like some kind of a kill-heach prep whatever right and typically you find branching high fee right you find branching high fee if it's candida that's the book they'll tell you that on exams you see on kill-heach prep you see spores and pseudo high fee okay you see spores and pseudo high fee and i guess one of the kill-heach prep thin right if they tell you that a person has like hypopecvented like macules again around like their upper trunk or their back you want to think about tinia vesicular right tinia vesicular remember tinia vesicular sometimes on exams to mess with your head your collipetrais is vesicular remember this is caused by malacisia ferifer on exams right and classic on kill-heach prep you'll find the spaghetti and meatballs are pattern right you'll find the spaghetti and meatballs are pattern and again again don't forget candida red skin with satellite lesions satellite papules and post-yups that's classic for that's classic for candida and in terms of treatment right so typically all tinias respond at least all the tinier corpore is tinier, krurris like the jock each other tinia tinia sorry tinia tinia pides which is also the at least food those things respond very well to like topical antifongals right topical antifongals like topical clotrimazole basically any topical antifongal agent will work however if a person has tinia capitis right or if a person has so like head fungus or a person has like onikomikosis right those people need an oral medication on any of the exams you can use oral terbina feme or you can use like oral etroconazole or you can also use oral grizzio fulving remember grizzio fulving is very good at penetratin

g keratin containing tissue keratin containing tissue for candida right the way to assist uh...

cutaneous candida you can use again like topical niestadine or any topical isal right like my conazole clotrimazole or whatever and then if a person has a tinia vesicle of the way treated is with uh... selenium sulfide right you can use selenium sulfide or again you can also use topical keratin oaconazole on an emium exam okay and uh... the last thing i will mention to the right again i want to keep this on the 30 minutes if you find a person that you know has like uh... like um... like umbilicated like papules on the skin right? uh... you want to think about moloscom contagious remember that's caused by the poxfires and really the way you treat these on exams you know you can do like cryotherapy or you can do like curatage right? and again usually shows up in a sexually active presence you know you can show up in a kid on a test right? um... if you see a person that has like a ton of moloscom contagious again you want to maybe begin to think about a HIV in that patient population so i think i'm going to go ahead and pause here today as i do at the end of every podcast i'd offer uh... one on one teeter and for many exams right? so step one, step two ck step two cs step three um... preclinical med school exams 30th shelf exams remember i do longitudinal tutoring where you know if you're a med student in your first year of med school or second year you're studying your 30th shelf rotations uh... your 30th rotations right?

i'll tutor you for all your block exams or your shelf exams and then at the same time i'll tutor you for the relevant USMLE content and again many people have done this with they've been extremely successful with it and then i do offer booster courses for step one, step two ck or step three um... it's all um... it's all one on one and again you'll be like 21 hour sessions or 10 to hour sessions and will comprehensively review the high yields for the different disciplines represented on each of those tests and then in recent times i've studied offering a group class right now it's a step two ck group class i you know try to hold it roughly every two weeks although it really depends on what my schedule looks like but the next one will be taking place on the 27th of this month i was... i've finally been able to confirm my schedule today so it's going to be taking place on the 27th of this month um... the details are the same as what i've released in the prior podcast we have talked about the reviews but you know basically from six to ten a.m. Pacific time in the morning and then known to four p.m. Pacific time in the afternoon and then six to eight p.m. Pacific time in the evening one day um... hold those sessions and in the future i'm going to try to split it up between these uh... so it's not like 10 hours early on one day but again in the meantime with the way my schedule is now i think i would have to stick with uh...

just 10 hours one day i mean you have 12 breaks in between so you can rest and in this course we basically review like 600 to 700 high yield concepts across like peeds, surgery, internal medicine, neurology, um...

obi-guin, psychonural right so we review all those things in a 10-hour period and again it's very high yield we'll cover a lot of content that you'll see represented on exams and i'll present them in like classical mbmiya vignette like the classic ways they tend to present those things on exams and as an update a step one course of that kind is going to be coming up very soon that's something that's currently in the works so that's something you're interested in feel free to reach out feel free to reach out to me now and then if you're if you're medicine are planning to resident in special this tricky application cycle like iris or a college student applying to med school so like an amcass application i'd refer like consulting right for like one-on-one for like rec letters personal statements applications, mock interviews i edit, i write, i do all these things with all these different things again if you have a tricky application no research graduated from med school 10 years ago something like that reach out to me and i can give you some more information on what i provide and then the life lesson for today is the importance of not enough right basically what do i mean by that i don't mean not being content with what you have but what i mean is always have the standard for excellence don't always think that you're good enough the thing is that should be your approach throughout life if you are good enough you're basically limiting yourself in life you're basically limiting yourself in life you always want to keep pushing the boundary pushing the boundary pushing the boundary you want to keep getting better and better and better you want your life to keep shining brighter don't think oh you know this is just good enough this is good enough remember those ATT ads that say just ok no that's not the kind of standard you want for your life you want to keep getting better a

nd better and better right i mean i love uh i mean i have many of you know i'm a Christian i love the book of daniel in the bible right where there's a part that says that oh daniel was so good that you could not find a single air in his work right i'm not saying that people can not make mistakes they can right but you should have that standard of excellence you should have that standard of excellence always try to keep getting better even if you are like doing really well you are at the very top you can always get better than that right you can always break new ground you can always break new barriers you can always blaze new trails i mean to be honest with you even if i'm a liquor fan one of the best uh names i love embassable are the portland trailblazers you want to be a person that blazey trails in life right those kinds of people they are always improving they are always getting better and the thing is those people will not be left behind because the person that is stuck in the past behind and the world will move on from them right so again just keep things you want to keep at the back of your mind i think those will help you in life so thank you for listening watch out for parts 2 and part 3 of the USMLE DEMATOLOGY series thank you and god bless you

Lichenification (skin appears very fissured).

Type IV hypersensitivity reaction.

Vesicles that are grouped and in a linear distribution.

Older adults: Flexural surfaces (e.g., antecubital/popliteal fossae). Young children: Extensor surfaces first, then flexural surfaces.

Xerotic dermatitis (or asteatotic eczema).

The rash of rosacea does NOT spare the nazolibial folds, whereas lupus typically spares them.

Trichophyton species (e.g., T. rubrum).

Trichophyton, Microsporum, and Epidermophyton.

A circular lesion with central clearing (ringworm).

Apocrine sweat glands; typically found in intertriginous areas (axilla, inframammary folds, gluteal cleft).

Topical Vitamin D analogs (e.g., calcipotriene) or coal tar/topical retinoids.

Selenium sulfide shampoo.

Idiopathic intracranial hypertension (pseudotumor cerebri).

Branching hyphae.

Trichophyton, Microsporum, and Epidermophyton.

A circular lesion with central clearing (ringworm).

Apocrine sweat glands; typically found in intertriginous areas (axilla, inframammary folds, gluteal cleft).

Topical Vitamin D analogs (e.g., calcipotriene) or coal tar/topical retinoids.

Selenium sulfide shampoo.

Idiopathic intracranial hypertension (pseudotumor cerebri).

Branching hyphae.