65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

ABFM Family Medicine Certification Study Guide Exam

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1 Chapter 1: Exam Structure, Blueprint & Clinical Decision-Making

1.1 Exam Blueprint, FMCLA vs. One-Day Exam & Board Scoring 1.2 Clinical Reasoning, Test-Taking Strategy & Ambiguity Management 1.3 Evidence-Based Medicine & Clinical Practice Guidelines in Primary Care

2 Chapter 2: Healthcare Systems, Practice Management & Quality

2.1 Practice Management, Billing, Coding & Documentation 2.2 Quality Improvement, Patient Safety & Diagnostic Stewardship 2.3 Interprofessional Team-Based Care & Care Coordination

3 Chapter 3: Ethics, Law, Biostatistics & Health Equity

3.1 Medical Ethics, Informed Consent & Surrogate Decision-Making 3.2 Biostatistics, Clinical Epidemiology & Diagnostic Test Interpretation 3.3 Social Determinants of Health, Health Equity & Cultural Humility 3.4 Physician Wellness, Burnout Prevention & Professionalism

4 Chapter 4: Lifestyle Counseling & Behavior Change

4.1 Alcohol Use Screening & Brief Intervention 4.2 Illicit Drug & Cannabis Counseling 4.3 Tobacco & Vaping Cessation Counseling

5 Chapter 5: Nutrition, Physical Activity & Chronic Disease Prevention

5.1 Dietary Counseling for Obesity & Chronic Disease Prevention 5.2 Exercise Prescription & Physical Activity Counseling 5.3 Genetic Risk Assessment & Family History Counseling

6 Chapter 6: Routine Adult Immunizations

6.1 ACIP Adult Respiratory Vaccines: Influenza, COVID-19, RSV & Pneumococcal 6.2 ACIP Adult Non-Respiratory Vaccines: Tdap, Shingrix, HPV & Hep B 6.3 Immunizations in Special Populations: Pregnancy, Asplenia & Immunocompromise

7 Chapter 7: Pediatric Health Maintenance & Surveillance

7.1 Newborn Examination & Early Postnatal Care 7.2 Well-Child Care, Developmental Surveillance & Milestones 7.3 Pediatric & Adolescent Screening: Vision, Hearing, Anemia & Lead 7.4 Pediatric Oral Health, Dental Screening & Fluoride

8 Chapter 8: Behavioral Health & Safety Screening

8.1 Primary Care Depression, Anxiety & Behavioral Health Screening 8.2 Domestic Violence, Intimate Partner Violence & Firearm Safety 8.3 Occupational Health & Recreational Safety Counseling

9 Chapter 9: Adult Preventive Screening: Cardiovascular & Metabolic

9.1 Cardiovascular Disease & Hypertension Screening 9.2 Type 2 Diabetes Screening & Prediabetes Risk Stratification 9.3 Abdominal Aortic Aneurysm & Osteoporosis Screening

10 Chapter 10: Adult Cancer Screening: Breast & Gynecologic

10.1 Breast Cancer Screening & Risk-Assessment 10.2 Cervical Cancer Screening & ASCCP Algorithms 10.3 Skin Cancer Clinical Assessment & Counseling

11 Chapter 11: Adult Cancer Screening: Colorectal, Lung & Prostate

11.1 Colorectal Cancer Screening Modalities & Intervals 11.2 Lung Cancer Screening with Low-Dose CT 11.3 Prostate Cancer Screening & Shared Decision-Making

12 Chapter 12: Sexual Health, Infectious Disease Screening & Contraception

12.1 Sexual Health Counseling & Risk-Reduction Strategies 12.2 STI Screening: Chlamydia, Gonorrhea, Syphilis & Trichomoniasis 12.3 Bloodborne Infectious Disease Screening: HIV & Hepatitis C

13 Chapter 13: Reproductive Life Planning, Lactation & Preoperative Care

13.1 Preconception Planning & Comprehensive Contraception Management 13.2 Lactation Support & Breastfeeding Counseling 13.3 Preoperative Medical Evaluation & Pre-Participation Sports Exam

14 Chapter 14: Emergent Cardiovascular Conditions

14.1 Acute Coronary Syndromes & Myocardial Infarction 14.2 Acute Chest Pain Risk Stratification & Triage 14.3 Acute or Critical Valvular Heart Emergencies

15 Chapter 15: Cardiac Arrhythmias, Heart Failure & Hypertensive Crises

15.1 Acute Atrial & Ventricular Arrhythmias 15.2 Acute Decompensated Heart Failure & Cardiogenic Shock 15.3 Hypertensive Emergency & Urgency Management

16 Chapter 16: Vascular & Thromboembolic Emergencies

16.1 Pulmonary Embolism & Deep Vein Thrombosis 16.2 Acute Aortic Syndromes & Peripheral Vascular Emergencies 16.3 Critical Limb Ischemia & Acute Arterial Occlusion

17 Chapter 17: Neurologic Emergencies: Stroke & Altered Consciousness

17.1 Acute Ischemic Stroke & Intracranial Hemorrhage 17.2 Syncope Evaluation & Status Epilepticus 17.3 Acute Delirium, Encephalopathy & Severe Confusion

18 Chapter 18: Neurologic Trauma & Acute Cranial Emergencies

18.1 Concussion, Moderate-to-Severe TBI & Intracranial Injury 18.2 Thunderclap & Acute Severe Secondary Headaches 18.3 Acute Ophthalmologic Emergencies

19 Chapter 19: Acute Abdominal, Pelvic & Gastrointestinal Emergencies

19.1 Acute Abdominal & Pelvic Pain Triage 19.2 Upper & Lower Gastrointestinal Bleeding 19.3 Acute Hepatic Failure, Cholangitis & Severe Jaundice

20 Chapter 20: Acute Pulmonary & Airway Emergencies

20.1 Acute Hypoxic Respiratory Failure & ARDS 20.2 Severe Community-Acquired Pneumonia & Empyema 20.3 Acute Severe Epistaxis & Airway Obstruction

21 Chapter 21: Acute Traumatic Injuries & Wound Care

21.1 Major Trauma Resuscitation & Initial Assessment 21.2 Burn Assessment, Inhalation Injury & Resuscitation 21.3 Laceration Management, Complex Wounds & Animal Bites

22 Chapter 22: Acute Orthopedic & Musculoskeletal Emergencies

22.1 Acute Ambulatory Fractures & Initial Splinting 22.2 Compartment Syndrome & Major Orthopedic Trauma 22.3 Septic Arthritis & Acute Microcrystalline Crises

23 Chapter 23: Severe Infections, Sepsis & Systemic Emergencies

23.1 Sepsis, Septic Shock & Initial Fluid Resuscitation 23.2 Necrotizing Soft Tissue Infections & Severe CNS Infections 23.3 Anaphylaxis Diagnosis, Epinephrine Dosing & Airway Protection

24 Chapter 24: Metabolic, Endocrine & Electrolyte Emergencies

24.1 Diabetic Ketoacidosis & Hyperosmolar Hyperglycemic State 24.2 Critical Electrolyte Emergencies: Dyskalemias & Dysnatremias 24.3 Severe Calcium Abnormalities & Acute Adrenal Crisis

25 Chapter 25: Hematologic, Urologic & Dental Emergencies

25.1 Severe Symptomatic Anemias & Coagulopathic Emergencies 25.2 Testicular Torsion, Priapism & Acute Urinary Retention 25.3 Urgent Odontogenic Infections & Dental Trauma

26 Chapter 26: Psychiatric, Behavioral & Obstetric/Gynecologic Emergencies

26.1 Suicidal Ideation, Acute Agitation & Behavioral Emergencies 26.2 Acute Physical & Sexual Assault Care 26.3 Life-Threatening Vaginal Bleeding & Ectopic Pregnancy 26.4 Environmental Heat Stroke & Severe Hypothermia

27 Chapter 27: Acute Head, Neck & Neurologic Symptoms

27.1 Primary Acute Headaches: Migraine, Tension & Cluster 27.2 Concussion & Minor Closed Head Injury Evaluation 27.3 Transient Ischemic Attack Evaluation & ABCD2 Risk Scoring

28 Chapter 28: Acute Cranial Nerves, Hearing & Sensory Symptoms

28.1 Peripheral Neuropathies: Bell's Palsy, Carpal Tunnel & Radiculopathy 28.2 Acute Tinnitus, Sudden Sensorineural Hearing Loss & Cerumen Impaction 28.3 Acute Dizziness, Benign Paroxysmal Positional Vertigo & Vestibular Neuritis

29 Chapter 29: Acute Upper Respiratory Tract Infections

29.1 Acute Viral Rhinosinusitis vs. Bacterial Rhinosinusitis 29.2 Acute Pharyngitis: Group A Streptococcus & Centor Criteria 29.3 Acute Otitis Media, Otitis Externa & Serous Effusion

30 Chapter 30: Acute Lower Respiratory Infections & Cough

30.1 Influenza, COVID-19 & Viral Respiratory Syndromes 30.2 Acute Bronchitis & Lower Respiratory Tract Infections 30.3 Ambulatory Community-Acquired Pneumonia

31 Chapter 31: Allergic, Nasal & Non-Infectious Pulmonary Conditions

31.1 Allergic Rhinitis & Acute Non-Anaphylactic Allergic Reactions 31.2 Acute Dyspnea in Ambulatory Care 31.3 Interstitial Lung Diseases & Sarcoidosis Presentation

32 Chapter 32: Acute Chest, Cardiac & Vascular Symptoms

32.1 Palpitations Evaluation & Arrhythmia Triage in Primary Care 32.2 Deep Vein Thrombosis & Superficial Thrombophlebitis 32.3 Ambulatory Hypotension & Orthostasis Evaluation

33 Chapter 33: Acute Upper Gastrointestinal Conditions

33.1 Peptic Ulcer Disease & Gastritis 33.2 Dysphagia, Esophagitis & Acute Esophageal Disorders 33.3 Acute Nausea, Vomiting & Foodborne Illness

34 Chapter 34: Acute Lower Gastrointestinal Conditions

34.1 Acute Infectious Diarrhea & Gastroenteritis 34.2 Acute Constipation & Functional Bowel Changes 34.3 Ano-Rectal Disorders: Hemorrhoids, Fissures, Abscesses & Pruritus Ani

35 Chapter 35: Inflammatory, Functional & Malabsorptive GI Disorders

35.1 Acute Flares of Inflammatory Bowel Disease 35.2 Irritable Bowel Syndrome: Diagnosis, Subtyping & Management 35.3 Celiac Disease & Malabsorption Syndromes

36 Chapter 36: Acute Abdominal, Hepatic & Biliary Disorders

36.1 Ambulatory Abdominal & Pelvic Pain Triage 36.2 Acute Cholecystitis, Biliary Colic & Pancreatitis 36.3 Acute Liver Injury & Viral Hepatitis

37 Chapter 37: Acute Abdominal Wall, Hernias & Dental Conditions

37.1 Abdominal Wall, Inguinal & Ventral Hernias 37.2 Acute Dental Pain, Odontogenic Abscess & Aphthous Ulcers 37.3 Acute Edema: Unilateral vs. Bilateral Diagnostic Evaluation

38 Chapter 38: Acute Infectious Dermatoses

38.1 Bacterial Skin Infections: Impetigo, Cellulitis & Cutaneous Abscesses 38.2 Fungal Skin Infections: Tinea Corporis, Cruris, Pedis & Onychomycosis 38.3 Viral Cutaneous Infections: Herpes Simplex, Zoster & Molluscum Contagiosum

39 Chapter 39: Inflammatory, Allergic & Autoimmune Dermatoses

39.1 Atopic Dermatitis, Contact Dermatitis & Eczematous Flares 39.2 Non-Infectious Rashes: Urticaria, Drug Eruptions & Erythema Multiforme 39.3 Cutaneous Malignancies & Premalignant Lesions: AK, BCC, SCC & Melanoma

40 Chapter 40: Acute Shoulder, Elbow & Upper Extremity Injuries

40.1 Rotator Cuff Pathology, Tendinopathy & Shoulder Impingement 40.2 Lateral & Medial Epicondylitis, Olecranon Bursitis & Elbow Sprains 40.3 Wrist & Hand Soft-Tissue Injuries: De Quervain, TFCC & Finger Sprains

41 Chapter 41: Acute Knee, Ankle & Lower Extremity Injuries

41.1 Meniscal Tears, Ligamentous Knee Injuries & Patellofemoral Pain 41.2 Ankle Sprains, Ottawa Ankle Rules & Achilles Tendinopathy 41.3 Plantar Fasciitis, Shin Splints & Overuse Syndromes

42 Chapter 42: Acute Ambulatory Fractures & Dislocations

42.1 Distal Radius, Scaphoid & Common Upper Extremity Fractures 42.2 Metatarsal, Clavicle & Common Lower Extremity Fractures 42.3 Joint Dislocation Management: Nursemaid's Elbow & Shoulder Subluxation

43 Chapter 43: Acute Axial Musculoskeletal Pain & Falls

43.1 Acute Low Back Pain: Red Flags, Strain & Disc Herniation 43.2 Acute Cervical Strain, Whiplash & Axial Neck Pain 43.3 Evaluation of Falls in Ambulatory & Older Patients

44 Chapter 44: Acute Inflammatory Arthropathies & Generalized Pain

44.1 Acute Inflammatory Arthritis & Spondyloarthropathies 44.2 Myalgias, Rhabdomyolysis & Post-Viral Pain Syndromes 44.3 Acute Non-Headache Pain Management Strategies

45 Chapter 45: Acute Renal, Urinary & Genitourinary Conditions

45.1 Uncomplicated UTI, Pyelonephritis & Acute Urethritis 45.2 Hematuria Workup & Glomerulonephritis 45.3 Nephrolithiasis & Acute Urinary Tract Obstruction

46 Chapter 46: Acute Male Genitourinary & Prostatic Conditions

46.1 Acute Prostatitis, Epididymitis & Orchitis 46.2 Acute Scrotal Pain: Torsion vs Appendage, BPH & Male Genital Emergencies 46.3 Acute Urinary Retention & Incontinence Evaluation

47 Chapter 47: Acute Women's Health & Early Pregnancy Care

47.1 Early Pregnancy Diagnosis, Dating & Initial Complications 47.2 Abnormal Uterine Bleeding & Acute Menstrual Disorders 47.3 Premenstrual Syndrome & Premenstrual Dysphoric Disorder

48 Chapter 48: Breast Disorders, STIs & Pediatric Elimination

48.1 Palpable Breast Mass, Mastitis & Nipple Discharge 48.2 Sexually Transmitted Infections: Diagnosis, Staging & CDC Guidelines 48.3 Pediatric Enuresis & Encopresis

49 Chapter 49: Systemic Signs, Metabolic Dysregulation & Miscellaneous Infections

49.1 Acute Fever, Sepsis Screening & FUO in Primary Care 49.2 Acute Hyperglycemia & Symptomatic Hypoglycemia 49.3 Electrolyte Abnormalities: Mild-to-Moderate Disturbances 49.4 Vector-Borne, Tick-Borne & Rickettsial Illnesses

50 Chapter 50: Chronic Cardiovascular Diseases: Hypertension & Ischemia

50.1 Essential Hypertension Management: 2025 AHA/ACC Guideline & JNC Strategies 50.2 Chronic Coronary Artery Disease & Post-MI Secondary Prevention 50.3 Chronic Heart Failure: HFrEF, HFpEF & Quadruple GDMT

51 Chapter 51: Chronic Vascular, Valvular & Dyslipidemic Diseases

51.1 Peripheral Arterial Disease & Claudication 51.2 Chronic Valvular Heart Disease & Murmur Evaluation 51.3 Lipid Disorders & ASCVD Risk-Based Statin Therapy

52 Chapter 52: Chronic Respiratory Diseases: Asthma & COPD

52.1 Chronic Asthma Management: GINA Stepwise SMART Therapy 52.2 Chronic Obstructive Pulmonary Disease: GOLD Recommendations 52.3 Solitary Pulmonary Nodule Evaluation & Fleischner Society Criteria

53 Chapter 53: Chronic Metabolic Diseases: Diabetes Mellitus

53.1 Type 2 Diabetes Management: ADA Pharmacotherapy Algorithms 53.2 Type 1 Diabetes: Basal-Bolus Insulin, CGMs & Diabetic Complications 53.3 Diabetic Microvascular & Macrovascular Disease Surveillance

54 Chapter 54: Obesity, Nutrition & Metabolic Bone Diseases

54.1 Medical & Behavioral Management of Obesity & Incretin Mimetics 54.2 Osteoporosis & Metabolic Bone Disease: DEXA, FRAX & Antiresorptives 54.3 Nutritional Deficiencies: Vitamin D, B12, Iron & Malnutrition

55 Chapter 55: Chronic Endocrine Disorders

55.1 Primary & Subclinical Hypothyroidism, Hyperthyroidism & Nodules 55.2 Adrenal Disorders: Addison's Disease & Cushing's Syndrome 55.3 Hypercalcemia, Hyperparathyroidism & Pituitary Disorders

56 Chapter 56: Chronic Kidney Disease & Venous Disorders

56.1 Chronic Kidney Disease: KDIGO Staging & Renoprotective Therapy 56.2 Chronic Venous Insufficiency, Stasis Dermatitis & Lymphedema 56.3 Chronic Electrolyte & Acid-Base Management in CKD

57 Chapter 57: Chronic Gastrointestinal & Hepatic Diseases

57.1 Gastroesophageal Reflux Disease, Barrett's Esophagus & Dyspepsia 57.2 Chronic Liver Disease: MASLD/NAFLD, Cirrhosis & Portal Hypertension 57.3 Viral Hepatitis B & C: Long-Term Monitoring & DAA Therapy

58 Chapter 58: Colorectal Surveillance & Chronic Pancreaticobiliary Care

58.1 Post-Polypectomy Colorectal Polyp Surveillance Guidelines 58.2 Chronic Pancreatitis & Exocrine Pancreatic Insufficiency 58.3 Chronic Nausea, Gastroparesis & Functional GI Disorders

59 Chapter 59: Chronic Musculoskeletal & Rheumatologic Disorders

59.1 Osteoarthritis: Hip, Knee & Hand Management 59.2 Spinal Conditions: Spinal Stenosis, Spondylolisthesis & Compression Fractures 59.3 Chronic Myopathies & Fibromyalgia Syndrome

60 Chapter 60: Chronic Neurologic & Neurodegenerative Disorders

60.1 Dementia: Alzheimer's, Vascular & Lewy Body Disease 60.2 Parkinson's Disease & Essential Tremor 60.3 Epilepsy: Chronic Antiseizure Medications & Post-Stroke Care

61 Chapter 61: Chronic Peripheral Nerves, Pain & Sensory Disorders

61.1 Diabetic & Chronic Peripheral Neuropathies 61.2 Chronic Pain Syndromes & Chronic Daily Headaches 61.3 Chronic Tinnitus, Presbycusis & Persistent Dizziness

62 Chapter 62: Chronic Psychiatric Disorders

62.1 Major Depressive Disorder & Generalized Anxiety Disorder 62.2 Bipolar Disorder: Maintenance Pharmacotherapy & Lithium Monitoring 62.3 Adult & Pediatric Attention-Deficit/Hyperactivity Disorder

63 Chapter 63: Chronic Behavioral Health & Neurodevelopmental Conditions

63.1 Chronic Behavioral Conditions: PTSD, OCD & Somatization 63.2 Autism Spectrum Disorder & Intellectual Disabilities 63.3 Eating Disorders: Anorexia Nervosa, Bulimia & Binge Eating

64 Chapter 64: Chronic Substance Use Disorders & Tobacco Cessation

64.1 Alcohol Use Disorder: Pharmacotherapy & Relapse Prevention 64.2 Opioid & Stimulant Use Disorders: MOUD & Harm Reduction 64.3 Longitudinal Tobacco Cessation Pharmacotherapy

65 Chapter 65: Chronic Dermatologic Conditions

65.1 Acne Vulgaris, Rosacea & Seborrheic Dermatitis 65.2 Chronic Plaque Psoriasis & Biologic Therapies 65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

66 Chapter 66: Chronic Reproductive, Infectious & Geriatric Special Care

66.1 Chronic Menstrual Disorders, Infertility & Sexual Dysfunction 66.2 Menopause Management & Hormone Replacement Therapy 66.3 Chronic HIV Infection Management & Primary Care Integration 66.4 Gender-Affirming Primary Care & Hormone Therapy 66.5 Advance Care Planning, Palliative Care & End-of-Life Symptom Control

67 Chapter 67: Continuity Care: Sleep, Fatigue, Cancer, Pregnancy & the Adult Preventive Visit

67.1 Chronic Insomnia & Obstructive Sleep Apnea 67.2 Chronic Malaise, Fatigue & ME/CFS 67.3 Primary Care During Cancer Treatment & Survivorship 67.4 Routine Prenatal Care & Longitudinal Pregnancy Management 67.5 The Periodic Adult Health Examination & Medicare Annual Wellness Visit

65.3 Chronic Eczema, Hidradenitis Suppurativa & Cutaneous Lupus

Key Takeaways Explain This Topic AI

Chronic eczematous phenotypes display distinct clinical hallmarks: nummular eczema presents with coin-shaped itchy plaques on dry extremities; dyshidrotic eczema features deep-seated 'tapioca pudding' vesicles along finger margins; stasis dermatitis shows medial malleolar hemosiderin staining from venous hypertension (manage with compression when ABI >0.8); and lichen simplex chronicus manifests as circumscribed leathery plaques driven by repetitive rubbing.

Hidradenitis suppurativa (HS) is a chronic inflammatory follicular occlusion disease of intertriginous apocrine skin, clinically staged by the Hurley system: Stage I (isolated abscesses without sinus tracts/scars), Stage II (recurrent abscesses with sinus tracts and scarring), and Stage III (diffuse coalescent sinus tracts across entire regions).

Pathognomonic double-ended open comedones characterize HS; medical management ascends from topical clindamycin (Hurley I) to oral tetracyclines (Hurley II) and targeted biologic therapy with adalimumab or secukinumab (Hurley II refractory/Stage III), combined with tissue-sparing sinus tract de-roofing or wide surgical excision.

Cutaneous lupus erythematosus is classified into acute (malar rash sparing nasolabial folds; >90% systemic SLE association), subacute (anti-Ro/SSA-positive non-scarring annular/psoriasiform plaques), and chronic/discoid lupus (scarring violaceous plaques with follicular plugging ['carpet-tack' scale] causing cicatricial alopecia; 5–10% SLE risk).

First-line systemic disease-modifying therapy for all forms of cutaneous lupus is oral hydroxychloroquine (maximum dose ≤5.0 mg/kg actual body weight/day); mandatory baseline and annual retinal screening (visual fields and SD-OCT) after 5 years prevents irreversible bull's-eye retinopathy, and patients must be counseled that cigarette smoking reduces drug efficacy.

Last updated: September 2026

Chronic Eczematous Dermatoses: Phenotypic Distinctions & Management

Chronic eczema encompasses a spectrum of pruritic, inflammatory skin conditions sharing epidermal barrier dysfunction and immune hyperreactivity. While atopic dermatitis is the most prevalent pediatric form, four distinct chronic eczematous phenotypes frequently present in adult family medicine practice. DIFFERENTIAL MATRIX: CHRONIC ECZEMATOUS DERMATOSES

Disorder Clinical Morphology & Distribution Pathophysiology & Triggers First-Line Evidence-Based Therapies

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Nummular Eczema Sharply demarcated, coin-shaped ("nummular"), Epidermal lipid depletion, • Class 1–2 topical corticosteroids

(Discoid Eczema) intensely pruritic, 1–5 cm erythematous xerosis, low humidity (winter (Clobetasol 0.05% ointment)

scaly, crusted plaques; pretibial lower legs, months), harsh alkaline soaps; • Thick petrolatum-based emollients

dorsal hands, extensor upper extremities. KOH NEGATIVE (rules out tinea!). • "Soak and seal" bathing technique.

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Dyshidrotic Eczema Deep-seated, intensely pruritic, clear "tapioca Contact allergy (nickel, cobalt), • Ultra-potent topical corticosteroids

(Pompholyx) pudding-like" microvesicles along lateral excessive sweating (hyperhidrosis) (Clobetasol 0.05% under occlusion)

borders of fingers, palms, and soles; late- frequent wet work, psychological • Bland barrier repair ointments

stage desquamation and painful fissures. stress; NOT a sweat gland disorder!• Cotton glove liners under work gloves.

Stasis Dermatitis Golden-brown to brawny speckled pigmentation Chronic venous insufficiency, • Graduated compression therapy (20–30 mmHg;

(hemosiderin) over lower third of medial calf; ambulatory venous hypertension, MANDATORY ABI > 0.8 BEFORE WRAPPING!)

erythema, fine scaling, pruritus, pitting edema; extravasation of RBCs into dermis;• Leg elevation above heart levels

late "inverted champagne bottle" sclerosis. prone to secondary contact allergy.• Mid-to-high potency topical steroids.

Lichen Simplex Solitary, circumscribed, heavily thickened, THE INTRACTABLE "ITCH-SCRATCH • Super-potent topical steroids

Chronicus lichenified leathery plaque with accentuated CYCLE"; repetitive mechanical (Clobetasol ointment under occlusion)

(Neurodermatitis) skin markings and hyperpigmentation; posterior rubbing and scratching of a focal • Intralesional triamcinolone (5–10 mg/mL)

neck, ankles, wrists, anogenital region. pruritic trigger; neuropathic base.• Habit reversal training; hydroxyzine.

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Clinical Nuances of Adult Eczematous Variants

Nummular Eczema (Discoid Eczema) :

Predominantly affects older adults during cold, dry winter months ("winter itch"). Transepidermal water loss drives profound microfissuring and secondary cutaneous inflammation.

The Tinea Corporis Trap : Nummular plaques are frequently misdiagnosed as tinea corporis ("ringworm") because of their circular shape. However, nummular plaques are uniformly scaly and vesicular across their entire surface, whereas tinea corporis exhibits an active, advancing scaly border with central clearing. A negative potassium hydroxide (KOH) preparation definitively rules out tinea .

Management : High-potency topical corticosteroids (clobetasol 0.05% or betamethasone dipropionate 0.05% ointment) applied BID for 2 to 4 weeks. Emollient hydration using the "soak and seal" technique: the patient bathes in lukewarm water for 15 minutes, pats dry without rubbing, and immediately coats damp skin with thick petrolatum within 3 minutes.

Dyshidrotic Eczema (Pompholyx) :

Historical misnomer: it is not a disorder of sweat glands, though emotional stress and hyperhidrosis aggravate flares. Intensely pruritic vesicles reside deep within the thick stratum corneum of the palmar and plantar surfaces, giving the classic visual appearance of "tapioca pudding" embedded in the skin .

Chronic disease produces severe desquamation, painful bleeding fissures, and vulnerability to secondary bacterial infection ( Staphylococcus aureus ).

Management : Super-potent Class 1 topical corticosteroid ointments applied under occlusion (e.g., wearing white 100% cotton gloves overnight). Compresses with cold aluminum acetate (Burow's solution) for 15 minutes dry weeping acute vesicles.

Stasis Dermatitis & The Compression Mandate :

Driven by incompetence of the deep, superficial, or perforator venous valves in the lower extremities, causing sustained venous hypertension. Increased intravascular hydrostatic pressure forces erythrocytes through widened endothelial gaps into the interstitial dermis. Extravasated RBCs lyse, and macrophages break down hemoglobin into hemosiderin , generating the pathognomonic indelible reddish-brown or golden-brown pigmentation of the gaiter region.

Chronic untreated inflammation produces subcutaneous fat fibrosis: lipodermatosclerosis (woody induration tapering down the calf, producing an "inverted champagne bottle" or "bowling pin" deformity).

[!CRITICAL] Mandatory Pre-Compression Assessment: The Ankle-Brachial Index (ABI) Graduated compression therapy (20–30 mmHg or 30–40 mmHg stockings) is the undisputed cornerstone of stasis dermatitis management. However, compression is STRICTLY CONTRAINDICATED in the presence of severe peripheral artery disease . Physicians must check pedal pulses and calculate an Ankle-Brachial Index (ABI) before applying compression . If the ABI is < 0.5 <0.5 < 0.5 to 0.8 0.8 0.8 , compression can precipitate acute distal arterial ischemia and ischemic gangrene. Compression is completely safe only when ABI ≥ 0.8 \text{ABI} \ge 0.8 ABI ≥ 0.8 .

Contact Sensitization Alert : The skin in stasis dermatitis exhibits an extraordinary rate of allergic contact sensitization. Topical neomycin, bacitracin, lanolin, and fragrance-containing lotions must be strictly avoided , as they trigger severe secondary contact dermatitis in >50% of patients.

Lichen Simplex Chronicus (Neurodermatitis) :

Represents an end-stage reactive phenomenon: an intractable itch-scratch cycle . Repetitive mechanical rubbing and scratch trauma stimulate epidermal hyperplasia, hypergranulosis, and extensive orthohyperkeratosis, creating a raised, leathery, lichenified plaque with exaggerated skin markings.

The primary therapeutic objective is to physically break the itch-scratch cycle . Apply superpotent topical corticosteroids (clobetasol propionate 0.05% ointment) under an occlusive barrier (such as a hydrocolloid dressing or plastic wrap) that physically shields the skin from the patient's fingernails. For dense, recalcitrant plaques, intralesional triamcinolone acetonide (5 to 10 mg/mL) injected directly into the mid-dermis induces rapid flattening.

Hidradenitis Suppurativa (Acne Inversa): Staging & Escalation

Hidradenitis suppurativa (HS) is a chronic, recurrent, debilitating, destructive inflammatory disease of the terminal hair follicle in apocrine gland-bearing intertriginous anatomical zones. It carries an extraordinary psychological and physical burden, with profound pain, malodorous discharge, disfiguring contractures, and marked social isolation.

Pathophysiological Paradigm Shift

Historically mischaracterized as an infectious disorder of apocrine sweat glands, modern molecular dermatology has established that HS is primarily an auto-inflammatory disease of follicular occlusion :

Follicular Hyperkeratosis & Occlusion : Mechanical friction and nicotine-induced epidermal hyperkeratosis cause infundibular plugging of the terminal hair follicle in intertriginous skin.

Follicular Dilation & Rupture : Retained sebaceous and cellular contents cause massive follicular distension, culminating in rupture of the follicular basement membrane into the sterile deep dermis.

Massive Neutrophilic & Granulomatous Inflammation : Extruded keratin, bacteria, and lipid debris trigger Toll-like receptors, inflammasome activation (NLRP3), and an overwhelming release of pro-inflammatory cytokines: TNF-α, IL-1β, IL-17, and IL-12/23 .

Sinus Tract (Tunnel) Formation & Fibrosis : Repetitive inflammation prompts epithelial cells to proliferate downwards, forming epithelialized dermal tunnels ( sinus tracts ) that connect deep abscesses. Healing leads to extensive fibrotic scarring, tissue destruction, and dense keloidal bridging.

Anatomic Distribution & High-Yield Hallmarks

Sites : Axillae (most common), inguinal folds, perineum, perianal region, gluteal cleft, inframammary and intermammary creases, and inner thighs.

The Double-Ended Open Comedone : Also termed the "tombstone comedone" or bridge comedone. Comedones featuring two or more distinct communicating follicular orifices separated by a bridge of normal skin. This is the pathognomonic clinical sign of hidradenitis suppurativa .

Strong Clinical Associations :

Cigarette Smoking : Present in 80% to 90% of HS patients. Nicotine directly upregulates epidermal infundibular hyperkeratosis and fuels neutrophil chemotaxis. Smoking cessation is paramount.

Obesity & Metabolic Syndrome : Excess adipose tissue exacerbates mechanical shear forces, skin-on-skin friction, maceration, and chronic systemic hyperinsulinemia.

Depression & Suicide : HS carries the highest depression and suicide risk among all dermatologic conditions. THE HURLEY STAGING SYSTEM & STEPWISE MANAGEMENT FOR HS

Hurley Stage Clinical Criteria Evidence-Based Medical & Surgical Management

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Stage I Single or multiple isolated abscess formation; • Topical Clindamycin 1% lotion/gel BID for 12 weeks
NO sinus tract (tunnel) formation; • Oral Zinc Gluconate (90 mg daily) anti-inflammatory
NO cicatrization (scarring). • Antiseptic chlorhexidine 4% body washes

Intralesional triamcinolone (5–10 mg) for acute cysts.

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Stage II Recurrent, widely separated abscesses with • First-Line: Oral Doxycycline 100 mg BID for 10–12 weeks
evidence of sinus tract formation AND • Second-Line: Oral Clindamycin 300 mg BID PLUS
cicatricial scarring; isolated tracts. Oral Rifampin 300 mg BID combination for 10–12 weeks

Surgical de-roofing (unroofing) of isolated sinus tracts.

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Stage III Diffuse or near-diffuse involvement across an • TARGETED BIOLOGIC THERAPY:

entire anatomic region; multiple interconnected - Adalimumab (Humira) high-dose FDA regimen
sinus tracts and coalescent abscesses with - Secukinumab (Cosentyx) IL-17A inhibitor

extensive dense fibrotic scar networks. • Wide radical surgical excision down to deep fascia.

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Evidence-Based Escalation Protocol

Hurley Stage I : Initiated with topical clindamycin 1% solution or gel applied BID for 12 weeks . Add daily chlorhexidine 4% or benzoyl peroxide washes to suppress bacterial colonization. For acute, severely inflamed, painful nodules, administer intralesional triamcinolone acetonide (5 to 10 mg/mL) .

Hurley Stage II : Initiate systemic therapy with oral doxycycline 100 mg BID for 10 to 12 weeks . The primary therapeutic mechanism of doxycycline in HS is non-antibiotic anti-inflammatory: it inhibits matrix metalloproteinases and neutrophil migration. If disease is refractory to doxycycline, escalate to combination therapy: oral clindamycin 300 mg BID PLUS oral rifampin 300 mg BID for 10 to 12 weeks .

Hurley Stage III & Refractory Stage II: Targeted Biologics :

Adalimumab (Humira) : The first FDA-approved biologic for moderate-to-severe HS. Requires a substantially higher dosage than rheumatoid arthritis: Loading dose of 160 mg subQ at Week 0, 80 mg at Week 2, then 40 mg weekly (or 80 mg every other week) maintenance .

Secukinumab (Cosentyx) : Fully human anti-IL-17A monoclonal antibody, FDA-approved for moderate-to-severe HS. Dosed at 300 mg subQ weekly at Weeks 0, 1, 2, 3, and 4, followed by 300 mg every 4 weeks maintenance.

Surgical Interventions: Rules & Paradigms

Important

The Incision & Drainage (I&D) Fallacy Routine Incision and Drainage (I&D) of unruptured, inflammatory HS nodules should be avoided whenever possible . I&D does not address the underlying follicular pathology; it carries a recurrence rate approaching 100% within weeks , accelerates the development of chronic sinus tracts, and promotes severe fibrotic scarring. I&D should be reserved strictly as an emergency palliative measure to relieve agonizing fluid tension in large, fluctuant, pointing abscesses.

Sinus Tract De-Roofing (Unroofing) : A highly effective, tissue-sparing surgical technique performed under local anesthesia. The roof of the epithelialized sinus tract is blunt-dissected or excised using electrosurgery, the tract floor is scraped clean with a dermal curette, and the wound is left open to heal by secondary intention . Preserves surrounding healthy tissue with an exceptionally low localized recurrence rate (<10%).

Wide Radical Surgical Excision : In advanced Hurley Stage III disease with diffuse coalescent tunnels, complete surgical resection of all hair-bearing skin and subcutaneous tissue down to the deep muscular fascia is required, followed by healing by secondary intention or split-thickness skin grafting.

Cutaneous Lupus Erythematosus (CLE): Subtypes, Diagnosis & Therapeutics

Cutaneous lupus erythematosus encompasses a spectrum of autoimmune dermatoses categorized into acute, subacute, and chronic subtypes based on clinical morphology, histopathology, serological profile, and risk of systemic lupus erythematosus (SLE). CLASSIFICATION OF CUTANEOUS LUPUS ERYTHEMATOSUS

Subtype Clinical Morphology & Distribution Systemic SLE Risk & Autoantibodies Prognosis & Scarring

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Acute Cutaneous Lupus Malar / "Butterfly" rash: confluent erythema > 90% associated with active SLE; Non-scarring;

Erythematosus (ACLE) over nasal bridge and bilateral malar cheeks, Flares mirror systemic lupus flares; resolves without scarring;

CHARACTERISTICALLY SPARING NASOLABIAL FOLDS. ANA, anti-dsDNA, anti-Smith, low C3/C4 post-inflammatory dyschromia.

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Subacute Cutaneous Non-scarring photosensitive eruption on sun- ~50% meet criteria for mild SLE; Non-scarring;

Lupus (SCLE) exposed upper back, chest, shoulders, extensor STRONGLY ANTI-Ro/SSA POSITIVE (>80%); resolves with temporary

arms; annular/polycyclic OR papulosquamous. High rate of DRUG-INDUCED SCLE! vitiligo-like leukoderma.

Chronic Cutaneous Lupus Indurated, disk-shaped violaceous plaques LOW RISK OF SYSTEMIC SLE (only 5–10%);PERMANENT ATROPHIC

(Discoid Lupus / DLE) with adherent follicular scale, carpet-tack sign;ANA negative or low in > 60%; SCARRING; follicular

heals with central depigmentation and atrophy. Localized to head, scalp, ears, face. destruction, ALOPECIA.

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Clinical Nuances of Lupus Subtypes

Acute Cutaneous Lupus (ACLE) :

The Classic Malar ("Butterfly") Rash : Symmetrical erythema and edema spanning the bridge of the nose and the malar convexities of both cheeks. The high-yield diagnostic hallmark is strict sparing of the nasolabial folds (the skin folds between the nose and lips), distinguishing ACLE from rosacea and seborrheic dermatitis, both of which prominently involve the nasolabial folds.

ACLE is a direct cutaneous marker of active systemic lupus erythematosus (>90% correlation); flares parallel systemic multi-organ disease (especially lupus nephritis).

Subacute Cutaneous Lupus (SCLE) :

Presents as an intensely photosensitive, non-scarring eruption distributed across the sun-exposed upper torso ("V-neck" chest, upper back, shoulders, and extensor arms), typically sparing the central face.

Two clinical variants: 1) Annular/Polycyclic : ring-like erythematous plaques with central clearing and delicate peripheral scale; and 2) Papulosquamous/Psoriasiform : scaly red plaques that mimic psoriasis (distinguished by photodistribution and absence of thick silvery micaceous scale).

Serological Hallmark : Strongly associated with circulating anti-Ro/SSA antibodies (>80%) and anti-La/SSB antibodies .

Important

Drug-Induced SCLE SCLE has the highest incidence of drug induction among all cutaneous lupus forms. Major offending pharmacological triggers include:

Antifungals : Terbinafine (most common!)
Cardiovascular : Hydrochlorothiazide, Calcium channel blockers (diltiazem)
Gastrointestinal : Proton pump inhibitors (omeprazole, pantoprazole)
Biologics : TNF-alpha inhibitors

Drug-induced SCLE presents with anti-Ro/SSA antibodies and resolves completely within weeks to months following discontinuation of the culprit medication.

Discoid Lupus Erythematosus (DLE / CCLE) :

The most common subtype of chronic cutaneous lupus. Manifests as discrete, indurated, coin-shaped (discoid) violaceous plaques with adherent hyperkeratotic scale.

The "Carpet-Tack" Sign (Cat's Tongue Sign) : When the thick, adherent hyperkeratotic scale is mechanically peeled from an active discoid plaque, sharp, horn-like keratotic spicules are revealed on its undersurface, resembling carpet tacks. These spicules represent casts of keratin extending deep into dilated follicular infundibula.

Evolution & Cicatricial Alopecia : As active inflammation subsides, DLE plaques heal with permanent, irreversible central atrophy, porcelain-white depigmentation, telangiectasias, and hyperpigmented indurated borders. When DLE occurs on the scalp, it destroys hair follicle stem cells, resulting in permanent scarring (cicatricial) alopecia with complete loss of follicular ostia.

Diagnostic Evaluation: Biopsy & The Lupus Band Test

Punch Biopsy : A 4-mm punch biopsy from the active, indurated inflammatory border of a lesion establishes the diagnosis:

Interface Dermatitis : Vacuolar degeneration and liquefaction of the basal cell layer with necrotic, apoptotic keratinocytes ( Civatte bodies ).

Dense superficial and deep perivascular and periadnexal lymphocytic infiltrate.

Thickening of the epidermal basement membrane zone and substantial dermal mucin deposition (revealed by Alcian blue staining).

Direct Immunofluorescence (DIF / The Lupus Band Test) :

In lesional skin, direct immunofluorescence reveals a continuous, bright, granular band of immunoglobulin G (IgG) , IgM, and complement C3 deposited along the dermoepidermal junction.

High-Yield Concept : In pure discoid lupus, the Lupus Band Test is positive only in lesional skin . In systemic lupus erythematosus (SLE), the Lupus Band Test is frequently positive in both lesional and sun-protected, clinically normal, non-lesional skin .

Comprehensive Management of Cutaneous Lupus

Strict Broad-Spectrum Photoprotection : Ultraviolet radiation (UVA and UVB) triggers keratinocyte apoptosis, autoantigen translocation to the cell surface, and immune flare. Patients must practice rigorous photoprotection: daily application of broad-spectrum physical sunscreens ( SPF ≥50 containing zinc oxide or titanium dioxide ) reapplied every 2 hours, UV-protective clothing, wide-brimmed hats, and UV-filtering films on car and home windows.

Topical & Intralesional Therapies :

High-to-Superpotent Topical Corticosteroids : Clobetasol propionate 0.05% ointment is first-line for thick, hyperkeratotic discoid plaques on the scalp, ears, and trunk.

Topical Calcineurin Inhibitors : Tacrolimus 0.1% ointment or pimecrolimus 1% cream are preferred for facial lesions to prevent corticosteroid-induced skin atrophy, perioral dermatitis, and telangiectasias.

Intralesional Corticosteroids : Triamcinolone acetonide (5 to 10 mg/mL) injected directly into active, hyperkeratotic scalp or facial plaques halts scar progression.

First-Line Systemic Therapy: Hydroxychloroquine (HCQ) :

Antimalarial agent; accumulates within intracellular lysosomes, raises pH, suppresses Toll-like receptor (TLR-7, TLR-9) signaling, and inhibits antigen presentation. Highly effective across all forms of CLE.

Dosing Rule : Administered at 200 to 400 mg orally daily. Maximum daily dose must not exceed 5.0 mg/kg of ACTUAL body weight per day (American Academy of Ophthalmology [AAO] safety guideline to prevent retinal toxicity; dosing based on ideal body weight overdoses thin individuals).

Therapeutic Latency : Hydroxychloroquine requires 8 to 12 weeks of continuous therapy to reach steady-state tissue levels and demonstrate clinical efficacy. Patients must be counseled not to discontinue the drug prematurely.

Mandatory Retinal Screening Protocol (AAO Guidelines) :

Baseline Screen : Comprehensive dilated retinal examination within the first year of starting HCQ, including automated visual field testing (Humphrey Visual Field 10-2) and high-resolution Spectral-Domain Optical Coherence Tomography (SD-OCT) .

Annual Screening : Initiated after 5 years of continuous therapy in patients without risk factors (or annually from baseline if high-risk: dose >5.0 mg/kg actual weight, renal impairment [eGFR <60 mL/min], concurrent tamoxifen use, or pre-existing macular disease).

Pathology : HCQ binds melanin within the retinal pigment epithelium. Unmonitored toxicity produces irreversible, blinding "bull's-eye" maculopathy (concentric ring of pigment atrophy surrounding the fovea). SD-OCT detects subclinical parafoveal photoreceptor thinning ("flying saucer sign") before irreversible visual field loss occurs.

The Smoking Interaction Pearl : Cigarette smoking dramatically reduces the therapeutic efficacy of hydroxychloroquine by accelerating hepatic drug metabolism and altering lysosomal trapping. Smoking cessation is essential for clinical response.