The Derm Resident: Boards Fodder and Clinical Pearls for Dermatology Residents
High yield dermatology boards fodder and clinical pearls for derm residents, by derm residents.
The Derm Resident: Boards Fodder and Clinical Pearls for Dermatology Residents
Ep 1: Intro to Dermatology | Framework and Morphology
Use Left/Right to seek, Home/End to jump to start or end. Hold shift to jump forward or backward.
Dermatology Morphology Basics: Building Differentials & Primary vs Secondary Lesions | The Derm Resident
Hosts Dr. Jonny Hatch and Dr. Deven Curtis introduce The Derm Resident and outline the podcast’s goal of reviewing dermatologic diseases by pathogenesis, clinical features, workup, and management to help with clinic and boards. They discuss an approach to building differentials using a “tree” framework (neoplastic vs inflammatory, then infectious vs noninfectious) and emphasize that morphology is the core language of dermatology, sometimes outweighing patient history. The episode reviews key primary lesions—macule vs patch, papule vs plaque, nodules, wheals, vesicles vs bullae, and pustules—and explains why precise word choice matters. They then cover secondary changes including scale vs crust, fissures, excoriations, erosions vs ulcerations, atrophy, and lichenification, and end by stressing the importance of palpation in lesion assessment.
00:00 Welcome to the Podcast
00:52 How to Build a Differential
02:38 Disease Buckets and Pathogenesis
05:56 Morphology Is King
08:43 Primary Lesions Basics
11:54 Nodules and Wheals
14:49 Blisters and Pustules
19:52 Secondary Lesions Explained
21:06 Scale vs Crust and Micaceous
24:10 Breaks in the Skin
27:46 Atrophy and Lichenification
30:10 Palpation Pearls
32:17 Wrap Up and Next Episode
Welcome to the Derm Resident, high-yield dermatology by residents for residents. I'm your host, Dr. Johnny Hyatch. And every episode I sit down with my co-host, fellow resident, and former OCEM partner, Dr. Devin Curtis, a PGY2 resident. And we're excited to go through with you the basic concepts and clinical pearls that every Durm resident needs to know to be successful, both in the boards and in the clinic. We're so excited to have you join us today. And welcome, Devin, to the show. Excited to be doing this with you.
SPEAKER_01Thank you. Good morning, Johnny.
SPEAKER_00Glad to be here. Yeah, good morning. It's early. We're recording this bright and early because we both have clinic and things to do. We have families that we go to home to at night. So it's early in the morning for us, but we're excited to do this. And really, it's a great opportunity for us to learn right along there with you and to ask the stupid questions to each other so you don't have to ask those stupid questions to your attending. So hopefully it's a little bit helpful in that way. Um, but really what this podcast is about is we want to go through every disease, and it's gonna take a long time. But every disease, talk about the pathogenesis, the clinical features, the uh workup, the management, and then so you can be successful, as I said, both in the clinic and on the boards eventually. But really to start off, we need the foundation. We need to know the terminology that's used in dermatology to help build that foundation to help us throughout the rest of this this uh podcast. So, with that Dr. Curtis, Devin, you are a PGY1 resident. It's currently July when we're recording this episode. And one of the hard parts of being a first year resident is building a differential. When you walk into a patient room and you're trying to build a differential, how do you approach that patient? Do you have any buckets or um thought processes thought processes that you go through as you're trying to build a differential for a patient?
SPEAKER_01Yeah, so yeah, just for the benefit of our listeners, I yeah, I just finished my intern year in internal medicine and and I'm starting, I'm on like week three of dermatology residency. So I'm very much in the thick of it and just learning these things for the first time. I do like the bucket. There's different approaches, I think, to categorizing diseases and and so you're not memorizing thousands of rashes, but you're thinking in a reasonable way, um, in ways that basically work down an algorithm and give you a uh an intelligent differential for any given thing. Um, but yeah, I'm I honestly don't have a good concept yet for what all those buckets are. So I'm wondering, you know, maybe I can return that to you. What what what buckets do you usually use, Johnny?
SPEAKER_00Yeah, yeah. So it really depends. And that's the beautiful thing about dermatology, is there's a lot of different algorithms you can take, right? Um one way I like to frame diseases in my mind is around the pathogenesis. Where do these, how are these diseases formed, right? There's a great chart in Bologna, and I believe it's from an outside paper that they reference, but it uses a tree analogy. And essentially you have a trunk, and each branch of the tree puts you further and further and down to the leaves, and the leaves are individual diseases. So the first branch point would be inflammatory versus non-inflammatory. And the non-inflammatory things are like those neoplastic things. And if we remember from medical school, neoplasia is essentially abnormal growth of cells, right? And you have benign neoplasia and you have malignant neoplasia. So benign neoplasia would be like a mole, right? You have this proliferation of melanocytes that creates a mole. But a malignant neoplasia would be something like melanoma, where you have a malignant increase in neoplasia of melanocytes. So that's the first branch point, neoplassic versus inflammatory. And then on the inflammatory route, you have non-infectious and infectious. And so if we think about something, right? If we think about a rash, you walk into a rash and you see somebody with these thin plaques to patches that are uh xerotic, maybe excoriated. That could be a lot of things, right? On the neoplastic route, it could be something like mycosis fungoides. On the uh inflammatory route, it could be something like atopic dermatitis. On the infectious route, it could be something like empetigo or uh empathygohepatophor uh uh eczema herpeticum, right? All these things may have a similar morphology, but the etiology, the pathogenesis is much different. And that's kind of that framework, that tree analogy of thinking about okay, inflammatory, neoplastic, infectious, those sort of things. So a lot of different ways to think about things, but that's one helpful way to think about diseases when you're in the clinic.
SPEAKER_01So, Johnny, then is it fair to say that like if I was to apply this framework, I walk in, my patient has uh a new spot of concern, and I'm not sure if it's a rash or I'm not sure, I'm not sure what it is. Um, and the moment I see it, I start categorizing. I'm saying, okay, is this neoplastic or is this inflammatory? And by by choosing one of those two branches, I've eliminated, you know, dozens of diseases that I don't super have to consider at this time. Um is that kind of how you're you're suggesting we approach this?
SPEAKER_00So eventually. So at first, it's helpful to not cut off any tree branches right away, right? At first, when you go into a room, you want to have a broad differential, right? When you see a lesion, let's say it's a solitary lesion, usually that means neoplasia, right? Because if it's inflammatory, it's gonna be more of multiple re lesions forming a rash, right? Yeah, you can say, okay, this is definitely neoplastic, and then you can cross out anything that's infectious or inflammatory.
SPEAKER_01Okay, that's helpful. Thanks for explaining that.
SPEAKER_00Yeah, yeah, yeah. So we want to dive into the next part of our episode where we talk about morphological terms. Morphology is pretty much our framework for describing lesions, it's our dictionary, it's the language of dermatology. Um Devin, you are an expert in English. Tell us what morphology means.
SPEAKER_01Yeah, so morphology means the study of form. So you think like I used to read the what those goofy little books that I'd read is like a middle schooler, um, the metamorph series or whatever. Oh, anamorphs. Yeah, animorphs. There you go. Thanks. So so morph uh means form, and anything that's ology is obviously the study of. And so, yeah, I mean, I've I've learned through my derma rotations as a med student and coming up in residency that that they always say the classic line is morphology is king, right? Like that you do if you're gonna hang your hat on any of the findings, hang it on morphology just because it's it's reliable, it's consistent, um, and it's what we've used in dermatology for you know hundreds of years because we didn't used to be able to take pictures. You had to literally describe in a very um set lexicon what you're seeing so that someone else could picture that. You have to paint that picture in their mind. Um, yeah, so morphology is king.
SPEAKER_00Yeah, yeah. And I've run into that trap myself where I listen to a patient give a pro tell their story and I place more emphasis on their history, but I ignore the morphology, and that can be very dangerous because patients want some sort of explanation for their disease, but they don't have the background that we have in terms of medical training. They're very intelligent, you know, our patients are incredible, but sometimes you need to separate the history from what you're seeing morphologically, and then sometimes, you know, you you need to consider both. I had a friend recently reach out to me about a rash on his legs, and he's like, Yeah, I haven't really been around any bugs or anything, but they were excoriated papules just isolated to the lower legs, which are uncovered when he goes outside, nowhere else on his body, and like you know, it still looks like bug bites, even though you're saying nobody else in your family has bug bites, even though you say you got you know you you didn't see any mosquitoes around, it still looks like bug bites. That's what fits. Um, so sometimes you have to ignore some of that patient history. So morphology is key. So when it comes to dermatology, you can think about okay, papillosquamous, lycanoid, but what does that even mean? What do those turns even mean? The very basics is we have to understand the language of dermatology. And some of this we may have learned in medical school, but I think it's a great time to refresh. And so I wanted to dive into these more precise morphological terms. And the first one is macule versus a patch. Devin, can you tell us what is a macula? What is a patch?
SPEAKER_01Yeah, yeah. So I think that these the primary lesions is what I've been taught, should be what you hang everything on. There's primary change and secondary change. The primary lesion is what the actual um issue is, and you have to be able to see through that. Uh uh in the terms of the nouns of what the actual lesion is. The macul is a flat uh area that you would not be, I think they define it as if you close your eyes, you can't tell where it starts or ends if you run your finger across it, and that's what makes it a macule. And if it's a macule, it's under one centimeter in diameter. Whereas if it was two or three or more, then you would call that a patch. Uh but it's defined as not being able to detect any raised elevation, texture, anything that way.
SPEAKER_00Excellent. Yeah, so some classic examples of a macul or a patch. A macul would be like a solar lentigo. Oftentimes, these sunspots are hyperpigmented macules, very small on the face, somebody with a lot of sun damage, whereas a patch would be more so something like vitiligo, where you have extensive patches of depigmentation over the body or melasma as well. There's a lot of examples of patches. So excellent. And that can help us build a differential in our mind. And I like what you said about focusing on the primary lesion. Oftentimes, if somebody's very itchy, they'll have a lot of scratching, excoriation, some lycentification, and we'll get to those terms in the future, but that can confuse the primary morphology. But if you can slow down, like you say, and look through the secondary changes to the primary lesion, that will help you a lot in determining which bucket to pull from, which bucket to go search deeper into when you're thinking about differentials. Okay, what about a papule versus a plaque?
SPEAKER_01Yeah, so I think it follows the exact same logic. Um this the size cutoff is the same, so it's a one-centimeter lesion. Um smaller than one centimeter would be a papu, larger would be a plaque. The difference between these and the macules and patches is that the lesions are either elevated or palpable in some way.
SPEAKER_00Yeah, yeah, exactly. Do you have any examples of what a papu or a plaque, what uh diseases might fall into those categories?
SPEAKER_01Yeah, so I I don't want to say maybe even most, most of the things I think we see in clinic. I think I see papilles and plaques more often than I see um macules and patches, but I mean everything from um psoriasis, which which will have like the large inflamed, uh kind of silvery scaly plaques, um actinok keratoses, basal cells, a lot of the neoplastic things come up as papules or plaques. So there's there's a lot in that category.
SPEAKER_00Yeah, okay. So nodule. The term nodule, sometimes when I think about a nodule, it's just like a big papule, but they're a little bit different. Can you what experience do you have with nodules? How do you differentiate nodules from papules?
SPEAKER_01Yeah, usually nodules feel more dermal, meaning they're underneath um the epidermis. And so um yesterday I had a patient who had a long incision on his leg from compartment syndrome, actually, a year a year ago. And he has these deep nodules along the long axis of that lesion, and they're mobile and firm. And the nodules, I guess, don't have to be firm, um, but they're they involve more of the dermis and the subcutus rather than just the epidermis, compared to a papule, which is usually an epidermal, uh more superficial change.
SPEAKER_00Excellent, excellent. Totally agree. Oftentimes I think about epidermoid cysts, lipomas as being these subcutaneous subcutaneous mobile nodules. They don't always have to be nodules. Sometimes, occasionally, you'll get like a metastasis that will have dermal and epidermal involvement, um, but they will have a large portion of it with that subcutaneous component. And so one of the beautiful things about dermatology is it's like an art. You know, not everything has an exact definition. Sometimes you'll present to your attending and you'll say, you know, a large papule, almost more like a subcutaneous nodule, and you'll throw both in there so that they get an idea of where on the spectrum we're talking, and they'll understand that because they've seen it before and understand that there is this spectrum that we're talking about, right? It's not exact buckets either. So okay, next primary lesion is a wheel. What is a wheel?
SPEAKER_01Yeah, I think I think a wheel is I think the definition is dermal edema, and it's basically when you have I think it's usually histamine-mediated urticaria, um, where you'll get fluid that goes into the dermis, raises up, usually really itchy. Um, I honestly, if you were just to look at a single lesion, it can almost look a little bit like tinnia. It's it's a little bit uh elevated red border, a little bit of a central clearing. Uh, but I think that the diagnostic key, when you say wheel, it really can't be much else. Uh, at least in my experience, I don't know if yours is different, other than urticaria, because there's not much that comes and goes um and is itchy within a matter of hours.
SPEAKER_00Yes, yes, pretty much. When most people, when we think of wheels, we think urticaria, and it's pretty classic. Sometimes there can be some confusion if it looks like a wheel but is actually not a wheel. But I love it. I think that's excellent. The next one is vesicle or ebola. What's the difference between a vesicle and a bulla, bulla? And uh tell us a little bit about those.
SPEAKER_01Yeah, so vesicles are they're both blisters, right? Before coming to dermatology, my word for both of those things was blisters, small blisters and big blisters. So a vesicle is underneath, it's lower, smaller, sorry, than a centimeter, whereas a bulla is larger than a centimeter. And a single bulla is B-U-L-L-A, um, but but plural, if you have multiple bulla, as in something like a pemphagoid disorder, then it's B-U-L-L-A-E. So bull A would be plural.
SPEAKER_00Okay, so you are actually you have a master's degree in English, right?
SPEAKER_01Well, I have an I have a bachelor's degree in English and half of a master's degree in English, because I quit my master's program to go to medical school because I figured out I couldn't do both. But I did I did start a master's degree in English. Um, got about halfway through.
SPEAKER_00So so you know the difference. So, okay, so how do I say bola and bullet? Bola is the singular form and bole is the plural form.
SPEAKER_01Yeah, yeah, exactly.
SPEAKER_00Okay, we need you on here to correct us on all our pronunciation errors.
SPEAKER_01Don't make me the grammar police. That's that's never a fun job.
SPEAKER_00Yeah, but hey, it's better to have a grammar police here on the podcast than to get grammar policed by a supervising physician while you're staffing.
SPEAKER_01So I'll I'll speak up, I'll speak up where I feel like it's relevant then. I also am still learning a lot of these things, but uh well, excellent.
SPEAKER_00Okay, so you have a blister. Now what if that blister is filled with pus?
SPEAKER_01Yeah, it becomes a it becomes so I think that's the key differentiation because we use vesicle and bulla um if they're clear, the fluid inside them is clear. Um, but if that blister is filled with pus, like a yellow pussy substance, then we call it a pushule.
SPEAKER_00Excellent, excellent. I had a attending once, I described a lesion as being pussy, and he said, How would you spell that? And I said, Oh, okay. So that's a huge thing. When you're describing these lesions, they are purulent, they're filled with purulent fluid, and uh, that'll save you from embarrassment later on. Um one thing that I got caught up on as a first-year resident that I also see early learners get caught up on is whenever they see like a white papule, they're really quick to call it a pustule. But not all white papilles are filled with pus. Sometimes they're more like a hyperkeritotic papule or just a firm white papu or a skin-colored papu. And so you need to be very careful and just very attentive when you examine lesions. What truly is the morphology here? Is it a hyperkeritotic papule? Is it a white papu? Is it a skin-colored papule? Is it an umbilicated papu? Or is it truly a pustule? Because all of those things matter and they change your differential. A hyperkeritotic papule, you may think something like keratosis pylaris. A white papule, you may think something like lyconiditus. Whereas a pustule, you may think something more of like a folliculitis. And so these things are very important to really pay attention to when you're examining a patient. And it's what makes the difference between an average dermatologist and a great dermatologist.
SPEAKER_01Yeah, Johnny, and I just on that note, um, I have to say we we play a game in our clinical images probably once, maybe twice a week here in our early morning sessions, where we'll have the senior residents sit with their back facing the projector screen. And then us first years are on the front row, and we have to picture pops up, senior can't see it, we can, and then it'll be my job. You take turns, my job to describe what's what's on the screen, you know. And then the senior has to generate their differential diagnosis based only on the descriptors that I give. And I have to say that like choose your word choice matters tremendously because historically dermatology existed for hundreds of years without pictures. So it was entirely verbal, right? Morphology is king for that reason. And so um, the descriptors, if I choose to use the word wheel rather than uh elevate it with like an arythematous plaque with the central clearing, like that totally changes what my senior is gonna say. And uh like with your attending, if you say pustules when it's actually vesicles, your attending's mind is gonna go down a different uh algorithm than if you had used the more general descriptor. So I I do agree that sometimes we're too quick and we use words that um have connotations we don't mean to uh use. So that I love that.
SPEAKER_00I want I want to start doing that game in our residency program. It sounds like a blast.
SPEAKER_01It's it's fun.
SPEAKER_00Very informative too, I think, for everybody involved. Yeah, so okay, so we talked about primary lesion. You touched a little bit about what a secondary lesion is. Can you explain a little bit more? Okay, what exactly is a secondary lesion, and then we'll get dive into the different secondary, uh, the different secondary lesions that are important.
SPEAKER_01Yeah, so so what counts as a secondary lesion um usually reflects like the either outside environment or the passage of time. So like scale or crust is never a primary lesion. That's always a secondary change. The only there's only a few primary lesions. I don't remember how many we went over, like eight or ten. Um, and that's that's really the the skeleton of the diagnosis, and everything else hangs on that. So so the plaque or the papule is the main thing, and the scale, the crust, the erosion, the lichenification, all of that is secondary change. And sometimes it's hard. I mean, I still I'm trying to figure out how to see through secondary change to make sure I've got the primary lesion. Um that's still a challenge.
SPEAKER_00Excellent. Okay, so a lot of a lot of secondary changes that we can discuss, and we're gonna try and not talk about as many of them as we can. The first two that I want to discuss are crust and scale. And these can look similar. Tell us a little bit about crust and scale, what they look like, how they're different, how they're the same.
SPEAKER_01Yeah, so so both are material on top of a lesion, right? So crust is is usually like a dried serous fluid or blood or purulence pus, uh, whereas scale is thought of as secondary, but it usually is the keratinocytes themselves flaking off or uh some kind of a hypercarototic epidermalytic process where you're you're shedding those cells.
SPEAKER_00Excellent, excellent. I agree. So, crust, you get some sort of exudate coming out of the skin, whether that's blood, pus, or fluid, and then it dries out and leaves crust and then. Scale, you get this hyperkeratosis where essentially when you look underneath the microscope, and we haven't gotten to this point yet, but on histology, you'll see increase in the stratum corneum, right? That is the scale, is an increase in the stratum corneum. In histology, this could be orthokeratosis or perikeratosis, depending on the condition, but it's increase in the stratum cornea. Um, usually not like a compact orthokerosis, but um that that's excellent. So some classic examples we think about with scale are psoriasis, where it gives that silvery or quote micaceous scale. Um now, Dr. Curtis, Devin, you were talking to me earlier about entomology and how much you love entomology. Do you know where the word micaceous comes from?
SPEAKER_01I will after a quick Google. You know, I think that's uh I've never I've never looked up the etymology of micaceous but oh, it's from Micah. Okay, so like I don't know if you've ever seen this, but Micah is uh is a mineral. My dad's a rock hound, and my dad's entire house is filled with shelves and shelves of rocks. He just loves them.
SPEAKER_00What?
SPEAKER_01Um and Micah, yeah. So Micah is a uh it's like a flaky. I wish I could show a picture of it, but I just looked one up. You can look up like the mica, the mineral, and it's it's like a rock, it's kind of shiny, and then the scales almost or the the rock almost flakes off like uh gypsum, if you've ever played with gypsum crystals or anything like that. But it the Latin word it comes from crumb or grain, um, and it says that it was a 1700s term used to describe the mineral because it flakes off. So micaceous would would mean that you're just shedding the top layer and scales.
unknownCool.
SPEAKER_00No, I'm looking at a picture right now, and it actually looks like psoriasis is like these layers of silvery rock stacked on top of each other. And I mean, it's honestly a great description for psoriasis, is micaceous scale. So cool. Okay, talked about scale. We talked about crust. Next is fissuring, excoriation, erosion, ulceration. All of these are similar, but they're actually different and they can help us when we're building a differential. Can you talk to us about the difference between a fissure, an excoriation, erosion, and an ulceration?
SPEAKER_01Yeah, so fissures, I would just call these cracks originally because my my parents who have very dry hands would always develop these deep, like cracks in the in the folds of their hands and their skin, and they would bleed and they were super painful. So I think that fissure is just a linear crack um kind of down in the skin. So we'd never call it a crack, we'd call it a fissure. It almost looks like a cut, but it's opened up just because of the dry skin um or the disease process. Um, whereas the uh like an excoriation, so I don't know. This is this is one of those contended terms because I was taught on several of my rotations never to use an excoriation because it assumes something about the origin of the lesion. An excoriation to excoriate is to scratch, right? So it assumes that what I'm looking at is because of scratching and not some other process. Um at my current residency where I'm at, they there's no such um warnings on the word excoriation. We use it all the time. So, but yeah, excoriation is like, you know, when you you scratch your arm and you kind of get this this uh linear erythematous, uh what would I call it? Uh maybe a plaque or um after your after scaly linear patch. Yeah, exactly. Exactly. Um and erosion is is you know almost like where it's the center of a lesion. Um has like we look think about this with like a basal cell or like scary nodular melanomas, um, or some of the other uh like the pemphigoid, where you'll get the vesicle that goes away and it leaves a small indentation, a small area where the skin is is missing or or is flaking off. Um and then ulceration, I it in my understanding is just a deeper erosion. It's where you lose more of the epidermis and you extend down into the dermis or subcutus. And, you know, I think we all understand what ulcers are, but that's kind of the idea.
SPEAKER_00Exactly. No, and it's funny because so you're exactly right. So erosion is loss of the skin, partial loss through parts of the epidermis. If it goes through the epidermis to the dermis or subcutus, that is an ulceration. So erosion, just loss of the epi, and then, or just loss of partial epi, ulceration is full loss of the epi, some of the dermis, or even into the subcutus. So that's how you differentiate the two. If you think about pemphigous uh foliceous or like empetygo, impetygo is a good example of um erosion, or sometimes you'll have erosions in things like basal cell carcinoma. I think that's a great one also to think about. Whereas ulcers, if you think about a venous ulcer, arterial ulcer, pyoderma gangrinosa, much deeper. So I think that's excellent. Now, I I have to ask a follow-up question. What did they want you to say if you saw something that looked excoriated? What were you supposed to say on those other rotations?
SPEAKER_01You were just supposed to describe the the primary morphology, right? So, like, and I can't even remember what what rotation it was, but I remember getting my hand slapped for using excoriation. I was like, oh, okay, I won't I won't use that word. That's funny.
SPEAKER_00That's really funny. Okay, so we talked a little bit. Um we talked a little bit about fissuring excoriation erosions and ulcers. Another one is atrophy. Sometimes you can get atrophy of the skin. I think this one's fairly self-explanatory. When you look at something that's atrophied, you'll often see like this tissue paper appearance, or it'll be a little wrinkled and shiny in appearance. Um, depending on where the atrophy is, if it's more epidermal or if it's more dermal, that atrophy may be more thick and you may actually get like a depression of the skin. And another one I wanted to touch on is lycenification. Can you tell us what the term lycenification means?
SPEAKER_01Yeah, so lichenification, I think it's a secondary term that refers to chronic thickening due to like I mean, generally, like the classic is that you'll you'll get prorigo or itchiness or whatever, and then you'll scratch a certain spot, and then the the body's response to that is to increase the proliferation of the keratinocytes, to increase the stratum corneum, to protect against the friction, and then you'll get this lycenified, and it looks almost like like cracked lake bed, right? Like dried riverbed. Um, you'll get an accentuation of the normal skin lines. Um, so yeah, that's lycinification.
SPEAKER_00Yeah. For me, the classic example is somebody with really bad atopic dermatitis who's constantly rubbing. I see patients like this all the time, especially on the hands or the anticubital fossa. And yes, exactly the accentuation of normal skin lines. So it's almost like their normal skin lines are intact, but they're just thicker and more robust. And you're exactly right. So um the one clarifying thing I will say is you can have increase of the stratum corneum on dermos uh on histology. You'll also have acanthosis. And acanthosis, so hyperkeratosis is when you have increase in the stratum corneum, and then acanthosis is when you have increased thickness of the whole epidermis. And so those two things are a little bit different and appear a little bit different on your clinical exam. A hyperkeratosis will present more as like a scale or like a callus, and then acanthosis will present more as a thickened plaque, or in this case, like an effecation. So um anyway. Let's see. So the next thing we want to talk about is palpation, the importance of palpating. This to me is also fairly self-explanatory, but also very important. How often are you palpating your patients?
SPEAKER_01I'm I mean, I don't feel like I can say my exam is done unless I've touched whatever the lesion of concern is. And I just think it's natural. And I watch my attendings do the same thing. The spot of concern comes up, you pull out the dramatoscope, you get a good light, you get in close, and then you run a finger over it. You're trying to tell, is it tender? Because that tells you something. If it's tender, is it blanchable? Um, is it rough? Is it smooth? Is it if it's a nodule? Is it fixed? Is it mobile? Um, you know, even even the temperature, right? You think about like Raynaud or something like that, or an active infection. If it's hot to touch, it's like, wow, you know, touching really helped.
SPEAKER_00Yes, for sure, for sure. I see some of my older attendings, maybe that's not not the best way to say it, but they'll when they're examining a neoplastic lesion, like a lesion of concern, are they trying to determine, okay, is this squamous cell? Is this just an ISK? Oftentimes they'll feel for induration and how deep the lesion goes, because uh separate keratosis will often be fairly epidermal, but if you have a squamous cell carcinoma, it can often extend and invade as well as can be more tender. So all those things can be important to feel. And so I love the palpation portion. Do you use gloves or not gloves, Dr. Curtis? The most important question.
SPEAKER_01Probably 80% of the time I don't use gloves, um, unless I get a little uh spider sense that says, hey, put some gloves on.
SPEAKER_00I'm the same way. I'm I'm a hand sanitizer on my way in, hand sanitizer on my way out. I'll use gloves depending on the area of the body I am examining or my suspicion, my spidey sense. I love it. The spidey sense. Excellent. Thank you for joining us on this episode of the Derm Resident. We're super excited to have you. Please share this episode with a friend or fellow resident who could use it. And until next time, we'll see you next week.