Core c u r r i c u l u m II

IIII

I

III

I

II

II

II

Core curriculum for dermatology*

This Committee seeks to help organize and improve the high quality of the educational offerings of the American Academy of Dermatology. We also seek to improve the knowledge, skills, attitudes, competence, and performance of practicing dermatologists. Of course, the overriding purpose of both types of efforts is to improve the quality of care given to patients who seek the help of dermatologists. The Committee has sought to develop a core curriculum that is practical. The Committee was also concerned that those matters of knowledge, skills (both interpersonal and technical), and attitudes which we might list in our curriculum should strive always to be related as much as possible to clinical judgment (problem-solving) and not just rote memory. The Council on Educational Affairs of the Academy has stated, "The ultimate goal of the educational program is the maintenance and advancement of knowledge, skills, and attitudes in medical practice that pertain to dermatology and related disciplines." John Gardner has said, "The ultimate goal of the educational system is to shift to the learner the burden of pursuing his own education." We feel these statements embody a satisfactory charge and philosophy, and so the curriculum we here suggest is meant to be helpful to individual learners, as well as to those who have educational responsibility within the Academy. The Committee engaged in its work through correspondence and meetings. Our most difficult chal-

Fig. 1. The illusion of a core common to all possible curricular descriptions.

*Richard M. Caplan, M.D., Chairman, Iowa City, IA; Richard S. Greene, M.D., Plantation, FL; Robert E. Kellum, M.D., Seattle, WA; Herbert Mescon, M.D., Boston, MA; lames A. Philpott, Jr., M.D., Aspen, CO; David L. Ramsay, M.D., New York, NY; Seymour I. Shapiro, M.D., Tucson, AZ; Harry L. Wechsler, M.D., McKeesport, PA; and Dennis A. Weigand, M.D., Oklahoma City. OK.

lenge lay in agreeing on matters of classification and emphasis. Then we wished to become more specific but made no attempt to spell out highly detailed instructional objectives. That kind of "fleshing out" of the curriculum must be left to individual teachers who, depending on time, resources available to them, and their own sense of what is important at the time, will in turn spell out the particulars for any segment of instruction. One might think there surely must be some central commonality in a cluster of interlocking circles, such as shown in Fig. 1. We have come to the conclusion that this is a naive expectation. Just as our Committee struggled and finally realized that we can develop something and call it a core, any other committee, or even this committee at a different time, would produce something different and call that the core. We perhaps should not call it the core but a core curriculum among many potentially describable core curricula. What really matters is whether that which we call a core curriculum provides a usefid framework for educational planning by the Academy, the American Board of Dermatology, training programs, or individual dermatologists.

0190.9622/79/020173 + 24502.40/0 © 1979Am Acad Dermatol

173

174

Core curriculum

The Committee accepted certain premises: 1. Our curriculum should be practical and be judged suitable for practitioners of dermatology. 2. With only rare exception our learners are satisfactorily competent at the end of their residency. 3. Ambulatory practice, so characteristic of most dermatologic work, tends to foster isolation from the thought and advances of dermatology and of medicine in general. 4. With time, a practitioner tends to grow more embroiled with common problems and become less competent in dealing with the less frequent or more serious problems. 5. Instances of inappropriate care or behavior on the part of any physician are less often due to a knowledge defect than to some other confounding factor(s). 6. The practicing dermatologist should be knowledgeable about the total gamut of skin diseases but should give more emphasis in planning his or her continuing education to the more commonly encountered dermatoses. Similarly, educational providers should center relatively more effort on the more common problems, on those with greater morbidity, mortality, or cost to the patient and society, and on those in which effective intervention is available. (That does not mean that rare and otherwise esoteric matters should not be considered, but we want to emphasize the practical.) 7. Those practitioners whose individual activities produce an unusual practice profile would be expected to seek special educational activity to correspond to that special profile (for example, surgery, radiation therapy, histopathologic consuiting service, etc.). 8. The practitioner should know how to app r o a c h problems and be able to engage effectively in problem-solving. There is good reason to try to have a core curriculum " b a s e d on the demonstrated educational needs of the clinician." That idea is theoretically an excellent one. It is impossible, however, to have genuine demonstration of educational needs without test scores (both those of the American Board of Dermatology and the Academy's selfassessment examination), practice audits, colleague descriptions of "critical incidents," etc., and none of these are presently available. Therefore, the curriculum will have to be based upon expert and peer opinion about wants and "felt n e e d s " rather than "demonstrated n e e d s . "

Journal of the American Academy of Dermatology

What is a core curriculum? It is essential to explore this question because only with a clear notion of what a core curriculum is and is not can there be any satisfaction or progress made in its development or use. One definition may be that the core is "the minimum knowledge required by a physician to practice competently in his own practice setting." Such a definition implies clearly that there will be many different core curricula, perhaps one for each specialty or each setting, and maybe even a core curriculum which is unique to each practitioner. Such a notion seems to vitiate the very idea that there are commonalities appropriately generalizable to all. A core is somewhat like the pot of gold at the end of the rainbow. We speak at times as if it were a tangible reality, but we know it is not. It is a will-o'-the-wisp. Any good textbook can be thought of as a core curriculum, or at least its table of contents can, and, of course, every table of contents is different from all others. Perhaps a core curriculum is simply one of m a n y possible ways to organize one's study effort in a systemic and weighted fashion in behalf of maximum effectiveness (regarding retention, understanding, and clinical skills, and a minimum of gaps among the important elements). This view emphasizes curriculum more as a process and less as a statement of content. Another approach to " t h e core" outlines three levels or tiers of knowledge. One is a basic package of knowledge and skills to be had by all physic i a n s - f o r example, cardiopulmonary resuscitation, control of hemorrhage, aid for patients having seizures, the methods to channel patients in the health care system, etc. The next tier deals with the knowledge needed to practice within one's general field--for example, dermatology. The final tier is a subspecialized tier which, in the case of dermatology, would include such special skills and interests as electron microscopy, dermatopathology, pediatric dermatology, dermatologic surgery, dermatologic radiotherapy, etc. It may be useful to think of distinct tiers; yet these " t i e r s " are interrelated, and attempts to separate them produce artificialities. No matter what curricular proposal is suggested, our Committee recognizes that it will not be viewed as satisfactory, adequate, appropriate, or realistic by all practitioners, academicians, or interested third parties. Instead, what we propose is one attempt at assisting us all toward interesting

Volume 1 Number 2 August, 1979

and relevant continuing education. Both the framework and the details will doubtless be changed as time and new personnel continue to strive for improved and timely guides to practitioner competence. In spite of the disclaimers just stated about the concept of a "core curriculum," we nonetheless faced the question of what to put into our core curriculum. Our method used rounds of correspondence plus discussion to attain consensus among a panel that we hope was appropriately expert and suitable by virtue of their kind of work, range of age, and geographical distribution. We approached our work by looking at: various kinds of objectives and activities of teaching programs; the American Board of Dermatology's syllabus that outlines the preparation appropriate to certification; textbook contents; Academy programs, and so on. The curriculum that we developed is included as Appendices I to III. In Appendix I the reader will find diseases or groups of diseases which extend down the vertical axis of the matrix. The headings were chosen mainly from the classification scheme used in the 1975 textbook Dermatology by Moschella, Pillsbury, and Hurley. This was an arbitrary choice on the part of our Committee, who recognized that any classification scheme would inevitably be less than optimal. This particular one has the advantages of being recent, widely available, and having categories enough to provide for distinctions, yet not so many categories as to be overpowering. The reader may feel consoled to know that some Committee members wished our classification scheme collapsed to perhaps ten categories, while others favored expansion because our present categories caused the lumping together of entities they felt should be separated. The Committee members rated all categories with a single plus, two pluses, or three pluses, and these weights were then averaged in the manner used for computing academic grade point averages. The numerical value of the consensus ("Committee Emphasis") is found beside the name of the category. The variables extending along the horizontal axis were considered the most important among possible options, and also sufficiently encompassing. Our sense of the relative importance of each of these variables is shown by one, two, or three plus marks at the top of the column given to that variable. All of the cells of the matrix were then considered individually. When the Committee thought

Core curriculum

175

a cell deserved more or less emphasis than the general expression of emphasis shown at the top of that column, we indicated our feeling b y an arrow pointing upward ("this item needs more emphasis than shown at the top") or an arrow pointing downward ("this item needs less emphasis than shown at the top"). Although we finally compromised on a two-plus emphasis for histopathology, for example, we recognize that those individuals who read their own slides probably need maximum emphasis, while those who do not will need less. In order to prevent Appendix I from seeming overwhelming, we attached an abbreviation of it as Appendix II. It eliminates those categories from the horizontal axis of Appendix I that have only a one-plus rating. It eliminates categories from the vertical axis of Appendix I that achieved less than 2.25 in "committee emphasis," and it has rearranged those remaining in order,of decreasing emphasis. Appendix III consists of the thirty-seven segments of Appendix I that deal with areas of cognitive knowledge and skill, each segment "fleshed out" with more detailed description. These thirtyseven segments were prepared by many different individuals. Because the Committee wished to have diversity of participation and to call generally upon expert resource persons, we accepted the resultant diversity of approach and the varied levels of abstraction. The panel of resource persons were all given the same information about what we were seeking and the intended shape of the final product. The resultant variations are themselves a fascinating array of responses that demonstrate again how unique rather than universal are notions of core curriculum. The Committee considered each of the thirty-seven submitted segments and made relatively small substantive or editorial changes but has, in general, tried to accept the material provided by our invited resource persons. To each of the individuals serving as the primary generator of a curriculum segment (identified on the appropriate page of Appendix II1), the Committee expresses its great appreciation. Skills are best learned by performing them under supervision--not by reading, listening to lectures, or other passive experiences. Likewise, evaluation of skills and their attainment should be accomplished through active assessment of the learner performing the skill. This requires a great deal of individualizing (especially in surgery, for example)

176

Core curriculum

and must be proportioned to the amount of it which the individual does. Attitudes are exceedingly important, and our Committee gave great emphasis to all of the listed aspects of attitudes. We recognize, however, that w e are not likely to be able to specify much or teach much to practitioners in regard to attitudes. A development of suitable attitudes requires a great deal of proper example (modeling), small group opportunities, much time, and early access to the learner, because attitudes tend to be formed early in life or career and generally grow increasingly difficult to change as time goes by. The following comments are meant to help the reader understand the perspective of the Committee, and to answer some questions we anticipate. 1. The " O t h e r Areas of Curriculum" in Appendix I are to receive special emphasis, or perhaps permit a special approach, or are listed just to be sure that the topic is dealt with. 2. The number of pluses on the horizontal axis of Appendices I and II does not mean "spend your study time in this proportion," but, rather, is a general, not precise, indication of the Committee's feeling for the topic's importance in relation to patient care. An individual may already know a great deal about an item that is marked with three pluses and, therefore, m a y not need to give any extra study to it at all. 3. The Committee chose not to try to establish a curriculum according to the type of practice one has. Rather, our curriculum is meant to be basic enough to expect all who call themselves dermatologists to work to achieve a level of mastery (which will have to be determined further by those engaged in what is technically termed "evaluation"). 4. The Committee does not feel that the curriculum should be related to the age of the practitioner. 5. This core curriculum may be used operationally by individuals, by the American Academy of Dermatology in its educational planning, and as a guide to the American Board of Dermatology as they plan both certification and recertification. Individuals can use this curriculum as a guide for personal learning and needs-diagnosis. It will further aid the individual practitioner in that the educational offerings by the Academy may become improved. The curriculum may be a guide in developing program activity by the Academy (both for its annual program and new types of program

Journal of the American Academy of Dermatology

effort it is likely to undertake) and also in the assistance it will provide the American Board of Dermatology about matters of recertification. 6. The core curriculum that we offer is meant to be a guide, not a piece of legislation. Therefore, those who implement it (leaders and teachers of the Academy) and the learners (practitioners) may in their activities manifest either great or little relationship to what we present. This curriculum leads the Committee to make certain recommendations to the Academy: 1. Consider the publication of a precis or some kind of annual or at least regularly appearing book or audiovisual item which is developed in concert with our curriculum to help with the process of regular educational refurbishing. The new JOURNAL could perhaps serve this role. 2. The Academy might publish a disease-of-themonth or a category-of-the-month topic which provides for specific updating. The monthly or bimonthly or trimonthly offering should be not so much a newly prepared summary of information like a textbook chapter or a review article but, rather, an updated, annotated bibliography guiding the reader to brief articles, passages, patient management problems, home study courses, and so on that would seem to correspond to the emphases shown in that table of specifications we call our curriculum. Particularly good articles might be summarized or reprinted. Quiz items should be incorporated, with answers that include a pertinent reference. Any further self-assessment examinations of the Academy could be developed as small segments to be published periodically. Choice of topic should be guided by this curriculum. 3. The Academy should designate certain presentations or segments of the annual (or regional) meeting(s) as being related to this core curriculum. The Academy will still need to offer a great many options at each meeting. If individuals wished, however, to take or attend all of those items identified by the Academy as "core items" (core curriculum refresher), they should find themselves cycled through the entire curriculum approximately every six years. Also, those portions of the Academy program identified as core might perhaps be presented at regional meetings. The core material which will make up a part of each Academy meeting warrants special planning that emphasizes the evaluation o f learning, whereas those planning the remainder of the annual smorgasbord might not

Volume 1 Number 2 August, 1979

Core curriculum

feel pressured as much to focus on evaluation and demonstrated attainment of the objectives. 4. The practitioner needs to be kept abreast of leading developments in all other fields of medicine. During residency training the task is usually accomplished by journal clubs and guest speakers at home, regional meetings, or Academy meetings. For the practitioner a careful synopsis of such developments would be useful. The Academy could see to the selection of material and include it as an item at the Academy or in its new JOURNAL.

(4) evaluating the learning. Needs identification may include the opinion obtained from a committee such as this, questionnaires, self-assessment quizzes, American Board of Dermatology examinations, health care data involving frequency, morbidity, and cost, etc. The educational objectives should be spelled out in detail by those chosen to implement the learning activities. That would most usually be the Council on the Annual Program, the Home Study Program Committee, and those chosen to organize and conduct the various courses, symposia, and so on. The evaluation of learning can be undertaken by the Evaluation Committee but, preferably, in collaboration with those who select the instructional objectives and plart the learning strategies.

The total educational planning of the Academy should involve the major areas of: (I) needs identification, (2) setting of educational obJectives, (3) implementing the educational effort, and

Appendix I

Areas of curriculum (knowledge) by disease or disease groups

Disorders of immunity, hypersensitivity, and inflammation (includes urticaria) Contact dermatitis (excluding industrial) Atopic dermatitis Other eczemas Photosensitivity (drug and contact mainly--not metabolic) Drug eruptions Hypersensitivity and erythemas Psoriasis Other papulosquamous disorders Bullous disease Bacterial infections Viral infections Rickettsial infections

177

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178

Journal of the American Academy of Dermatology

Core cttrriculum

Appendix I. Cont'd

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Connective tissue diseases Diseases of corium and subcutaneous tissue Hereditary cutaneous diseases-concepts Disorders of cornification Disturbances of pigmentation Acne and acneiform dermatoses Apocrine gland disorders; not tumors Eccrine gland disorders; not tumors Disorders of the hair Disorders of the nails Diseases of nutrition and metabolism Tumors of the skin Lymphomas of the skin Reactions to physical agents Industrial dermatoses

2.25

t

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Volume 1 Number 2 August, 1979

Core curriculum

179

Appendix I. Cont'd

Committee emphasis

Other areas of curriculum

Understanding statistics and scientific reasoning in the dermatologic literature Core material, summarizing other disciplines, that seems pertinent to dermatology Practice management Medicolegal Medical politics Immunofluorescence Surgery Ionizing radiologic therapy Ultraviolet therapy Pharmacotherapy (including drugdrug interactions)

2.38 2.00 2.38 2.50 2.50 1.88 2.25 1.50 1,88 2.88

I Committee Other areas of curriculum

emphasis

Laboratory assistance in diagnosis/Pv Dermatopathology Allergy-immunology Dermadromes Cosmetic problems "Attitude" Interest Enthusiasm Seeks own continuing education Seeks colleague contact Concern for cost control Concern for preventing problems Concern for patient as "whole person" Medical emergencies

1.88 2.38 2.25 2.50 1.75

3.00 3,00 3.00 2.88 2.88 2.88 3.00 3.00

A p p e n d i x II +++

+

+

++

+

!

!

+

¢1

Management +++

+++ k~

Areas of curriculum (knowledge) by disease or disease groups

Contact dermatitis (excluding industrial) Atopic dermatitis Other papulosquamous Viral infections Acne and acneiform eruptions Tumors of the skin Hypersensitivity and erythemas Photosensitivity (drug and contact mainly--not metabolism) Superficial mycotic infections Disorders of immunity, hypersensitivity, and inflammation (includes urticaria)

Committee emphasis

3,00 3.00 3.00 3.00 3.00 3.00 2.75

2.63 2,63 2.63 continued

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Journal of the American Academy of Dermatology

Core c t w r i c u l u m

Appendix I I . C o n t ' d +q-

+

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Areas of curriculum (knowledge) I Committee by disease or disease groups emphasis Psoriasis Connective tissue disease Lymphomas of the skin Medical emergencies "Attitude" Interest Enthusiasm Seeks own continuing education Concern for patient as "whole person" Seeks colleague contact Concern for cost control Concern for preventing problems Pharmacotherapy (including drug-drug interactions Medicolegal Medical politics Dermadromes Dermatopathology Practice management Understanding statistics and scientific reasoning in the dermatologic literature Surgery Allergy-immunology

o-

E

2,38 2.25 2.25 3.00 3.00 3.00 3.00 3.00 2.88 2.88 2.88 2.88 2.50 2.50 2,50 2.38 2.38

2.38 2.25 2.25

APPENDIX IlI Disorders of immunity, hypersensitivity, inflammation (includes urticaria) Richard M. Caplan, M.D. Iowa City, 1.4 I. Recent information about the immune system A. B and T cells B. Immunoglobulins C. Cell-mediated immune mechanisms

and

D. Immune deficiency disorders 1. Congenital and acquired hypogammaglobulinemia 2. Wiskott-Aldrich syndrome 3. Mucocutaneous candidiasis 4. Chronic granulomatous disease of children 5. Ch6diak-Higashi syndrome E. The complement system F. Chemical mediators (cyclic adenosine monophosphate (AMP); prostaglandins

Volume 1 Number 2 August, 1979

II. Nature of anaphylaxis III. Urticaria and angioedema A. B. C. D. E. F. G.

Allergic Contact Physical Secondary Cholinergic Hereditary Idiopathic

C o n t a c t dermatitis (excluding industrial) William P. Jordan, Jr., M.D., and Seymour I. Shapiro, M.D. Richmond, VA, and Tucson, AZ l. Distinctions between primary irritant and aUergic contact dermatitis. 2. Review of immunologic basis for allergic contact reactions. 3. Clinical appearance and distribution patterns of contact dermatitis. 4. Association with other disorders and ways of distinguishing from them (atopic dermatitis, superficial infection, photocontact, phototoxic, etc.). 5. Hazards of therapeutic contact dermatitis. 6. Patch testing--indications, methods, interpretation. 7. Phenomenon of cross-sensitization. 8. Avoidance of causative and related antigens in therapy. 9. Nonspecific therapy. 10. Role of patient education in care and future prevention. A t o p i c dermatitis Jon M. Hanifin, M.D. Portland, OR 1. Diagnosis of atopic dermatitis (AD) depends upon appreciation of a constellation of features. There is no primary lesion and no specific histopathology. A firm diagnosis would be difficult without (a) pruritus; (b) typical distribution (facial and extensor in infancy, flexural in childhood and adults); (c) chronic or chronically relapsing course. 2. White dermographism and delayed blanch to cholinergic agents are probably not specific for AD. 3. Problems with cutaneous herpes simplex, vaccinia, wart, and molluscum contagiosum infections and high incidence of irritant hand dermatitis are all seen in patients with AD. 4. Understand the role of AD in contributing to chronic dermatitis, especially of hands and feet. 5. Distinguish AD from its mimics. 6. AD is not caused by delayed hypersensitivity (type IV) reactions, and most evidence indicates that delayed cutaneous hypersensitivity has a reduced incidence in patients with AD.

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181

7. Most evidence indicates that IgE does not have a pathogenic role in atopic dermatitis. 8. Over 90% of AD patients are colonized with pathogenic Staphylococcus aureus, and superficia/ Staphylococcus pustulations are probably more common than previously realized. 9. Leukocyte function abnormalities, including depressed lymphocyte transformation, decreased neutrophil and monocyte chemotaxis, and decreased T cell rosettes, have been clearly demonstrated in AD. However, these defects appear to be transient and correlate directly with clinical severity. 10. The various immunologic defects in AD could be based on disordered cellular regulation and control mechanisms such as defective cyclic nucleotide metabolism. 11. While environmental allergens may occasionally cause pruritus and urticaria in patients with AD, such antigens exacerbate the disease in only a small percentage of cases. 12. There is no good evidence that hyposensitization therapy is useful in AD. 13. Know the broadly appropriate and inappropriate treatment suitable for acute, subacute, or chronic dermatitis. 14. Appreciate the great importance of educating the patient (and family) in how to live with this chronic disorder. 15. AD has strong familial associations, but inheritance patterns have not been clarified; a polygenic pattern seems most likely. Other eczemas Richard M. Caplan, M.D, Iowa City, IA 1. Definition as a pruritic'symptom complex. 2. Clinical features: Erythema, swelling, vesiculation/ oozing, crusting and scaling, excoriation, hyperpigmentation, thickening, and lichenification. 3. Microscopic features. 4. Understanding of phenomenon of autoeczematization in all forms of eczema. 5. Recognition of nonspecific aspects of care: Freedom from mechanical and chemical irritation; symptomatic relief via soaks, bland Vehicles, topical steroids, occlusion, tar, light; relief of emotional tension. 6. Importance of effective patient education. 7. Recognition of clinical patterns and pathophysiologic factors of unique importance to several common eczemas: a. Seborrheic dermatitis: Special care appropriate to management of scalp, external ears, and ear canals. b. Nummular dermatitis: Recognition of such important background factors as atopy, asteatosis, and cutaneous or focal bacterial infection.

182

Journal of the American Academy of Dermatology

Core curriculum

c. Lichen simplex chronicus: Relation to psychologic factors; clinical variations such as prurigo and "old-old" disease. d. Stasis dermatitis: Role of mechanical and hemodynamic factors; role for special aspects of care such as surgery, Unna type boots, diuretics, elastic stocking counterpressure, prevention of sensitization. e. Chronic nonspecific eczematous dermatitis. f. Infectious eczematoid dermatitis. g. Infantile eczema: Special considerations of contact, atopic, seborrheic, infectious, and exfoliative varieties, as well as the particular association with Various hereditary/metabolic disorders (e.g., Wiskott-Aldrich syndrome, phenylketonuria). h. Dermatitis of hands and feet. Special varieties: Dyshidrotic eczema, fungal infection, psoriasis, acrodermatitis continua (dermatitis repens), chronic pustular dermatosis of hands and feet. i. Anogenital pruritus: Importance of seeking a specific cause; role of multiple factors operating in most cases, requiring multiple aspects of care for optimum result. j. Eczema hiemalis (predisposition by xerosis; prevention).

Photosensitivity (drug and contact mainlymnot metabolic) John H. Epstein, M.D. San Francisco, CA

I. Photosensitivity to exogenous chemicals (topical) + + + A. Clinical characteristics I. Distribution 2. Character of lesions (phototoxic vs photoallergic) + + + B. History 1. Contactants 2. Systemic agents (drugs) + + C. Histology (phototoxic vs photoallergic) 1. H & E 2. Immunofluorescence 3. Electron microscopy + + D. Differential diagnosis 1, Contact dermatitis 2. Loss or lack of protection 3. Other photosensitive diseases a. Polymorphous light eruption (most important), the porphyrias, lupus erythematOSUS, etc. + + + E. Mechanisms 1. Absorption and action spectrum 2. Photosensitivity a. Phototoxic: Photodynamic and nonphotodynamic b. Photoallergic: Immediate or delayed F. Other laboratory procedures + + + 1. Photopatch tests (contact photoallergy)

±

2. Phototests (differential diagnosis, i.e., with polymorphic light eruption (PMLE), systemic photosensitizers) 3. Light sources and filters a. UVA, UVB, visible (sun is best) ++ 4. Porphyrias, test for lupus erythematosus antinuclear antibodies (ANA) good for screening 5. Lymphocyte stimulation and migration inhibition factor (MIF) procedures G. Management i. Pharmacology +++ a. Discontinue association with photosensitizer b. Problem of persistent light reactor + c. Medication (1) Acute (a) Topical anti-inflammatory (b) Systemic anti-inflammatory (c) Sun protection (2) Chronic (persistent light reactor) (a) Anti-inflammatory (b) Education as noted (c) Sun protection H. Prognosis 1. Good except for persistent light reactors + I. New advances 1. Types of reactions 2. Mechanisms of reactions 3. New photosensitizers 4. New testing methods and light sources II. Photosensitivity to exogenous chemicals (systemic) III. Photosensitivity to endogenous origin (e.g., porphyrias, lupus erythematosus, PMLE, xeroderma pigmentosum) Drug eruptions Seymour I. Shapiro, M.D. Tucson, AZ

1. Multiform cutaneous manifestations of drug eruptions. 2. Associated drug reactions in other organs, e.g., drug fever, laryngeal edema, etc. 3. Techniques in eliciting a complete drug history. 4. Exposure to occult drugs in food products and personal care products. 5. Characteristics of allergic (vs nonallergic) drug reactions. 6. Unreliability of skin tests in suspected drug allergies. 7. Cross-sensitization in diagnosis and therapy. 8. Exacerbation of eczematous contact dermatitis by systemic exposure to the same or related antigen. 9. Ubiquity of certain drugs in the environment, e.g., salicylates, the para-aminophenyl group.

Volume 1 Number 2 August, 1979

Core curricuhlm

(especially adults where the care should be like the care provided in burn units); usually avoid corticosteroids in children

10. Educating the patient with a drug eruption to avoid exposure to known or suspected drug allergens.

Hypersensitivity and erythemas Richard M. Caplan, M.D. Iowa City, 1,4

This is a miscellaneous group of disorders that are usually relatively easy to diagnose but often difficult to understand or to elucidate a cause, and sometimes present extremely challenging problems of management. I. Simple erythemas A. Recognize possible relation to fever, blushing, physical factors, mastocytosis, carcinoid syndrome, drug reactions, collagen vascular diseases, infectious illnesses, etc. ti. Erythema ab igne A. Recognize clinical features, cause, benignity, and inadequacy of therapy III. Erythema multiforme and erythema nodosum A. B. C. D. E.

A symptom complex, not a disease Multiplicity of triggering circumstances Clinical features Microscopic features Differential diagnosis (include reasonable laboratory tests) F. Treatment G. Course IV. Figurate and fixed erythemas (erythema annulare centrifugum, erythema marginatum, erythema dyschromicum perstans, erythema chronicum migrans, erythema gyratum, and erythema perstans) A. Only occasional success in identifying a cause B. Clinical and microscopic features that permit diagnosis C. Approaches to treatment (relatively unsuccessful) V. Erythema neonatorum toxicum A. Identification of it via clinical features and smear of pus B. Knowledge of its benignity and noncontagiousness C. Acceptance that passage of time is the only necessary treatment VI. Toxic epidermal necrolysis A. Clinical and microscopic features that permit diagnosis B. Distinction of childhood variety related to an exfoliative staphylococcal toxin, and adult variety usually related to a drug reaction C. Importance of antibiotics in childhood variety and very good supportive care in all patients

183

VII. Reiter's syndrome A. Clinical and microscopic features that permit diagnosis B. State of our knowledge of it as a consequence of venm:eal infection C. Relationship to HL-A status D. Aspects of treatment

' VIII. Beh~et's syndrome A. B. C. D.

Features that permit diagnosis Relationship to involvement of other organs Inadequacy of present treatment Treatment, course, and prognosis

IX. Relapsing polychondritis A. Clinical features that permit diagnosis B. Important hazards and complications of the illness C. Symptomatic management

Psoriasis Robert Auerbach, M.D. New York, N Y

1. Typical and atypical forms, differential, and the occasional need to biopsy. 2. Genetics and epidermal kinetics. 3. Characteristic histopathology related to characteristic clinical forms. 4. Most patients can be treated with conventional topical methods; the role of topical steroids, including their possible side effects. 5. The skillful and intelligent use of UVB and tar at home. This can be combined with anthralin, judicious intralesional steroids, and topical steroids to selected areas. 6. Necessity for patient instructions and education. 7. Knowing when and how to use systemic methods, e.g., methotrexate and PUVA; how to avoid their use in maintenance. 8. Looking upon psoriasis as a chronic disease which can be cleared, and clearing maintained with the least toxic approach. 9. Indications for hospitalization.

Other papulosquamous disorders Richard M. Caplan, M.D. Iowa City, IA

I. Pityriasis rosea A. Clinical appearance and a few common variations B. Major differential diagnosis (psoriasis, syphilis, drug eruption, seborrheic dermatitis, fungal infection, parapsoriasis)

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Journal of the American Academy of Dermatology

C o r e cttrriculum

C. Need to keep therapy minimal, safe, and inexpensive II. Pityriasis rubra pilaris A. The few clinical and microscopic features that help distinguish it from its look-alikes B. The knowledge of familial and sporadic instances C. The role of oral vitamin A therapy, and various symptomatic topical measures Ill. Lichen planus A. Knowledge of usual clinical features and uncommon presentations (hypertrophic, atrophic, annular, bullous, Graham Little, etc.) B. Microscopic appearance C. Knowledge of drugs and other chemicals that can produce a picture simulating LP D. Awareness of hazard that chronic hypertrophic and oral LP may produce cancer and therefore these patients need more careful following E. Acquaintance with the great range of useful and useless treatments IV. Lichen nitidus A. Clinical and microscopic features that permit diagnosis V. Parapsoriasis A. Acute vasculitic parapsoriasis (Mucha-Habermann syndrome) 1. Clinical and microscopic features that permit diagnosis 2. Approaches to treatment 3. Knowledge of highly variable but benign course and prognosis B. Guttate parapsoriasis (pityriasis lichenoides chronica) 1. Clinical and microscopic features that permit diagnosis 2. Approaches to treatment, and their discouraging ineffectiveness 3. Knowledge of chronic course and uncertain but benign outcome C. Parapsoriasis en plaques 1. Clinical and microscopic features that permit diagnosis 2. Awareness of a benign and a premalignant form 3. Knowledge of expected course and relative nonefficacy of treatment VI. Exfoliative dermatitis A. Knowledge of variety of causes and need to attempt to identify basic cause B. Knowledge of a practical plan of workup to identify cause C. Biopsy and other laboratory findings that may be present

D. Awareness of specific and nonspecific kinds of therapy that may be useful E. Knowledge of anticipated important complications and how to recognize and manage them F. Indications for hospitalization

Bullous diseases (pemphigus vulgaris, bullous pemphigoid, dermatitis herpetiformis, herpes gestationis, Harley-Harley disease) W. Mitchell Sams, Jr., M,D. Chapel Hill, N C

1. Clinical presentation. 2. Differential diagnosis of mucous membrane erosions in the absence of skin lesions. 3. Preparation of a Tzanck smear, and biopsy for H & E and direct immunofluorescence. 4. Interpretation of routine histology and direct and indirect irnmunofluorescence. 5. Relation of disease to antibody titer. 6. Evidence for an autoimmune pathogenesis. 7. When to treat with systemic corticosteroids, cytotoxic agents, and/or gold; knowledge of proper laboratory monitoring. 8. Complications of systemic corticosteroid therapy. 9. Indications for hospitalization.

Bacterial infections James J. Leyden, M.D., and Richard M. Caplan, M.D. Philadelphia, PA, and Iowa City, 1A

The dermatologic practitioner should know: l. The normal microbiologic flora of the skin, the usual habitat of the organisms, and the degree to which they may be opportunistic pathogens. 2. Which clinical pictures are produced by which organisms. 3. The relative effectiveness of the different techniques that attempt to "sterilize" the skin's surface. 4. How to distinguish (on clinical and laboratory grounds) primary from secondary cutaneous infections. Be able to generate a useful classification of primary and secondary infections. 5. The clinical signs and symptoms, differential diagnosis, prognosis, and treatment for the common cutaneous infections*; know how to get the necessary corresponding information for the uncommon infections. 6. The systemic complications that may occasionally arise from infections that are usually considered "cutaneous." 7. The types of infection that usually arise in the skin but that customarily become systemic or have important systemic effects. *impetigo, erythema, varieties of folliculitis and boils, cellulitis including erysipelas, paronychia.

Volume 1 Number 2 August, 1979

Core curriculum

8. The cutaneous infections that arise secondary to infection in other organs and that spread to skin via local extension or systemic circulation. 9. How to take specimens for culture and interpret laboratory results.

lowa City, 1A

The practicing dermatologist should be able to: 1. Describe the general physical and biologic characteristics of viruses. 2. Describe the variety of pathologic responses that viruses may induce. 3. Enumerate the viruses that most frequently afflict humans. 4. Provide current information about each virus named in List A below, such information dealing with each of the categories in List B below. List A

e. f. g. h. i. j. k. 1. m. n. o.

Herpes simplex Varicella/zoster Warts Molluscum contagiosum Vaccinia/smallpox/cowpox Cat-scratch disease Milkers' nodule Orf Measles Rubella Erythema infectiosum Roseola Hand-foot-andmouth disease Infectious mononucleosis Herpangina

10. Prognosis of the rickettsioses. 11. Newer advances in rickettsial diseases.

Superficial mycotic infections Andrew H. Rudolph, M.D., and Richard M. Caplan, M.D. Houston, TX, and lowa City, 1A

Viral infections Richard M. Caplan, M.D.

a. b. c. d.

185

List B

a. Morphologic appearance b. Unusual manifestations c. Localor systemic symptoms and signs d. Laboratory aids to diagnosis, including biopsy appearance e. Usual course, untreated and treated f. Differential diagnosis g. Therapy that is helpful h. Commonly used therapy that is not helpful, other than as a placebo i. Preventive measures j. Most important needs in patient education to achieve best outcome in the shortrange and long-range

Rickettsial infections Joseph W. Burnett, M.D. Baltimore, MD

1. Extracutaneous manifestations of rickettsiosis. 2. Morphologic characteristics of a rickettsial eruption. 3. Differential diagnosis of rickettsiosis. 4. Nature, properties, and life cycle of rickettsiae. 5. Pathology of rickettsial infection. 6. Diagnostic tests for patients with rickettsiosis. 7. Drug therapy of rickettsiosis. 8. General, ancillary, and rehabilitative therapy. 9. Prevention procedures available for rickettsioses.

1. Causative agents, pathogenesis, clinical presentations, and differential diagnosis of: a. Superficial fungal infections. b. Mucocutaneous and cutaneous candidiasis. c. Dermatophyte infections of hair, nails, glabrous skin, intertriginous skin, and palms and soles. 2. Epidemiology of mycotic infections, and aspects of patient education derived from that information. 3. Collection of clinical materials from hair, glabrous skin, interspaces and nails, and techniques for inoculation of these specimens onto media. 4. Proper use and interpretation of potassium hydroxide (KOH) examination of specimens from skin, hair, and nails, and appearance of certain fungi in KOH preparations and their significance (i.e., type of hair invasion, hyphal structures, etc.). 5. Use of the Wood's light in superficial mycotic infections. 6. Selection of media and their limitations. 7. Recognition of the common pathogenic and contaminant fungi by their gross and microscopic morphology. 8. Treatment including topical antifungal and anticandidal preparations and, when indicated, systemic antifungal (griseofulvin) and anticandidal agents.

Deep mycotic infections Richard M. Cap[an, M.D. Iowa City, IA

This is a large topic and there is much that can and should be reviewed by the practicing dermatologist. In order to express the principal elements of importance and not make huge lists or write a long monograph, the following matrix is offered (Table I).

Treponemal infections Charles L. Heaton, M.D. Philadelphia, PA

I. Syphilis A. Etiology and epidemiology B. Clinical recognition of, diagnostic criteria for, and differential diagnosis of: 1. Acquired syphilis a. Primary syphilis b. Secondary syphilis c. Latent syphilis (early and late) d. Late manifest syphilis (tertiary)

Journal of the American Academy of Dermatology

186 Core cttrricuhtm

Table I 8

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1. Principles of infection (for example, p r o o f of pathogenicity, tissue invasion, local vs spread) 2. Principles of immunology (e.g., skin tests, serum tests, host factors) 3. Epidemiology (e.g., social and geographic factors) 4. Mode of transmission and contagiou snes s 5. Clinical features for diagnosis 6. Laboratory features for diagnosis (including basic mycologic features on scrapings and cultures) 7. Treatment 8. Clinical course 9. Prognosis C. Laboratory diagnosis 1. Usefulness and pitfalls of dark-field microscopy 2. Serologic tests for syphilis--all that are currently in wide use: a. Variations in test results at each stage of the disease with and without therapy b. Limitation of serotesting--clinical and laboratory c. Biologic false-positive tests for syphilis-their clinical and differential diagnostic importance 3. Other, i.e., x-ray findings, cerebrospinal fluid, and blood chemistry findings D. Therapy--guidelines for the adequate treatment and long-term follow-up for all stages of congenital and acquired disease; include alternate antibiotic treatment and follow-up schedules E. Patient and public education about cause, prevention, and appearance F. Prognosis with and without treatment

Nontreponemal sexually transmitted diseases, concepts Charles L. Heaton, M.D. Philadelphia, PA The following diseases should be included in this grouping: I. Bacterial A. Gonorrhea B. Chancroid C. Granuloma inguinale II. Chtamydiaceae and Mycoplasmataceae A. Nongonorrheal urethritis 1. Mycoplasma 2. Chlamydia trachomatis B. Lymphogranuloma venereum III. Viral A. Herpes simplex, types I and II B. Molluscum contagiosum C. Verruca vulgaris IV. Protozoan A. Trichomoniasis

Volume 1 Number 2 August, 1979

V. Parasitic A. Scabies B. Pediculosis VI. Fungal A. Candidiasis B. Dermatophytosis

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The most frequently occurring of the above diseases are: Gonorrhea Chlamydial nongonorrheal urethritis Herpes simplex, type II Trichomoniasis Candidiasis Verruca vulgaris Parasitic infestations

A. Hyperplasias (e.g., dermatofibroma, histiocytoma, xanthogranuloma, forms of pseudolymphoma, persistent insect bite, the spectrum of histiocytosis X) B. Granulomatous reactions 1. Infectious (e.g., due to various species of Mycobacterium and Leishmania) 2. Noninfectious (e.g., hypersensitivity granuloma, foreign body granuloma, sarcoidosis, "palisading granulomas") C. Granulomatous vasculitides (e.g., granuloma faciale, erythema elevatum diutinum, Wegener's granulomatosis, midline lethal granuloma, giant cell arteritis D. Halogenodermas

The remaining diseases are less frequent in day-to-day practice. The core of information needed for each disease process would be as follows:

Diseases of peripheral vessels and their contents Thomas H. Rea, M.D., Seymour I. Shapiro, M.D., and Richard M. Caplan, M.D. Los Angeles, CA, Tucson, AZ, and Iowa City, 1A

A. Etiology and epidemiology

The practicing dermatologist should be able to enumerate clinical characteristics, choose appropriate laboratory tests, do a biopsy (if appropriate), manage (if treatment available), and know when to refer, for these conditions:

B. Clinical characteristics 1. Common and uncommon clinical signs and symptoms 2. Diagnostic criteria 3. Organ systems involved 4. Predisposing factors, if any 5. Differential diagnosis C. Laboratory diagnosis 1. Use of appropriate smears, stains, scrapings, etc. 2. Use of appropriate culture media and collection techniques, if any 3. Use of appropriate serologic tests, if any a. Reliability b. Limitations 4, Biopsy D. Therapy--guidelines for adequate treatment and follow-up; alternate drug schedules should be included if available E. Methods to assist in the diagnosis of multiple (mixed) infections F. Prognosis with and without treatment G. Importance of patient and public education

Benign retieuloendothelial diseases Richard M. Caplan, M.D. Iowa City, IA I. The histologic and functional nature of the "R-E system" II. The etiology, diagnosis, course, microscopic pathology, and major methods of treatment (if available) for:

I. Arteriosclerosis obliterans II. Thromboangiitis obliterans III. Vasculitis A. Atrophie blanche B. Hypertensive ischemic ulcer C. Livedo reticularis D. Degos' syndrome E. Mucha-Habermann syndrome F. Leukocytoclastic angiitis G. Acute febrile neutrophilic dermatosis H. Periarteritis nodosa, benign and systemic IV. Purpura A. Paraproteinemias B. Platelet disturbances C. Coagulopathies D. Nutritional E. Purpura pigmentosa chronica V. Telangiectasias VI. Diseases of peripheral veins A. Varicosities, and stasis dermatitis and ulcer B. Thrombophlebitis VII. Lymphedema VIII. Pyoderma gangrenosum

Connective tissue diseases (spectrum i n c l u d e s lupus e r y t h e m a t o s u s , morphea, s c l e r o d e r m a ,

188

Core c u r r i c u l u m

d e r m a t o m y o s i t i s r h e u m a t i c disease, a n d Sj6gren's syndrome) Seymour I. Shapiro, M.D. Tucson, AZ *A. Similarities and variations in clinical characteristics 1. Cutaneous patterns 2. Systemic features 3. Age and sex distribution 4. Course and prognosis B. Etiology--pathogenesis 1. Presence of fibrinoid necrosis 2. Role of autoimmunity 3. Genetic factors 4, Prior bacterial infection 5. Relationship to systemic malignancy 6. Relation of localized to systemic forms in lupus erythematosus and scleroderma C. Laboratory diagnosis 1, Which serologic tests can be expected to be abnormal and/or diagnostic in the several diseases 2, What bistopathologic and immunopathologic findings would be expected in several diseases *D. Therapy 1. Topical care 2. Systemic medications, dose, and suitable adjustments of dose a. Antimalarials b. Corticosteroids c. Immunosuppressive agents 3. Laboratory and clinical examinations useful in monitoring systemic therapy *E. Patient education 1. Importance of climatic influence on the several diseases 2. Significance of emotional stress 3. Indications for genetic counseling Diseases of corium and subcutaneous tissue Harold O. Perry, M.D. Rochester, &IN I. Macular atrophy A. Most common clinical presentation B. Most common location of skin lesions C. Variations in clinical presentations D. Histology that characterizes the disease II. Atrophoderma of Pasini and Pierini A. Clinical presentation B. Clinical location of lesions on the body C. Clinical differentiation from morphea D. Duration of diseases E. Relationship to scleroderma III. Acrodermatitis chronica atrophicans *Increased emphasis.

Jouma/ of the American Academy of Dermatology

A. Most common clinical presentations B. Most common location of skin lesions and epidemiologic characteristics C. Other skin lesions associated with acrodermatitis chronica atrophicans D, Diagnostic histologic changes E. Effective therapy F. Differential diagnosis IV. Lichen sclerosus et atrophicus A. Most common clinical presentation B. Histologic changes C. Complications from fibrosis D. Association with ma/ignancy V. Scleredema A, Most common clinical presentation B. Most common location of skin lesions C. Other organs that may be involved D. Associated diseases VI. Etastosis perforans serpiginosa A. Most common clinical presentation B. Most common location C. Histologic alteration D. Associated diseases VII. Reactive perforating collagenosis A. Characteristics of primary lesion B. Location of primary lesions C. Characteristic dermatopathologic changes VIII. Perforating folliculitis A. Character of primary lesions B. Location of skin lesions C. Characteristic dermatopathology IX. Marfan's syndrome A. Most common clinical presentation B. Most common associated findings C. Basic defect found in involved tissues X. Ehlers-Danlos syndrome A. Most common clinical presentation B. Inheritance patterns recognized C. Differentiation from other diseases with pathologic changes in corium XI, Werner's syndrome A. Most common clinical presentation B. Differentiation from other hereditary disorders of the connective tissue XII, Focal dermal hypoplasia A. Most common cutaneous clinical presentation B. Other organ systems involved XIII. Pseudoxanthoma elasticum A. Most common clinical presentation B. Most common location of skin lesions C. Organs commonly involved

Volume i Number 2 August, 1979

D. Complications from the disease E. Dermatopathology of skin lesions XIV. Generalized elastolysis (cutis laxa) A. Most common clinical presentation B. Classification of the disease C. Other organs that may be involved D. Complications of the disease E. Dermatopathology F. Presumed pathogenesis XV. Fibromatosis A. Characteristics offibromatosis B. Clinical presentation of fibromatosis XVI. Total lipodystrophy A. Cutaneous manifestations of total lipodystrophy B. Other organ involvement that can occur XVII. Partial lipodystrophy A. Clinical characteristics B. Other organ involvement associated XVIII. Facial hemiatrophy A. Clinical presentation B. Other organ involvement XIX. Sclerema neonatorum A. Most common clinical presentation B. Associated clinical findings C. Pathogenesis of the disease D. Prognosis E. Dermatopathology XX. Weber-Christian disease A. Most common clinical presentation B. Associated findings C. Dermatopathology

Hereditary cutaneous diseases---concepts Lowell A. Goldsmith, M.D.

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189

epidermolyis bullosum, xeroderma pigmentosum, anhidrotic ectodermal dysplasia, mastocytosis, and the porphyrias.

Disorders of eornification Irwin M. Freedberg, M.D. Baltimore, MD

1. The concept and details of epidermal turnover. 2. An appreciation of stratum corneum--its contents as cell membrane, protein, and lipid; the role of hydration. 3. Clinical presentation and histologic pattern of the common types of ichthyosis (ichthyosis vulgaris, x-linked ichthyosis, lamellar ichthyosis, and epidermolytic byperkeratosis) and Darier's disease. 4. Knowledge of ichthyosis as a reaction to drugs and illness in other organs, including acanthosis nigricans. 5. Knowledge of where to find recent lists of rare types of scaling problems, to permit diagnosis when clinical picture is not clear--appreciation of types of disease associated with such problems, i.e., storage disease, endocrine disease. 6. Enough appreciation of genetics to permit appropriate counseling. 7. Therapy of common types of ichthyosls and Darier's disease including patient and family education. 8. Appreciation of clinical picture and therapy of common types of keratosis of palms and soles. 9. Knowledge of rarer types of keratosis of palms and soles which may be associated with underlying disease or endocrine abnormalities. 10. Ability to recognize and appreciate significance, or, better, lack of significance of entities such as knuckle pads, transient acantholytic dermatosis, porokeratosis.

Dt~rham, NC

Disturbances of pigmentation

+ + + 1. Molecular genetics; patterns of inheritance, Lyon hypothesis. + + + 2. Genetic heterogeneity. + + 3. Pleiotropism--and its diagnostic usefulness. + + 4. Variability--expression--penetrance. + 5. Modes of inheritance and implications for counseling. + 6. When to do chromosome analysis, amino acid analysis, amniocentesis. + + 7, Serious manifestations of apparently benign genetic diseases (e.g., internal malignancy, skin malignancy). + + + 8. Treatable and preventable genetic skin diseases. These concepts should be illustrated by representative important genodermatoses, such as these: tuberous sclerosis, neurofibromatosis, Sturge-Weber syndrome,

Arthur J. Sober, M.D. Boston, MA

I. Clinical presentation A. Common pigmentary disorders of pigmentation of uncertain cause (vitiligo, melasma) B. Medications producing hyperpigmentation C. Diseases associated with diffuse hyperpigmentation D. Significance of lentigines E. Significance of velvety brown hyperpigmentation in axillae and other body folds (acanthosis nigricans) F. Significance of blue-gray hyperpigmentation G. Chemicals associated with hypopigmentation H. Markers of internal diseases (genodermatoses): 1. Neurofibromatosis 2. Tuberous sclerosis

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Core curriculum

3. Chfdiak-Higashi syndrome 4. Peutz-Jeghers syndrome 5. Leopard syndrome II. Diagnosis A. Distinguishing hypomelanotic lesions from amelanotic lesions B. Distinguishing epidermal location of melanin from dermal C. Histopathology 1. Decreased vs absent melanocytes 2. Giant melanosomes D. Other laboratory tests of use in hypo- or hypermelanotic states III. Management A. Genetic counseling: Tuberous sclerosis, neurofibromatosis B. Use of sunscreens: Oculocutaneous albinism, melasma C. Use of depigmenting agents: Mutilating vitiligo, melasma D. Use of repigmenting agents: Psoralens Aene and a e n e i f o r m dermatoses John S. Strauss, M.D. Iowa City, IA Acne This disease is certainly recognizable by all practicing dermatologists, so therefore while the clinical characteristics have been rated + + + by the core curriculum committee, they probably do not have to be taught as part of a post-training dermatology core program. There are two major components felt to be of importance to such a core. These are (1) pathogenesis of the disease and (2) treatment and complications of treatment. Pathogenesis needs to be stressed since it is only through comprehensive knowledge of the cause of acne that the practicing dermatologist can understand and tailor treatment for the appropriate care. The specifics are as follows: I. Pathogenesis of acne and the interrelationships of etiologic factors A. Anatomy of the pilosebaceous apparatus involved in ache B. Endocrinologic factors in acne, including, for example, the hormonal control of the development of the sebaceous follicle, and how hormone administration modifies sebaceous gland function C. Role of abnormal follicular keratinization in the pathogenesis of acne D. Histopathology of acne E. Role of lipids in the pathogenesis of acne F. Role of the follicular microflora in the pathogenesis of ache G. Host and immunologic factors in acne

II. Treatment and complications A. Rationale, appropriateness, and method of use of: 1. Topical agents (sulfur and resorcinol, benzoyl peroxide, vitamin A acid, topical antibiotics, antiseborrheic measures) 2. Physical therapy (ache surgery, ultraviolet light, x-ray) 3. Systemic agents (antibiotics, estrogens, corticosteroids, sulfones) 4. Miscellaneous therapy (intralesional steroids) B. Complications 1. Recognition and management of potential side effects of systemically administered agents (antibiotics, corticosteroids, estrogens, sulfones) 2. Specific recognition and management o f gram-negative folliculitis 3. Recognition of iatrogenic acne (drug and otherwise induced) C. Education of patients regarding role, or nonrole, of faithful care, avoiding picking, diet, etc. Aeneiform dermatoses I. The practitioner should be able to recognize and manage the following, especially where therapy is different from that of acne vulgaris: A. Ache conglobata B. Acne fulminans C. Occupational acne D. Drug-induced acne 1. Steroids, systemically and orally 2. Halogens' 3. Other drugs E. Acne cosmetica F. Acne estivalis G. Topical acne H. Perioral dermatitis II. Rosacea A. Diagnosis and differential diagnosis B. Management 1. Systemic antibiotics 2. Topical therapy C. Eye complications D. Associated gastrointestinal problems Apocrine gland disorders; not tumors Harry J. Hurley, Jr., M.D. Upper Darby, PA I. The dermatologist will be able to diagnose and treat these disorders of apocrine function: A. Bromhidrosis B. Apocrine chromhidrosis C. Fox-Fordyce disease D. Hidradenitis suppurativa

Volume 1 Number 2 August, 1979

1. Epidemiology a. Age of onset b. Sexual variation of disease localization c. Association with other disorders d, Environmental influences 2. Pathogenesis a. Sequential cutaneous alterations b. Role of endocrine factors 3. Clinical features a. Sites of involvement b. Local changes---early and late c. Effects on adjacent structures d. Bacteriologic findings 4. Conditions to be distinguished from hidradenitis suppurativa 5. Methods of treatment a. Early state b. Localized recurrent form c. Chronic extensive form 6. Prognosis; complications Eeerine gland disorders; not tumors Richard L. Dobson, M.D. Btorfalo, NY 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12.

Emotional vs thermal sweating. Cholinergic vs adrenergic stimulation. Palmar and plantar hyperhidrosis. Localized hyperhidrosis, its causes and treatment. Systemic significance of acquired anhidrosis. Pathogenesis and treatment of miliaria. Generalized skin diseases and temperature regulation. Congenital anhidrosis and related syndromes. Pustular periporitis of infancy. Mechanism of effect of antiperspirants. Relation between sweat gland function and xerosis. Heat stress syndromes.

Disorders of the hair Vera H. Price, M.D. San Francisco, CA I. Assessment of the patient A, History 1. Is hair coming out "by the roots" or is it breaking? 2. Which predominates: increased shedding or increased thinning? 3. Duration 4. All drugs taken, including three months before onset to present 5. Menses, pregnancies, menopause 6. Past health, from year before onset 7, Hair care, hair cosmetics 8. Family history 9. Diet: Diet prior to onset? If vegetarian, what are sources of protein?

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191

10. In children, check mental and physical development (teeth, nails, eyes, ears, heat intolerance) B. Clinical examination 1. Hair texture 2. How long does hair grow? Does all hair grow to same length? 3. Pattern and distribution of hair loss 4. "Pull test": How many hairs/pull in 3 different regions? 5. Hair tips: Tapered or broken? 6. Scalp: Is it normal? 7. Hair elsewhere: Too much or too little? 8. Ache, virilization C. Hair mount 1. Prepare mount when examination of hair shaft or bulb indicated 2. Need contrasting white or black background (velvet best) when working with hair 3. Mount 4 or 5 short, selected segments of hair on 1 slide 4. Mounting medium--Permount, Harleco syn thetic resin, balsam D. Scalp biopsy 1. Must biopsy all scarring alopecias 2. In nonscarring alopecia, scalp biopsy may help in diagnosis of androgenetic alopecia, alopeeia areata, triehotillomania 3. Site of biopsy is important 4. Size and depth of biopsy are important E. Laboratory tests to aid diagnosis--when indicated only: 1. Plasma testosterone 2. T,, T~, TSH 3. VDRL

4. CBC 5. Thyroglobulin, adrenal, parietal cell antibodies--of interest in alopecia areata, but do not change management of hair loss II. Types of alopecia A. Nonscarring alopecia 1. Differential diagnosis of hair coming out " b y the roots": a. Telogen effluvium (1) Normal hair cycle (2) Effect of stress on hair cycle (3) Hallmark of telogen effluvium (4) Causes of telogen effluvium: (a) High fever (b) Childbirth (c) Severe infections, severe flu (d) Severe chronic illness (e) Severe psychologic stress (f) Major surgery

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(g) Hypothyroidism, hyperthyroidism (h) Crash diets; inadequate protein intake (i) Drugs (5) Course--usually self-limited, reversible; exceptions--must correct thyroid disease, stop crash diet, and stop offending drug b. Androgenetic alopecia (1) Common baldness is caused by androgens in genetically susceptible men and women (2) Results in the progressive miniaturization of coarse terminal to fine velluslike hair (3) Hair follicles all present (4) Pathophysiology: Increased 5a-reduction of testosterone in affected follicles (5) Clinical presentation in men (6) Clinical presentation in women (7) Women with advanced thinning should be screened (8) Treatment: In men (9) Treatment: In women c. Hair loss secondary to oral contraceptive s (1) While taking oral contraceptives (2) After stopping oral contraceptives (3) Two components of oral contraceptives (4) Activity of synthetic estrogens is dose-related (5) Activity of synthetic progestins (or progestogens) is related both to dosage and to metabolic products and their relative estrogenic, antiestrogenic, androgenic, and progestational effects (6) The most estrogenic progestin (7) Second most estrogenic progestin (8) Two estrogen-dominant oral contraceptives (9) In acne, androgenetic alopecia, and hirsutism, an estrogen-dominant oral contraceptive is preferable (10) Before using estrogen-dominant oral contraceptive, have patient checked for menorrhagia and fibroids, and do Pap smear (11) Do not confuse progesterone with synthetic progestins; progesterone is not androgenic (12) Hair loss may occur while taking oral contraceptive; this is usually in women predisposed to androgenetic

Journal of the American Academy of Dermatology

alopecia, and is usually due to androgenic progestin d. Alopecia areata (1) Incidence (2) Course (3) Factors affecting prognosis (4) Associated autoimmune diseases (5) Associated autoantibodies (6) Relatives have increased incidence of which diseases? (7) When to use intralesional corticosteroids (8) How to use intralesional corticosteroids (9) When to consider systemic corticosteroids e. Syphilitic alopecia: (1) In secondary syphilis (2) Two possible presentations (3) Areas of involvement (4) Serologic tests (5) Scalp biopsy (6) Treatment and response 2. Differential diagnosis of hair breaking: a. Tinea capitis (1) Factors affecting clinical presentation (2) Clinical features that suggest tinea capitis (3) How to make the diagnosis (4) Treatment is modified by the clinical picture and degree of inflammation b. Structural hair shaft anomalies (I) Those with increased fragility: (a) Monilethrix (b) Bamboo hair (c) Trichorrhexis nodosa (d) Pili torti (2) Those without increased hair fragility: (a) Pill annulati (b) Pseudo pill annulati c. Trichorrhexis nodosa (i) Proximal vs distal (cause and clinical presentation) (2) Influence of race (3) Management d. Breakage secondary to improper hair care and/or cosmetics (1) Combing and brushing (2) Weathering (3) Shampooing (4) Chemical treatments e. Trichotillomania (1) Prevalence (2) Clinical findings

Volume l Number 2 August, 1979

(3) Biopsy findings (4) Differential diagnosis (5) Prognosis (6) Treatment f. Anagen arrest (l) Drugs involved (2) Mechanism of anagen effluvium (3) Morphologic hair changes and mechanism of hair loss (4) Timing of the hair loss (5) Percentage of hair affected (6) Reversibility (7) Difference between anagen effluvium and radiation effects on hair roots B. Scarring alopecia Scarring skin diseases: a. Lupus erythematosus b. Lichen planus c, Alopecia mucinosa d. Pseudopelade e. Scleroderma; morphea 2. Infections a. Viral b. Fungal c. Bacterial 3, Neoplasms 4. Physical agents 5. Biopsy essential 6. Two conditions which are reversible if treated early with local corticosteroids (discoid lupus erythematosus, lichen planus); may use intralesional corticosteroids, using same technique as in alopecia areata . In treatment of pseudopelade: a, Attempt to arrest process by injecting corticosteroids at margin of lesions; use same technique as in alopecia areata b. Try three test hair transplants; about 50% are donor-dominant

Disorders of the nails Lawrence A. Norton, M.D. Dedham, MA

* 1. *2. *3. 4. *5. *6.

Origin of alterations of nail structure in disease. Etiology and pathogenesis of chronic paronychia. Normal progression of fungal infections of the nail. Associated findings in genetic disorders of the nail. Drug reaction in the nail. Treatment of fungal infections of the nail and prognosis. 7. Laboratory findings in diseases of unknown etiology. 8. Diagnosis of tumors under or adjacent to the nail (especially, the importance of early biopsy).

*More important concepts.

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9. Differential diagnosis in nail plate alterations (e.g., the importance of distinguishing psoriatic from fungal nail),

Diseases of nutrition and metabolism Frank Parker, M.D. Portland, OR

I. Acrodermatitis enteropathica A. Most common clinical presentation B. What is known about basic metabolic defects as relates to zinc? C. Various approaches to therapy II. Amyloidosis A. Clinical features of the disease B, Types of underlying diseases C. Method of diagnosis III. Xanthomatosis A. Clinical associations with xanthomatosis B. Approach to clinical evaluation of patients with xanthomas C. Approach to therapy IV. Myxedema (generalized and pretibial) A. Clinical features and associations B. Therapy V. Diabetes and the skin A, Foot ulcers 1. Factors responsible for leg and foot ulcerations 2. Therapy of ulcerations B. Necrobiosis lipoidica diabeticorum 1. Clinical features and associated findings 2. What if any therapy C. Susceptibility to bacterial and fungal infections VI. Vitamin/metabolic abnormalities A. Pellagra 1. Clinical picture, diagnosis, and treatment B. Hypervitaminosis A 1. Clinical picture, diagnosis VII. Porphyria (porphyria cutanea tarda and erythropoietic porphyria) A. Clinical manifestations B. Laboratory findings C. Treatment programs Tumors of the skin Alfred W. Kopf, M.D. New York, NY

I. Have skills in clinical diagnosis of all types of cutaneous neoplasms II. Be aware of the proper examination procedures, both clinical and histologic

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Journal of the American Academy of Dermatology

Core curriculum

IlI. Have the ability to describe cutaneous tumors properly IV. Have the ability to perform properly various biopsy procedures V. Be able to either treat personally most cutaneous neoplasms or know how to refer specific problems to others VI. Should know therapeutic modalities commonly used in the management of cutaneous tumors: A. Standard modalities 1. Scalpel excision 2. Curettage-electrodesiccation 3. X-ray therapy 4. Mohs' surgery B. N e w modalities 1. Cryotherapy 2. Chemotherapy C. Experimental modalities 1. Immunotherapy VII. Have a thorough understanding of the indications, contraindications, cosmetic results, and complications of the modalities just listed VIII. Knowledge should be attained concerning the following aspects for each type of cutaneous tumor: A. Clinical features B. Common synonyms C. Histogenesis D. Histopathology E. Incidence or prevalence F. Sex G. Age distribution H. Hereditary or familial factors I. Pathogenesis or etiology J. Course and prognosis K. Differential diagnosis L. Treatment IX. The cutaneous tumors can be divided into the following major categories: A. Nevi, benign tumors, and related conditions B. Precanceroses C, Carcinoma in situ D. Aggressive tumors E. Pseudocancers F. Malignant tumors G. Cutaneous manifestations of systemic tumors H. Cysts and sinuses I. Miscellaneous tumors Note: For eacb kind of cutaneous tumor it would be possible to have a considerably more detailed "curriculum." For example, the items for malignant melanoma could be as follows: 1. Clinical features of the types of malignant melanoma (lentigo maligna melanoma, superficial

2. 3. 4. 5. 6. 7. 8. 9. 10.

spreading melanoma, nodular melanoma, acral lentiginous melanoma, mucous membrane melanomas). Levels of dermal invasion (I, II, III, IV, V) (Clark). Thickness of melanoma (Breslow). Staging of malignant melanoma. Biologic behavior of various types of malignant melanoma. Diagnostic workup of malignant melanoma. Prognostic factors in malignant melanoma. Therapy of malignant melanoma. Epidemiology of malignant melanoma. Prognosis of malignant melanomas.

Lymphomas of the skin Richard L. Edelson, M.D. New York, N Y

*1. t2. 3. t4. t5. 6. 7.

Clinical presentation. Histopathology of mycosis fungoides. Nature of extracutaneous spread. Laboratory evaluation of patients. Characterization of the neoplastic lymphocytes. Prognostic indicators. Special studies which may be helpful to the consultant physician. 1"8. Treatment of aleukemic cutaneous lymphoma, limited to skin. t9. Treatment of aleukemic cutaneous lymphoma, with extracutaneous extension. tl0. Treatment of leukemic phase of cutaneous lymphoma. Reactions to physical agents Arthur H. Gladstein, M.D., and Richard M. Caplan, M.D. Long lsland City, NY, and 1own City, 114

I. Reactions to mechanical injury A. Callouses and corns, diagnosis and care II. Reactions to heat A. Thermal burns, classification and emergency care B. Cholinergic urticaria III. Reactions to cold A. Frostbite, care B. Trench/immersion/seaboot foot, diagnosis and care C. Chidblains, diagnosis and care D. Raynaud's disease and phenomenon, distinguishing between them, and appropriate treatment E. Cold urticaria, diagnosis, basic mechanisms, patient education for prevention

*Emphasis on T cell types. tMore important concepts.

Volume 1 Number 2 August, 1979

IV. Reactions to ionizing radiation A. Knowledge of basic biophysics 1. Production of ionizing energy 2. Factors affecting dose and tissue damage B. Classification of degrees of cutaneous reaction C. Morphologic and histologic evidence of radiation effects, and the treatment for these effects/ disorders 1. Erythema 2. Pigmentation 3. Acute radiation dermatitis 4. Chronic radiation dermatitis 5. Radiation-induced cancer (skin and underlying tissues) D. Requirements for shielding of patients and others Industrial dermatoses Gerald A. Gellin, M.D. San Francisco, CA

1. Recognition that the dermatitis of the patient is related to work. 2. Common and unusual causes of an occupational skin disease (especially to include classical clinical patterns, such as chronic chemical irritant reaction of the hands, chrome ulcers, arsenical keratoses). 3. Value of the patch test to identify industrial allergens. 4. Preventive measures including education of employer and worker. 5. Role of the dermatologist in workers' compensation litigation. 6. Dermatologist's role in helping the worker and employer with vocational rehabilitation, as appropriate.

Parasitology and tropical dermatoses Richard M. Caplan, M.D. lowa City, IA

The practicing dermatologist should: I. Maintain a high level of suspicion regarding parasitic diseases of the skin for any patient who has been living or traveling outside this country. 2. Be able to define parasitosis, endoparasites, and ectoparasites. 3. Know where to obtain more detailed information about parasitic organisms of any type, their biologic behavior, pathophysiology in man, clinical manifestations, prevention, and treatment. 4. Recognize the relation between habitat of organisms and the recreational and occupational proclivities of the patient. 5. Recognize the demographic and biologic factors that relate to epidemics, and the social and hygienic measures that might appropriately be invoked.

Core curriculum

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6. Be able to list six major disorders* due to these principal categories of parasitic organisms: protozoa, worms, and arthropods; and for each disorder she/he should be able to describe clinical symptoms and signs, differential diagnosis, techniques to establish the diagnosis, current methods for prevention, management or cure, approaches to rehabilitation (as appropriate), public health measures that would be appropriate, and aspects of societal or individual education that should be undertaken. 7, Be able to offer a list of at least six varieties of "tropical ulcers" of the skin and say how a definitive diagnosis might be made in each instance. *Note: The "Key Concepts" for each disorder will vary with the particular teacher. The range here is great, from such concepts (or "facts") as: a. Sea bather's eruption tends to affect areas covered by the bathing suit; or b. The brown recluse spider can be identified easily by its size, its eight legs, and the "violin" marking on the dorsal surface of its cephalothorax; to c. Body lice, in contrast to pubic and head lice, do not remain on the body, but retreat after feeding to the seams of clothing.

Psychogenic and neurogenic skin disorders Roland S, Medansky, M,D. Park Ridge, IL

t. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18.

Psychosomatic medicine--an interpretation. A classification of psychocutaneous disorders. Delusions ofparasitosis. Factitial ulcers. Neurotic excoriations. Dyshidrotic eczema; hyperhidrosis. Trichotillomania. Anxiety therapy. Psychotropic drug mechanisms. Depression--diagnosis. Depression--therapy. Depression--medication. Skin sensation pathophysiology. Pathophysiology of vascular changes and sweating. Paresthesia. Hyperesthesia. Postherpetic neuralgia. Neurotrophic ulcers.

Disorders of the oral cavity Roy S. Rogers III, M.D. Rochester, MN

I. Contact stomatitis A. Most common causes of allergic contact sto. matitis

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Journal of the American Academy of Dermatology

Core curricttlum

B. Reasons for the low incidence of allergic contact stomatitis C. Establishing the diagnosis D, Most common cause of irritant contact stomatitis II. Disorders of the tongue A. Clinical presentations B. Differential diagnosis C. Management III. Denture-sore mouth (mechanical trauma) A, Clinical presentation B, Etiologic factors C. Treatment IV. Recurrent aphthous stomatitis A. Clinical presentation B. Natural history C. Associated diseases D. Differential diagnosis E. Pathogenesis F. Treatment V. Stomatitis medicamentosa A. Clinical presentation B. Most common causes C. Mechanisms involved D. Treatment VI. Lichen planus A, Clinical presentation B. Establishing the diagnosis C. Prognosis

D, Treatment E. Complications VII, Bullous diseases A. Clinical presentation B. Establishing the diagnosis C. Complications of the disease VIII. Benign and malignant oral lesions A. Early recognition B. Clinical presentation C. Establishing the diagnosis IX. Perl~che A. Intertrigo (especially related to inadequate height of dentures) B. Candida C. Nutritional deficit X. Blood dyscrasias A, Anemias B. Cyclic neutropenia C. Leukemias XI. Miscellaneous A. Pyodermatitis (with ulcerative colitis) B. Dental sinus C. Cheilitis granulomatosa D. Melkersson-Rosenthal syndrome E. Avoidance of tetracycline therapy in children and pregnant women F. Xerostomia G. Mucocele H. Herpetic gingivostomatitis