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NLE Integumentary & Skin Integrity — Burns and Dermatologic DisordersCheat Sheet

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A printable cheat sheet for Burns and Dermatologic Disorders, built for NLE reviewers who want one go-to reference in the final stretch. Covers formulas, key definitions, common question types, and the Professional Regulation Commission (PRC) — Board of Nursing-specific twists you will see on NLE day.

Exam context

For the Philippine Nurse Licensure Examination (PNLE), Professional Regulation Commission (PRC) — Board of Nursing tests Integumentary & Skin Integrity under a "Core" label, with Burns and Dermatologic Disorders in the 2nd slot across 2 chapters. NLE candidates must clear the 75% weighted average with no sub-test below 60% cut on the 2026 paper, which draws about 50 Integumentary & Skin Integrity questions. Date to watch: Bi-annual.

Burns and Dermatologic Disorders - Cheat Sheet

Your last-minute rapid-fire revision guide for burn classification, fluid resuscitation, phases of injury, and dermatologic conditions. Cover formulas, depth classifications, TBSA estimation, and nursing priorities in 30 minutes.

Sections

Section Title

Burn Classification by Depth

Important Facts

**Superficial (first-degree) burns are NOT counted in TBSA calculations**—only partial- and full-thickness burns count.
**Superficial partial-thickness (blistered) burns are the MOST PAINFUL** because nerve endings are stimulated, not destroyed.
**Full-thickness burns are PAINLESS in the center** because nerve endings are destroyed; pain is only at the edges (transition zone).
**Full-thickness burns do NOT blanch** with pressure (capillaries destroyed, no blood return).
**Electrical burns** cause deep tissue damage far exceeding surface appearance; high risk of cardiac dysrhythmias and rhabdomyolysis (dark urine).
**Chemical burns:** remove agent, brush off dry powder first, then flush with copious water/saline for 20+ minutes.
**Inhalation injury** = facial burns, singed nasal hairs, carbonaceous (sooty) sputum, hoarseness, stridor; **carbon monoxide poisoning**; give 100% humidified O₂.

Key Definitions

Term

Superficial (First-Degree) Burn

Example

Sunburn after beach exposure

Definition

Epidermis only; red, dry, painful, blanches with pressure, no blisters; heals in 3–6 days without scarring.

Term

Superficial Partial-Thickness (Second-Degree)

Example

Accidental scald from hot water on arm

Definition

Epidermis + upper dermis; blisters, moist weeping surface, severe pain, blanching; heals in 2–3 weeks.

Term

Deep Partial-Thickness (Second-Degree)

Example

Contact burn from heated object held briefly

Definition

Extends into deep dermis; red to waxy white, drier, less pain (nerve damage), slow capillary refill; may require grafting.

Term

Full-Thickness (Third-Degree)

Example

Severe house fire or prolonged contact with high heat

Definition

Entire epidermis and dermis destroyed; dry, leathery, inelastic eschar (white, waxy, tan, brown, or charred); painless (no nerves); does NOT blanch; requires grafting.

Term

Fourth-Degree Burn

Example

Lightning strike or extreme thermal injury

Definition

Extends into muscle, fascia, and bone; charred; may require amputation.

Diagrams To Know

Cross-section of skin showing epidermis, dermis, subcutaneous layers and how each burn depth extends
Color/appearance chart: first-degree red and dry → second-degree blistered/moist → third-degree white/leathery/charred

Formulas

Formula

Rule of Nines (Adult TBSA Distribution)

Meaning

Divides body into regions that are multiples of 9% to rapidly estimate burned percentage.

Watch Out

**Do NOT include superficial (first-degree) burns in TBSA count**—only partial- and full-thickness burns. Use **Lund-Browder chart** for children (larger head). Use **palmar method** (patient's palm ≈ 1% TBSA) for small scattered burns.

When To Use

For any adult burn victim when quick TBSA assessment is needed in the field or emergency department.

Common Values

Value

Symbol

H/N

Quantity

Head and neck (adults)

Value

Symbol

Quantity

Each arm (adults)

Value

18%

Symbol

Quantity

Anterior trunk

Value

18%

Symbol

Quantity

Posterior trunk

Value

18%

Symbol

Quantity

Each leg (adults)

Value

Symbol

Quantity

Perineum/genitalia

Section Title

TBSA Estimation: Rule of Nines (Adult)

Important Facts

**Lund-Browder chart** is more accurate than Rule of Nines for children (head is ~18% in infants vs. 9% in adults).
**Palmar method:** patient's entire palm (including fingers) ≈ 0.5–1% TBSA; useful for scattered or small burns.
**Only count partial- and full-thickness burns**; superficial (first-degree) burns are excluded from TBSA.
TBSA estimation directly determines **fluid resuscitation volume** via Parkland formula.

Key Definitions

Term

Total Body Surface Area (TBSA)

Example

A patient with 50% TBSA burn requires aggressive IV fluid replacement per Parkland formula.

Definition

Percentage of body area affected by partial- or full-thickness burns; used to estimate fluid loss and resuscitation needs.

Term

Rule of Nines Breakdown (Adult)

Example

Patient with bilateral arm burns (full-thickness) + anterior trunk (partial) = 9% + 9% + 18% = 36% TBSA

Definition

Diagrams To Know

Anterior and posterior body diagram labeled with Rule of Nines percentages
Comparison of body proportions in infant vs. adult (head size difference)

Formulas

Formula

**Total 24-hour fluid = 4 mL × body weight (kg) × %TBSA burned**

Meaning

4 mL (lactated Ringer's) × patient weight in kilograms × percentage of TBSA burned (partial- and full-thickness only) = total volume over 24 hours.

Watch Out

**CRITICAL TIMING:** Divide in half—give **50% in the FIRST 8 HOURS from time of injury** (NOT from IV insertion or ED arrival), and **50% over the next 16 hours**. If the injury was 2 hours before the IV is started, the first-8-hour volume must still be delivered by 8 hours post-injury (compressed into 6 hours). Do NOT rigidly follow the formula—**titrate IV rate based on urine output**, not the calculated rate.

When To Use

For any partial-thickness or full-thickness burn >15% TBSA in adults (>10% TBSA in children) requiring IV resuscitation; calculate immediately upon admission.

Formula

**Hourly infusion rate (first 8 hours) = Total 24-hour volume ÷ 8 hours**

Meaning

Divide the total 24-hour Parkland volume by 8 to get the mL/hr rate for the first 8 hours post-injury.

Watch Out

This is a **starting point only**. Inadequate urine output = increase rate. Excessive urine output or rising creatinine = decrease rate. Do NOT blindly follow the calculated rate.

When To Use

Initial IV rate setting; must be adjusted based on hourly urine output assessment.

Formula

**Target urine output: 0.5 mL/kg/hr (adults) or 1 mL/kg/hr (children)**

Meaning

Multiply body weight in kg by 0.5 (adults) or 1 (children) to get target hourly urine output in mL. This is the **gold standard for assessing adequacy of resuscitation**.

Watch Out

**Urine output trumps the Parkland formula.** If output is low, increase fluids. If output is high or patient has rising creatinine, decrease fluids. In electrical burns with rhabdomyolysis, target urine output is higher (up to 1–1.5 mL/kg/hr) to flush myoglobin.

When To Use

Every hour—assess urine output and adjust IV rate to meet or maintain target output. Most reliable indicator of adequate perfusion.

Common Values

Value

4 mL/kg/%TBSA

Symbol

4 mL

Quantity

Parkland formula constant

Value

50% of 24-hour total

Symbol

T/2

Quantity

First 8-hour portion

Value

50% of 24-hour total

Symbol

T/2

Quantity

Remaining 16-hour portion

Value

0.5 mL/kg/hr (~30–50 mL/hr)

Symbol

Quantity

Target urine output (adults)

Value

1 mL/kg/hr

Symbol

UO_peds

Quantity

Target urine output (children)

Value

1–1.5 mL/kg/hr

Symbol

UO_rhabdo

Quantity

Target urine output (rhabdo/electrical)

Section Title

Parkland (Baxter) Formula for Fluid Resuscitation

Important Facts

**Worked example:** 70 kg adult with 50% TBSA burn. 4 × 70 × 50 = 14,000 mL total in 24 hours. First 8 hours: 7,000 mL (875 mL/hr). Next 16 hours: 7,000 mL (437 mL/hr). **BUT adjust based on urine output**.
**Urine output is the BEST indicator of adequate resuscitation**—not blood pressure, not heart rate, not the formula rate.
Target urine output of **0.5 mL/kg/hr (~30–50 mL/hr for 70 kg adult)** or **1 mL/kg/hr in children** or **burn patients with electrical injury/rhabdomyolysis**.
**Overresuscitation risks:** fluid overload, pulmonary edema, compartment syndrome. **Underresuscitation risks:** shock, acute kidney injury, death.
Fluid shifts are **greatest in the first 8–12 hours**; after 24–48 hours capillary integrity returns and diuresis begins (watch for fluid overload then).
**Insert foley catheter immediately** to monitor hourly urine output; this is mandatory for burn >15% TBSA.
**Electrical burns with rhabdomyolysis** require even higher urine output target (1–1.5 mL/kg/hr) to prevent acute kidney injury from myoglobin precipitation.

Key Definitions

Term

Lactated Ringer's (LR) Solution

Example

Used for all Parkland formula calculations; never use normal saline alone for burn resuscitation.

Definition

Crystalloid of choice for burn resuscitation; contains potassium, sodium, chloride, calcium, and lactate (converted to bicarbonate by liver); **normal saline alone causes hyperchloremic metabolic acidosis**.

Term

Hypovolemia (Burn Shock)

Example

If Parkland formula is delayed or inadequate, patient develops shock: ↓BP, ↑HR, ↓LOC, acidosis.

Definition

Severe loss of intravascular fluid into the interstitium due to increased capillary permeability; major threat in emergent phase; prevented/treated by timely Parkland resuscitation.

Diagrams To Know

Timeline showing Parkland formula timing: injury → 8-hour mark (50% fluid delivered) → 24-hour mark (100% delivered) with urine output checkpoint every hour
Flowchart: assess urine output → if low, increase IV rate | if high, decrease IV rate | recheck hourly

Section Title

Emergent (Resuscitative) Phase—Onset to 24–48 Hours

Important Facts

**AIRWAY FIRST**—assess for inhalation injury; intubate early if facial burns, singed nasal hairs, sooty sputum, or stridor (swelling can close airway in hours).
Suspect **carbon monoxide poisoning**; give **100% humidified oxygen** (if unresponsive, consider hyperbaric oxygen).
**Large-bore IV access (two 18G or larger)** immediately; insert **Foley catheter** to monitor urine output hourly.
**Pain management: IV opioids ONLY** (IM/SC absorption unreliable with edema and poor perfusion); titrate IV morphine or fentanyl to effect.
**Keep patient warm and NPO** (risk of paralytic ileus); cover with sterile dry sheet to minimize heat loss and contamination.
**Circumferential burns** of limb or chest risk compartment syndrome/airway obstruction → may need **escharotomy** (no anesthesia needed; eschar is painless).
Monitor for **hyperkalemia** (peaked T waves, dysrhythmias) and **hyponatremia** (seizures, altered LOC); obtain baseline labs and repeat frequently.
**Tetanus prophylaxis** required (burns are tetanus-prone).
Mark burn borders with a pen for tracking progression and swelling.
**Avoid hypothermia**—burns cause rapid heat loss; prevent external exposure to cold environments.

Key Definitions

Term

Third Spacing

Example

In first 24–48 hours post-burn, fluids pour into burn wounds and surrounding tissue, shrinking the blood volume despite massive fluid administration.

Definition

Fluid shift from intravascular space into interstitium (tissue) due to increased capillary permeability; causes edema, hypovolemia, and hemoconcentration (↑Hb, ↑Hct).

Term

Hyperkalemia (Emergent Phase)

Example

Severe burn causes rhabdomyolysis and electrolyte chaos; monitor ECG for peaked T waves; may need calcium gluconate, insulin/dextrose, or dialysis.

Definition

Elevated serum potassium due to massive cell destruction (lysis) releasing intracellular K⁺; risk of cardiac dysrhythmias, peaked T waves, widened QRS.

Term

Hyponatremia (Emergent Phase)

Example

Despite IV fluid administration, serum Na⁺ may be low; avoid hypotonic fluids; use LR (which is relatively hypotonic).

Definition

Low serum sodium because Na⁺ is trapped in edema fluid (third space) and diluted by hypotonic fluids; risk of seizures, altered LOC.

Term

Inhalation Injury

Example

Fire in enclosed room → sooty sputum, stridor, hoarseness → intubate early before swelling closes airway; give 100% humidified O₂.

Definition

Damage to airway/lungs from heat, smoke, gases, or carbon monoxide; risk of airway edema, respiratory failure, death; leading cause of early burn mortality.

Term

Escharotomy

Example

Circumferential burn of entire arm → compartment syndrome risk → escharotomy to decompress and restore distal perfusion.

Definition

Surgical incision through full-thickness eschar to relieve circumferential constriction of limb or chest; restores circulation and breathing; performed without anesthesia (eschar is painless).

Diagrams To Know

Cross-section showing third spacing: fluid leaves intravascular space → edema forms → burn wound swells
Decision tree: facial burns or singed hairs → suspect inhalation injury → give 100% O₂ → intubate if stridor

Section Title

Acute Phase—From 48–72 Hours Until Wound Closure

Important Facts

**Diuresis begins 48–72 hours post-injury**; fluid shifts back into vascular space → ↑urine output, risk of overhydration → **reduce IV rate** to avoid pulmonary edema.
**Hypermetabolism** is extreme; provide **high-calorie, high-protein nutrition** (up to 3000+ kcal/day for large burns); use **enteral feeding if possible** (better outcomes, cheaper, maintains gut flora).
**Early enteral feeding** (within 24–48 hours) reduces sepsis risk and supports healing; add **vitamin C, vitamin A, zinc** as supplements.
**Hypokalemia develops** as K⁺ re-enters cells and is lost in urine → supplement with oral/IV KCl; monitor ECG and K⁺ levels frequently.
**Wound care:** daily cleansing, debridement of dead tissue (eschar), application of **topical antimicrobial** (silver sulfadiazine, mafenide acetate), sterile dressings.
**Autografting** (skin graft from patient's own unburned skin) is the definitive treatment for full-thickness burns; temporarily use **allograft** (cadaver skin) or **xenograft** (pig skin) as biologic dressing.
**Infection prevention:** strict aseptic technique, isolation precautions, no prophylactic systemic antibiotics (causes resistance); culture wounds and start antibiotics **only if sepsis documented**.
**Prophylactic Curling ulcer prevention:** proton pump inhibitor (omeprazole) or H2-blocker (famotidine); monitor for melena, hematemesis.
**Begin positioning and splinting** early to prevent contractures (most common late complication).
**Infection signs (subtle in burns):** altered mental status, ileus, unexplained tachycardia, fever, hyperglycemia in non-diabetic patient → suspect sepsis.

Key Definitions

Term

Diuresis (Acute Phase)

Example

By day 2–3 post-burn, swelling decreases and patient enters diuretic phase; IV rate must be reduced to avoid volume overload.

Definition

Fluid shift back from interstitium into intravascular space as capillary integrity returns; increased urine output (may exceed 200 mL/hr); risk of fluid overload and pulmonary edema.

Term

Hypokalemia (Acute Phase)

Example

As acute phase progresses, despite earlier hyperkalemia, K⁺ may drop → supplement with KCl; monitor K⁺ levels and ECG.

Definition

Low serum potassium as K⁺ re-enters cells (healing) and is lost in increased urine output; risk of dysrhythmias, muscle weakness, ileus.

Term

Curling Ulcer (Stress Ulcer)

Example

Prophylactic proton pump inhibitor (omeprazole) or H2-blocker (famotidine) given routinely to prevent Curling ulcer.

Definition

Acute gastric ulcer that develops in burn patients due to stress, decreased gastric pH, and compromised mucosal perfusion; risk of GI bleed.

Term

Burn Sepsis

Example

Monitor for mental status changes, feeding intolerance, or unexplained tachycardia; obtain blood cultures; start broad-spectrum antibiotics only if documented infection (not prophylactically).

Definition

Systemic infection from colonization of devitalized burn tissue; leading cause of late burn death; presents with subtle signs: altered LOC, ileus, temp/glucose instability, rather than classic fever.

Diagrams To Know

Timeline: emergent phase (0–48 hr, third spacing, hyperkalemia) → acute phase (48 hr–closure, diuresis, hypokalemia, infection risk) → rehabilitation phase
Wound care cycle: assess → cleanse → debride → apply topical antimicrobial → dress → assess infection signs daily

Section Title

Rehabilitation Phase—From Wound Closure Onward

Important Facts

**CONTRACTURE PREVENTION** is the central goal: position joints in **extension** (not flexion), use **splints** (overnight), and perform **active/passive ROM** exercises multiple times daily.
**Pressure garments** (compression sleeves, gloves, wraps) worn **up to 23 hours/day** for months/years to reduce hypertrophic scarring and contracture; educate patient on importance of compliance.
**Early mobilization** and exercise are critical; even acute phase, position patient and encourage movement to prevent stiffness.
**Psychological support** essential—body-image disturbance, depression, PTSD common; connect patient with support groups, counseling, social work.
**Community reintegration:** help with vocational rehabilitation, return-to-work planning, school reentry for pediatric patients.
**Scar appearance improves over 12–24 months**; manage expectations—scars do not completely disappear.
**Itching is common** post-burn; manage with **antihistamines, moisturizers, pressure garments**; reassure patient it decreases over time.
**Serial releases** (surgical revision) may be needed if contractures form despite prevention efforts.
Continue **vitamin C, vitamin A, zinc supplementation** through rehabilitation phase to optimize healing.
Monitor for **functional limitations**—fingers, hands, eyelids, joints most critical for quality of life.

Key Definitions

Term

Contracture

Example

Burn over knee heals with tight scar → knee flexed permanently unless actively stretched and positioned in extension → loss of function.

Definition

Shortening of scar tissue across a joint, limiting movement and causing permanent disfigurement/disability; the major late complication of burn injury.

Term

Hypertrophic Scarring

Example

Burn that takes 3+ weeks to heal often develops hypertrophic scar; pressure garment compression reduces collagen deposition.

Definition

Excessive scar tissue formation (raised, red, itchy scar); common in deep partial-thickness burns; minimized by **pressure garments** (23 hr/day for months).

Term

Scar Maturation

Example

Tell patient that red, raised scar at 3 months will likely improve over the next year with continued pressure garment use and range-of-motion exercise.

Definition

Process of scar tissue remodeling over 1–2 years post-injury; scar gradually fades from red to pale, flattens, and becomes more pliable; patient education essential.

Diagrams To Know

Positioning guide: elbow, knee, hip, shoulder in extension (not flexion) to prevent contractures
Timeline of scar maturation: red/raised at 3 months → gradual fade to pink at 6–12 months → pale/flat at 12–24 months

Section Title

Burn Pharmacology: Topical Antimicrobials & Systemic Drugs

Important Facts

**Silver sulfadiazine:** broad-spectrum, painless application, **transient leukopenia common but self-limiting**; watch **sulfa allergy, pregnancy, newborns**.
**Mafenide acetate:** best penetration through eschar (use on ears, nose, cartilage areas); **painful**, causes **metabolic acidosis**—monitor ABGs, may need systemic treatment.
**IV opioids ONLY** for burn pain—IM/SC won't work due to edema and poor perfusion; use **continuous infusion + boluses** for dressing changes; consider **procedural sedation** (midazolam, propofol) for major dressing changes/debridement.
**Systemic antibiotics ONLY for documented infection**, not prophylactically—resistant organisms develop with indiscriminate use; obtain cultures before starting.
**Escharotomy performed without anesthesia** because eschar is painless (nerves destroyed).
**Tetanus prophylaxis mandatory**—burns are highly susceptible wound; verify and update status immediately.
Monitor **mafenide acetate use** for **metabolic acidosis** (rapid, shallow breathing, ↓pH, ↓HCO₃); may need IV sodium bicarbonate.
Topical antimicrobials applied **daily after cleansing**; some sources recommend **twice daily** for heavy contamination.
**Enzymatic debridement agents** (collagenase) may be used to selectively remove dead tissue without harming viable tissue.

Key Definitions

Term

Silver Sulfadiazine (Silvadene)

Example

Applied daily to clean burn wounds as primary topical agent; contraindicated in sulfa allergy, near-term pregnancy, and newborns (risk of kernicterus).

Definition

Broad-spectrum topical antimicrobial of choice for most burns; bactericidal against Gram + and Gram − organisms and fungi; watch for **transient leukopenia** and **sulfa allergy**.

Term

Mafenide Acetate

Example

Used for deep burns over cartilage (ears, nose) where penetration is critical; warn patient about pain on application and monitor acid-base status.

Definition

Topical antimicrobial that **penetrates eschar well** (good for cartilage, ears, nose); bacteriostatic; **painful on application** and causes **metabolic acidosis** by inhibiting carbonic anhydrase.

Term

Burn Analgesia Strategy

Example

During dressing changes and debridement, give IV fentanyl 50–100 mcg + midazolam 2–4 mg IV 15–30 min before procedure; continue baseline IV morphine for continuous pain control.

Definition

**IV opioids only** (morphine, fentanyl) during emergent/acute phases; IM/SC absorption unreliable due to edema and poor perfusion; titrate to effect; consider anxiolytic (midazolam) for procedural pain.

Term

Tetanus Prophylaxis

Example

Obtain tetanus history on admission; update immediately; document in chart.

Definition

All burns are tetanus-prone wounds; give **tetanus toxoid IM** (0.5 mL) if last dose >5 years ago, or **tetanus immunoglobulin (TIG) + toxoid** if unknown history and full-thickness burn.

Diagrams To Know

Decision tree: wound type → if cartilage/ears → consider mafenide | if standard → silver sulfadiazine | both penetration + toxicity considerations
Pain management algorithm: baseline pain → continuous IV opioid infusion | procedural pain → bolus IV opioid + anxiolytic

Section Title

Dermatologic Disorders: Dermatitis (Eczema)

Important Facts

**Trigger identification and avoidance** is THE most important treatment for dermatitis—remove irritant/allergen, skin improves.
**Emollients and moisturizers** are foundation of therapy—apply immediately after bathing to damp skin; use fragrance-free (fragrance is irritant).
**Topical corticosteroids** for acute flares—low potency (hydrocortisone) for face/intertriginous areas; medium/high potency (triamcinolone, fluocinonide) for body; short-term use to avoid atrophy.
**Antihistamines** (cetirizine, loratadine, diphenhydramine) reduce itch; diphenhydramine causes sedation (useful at bedtime to prevent nocturnal scratching).
**Avoid scratching**—educate on itch-scratch cycle: itch → scratch → skin barrier breaks → secondary infection → worse dermatitis; trim nails, use mittens.
**Secondary infection risk**—if lesions ooze, crust, or worsen, suspect **impetigo** (Streptococcus/Staphylococcus); obtain culture, start topical/oral antibiotics.
**Bath/shower practices:** use **lukewarm water** (hot water dries skin), **mild cleansers**, **pat dry gently**, apply moisturizer immediately.
**Atopic dermatitis is lifelong** but manageable; reassure patient symptoms improve with consistent skincare and trigger avoidance.
**Flares often triggered by** stress, weather changes, infection, harsh soaps, overwashing; identify personal triggers with patient.

Key Definitions

Term

Contact Dermatitis

Example

Nurse develops red, itchy skin on hands from frequent hand sanitizer/glove use → switch to gentler soap, moisturize frequently, avoid trigger.

Definition

Acute inflammatory response to an irritant (soap, detergent) or allergen (latex, poison ivy); presents with erythema, pruritus, scaling, sometimes blistering; resolves when trigger removed.

Term

Atopic Dermatitis (Eczema)

Example

Child with eczema on cheeks, neck, antecubital fossae; intense itching → scratching → secondary infection risk; manage with daily moisturizers, topical steroids, identify triggers.

Definition

Chronic inflammatory skin condition (often with family/personal history of allergy/asthma); erythematous, pruritic, dry skin; flares triggered by irritants, stress, weather; **not contagious**.

Term

Pruritus (Itch)

Example

Teach patient **not to scratch** (trim nails, use mittens, keep hands busy); apply **cool compresses, moisturizer** frequently; use **antihistamine** (cetirizine) if needed.

Definition

Urge to scratch; in dermatitis, caused by inflammation, dryness, histamine release; scratching breaks skin barrier → infection risk.

Diagrams To Know

Itch-scratch cycle: inflammation → pruritus → scratching → skin barrier disruption → secondary infection → worsening inflammation; break cycle with moisturizer, antihistamine, behavioral strategies
Topical steroid potency guide: low (hydrocortisone) → medium → high; face/skin folds = low; body = medium/high

Section Title

Dermatologic Disorders: Psoriasis

Important Facts

**Psoriasis is NOT contagious**—educate patient and family to reduce stigma and isolation.
**Topical corticosteroids and calcipotriene (vitamin D analogue)** are first-line for mild-moderate disease; apply to plaques.
**Coal tar preparations** reduce inflammation and cell turnover; use for scalp psoriasis; stains skin/clothes; antiquated but still effective.
**Phototherapy (UVB)** effective for generalized psoriasis; requires multiple sessions over weeks; specialist dermatology.
**Systemic agents for severe/resistant psoriasis:** **methotrexate** (immunosuppressant, monitor CBC/LFTs), **biologic agents** (TNF inhibitors—infliximab, etanercept; IL-17/IL-23 inhibitors—secukinumab, ixekizumab); all carry infection risk.
**Trigger management:** stress reduction, infection control (promptly treat strep throat), avoid alcohol and smoking, weight loss if overweight.
**Scalp psoriasis:** use keratolytic shampoos (salicylic acid), coal tar shampoos; topical steroids/calcipotriene to scalp.
**Nail involvement:** nail pitting, onycholysis, discoloration; difficult to treat; may improve with systemic agents.
**Psychosocial impact significant**—psoriasis affects quality of life, self-esteem, social/sexual function; address anxiety/depression; support groups helpful.
**Monitoring on systemic agents:** CBC (methotrexate, biologic agents), LFTs (methotrexate), TB screening (biologics), regular dermatology follow-up.

Key Definitions

Term

Psoriasis

Example

Patient with bright red, scaly patches on elbows and knees that do not improve with topical steroids alone; may have nail pitting, family history of psoriasis.

Definition

Chronic autoimmune disorder of accelerated epidermal cell turnover; **NOT contagious**; presents with **well-demarcated, raised, red plaques covered in silvery-white scales**; commonly on extensor surfaces (elbows, knees, scalp, sacrum), nails.

Term

Remitting-Relapsing Course

Example

Patient in remission for months, then develops strep throat → psoriasis suddenly flares; manage stress and infection aggressively to minimize flares.

Definition

Psoriasis characteristically cycles between periods of flare (worsening) and remission (improvement); triggered by stress, infection (strep), certain drugs (beta-blockers), alcohol, smoking.

Term

Metabolic Syndrome Association

Example

Psoriasis patient should be screened for hypertension, dyslipidemia, diabetes; lifestyle modifications reduce disease burden and CV risk.

Definition

Psoriasis is associated with **increased cardiovascular risk**, obesity, type 2 diabetes, and metabolic syndrome; screen and counsel on weight, exercise, smoking cessation.

Diagrams To Know

Psoriasis flare triggers: stress, infection (strep), drugs (beta-blockers), alcohol, smoking → accelerated cell turnover → plaques; manage triggers to reduce flares
Treatment hierarchy: mild (topical steroids, calcipotriene) → moderate (phototherapy, coal tar) → severe (methotrexate, biologics)

Section Title

Dermatologic Disorders: Cellulitis & Skin Infections

Important Facts

**Risk factors for cellulitis:** breaks in skin (wounds, insect bites, athlete's foot, ulcers), venous/lymphatic insufficiency, obesity, diabetes, immunosuppression.
**Signs of cellulitis:** erythema, warmth, edema, tenderness, **poorly defined borders**; may have fever, chills, malaise.
**MRSA risk factors:** recent hospitalization, healthcare worker contact, IV drug use, previous MRSA infection/colonization, recurrent skin infections.
**Empiric antibiotics** without waiting for culture if cellulitis clinically obvious; obtain culture if abscess present or patient toxic; Gram stain not reliable for cellulitis.
**Elevation of affected limb** reduces swelling; **warm compresses** comfort; **mark border of redness with pen** to track progression and measure response to antibiotics (redness should recede within 24–48 hrs).
**Beware of rapid progression, lymphangitic streaks, fever, or signs of systemic toxicity** → escalate to IV antibiotics and consider hospitalization; risk of **necrotizing fasciitis** (surgical emergency).
**Impetigo (superficial skin infection):** honey-crusted lesions, highly contagious; treat with **topical antibiotics** (mupirocin) for localized, **oral antibiotics** (amoxicillin-clavulanate, cephalexin) for widespread; excellent hygiene to prevent spread.
**Herpes zoster (shingles):** painful vesicular rash in dermatomal distribution (reactivation of varicella-zoster); treat with **antivirals** (acyclovir 800 mg 5×/day, or valacyclovir 1 g TID) if started within 72 hours of rash onset; **contact/airborne precautions** if disseminated or immunocompromised.
**Fungal infections (tinea, candidiasis):** treat with **topical antifungals** (miconazole, clotrimazole, terbinafine) or **systemic antifungals** (fluconazole, itraconazole) if widespread; **keep area dry** (moisture promotes fungal growth); treat for full duration (3–4 weeks typical).
**Complications of untreated cellulitis:** abscess formation, necrotizing fasciitis, sepsis, bacteremia, death; emphasize importance of completing antibiotics.

Key Definitions

Term

Cellulitis

Example

Patient with puncture wound on foot → enters stream playing → develops warm, red, tender swelling with diffuse borders on lower leg within 24–48 hours → cellulitis.

Definition

Acute bacterial infection of the dermis and subcutaneous tissue; usually from **Streptococcus pyogenes (Group A Strep) or Staphylococcus aureus** (including MRSA); enters through break in skin (wound, insect bite, athlete's foot).

Term

Cellulitis vs. Erysipelas

Example

Cellulitis on leg = warm, red, tender, borders not raised, ill-defined. Erysipelas on cheek = bright red, raised border, sharply demarcated, facial edema.

Definition

**Cellulitis:** deeper infection (dermis, subcutaneous), diffuse borders, less superficial. **Erysipelas:** superficial infection (upper dermis), raised borders, brighter red, more toxic appearance, often on face.

Term

Systemic Antibiotics for Cellulitis

Example

Mild cellulitis without systemic toxicity → cephalexin 500 mg PO QID × 10–14 days. Severe cellulitis/fever/immunocompromised → cefazolin 1 g IV Q6H + consider vancomycin.

Definition

Empiric coverage for **Strep and Staph** (including MRSA if risk factors); first-line = **cephalexin or dicloxacillin** (oral for mild) or **cefazolin IV** (moderate/severe); add **vancomycin or clindamycin** if MRSA suspected.

Term

Lymphangitic Streaking

Example

Cellulitis on hand with red streaks up forearm to axillary nodes → concerning for rapid spread → IV antibiotics, possible hospitalization.

Definition

Red, warm streaks along lymphatic vessels extending from cellulitis site toward regional lymph nodes (lymphadenitis); sign of rapidly spreading infection, requires escalation of therapy.

Diagrams To Know

Decision tree: cellulitis suspected → assess for MRSA risk → no MRSA → cephalexin/dicloxacillin | MRSA risk → vancomycin/clindamycin | systemic toxicity/fever → IV antibiotics + consider hospitalization
Cellulitis vs. erysipelas comparison: cellulitis = deeper, diffuse, ill-defined | erysipelas = superficial, raised borders, sharply demarcated

Must Remember

**Parkland Formula (4 mL × kg × %TBSA over 24 hrs): Half in first 8 hours from TIME OF INJURY, half over next 16 hours—titrate based on urine output (0.5 mL/kg/hr adults, 1 mL/kg/hr children), NOT the calculated rate.**
**Rule of Nines (adults): Head/neck 9%, each arm 9%, anterior trunk 18%, posterior trunk 18%, each leg 18%, perineum 1%. ONLY count partial- and full-thickness burns—exclude superficial (first-degree) burns from TBSA.**
**Burn Classification: Superficial = red/dry/painless/blanches, no scarring | Superficial partial-thickness = blistered/moist/MOST PAINFUL/blanches/2–3 week heal | Deep partial = red-waxy/less pain/slow refill/may graft | Full-thickness = white-leathery/PAINLESS/NO blanch/requires graft.**
**Emergent Phase (0–48 hrs): Hyperkalemia + hypovolemia (fluid shifts out); threat = burn shock. Acute Phase (48 hrs–closure): Hypokalemia + diuresis; threat = infection/sepsis. Rehabilitation: Threat = contractures (position extension, splint, mobilize).**
**Airway is FIRST priority in burns—suspect inhalation injury if facial burns, singed nasal hairs, sooty sputum, stridor, or hoarseness. Give 100% humidified oxygen for carbon monoxide poisoning. Intubate early if airway edema developing (swelling closes airway rapidly).**
**Burn Pain Management: IV opioids ONLY (IM/SC unreliable with edema); give continuous infusion + boluses for procedures. Mafenide acetate causes metabolic acidosis and severe pain on application. Silver sulfadiazine can cause transient leukopenia—avoid in sulfa allergy, newborns, near-term pregnancy.**
**Topical Antimicrobials: Silver sulfadiazine = broad-spectrum, painless, poor eschar penetration | Mafenide acetate = excellent eschar penetration (use on ears/nose/cartilage), painful, causes acidosis. Apply daily to clean wounds.**
**Dermatitis Management: Identify and remove trigger; use emollients/moisturizers (fragrance-free), topical steroids for flares, antihistamines for itch; teach NOT to scratch (breaks barrier, invites infection). Atopic eczema is lifelong but manageable.**
**Psoriasis: Well-demarcated silvery plaques on extensor surfaces, autoimmune, NOT contagious, lifelong remitting-relapsing course. Triggers = stress, infection (strep), drugs, alcohol, smoking. Treat with topical steroids, calcipotriene, phototherapy, systemic agents (severe).**
**Cellulitis: Acute bacterial infection (Strep, Staph, MRSA) of dermis/subcutaneous with warm, red, edematous area and POORLY DEFINED borders. Treat with systemic antibiotics (cephalexin or dicloxacillin for non-MRSA; add vancomycin/clindamycin for MRSA), elevation, warm compresses. Mark border with pen to track progression.**

Last Minute Tips

**On exam, if asked about burn resuscitation: 'How much fluid and when?'—Always answer 'Parkland formula: half in first 8 hours from TIME OF INJURY, other half over next 16 hours; titrate based on urine output 0.5 mL/kg/hr.'** Examiners test this relentlessly because it's lifesaving.
**When a burn question lists symptoms (singed nasal hairs, sooty sputum, stridor), immediately flag inhalation injury and 100% O₂—this is a high-mortality complication that requires immediate action. Don't delay intubation waiting for labs.**
**For any skin condition question, check for 'red flags' signaling infection (purulent drainage, warmth, spreading borders, fever, lymphangitic streaks, altered LOC). If present, escalate to IV antibiotics and consider hospitalization—don't rely on topical agents alone.**
**Psoriasis vs. eczema confusion on exam: Remember psoriasis = silvery PLAQUES on extensor surfaces, not very itchy, autoimmune. Eczema = erythematous, dry, intensely itchy, often flexural (arms/behind knees), allergic/atopic. Psoriasis is lifelong; eczema may improve with moisturizing.**
**In burn phases: Emergent phase = IV fluids are HERO (Parkland). Acute phase = wound care + infection control are HERO (topical agents, clean dressings, early feeding). Rehab phase = positioning + splinting + pressure garments are HERO (prevent contractures). Each phase has different priorities—don't confuse them.**

Comparison Tables

Rows

Values

Epidermis only
Red, dry
Painful
Yes
No
3–6 days
No

Property

Superficial (1st)

Values

Epidermis + upper dermis
Red, moist, blistered
SEVERE pain
Yes
Yes
2–3 weeks
No (usually)

Property

Superficial Partial (2nd)

Values

Deep dermis
Red to waxy white, drier
Less pain (some nerve damage)
Slow
Yes
2–3+ weeks
Possibly

Property

Deep Partial (2nd)

Values

Epidermis, dermis, subcutaneous
White/tan/brown/charred, leathery
PAINLESS (nerves destroyed)
No
No
Weeks to months (requires grafting)
Yes (mandatory)

Property

Full-Thickness (3rd)

Values

Muscle, fascia, bone
Charred, mummified
Painless
No
No
Months or amputation
Yes or amputation

Property

Fourth-Degree

Columns

Burn Degree
Depth Involved
Color/Appearance
Pain Level
Blanches?
Blisters?
Healing Time
Grafting?

Table Title

Burn Depth Classification—Key Distinguishing Features

Rows

Values

0–48 hrs post-injury
Hypovolemia & edema
OUT (third spacing)
↑ HIGH (cell lysis)
↓ LOW (trapped in edema)
Parkland formula; aggressive IV
Burn shock, cardiac dysrhythmias

Property

Emergent

Values

48 hrs–closure
Fluid overload & infection
IN (diuresis, capillary integrity returns)
↓ LOW (K⁺ in cells, lost in urine)
Can be low or high; monitor
Reduce IV rate; monitor output
Sepsis, acute kidney injury, pulmonary edema

Property

Acute

Columns

Phase
Timeline
Primary Problem
Fluid Shift
K⁺ Status
Na⁺ Status
IV Focus
Major Threat

Table Title

Emergent vs. Acute Phase Burn Management—Fluid & Electrolyte Changes

Rows

Values

Broad (Gram +, −, fungi)
Poor (doesn't penetrate eschar)
No (painless)
Transient leukopenia (rare)
General burn wounds
Sulfa allergy, newborn, pregnancy

Property

Silver sulfadiazine (Silvadene)

Values

Broad
Excellent (penetrates eschar)
YES (very painful)
Metabolic acidosis, ototoxicity
Cartilage burns (ears, nose, joints)
Respiratory disease (worsens acidosis)

Property

Mafenide acetate

Columns

Agent
Spectrum
Penetration
Pain on Application
Side Effect Warning
Special Indication
Avoid If...

Table Title

Topical Antimicrobials for Burns—Characteristics & Use

Rows

Values

Irritant or allergen exposure
Erythema, pruritus, scaling, sometimes blisters; resolves when trigger removed
Site of exposure (hands, face, neck)
No
Remove trigger; topical steroids; emollients
No (acute, resolves)

Property

Contact Dermatitis

Values

Genetic/immune (allergy history)
Chronic erythematous, pruritic, dry skin; flares triggered by irritants, stress, weather
Face, neck, antecubital/popliteal fossae, hands
No
Emollients; topical steroids; identify triggers; antihistamines
Yes (lifelong, remitting-relapsing)

Property

Atopic Dermatitis (Eczema)

Values

Autoimmune; accelerated epidermal turnover
Well-demarcated raised red plaques with silvery-white scales; nail pitting; not itchy or only mildly so
Extensor surfaces (elbows, knees, scalp, sacrum)
No
Topical steroids, calcipotriene, coal tar; phototherapy; systemic agents (severe)
Yes (lifelong, remitting-relapsing; triggered by stress, infection, drugs)

Property

Psoriasis

Values

Bacterial (Strep, Staph, MRSA) via skin break
Erythema, warmth, edema, tenderness, poorly defined borders; fever/malaise
Site of wound/break (often lower leg, hand)
No (but contagious if open)
IV/oral antibiotics (Strep + Staph coverage); elevation; warm compresses
No (acute infection; resolved with antibiotics)

Property

Cellulitis

Values

VZV reactivation
Painful vesicular rash in dermatomal distribution; may have prodrome (pain before rash)
One dermatome (unilateral)
Yes if disseminated or immunocompromised
Antivirals (acyclovir, valacyclovir) if <72 hrs; pain management; consider antihistamines
No (resolves in weeks, but postherpetic neuralgia possible)

Property

Herpes Zoster (Shingles)

Values

Bacterial (Strep, Staph) via skin break; highly contagious
Honey-crusted lesions, sometimes vesicles/bullae; superficial
Face, extremities, areas of trauma
YES (highly contagious)
Topical antibiotics (mupirocin) for localized; oral antibiotics (amoxicillin-clavulanate, cephalexin) for widespread; strict hygiene
No (resolves with treatment)

Property

Impetigo

Columns

Disorder
Cause/Trigger
Key Features
Distribution
Contagious?
First-Line Treatment
Chronic?

Table Title

Dermatologic Disorders—Comparison of Presentation & Management

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