This Committee seeks to help organize and im- prove the high quality of the educational offerings of the American Academy of Dermatology. We also seek to improve the knowledge, skills, atti- tudes, 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 derma- tologists.
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 atti- tudes 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 Acad- emy has stated, "The ultimate goal of the educa- tional program is the maintenance and advance- ment of knowledge, skills, and attitudes in medical practice that pertain to dermatology and related disciplines." John Gardner has said, "The ul- timate goal of the educational system is to shift to the learner the burden of pursuing his own educa- tion." We feel these statements embody a satisfac- tory 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 cor- respondence and meetings. Our most difficult chal-
*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., Okla- homa City. OK.
Fig. 1. The illusion of a core common to all possible curricular descriptions.
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, re- sources 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 curri- culum provides a usefid framework for educa- tional planning by the Academy, the American Board of Dermatology, training programs, or indi- vidual dermatologists.
173
174 Core curriculum Journal of the
American Academy of Dermatology
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 resi- dency.
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 dis- eases but should give more emphasis in planning his or her continuing education to the more com- monly encountered dermatoses. Similarly, educa- tional providers should center relatively more ef- fort on the more common problems, on those with greater morbidity, mortality, or cost to the patient and society, and on those in which effective inter- vention is available. (That does not mean that rare and otherwise esoteric matters should not be con- sidered, but we want to emphasize the practical.)
7. Those practitioners whose individual activ- ities 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 con- suiting service, etc.).
8. The practitioner should know how to ap- proach problems and be able to engage effectively in problem-solving.
There is good reason to try to have a core cur- riculum "based 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 self- assessment examination), practice audits, col- league descriptions of "critical incidents," etc., and none of these are presently available. There- fore, the curriculum will have to be based upon expert and peer opinion about wants and "felt needs" rather than "demonstrated needs ."
What is a core curriculum? It is essential to ex- plore this question because only with a clear no- tion 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 prac- tice setting." Such a definition implies clearly that there will be many different core curricula, per- haps 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 appro- priately 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 many possible ways to organize one's study effort in a systemic and weighted fashion in behalf of maxi- mum effectiveness (regarding retention, under- standing, 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 " the core" outlines three levels or tiers of knowledge. One is a basic package of knowledge and skills to be had by all physi- c i a n s - f o r example, cardiopulmonary resuscita- tion, 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, dermatopathol- ogy, pediatric dermatology, dermatologic surgery, dermatologic radiotherapy, etc. It may be useful to think of distinct tiers; yet these " t iers" are interre- lated, and attempts to separate them produce artificialities.
No matter what curricular proposal is sug- gested, 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 at tempt at assisting us all toward interesting
Volume 1 Number 2 August, 1979
Core curriculum 175
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 practi- tioner 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 corre- spondence plus discussion to attain consensus among a panel that we hope was appropriately ex- pert 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 pro- grams, and so on. The curriculum that we de- veloped 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, Pills- bury, 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 advan- tages 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 Com- mittee 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 aver- aged in the manner used for computing academic grade point averages. The numerical value of the consensus ("Committee Emphasis") is found be- side the name of the category.
The variables extending along the horizontal axis were considered the most important among possible options, and also sufficiently encompass- ing. 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 vari- able. All of the cells of the matrix were then con- sidered individually. When the Committee thought
a cell deserved more or less emphasis than the general expression of emphasis shown at the top of that column, we indicated our feeling by 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 compro- mised 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 rear- ranged those remaining in order,of decreasing em- phasis.
Appendix III consists of the thirty-seven seg- ments of Appendix I that deal with areas of cogni- tive knowledge and skill, each segment "fleshed out" with more detailed description. These thirty- seven 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 per- sons 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 uni- versal are notions of core curriculum. The Com- mittee considered each of the thirty-seven sub- mitted segments and made relatively small substantive or editorial changes but has, in gen- eral, tried to accept the material provided by our invited resource persons. To each of the indi- viduals serving as the primary generator of a cur- riculum 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 accom- plished through active assessment of the learner performing the skill. This requires a great deal of individualizing (especially in surgery, for example)
176 Core curriculum Journal of the
American Academy of Dermatology
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 we 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 increas- ingly difficult to change as time goes by.
The following comments are meant to help the reader understand the perspective of the Com- mittee, and to answer some questions we antici- pate.
1. The "Other Areas of Curriculum" in Appen- dix 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 proport ion," 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, may 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 derma- tologists to work to achieve a level of mastery (which will have to be determined further by those engaged in what is technically termed "evalua- t ion").
4. The Committee does not feel that the curricu- lum should be related to the age of the practitioner.
5. This core curriculum may be used operation- ally 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. In- dividuals 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 be- come improved. The curriculum may be a guide in developing program activity by the Academy (both for its annual program and new types of program
effort it is likely to undertake) and also in the as- sistance it will provide the American Board of Der- matology 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 rela- tionship 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 con- cert 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-the- month or a category-of-the-month topic which pro- vides 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 man- agement 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 perti- nent reference. Any further self-assessment exam- inations of the Academy could be developed as small segments to be published periodically. Choice of topic should be guided by this curricu- lum.
3. The Academy should designate certain pre- sentations 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 i tems" (core curriculum refresher), they should find themselves cycled through the entire curriculum approximate- ly every six years. Also, those portions of the Academy program identified as core might perhaps be presented at regional meetings. The core ma- terial 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 177
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 med- icine. 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.
The total educational planning of the Academy should involve the major areas of: (I) needs identification, (2) setting of educational obJec- tives, (3) implementing the educational effort, and
(4) evaluating the learning. Needs identification may include the opinion obtained from a com- mittee such as this, questionnaires, self-assess- ment quizzes, American Board of Dermatology examinations, health care data involving fre- quency, 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 evalua- tion of learning can be undertaken by the Evalua- tion Committee but, preferably, in collaboration with those who select the instructional objectives and plart the learning strategies.
Appendix I
Areas of curriculum (knowledge) I Committee emphasis by disease or disease groups
Disorders of immunity, hypersensi- tivity, and inflammation (includes urticaria) 2.63
Contact dermatitis (excluding in- dustrial) 3.0t)
Atopic dermatitis 3.00 Other eczemas 3.01) Photosensitivity (drug and contact
mainly--not metabolic) 2.63
Drug eruptions 2.00 Hypersensitivity and erythemas 2.75 Psoriasis 2.38 Other papulosquamous disorders 3.00 Bullous disease 1.63 Bacterial infections 2.13 Viral infections 3.00 Rickettsial infections 1.13
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178 Core cttrriculum Journal of the
American Academy of Dermatology
Appendix I . Cont'd
Areas of curriculum (knowledge) Committee by disease or disease groups emphasis
Superficial mycotic infections 2.63 Deep mycotic infections 1.38 Trepon emal infections 2.13 Nontreponemal sexually trans-
mitted diseases--concepts 1.13 Benign reticuloendothelial diseases 1.13 Diseases of peripheral vessels and
their contents 1.50
Connective tissue diseases 2.25 Diseases of corium and subcutane-
ous tissue 1.38 Hereditary cutaneous diseases--
concepts 1.50 Disorders of cornification 1.83 Disturbances of pigmentation 1.75 Acne and acneiform dermatoses 3.00 Apocrine gland disorders; not
tumors 1.13 Eccrine gland disorders; not tumors 1.38 Disorders of the hair 1.75 Disorders of the nails 1.50 Diseases of nutrition and metabo-
lism 1.75 Tumors of the skin 3.00 Lymphomas of the skin 2,25 Reactions to physical agents 1.50 Industrial dermatoses 1.88
Parasitology and tropical dermatoses 1.13 Psychogenic and neurogenic skin
disorders 1.38 Disorders of the oral cavity 1.75
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Volume 1 Number 2 August, 1979
Core curriculum 179
Appendix I. Cont'd
Other areas of curriculum Committee emphasis Other areas of curriculum
I Committee emphasis
Understanding statistics and scien- tific reasoning in the dermatologic literature 2.38
Core material, summarizing other disciplines, that seems pertinent to dermatology 2.00
Practice management 2.38 Medicolegal 2.50 Medical politics 2.50 Immunofluorescence 1.88 Surgery 2.25 Ionizing radiologic therapy 1.50 Ultraviolet therapy 1,88 Pharmacotherapy (including drug-
drug interactions) 2.88
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
Areas of curriculum (knowledge) Committee by disease or disease groups emphasis
+ + + + + + +
! !
Management + + + + + +
k~
+ +
¢1
Contact dermatitis (excluding industrial) 3,00
Atopic dermatitis 3.00 Other papulosquamous 3.00 Viral infections 3.00 Acne and acneiform eruptions 3.00 Tumors of the skin 3.00 Hypersensitivity and eryth-
emas 2.75 Photosensitivity (drug and
contact mainly--not metab- olism) 2.63
Superficial mycotic infections 2,63 Disorders of immunity, hyper-
sensitivity, and inflamma- tion (includes urticaria) 2.63
continued
180 Core c twr icu lum Journal of the
American Academy of Dermatology
Appendix I I . C o n t ' d
Areas of curriculum (knowledge) by disease or disease groups
I Committee emphasis
Psoriasis 2,38 Connective tissue disease 2.25 Lymphomas of the skin 2.25 Medical emergencies 3.00 "Attitude"
Interest 3.00 Enthusiasm 3.00 Seeks own continuing educa-
tion 3.00 Concern for patient as "whole
person" 3.00 Seeks colleague contact 2.88 Concern for cost control 2.88 Concern for preventing prob-
lems 2.88 Pharmacotherapy (including
drug-drug interactions 2.88 Medicolegal 2.50 Medical politics 2.50 Dermadromes 2,50 Dermatopathology 2.38 Practice management 2.38 Understanding statistics and
scientific reasoning in the dermatologic literature 2.38
Surgery 2.25 Allergy-immunology 2.25
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+ + + + + +
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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 hypogammaglobu- linemia
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 mono-
phosphate (AMP); prostaglandins
Volume 1 Number 2 August, 1979
Core curriculum 181
II.
III.
Nature of anaphylaxis
Urticaria and angioedema
A. Allergic B. Contact C. Physical D. Secondary E. Cholinergic F. Hereditary G. Idiopathic
Contact 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 dis- tinguishing 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 preven- tion.
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) pru- ritus; (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 cholin- ergic 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.
7. Most evidence indicates that IgE does not have a pathogenic role in atopic dermatitis.
8. Over 90% of AD patients are colonized with patho- genic Staphylococcus aureus, and superficia/ Staphylococcus pustulations are probably more common than previously realized.
9. Leukocyte function abnormalities, including de- pressed lymphocyte transformation, decreased neutrophil and monocyte chemotaxis, and de- creased T cell rosettes, have been clearly demon- strated in AD. However, these defects appear to be transient and correlate directly with clinical sever- ity.
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, hyperpig- mentation, thickening, and lichenification.
3. Microscopic features. 4. Understanding of phenomenon of autoeczematiza-
tion in all forms of eczema. 5. Recognition of nonspecific aspects of care: Freedom
from mechanical and chemical irritation; symptomat- ic 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 ec- zemas: a. Seborrheic dermatitis: Special care appropriate
to management of scalp, external ears, and ear canals.
b. Nummular dermatitis: Recognition of such im- portant background factors as atopy, asteatosis, and cutaneous or focal bacterial infection.
182 Core c u r r i c u l u m Journal of the
American Academy of Dermatology
c. Lichen simplex chronicus: Relation to psycho- logic factors; clinical variations such as prurigo and "old-old" disease.
d. Stasis dermatitis: Role of mechanical and hemo- dynamic factors; role for special aspects of care such as surgery, Unna type boots, diuretics, elas- tic stocking counterpressure, prevention of sen- sitization.
e. Chronic nonspecific eczematous dermatitis. f. Infectious eczematoid dermatitis. g. Infantile eczema: Special considerations of con-
tact, 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 photo-
allergic) + + + 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 im- portant), the porphyrias, lupus erythema- tOSUS, etc.
+ + + E. Mechanisms 1. Absorption and action spectrum 2. Photosensitivity
a. Phototoxic: Photodynamic and nonphoto- dynamic
b. Photoallergic: Immediate or delayed F. Other laboratory procedures
(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 (sys- temic)
III. Photosensitivity to endogenous origin (e.g., por- phyrias, lupus erythematosus, PMLE, xeroderma pigmentosum)
Drug eruptions Seymour I. Shapiro, M.D. Tucson, AZ
1. Multiform cutaneous manifestations of drug erup- tions.
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 per-
sonal care products. 5. Characteristics of allergic (vs nonallergic) drug reac-
tions. 6. Unreliability of skin tests in suspected drug aller-
gies. 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 curr icuh lm 183
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 chal- lenging problems of management.
I. Simple erythemas
A. Recognize possible relation to fever, blushing, physical factors, mastocytosis, carcinoid syn- drome, drug reactions, collagen vascular dis- eases, infectious illnesses, etc.
ti. Erythema ab igne
A. Recognize clinical features, cause, benignity, and inadequacy of therapy
III. Erythema multiforme and erythema nodosum
A. A symptom complex, not a disease B. Multiplicity of triggering circumstances C. Clinical features D. Microscopic features E. Differential diagnosis (include reasonable lab-
oratory tests) F. Treatment G. Course
IV. Figurate and fixed erythemas (erythema annulare centrifugum, erythema marginatum, erythema dyschromicum perstans, erythema chronicum mi- grans, 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 unsuc-
cessful)
V. Erythema neonatorum toxicum
A. Identification of it via clinical features and smear of pus
B. Knowledge of its benignity and noncontagi- ousness
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 va- riety usually related to a drug reaction
C. Importance of antibiotics in childhood variety and very good supportive care in all patients
(especially adults where the care should be like the care provided in burn units); usually avoid corticosteroids in children
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
Beh~et's syndrome
A. Features that permit diagnosis B. Relationship to involvement of other organs C. Inadequacy of present treatment D. 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, NY
1. Typical and atypical forms, differential, and the occa- sional need to biopsy.
2. Genetics and epidermal kinetics. 3. Characteristic histopathology related to characteris-
tic clinical forms. 4. Most patients can be treated with conventional
topical methods; the role of topical steroids, includ- ing 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 varia-
tions B. Major differential diagnosis (psoriasis, syphilis,
drug eruption, seborrheic dermatitis, fungal in- fection, parapsoriasis)
' VIII.
184 C o r e cttrriculum Journal of the
American Academy of Dermatology
C. Need to keep therapy minimal, safe, and inex- pensive
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 in-
stances C. The role of oral vitamin A therapy, and various
symptomatic topical measures
Ill. Lichen planus A. Knowledge of usual clinical features and un-
common 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-Haber-
mann 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 discour-
aging 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 at-
tempt 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 compli- cations 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, NC
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 in-
direct irnmunofluorescence. 5. Relation of disease to antibody titer. 6. Evidence for an autoimmune pathogenesis. 7. When to treat with systemic corticosteroids, cyto-
toxic agents, and/or gold; knowledge of proper labo- ratory 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 or- ganisms.
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 infec- tions. Be able to generate a useful classification of primary and secondary infections.
5. The clinical signs and symptoms, differential diag- nosis, prognosis, and treatment for the common cuta- neous infections*; know how to get the necessary corresponding information for the uncommon infec- tions.
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 impor- tant systemic effects.
*impetigo, erythema, varieties of folliculitis and boils, cellulitis including erysipelas, paronychia.
Volume 1 Number 2 August, 1979
Core curriculum 185
8. The cutaneous infections that arise secondary to in- fection in other organs and that spread to skin via local extension or systemic circulation.
9. How to take specimens for culture and interpret labo- ratory results.
Viral infections Richard M. Caplan, M.D. lowa City, 1A
The practicing dermatologist should be able to: 1. Describe the general physical and biologic character-
istics 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 List B a. Herpes simplex a. Morphologic appearance b. Varicella/zoster b. Unusual manifestations c. Warts c. Localor systemic symptoms d. Molluscum con- and signs
tagiosum d. Laboratory aids to diag- e. Vaccinia/small- nosis, including biopsy ap-
pox/cowpox pearance f. Cat-scratch dis- e. Usual course, untreated and
ease treated g. Milkers' nodule f. Differential diagnosis h. Orf g. Therapy that is helpful i. Measles h. Commonly used therapy that j. Rubella is not helpful, other than as k. Erythema infec- a placebo
tiosum i. Preventive measures 1. Roseola j. Most important needs in m. Hand-foot-and- patient education to achieve
mouth disease best outcome in the short- n. Infectious mono- range and long-range
nucleosis o. Herpangina
Rickettsial infections Joseph W. Burnett, M.D. Baltimore, MD
1. Extracutaneous manifestations of rickettsiosis. 2. Morphologic characteristics of a rickettsial erup-
tion. 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.
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
1. Causative agents, pathogenesis, clinical presenta- tions, 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 inocu- lation 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 infec- tions.
6. Selection of media and their limitations. 7. Recognition of the common pathogenic and contami-
nant fungi by their gross and microscopic morphol- ogy.
8. Treatment including topical antifungal and antican- didal 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)
186 Core cttrricuhtm Journal of the
American Academy of Dermatology
Table I
1. Principles of infection (for ex- ample, p roof of pathogenicity, tissue invasion, local vs spread)
D. Therapy--guidelines for the adequate treatment and long-term follow-up for all stages of congeni- tal and acquired disease; include alternate anti- biotic treatment and follow-up schedules
E. Patient and public education about cause, preven- tion, 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 group- ing:
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
Core curr i cu lum 187
V. Parasitic A. Scabies B. Pediculosis
VI. Fungal A. Candidiasis B. Dermatophytosis
The most frequently occurring of the above diseases are:
Gonorrhea Chlamydial nongonorrheal urethritis Herpes simplex, type II Trichomoniasis Candidiasis Verruca vulgaris Parasitic infestations
The remaining diseases are less frequent in day-to-day practice.
The core of information needed for each disease pro- cess would be as follows:
A. Etiology and epidemiology
B. Clinical characteristics 1. Common and uncommon clinical signs and symp-
toms 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 fol- low-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 pathol- ogy, and major methods of treatment (if available) for:
A. Hyperplasias (e.g., dermatofibroma, histiocy- toma, xanthogranuloma, forms of pseudolym- phoma, 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 granu-
loma, foreign body granuloma, sarcoidosis, "palisading granulomas")
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
The practicing dermatologist should be able to enu- merate clinical characteristics, choose appropriate labo- ratory tests, do a biopsy (if appropriate), manage (if treatment available), and know when to refer, for these conditions:
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 inc ludes lupus e ry thematosus , morphea, s c l e r o d e r m a ,
188 Core curr icu lum Jouma/ of the
American Academy of Dermatology
de rma tomyos i t i s rheumat ic disease, and 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 ab-
normal 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 adjust-
ments 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 cor ium 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.
A. Most common clinical presentations B. Most common location of skin lesions and
epidemiologic characteristics C. Other skin lesions associated with acro-
dermatitis 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 dis-
orders of the connective tissue
XII, Focal dermal hypoplasia A. Most common cutaneous clinical presenta-
tion 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
Core curr icuhtm 189
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 lipo-
dystrophy 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. Dt~rham, NC
These concepts should be illustrated by representa- tive important genodermatoses, such as these: tuberous sclerosis, neurofibromatosis, Sturge-Weber syndrome,
epidermolyis bullosum, xeroderma pigmentosum, anhi- drotic 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 epi- dermolytic byperkeratosis) and Darier's disease.
4. Knowledge of ichthyosis as a reaction to drugs and illness in other organs, including acanthosis nigri- cans.
5. Knowledge of where to find recent lists of rare types of scaling problems, to permit diagnosis when clini- cal 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 appro- priate counseling.
7. Therapy of common types of ichthyosls and Darier's disease including patient and family educa- tion.
8. Appreciation of clinical picture and therapy of com- mon types of keratosis of palms and soles.
9. Knowledge of rarer types of keratosis of palms and soles which may be associated with underlying dis- ease 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.
Disturbances of pigmentation 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 hyperpigmen-
tation D. Significance of lentigines E. Significance of velvety brown hyperpigmenta-
tion 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):
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, neuro-
fibromatosis B. Use of sunscreens: Oculocutaneous albinism,
melasma C. Use of depigmenting agents: Mutilating vitiligo,
melasma D. Use of repigmenting agents: Psoralens
Aene and aene i fo rm dermatoses John S. Strauss, M.D. Iowa City, IA
Acne
This disease is certainly recognizable by all practicing dermatologists, so therefore while the clinical character- istics have been rated + + + by the core curriculum com- mittee, 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 comprehen- sive 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 in-
volved in ache B. Endocrinologic factors in acne, including, for
example, the hormonal control of the develop- ment of the sebaceous follicle, and how hor- mone 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 patho-
genesis 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)
4. Miscellaneous therapy (intralesional steroids) B. Complications
1. Recognition and management of potential side effects of systemically administered agents (antibiotics, corticosteroids, estro- gens, sulfones)
2. Specific recognition and management of gram-negative folliculitis
3. Recognition of iatrogenic acne (drug and otherwise induced)
C. Education of patients regarding role, or non- role, 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 t reat these disorders of apocrine function: A. Bromhidrosis B. Apocrine chromhidrosis C. Fox-Fordyce disease D. Hidradenitis suppurativa
Volume 1 Number 2 August, 1979
Core curriculum 191
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 hidradeni- tis suppurativa
5. Methods of treatment a. Early state b. Localized recurrent form c. Chronic extensive form
6. Prognosis; complications
Eeer ine gland disorders; not tumors
Richard L. Dobson, M.D. Btorfalo, NY
1. Emotional vs thermal sweating. 2. Cholinergic vs adrenergic stimulation. 3. Palmar and plantar hyperhidrosis. 4. Localized hyperhidrosis, its causes and treatment. 5. Systemic significance of acquired anhidrosis. 6. Pathogenesis and treatment of miliaria. 7. Generalized skin diseases and temperature regula-
tion. 8. Congenital anhidrosis and related syndromes. 9. Pustular periporitis of infancy.
10. Mechanism of effect of antiperspirants. 11. Relation between sweat gland function and xerosis. 12. 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 be-
fore 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?
10. In children, check mental and physical de- velopment (teeth, nails, eyes, ears, heat in- tolerance)
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 differ-
ent 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 indi- cated only: 1. Plasma testosterone 2. T,, T~, TSH 3. VDRL 4. CBC 5. Thyroglobulin, adrenal, parietal cell anti-
bodies--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 "by 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
ible; exceptions--must correct thy- roid disease, stop crash diet, and stop offending drug
b. Androgenetic alopecia (1) Common baldness is caused by an-
drogens in genetically susceptible men and women
(2) Results in the progressive minia- turization of coarse terminal to fine velluslike hair
(3) Hair follicles all present (4) Pathophysiology: Increased 5a-re-
duction 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 contracep- tive s (1) While taking oral contraceptives (2) After stopping oral contraceptives (3) Two components of oral contracep-
tives (4) Activity of synthetic estrogens is
dose-related (5) Activity of synthetic progestins (or
progestogens) is related both to dos- age and to metabolic products and their relative estrogenic, antiestro- genic, androgenic, and progesta- tional effects
(6) The most estrogenic progestin (7) Second most estrogenic progestin (8) Two estrogen-dominant oral contra-
ceptives (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 an- drogenic 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 cortico-
steroids (8) How to use intralesional cortico-
steroids (9) When to consider systemic cortico-
steroids 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 presenta- tion
(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 fragil- ity: (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
f. Anagen arrest (l) Drugs involved (2) Mechanism of anagen effluvium (3) Morphologic hair changes and mech-
anism 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
alopecia Scarring skin diseases: a. Lupus erythematosus b. Lichen planus c, Alopecia mucinosa d. Pseudopelade e. Scleroderma; morphea Infections a. Viral b. Fungal c. Bacterial Neoplasms Physical agents Biopsy essential Two conditions which are reversible if treated early with local corticosteroids (dis- coid 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
B. Scarring
2.
3, 4. 5. 6.
.
Disorders of the nails Lawrence A. Norton, M.D. Dedham, MA
* 1. Origin of alterations of nail structure in disease. *2. Etiology and pathogenesis of chronic paronychia. *3. Normal progression of fungal infections of the nail. 4. Associated findings in genetic disorders of the nail.
*5. Drug reaction in the nail. *6. Treatment of fungal infections of the nail and prog-
nosis. 7. Laboratory findings in diseases of unknown etiol-
ogy. 8. Diagnosis of tumors under or adjacent to the nail
(especially, the importance of early biopsy).
*More important concepts.
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 ulcera- tions
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 infec- tions
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 erythro- poietic 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
194 Core cur r i cu lum Journal of the
American Academy of Dermatology
IlI. Have the ability to describe cutaneous tumors properly
IV. Have the ability to perform properly various biop- sy 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
VII. Have a thorough understanding of the indications, contraindications, cosmetic results, and compli- cations of the modalities just listed
VIII . Knowledge should be attained concerning the fol- lowing 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 fol- lowing 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 malig- nant melanoma could be as follows:
1. Clinical features of the types of malignant mela- noma (lentigo maligna melanoma, superficial
2. Levels of dermal invasion (I, II, III, IV, V) (Clark). 3. Thickness of melanoma (Breslow). 4. Staging of malignant melanoma. 5. Biologic behavior of various types of malignant
melanoma. 6. Diagnostic workup of malignant melanoma. 7. Prognostic factors in malignant melanoma. 8. Therapy of malignant melanoma. 9. Epidemiology of malignant melanoma.
10. Prognosis of malignant melanomas.
Lymphomas of the skin Richard L. Edelson, M.D. New York, NY
*1. Clinical presentation. t2. Histopathology of mycosis fungoides. 3. Nature of extracutaneous spread.
t4. Laboratory evaluation of patients. t5. Characterization of the neoplastic lymphocytes. 6. Prognostic indicators. 7. Special studies which may be helpful to the con-
sultant physician. 1"8. Treatment of aleukemic cutaneous lymphoma,
limited to skin. t9. Treatment of aleukemic cutaneous lymphoma,
with extracutaneous extension. t l0. Treatment of leukemic phase of cutaneous lym-
phoma.
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, distin-
guishing between them, and appropriate treat- ment
E. Cold urticaria, diagnosis, basic mechanisms, patient education for prevention
*Emphasis on T cell types. tMore important concepts.
Volume 1 Number 2 August, 1979
Core curr iculum 195
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 radia-
tion 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 under-
lying 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 aller- gens.
4. Preventive measures including education of em- ployer and worker.
5. Role of the dermatologist in workers' compensa- tion litigation.
6. Dermatologist's role in helping the worker and employer with vocational rehabilitation, as appro- priate.
Parasitology and tropical dermatoses Richard M. Caplan, M.D. lowa City, IA
The practicing dermatologist should: I. Maintain a high level of suspicion regarding para-
sitic 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 bio- logic behavior, pathophysiology in man, clinical manifestations, prevention, and treatment.
4. Recognize the relation between habitat of or- ganisms and the recreational and occupational pro- clivities of the patient.
5. Recognize the demographic and biologic factors that relate to epidemics, and the social and hy- gienic measures that might appropriately be in- voked.
6. Be able to list six major disorders* due to these principal categories of parasitic organisms: proto- zoa, worms, and arthropods; and for each disorder she/he should be able to describe clinical symp- toms and signs, differential diagnosis, techniques to establish the diagnosis, current methods for pre- vention, management or cure, approaches to reha- bilitation (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 in- stance.
*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 "vio- lin" 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. Psychosomatic medicine--an interpretation. 2. A classification of psychocutaneous disorders. 3. Delusions ofparasitosis. 4. Factitial ulcers. 5. Neurotic excoriations. 6. Dyshidrotic eczema; hyperhidrosis. 7. Trichotillomania. 8. Anxiety therapy. 9. Psychotropic drug mechanisms.
I. Contact stomatitis A. Most common causes of allergic contact sto.
matitis
196 Core curricttlum
Journal of the American Academy of
Dermatology
B. Reasons for the low incidence of allergic con- tact stomatitis
C. Establishing the diagnosis D, Most common cause of irritant contact stoma-
titis
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
