Hello and welcome to the Physician Assistant Exam Review Podcast. This week we’re going to be covering the dreaded childhood exanthems. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review, and I want to make something very clear right up front. This is not just about medical facts. This is not what we do here. It’s about how to think, study, and perform on high-stakes exams.

Our motto is think different, work different, score different, and there’s a reason for that. We believe that content alone is not enough to get you through. You have to be able to think. You have to be able to understand test taking. You have to be able to understand peak performance and anxiety management. In each episode, we take real medical content and break it down so that you can recognize it on the exams. You can understand how to organize it when you’re studying.

And we can help you avoid some common pitfalls so that you can score the best possible score you can get. So if you’re working hard, if you’re studying tons of time, but you’re not quite getting the scores you want, then this is the place for you. What else might be the place for you is that this Thursday, January 15th at 8 p.m., I’m going to be hosting a PANCE Game Plan Master Class on preparing your calendar for how you’re going to get ready for the PANCE. On preparing your study sessions. Each study session, how you’re going to end it, how you’re going to start it, how you’re going to end it, how that’s going to go. And then the last piece is we’re going to cover an anti-anxiety protocol that I use to make sure that I’m ready before my exams and then during my, especially during the exams. You can find out more about that at physicianassistantexamreview.com/masterclass.

You can register, get all the information there. Please share that with any of your classmates or faculty. If you can think of one person who might be struggling or behind, that would be a great thing you could do to help them. So we’re going to cover all of that stuff on Thursday night. And if you can’t make Thursday night, I’m going to do it again on Monday. I think it’s the 19th and also at 8 p.m. Eastern time.

All right, let’s jump in to this week. We’re going to be covering the second part of derm infections. This week we’re going to be doing viruses, and I broke them out into a way that I think will be most helpful as far as getting ready for your exam and making sure you have a good idea of what everything looks like.

So let’s get started with our priming questions. A rash that appears after several days of high fever in an infant suggests what diagnosis? A rash that appears after several days of high fever in an infant suggests what diagnosis? Painful oral ulcers with vesicles on the hands and feet suggest what viral illness? Painful oral ulcers with vesicles on the hands and feet suggest what viral illness? Vesicular lesions in multiple stages at the same time suggest what infection? Recurrent painful grouped vesicles on an erythematous base suggest what virus?

Recurrent painful grouped vesicles on an erythematous base suggest what virus? Painless umbilicated papules on the trunk of a child suggest what diagnosis? Painless umbilicated papules on the trunk of a child suggest what? Diagnoses Alright, those are designed to get you thinking, to get you moving a little bit Don’t just gloss over those when I do them, pay attention, work them through I know some of you are not going to know the answers. Some of you getting ready for your PANCE, hopefully those are low-lying fruit and pretty straightforward and easy. But if they’re hard, thinking about them still helps.

Okay, we’re going to jump into viral skin conditions. Actually, there’s going to be one that’s not a virus, so I’ll hit that as we go. But I group these in such a way because they’re organized by age, by distribution, and by systemic involvement. So don’t memorize individual viruses. Don’t memorize individual data points different pieces we’re going to group them because that’s how they’re going to come on your exam they’re going to test childhood exanthems up against each other so if you learn them one at a time that’s not going to be the most efficient use of your time I know it sounds kind of markety and gimmicky when I say that I teach students to spend less time studying remember more and have their scores go up. But this is part of how we do it. There’s a whole lot of other techniques and things, but one is by learning things as groupings rather than as individual data points.

Learning them is how they’re going to come on your test. So you’re going to get in pediatrics, right? You’re going to get the viral exanthems. You’re going to get hand, foot, and mouth. And you’re going to get chickenpox. Right, and you’re going to tell those apart based on the age, the fever timing, and the rash distributions. And then you’re going to have these localized viral lesions, which are going to be herpes, molluscum contagiosum, and warts.

Verruca, I’m not sure exactly how you pronounce that. I’m not in derm, sorry. And we go from here. The presentation is going to go from your sick kid, the mom bringing in or the dad bringing in a sick child, to the morphology of the diagnosis. What it looks like, what that lesion looks like. And then lastly, you’re going to have condyloma acuminatum, which is going to be sexually transmitted. So you’re going to have a different story behind it.

I hope that makes sense. And how we group things, how we think about things, how we try to present them so that you can hold on to them. And they’re there for you on test day. One of the reasons people blank out on test day is because they’ve just memorized list after list after list. And especially in the PANCE, 300 questions, all of medicine. There’s just a lot to dig through there. It’s really, really tough.

So we’re going to start with childhood exanthems. Exanthem just means widespread rash. It comes from a, I think it’s a Greek term meaning outbreak. So we’re talking about a widespread rash, and there’s also usually some sort of systemic piece that goes with it. These were traditionally numbered. So that’s where you get your first disease, second disease, third disease, fourth, and fifth. Don’t worry about that.

I’m going to touch on it only because it’s, some of your PA programs may have mentioned it. I would not memorize them that way. It’s not really of any value. It’s just think about when they were initially describing these, they didn’t really have names, right? So they just named them first, second, you know, really unimaginative way of dealing with this. But that was the one way of classifying them. But we really don’t use that anymore.

So as far as studying goes, I wouldn’t put any time or effort into it. I’m just mentioning it so it doesn’t confuse you. Most of these are viral issues except for scarlet fever, which is a bacterial issue. And again, these are differentiated by fever, the timing of the fever most importantly, the rash distribution, and any other findings. But don’t worry about memorizing the numbers. I’m just going to mention it because some of you will want it. So our first one is measles or rubeola.

That’s the other problem here. This is first disease. So this diagnosis has three names. First disease, rubeola, and measles. To me, that’s what makes it so difficult. That’s what makes it so hard. I have trouble separating all that out.

So how would I handle that? This would go up on a note card or on a whiteboard or something where I saw it all the time. And I could do measles and rubeola and equate the two until I didn’t even have to think about it. And it became just 3 times 3 is 9, measles equals rubeola. Clinical presentation here is high fever, cough, coryza, and conjunctivitis, diffuse maculopapular rash spreading head to toe. That head to toe spread is also valuable, right? The way that the distributions occur.

We’re just going to go in order. So second disease is scarlet fever. This is bacterial, obviously not viral. So it’s a little it’ll get covered in in under infectious disease as well so not really sort of redundant here but i just want to put it in for completeness so this is obviously going to have a fever and sore throat because this comes following a strep throat infection here you have a diffuse erythematous sandpaper rash that sandpaper rash is your key i’m not going to tell you this is the only place you see a sandpaper rash i can’t think of anything else off the top of my head, but I don’t think it’s pathognomonic, but it really, really helps. That with a strawberry tongue. And the tongue literally looks like a strawberry. Look up some pictures.

I’ll put them on the website for you. Maybe that’ll help. And this is caused by a group A strep. Third disease is rubella.

Now, not only did they make it difficult and give measles two different names, but they made rubella and rubeola close enough to screw me up too, right? So now I need another note card or another line on my whiteboard or another set of sticky notes on my mirror, something that I see all the time until this is second nature, until I don’t have to think about it. This is what takes time on your exams. When you have to sit and think, oh, was measles rubella or rubeola? Oh, when you have to stop and think through that, that’s taking away from your focus and your concentration and your energy levels towards hard information. You’ve got to have this stuff down like your times tables. Clinical presentation.

Here is mild systemic symptoms, diffuse macular papular rash. The key here is posterior auricular and occipital lymphadenopathy. The lymphadenopathy with rubella is your secret key. This is often more mild than measles. Fourth disease is historical. I don’t even have the name for it. I’m not even going to tell you.

It’s not something we see anymore. But fifth disease is erythema infectiosum parvovirus B19. So again, we get two lovely names to go with it. This is our slapped cheek rash, followed by a lacy reticular rash on the trunk and extremities. Here the kid’s not really very sick is another piece of the puzzle.

Now, another piece of why this drives everyone crazy, or at least me in my brain, is we have rubella, we have rubeola, and then we have roseola, right? So it’s enough that I’m going to struggle. Roseola infantum is sixth disease. Here we have a high fever for several days. That’s the real definitive difference here, that high fever. The rash appears after the fever resolves. This is common in infants and young children.

Now we get to the nice part the really good part of childhood exanthems and that’s the treatments because what’s the treatment for childhood exanthems? Supportive care we don’t do anything right? Maybe something for the fever in roseola but mostly it’s just supportive care so they’re not going to ask you about treatment so when you study this don’t study each treatment individually. Study them all together. All childhood exanthems, we do supportive care. So are you likely to get a test question that’s going to ask you how to treat childhood exanthem? I think that’s unlikely.

I think it’s possible, but I think it’s unlikely. I think you’re far more likely to have to tell the difference between them based on the story, based on the rash.

Now, the only caveat here is scarlet fever, for which you’re going to give antibiotics, right? Because there we have a bacterial infection. So our exam keys here are slapped cheek, so that redness on both cheeks equals parvovirus B19. Rash after fever resolves is roseola. Sandpaper rash and a sore throat is scarlet fever. And that sick kid, that cough, that coryza, the conjunctivitis, that’s going to be measles. The last piece I actually should add here for roseola is that higher fever.

The other thing this made me think of with the higher fever is Kawasaki’s. How does Kawasaki’s fit in here? Well, Kawasaki’s is not a dermatological infection. You do get a rash with it. But from my understanding, it is a vasculitis that has a high fever for five days, or more than five days. You get multi-system involvement. And the rash is a supporting piece.

It’s not the main piece. So although you may conflate that into this section, and I have before, it’s really not part of this group. Although, could it be tested under this group? Yeah, I guess it could be part of an answer choices. So depending on how you set up your notes, you may want to include it in this section because it could be associated with it, like I said, in the answer choices, if you have, you know, you may have to separate out something like roseola and Kawasaki’s. But that’s how I’m always thinking, is how do we, what are the test questions going to come? What are they going to look like?

How is this going to function on my exam? And how’s that going to look in the office, right? How am I going to tell the difference between a child who comes in with Kawasaki’s and a child who comes in with roseola or measles? That’s the real questions can I do that next we have hand foot and mouth disease the PAs I work with the group between them probably what do we have I don’t know we have a handful of children from the ages of two down to just a few weeks old and one of them came in one of the moms came in the other day with their poor child had hand, foot, and mouth disease. This is a common viral illness most often caused by the Coxsackievirus A. Primarily, it’s in infants and young children is where you’re going to see this. What it looks like, you get this vesicular lesions on the palms and soles.

That’s going to be the key, right? The other key is they’re painful. It may involve the buttocks and the extremities. You’re also going to find them in the mouth, and that’s where they’re really painful. You may find that the initial presentation, maybe, that the child doesn’t want to eat, right, because it hurts. So this can be on the tongue, on the buccal mucosa, and the soft palate. They’re going to get a low-grade fever, malaise, and a bit of a sore throat with this, but really it’s that mouth pain, and then the hand and foot vesicles that are painful.

That pain and the vesicles in that pattern should be enough to determine it for you. So that’s what your question stem is going to look like, right? You’re going to have a child with painful mouth sores, maybe not eating, and this vesicular rash on their hands and feet. But again, we’re back to supportive care, hydration, pain control. That’s it. That’s what we’re doing. So this section, although it’s difficult as far as the diagnosis goes, you’re not looking at labs.

These are all clinical diagnoses. There are no labs. There are no imaging. There is no, the treatment is basically the same. So as much as this section may feel hard to tell the differences, to me, one of the places people struggle the most is with pharmacology, with antibiotics, with names of things. Here you just about remove that whole bit.

Exam keys here, vesicles on the palms and soles. Oral ulcers help you to distinguish hand, foot, and mouth from other exanthems. So if you have oral ulcers, you don’t have measles. You don’t have rubella. Next we have chickenpox or varicella this is primary infection with the varicella zoster virus most common in unvaccinated children our skin findings are a vesicular rash here’s the key it’s in different stages so these lesions come in waves or I remember my PA faculty telling me they come in crops which I didn’t really understand But if you picture planting, rotating crops, so you plant some corn in, I don’t know, early in the season, then you plant some corn a little later in the season, then you plant some corn in the early fall. The vesicular rash comes in those crops. So you get papules and then you get vesicles and then you get crusts.

But each wave is all present at the same time, right? So because it just keeps kind of coming. That’s unlike most of your other rashes. Is these vesicles look like little drops on a red base so that’s one way you can picture them i know that the historical way of describing that is a dew drop on a rose petal meaning you just get that little bump of what looks like a vesicle of fluid filled sac sitting on top of a red lesion this usually begins on the trunk then spreads to the face and the extremities and the other thing is these are itchy right they’re very pruritic if you ever had this i don’t know i did i was fortunate enough to have this with at the same time that i had broken my arm so i was in a cast that came up above my elbow and when i had chickenpox i would stick apparently stick pens and pencils and all kinds of things down there to try to scratch the lesions inside of the cast. So when they cut my cast off, they found paper clips and all sorts of wonderful things down there that I had been trying to use to take care of that problem. This can get bad systemically. You can get a fever, malaise.

You can get sometimes the symptoms precede the rash by a day or two, but in older people, in teenagers, in adults, this can be pretty nasty. They get very, very sick. Usually you’re going to talk about this in a younger child.

Let’s just say for sake of discussion, like, I don’t know, under 10. So what you may see in your question is going to be something like a child with a fever and an itchy vesicular rash with lesions in multiple stages that begin on the trunk. That’s kind of what you’re looking for. Generally speaking, this is, again, supportive care. We’re not going to do much. We’re just going to wait this out. Maybe something topical to help with the itching.

Until we get to adolescents, adults, and immunocompromised patients where this can be kind of severe, and we’re going to treat that with acyclovir. The key here is pruritic lesions in multiple stages. That’s really going to be your key. It just occurred to me, before we move into herpes simplex virus, that with measles, because I was talking about hand, foot, and mouth and the oral part of it, and I was trying to think off the top of my head and I was struggling to come up with it. So I just paused the recording and pulled up my notes. And what we missed was Koplik spots. So that’s with measles.

That’s something else that goes along with measles. So you can get these small white or bluish white spots on the buccal mucosa for measles. These appear before the rash happens. So that may be relevant. Something I just did. I want, like I said, I didn’t initially have it on my notes. I must’ve missed it somewhere.

But when we talked about hand, foot and mouth, it was just running in the back of my head that there was another oral issue. So that might be something to consider.

All right, let’s move along to herpes simplex of a virus. This is a localized viral infection, right? So now we’ve moved out of exanthems or rashes, right? I know varicella is not technically an exanthem, but it has that rash. So we’re going to be comparing them to a localized viral infection. This isn’t a rash. This isn’t a widespread issue.

But it does have these recurrent outbreaks. That’s really one of the main keys here. These are grouped vesicles on an erythematous base. So the description is kind of like chickenpox, where we talk about that vesicle on an erythematous base. But these are all grouped together in one localized area, not a widespread issue. These can rupture and become painful ulcers. Generally speaking, HSV1, we talk about with oral issues and HSV2, we talk about genital or perianal issues.

I’ve heard recently that that sort of has gone away, but historically and for the sake of our notes, I’m going to leave it that way. So that oral herpes is going to be what we call cold sores, right? Is associated with pain, burning, and tingling, which precedes the lesions. You get that nerve pain in the area. Usually this is common on the vermilion border. You might get some local lymphadenopathy. And you get these painful grouped vesicles on an erythematous base, but often with that history of recurrence.

That’s what the question stem should focus on, most likely. That nerve pain with those vesicles, and it happens over and over. The things that trigger this are stress, right? If you think about how herpes works or how varicella works, these are viruses we don’t clear. This is hard to get your head around, but your immune system doesn’t clear them. These are viruses that live in your nerves and hang out there and you can fight them down and keep them at bay, but they never really leave your system. And that sounds crazy until you think about all the bacteria in your gut and all over your body, that your job’s not always to completely eradicate things.

So HSV hangs around, and normally it’s under control. It’s not causing a problem. But when you’re under stress for one reason or another, when your immune system’s beat up for one reason or another, it can get the upper hand, which we’re not going to talk about today, but… But that’s where you get the varicella, the chickenpox, becomes… Oh, why am I struggling with the word? Shingles. That’s it.

Shingles. And that’s usually the person’s under some stress or some kind of issue when that shingles outbreak occurs, generally speaking, or there’s some kind of immunocompromised issue or somewhere where their immune system’s down. The treatment here is going to be acyclovir, valacyclovir, or famciclovir. You can get a topical or oral. Again, it’s that grouped vesicles. That’s really key, especially like on the vermilion borders, a good place to talk about it. The pain is a good way to distinguish it.

That nerve pain, that numb, tingly, that happens just before the outbreak. And then the fact that they’re recurrent.

All right. So next we have molluscum contagiosum, which is a benign viral skin infection, and it’s caused by the pox virus. It’s common in children, but we’d look at this more as a sexually active adult or immunocompromised patient issue. The clinical presentation is going to be a small, firm, dome-shaped papule with a central umbilication, so a little divot in the middle of that dome. That’s the keys to what you’re looking for here. It’s flesh colored so it’s not red is really the key here you may find on the trunk on the extremities it’s usually painless and doesn’t itch so that’s your this one should be super easy this is one i always found test questions are very very easy on because it has that very classic shape with that central umbilication umbilication and it’s painless and doesn’t itch it may spread with skin-to-skin contact. You can get auto-inoculation, meaning you can give it to yourself in more than one place.

So what you’re looking for here is just that same description, right? The treatment is going to be observation. It’s self-limited. There’s not much to do. You can physically remove it with curettage or cryotherapy if the person really bothers them. That umbilicated papule in a dome shape and the fact that it’s painless makes it obviously stand out. Next we have warts.

These are benign epithelial proliferations caused by the HPV human papillomavirus. Easy for me to say. These spread through direct contact or auto-inoculation. What you’ll see are hyperkeratotic papules or plaques with a rough irregular surface. These can have that black punctate dots. Those are actually thrombosed capillaries. If you’ve ever seen this, it’s pretty obvious.

You’ll know what you’re looking at. But it’s sort of these black dots or lines inside of a wart. Verruca vulgaris are hands and finger warts. Plantar warts are on the soles of the feet. These can be painful, especially because you’re walking on them. And then you can get flat warts on the face or extremities. These are usually painless, except those plantar warts we talked about.

They’re slow growing, but they may last for years, usually months, but years. The treatment, again, is going to be mostly just observation. So you can do a salicylic acid or cryotherapy if you want to get them removed. So there’s some easy distinctions to tell these apart and again the treatments are just so straightforward that i think this section shouldn’t be as hard as what people make it out to be lastly we have condyloma acuminata which is genital warts these are sexually transmitted viral infection caused by hpv so the other warts are not sexually transmitted these are caused by HPV 6 and 11 these are usually benign but it is sexually transmitted these are soft flesh colored or gray papules they’re cauliflower like or verrucous surfaces they could be singular there could be lots of them they commonly involve the external genitalia the perianal region and the cervix. Usually these are painless. They may be itching or irritating and they don’t really go away. You can do topical therapies, imiquimod.

You can get cryotherapy or have them excised. It’s really a bother.

All right and that’ll wrap us out for the section on infectious dermatological issues i want you to see as we went through that how different these are they sound similar and they can be misconstrued but i want you to see how different but also how similar they are meaning the treatment’s similar. We’re not doing cryotherapy on exanthems, right? That’s not what we’re doing. We’re doing watchful waiting. So if you can group them by treatments, if you can group them by presentation, they become so much easier to follow, so much easier to remember, so much easier on your exams.

All right, before we do our priming questions, just our study tip for today, this one’s really straightforward. And the answer is, do you have a plan for your study session? What I mean by that is when you sit down, is there a beginning, a middle, and an end? Have you created some kind of a system or structure to what you’re doing? If you have an hour, what does it look like? If you have two hours, what does it look like? If you’re in the library all day on a Saturday, what does that look like?

Or do you do what I used to do in PA school give yourself an unbelievable amount of information to get through that you couldn’t do in six months have no plan just start attacking it and wonder why at the end of the day you didn’t feel like you got anywhere and then wonder why you’re not retaining any of it I spent a good chunk of PA school with that as my plan Obviously, any plan is better than that. But do you have a structure? Do you have something in place? Some kind of, and by the way, if you haven’t thought of one, you do have one. It just wasn’t done on purpose. So one of the things we’re going to do on January 15th in the PANCE Game Plan class is we’re going to walk through what a study session, what I would do now after 15 years of researching this stuff and going through it and working on it. And I’m going to map out for you exactly what I would be doing now to make sure my study sessions, each session, went as well as it possibly could.

What my goals are for those sessions, how to get the most out of it. Because honestly, the biggest issue in PA school.