155 Benign vs Concerning Skin Lesions – “Do I Worry?” Patterns You’ll See on PANCE

Hello and welcome to the Physician Assistant Exam Review Podcast. This week, episode 155, we’re going to be continuing with dermatology. We’re going to be covering keratotic lesions, vascular lesions, benign soft tissue growths, and hyper… I’m sorry, hidradenitis suppurativa. Wow, I know I can say it. It’s in there someplace. Here we go.

This is not just about the medical facts, though. This is what I need you to understand. It’s about how to think, study, and perform on high-stakes exam. Remember, our motto here is think different, work different, score different. It’s so important that you don’t just do what your neighbors are doing. You don’t just do what your classmates are doing. You think through and do what works best for you.

And that’s a lot of what we talk about throughout these episodes. We use the medical content to break it down and go through it because medical content review is necessary. But the reality is what we’re trying to get at is the techniques and the way to approach it so that your studying is organized in such a manner that you know how to avoid common thinking traps that cost points and you know how to score high on your exams. So if you’re working hard but your scores aren’t reflecting it, this is the place for you. The February cohort is off and running, doing amazingly well. We had our second meeting last night. Absolute ton of fun.

They’re crushing it. Absolutely crushing it, this cohort. For those of you who don’t know or are interested, because I’ve gotten like two or three emails this week about people wanting to join because their tests are in April and our next cohort isn’t until April. Well, I can’t run the program. We run this as a cohort. I can’t just drop you in a week late, two weeks late, three weeks late. It doesn’t really work that way.

Think about it like joining a PA program two months late instead of on the start day. You’d just be so far behind that you would be confused. You’d be lost. It’d be really hard to get you caught up and you would feel disconnected from everyone else. It just wouldn’t work the same. I’m saying that because I feel really bad. I wish there was something else I could offer, but right now there isn’t.

What we did do this year to make things easier after talking with my coaches is we have decided for the first time to run a cohort every other month. So what that means is we’re going to be, we have the February cohort. We’ll do April. We’ll do June. Then we’ll do August. Then October. And then we’ll have a December cohort this year.

We usually only do two in the second half of the year, but this year we decided to make it easy on everyone so they know ahead of time, which is going to be every other month. Very straightforward. Although I’ll also say on that topic is you could jump in early. Don’t wait until right before your test, right? We’re learning all kinds of new skills and techniques and our clinical students are killing it. Our didactic students are killing it. So you could use those skills for longer term.

You don’t have to wait until right before your test. That’s absolutely, I get why you might think that that’s the case based on the way that I present it, but it’s really, really not based on the fact that it’s called 33 Days to Pass the PANCE. But honestly, it’s a program for improved studying, improved test taking, improved anxiety management, and peak performance, which really equates across the board. Anyway, let’s go ahead and get started with today our priming questions. A recurrent abscess in the axilla or groin, what diagnosis are you thinking? Recurrent abscesses in the axilla or groin, what diagnosis are you thinking? Rough scaly sandpaper like lesion on sun-exposed skin, what’s the diagnosis?

Rough scaly sandpaper like lesion on sun-exposed skin, what’s the diagnosis? Waxy stuck on pigmented lesion, what’s the diagnosis? Waxy stuck on pigmented lesion. Soft, rubbery, freely mobile, subcutaneous mass. We’re going to talk about two things today that have that sort of description. Can you pick up one of them? Soft, rubbery, freely mobile, subcutaneous mass.

And we’re not musculoskeletal, so it’s not a ganglion cyst. First-line treatment for actinic keratosis. What’s the first-line treatment for actinic keratosis?

All right, fantastic. We’re going to start with keratotic lesions. These are defined by abnormal thickening of the stratum corneum, producing a rough, scaly texture that is often felt more than seen. So you may have someone come in saying that they feel like their skin is sandpapery, but it doesn’t look like much. This is usually on chronically sun-exposed skin. So think head, ears, neck, that kind of thing. And there’s obviously the question here of benign change versus pre-malignant risks.

We’re going to start with actinic keratosis, and then we’re going to do seborrheic keratosis. Those are the two in this section. Then we’ll kind of wrap them up together to make sure we can tell them apart on an exam. So actinic keratosis is a premalignant keratinocyte lesion. This is caused by sunlight, UV exposure. And it’s defined by abnormal thickening of the stratum corneum, like we talked about, producing rough, scaly surfaces. And it’s a risk factor for squamous cell carcinoma.

We’ll get into carcinomas in the next podcast. Clinical presentation here is, again, that rough, scaly erythematous papules or thin plaques with the classic sandpaper texture. Found in the face, scalp, ears, forearms, and hands. And again, often easier to feel than to see. So what’s the question stem going to look like here if they’re trying to get you to this diagnosis? Well, it’s going to be an older outdoor worker who notices a rough patch of skin, either on the ears or the scalps or something that feels like sandpaper. It might be the spouse who sends them in.

So you might have like a 72-year-old farmer comes into the office. A 68-year-old roofer comes into the office. They’re not going to say sun-exposed skin, right? They’re going to give you, we were talking about this on the meeting last night, because I talk a lot about key terms and buzzwords. And people are like, well, I don’t necessarily see them on the questions. No, you won’t. They’re not going to say on the sun-exposed skin area.

They’re going to say this is someone who works outside all the time. And you have to then infer the next step. Because that’s how it’s going to be in the clinic. They’re not trying to trick you. You have to put all those pieces together in the office just the same as you would on a test question. There’s a clinical diagnosis, and you can do a biopsy if it’s thickened or ulcerated. Obviously, if it’s bleeding, rapidly growing, non-healing, that kind of thing.

Because then you’re worried about cancers. First-line treatment here is cryotherapy with liquid nitrogen. You can also do topical fluorouracil. And your keys here are rough, scaly, sun-exposed skin. In an older patient, it is actinic keratosis. That’s what you’re thinking. You also want to think that this is premalignant, looking at squamous cell carcinoma, not melanoma.

We’ll get into those again in the next episode. Seborrheic keratosis is benign epidermal proliferation characterized by hyperkeratosis and acanthosis with no malignant potential. That’s the key here, commonly seen in older adults. So what you want to know, both in the office and on your test, is do I need to freak out about this, or is it something we can just kind of hang on to? Clinical presentation is a waxy, verrucous, well-circumscribed papule or plaque with classic stuck-on appearance. That stuck-on appearance is key. I’m not exactly sure how that’s going to look on your test.

It’s tough to describe outside of just saying stuck-on appearance, but keep an eye out for it. The color ranges from tan to dark brown or black. Common on the face, trunk, and extremities, but it does spare the palms and soles. It’s usually asymptomatic. Here the question stem is going to be similar. It’s going to be an older patient, probably coming in for something unrelated, who has a dark or raised spot on their back or something that looks like it’s glued on or stuck on or like a sticker. It’s a clinical diagnosis, but it could be biopsy if there’s some kind of reason to do that, like if it’s, again, bleeding or you’re not sure what it is.

Main treatment here is going to be reassurance. This is not a progressive to cancer, so there’s nothing going on here that’s going to be a real problem for the person. But if it’s irritating or for cosmetic reasons, you can do cryotherapy or a shave removal. Again, these are benign, and that waxy stuck-on appearance in an older person is seborrheic keratosis until proven otherwise. That’s what you’re looking for.

All right, so when you’re studying these, you’re going to study them together, right? Like we just did, but now you’re going to wonder, how on a test am I going to know the difference between them? Because that’s how the questions are going to come, right? So actinic keratosis, sorry, hang on one second, is going to be that rough, scaly sandpaper texture, right? That’s the difference, as opposed to the waxy stuck-on appearance. Flat versus raised, actinic keratosis is going to be flat or thin. Seborrheic keratosis is going to be raised.

Actinic keratosis is more often that you can see it, I’m sorry, it’s more often that you feel it. It’s that sandpapery feeling, but not necessarily something that you see, where the seborrheic keratosis is one that you’re going to see. That’s how you’re going to separate these on a test. Moving on to vascular lesions. Lesions arise from blood vessels, typically present as a red, purple, or blue changes, where the patient questions whether this represents a benign vascular proliferation or a clue to systemic disease. That’s really the key here. So these are vascular issues.

And what you’re trying to do is determine if this is just not a big deal, or if they’re showing you a systemic disease, or bleeding risk, or something else that’s going on underneath the surface. That’s kind of the secret to vascular lesions. Under vascular, we have cherry angioma, we have hemangioma, we have purpura, we have telangiectasias, and then, I’m sorry, and then that ends vascular lesions. So we’ll start with cherry angioma. This is a benign vascular proliferation of capillaries, extremely common with aging and no malignant potential. Clinical presentation is bright red to purple, round papule with a smooth surface. Typical, typically small and well circumscribed.

These look like little cherry dots. They’re common on the trunk and extremities. They are asymptomatic. And the question would be something like a patient comes in for something else and casually asks about a small bright red dot on their torso that have slowly appeared over time. These are, there’s nothing to do here. These are a clinical diagnosis. There’s no labs.

It’s a reassurance. You can get them removed for cosmetic reasons with laser or cautery, but really not a huge deal. They’re called cherry angiomas because they look like little tiny cherries. Like millimeter-sized cherries. Hemangiomas, on the other hand, are a vascular tumor most commonly seen in infants caused by proliferation of capillaries. These are bright red raised lesions. So you get a, what’s a strawberry hemangioma, it might be called, or a deep bluish lesion if it’s subcutaneous.

It appears in the first few weeks of life, enlarges during infancy, then gradually involutes. Commonly found in the head, neck, and trunk. Usually asympt, wow, I’m struggling today. Usually asymptomatic, but may ulcerate or bleed if traumatized. So your stem is going to be something like a newborn or young infant with a red raised lesion that has grown rapidly over the first few months of life. You’re going to be thinking hemangioma. You’re not going to be thinking cherry angioma because that’s in someone who’s older.

They don’t really grow. And they’re small. And so you start to picture these differences and how these things work together and how they’re going to come into your office and how they’re going to come into your test questions. It’s a clinical diagnosis. Treatment’s going to be observation. They usually go away on their own. You can do oral propranolol for large or ulcerative angiomas or a topical beta blocker.

But most of the time, these are going to resolve without an issue. Purpura are non-blanching discoloration of the skin due to extravasation of blood, reflecting vessel fragility, platelet disorders, anticoagulation, or systemic disease rather than true vascular growth. So the other ones were overgrown capillaries. Right? Our cherry angioma and our hemangioma. This one is actually like bleeding under the skin. Right?

Here are the issues. You need to stop and think. You have a platelet problem or an anticoagulation problem or some other systemic disease and you have some worries. These are purple or red macules or patches that do not blanch with pressure. That’s a great one to hold on to. They may be palpable or non-palpable. That’s just fun to say.

Common dependent areas, especially lower extremities. Here’s a big key. These are associated with medications. Right? We said it’s an issue with clotting, platelets, or anticoagulation. So warfarin, aspirin, clopidogrel, chronic steroid use. Those all may be issues.

Questions you want to ask. They may also have platelet abnormalities. So what are we talking about here? What are some underlying diseases with platelet abnormalities? Thrombocytopenia, platelet dysfunction. So you need to think about those things if you come across this or you see it in one of your patients. So here our stem is going to be something like an older patient on a blood thinner with recent illness who develops new purple patches on his arms or legs that do not fade when pressed.

You see how that didn’t say they don’t blanch? Because it’s not necessarily going to use those terms. You need to see the whole picture. This is clinical recognition first, then you’re going to evaluate the platelets. So you can do coag studies and figure out what’s going on. You’re going to treat the underlying cause or stop the medication or adjust it. And that’s it for that section.

So telangiectasias are next. This is a dilated superficial blood vessel visible in the skin or mucosa, typically benign, but important as a possible clue to underlying systemic disease. These are fine red linear vessels that blanch with pressure. Common on the face, lips, oral mucosa, hands, or sun-exposed areas, and they’re usually isolated and benign. That’s most of the time. But if you come across a grouping of them, you should consider that there’s something more sinister underneath. So this would be a patient with visible red lines on the face or lips that blanch when pressed, sometimes mentioned almost as an aside.

So they’re not necessarily coming in for this. It’s just something that they’ve noticed or you can see. Just kind of like that cherry angioma. These are associated with chronic sun exposure and aging. Rosacea, chronic liver disease, or estrogen excess. Or they can be hereditary. It’s a clinical diagnosis and you really don’t need to do any more of a workup for this.

Unless you believe that there’s some sort of systemic disease, right? Like chronic liver disease. Then we’re heading in that direction. Treatment in general is reassurance. If they’re small and they’re not grouped, and you can do laser therapy for cosmetic reasons. Otherwise, you’re going to start treating the underlying issues. So blanching linear red vessels equal telangiectasia.

It’s really pretty straightforward. Isolated or benign, clustered are a concern.

All right, so how do we tell these apart on your exam? When I was fumbling earlier, by the way, this is the section of my notes I was looking for. I forgot to put it at the end instead of after each diagnosis this week. So a cherry angioma versus purpura. What’s the difference? So I’m going to ask you as we go, stop and think for a second. Here’s where I want you to be paying attention.

How do you know the difference between a cherry angioma versus purpura? What’s the difference? We have a blanching bright red papules versus non-blanching purple patches. Pretty straightforward. It’s a little hard to say, but it’s pretty straightforward if you can picture it. What about a cherry angioma versus telangiectasia? How are you going to tell those apart?

They’re both red. Well, one is round papules, the other is fine linear vessels. Telangiectasia are those little fine linear vessels. What about a hemangioma versus a cherry angioma? What’s going to really tell that apart? Well, age is the main one, right? Hemangiomas we talked about with infants.

Cherry angioma would be adults. Telangiectasia versus purpura. One blanches with pressure, one does not blanch with pressure, right? These are the kind of things I’d be putting down in my notes. I’m looking not to highlight every single thing in the book. I’m looking to highlight the couple of things that matter and we’ll stand out on a test. This is what we’re doing here.

What about purpura versus vascular growths? Well, purpura has the blood outside the vessel versus the vessel dilation or proliferation in the vascular growths, right? So they’re just a different species.

All right, we’re moving along. The two smaller sections here are benign soft tissue growths and hidradenitis suppurativa. Benign soft tissue growths are slow growing, non-inflammatory masses arising from subcutaneous tissue or skin. Typically, these are painless and benign where the exam question is whether the lesion is truly harmless or something that needs further workup. So this is a, these are bumps under the skin that are relatively common and generally speaking benign, but you have to be able to recognize them. So a lipoma is the first one we’re talking about. This is a benign tumor of adipose tissue, so it’s fat, presenting a soft, mobile, painless, subcutaneous mass with no malignant potential.

So this is a benign, fatty growth. We actually take these out, not, I don’t know, I was going to say all the time, not all the time, but I work with plastic surgeons, so we take these out from time to time and they can get big, I mean like softball size big. Most of the time they’re not that large, but it certainly can happen. But you can feel them, they feel rubbery, they feel like they move around under the skin, they don’t hurt, they don’t cause any problem, the patient just recognizes them and at some point they’re like, man, I need to get this off. They grow very slowly, they’re common on the trunk, shoulders, neck, and proximal extremities. And the skin appears normal, there’s nothing that looks out of whack except this bump. A patient notices a soft lump under the skin that moves easily when pushed and has been slowly growing for years.

It’s a clinical diagnosis. There’s any major reasons, I guess you could image it or biopsy it, but treatment is reassurance if asymptomatic, so if it’s small and asymptomatic, no big deal. Or you can go in surgically and remove them if they’re painful, large, or cosmetically an issue. Our next one is epidermal inclusion cyst. This is a benign cyst formed from trapped keratin within the epidermis arising from a hair follicle and commonly mistaken for an abscess or lipoma. This is a firm, round subcutaneous nodule with a central punctum. It grows slowly and it’s usually painless, common on the face, neck, trunk, or upper back, but it may become tender, erythematous, or fluctuant if inflamed or infected.

So a patient with a long-standing lump under the skin that occasionally becomes red and painful, it might have a small central opening. It was probably 15 years ago, I had one of these on the back of my neck in my hairline, and it was growing super slow, I didn’t really care about it, didn’t really think about it, I actually thought it was a lipoma, until suddenly on a Saturday night, it became so painful that I couldn’t even see. I mean, it was that painful, I couldn’t sleep, I couldn’t touch it, I couldn’t go near it. At that point, it hurt so much, I worked with a foot and ankle surgeon in orthopedics, it was my first job, so I’m a couple years into working with him, and I go to office hours and I’m just dying, this thing hurts so bad. And it hurts so much that I pretty much forced him to take a scalpel to the back of my head at the end of office hours and take this thing out and let the pressure out because it hurts so badly. So he did me that favor of sticking a knife in the back of my head, and a couple days later I met with a general surgeon who went and took the cyst out and the cyst wall and everything. So that’s your difference between a lipoma and a epidermal inclusion cyst.

This is a clinical diagnosis, you don’t need any imaging, generally speaking it’s a reassurance, you can go and take these out, but really, and this was part of the problem, it’s actually coming back a little bit now because I had the foot and ankle guy poke a hole in it and drain it, and then the general surgeon went in to remove it, but he probably left some of the wall, and if you leave a cyst wall behind, then it’s going to come back. So yeah, I&D alone won’t cure it, you have to get that cyst wall. That’s the same with like ovarian cysts and things too. You can’t just drain them, you have to take the cyst wall out.

Okay. Okay.

All right, our last one for today is hidradenitis suppurativa. This is a chronic inflammatory disorder of hair follicles leading to recurrent painful nodules and abscesses in intertriginous areas, often mistaken for infection, but not primarily infectious process. So this is a little weird to get your head around. It took me actually until I was operating on a couple of these people who had this problem that I could wrap my head around it. These patients get these deep painful abscesses either in the groin or in the axilla and they’re not really infectious processes. So antibiotics aren’t going to do anything. They can form these nasty sinus tracts and scarring and this is really a chronic issue.

It is associated with obesity and smoking, but it doesn’t have to be. So your question stem is going to be here something like a young adult with repeated boils in the armpits or groin that keep coming back despite antibiotics. There’s no labs or anything. This is a clinical diagnosis. So as far as treatment goes, you’re going to do weight loss and stop smoking. That’s going to help because if you can get the, if you can keep the area clean, it helps. If you can keep it sweat free, it helps.

Topical clindamycin will help a little. Oral antibiotics will help some. But what the cases I’ve seen because I work in the OR with general surgeons who we actually just literally go in and cut out chunks of patient skin. It’s a pretty nasty procedure in order to get rid of the scarring and get rid of this, the tissue. It does tend to be effective, but depending on how widespread the disease is, obviously you can only cover so much skin, that you take out. So it’s a little bit of it. It’s, it’s, it’s not pleasant.

All right. And that wraps up our content for today.

Perfect. Now, the one thing I wanted to hit before we do the priming questions is our study tip for the day. And our study tip today is really, really straightforward. Maybe the most important piece of advice I can give you. As far as study goes, we talk about all kinds of different techniques and methods. And, you know, we just got done week one of the 33 Days program where we dive into all these different new methods for students to utilize and the methods work great and new techniques and tools work great. But here’s the thing.

Here’s the tip for today. You have to get to work. When you sit down to study, sit down to study. Major key. When it’s work time, do the work. I’m guilty of this as anyone else. When I go to sit down to do work, all of a sudden I have to use the bathroom.

All of a sudden I need to make a cup of coffee. All of a sudden I need water. I don’t have a drink of water. I’m missing my, the right pencil, whatever it is. None of that counts as study time. None of that counts as study time. Study time is when you are working.

I literally put a timer in front of me. 45 minutes, 30 minutes, an hour, whatever it is. And I hit start. And that’s work time. That’s not fiddle around time. That’s not try to get started time. That’s work time.

So all the tools and tricks and techniques aren’t going to mean anything if you’re not working. Working hard will solve a lot of the problems before the problems. Then when things get really hard, then we can move to the techniques and the principles and other things. But if you’re not working for the time you sit there, then no amount of techniques is going to help you. So figure it out. Set a timer. I sometimes set a starting timer and I say in 10 minutes I’m going to sit down and get to work so that I have that sort of leading into it.

I have what I’m going to do all mapped out like we talked about in the last episode so I know where I’m headed, what I’m doing. So when I hit go on my timer, that’s study time. That’s work time. That’s writing time. Whatever it is I pick to do during that sequence. And then when I think to myself, oh, I should just check my email real quick. Oh, I should just check in on the 33 day students to see if anyone needs anything.

Oh, maybe I’ll just check the news real fast or the weather. No, it’s study time. It’s work time. It’s really easy when you set it up like that in your head. It’s really hard when you don’t.

All right, let’s talk about our priming questions. Recurrent abscesses in the axilla or groin. What’s the diagnosis? Just because I mispronounce it doesn’t mean you don’t know it. Hidradenitis suppurativa. Hidradenitis suppurativa. Roughly rough scaly sandpaper like lesion on the sun exposed skin.

What’s the diagnosis? Here we have actinic keratosis. Waxy stuck on pigmented lesions. This should jump off the page. And the other thing that’s cool that I do a lot is so if I have trouble remembering that actinic keratosis is rough scaly sandpaper like lesions on sun exposed skin and I just for whatever reason doesn’t stick. Different things stick with different people. This one doesn’t stick for me.

What I can do instead is understand that when I get a test question it’s going to be actinic keratosis or seborrheic keratosis compared to each other just like it’s going to be Addison’s not Addison’s or Crohn’s. It’s going to be ulcerative colitis or Crohn’s disease. Right? It’s going to be actinic keratosis or seborrheic keratosis. So if I can remember one of them if I can remember waxy stuck on pigmented lesions or seborrheic keratosis then I almost don’t need to remember what actinic keratosis. I just have to know it’s not waxy stuck on pigmented lesions. Does that make sense?

I hope it does because that’s really powerful. I do the same thing when I’m looking at like heart murmurs. If I can remember one that helps me get to the answer on all the others because I know it’s not that one. If I can remember two even more so. Right? So I look at it like that. I don’t look at it as necessarily need to know every detail.

But if I can get seborrheic keratosis right every single time when it’s not that I know it’s actinic keratosis. So it’s just process of elimination because they’re giving you multiple choice questions. Different than in the office of course but in the sense of your test it works really well. That’s a free study tip this week. Soft, rubbery, freely mobile, subcutaneous mass. What two diagnoses should we be thinking of? We’re thinking of a lipoma or an epidermal inclusion cyst.

And lastly what was our first line treatment for actinic keratosis? Cryotherapy with liquid nitrogen.

Fantastic. All right. If this episode helped, here’s the important takeaway. It’s not about memorizing all these facts. It’s about what to notice, how to organize it, and how to think about it under pressure. That’s the other key. And it doesn’t, you know, I get a lot of students who come back to me.

I was asking, I headed out to Ashland, Ohio this week. And the students I’m going to talk to have their PACKRATs. I was talking with some of the students in the 33 Days program. I was talking with some of my coaches. And I was saying, you know, how did the PACKRAT affect you, you know, in the couple days before, in the week before? What were you feeling? What were you doing?

And a couple of them said that they used it as a benchmark, but it wasn’t really a great predictor anyway. Some of them thought they would do great on their test because their PACKRAT scores were great, and they wound up failing. Some of them thought they were going to do terrible because their PACKRAT scores were terrible, and they wound up doing fine. The pressure that day just changes things for a lot of people. So it’s not just about memorizing facts. It’s about performing on that day. That’s why we focus so much on performance here.

Remember, that’s why we talk about think different, work different, score different. It’s not just about memorizing facts. That’s really what I just want you to have that so locked in. Anyway, so like I said, if you’d like to join us for the 33 Days to Pass the PANCE program moving forward, we are doing cohorts every other month in 2026. The next one will be in April and then in June. But get in early. Don’t wait to just before your exam.

All right, that’s it for today. Good luck on your test coming up, and I look forward to hearing from you guys. Take care.