Dermatology

Minci Yazumin

Outline
Approach to patient Identify skin lesions Skin infections Papulo-s uamous!inflammatory rashes Systemic disease Skin tumours Skin failure " #$

%istory taking
&ime course of rash Distri'ution of lesions ( fle)ural* e)tensor* acral* symmetrical* localized* +idespread* facial* unilateral* linear* centriceptal* annular and reticulate, Symptoms ( itch!pain -% .atopy / psoriasis0 PM% Pro1ocating f.)0 ( sunlight / diet Pre1ious skin &)

#)amination
2ook and -eel 3oncentrate on colour, moisture, temperature, turgor, presence of pathological efflorescence, bleeding manifestations* and oedemas, Assess ( 4ails* %air and Mucosal Surfaces

 5, 6, 7, 9, ;, <, >, ?,

3olour Pale ( +hole* local $ed 8lue ( central* peri Yello+ ( :aundice* )antosis 8ro+n ( localise* diffuse =rey-'ro+n Al'inism Addison@s disease

Moisture 5, #nhanced ( 2ocal* Diffuse 6, $educed

&emperature 5, Increase ( reddening* oedema .inflammation0 6, Decrease ( pallid* cold skin . ischaemia* $aynaud@s0

Skin efflorescence &rophic skin changes ( 1ascular / inner1ation disorders 6, 8edsore.decu'itus0 7, Aaricose ulcer

Skin turgor
depends on hydration of the skin, the epidermis and its structure. Decreased turgor is common in older age and is caused 'y decreased elasticity of epidermis, In other cases dehydration caused 'y fluid loss contri'utes to decreased turgor .decompensated dia'etes mellitus* dia'etes insipidus* intensi1e diuretic therapy0 or dehydration can 'e caused 'y insufficient intake of fluids .reduced thirst feelings in elderly people0, &he com'inations of 'oth causes are fre uent* too,

 %air
Thin hair can 'e found in 'oth se)es in hypogonadism* hypopituitarism* hypothyroidism* and hepatic cirrhosis and in males treated 'y oestrogens, Stronger and denser hair (hypertrichosis, hirsutism) is important in +omen, 3ushingBs syndrome, More se1ere forms accompany androgenic tumours of the adrenal corte) and androgen treatment .dopingC0, Alopecia is diffuse or local loss of hair, It occurs in cytostatic treatment* in a'dominal typhus* and thyroto)icosis, In some men* the diffuse alopecia is a common finding, 2ocal alopecia .alopecia areata0 is rather rare to find,

4ails
Fragile and fraying nails are most common in thyroto)icosis and sideropenic anaemia, Spoon-shape bent nails .koilonychia0 occur in thyroto)icosis, Spherical nails accompany congenital heart disorders* chronic pulmonary diseasesD less fre uently can 'e found in hepatic cirrhosis as a part of clu''ed fingers .the shape of +rist +atch glass0, !hite .hepatic0 nails occur in hepatic cirrhosis .the +hite part of the nail* so called lunula occupies a significant part of the nail area0, "ails deformed +ith une1en surface* thick* changed in colour .particularly on toes0 are affected 'y mycosis .onychomycosis

 Atrophy ( thinning of skin

 8ulla ( large fluid-filled 'lister

 3rusted ( Dried serum or e)udate on skin

 #cchymosis ( large confluent area of purpura .'ruise0

 #rosion ( denuded area of skin .partial epidermal loss0

 #)coriation ( Scratch mark EPerleche .lip licking0 * neurotic e)coriation

 2ichenification ( &hickened epidermis +ith prominent normal skin markings

 Macule ( -lat* circumscri'ed* non-palpa'le lesion, =enerally less than 9cm +ith different colour from surrounding tissue

 Papule ( Small palpa'le* circumscri'ed * ele1ated lesion .F G,9cm0

 4odule ( large papule .,G,9cm0

 Petechiae ( pinpoint-sized macule of 'lood in the skin

 Pla ue ( 2arge* flat-topped* palpa'le lesion

Purpura ( large macule or papule of 'lood in skin +hich does not 'lanch +ith pressure

 Pustule ( Yello+ish +hite pus-filled lesion

 Scaly ( Aisi'le flaking and shedding of skin surface

 &elengiectasia ( A'normal 1isi'le dilation of 'lood 1essels

Hlcer ( deeper denuded area of skin .full epidermal and dermal loss0

 Aesicle ( small fluid-filled 'lister

 Ieal ( Itchy raised Jnettle rash@-like s+elling due to dermal oedema

Drug-induced rashes

 Maculopapular - penicillin

 Hrticaria .%i1es0 Penicillin* aspirin

 Aasculitis =old* hydralazine

 -i)ed drug rash ( Phenolpthalein in la)ati1es* tetracyclines* paracetamol Pigmentation ( Minocycline .'lack0* amiodarone .slate grey0 Pustular - car'amazepine

 2upus erythematosus Penicillamine* isoniazid

 Photosensiti1ity &hiazides* chlopromazine* sulphonamides* amiodarone,

 #rythema nodosum specific painful red and 1iolet infiltrates located on the shanks .sarcoidosis* idiopathic intestinal inflammations* or the origin may 'e unclear0, Sulphonamides* oral contracepti1e pills

 #rythema multiforme .#M0 acute* self-limiting* inflammatory skin eruption, &he rash is made of spots that are red +elts* sometimes +ith purple or 'listered areas in the center, It often also affects the mouth* eyes and other moist surfaces, 8ar'iturates

 Acneiform comedones* papulopustules* cysts* or nodules that resem'le acne 1ulgaris 3orticosteroids

 2ichenoid keratinocyte enlargement associated +ith 3i1atte 'ody .colloid 'ody0 production 3hloro uine* thiazides* gold

 &o)ic epidermal necrolysis Penicillins* cotrimo)azole* car'amazepine* 4SAIDs

 Pemphigus autoimmune disorder that causes 'listering and ra+ sores on skin and mucous mem'ranes Penicillamine* A3# inhi'itors

 #ryhtroderma generalized skin disorder characterized 'y reddening and scaling of KGGL of the skin, It is also kno+n as erythrodermatitis* generali$ed e%foliati&e dermatitis* and red man syndrome, &here may also 'e normal areas of skin present =old* sulphonylureas* allopurinol,

Skin -ailure and #$ Dermatology

&o)ic epidermal necrolysis .&#40

detachment of the epidermis from the dermis all o1er the 'ody, &#4 affects mucous mem'ranes - mouth* eyes* and 1agina, &he se1ere findings of &#4 are often preceded 'y K to 5 +eeks of fe1er, &hese symptoms may mimic those of a common upper respiratory tract infection, Ihen the rash appears it may 'e o1er large and 1aried parts of the 'ody* and it is usually +arm and appears red, In hours* the skin 'ecomes painful and the epidermis can 'e easily peeled a+ay from the underlying dermis, &he mouth 'ecomes 'listered and eroded* making eating difficult and sometimes necessitating feeding through a 4= tu'e or a gastric tu'e, &he eyes are affected* 'ecoming s+ollen* crusted* and ulcerated,

-irst 2ineM early +ithdra+al of culprit drugs* early referral and management in 'urn units or I3H* supporti1e management* nutritional support Second 2ineM Intra1enous immunoglo'ulin .IAI=0 - Hncontrolled trials sho+ed promising effect of IAI= on treatment of &#4 &hird 2ineM cyclosporin* cyclophosphamide* plasmapheresis* pento)ifylline* 4-acetylcysteine* ulinastatin* infli)ima'* =ranulocyte colony-stimulating factors .if &#4 associated-leukopenia0 Systemic steroids are unlikely to offer any 'enefits, 'rognosis &he mortality for to)ic epidermal necrolysis is 6G-7GL Deaths are caused either 'y infection or 'y respiratory distress +hich is either due to pneumonia or to the damage to air+ay linings,

Ste1ens Nohnson Syndrome

Milder form of &#4D hypersensiti1ity comple)* rare - K case per million people per year, flu-like prodormal period of fe1er* sore throat* and headache* +hich may also 'e accompanied 'y photopho'ia and redness in the eyes* follo+ed 'y the sudden de1elopment of circular mucocutaneous lesions that can co1er the ma:ority of the skin, &hese lesions 'egin as macules and can de1elop into papules* 1esicles* 'listers* or urticaria, SNS is usually defined to refer to those cases +here less than KGL of 'ody surface is in1ol1ed

3aused 'y infections usually follo+ing 1iral infections* allergic reactions to drugs* malignancy or idiopathic factors .up to 9GL of the time0, SNS has also 'een consistently reported as an uncommon side effect of her'al supplements containing ginseng, SNS may also 'e caused 'y cocaine usage,

Treatment Discontinue all medications* particularly those kno+n to cause SNS reactions, &reatment is initially similar to that of patients +ith thermal 'urns* and continued care can only 'e supporti1e .e,g, IA fluids0 and symptomatic .e,g, analgesic mouth rinse for mouth ulcer0D there is no specific drug treatment &reatment +ith corticosteroids is contro1ersial since it might aggra1ate the condition or increase risk of secondary infections, Other common supporti1e measures include the use of topical pain anesthetics and antiseptics* maintaining a +arm en1ironment* and intra1enous analgesics, An ophthalmologist should 'e consulted immediately* as SNS fre uently causes the formation of scar tissue inside the eyelids leading to corneal 1ascularization and impaired 1ision* as +ell as a host of other ocular pro'lems, Also* an e)tensi1e physical therapy program ensues after the patient is discharged from the hospital

4e)t +eek
Angiooedema Acute meningococcacaemia