Dermatology

A handbook for medical students & junior doctors

British Association of Dermatologists

Dermatology: Handbook for medical students & junior doctors

This publication was supported by the British Association of Dermatologists.

First edition 2009 Revised first edition 2009

For comments and feedback, please contact the author at chiangyizhen@gmail.com.

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British Association of Dermatologists

Dermatology: Handbook for medical students & junior doctors

Dermatology
A handbook for medical students & junior doctors

Dr Nicole Yi Zhen Chiang MBChB (Hons) Core Medical Trainee Salford Royal NHS Foundation Trust Hope Hospital Salford M6 8HD

Professor Julian Verbov MD FRCP FRCPCH CBiol FSB FLS Professor of Dermatology Consultant Paediatric Dermatologist Alder Hey Children’s Hospital Liverpool L12 2AP

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British Association of Dermatologists

Dermatology: Handbook for medical students & junior doctors 3 British Association of Dermatologists .

Dermatology: Handbook for medical students & junior doctors Contents Page Preface Foreword What is dermatology? What is dermatology? Essential Clinical Essential clinical skills Skills Background Knowledge Emergency Dermatology Skin Infections / Infestations Skin Cancer Inflammatory Skin Conditions Common Important Problems Management Practical Skills Acknowledgements 5 6 47 58 23 28 36 39 44 50 60 63 67 4 British Association of Dermatologists .

Dr Chiang is to be congratulated for her exceptional industry and enthusiasm in converting an idea into a reality. This text is available online and in print and should become essential reading. For many reasons. Julian Verbov Professor of Dermatology Liverpool 2009 5 British Association of Dermatologists . most UK medical schools provide inadequate exposure to the specialty for the undergraduate.Dermatology: Handbook for medical students & junior doctors Preface This Handbook of Dermatology is intended for senior medical students and newly qualified doctors. A basic readable and understandable text with illustrations has become a necessity. including modern medical curriculum structure and a lack of suitable patients to provide adequate clinical material.

well illustrated. Any handbook must meet the challenges of being comprehensive.Dermatology: Handbook for medical students & junior doctors Foreword There is a real need for appropriate information to meet the educational needs of doctors at all levels. I wish it had been available when I was in need. This book does just that. It has valuable sections on clinical method. designed and developed by the very people at whom it is aimed. but brief. or dipped into for specific clinical problems. I am delighted to associate the BAD with this excellent handbook. It may be read straight through. I am sure that you will all use it well in the pursuit of excellent clinical dermatology! Dr Mark Goodfield President of the British Association of Dermatologists 6 British Association of Dermatologists . and useful tips on practical procedures. It should find a home in the pocket of students and doctors in training. and focused to clinical presentations as well as disease groups. and matching the medical student and junior doctor curriculum directly. and will be rapidly worn out. and is accessible and easily used. The hard work of those who produce the curricula on which teaching is based can be undermined if the available teaching and learning materials are not of a standard that matches the developed content.

bad.uk/Portals/_Bad/Education/Undergraduate%20Edu cation/(Link2)%20Core%20curriculum. • In 2006-07. and social and occupational restrictions. They can cause physical damage. and oral and genital mucous membranes. Some skin conditions can be life-threatening. Chronic skin diseases may cause financial constraints with repeated sick leave.pdf). • Skin diseases have serious impacts on life. What is this handbook about? • The British Association of Dermatologists outlined the essential and important learning outcomes that should be achieved by all medical undergraduates for the competent assessment of patients presenting with skin disorders (available on: http://www. nails. embarrassment. 7 British Association of Dermatologists . affecting up to a third of the population at any one time. • This handbook addresses these learning outcomes and aims to equip you with the knowledge and skills to practise competently and safely as a junior doctor. the total NHS health expenditure for skin diseases was estimated to be around ₤97 million (approximately 2% of the total NHS health expenditure). Why is dermatology important? • Skin diseases are very common.org.Dermatology: Handbook for medical students & junior doctors What is dermatology? • Dermatology is the study of both normal and abnormal skin and associated structures such as hair.

hair. asthma. nails and mucous membranes systematically showing respect for the patient 5. allergic rhinitis. hair. Learning outcomes: 1. Ability to take a dermatological history 2. illness and travel History of sunburn and use of tanning machines* Skin type (see page 65)* Past medical history History of atopy i. eczema History of skin cancer and suspicious skin lesions Family history Social history Family history of skin disease* Occupation (including skin contacts at work) Improvement of lesions when away from work Medication and allergies Impact on quality of life Regular.e. below are the important points to consider when taking a history from a patient with a skin problem (Table 1). pay attention to questions marked with an asterisk (*). Ability to interact sensitively with people with skin disease 4. Ability to describe physical signs in skin. Ability to examine skin. Taking a dermatological history Main headings Presenting complaint History of presenting complaint Key questions Nature. recent and over-the-counter medications Impact of skin condition and concerns 8 British Association of Dermatologists . • For dark lesions or moles. Ability to record findings accurately in patient’s records Taking a dermatological history • Using the standard structure of history taking. nails and mucosa 6. stressful events.Essential Clinical Skills – Taking a dermatological history Dermatology: Handbook for medical students & junior doctors Essential Clinical Skills • Detailed history taking and examination provide important diagnostic clues in the assessment of skin problems. site and duration of problem Initial appearance and evolution of lesion* Symptoms (particularly itch and pain)* Aggravating and relieving factors Previous and current treatments (effective or not) Recent contact. Table 1. Ability to explore a patient’s concerns and expectations 3.

Margin (border) *If the lesion is pigmented. Table 2. pattern of distribution and configuration DESCRIBE the individual lesion SCAM Size (the widest diameter). remember ABCD (the presence of any of these features increase the likelihood of melanoma): Asymmetry (lack of mirror image in any of the four quadrants) Irregular Border Two or more Colours within the lesion Diameter > 7mm PALPATE the individual lesion Surface Consistency Mobility Tenderness Temperature SYSTEMATIC CHECK Examine the nails. Shape Colour Associated secondary change Morphology. hair & mucous membranes General examination of all systems 9 British Association of Dermatologists . Examining the skin Main principles INSPECT in general Key features General observation Site and number of lesion(s) If multiple. PALPATE and SYSTEMATIC CHECK (Table 2). scalp. DESCRIBE.Essential Clinical Skills – Examining the skin Dermatology: Handbook for medical students & junior doctors Examining the skin • There are four important principles in performing a good examination of the skin: INSPECT.

Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Communicating examination findings • In order to describe. record and communicate examination findings accurately. it is important to learn the appropriate terminology (Tables 3-10). Table 3. bacteria and cellular debris. General terms Terms Pruritus Lesion Rash Naevus Meaning Itching An area of altered skin An eruption A localised malformation of tissue structures Example: (Picture Source: D@nderm) Pigmented melanocytic naevus (mole) Comedone A plug in a sebaceous follicle containing altered sebum. can present as either open (blackheads) or closed (whiteheads) Example: Open comedones (left) and closed comedones (right) in acne 10 British Association of Dermatologists .

heels Dermatome An area of skin supplied by a single spinal nerve Photosensitive Affects sun-exposed areas such as face. ankles. shins Pressure areas Sacrum. groin. elbows. behind ears.Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Table 4. buttocks. popliteal and antecubital fossa Knees. Distribution (the pattern of spread of lesions) Terms Generalised Widespread Localised Flexural Extensor Meaning All over the body Extensive Restricted to one area of skin only Body folds i. neck.e. neck and back of hands Example: Sunburn Köebner A linear eruption arising at site of trauma phenomenon Example: Psoriasis 11 British Association of Dermatologists .

Configuration (the pattern or shape of grouped lesions) Terms Discrete Confluent Linear Target Meaning Individual lesions separated from each other Lesions merging together In a line Concentric rings (like a dartboard) Example: Erythema multiforme Annular Like a circle or ring Example: Tinea corporis (‘ringworm’) Discoid / Nummular A coin-shaped/round lesion Example: Discoid eczema 12 British Association of Dermatologists .Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Table 5.

Colour Terms Erythema Meaning Redness (due to inflammation and vasodilatation) which blanches on pressure Example: Palmar erythema Purpura Red or purple colour (due to bleeding into the skin or mucous membrane) which does not blanch on pressure – petechiae (small pinpoint macules) and ecchymoses (larger bruise-like patches) Example: Henoch-Schönlein purpura (palpable small vessel vasculitis) 13 British Association of Dermatologists .Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Table 6.

Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Hypo- Area(s) of paler skin pigmentation Example: Pityriasis versicolor (a superficial fungus infection) De- White skin due to absence of melanin pigmentation Example: Vitiligo (loss of skin melanocytes) Hyper- Darker skin which may be due to various causes (e. post-inflammatory) pigmentation Example: Melasma (increased melanin pigmentation) 14 British Association of Dermatologists .g.

Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Table 7. Morphology (the structure of a lesion) – Primary lesions Terms Macule Meaning A flat area of altered colour Example: Freckles Patch Larger flat area of altered colour or texture Example: Vascular malformation (naevus flammeus / ‘port wine stain’) Papule Solid raised lesion < 0.5cm in diameter Example: Xanthomata 15 British Association of Dermatologists .

Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Nodule Solid raised lesion >0.5cm in diameter (large blister) Example: Reaction to insect bites 16 British Association of Dermatologists .5cm in diameter with a deeper component Example: (Picture source: D@nderm) Pyogenic granuloma (granuloma telangiectaticum) Plaque Palpable scaling raised lesion >0. clear fluid-filled lesion <0.5cm in diameter (small blister) Example: Acute hand eczema (pompholyx) Bulla Raised.5cm in diameter Example: Psoriasis Vesicle Raised. clear fluid-filled lesion >0.

Essential Clinical Skills – Communicating examination findings

Dermatology: Handbook for medical students & junior doctors

Pustule

Pus-containing lesion <0.5cm in diameter Example:

Acne

Abscess

Localised accumulation of pus in the dermis or subcutaneous tissues Example:

Periungual abscess (acute paronychia)

W(h)eal

Transient raised lesion due to dermal oedema Example:

Urticaria

Boil/Furuncle Staphylococcal infection around or within a hair follicle

Carbuncle

Staphylococcal infection of adjacent hair follicles (multiple boils/furuncles)

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British Association of Dermatologists

Essential Clinical Skills – Communicating examination findings

Dermatology: Handbook for medical students & junior doctors

Table 8. Morphology - Secondary lesions (lesions that evolve from primary lesions) Terms Excoriation Meaning Loss of epidermis following trauma Example:

Excoriations in eczema

Lichenification Well-defined roughening of skin with accentuation of skin markings Example:

Lichenification due to chronic rubbing in eczema

Scales

Flakes of stratum corneum Example:

Psoriasis (showing silvery scales)

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British Association of Dermatologists

Essential Clinical Skills – Communicating examination findings

Dermatology: Handbook for medical students & junior doctors

Crust

Rough surface consisting of dried serum, blood, bacteria and cellular debris that has exuded through an eroded epidermis (e.g. from a burst blister) Example:

Impetigo

Scar

New fibrous tissue which occurs post-wound healing, and may be atrophic (thinning), hypertrophic (hyperproliferation within wound boundary), or keloidal (hyperproliferation beyond wound boundary) Example:

Keloid scars

Ulcer

Loss of epidermis and dermis (heals with scarring) Example:

Leg ulcers

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British Association of Dermatologists

growth spurts and pregnancy) Example: Striae 20 British Association of Dermatologists .Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Fissure An epidermal crack often due to excess dryness Example: Eczema Striae Linear areas which progress from purple to pink to white. with the histopathological appearance of a scar (associated with excessive steroid usage and glucocorticoid production.

Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Table 9. Hair Terms Alopecia Meaning Loss of hair Example: Alopecia areata (well-defined patch of complete hair loss) Hirsutism Androgen-dependent hair growth in a female Example: Hirsutism Hypertrichosis Non-androgen dependent pattern of excessive hair growth (e. in pigmented naevi) Example: Hypertrichosis 21 British Association of Dermatologists .g.

eczema and alopecia areata) Example: (Picture source: D@nderm) Pitting 22 British Association of Dermatologists .Essential Clinical Skills – Communicating examination findings Dermatology: Handbook for medical students & junior doctors Table 10. Nails Terms Clubbing Meaning Loss of angle between the posterior nail fold and nail plate (associations include suppurative lung disease. psoriasis. fungal nail infection and hyperthyroidism) Example: (Picture source: D@nderm) Onycholysis Pitting Punctate depressions of the nail plate (associations include psoriasis. inflammatory bowel disease and idiopathic) Example: (Picture source: D@nderm) Clubbing Koilonychia Spoon-shaped depression of the nail plate (associations include iron-deficiency anaemia. congenital and idiopathic) Example: (Picture source: D@nderm) Koilonychia Onycholysis Separation of the distal end of the nail plate from nail bed (associations include trauma. cyanotic heart disease.

sebaceous glands and sweat glands.Background Knowledge – Functions of normal skin Dermatology: Handbook for medical students & junior doctors Background Knowledge • This section covers the basic knowledge of normal skin structure and function required to help understand how skin diseases occur. Ability to describe the structure of normal skin 3. The skin appendages (structures formed by skin-derived cells) are hair. It is composed of the epidermis and dermis overlying subcutaneous tissue. Epidermis • The epidermis is composed of 4 major cell types. 23 British Association of Dermatologists . Learning outcomes: 1. Ability to describe the functions of normal skin 2. Ability to describe the difficulties. each with specific functions (Table 11). that may be experienced by people with chronic skin disease Functions of normal skin • These include: i) ii) iii) iv) v) vi) Protective barrier against environmental insults Temperature regulation Sensation Vitamin D synthesis Immunosurveillance Appearance/cosmesis Structure of normal skin and the skin appendages • The skin is the largest organ in the human body. physical and psychological. nails. Ability to describe the principles of wound healing 4.

g.e. crusting. Stratum corneum (Horny layer) Layer of keratin. This consists of paler. Table 12. Composition of each epidermal layer Epidermal layers Stratum basale (Basal cell layer) Stratum spinosum (Prickle cell layer) Stratum granulosum (Granular cell layer) So-called because cells lose their nuclei and contain granules of keratohyaline.Background Knowledge Dermatology: Handbook for medical students & junior doctors Table 11.or hyper-pigmented skin 24 British Association of Dermatologists . which gives pigment to the skin and protects the cell nuclei from ultraviolet (UV) radiation-induced DNA damage Merkel cells Contain specialised nerve endings for sensation – Structure of normal skin and the skin appendages • There are 4 layers in the epidermis (Table 12). compact keratin.g. there is a fifth layer. stratum lucidum. hypo. exudate. • Pathology of the epidermis may involve: a) changes in epidermal turnover time .e. psoriasis (reduced epidermal turnover time) b) changes in the surface of the skin or loss of epidermis . The average epidermal turnover time (migration of cells from the basal cell layer to the horny layer) is about 30 days. They secrete lipid into the intercellular spaces.g. most superficial layer Differentiating cells Composition Actively dividing cells. Main functions of each cell type in the epidermis Cell types Keratinocytes Langerhans’ cells Melanocytes Main functions Produce keratin as a protective barrier Present antigens and activate T-lymphocytes for immune protection Produce melanin. scales.e. each representing a different stage of maturation of the keratinocytes. deepest layer • In areas of thick skin such as the sole. ulcer c) changes in pigmentation of the skin . beneath the stratum corneum.

which are synthesised by fibroblasts.Background Knowledge – Structure of normal skin and the skin appendages Dermatology: Handbook for medical students & junior doctors Dermis • The dermis is made up of collagen (mainly). • The dermis also contains immune cells. eyebrows.g.g. eyelashes and pubic areas) • Each hair consists of modified keratin and is divided into the hair shaft (a keratinized tube) and hair bulb (actively dividing cells.g. urticaria (increased permeability of capillaries and small venules). they provide the dermis with strength and elasticity. elastin and glycosaminoglycans. formation of papules. Collectively.g.g. erythema (vasodilatation). • Pathology of the dermis may involve: a) changes in the contour of the skin or loss of dermis e. This occurs in 3 main phases: a) anagen (long growing phase) b) catagen (short regressing phase) c) telogen (resting/shedding phase) • Pathology of the hair may involve: a) reduced or absent melanin pigment production e. disorders of hair. nodules. skin atrophy and ulcers b) disorders of skin appendages e. purpura (capillary leakage) Hair • There are 3 main types of hair: a) lanugo hair (fine long hair in fetus) b) vellus hair (fine short hair on all body surfaces) c) terminal hair (coarse long hair on the scalp. • Each hair follicle enters its own growth cycle. hair loss (premature entry of hair follicles into the telogen phase) c) shaft abnormalities 25 British Association of Dermatologists . grey or white hair b) changes in duration of the growth cycle e. nerves. acne (disorder of sebaceous glands) c) changes related to lymphatic and blood vessels e. skin appendages as well as lymphatic and blood vessels. and melanocytes which give pigment to the hair).

areolae.g. discoloured nails.g. • • • They are divided into two types: eccrine and apocrine sweat glands.Background Knowledge – Structure of normal skin and the skin appendages Dermatology: Handbook for medical students & junior doctors Nails • The nail is made up of a nail plate (hard keratin) which arises from the nail matrix at the posterior nail fold.g. and rests on the nail bed.g. thickening of nails Sebaceous glands • Sebaceous glands produce sebum via hair follicles (collectively called a pilosebaceous unit). Pathology of the nail may involve: a) abnormalities of the nail matrix e. They secrete sebum onto the skin surface which lubricates and waterproofs the skin. • Sebaceous glands are stimulated by the conversion of androgens to dihydrotestosterone and therefore become active at puberty.g.g. splinter haemorrhage c) abnormalities of the nail plate e. Apocrine sweat glands are found in the axillae. They only function from puberty onwards and action of bacteria on the sweat produces body odour. • Pathology of sweat glands may involve: a) inflammation/infection of apocrine glands e. hidradenitis suppurativa b) overactivity of eccrine glands e. and modified glands are found in the external auditory canal. acne b) sebaceous gland hyperplasia Sweat glands • Sweat glands regulate body temperature and are innervated by the sympathetic nervous system. • • The nail bed contains blood capillaries which gives the pink colour of the nails. hyperhidrosis 26 British Association of Dermatologists . • Pathology of sebaceous glands may involve: a) increased sebum production and bacterial colonisation e. genitalia and anus. Eccrine sweat glands are universally distributed in the skin. pits and ridges b) abnormalities of the nail bed e.

Background Knowledge – Principles of wound healing Dermatology: Handbook for medical students & junior doctors Principles of wound healing • Wound healing occurs in 4 phases: haemostasis. proliferation and remodelling (Table 13). Table 13. Stages of wound healing Stages of wound healing Haemostasis Mechanisms ● Vasoconstriction and platelet aggregation ● Clot formation Inflammation ● Vasodilatation ● Migration of neutrophils and macrophages ● Phagocytosis of cellular debris and invading bacteria Proliferation ● Granulation tissue formation (synthesised by fibroblasts) and angiogenesis ● Re-epithelialisation (epidermal cell proliferation and migration) Remodelling ● Collagen fibre re-organisation ● Scar maturation 27 British Association of Dermatologists . inflammation.

Stevens-Johnson syndrome .eczema herpeticum . Ability to recognise these emergency presentations. consists of: i) ii) iii) iv) full supportive care .erythema nodosum . Ability to recognise and describe these skin reactions: .necrotising fasciitis 28 British Association of Dermatologists .ABC of resuscitation withdrawal of precipitating agents management of associated complications specific treatment (highlighted below under each condition) Learning outcomes: 1.erythroderma .Emergency Dermatology Dermatology: Handbook for medical students & junior doctors Emergency Dermatology • These are rapidly progressive skin conditions and some are potentially lifethreatening. like any emergency. discuss the causes. • • Some are drug reactions and the offending drug should be withdrawn. potential complications and provide first contact care in these emergencies: .erythema multiforme 2.toxic epidermal necrolysis .urticaria . Early recognition is important to implement prompt supportive care and therapy. The essential management for all dermatological emergencies.acute meningococcaemia .anaphylaxis and angioedema .

raising the epidermis): itchy wheals ● Angioedema (deeper swelling involving the dermis and subcutaneous tissues): swelling of tongue and lips ● Anaphylaxis (also known as anaphylactic shock): bronchospasm. latex). autoimmune. food (e. sesame seeds. leukotrienes.Emergency Dermatology – Urticaria. non-steroidal antiinflammatory drugs (NSAIDs). cardiac arrest and death Urticaria Angioedema 29 British Association of Dermatologists . viral or parasitic infections. nuts. angiotensin-converting enzyme inhibitors (ACE-i)). drugs (e. insect bites. hypotension. corticosteroids and antihistamines for anaphylaxis Complications ● Urticaria is normally uncomplicated ● Angioedema and anaphylaxis can lead to asphyxia. can present initially with urticaria and angioedema Management ● Antihistamines for urticaria ● Corticosteroids for severe acute urticaria and angioedema ● Adrenaline. A large number of inflammatory mediators (including prostaglandins. Angioedema and Anaphylaxis Causes ● Idiopathic. and hereditary (in some cases of angioedema) Description ● Urticaria is due to a local increase in permeability of capillaries and small venules. morphine.g. Angioedema and Anaphylaxis Dermatology: Handbook for medical students & junior doctors Urticaria. contrast media. facial and laryngeal oedema. contact (e. Presentation ● Urticaria (swelling involving the superficial dermis.g. Local mediator release from mast cells can be induced by immunological or non-immunological mechanisms. penicillin. dairy products). and chemotactic factors) play a role but histamine derived from skin mast cells appears to be the major mediator. shellfish.g.

Emergency Dermatology – Erythema nodosum Dermatology: Handbook for medical students & junior doctors Erythema nodosum Description ● A hypersensitivity response to a variety of stimuli Causes ● Group A beta-haemolytic streptococcus. malignancy. primary tuberculosis. inflammatory bowel disease (IBD). pregnancy. chlamydia and leprosy Presentation ● Discrete tender nodules which may become confluent ● Lesions continue to appear for 1-2 weeks and leave bruise-like discolouration as they resolve ● Lesions do not ulcerate and resolve without atrophy or scarring ● The shins are the most common site Erythema nodosum 30 British Association of Dermatologists . sarcoidosis.

31 British Association of Dermatologists . Stevens-Johnson syndrome may have features overlapping with toxic epidermal necrolysis including a prodromal illness. Skin involvement may be limited or extensive. The extensive necrosis distinguishes StevensJohnson syndrome from erythema multiforme. is an acute self- limiting inflammatory condition with herpes simplex virus being the main precipitating factor. Stevens-Johnson syndrome. Mucosal involvement is absent or limited to only one mucosal surface. Epithelial necrosis with few inflammatory cells is seen on histopathology. Arch Dermatol 1993.129:92-96. et al. Stevens-Johnson syndrome and Toxic epidermal necrolysis Description ● Erythema multiforme.Emergency Dermatology – Erythema multiforme. Clinical classification of cases of toxic epidermal necrolysis. ● Stevens-Johnson syndrome is characterised by mucocutaneous necrosis with at least two mucosal sites involved. is an acute severe similar disease characterised by extensive skin and mucosal necrosis accompanied by systemic toxicity. often of unknown cause. Stevens-Johnson syndrome and Toxic epidermal necrolysis Dermatology: Handbook for medical students & junior doctors Erythema multiforme. and erythema multiforme. On histopathology there is full thickness epidermal necrosis with subepidermal detachment. Stern RS. Rzany B. Management ● Early recognition and call for help ● Full supportive care to maintain haemodynamic equilibrium Complications ● Mortality rates are 5-12% with SJS and >30% with TEN with death often due to sepsis. electrolyte imbalance or multi-system organ failure Erythema multiforme Stevens-Johnson syndrome Further reading: Bastuji-Garin S. Drugs or combinations of infections or drugs are the main associations. Other infections and drugs are also causes. ● Toxic epidermal necrosis which is usually drug-induced.

Emergency Dermatology – Acute meningococcaemia Dermatology: Handbook for medical students & junior doctors Acute meningococcaemia Description ● A serious communicable infection transmitted via respiratory secretions. myalgia) and a typical rash ● Non-blanching purpuric rash on the trunk and extremities.com/cgi/content/full/333/7570/685) 32 British Association of Dermatologists .333:685-690 (http://www. BMJ 2006.g. multi- organ failure and death Further reading: Hart CA. septicaemia (e. Thomson APJ. fever.g. haemorrhagic bullae and tissue necrosis Management ● Antibiotics (e. headache. which may be preceded by a blanching maculopapular rash. bacteria get into the circulating blood Cause Presentation ● Gram negative diplococcus Neisseria meningitides ● Features of meningitis (e.bmj. neck stiffness). and can rapidly progress to ecchymoses. hypotension. Meningococcal disease and its management in children. rifampicin) for close contacts (ideally within 14 days of exposure) Complications ● Septicaemic shock.g.g. fever. disseminated intravascular coagulation. benzylpenicillin) ● Prophylactic antibiotics (e.

penicillin. lymphoma. high-output cardiac failure and capillary leak syndrome (most severe) Prognosis ● Largely depends on the underlying cause ● Overall mortality rate ranges from 20 to 40% Erythroderma 33 British Association of Dermatologists . captopril) and idiopathic Presentation ● Skin appears inflamed.Emergency Dermatology – Erythroderma Dermatology: Handbook for medical students & junior doctors Erythroderma (‘red skin’) Description Causes ● Exfoliative dermatitis involving at least 90% of the skin surface ● Previous skin disease (e. gold.g. eczema.sulphonamides. allopurinol. drugs (e. psoriasis). oedematous and scaly ● Systemically unwell with lymphadenopathy and malaise Management ● Treat the underlying cause.g. where known ● Emollients and wet-wraps to maintain skin moisture ● Topical steroids may help to relieve inflammation Complications ● Secondary infection. fluid loss and electrolyte imbalance. sulphonylureas. hypothermia.

encephalitis. blisters and erosions ● Systemically unwell with fever and malaise Management ● Antivirals (e.serious complication of atopic eczema or less commonly other skin conditions Cause Presentation ● Herpes simplex virus ● Extensive crusted papules.g.Emergency Dermatology – Eczema herpeticum Dermatology: Handbook for medical students & junior doctors Eczema herpeticum (Kaposi’s varicelliform eruption) Description ● Widespread eruption . aciclovir) ● Antibiotics for bacterial secondary infection Complications ● Herpes hepatitis. death Eczema herpeticum 34 British Association of Dermatologists . disseminated intravascular coagulation (DIC) and rarely.

diabetes. and necrotic skin ● Systemically unwell with fever and tachycardia ● Presence of crepitus (subcutaneous emphysema) ● X-ray may show soft tissue gas (absence should not exclude the diagnosis) Management ● Urgent referral for extensive surgical debridement ● Intravenous antibiotics Prognosis ● Mortality up to 76% Further reading: Hasham S. Necrotising fasciitis.bmj.Emergency Dermatology – Necrotising fasciitis Dermatology: Handbook for medical students & junior doctors Necrotising fasciitis Description ● A rapidly spreading infection of the deep fascia with secondary tissue necrosis Causes ● Group A haemolytic streptococcus. Matteucci P.330:830-833 (http://www. blistering.g. BMJ 2005. Stanley PRW.com/cgi/content/full/330/7495/830) 35 British Association of Dermatologists . malignancy) ● 50% of cases occur in previously healthy individuals Presentation ● Severe pain ● Erythematous. Hart NB. or a mixture of anaerobic and aerobic bacteria ● Risk factors include abdominal surgery and medical co-morbidities (e.

g.g. Herpes zoster (shingles) infection due to varicella-zoster virus affecting the distribution of the ophthalmic division of the fifth cranial (trigeminal) nerve Learning outcomes: Ability to describe the presentation. and fungal (e.cellulitis and erysipelas . yeasts). when there is skin damage. investigation and management of: . • There are 3 main types of skin infections according to their sources: bacterial (e. However.staphylococcal scalded skin syndrome 36 British Association of Dermatologists . staphylococcal and streptococcal). microorganisms can penetrate resulting in infection. Infestations (e. viral (e.g. human papilloma virus. cutaneous leishmaniasis) can also occur.g. herpes simplex and herpes zoster (see below)). scabies (see page 53 & 54).Skin Infections / Infestations Dermatology: Handbook for medical students & junior doctors Skin Infections / Infestations • The normal skin microflora and antimicrobial peptides protect the skin against infection.

abscess and septicaemia Cellulitis with elephantiasis of the penis Erysipelas 37 British Association of Dermatologists . may be associated with lymphangitis ● Systemically unwell with fever. red raised border Management ● Antibiotics (e. leg elevation. warmth (calor). malaise or rigors. erythema (rubor).g. toeweb intertrigo.Skin Infections and Infestations – Erysipelas and Cellulitis Dermatology: Handbook for medical students & junior doctors Erysipelas and Cellulitis Description ● Spreading bacterial infection of the skin ● Cellulitis involves the deep subcutaneous tissue ● Erysipelas is an acute superficial form of cellulitis and involves the dermis and upper subcutaneous tissue Causes ● Streptococcus pyogenes and Staphylococcus aureus ● Risk factors include immunosuppression. particularly with erysipelas ● Erysipelas is distinguished from cellulitis by a well-defined. pain (dolor). sterile dressings and analgesia Complications ● Local necrosis. flucloxacillin or benzylpenicillin) ● Supportive care including rest. and minor skin injury Presentation ● Most common in the lower limbs ● Local signs of inflammation – swelling (tumor). leg ulcers. wounds.

fusidic acid. erythromycin or appropriate cephalosporin) ● Analgesia Staphylococcal scalded skin syndrome 38 British Association of Dermatologists .g. and may be worse over the face. axillae or groins ● A scald-like skin appearance is followed by large flaccid bulla ● Perioral crusting is typical ● There is intraepidermal blistering in this condition ● Lesions are very painful ● Sometimes the eruption is more localised ● Recovery is usually within 5-7 days Management ● Antibiotics (e.Skin Infections and Infestations – Staphylococcal scalded skin syndrome Dermatology: Handbook for medical students & junior doctors Staphylococcal scalded skin syndrome Description Cause ● Commonly seen in infancy and early childhood ● Production of a circulating epidermolytic toxin from phage group II. a systemic penicillinase-resistant penicillin. benzylpenicillin-resistant (coagulase positive) staphylococci Presentation ● Develops within a few hours to a few days. neck.

Sun exposure is the single most preventable risk factor for skin cancer. In general.Skin Cancer Skin Cancer • • • • Learning outcomes: Ability to recognise: . 39 British Association of Dermatologists . Malignant melanoma is the most life-threatening type of skin cancer and is one of the few cancers affecting the younger population.basal cell carcinoma .malignant melanoma Dermatology: Handbook for medical students & junior doctors Skin cancer is one of the most common cancers.squamous cell carcinoma . skin cancer can be divided into: non-melanoma (basal cell carcinoma and squamous cell carcinoma) and melanoma (malignant melanoma).

and genetic predisposition Presentation ● Various morphological types including nodular (most common).when surgery is not appropriate ● Other e. history of frequent or severe sunburn in childhood.treatment of choice as it allows histological examination of the tumour and margins ● Radiotherapy . the lesion may have a necrotic or ulcerated centre (rodent ulcer) ● Most common over the head and neck Management ● Surgical excision . skin type I (always burns.g. increasing age. skin-coloured papule or nodule with surface telangiectasia.Skin Cancer – Basal cell carcinoma Dermatology: Handbook for medical students & junior doctors Basal cell carcinoma Description ● A slow-growing. growth pattern/histological subtype. never tans). and a pearly rolled edge. topical photodynamic therapy. imiquimod cream) . locally invasive malignant tumour of the epidermal keratinocytes normally in older individuals. keratotic and pigmented ● Nodular basal cell carcinoma is a small. immunosuppression. and topical treatment (e. failure of previous treatment/recurrence. superficial (plaque-like). cryotherapy. site. curettage and cautery.g. morphoeic (sclerosing). cystic. male sex. and immunosuppression Basal cell carcinoma – nodular type 40 British Association of Dermatologists . only rarely metastasises ● Most common malignant skin tumour Causes ● Risk factors include UV exposure. previous history of skin cancer.for small and low-risk lesions Complications Prognosis ● Local tissue invasion and destruction ● Depends on tumour size. type.

chronic inflammation (e. histological pattern. crusty). excision of the lesion and tissue borders are progressively excised until specimens are microscopically free of tumour) . depth of invasion. which has the potential to metastasise Causes ● Risk factors include excessive UV exposure.g. actinic keratoses). perineural involvement. ill-defined nodule which may ulcerate ● Surgical excision .treatment of choice ● Mohs’ micrographic surgery (i.for high risk.e. leg ulcers.Skin Cancer – Squamous cell carcinoma Dermatology: Handbook for medical students & junior doctors Squamous cell carcinoma Description ● A locally invasive malignant tumour of the epidermal keratinocytes or its appendages. non-resectable tumours ● Chemotherapy . immunosuppression and genetic predisposition Presentation Management ● Keratotic (e.g.for metastatic disease Prognosis ● Depends on tumour size.for large. pre-malignant skin conditions (e. scaly.g. site. recurrent tumours ● Radiotherapy . wound scars). and immunosuppression Squamous cell carcinoma – adjacent to ear (left) and glans penis (right) 41 British Association of Dermatologists .

M0) – 80%. skin type I (always burns.76mm-1. related to intermittent high-intensity UV exposure ● Lentigo maligna melanoma . stage 3 (N≥1.Skin Cancer – Malignant melanoma Dermatology: Handbook for medical students & junior doctors Malignant melanoma Description ● An invasive malignant tumour of the epidermal melanocytes. never tans). stage 2 (T>2mm thick. >1. history of multiple moles or atypical moles. N0.5mm thick – high risk ● 5-year survival rates based on the TNM classification (primary Tumour. and family history or previous history of melanoma Presentation ● The ‘ABCDE Symptoms’ rule (*major suspicious features): Asymmetrical shape* Border irregularity Colour irregularity* Diameter > 7mm Evolution of lesion (e. soles and nail beds. M0) – 40. related to long-term cumulative UV exposure ● Acral lentiginous melanoma . change in size and/or shape)* Symptoms (e. related to intermittent highintensity UV exposure ● Nodular melanoma .g. in young and middle-aged adults. regional Nodes. in young and middle- aged adults.common on the trunk.50%. in elderly population.5mm thick – medium risk. in elderly population. N0. M0) . itching) ● More common on the legs in women and trunk in men Types ● Superficial spreading melanoma – common on the lower limbs.common on the face.g.common on the palms. 0. Metastases): stage 1 (T <2mm thick.76mm thick – low risk. no clear relation with UV exposure Management ● Surgical excision . bleeding. which has the potential to metastasise Causes ● Risk factors include excessive UV exposure.90%.definitive treatment ● Radiotherapy may sometimes be useful Prognosis ● Recurrence of melanoma based on Breslow thickness (thickness of tumour): <0. and stage 4 (M ≥ 1) – 20-30% 42 British Association of Dermatologists .

Skin Cancer – Malignant melanoma Superficial spreading melanoma Lentigo maligna melanoma Dermatology: Handbook for medical students & junior doctors Nodular melanoma Acral lentiginous melanoma 43 British Association of Dermatologists .

atopic eczema .Inflammatory Skin Conditions Dermatology: Handbook for medical students & junior doctors Inflammatory Skin Conditions • Eczema. Patient education is important in these chronic skin conditions and should concentrate on providing information about the nature of condition.psoriasis 44 British Association of Dermatologists . formulate a differential diagnosis. Complications are mainly due to the psychological and social effects. acne and psoriasis are chronic inflammatory skin disorders that follow a relapsing and remitting course.acne . aims of treatment and the available treatment options. There are many types of eczema but we shall just consider atopic eczema here. demonstrate assessment. Management is aimed at achieving control and not providing a cure. Learning outcomes: Ability to describe the presentation. • • • • These skin disorders are not infectious. instigate investigation and discuss how to provide continuing care of: .

and antivirals (e. oral prednisolone.g. topical immunomodulators (e. viral warts and eczema herpeticum (see page 34) 45 British Association of Dermatologists . erythematous dry scaly patches ● More common on the face and extensor aspects of limbs in infants. tacrolimus. sweating. heat and severe stress Presentation ● Commonly present as itchy.g.usually develops by early childhood and resolves during teenage years (but may recur) Epidemiology Causes ● 20% prevalence in <12 years old in the UK ● Not fully understood. allergens (e.molluscum contagiosum (pearly papules with central umbilication).responsive cases Complications ● Secondary bacterial infection (crusted weepy lesions) ● Secondary viral infection . azathioprine. allergic rhinitis) is often present ● A primary genetic defect in skin barrier function (loss of function variants of the protein filaggrin) appears to underlie atopic eczema ● Exacerbating factors such as infections. pet fur). vesicular and weepy (exudative) ● Chronic scratching/rubbing can lead to excoriations and lichenification ● May show nail pitting and ridging of the nails Management ● General measures .e. ciclosporin) for severe non.g. antibiotics (e. flucloxacillin) for secondary bacterial infections. asthma. chemicals. eczema.avoid known exacerbating agents.Inflammatory Skin Conditions – Atopic eczema Dermatology: Handbook for medical students & junior doctors Atopic eczema Description ● Eczema (or dermatitis) is characterized by papules and vesicles on an erythematous base ● Atopic eczema is the most common type . pimecrolimus) can be used as steroid-sparing agents ● Oral therapies .bandages and bath oil/soap substitute ● Topical therapies – topical steroids for flare-ups. food.antihistamines for symptomatic relief. aciclovir) for secondary herpes infection ● Phototherapy and immunosuppressants (e. but a positive family history of atopy (i.g.g. and the flexor aspects in children and adults ● Acute lesions are erythematous. dust. frequent emollients +/.

nice.Inflammatory Skin Conditions – Atopic eczema Dermatology: Handbook for medical students & junior doctors Atopic eczema Further reading: NICE guidelines. http://www.org. Dec 2007.uk/Guidance/CG57 46 British Association of Dermatologists . Atopic eczema in children.

and anti-androgens (in females) ● Oral retinoids (for severe acne) Complications ● Post-inflammatory hyperpigmentation.Inflammatory Skin Conditions – Acne vulgaris Dermatology: Handbook for medical students & junior doctors Acne vulgaris Description Epidemiology Causes ● An inflammatory disease of the pilosebaceous follicle ● Over 80% of teenagers aged 13. bacterial colonization (Propionibacterium acnes) and inflammation Presentation ● Non-inflammatory lesions (mild acne) . psychological and social effects Comedones Papules and nodules 47 British Association of Dermatologists . pustules. and cysts ● Commonly affects the face.18 years ● Hormonal (androgen) ● Contributing factors include increased sebum production. and topical retinoids (comedolytic and anti-inflammatory properties) ● Oral therapies (for moderate to severe acne) . deformity.papules.no specific food has been identified to cause acne.oral antibiotics.benzoyl peroxide and topical antibiotics (antimicrobial properties). abnormal follicular keratinization. scarring. treatment needs to be continued for at least 6 weeks to produce effect ● Topical therapies (for mild acne) .open and closed comedones (blackheads and whiteheads) ● Inflammatory lesions (moderate and severe acne) . nodules. chest and upper back Management ● General measures .

immunological and environmental factors ● Precipitating factors include trauma (which may produce a Köebner phenomenon).Inflammatory Skin Conditions – Psoriasis Dermatology: Handbook for medical students & junior doctors Psoriasis Description ● A chronic inflammatory skin disease due to hyperproliferation of keratinocytes and inflammatory cell infiltration Types ● Chronic plaque psoriasis is the most common type ● Other types include guttate (raindrop lesions). and arthritis mutilans (flexion deformity of distal interphalangeal joints) Management ● General measures . pitting. ciclosporin. psoralen+UVA ● Oral therapies (for extensive and severe psoriasis.phototherapy i. and erythrodermic (total body redness) Epidemiology Causes ● Affects about 2% of the population in the UK ● Complex interaction between genetic. and alcohol Presentation ● Well-demarcated erythematous scaly plaques ● Lesions can sometimes be itchy. topical retinoids. asymmetrical oligomonoarthritis. pustular (palmar-plantar).e. mycophenolate mofetil. coal tar preparations. burning or painful ● Common on the extensor surfaces of the body and over scalp ● Auspitz sign (scratch and gentle removal of scales cause capillary bleeding) ● 50% have associated nail changes (e.avoid known precipitating factors. dithranol. stress. keratolytics and scalp preparations ● Phototherapy (for extensive disease) . drugs. or psoriasis with systemic involvement) .methotrexate. psoriatic spondylosis. fumaric acid esters.e. emollients to reduce scales ● Topical therapies (for localised and mild psoriasis) . UVB and photochemotherapy i. tonsillitis). 48 British Association of Dermatologists . lone distal interphalangeal disease. topical corticosteroids. oral retinoids. infection (e.g. onycholysis) ● 5-8% suffer from associated psoriatic arthropathy .symmetrical polyarthritis.vitamin D analogues. flexural (body folds). seborrhoeic (naso-labial and retro-auricular).g.

Inflammatory Skin Conditions – Psoriasis Dermatology: Handbook for medical students & junior doctors and biological agents (e. infliximab. etanercept.g. efalizumab) Complications ● Erythroderma (see page 33). psychological and social effects Köebner phenomenon Plaque psoriasis Nail changes and arthropathy Scalp involvement 49 British Association of Dermatologists .

Common Important Problems Dermatology: Handbook for medical students & junior doctors Common Important Problems • There are several commonly-encountered skin problems in clinical practice. Learning objectives: Ability to formulate a differential diagnosis.a red swollen leg 50 British Association of Dermatologists .a changing pigmented lesion . describe the investigation and discuss the management in patients with: .itchy eruption . Below are some of the important differential diagnoses for each of these presentations. investigating and managing these skin problems.purpuric eruption . • Clinical exposure is the key to achieve competence in diagnosing.chronic leg ulcers .

there can be mixture of arterial. arterial and neuropathic ulcers. infected ulcers (purulent discharge. Other causes include vasculitic ulcers (purpuric. In general.g. squamous cell carcinoma in long-standing non-healing ulcers). punched out lesions). venous and/or neuropathic components in an ulcer. • In clinical practice. Dermatology: Handbook for medical students & junior doctors British Association of Dermatologists Venous ulcer Arterial ulcer 51 Common Important Problems – Chronic leg ulcers Neuropathic ulcer British Association of Dermatologists 51 . may have systemic signs) and malignancy (e.Dermatology: Handbook for medical students & junior doctors Chronic leg ulcers • Leg ulcers are classified according to aetiology. there are three main types: venous.

Pressure sites e. varicose veins. appropriate footwear and good nutrition British Association of Dermatologists Management .g.Often painful.Shiny pale skin . pretibial. worse when legs are elevated . weak or absent pulses if it is a neuroischaemic ulcer .Often painless .ABPI < 0.Peripheral neuropathy Possible investigations .g. heel.Pressure and trauma sites e. metatarsal heads History .Leg oedema. toes .Normal peripheral pulses* *cold.History of arterial disease e.Painful especially at night. atherosclerosis .Compression bandaging (after excluding arterial insufficiency) .X-ray to exclude osteomyelitis .Warm skin .Small.History of diabetes or neurological disease .g.8-1) .Warm skin .e.ABPI < 0.8 implies a neuroischaemic ulcer .Compression bandaging is contraindicated 52 British Association of Dermatologists .Abnormal sensation . haemosiderin and melanin deposition (brown pigment). shallow irregular ulcer .Malleolar area (more common over medial than lateral malleolus) Lesion .Regular repositioning.History of venous disease e. supramalleolar (usually lateral).Wound debridement .presence of arterial insufficiency .Necrotic base Dermatology: Handbook for medical students & junior doctors Common Important Problems – Chronic leg ulcers 52 Associated features .Exudative and granulating base . callus) .Variable size and depth .Normal ankle/brachial pressure index (i.Normal peripheral pulses .Granulating base . and at distal points e.g.Dermatology: Handbook for medical students & junior doctors Chronic leg ulcers Venous ulcer Arterial ulcer Neuropathic ulcer . deep vein thrombosis Common sites . lipodermatosclerosis. sharply defined deep ulcer .Loss of hair .Cold skin .Doppler studies and angiography . toes.Vascular reconstruction . soles.May be surrounded by or underneath a hyperkeratotic lesion (e. worse on standing .g.Weak or absent peripheral pulses .Large.8 . ABPI 0. and atrophie blanche (white scarring with dilated capillaries) .g.

varicella).g. infestation (e.g.Dermatology: Handbook for medical students & junior doctors Itchy eruption • An itchy (pruritic) eruption can be caused by an inflammatory condition (e. some cases of urticaria) or an unknown cause.g. eczema). scabies). allergic reaction (e. Dermatology: Handbook for medical students & junior doctors British Association of Dermatologists Chronic fissured hand eczema Scabies Urticaria Lichen planus 53 Common Important Problems – Itchy eruption Wickham’s striae British Association of Dermatologists 53 . lichen planus).g.g. possibly autoimmune (e. infection (e.

Sides of fingers.Emollients . nipples and genitals .Secondary eczema and impetigo Eczema .Violaceous (lilac) flat-topped papules .Secondary bacterial or viral infections Possible investigations .Immunomodulators . vesicular and exudative . wrists. wrists.Precipitating factors (e.Antihistamines . drugs) Lichen planus . annular.Exacerbating factors (e.Dry.Pink wheals (transient) .May be round. flexor aspects in children and adults with atopic eczema) .Dermatology: Handbook for medical students & junior doctors Itchy eruption History Scabies . irritants) . and legs . permethrin (Lyclear) or malathion (Prioderm)) .Pruritus worse at night .Antihistamines 54 British Association of Dermatologists .g.Symmetrical distribution . feet.Patch testing .May have history of contact with symptomatic individuals .Skin biopsy Dermatology: Handbook for medical students & junior doctors Common Important Problems – Itchy eruption 54 Associated features . ankles.May be associated with angioedema or anaphylaxis .g.Corticosteroids .Nail changes and hair loss .Lacy white streaks on the oral mucosa and skin lesions (Wickham’s striae) .Forearms.Variable (e. food.Personal or family history of atopy .Serum IgE levels .May be drug-induced Common sites Lesion . finger webs. contact.Acute eczema is erythematous.Antihistamines .Family history in 10% of cases .Corticosteroids .Skin scrape. or polycyclic . erythematous patches . allergens.Antihistamines .Always examine the oral mucosa .g.Scabicide (e.Corticosteroids British Association of Dermatologists Management .No specific tendency Urticaria .Bloods and urinalysis to exclude a systemic cause . extraction of mite and view under microscope . elbows.Skin swab .Linear burrows (may be tortuous) or rubbery nodules .g.

seborrhoeic wart) or malignant (e.A changing pigmented lesion • A changing pigmented lesion can be benign (e. British Association of Dermatologists Congenital naevus Seborrhoeic keratoses 55 Common Important Problems – A changing pigmented lesion Dermatology: Handbook for medical students & junior doctors 55 Malignant melanoma British Association of Dermatologists . melanocytic naevi.g. malignant melanoma).g.

and/or hairy .Often multiple and asymptomatic .Features of ABCDE: .‘Stuck on’ appearance.May be symptomatic (e.Variable .Compound naevi are usually raised.More common on the legs in women and trunk in men .Rarely needed . warty. bleeding) . protuberant and hairy edges Border irregularity . flat and dark Colour irregularity .Intradermal naevi are usually dome-shape papules or nodules Diameter > 7mm . itchy.Tend to occur in adults or the middle-aged .Tend to arise in the middle-aged or elderly .Asymptomatic .Rarely needed .History of evolution of lesion during infancy. with well-defined Asymmetrical shape pigmented.Face and trunk .Congenital naevi may be large.g.Not usually present at birth but develop .Warty greasy papules or nodules . childhood or adolescence .Presence of risk factors .Junctional naevi are small.Dermatology: Handbook for medical students & junior doctors A changing pigmented lesion History Common sites Lesion Common Important Problems – A changing pigmented lesion 56 Management Benign Malignant Melanocytic naevi Seborrhoeic wart Malignant melanoma . Evolution of lesion hyperkeratotic.Excision British Association of Dermatologists 56 British Association of Dermatologists . .

meningococcal septicaemia.g.g. • Platelet counts and a clotting screen are important to exclude coagulation disorders.g. British Association of Dermatologists Henoch-Schönlein purpura Senile purpura 57 Common Important Problems – Purpuric eruption British Association of Dermatologists 57 .g. aged skin.Dermatology: Handbook for medical students & junior doctors Purpuric eruption • A purpuric eruption can be thrombocytopenic (e. trauma. drugs (e. steroids). idiopathic thrombocytopenic purpura) or non-thrombocytopenic e. vasculitis (e. disseminated intravascular coagulation. Henoch-Schönlein purpura).

Bloods .Systemically well .Dependent areas (e.Steroids and immunosuppressants if there is systemic involvement . ecchymoses.Skin biopsy Common Important Problems – Purpuric eruption 58 .Spontaneous bleeding from ear.Treat the underlying cause .Systemically unwell .Non-palpable purpura . obstetric complications. or liver failure .Acute onset . haemorragic bullae and/or tissue necrosis .Anticoagulants for thrombosis Disseminated intravascular coagulation .Treat the underlying cause .g.Arise in the elderly population with sun-damaged skin .Painful lesions Vasculitis Senile purpura . haemorrhagic bullae and/or tissue necrosis . legs. transfusions. nose and throat.History of trauma.Palpable purpura (often painful) .Symptoms of meningitis and septicaemia .Surrounding skin is atrophic and thin .Bloods and urinalysis .Extremities Lesion .Systemically unwell .Transfuse for coagulation deficiencies . gastrointestinal tract. malignancy. buttocks. sepsis.Lumbar puncture Management . respiratory tract or wound site . ecchymoses.No investigation is needed Associated features Possible investigations .Antibiotics .Bloods (a clotting screen is important) .Such skin is easily traumatised History Common sites .Petechiae.No treatment is needed British Association of Dermatologists 58 British Association of Dermatologists .Systemically unwell .Dermatology: Handbook for medical students & junior doctors Purpuric eruption Meningococcal septicaemia .Extensor surfaces of hands and forearms . flanks) .Petechiae.

History of abrasion or ulcer Lesion . venous thrombosis and chronic venous insufficiency.Dermatology: Handbook for medical students & junior doctors A red swollen leg • The main differential diagnoses for a red swollen leg are cellulitis.May have lymphangitis British Association of Dermatologists Possible . which is worse on standing and relieved by walking .Skin swab Management . creating ‘champagne bottle’ appearance) .History of venous thrombosis . erysipelas. Cellulitis/Erysipelas .Discoloured (blue-purple) .Lipodermatosclerosis (erythematous induration.Usually systematically well .May present with pulmonary embolism Venous thrombosis History . scaly and crusted erosions) .Pain with swelling and redness .Doppler ultrasound and/or venography .Systemically unwell with fever and malaise .Venous ulcer . long haul flights or clotting tendency .Anticoagulants 59 Common Important Problems – A red swollen leg Chronic venous insufficiency .Anti-streptococcal O titre (ASOT) investigations .Erysipelas (well-defined edge) .Heaviness or aching of leg.Oedema (improved in the morning) .Antibiotics .Complete venous occlusion may lead to cyanotic discolouration .Stasis dermatitis (eczema with inflammatory papules.Cellulitis (diffuse edge) Associated features .Doppler ultrasound and/or venography .Sclerotherapy or surgery for varicose veins British Association of Dermatologists 59 .Venous congestion and varicose veins .D-dimer .Leg elevation and compression stockings .History of prolonged bed rest.Painful spreading rash .

cryotherapy.Topical/oral antibiotics/antiseptics . lasers and surgery). It is suitable for localised and less severe skin conditions.Management Dermatology: Handbook for medical students & junior doctors Management and therapeutics Management • Treatment modalities for skin disease can be broadly categorised into medical therapy (topical and systemic treatments) and physical therapy (e. ointment (oil with little or no water) and paste (powder in ointment).g. However.Oral retinoids 60 British Association of Dermatologists . tar.Oral antihistamines . Examples of active ingredients are steroids. photodynamic therapy.Oral aciclovir .Emollients . Learning objectives: Ability to describe the principles of use of the following drugs: . if the treatment is ineffective topically or if there is systemic involvement.Topical/oral corticosteroids . immunomodulators. • Topical treatments directly deliver treatment to the affected areas and this reduces systemic side effects. they have the disadvantage of causing systemic side effects. transparent). retinoids. The common forms of base are lotion (liquid). and antibiotics. gel (organic polymers in liquid. They consist of active constituents which are transported into the skin by a base (also known as a ‘vehicle’). cream (oil in water). phototherapy. • Systemic therapy is used for extensive and more serious skin conditions.

emulsifying ointment.betamethasone valerate (Betnovate)). connective tissue diseases. potent (e. due to preservatives or perfumes in creams) Topical/Oral corticosteroids Examples ● Topical steroids: classified as mildly potent (e. acne. moderately potent (e. hydrocortisone). and vasculitis Side effects ● Local side effects (from topical corticosteroids): skin atrophy (thinning).g. cataract.g. osteoporosis. ● Systemic side effects (from oral corticosteroids): Cushing’s syndrome. and allergic contact dermatitis.g. striae. Topical/Oral corticosteroids. clobetasol propionate (Dermovate)) ● Oral steroids: prednisolone Quantity Indications ● Usually 30 grams per tube (enough to cover the whole body once) ● Anti-inflammatory and anti-proliferative effects ● Useful for allergic and immune reactions. bullous and blistering disorders. or perioral dermatitis. and steroid-induced psychosis Oral aciclovir Examples Indications Side effects ● Aciclovir ● Viral infections due to herpes simplex and herpes zoster virus ● Gastrointestinal upsets. may mask. liquid paraffin and white soft paraffin in equal parts (50:50) Quantity Indications ● 500 grams per tub ● To rehydrate skin and re-establish the surface lipid layer ● Useful for dry. telangiectasia. clobetasone butyrate (Eumovate)).g. and very potent (e. cause or exacerbate skin infections. scaling conditions Side effects ● Reactions may be irritant or allergic (e. and haematological disorders 61 British Association of Dermatologists . diabetes.g. Oral aciclovir Dermatology: Handbook for medical students & junior doctors Emollients Examples ● Aqueous cream. immunosuppression. raised liver enzymes. inflammatory skin conditions. hypertension.Management – Emollients. reversible neurological reactions.

neomycin ● Oral antibiotics: penicillins. during and at least one month after isotretinoin.Management – Oral antihistamines. blurred vision. psoriasis. chlorpheniramine. macrolides. hydroxyzine) Indications ● Block histamine receptors producing an anti-pruritic effect ● Useful for type-1 hypersensitivity reactions and eczema (especially sedative antihistamines for children) Side effects ● Sedative antihistamines can cause sedation and anticholinergic effects (e. cephalosporins. Acitretin ● Acne. hypercholesterolaemia. Topica/Oral antibiotics/antiseptics. antibiotic-associated infection such as Clostridium difficile. disordered liver function. dry lips and dry eyes. gentamicin. nitrofurantoin. tetracyclines. mupirocin (Bactroban). and antibiotic resistance (rapidly appears to fusidic acid) Oral retinoids Examples Indications Side effects ● Isotretinoin.g. dry mouth. and constipation) Topical/Oral antibiotics/antiseptics Examples ● Topical antiseptics: chlorhexidine ● Topical antibiotics: fusidic acid. but for two years after Acitretin (consult current BNF for further details) 62 British Association of Dermatologists .g. hypertriglyceridaemia. and some are used for acne ● Local side effects (from topical antibiotics): local skin irritation/allergy ● Systemic side effects (from oral antibiotics): gastrointestinal upset. arthralgia and depression ● Teratogenicity: effective contraception must be practised one month before. metronidazole. and disorders of keratinisation ● Mucocutaneous reactions such as dry skin. Oral retinoids Dermatology: Handbook for medical students & junior doctors Oral antihistamines Examples ● Classified into nonsedative (e. quinolones. anaphylaxis. urinary retention. loratadine) and sedative antihistamines (e. vancomycin. trimethoprim Indications Side effects ● Useful for bacterial skin infections. rashes. vaginal candidiasis. myalgia. cetirizine.g.

Describe the principles of prevention in: . Ability to perform the following tasks: . and prevention strategies ii) Effective written communication to general practitioner so that patients care can be continued appropriately iii) Good prescribing skills iv) Good clinical examination and appropriate investigations to facilitate accurate diagnosis • This section highlights several general points on the important clinical skills in dermatology. Learning objectives: 1.pressure sores .Practical Skills Dermatology: Handbook for medical students & junior doctors Practical Skills • There are four main aspects to focus on in clinical practice: i) Patient education.take a skin scrape .write a prescription for emollient .take a skin swab . particularly on the nature of disease.make a referral .sun damage and skin cancer 63 British Association of Dermatologists .write a discharge letter .explain how to use an emollient or a topical corticosteroid .measure the ankle-brachial pressure index and interpret the result 2. treatment and ways to achieve full compliance and effectiveness.

and use of pressure relieving devices e.Practical Skills – Patient education Dermatology: Handbook for medical students & junior doctors Patient education How to use emollients ● Apply liberally and regularly How to use topical corticosteroids ● Apply thinly and only for short-term use (often 1 or 2 weeks only) ● Only use 1% hydrocortisone or equivalent strength on the face ● Fingertip unit (advised on packaging) – strip of cream the length of a fingertip Preventing pressure sores ● Pressure sores are due to ischaemia resulting from localised damage to the skin caused by sustained pressure. particularly over bony prominences. special beds Preventing sun damage and skin cancer ● Excessive exposure to UV radiation is the most significant and preventable risk factor for the development of skin cancer (Table 14) ● Skin types I and II are at higher risk of developing skin cancer with excessive sun exposure than other skin types (Table 15) Table 14. wide-brimmed hat and sunglasses Remember to take extra care with children Then use Sun Protection Factor (SPF) 20+ sunscreen 64 British Association of Dermatologists . nutritional support.g. ● Preventative measures involve frequent repositioning. SMART ways to avoid excessive sun exposure Spend time in the shade between 11am-3pm Make sure you never burn Aim to cover up with a t-shirt. friction and moisture.

and response to treatment Writing a discharge letter Important points to include: ● Reason(s) for admission and current presentation ● Hospital course ● Investigation results ● Diagnostic impression ● Management plan (including treatment and follow-up appointment) ● Content of patient education given Prescribing skills Writing a prescription General tips: ● Include drug name. sometimes tans Sometimes burns. current presentation. always tans Written communication Writing a referral letter Important points to include: ● Reason(s) for referral. always tans Never burns.Practical Skills – Written communication and Prescribing skills Dermatology: Handbook for medical students & junior doctors Table 15. never tans Always burns. and impact of disease ● Patient’s medical and social background ● Current and previous treatment. Skin types Skin types I II III IV Description Always burns. frequency and an intended duration/review date ● 30 grams of cream/ointment covers the whole adult body area ● 1 fingertip unit covers the area of two palms and equals ½ gram 65 British Association of Dermatologists . length of treatment. dose.

ulcers and mucosal surfaces for microbial culture. ointment-based emollients are useful for dry. cream. erosions. • Surface swabs are generally not encouraged. 66 British Association of Dermatologists .8.g. • Inappropriately high reading will be obtained in calcified vessels (often in diabetics). Measuring ankle-brachial pressure index (ABPI) • ABPI is used to identify the presence and severity of peripheral arterial insufficiency. pustules. and is normally >0.e. inflamed and weeping lesions Prescribing topical corticosteroids General tips ● Prescribe the weakest potency corticosteroid that is effective ● Use only for short term ● Need to specify the base i. evidence of fungal hyphae and/or spores) and burrows in scabies (see page 53 & 54). • The ABPI is measured by calculating the ratio of highest pressure obtained from the ankle to highest brachial pressure of the two arms. which is important in the management of leg ulcers. scaling skin whereas creams and lotions are for red. • Measure the cuff pressure of dorsalis pedis or posterior tibial artery using a Doppler and compare it to the pressure of brachial artery. lotion or ointment Clinical examination and investigations Taking a skin swab • Skin swabs can be taken from vesicles. Taking a skin scrape • Skin scrapes are taken by using a scalpel or glass slide from scaly lesions in suspected fungal infection (e.Practical Skills – Clinical examination and investigations Dermatology: Handbook for medical students & junior doctors Prescribing emollients General tips ● Emollients come in 500 gram tubs ● In general.

Oxford Radcliffe Hospitals NHS Trust. 67 British Association of Dermatologists . for writing the Foreword. and Professor Lesley Rhodes. Professor of Experimental Dermatology. Southampton General Hospital. Foundation Year 1 Doctor. All illustrations in this handbook were obtained from "D@nderm" with his permission. Veien for allowing us to use his photographs.Dermatology: Handbook for medical students & junior doctors Acknowledgements We wish to acknowledge the following contributors: • Dr Mark Goodfield. President of the British Association of Dermatologists. Emeritus Professor of Dermatology. Salford Royal NHS Foundation Trust for contributing the chapter Common Important Problems. University of Manchester for reviewing and contributing valuable suggestions. Professor Peter Friedmann. • Dr Susan Burge. • Dr Kian Tjon Tan. University Hospital of South Manchester NHS Foundation Trust for contributing the chapter Background Knowledge. Academic Foundation Year 2 Doctor. Consultant Dermatologist. • Dr Yi Ning Chiang. • Dr Niels K.

Dermatology: Handbook for medical students & junior doctors British Association of Dermatologists .

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