DERMATOLOGYBASICS OF DERMATOLOGY of modern academic Dermatology: Thomas 6. Fitzpatrick oe epidermis & Fagement membrant zone / DEJ 2 Se . i Contains cells be | oe pallmark: presence of keratin filaments or tonaflaments or intermediate filaments, Eg, Kr/K.» in stratus basale which if defected, leads to Epidermolyss Bullosa Simplex gp melancceytes | Derived from neurol crest and migrate to stratum basale | synthesize melanosomes which contain melanin 3 fpidermal melanin unit: 36 keratinocytes / melanoeyte “5 Melanocytes in retina are present in optic cup. eg Merkel cell | 4 Present in stratum basale | 4 They are type 4 slow adapting touch receptors | ds Langerhans cells | 4 Mainly present in stratum spinosum Hallmark: Birbeck granules which are tennis racquet / rod shaped. ‘These are antigen presenting cells so help in phagocytosis. Markers of Langerhans cell histiocytosis is CD 4a, CD 207 and $400 4.LCs in Psoriasis, Sarcoidosis and Basal cell carcinoma a i 4Layers of Epidermis is ak Keratinocytes as they move up | Layers of Epidermis _ +. Flat cells | 1. Stratum corneum Superficial 2.4 Size 2 Stefan Wild) sage) | oe 3. Loss of nucleus 3. Stratum granulosum g 4, Dehydrated 4. Stratum spinosuma = 5. Columnar ells S. Stratum basale Ear a i. Stratum Basale (first ¢o be formed) al Has high mitotically active keratinocytes Housekeeping organelles > Epidermal turn over time / Skin doubling time = 's S2-~7Sdays (average Sédays) » In psoriasis epidermal turn over time is reduced to 4days. y a ii. Stratum Spinosum 62M css= > Desmosomes prominently seen here join keratinocytes. > Thickest layer > Desmosome require Desmosomal protein / Ca” dependent adhesion molecules Eg. Desmoglein (Dsg) Desmocollin (Dsc) | defects in any of these Desmoplakin (Dp){ may lead to intra Plakoglobin (Pg) J -epidermal disorder > Defect in desmoglein (Dsq) leads to pemphigus. Le iii. Straturn granulosum pecs =o a Keratohyaline granules santhesize flaggrin in precursor form so also caled as proflaggrin. &. Membrane coating granules / lamellar granules / odland Function of filaggrin is to aggregate protein thus called. as fila ment aggregating protein. Def. of filaggrin causes lchthyosis vulgaris bodies — synthesizes lipid which forms a protective barrier. If defective then causes Asteatotic / Winter Eczema. jv, Stratum Lucidum > Clear cell layer / Translucent due to refractile granules of eleidin. vv. Stratum corneum absent in LBW/preterm baby.| keratinization malignant condition like squamous cell carcinoma malignant conditions like Bowen's disease itions like Darier‘s disease & Hailey-Halley disease. © seen in ed ry tip microabscess in Dermatitis Herpetiformis munro’s microabscess in Psoriasis _kogel's pustule in Psoriasis je microabscess oy Pastrian’s microabscess in waycoss Fungoides [2 osinaphilic microabscess in pemphigus vegetans 4 Separation of keratinocytes due to defect in desmosomes [oy Teste acanthocytes we prepare Teanck smear. a tfacanthocytes are seen it is Pemphigus = if multinucleated giant cells are seen itis herpes / chicken por Reason Dig 3 Dag 3 ie | Desmoplakin, Plakoglobin BP Ags 2 collagen 7 is is called papillary dermis. is called reticular dermis. thas collagen Type (> I ct cells are fibroblast+ Septal Panniculitis Erythema nodosum > Lobular Panniculitis Erythema induratum Causes of Erythema Nodosum onic: NODOSUM NO ~ No cause (Idiopathic) D - Drugs o- ocr S - Sarcoidosis, Streptococcus U - Ulcerative colitis M~ Maternity (Pregnancy), Mycobacterial infections > Dermographism : Urticaria (because of triple response) White dermographisna : Atopic dermatitis (vasoconstriction) Darier's sign Urticaria pigmentosa (cutaneous mastocytosis) Pseudo-darier's sign 1 Smooth muscle hamartoma (Piloerection) Skin Appendages Hair follicles Nails > Glands Hair follieles+ Bulge area also called as Adamson's fringe stem cells are present. Hair cycle + 3 phases (A+C>7) 2. Anagen 3 Years 2. Catagen — 3 weeks (involution) 3. Telogen ~ 3 months (resting) Hair Disorders \ U/ Anagen effluvium — ~ Chemotherapy Se) Nd Telogen effluvium ——~ after 3 months of pregnancy, typhoid fever, chronic illness Androgenic alopecia — due to Dihydrotestosterone (DHT) Mate Patterned Hair loss i. Male pattern hair loss called as Hamilton Pattern = Frontal hair line gradually recedes backwards ule ak = Loss of hair from vertex portion of skull fi, Female pattern hair loss called as Ludwig and Olsen Pattern 4 ~ Ludwig Pattern: Frontal hair line is maintained with loss of hair From frontal and vertex portion of skull. = Olsen Pattern: Frontal hair line is maintained with loss of hair from site where female parts her hair. S-a-Reductase inhibitor (stops testosterone to DHT conversion) ‘Type ll x-Reductase inhibitor Finasteride given 1mg daily; 5: Nail Pitting Regular & Superficial a nal: Perifolicular / peribulbar lymphocytic intrate i Topicall oper 0ids pically Systemically D contact irritant Dinitrochlorobenzene Phototherapy «Visible nail matrix ry ‘7 chia : distal junction of the nails see | cannes = Methe m/e site for oncychormycoss = te to be involved in fungal infections) — é = “Weis irregular & deep pitting “Most characteristic is oil drop sign / salmon ch due to defect in nail bed in Lichen Planus characteristic is pterygium (nails appear white) Leukonychia Terry nails: Hepatie failure - af ke Half / Lindsay's nai! 7 ¥ ' portion of nail is white): CRF ‘Muehreke lines (white lines parallel pink area on between): = | itchy papules in axilla Fox Fordyce disease : Blockage in Apocrine duct Female: 2% decade 4 5| sebaceous Glands Ectopic (present alone) Disorders: Lips : Fordyce spots Glands : Tyson Glands Eyelid + Meibornian glands && glands of zis ‘Areola : Montgomery tubercles With hair follicle k/a Pilosebaceous unit Disorders: Acne vulgaris Rosacea Glands of moll & ceruminous glands are modified apocrine sweat glands. Acne Vulgaris: + M/c form of acne * Most characteristic lesion’ Comedones Closed/White (a) is: Open/Black —(b) . Grading + Grade 4 (Severe): Nodulocystic (¢) + DOC: Isotretinoin (13-cis retinoic acid) + S/E:M/e ——_~ Dryness of lips Most severe _— Diffuse interstitial skeletal hyperostesis (DISH) Others = Pseudotumor cerebri (Benign raised ICT) ~Teratogenic (lasts for 2 month) NOTE: Acitretin (DOC for pustular psoriasis) has 3 years period of teratogenicity Rosacea “5 Site: Convex areas of face eg. cheek, nase, chin & nasolabial folds M/e type: Erythemo-telengiectic ‘Associated: H/O flushing on working in hot area, drinking tea/coffee D/D: SLE butterfly rash ie. am - Fixed erythema = Malar evninence & nose = Nasolabial folds are spared _ Associated with other systemic features like fever, arthralgia, photosensitivity Vet Blistering disorders| > — Fluid filled lesions + 0.5 cm are called as Bulla. 1. Pemphigus + Autoimmune disorder > 9G antibodies are directed against Dsg causing intraepidermal bullae. Erosion with crusting may be seen =Pemphigus vi +» Bullas spread sign/Asboe » They are +ve in both but P = Histology » Acanthocytes + Row of tom DF + Fish net like patterns due to in: ‘Treatment + Steroids + Cyclophosphamide + Rituximab (Anti-CD20) 2 Bullous Pemphigoid + 1G against BP Ag2 > BP Agi + C/E: Tense subepidermal bullae thus do not ruture s tasily and the fluid gets absorbed so appear as settled bulla + Histology: Sub epidermal split with eosinophilic collection. > DIF: Linear IgG & complement deposits in Basement membrane zone. ellular depos 3. Linear IgA Disease + IgA against BP Ag 2, BP Agt > Bimodal: - Child (5 years): Face (perioral), groin (perianal) - Adults (60 years) : Trunk é& extremities > Grouped vesicles around erythematous plaques > String of pearl or crystal of jewel appearance 3or Extremely pruritic vesic Histology Papillary tip microabscesses i DIF Granular IgA deposits in dermal papilla boc Dapsone TOC Gluten freadist 5 Avoid “Can take | [7 6 barieg =o sons wlesnataurs URIS R Rye, | Maize © Oat (least amount of gluten) ‘| Ragi Ww :Wheat pasa Bat S. Herpes Gestationalis Autoimmune + C/E + Periumbilical lesions * Self limiting > DIF — : Linear C, > \gG deposits in BMZ + DOC: Steroid 6. Epidermolysis Bullosa + Aka mechanobullous disorder > Occurs at site of trauma, friction & pressure handling icopapules over extensors « develops in 3% Trimester « Fetal mortality: 307 pUPSS 4 Congenita ‘Acquisita Congenital Acquired Early Late Common Rare | Genetic Inanaunobullous Subtypes of Epidermolysis Bullosa Congenita i EB Simplex : defected K5/14 EB Junctional defected Laminin iii, EB Dystrophicans _: defected Collagen 7 7) Darier's Disease 8) Hailey-Hailey's Disease Inheritance ‘Autosomal Dominant ‘Autosomal Dominant Defect Ca ATPase Ca ATPase 2 2 Gene ATP 2A2 ATP 2ct — Site Sehorrhele area Inter-trigenous areas like axilla, inframammary folds Verrucous (warty lesion), greasy with sand paper feel Acantholysis, dyskeratosis, Corps ronds, Corps grains Recurrent, flaccid, vesicular (may rp" causing erosions) Acantholysis, dyskeratosis with dilap'é brick wall appearance ated BO: TEN. i Absent Grotky Sign 1 ee ‘saterial Infections + Corynebacterium D He releases Keratolytic enzyrnes which digests keratin > Im palin & sole it causes pitted keratolysis (1) > Inauillary hair follicle it causes yellowish discolouration k/a trichomycosis axillaris. | Reaiilarash develops k/a erytinrasima by C. minuttissimum (2) which under wood's lamp (4) light | appears coral red (3) Infections F Contagiosa (M/2)(2): Non bullous type caused by Streptococcus >. aureus leading to golden _ Yellow/honey colored crusting (2) : Bullosa (3): caused by S. aureus leading to subcorneal bullae. Are commonly seen in children and involve face fr) a [P)Preptadder3. Ecthyma i. Ecthyma pyogenicum Streptococcus, S. aureus fi, Ecthyma gangrenosum Pseudomonas tii Ecthyma contagiosum Parapoxvirus i 4. Erysipelas % 5. Cellulitis Caused by group A B hemolytic Caused by streptococcus, S. aureus Diffuse streptococci Borders — Sharp_ BE Fungal 2. Pityriasis versicolor + Cause: Malassezia globosa, Malassezia furfur + C/F: Hypopigmented perifollicular macules (2) due to azelaic acid Tyrosinase inhibitor) which gradually increases to form patch > The hyperpigmentation (2) is due to increase in size of melanosomes. > Fine rice powder like scaling seen > M/c site is upper trunk Investigation + KOH mount: Spaghetti & meat ball > Wood's lamp: Yellow/apple green color florescence Treatment + Topical: Ketoconazole, selenium sulphide + Systemic: Fluconazole, Itraconazole 2. Tinea Nigra > Phacoanellomyces werneckii 3. Candidiasis > M/c is oral candidiasis i.e. thrush / Acute pseudomembranous candidiasis (1) Vaginal candidiasis which presents with thick white curdy discharge €. Balanoposthitis ie. infection of glans & prepuce (2) C. intertrigo i. infection of intertriginous areas. lt shows satellite lesions. They are also seen in = BT type leprosy = Sporotrichosis ~ Candidiasis DOC: Auconazole 4 Piedra / Trichomycosis nodularis > Black/ Dark Piedra caused by Piedra hortae > White/light Piedra caused by Trichosporon beigelii S. Dermatophytosis > Trichosporon involves skin, & nail > Microsporum involves skin & hair > Epidermophyton involves skin & nail 6. Tinea infections i: Tinea capitis (2): 4 Types a Bees Sesling & lumphadenopathy by T. mentagrophyte & T. Verrucosum a erust k/a Seutula caused by T. Schoenlenii yyy_ .manuurm (Hands): Unilateral tit. pedis (Feet) (4,5): M/e site is interdigital spaces (webs) it +. unguium (Nall: m/c causes distal lateral subungual onychomycosis w 621 is (YT. circinata: Annular lesions (7) with active margins and central clearing vt corporis ( ¥ NOTE: Central clearing T. corporis Central crusting Leishmaniasis Central scarring Lupus vulgaris T Capitis: Griseofulvin T Cruvis T. Corporis T. mmanuur T. pedis T. unguium Deep fungal infections 1. Sporotrichosis (Rose gardener's disease) > M/c type is lymphatic variant with linear nodules along draining lymphatics over extremities DOC: Itraconazole > saturated solution of KI + Histology; Asteroid bodies Terbinafine > Itraconazole seusrrg 2 Chromoblastormycosis > Warty cauliflower like growth > Copper penny/medlar/muriformn/sclerotic bodies > Histology: Group of golden brown fungal cells with giant cells Doc: Itraconazole MYCOBACTERIAL INFECTIONS Cutaneous TB +) Lupus vulgaris > M/c type of cutaneous TB > Plaque with central scaring > Diaseopy: apple jelly nodules 2. Strofuloderma > M/e type in child 2 Contiguous spread From focus like LN, bone, > Commonly presents with sinus sinus & joint3. Tuberculid -> Due to mycobacterial hypersensitivity + 3 Types ~ Lichen serofulosorum / micropapular type ~ Papulonecrotic = Erythema induratum of bazin > Treatment: ATT ~ 2 months: HRZE = 4 months: HRE Leprosy > Ridley Jopling Classification: 5 types o>), Die Macs RR Be olde + From TT to LL bacterial load increases and cell mediated immunity decreases > TT: Single asymmetrical & U/L lesions + BT: 3 to 10 satellite lesions + BB: 10-20 punched out/inverted saucer shaped/swiss cheese/geographical lesions (as irregular borders) + BL: >20 symmetrical lesions > LL: Numerous, small, B/L symmetrical lesions on face (Leonine facies ie. diffuse skin, ear helix and lobe infiltration, saddle nose, lateral madarosis) : Nerve involvement (thickening), B/L symmetrical involvernent : Systemic involvement in form of gynaecomastia, testicular atrophy ete WHO Classification Paucibacillary (PB) Multibacillary (MB) Hypopigmented hypoanaesthetic patches | 1-5 > Nerve 1 22 Slit smear exam (AFB) Absent present > Treatment - It is same for both PB and MB except for the duration i.e. emonths for PB and 12months for MB - Rifamnpicin — : 600 mg/month Dapsone 2100 wmg/daily Clofazimine — : 300 mg/month & 50 mg/daily Common cranial nerve involved is facial Common peripheral nerve involved is ulnar > posterior tibial 2 sensation lost is temperature (cold > hot) Lepra Reaction 7 Tape I tis Type-Iv hypersensitivity reaction. DOC is steroid with no role of thalidomide ‘Type Il aka ENL (Erythema Nodosum Leprosum): It is Type -l itivi s ) fype-Ill hypersensitivity reaction. DOC is i steroid but gold standard is thalidomide. ts : Phenomenon > Type of lepra reaction seen in patients suffering From Lucio leprosy non in Central America (Mexico) teea Transmitted infections aya Warts (Condyloma acuminat by HPV © and 11. dimod. > Podophyllotox' applied &e are teratogen'¢ t xy: Cryotherapy ” application) ) in. Both are trichloroacetic+ Caused by Pox virus + Lesions: Pearly papules with central umbilication > Histology: Henderson Patterson bodies are seen. They are eosinophil lic inclusion bodies L | Lesion | single | single Muttiple __| single Painless | Painless | Painful | Painless indurated Transient (usually | Undermined edges | Beefy red & bleeds on touch SS eee peser ae Lagemph| B/L, Non-tender | U/L, Tender U/L, Tender | No LN, Pseudobubos seen [Node |, shotty rubbery ea a | — T/t | Benzathine Doxycycline Azithromycin 7] Azithromycin aE | Neurosyphilis where | | | Aqueous crystalline | penicillin is used | mrs ah | Syphlis chancre Condyloma LataMoth eaten Alopecia H. ducreyi: School of fish / chancroid 2. al elephantiasis Rail road track appearance Female: vulval elephantiasis (Esthionene) rile saxophone ‘ —, | oe or uf | Pseudobubos Donovan bodies Donovanosis[Syrdromic Management] ee Urethral or Anorectal KIT 1: Gray Tab Azithromycin 1 g (1 tab) F Cervical discharge Tab Cetixime 400 mg (1 tab) Vaginal Discharge KIT 2:Green Tab Secnidazole 2 g (1 tab) (Vaginitis) Tab Fluconazole 150 mg (1 tab) Genital Ulcer Disease KIT 3: While Inj. Benzathine Penicillin 2.4 MU (1 (Non Herpitic) Vial) + Tab Azithromycin 1 g (Kit also contains 10 ml disposable syringe 21 gauge needle + 1 vial of 10 mi sterile water Genital ulcer disease KIT 4: Blue Tab Doxycycline 100 mg (1 tab {(nonherpetic) in BD for 14 days) Patient allergic to Tab Azithromycin 1 g x 1 tab Penicillin Genital ulcer disease KIT5:Red Tab Acyclovir 400 mg x 1 tab TDS (Herpetic) x7 days Lower abdominal pain KIT 6: Yellow Tab Cefixime 400 mg x 1 tab (Pelvic Inflammatory Tab Metronidazole 400 mg x (1 BD Disease) 14 days) Tab Doxycycline 1 g (1 BO 14 days) Inguinal Bubo KIT 6: Black Tab Doxycycline 100 mg (1 BD x 21 days) Tab Azithromycin 1 g x 1 tab Papulosquamous Disorders 1. Psoriasis HLA-CWe association seen in juvenile psoriasis M/c type is P. vulgaris Erythematous plaque with silvery white/ vnica like Extensors are commonly involved. In inverse Psoriasis flexor are involved | > Guttate Psoriasis is seen in children after URTI, ‘Rupiold Psoriasis has adherent seales k/a Limpet / Conical scales, Nail changes: Pitting seen which is irregular &e deep art sealing Mtv yltiviel row ‘ez sign: Pin Point bleeding spots in vubbing ty 627} : ing the | Aen ring & Berkeley membrane is seen “8 © stole | Fons & Dilated blood vessels in dermis ovence of erate 3 anulosumn & thickening of stratum g Formal papa enlarged with Sura paplary thinning " is micro abscess & kogoj pustules seen vt aie: Methotrexate, Cyclosporine, Acitretin apical drugs: Corticosteroid Femtaytc agent: salicylic acid phototherapy © iological: Secukinumcab (Anti IL-17A), Ustekinumab (Anti 12/23) © spifa inhibitors: Infliximab, Etanercept, Adalimumab Munro# 4 voc | = Psoriatic arthritis Methotrexate = Enythrodermic psoriasis Methotrexate - pustular psoriasis Acitretin | covteostrts apr ue Psoriasis Guttate Psoriasis | Erythrodermic Psoriasis Common Sites2. Pityriasis Rosea eS eg. ‘1. Melasma = Brown pigmentation especially after pregnancy due to increase melanin synthesis lower back in infants Treatment: Tyrosine| Inhibitors Auspitz Sign Woronoff ring Associated with HHV 6 & 7 4" patch is k/a Herald/Mother patch x Lesions: Fir tree pattern seen on trunk Coramon in females = { Self-limiting Cigarette paper scales/collarette of scale seen Hanging curtain sign seen Lichen Planus * fee, - Skin: 5 P's ie. plane (Aat-topped), purple, i i polygonal, pruritic, papules/plaques. 4 Mucosa: Lacy/Reticulate pattern Nails: Pterygium Hair: Scarring alopecia Skin lesions have reticulate pattern k/a Wickham’s striae Associated with HCV Koebner's phenomenon seen Histology Civatte/colloid bodies seen Saw toothed appearance Max-Joseph space Thickening of stratum granulosum (Hypergranulosis) Thickening of stratum spinosum (Irregular Acanthosis) ‘T/t: Steroids Pigmenta ders 2. Mongolian Spot = Bluish lesion over hydroquinone= Blush lesions over maxillary Bluish lesions over neck and shoulder region and ophthalmic divisions due to acromioclavicular nerve involvement. a Contact Le Localized depigmentation due to bindi Hyperpigmented patch with hyper s | adhesive (para tertiary butyl phenol) seen in adolescent wale usually on upper trunk | or hair dye (para tertiary buty! catechol | = } ae imieaes a ~ Thick hyperpigmented velvety skin over neck ~ Autosomal dominant folds, axilla or groin | - Associated Gl polyps and perioral lentigens ~M/e cause is obesity zi (dark colored lesions) ts ed patch over lips/genitals due to drug intake. ixed as develops on same site each time. ycline & Cotrimoxazole affect genitals, NSAIDS affects lips, trunk and extremities, Carbocysteine affects face3. Grey-brown pigmentation — 4. Atrophic hypopigmented & depigmented lesions | ~ Lesions spread in linear fashion along Blaschko's lines | - These are lines of normal cell development of skin & are believed | to trace migration of embryonic cells. They do not correspond to | nervous, muscular or lymphatic system. The stripes are a type of genetic mosaicism. 24. Piebaldism + Rare autosomal dominant condition + Triangular patch over forehead with white forelock is seen 2. Vitiligo + Bilaterally symmetrical lesions on both sides with sharp demarcations of edges + Fit involves one area it is called focal type + IP it involves mucosa it is called as mucosal type > is called as Leukotrichia If in a patch hair follicles are also white it | Bilaterally symmetrical vitiligo Focal type vitiligo & Mucosal type vitiligo | Leukotrichia | ed Wardenburg Syndrome White forelock, broad nasal root, dytopia canthorum, blue eyes 23. Freckles / Ephilids + Hyperpigmentation seen on sun exposed area in fair skin people o « 14. P. Alba x + Hypopigmented lesions seen on face of children. - + Sensation is intact, scales may be present & atrophy is absent: + DID: Indeterminate leprosy where sensation is lost, scales are631 | 2 sroup of pin head sized lesions on Forearm, elbow & shaft of penis © pistology: Lymphocytes surrounded by rete ridges k/a ball in claw appearance | cutaneous T-cell lyraphorna | Histology: Epidermotropism seen towards epidermis |. peripheral blood smear shows Sezary cells i.e. those typical dark small cells) have tendency to mo Pautrier's mice |. small collection of S |. aggressive form is k/a Sezary syndror hyperkeratosis k 3 zy PATEH NODULAR MF SEZARY SYNDROME = Extensors involved mainly - Flexors may be involved ~ Deficiency of steroid sulphatase enzyme yTrichotillonnania appearance