Dermatology Easy Guide

DERMAT OLOGY
Dr. N. She ar
Najwa Esmail, Sab rina Ing and Marc Ke rb a, e d itors
Che ryl We in, associate e d itor
APPROACH TO THE DERMATOLOGY. . . . . . . . . 2 DRUG ERUPTIONS . . . . . . . . . . . . . . . . . . . . . . 22

PATIENT Exanthe matous Erup tions
History Urticaria
Physical Exam Fixe d Drug Erup tion
De laye d Hyp e rse nsitivity Synd rome
DEFINITIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Photose nsitivity Erup tions
Primary Morp hological Le sions
Se cond ary Morp hological Le sions Se rum Sickne ss - Like Re action
Othe r Morp hological Le sions
COMMON SKIN LESIONS . . . . . . . . . . . . . . . . 24
ACNEIFORM ERUPTIONS . . . . . . . . . . . . . . . . . . . . 3 Hyp e rke ratotic
Acne Vulgaris/Common Acne Fib rous
Rosace a Cysts
Pe rioral De rmatitis Vascular
Me lanocytic Ne vi
DERMATITIS/ECZEMA . . . . . . . . . . . . . . . . . . . . . . . 5 Misce llane ous
Alle rgic Contact De rmatitis
Irritant Contact De rmatitis MALIGNANT SKIN TUMOURS . . . . . . . . . . . 27
Atop ic De rmatitis Basal Ce ll Carcinoma
Sq uamous Ce ll Carcinoma
Se b orrhe ic De rmatitis Malignant Me lanoma
Stasis De rmatitis Othe rs
Nummular De rmatitis
Dyshyd rotic De rmatitis HERITABLE DISORDERS . . . . . . . . . . . . . . . . 30
Diap e r De rmatitis Ichthyosis Vulgaris
Ne urofib romatosis
INFECTIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 7 Vitiligo
Bacte rial
Sup e rficial Skin (Ep id e rmal) SKIN MANIFESTATIONS OF INTERNAL . . 31
De e p e r Skin (De rmal) CONDITIONS
Autoimmune Disord e rs
Hair Follicle s End ocrine Disord e rs
Pe riungual Re gion HIV
Othe rs Malignancy
Viral Othe rs
De rmatop hyte s Pruritus
Ye ast
Parasitic ALOPECIA (HAIR LOSS) . . . . . . . . . . . . . . . . . 32
Non-Scarring (Non-Cicatricial) Alop e cia
PAPULOSQUAMOUS DISEASES . . . . . . . . . . . . . . 16 Scarring (Cicatricial) Alop e cia
Psoriasis WOUNDS AND ULCERS . . . . . . . . . . . . . . . . . . 33
Liche n Planus
Pityriasis Rose a COSMETIC DERMATOLOGY. . . . . . . . . . . . . . 34
Che mical Pe e l
VESICULOBULLOUS DISEASES . . . . . . . . . . . . . . . 19 Lase r The rap y
Pe mp higus Vulgaris USEFUL DIFFERENTIAL DIAGNOSES . . . . 35
Bullous Pe mp higoid Diffe re ntial Diagnosis b y Morp hology
De rmatitis He rp e tiformis Diffe re ntial Diagnosis b y Location
Porp hyria Cutane a Tard a
Diffe re ntial of Primary Bullous Disord e r TOPICAL THERAPY . . . . . . . . . . . . . . . . . . . . . 37
Ve hicle s
ERYTHEMA MULTIFORME, . . . . . . . . . . . . . . . . . . 21 Top ical Ste roid s
STEVENS-JOHNSON SYNDROME AND Dry Skin The rap y
TOXIC EPIDERMAL NECROLYSIS SUNSCREENS AND PERVENTATIVE . . . . . 38
THERAPY
ERYTHEMA NODOSUM. . . . . . . . . . . . . . . . . . . . . . 22
MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 1

APPROACH TO THE DERMATOLOGY PATIENT Note s
HISTORY
❏ age , race , occup ation, hob b ie s
❏ d e tails of skin e rup tion
• location
• onse t
• p e rsiste nt/inte rmitte nt
• factors affe cting e rup tion (aggravating/re lie ving factors)
❏ associate d skin symp toms (itchine ss/b urning/p ain/d ry/d ischarge )
❏ p ast history of skin e rup tions
❏ associate d syste mic symp toms
❏ e nvironme ntal and p sychological factors
❏ alle rgie s, me d ications
❏ p ast me d ical history
❏ family history of skin and inte rnal d ise ase
PHYSICAL EXAM
❏ d istrib ution
❏ colour
❏ typ e of le sion (se e morp hological d e finitions)
❏ arrange me nt (annular, line ar, e tc...)
❏ re me mb e r to e xamine hair, mucous me mb rane s and nails
DEFINITIONS
PRIMARY MORPHOLOGICAL LESIONS
Table 1. Type s of Le s ions
< 1 cm diame te r ≥ 1 cm diame te r
rais e d s upe rficial le s ion papule (e.g. wart) plaque (e.g. psoriasis)
palpable de e p (de rmal) nodule (e.g. dermatofibroma) tumour (e.g. lipoma)

le s ion (not ne ce s s arily rais e d)
flat le s ion macule (e.g. freckle) patch (e.g. vitiligo)
e le vate d fluid fille d le s ions vesicle (e.g. HSV) bulla (e.g. bullous pemphigoid)
❏ p ustule : a ve sicle that contains p urule nt e xud ate (white , ye llow, gre e n)
(e .g. p ustular acne )
❏ e rosion: a d isrup tion of the skin involving the e p id e rmis alone
❏ ulce r: a d isrup tion of the skin that e xte nd s into the d e rmis or d e e p e r
❏ whe al: a sp e cial form of p ap ule or p laq ue that is b lanchab le and
transie nt, forme d b y e d e ma in the d e rmis (e .g. urticaria)
❏ scar: re p lace me nt fib rosis of d e rmis and sub cutane ous tissue
SECONDARY MORPHOLOGICAL LESIONS

❏ crust: d rie d se rum, b lood , or p urule nt e xud ate originating from a le sion
(e .g. imp e tigo)
❏ scale : e xce ss ke ratin (e .g. se b orrhe ic d e rmatitis)
❏ fissure : a line ar slit-like cle avage of the skin
❏ e xcoriation: a scratch mark
❏ liche nification: thicke ning of the skin and acce ntuation of normal
skin markings (e .g. chronic atop ic d e rmatitis)
❏ xe rosis: d ryne ss of skin, e ye s and mouth
❏ atrop hy: histological d e cre ase in size and numb e r of ce lls or tissue s
OTHER MORPHOLOGICAL LESIONS

❏ come d one s: colle ction of se b um and ke ratin
• op e n come d one (b lackhe ad )
• close d come d one (white he ad )
❏ p e te chiae : he morrhagic p unctate sp ot, 1-2 mm in d iame te r, non-b lanchab le
❏ p urp ura: e xtravasation of b lood re sulting in re d d iscolouration
❏ e cchymosis: macular re d or p urp le he morrhage > 2 mm d iame te r
De rmatology 2 MCCQE 2000 Re vie w Note s and Le cture Se rie s

ACNEIFORM ERUPTIONS Note s
ACNE VULGARIS/COMMON ACNE

(s e e Colour Atlas A5)
❏ a common inflammatory p ilose b ace ous d ise ase characte rize d b y come d one s,
p ap ule s, p ustule s, inflame d nod ule s and cysts, with occasional scarring
• p re d ile ction site s: face , ne ck, up p e r che st, b ack
• more se ve re in male s than fe male s
❏ p athoge ne sis
• and roge ns stimulate incre ase d se b um p rod uction
• se b um is come d oge nic, an irritant, and is conve rte d to fre e fatty
acid s b y microb ial lip ase s mad e b y anae rob ic d ip hthe roid
Propionibacterium acnes
• fre e fatty acid s + b acte ria = inflammation p lus d e laye d
hyp e rse nsitivity re action causing hyp e rke ratinization of follicle
lining with re sultant p lugging
❏ e xace rb ating factors
• me nstruation
• oral contrace p tive p ill (OCP) (low e stroge n formulations)
• corticoste roid s
• lithium, iod id e s, b romid e s
• come d oge nic top ical age nts – some cosme tics, sunscre e ns,
moisturize rs, gre ase s, tars
• NB: food s are NOT a major aggravating factor
❏ tre atme nt b ase d on se ve rity of acne
• 4 typ e s of acne se ve rity
• I – Come d onal. Fe w le sions. No scarring
• II – Pap ular. Mod e rate numb e r of le sions. Little scarring
• III – Pustular. Le sions > 25. Mod e rate scarring
• IV – Nod ulocystic. Se ve re scarring
Table 2. Acne Type s and Tre atme nts
Acne Type Tre atme nt
Typ e I – Non-inflammatory Be nzoyl Pe roxid e (2.5%, 5%, 10%) – b acte ricid al
Ad ap ale ne ge l/cre am
• not irritating, no inte raction with sun
• e xp e nsive
+/– Tre tinoin (Re tin-A)
• come d olytic more sun-se nsitive
• start with 0.01% and incre ase to 0.025% afte r one month
Typ e I – Inflammatory Be nzoyl Pe roxid e

Tre tinoin/ Ad ap ale ne ge l/cre am
Top ical Antib iotic (clind amycin, e rythromycin)
• b acte riostatic and anti-inflammatory
Typ e II Top ical Antib iotic

Be nzoyl Pe roxid e
Tre tinoin/ Ad ap ale ne ge l/cre am
Typ e III Top ical Antib iotic

Be nzoyl Pe roxid e
Tre tinoin
Oral Antib iotic (te tracycline , minocycline , e rythromycin)
Typ e IV Isotre tinoin (Accutane )

• 0.5 to 1.0 mg/kg/d ay for 3-4 months
• b ase line CBC, p re gnancy te sts, LFT, TG, and chole ste rol p rior to start of the rap y
• re p e at te sts at 2/6/10/14 we e ks
• S/E: te ratoge nic, skin and mucous me mb rane d ryne ss, hyp e rlip id e mia,
re ve rsib le alop e cia, ab normal LFT
❏ othe r tre atme nts

• cryothe rap y (for cysts)
• intrale sional ste roid s (for cysts)
• d e rmab rasion
• sp ironolactone – antiand roge n
ACNEIFORM ERUPTIONS . . . CONT. Note s
• Diane -35 OCP (cyp rote rone ace tate + e thinyl e strad iol)
• high-e stroge n OCP
❏ d iffe re ntial d iagnosis
• rosace a
• folliculitis
• p e rioral d e rmatitis
ROSACEA (s e e Colour Atlas A6)
❏ a chronic and re curre nt inflammatory d isord e r of the p ilose b ace ous
units and vasculature of the face characte rize d b y te langie ctase s,
flushing (d ue to cap illary vasod ilation), p ap ule s, and p ustule s
❏ d iffe re ntiate d from acne b y its ab se nce of come d one s
• F>M, 30-50 ye ars old
• symme trical; fore he ad , che e ks, nose , chin, e ye s
• may ge t conjunctivitis, b le p haritis, e p iscle ritis, or ke ratitis
• may d e ve lop rhinop hyma (nose e nlarge me nt)
❏ p rolonge d course common, re curre nce s common, may d isap p e ar
sp ontane ously
❏ unknown p athoge ne sis
❏ e xace rb ating factors
• he at, cold , wind , sun, stre ss, d rinking hot liq uid s, alcohol,
caffe ine , sp ice s
❏ tre atme nt
• top ical
• antib iotics (me tronid azole 0.75% ge l or cre am, clind amycin
or e rythromycin have anti-inflammatory me chanisms)
• syste mic
• te tracycline or e rythromycin 250 mg q id the n as ne e d e d
• alte rnative s: minocycline
• othe rs
• lase rs for te langie ctase s
• p lastic surge ry or lase r for rhinop hyma
• camouflage make up for e rythe ma
• SLE
• carcinoid synd rome
• acne vulgaris
• p e rioral d e rmatitis
PERIORAL DERMATITIS
❏ d iscre te e rythe matous microp ap ule s that ofte n b e come conflue nt
forming inflammatory p laq ue s on p e rioral and p e riorb ital skin
❏ sub se t of acne iform cond itions
• initial le sions usually in nasolab ial fold s, symme try common, rim
of sp aring around ve rmilion b ord e r of lip s
• 15 to 40 ye ar old
• fe male s p re d ominantly
• can b e aggravate d b y p ote nt top ical (fluorinate d ) corticoste roid s
❏ tre atme nt
• top ical
• me tronid azole 0.75% ge l or cre am to are a b id
• syste mic
• te tracycline 500 mg b id until cle ar, the n 500 mg d aily for
1 month, the n 250 mg d aily for 1 ad d itional month

DERMATITIS (ECZEMA) Note s
❏ sup e rficial inflammation of the skin, characte rize d b y p ruritic

p ap ulove sicle s, re d ne ss, crusting, scaling, and liche nification se cond ary
to scratching
ALLERGIC CONTACT DERMATITIS

❏ e p id e rmal and d e rmal inflammation cause d b y ce ll-me d iate d d e laye d
hyp e rse nsitivity re action
❏ clinical susp icion b y d iscre te are a of skin involve me nt
❏ susce p tib ility to alle rge n is acq uire d and sp e cific se nsitivity usually
p e rsists ind e finite ly
❏ alle rge ns includ e p oison ivy, rub b e r/late x, ne omycin, d ye s, lanolin,
nicke l
❏ d iagnosis b y p atch te sting
❏ tre atme nt
• avoid alle rge n and its cross re actants
• we t comp re sse s soake d in Burow’s solution (a d rying age nt),
change q 3h, b e tame thasone cre am
• syste mic corticoste roid s for e xte nsive case s (p re d nisone 1mg/kg
and re d uce ove r 2 we e ks)
IRRITANT CONTACT DERMATITIS

❏ e cze ma is ill-marginate d
❏ p hysical/che mical d amage : d amage to wate r and lip id -hold ing b arrie r,
d e naturing ke ratin and othe r p rote ins
❏ irritants includ e soap s, we ak alkali, d e te rge nts, organic solve nts,
alcohol, oils
❏ irritant and alle rgic d e rmatitis accounts for 30% of ind ustrial-re late d
me d ical d isab ility
❏ tre atme nt
• avoid ance , comp re sse s, top ical and oral ste roid s
ATOPIC DERMATITIS
❏ sub acute and chronic e cze matous re action cause d b y Typ e I
(IgE-me d iate d ) hyp e rse nsitivity re action (re le ase of histamine )
p rod ucing p rolonge d se ve re p ruritus
❏ incre ase d p e rsonal or family history of atop y
(asthma, e cze ma, hay fe ve r)
• 3% of infants – 50% cle ar b y age 13, fe w p e rsist > 30 ye ars of age
• p olyge nic inhe ritance : one p are nt > 60% chance for child ;
two p are nts > 80% chance for child
❏ associate d find ings
• ke ratosis p ilaris (hyp e rke ratosis of hair follicle s, “chicke n skin”)
• xe rosis
• atop ic p alms: p romine nt p almar cre ase s
• inflammation, liche nification, e xcoriations are 2º to re le ntle ss
scratching
Table 3. Phas e s of Atopic De rmatitis
Phas e Dis tribution
Infant (onse t at 2-6 months old ) Face , scalp , e xte nsor surface s
Child hood (>18 months) Fle xural surface s
Ad ult Hand s, fe e t, fle xure s, ne ck, e ye lid s, fore he ad , face , wrists
❏ tre atme nt
• b ath ad d itive (Ave e no oatme al) followe d b y ap p lication of
unsce nte d e mollie nts, or me nthol (cooling age nt)
• top ical corticoste roid s with oral antihistamine s
• avoid p rolonge d p ote nt d ose ; hyd rocortisone cre am for
mainte nance
• alte rnate with lub ricants or tar solution
• antib iotic the rap y if 2º infe ction b y S. aureus
• avoid syste mic corticoste roid s

DERMATITIS (ECZEMA) . . . CONT. Note s
SEBORRHEIC DERMATITIS
❏ gre asy, e rythe matous, ye llow, non-p ruritic scaling p ap ule s and p laq ue s
occurs in are as rich in se b ace ous gland s
• site s: scalp , e ye b rows, e ye lashe s, b e ard , face (flush are as,
b e hind e ars, fore he ad ), trunk, b od y fold s, ge nitalia
• p ossib le e tiologic association with the ye ast Pityrosp orum ovale
• incre ase d incid e nce in AIDS and Parkinson’s p atie nts
❏ tre atme nt
• face : non-fluorinate d hyd rocortisone cre am
• scalp : salicylic acid in olive oil (to re move scale ),
2% ke toconazole shamp oo (Nizarole ), low p ote ncy ste roid lotion
STASIS DERMATITIS
❏ p e rsiste nt skin inflammation of the lowe r le gs with a te nd e ncy toward
b rown p igme ntation, e rythe ma, and scaling
• commonly associate d with ve nous insufficie ncy
• comp lications: se cond ary b acte rial infe ctions, ulce ration
❏ tre atme nt
• sup p ort stocking
• re st and e le vate le gs
• moisturize r to tre at xe rosis
• mild top ical corticoste roid s to control inflammation
• surgical ve in strip p ing for cosme tic re asons only
NUMMULAR DERMATITIS
❏ annular coin-shap e d p ruritic p laq ue s
• d ry, scaly, liche nifie d
• ofte n associate d with atop y and d yshyd rotic e cze ma
❏ tre atme nt
• p ote nt corticoste roid ointme nt b id or intale sional triamcinolone
inje ction if se ve re
DYSHYDROTIC DERMATITIS
❏ p ap ulove sicular d e rmatitis of hand and foot; may b e come liche nifie d
with scaly p laq ue s
❏ misnome r – p athop hysiology is NOT re late d to swe ating
❏ tre atme nt
• top ical
• high p ote ncy corticoste roid with saran wrap occlusion to
incre ase p e ne tration
• intrale sional triamicinolone
• syste mic
• p re d nisone in se ve re case s
• antib iotics for 2º S. aureus infe ction
DIAPER DERMATITIS
(se e Pe d iatrics Note s)

INFECTIONS Note s
BACTERIAL
❏ ofte n involve the e p id e rmis, d e rmis, hair follicle s or p e riungual re gion.
❏ may also b e syste mic
SUPERFICIAL (EPIDERMAL)
Impe tigo Vulgaris (s e e Colour Atlas F5)
❏ acute p urule nt infe ction which ap p e ars ve sicular and p rogre sse s to
crusting (crust is gold e n ye llow and ap p e ars stuck on)
• age nt: GABHS, S. aureus, or b oth
• site s: commonly involve s the face , arms, le gs and b uttocks
• affe cte d : p re school and young ad ults living in crowd e d
cond itions, p oor hygie ne , ne gle cte d minor trauma
• comp lication: p ost-stre p . glome rulone p hritis
❏ tre atme nt
• re move crusts and use saline comp re sse s, p lus top ical antise p tic
soaks b id
• top ical antib acte rials such as mup irocin or fucid in, continue d for
7-10 d ays afte r re solution
• syste mic antib iotics such as cloxacillin or ce p hale xin
• infe cte d e cze ma, he rp e s simp le x, varice lla
Bullous Impe tigo
❏ scatte re d , thin walle d b ullae arising in normal skin and containing cle ar
ye llow or slightly turb id fluid with no surround ing e rythe ma
• age nt: S. aureus group II e lab orating e xfoliating toxin
• site s: trunk, inte rtriginous are as, face
• affe cte d : ne onate s and old e r child re n, e p id e mic e sp e cially in
d ay care
• comp lication: high le ve ls of toxin in immunocomp romise d or
young child re n may le ad to ge ne ralize d skin p e e ling or
stap hylococcal scald e d skin synd rome (SSSS)
❏ tre atme nt
• cloxacillin
• top ical antib acte rials such as fucid in and mup irocin,
continue d for 7-10 d ays
Erythras ma
❏ infe ction of the stratum corne um that manife sts as a sharp ly
d e marcate d , irre gularly shap e d b rown, scaling p atch
• age nt: Coryne b acte rium minutissimum
• site s: inte rtriginous are as of groin, axillae , inte rglute al fold s,
sub mammary, toe s
• affe cte d : ob e se , mid d le -age d , b lacks, d iab e tics, living in warm
humid climate
• d iagnosis: “coral-re d ” fluore sce nce und e r Wood ’s light (365 nm)
b e cause of a wate r-solub le p orp hyrin
❏ tre atme nt
• e conazole cre am ap p lie d b id and showe rs with p ovid one -iod ine
soap
• e rythromycin (250 mg q id for 14 d ays) for re fractory case s or
re curre nce s
• tine a cruris (p ositive scrap ing for hyp hae )
• se b orrhe ic d e rmatitis (no fluore sce nce )

INFECTIONS . . . CONT. Note s
DEEPER (DERMAL)
Table 4. Comparis on of Erys ipe las and Ce llulitis
Erys ipe las (s e e Colour Atlas F8) Ce llulitis
upper dermis lower dermis/subcutaneous fat
may be confluent, but well demarcated and poorly demarcated, not uniformly raised
raised, often with vesicles
Group A streptococcus GAS (most common), S. aureus (usually in

significantly sized wounds, doesn’t spread as much),
H. flu ( especially periorbital in kids < 5 years old,
may be blue), Pasteurella multocida (dog/cat scratch/bite)
spreads through lymphatics; long term recurrent

erysipelas can cause elephantiasis
PAINFUL (once called St. Anthony’s fire)
systemic symptoms: fever, chills, systemic symptoms less likely (but may
headache, weakness have fever, leukocytosis and lymphadenopathy)
more serious
complications include scarlet fever, streptococcal

gangrene, fat necrosis, coagulopathy
face and legs commonly legs
first line: Penicillin, Cloxacillin or Ancef first line: Cloxacillin or Ancef/Keflex

second line: Clindamycin or Keflex second line: Erythromycin or Clindamycin
If penicillin allergic, can use Erythromycin Cefuroxime in young kids;
TMP/SMX + Metronidazole in diabetic foot infections
m check for history of trauma, bites, saphenous vein graft, etc..., but often no inciting cause identified
m rarely culture bacteria by skin/blood culture; clinical diagnosis. If suspecting necrotizing fasciitis,
do immediate biopsy and frozen section histopathology
m DDx: DVT (less red, less hot, smoother), superficial phlebitis, RSD
HAIR FOLLICLES
Supe rficial Folliculitis
❏ sup e rficial infe ction of the hair follicle
❏ p se ud ofolliculitis: inflammation of follicle d ue to friction, irritation or
occlusion
❏ acute le sion consists of a sup e rficial p ustule surround ing the hair
• can occur on face (Staphylococcus most common), b e ard are a,
scalp or le gs, trunk (Pseudomonas), or b ack (Candida)
• common in AIDS
❏ tre atme nt
• top ical antib acte rial (fucid in, mup irocin or e rythromycin),
• oral cloxacillin for 7-10d
• mup irocin for S. aure us in nostril and on involve d hairy are a
Furuncle s (Boils )
❏ re d , hot, te nd e r, inflammatory nod ule s involving sub cutane ous tissue
that e volve s from a Staphylococcus folliculitis
• occurs whe re the re are hair follicle s and in are as of friction
and swe at (nose , ne ck, face , axillae , b uttocks)
❏ if re curre nt, rule out d iab e te s or hid rad e nitis sup p urativa (if in groin
or axillae )

Carbuncle s
❏ d e e p se ate d conglome rate of multip le coale scing furuncle s
❏ tre atme nt
• incise and d rain large carb uncle s to re lie ve p re ssure and p ain
• if afe b rile : hot we t p acks, top ical antib iotic
• if fe b rile /ce llulitis: culture b lood and asp irate p ustule s
(Gram stain and C&S)
• cloxacillin for 1 to 2 we e ks
PERIUNGUAL REGION
Paronychia
❏ inflammation around nail
• can cause nail d ystrop hy
• acute : S. aureus, Streptococcus
• chronic: C. albicans
❏ tre atme nt
• avoid e xp osure to moisture
• top ical fucid in or clotrimazole
OTHERS
Syphilis
❏ se xually transmitte d infe ction cause d b y Treponema pallidum
characte rize d b y a p ainle ss ulce r (chancre )
❏ following inoculation b e come s a syste mic infe ction with se cond ary
and te rtiary stage s
❏ p rimary syp hilis (s e e Colour Atlas F11)
• single re d , ind urate d , PAINLESS, round /oval, ind ole nt, chancre
(b uttonlike p ap ule ) that d e ve lop s into
p ainle ss ulce r with raise d b ord e r and scanty se rous e xud ate
• chancre d e ve lop s at site of inoculation afte r 3 we e ks of
incub ation and he als in 4-6 we e ks
• re gional non-te nd e r lymp had e nop athy ap p e ars < 1 we e k afte r
onse t of chancre
• VDRL ne gative
• d arkfie ld e xamination (for p rimary) - sp iroche te in tissue fluid
from chancre or lymp h nod e asp irate
• M:F = 2:1
• tre atme nt: b e nzathine p e nicillin G 2.4 million units IM
• d iffe re ntial d iagnosis
• chancroid : p ainful
• HSV: multip le le sions
❏ se cond ary syp hilis (s e e Colour Atlas F13)
• ap p e ars 2-10 we e ks afte r initial chancre , and 2-6 months afte r
p rimary infe ction
• ge ne ral e xam: ge ne ralize d lymp had e nop athy, sp le nome galy,
+/– fe ve r
• le sions he al in 1-5 we e ks, and may re cur for 1 ye ar
• typ e s of le sions
1. macule s and p ap ule s, round to oval, flat top , scaling,
non-p ruritic, sharp ly d e fine d , circular (annular) rash
• trunk, he ad , ne ck, p alms, sole s, mucous me mb rane s
• d iffe re ntial d iagnose s: p ityriasis rose a, tine a corp oris, d rug
e rup tions, liche n p lanus
2. cond yloma lata: moist p ap ule s around ge nital/p e rianal re gion
• e xud ate te e ming with sp iroche te s
• d iffe re ntial d iagnosis includ e s cond yloma acuminata
3. mucous p atche s: mace rate d p atche s mainly found in oral
mucosa
• associate d find ings: p haryngitis, iritis, p e riostosis,
“acute illne ss” synd rome - he ad ache , chills, fe ve r,
arthralgia, myalgia, malaise , p hotop hob ia
• VDRL p ositive
• FTA-ABS +ve ; –ve afte r 1 ye ar following ap p e arance of chancre
• TPI +ve ; d arkfie ld +ve in all se cond ary syp hilis e xce p t macular
e xanthe m
• se rologic te st may b e –ve if und ilute d se rum, or if HIV-infe cte d
• tre atme nt as for p rimary syp hilis

❏ te rtiary syp hilis

• e xtre me ly rare
• 3-7 ye ars afte r se cond ary
• main skin le sion: ‘Gumma’ - a granulomatous nod ule
• ind e p e nd e nt of othe r te rtiary syp hilis manife stations
• VDRL: b lood p ositive , CSF ne gative
Gonococce mia (Dis s e minate d Gonococcal Infe ction)

❏ p ustule s on a p urp uric e rythe matous b ase and he morrhagic, te nd e r,
ne crotic p ustule s (aka “arthritis-d e rmatitis synd rome ”)
• Gram ne gative d ip lococcus Neisseria gonorrheae
• skin manife stations d e ve lop in gonococce mia with vasculitis
• d istal asp e cts of e xtre mitie s
• associate d with fe ve r, asymme tric oligoarticular arthritis, and
te nosynovitis
• conjunctivitis if infe cte d via b irth canal
• e xamine contacts and notify authoritie s
• look for syp hilis and othe r STDs
• avoid inte rcourse until ne gative culture s
• d o not confuse with skin le sion of me ningococce mia:
p e te chiae which may e volve into p urp ura and e cchymosis
(s e e Colour Atlas F1)
❏ tre atme nt: ce ftriaxone (d rug of choice )
VIRAL
He rpe s Simple x (s e e Colour Atlas F12)
❏ group e d ve sicle s (he rp e tiform arrange me nt) on an e rythe matous
b ase on skin or mucous me mb rane s
• transmitte d via contact with e rup te d ve sicle s
• p rimary
• child re n and young ad ults
• usually asymp tomatic
• may have high fe ve r, re gional lymp had e nop athy, malaise
• se cond ary
• re curre nt form se e n in ad ults
• p rod rome of tingling, p ruritus, p ain
• much more commonly d iagnose d than p rimary
HSV I
❏ re curre nt on face , lip s
❏ rare ly on mucous me mb rane s (rule out ap hthous ulce r)
❏ virus in p oste rior root ganglion (Gasse rian ganglion of trige minal ne rve ,
sacral ganglion)
❏ re activate d b y: sunlight, fe ve r, me nstruation, stre ss, up p e r re sp iratory
infe ction, p hysical trauma
• imp e tigo
• e cze ma
HSV II
❏ incub ation 2-20 d ays
❏ gingivostomatitis (e ntire b uccal mucosa involve d with e rythe ma and
e d e ma of gingiva)
❏ vulvovaginitis (e d e matous, e rythe matous, e xtre me ly te nd e r, p rofuse
vaginal d ischarge )
❏ ure thritis (wate ry d ischarge in male s)
❏ re curre nt on vulva, vagina, p e nis, lasting 5-7 d ays
❏ 8% risk of transmission to ne onate via b irth canal if mothe r is
asymp tomatic
❏ d iagnosis confirme d with –ve d arkfie ld , –ve se rology for syp hilis,
–ve b acte rial culture s
• Tzanck sme ar shows multinucle ate d giant e p ithe lial ce lls
with Gie msa stain
• tissue culture and EM on ve sicular fluid
• skin b iop sy (intrae p id e rmal, b allooning d e ge ne ration, giant ce lls)
❏ antib od y titre s incre ase 1 we e k afte r p rimary infe ction, howe ve r,
incre ase in titre s are not d iagnostic of re curre nce
❏ tre atme nt
• rup ture ve sicle with ste rile ne e d le
• te p id we t d re ssing with aluminum sub ace tate solution,
Burow’s comp re ssion, or b e tad ine solution
• acyclovir: 200 mg PO, 5 time s a d ay for 10 d ays for 1st e p isod e
• top ical the rap y is ge ne rally not as e ffe ctive
• famciclovir and valacyclovir may b e sub stitute d
❏ comp lications
• d e nd ritic corne al ulce rs
• stromal ke ratitis
• e rythe ma multiforme
• he rp e s simp le x e nce p halitis
• HSV infe ction on atop ic d e rmatitis causing Kap osi’s varice lliform
e rup tion (e cze ma he rp e ticum)
Diffe re ntial Diagnos is of Ge nital Ulce rations

❏ HSV II
❏ multip le syp hilitic chancre s
❏ chancroid
❏ Cand id a b alanitis
❏ lymp hogranuloma inguinale
He rpe s Zos te r (s hingle s ) (s e e Colour Atlas F9)

❏ a localize d infe ction cause d b y varice lla zoste r virus characte rize d
b y unilate ral p ain and ve sicular/b ullous e rup tion limite d to a d e rmatome
• risk factors: old age , immunosup p re ssion, occasionally
associate d with he matologic malignancy
• occurs whe n d e cre ase d ce llular and humoral immunity to VZV
• thoracic (50%), trige minal (10-20%), ce rvical (10-20%),
d isse minate d in HIV p atie nts
• e rup tion b e gins d ay 3-5 afte r p ain and p are sthe sia of a d e rmatome
• le sions usually last d ays-we e ks
• p ain: p re -he rp e tic, synchronous with rash, or p ost-he rp e tic
and may p e rsist for months and ye ars
• se ve re p ost-he rp e tic ne uralgia ofte n occurs in e ld e rly
• if tip of nose involve d = e ye involve me nt
(conjunctivitis, ke ratitis, scle ritis, iritis)
❏ tre atme nt
• comp re sse s with normal saline , Burow’s, or b e tad ine solution
• analge sics
• NSAID, amitrip tyline
• for p atie nts ove r 50 ye ars old or with se ve re acute p ain or
op hthalmic involve me nt
• famciclovir 500 mg tid for 7 d ays or
valacyclovir 1000 mg tid for 7 d ays or
acyclovir 800 mg 5x d ay for 7 d ays (if immunocomp romise d )
Clinical Pe arl
❏ In He rpe s Zos te r, antiviral tre atme nt mus t be s tarte d within
72 hours of the ons e t of ras h unle s s ophthalmic involve me nt

• MI, p le ural d ise ase , acute ab d ome n, ve rte b ral d ise ase
• contact d e rmatitis
• localize d b acte rial infe ction
• zoste riform he rp e s simp le x virus (more p athoge nic for the
e ye s than varice lla zoste r)
Hand-Foot-and-Mouth Dis e as e
❏ gre y ve sicle s in p aralle l alignme nt to p almar and p lantar cre ase s of
hand s, fe e t and d iap e r are a with a p ainful ulce rative e xanthe m ove r
b uccal mucosa and p alate
• young child re n ofte n p re se nting with re fusal to e at
• Coxsackie A16, highly contagious
• 3-6 d ay incub ation, re solve s in 7-10 d ays
❏ tre atme nt
• xylocaine ge l as analge sic

Mollus cum Contagios um (s e e Colour Atlas F3)

❏ d iscre te d ome -shap e d and umb ilicate d p e arly white p ap ule s cause d
b y DNA p ox virus
• afflicts b oth child re n and ad ults
• ne ck, axillae , trunk, p e rine um, e ye lid s (may cause conjunctivitis)
• M > F, HIV p atie nts (common on face in AIDS p atie nts)
• transmission: d ire ct contact, auto-inoculation, se xual
❏ tre atme nt
• top ical cantharid in (p ainle ss ap p lication, b liste rs within d ays)
• liq uid nitroge n cryothe rap y (10-15 se cond s)
• cure ttage
• fib romata, ne vi, ke ratoacanthoma, b asal ce ll carcinoma
Ve rruca Vulgaris (Common Warts ) (s e e Colour Atlas F4)
❏ hyp e rke ratotic, e le vate d d iscre te e p ithe lial growths with p ap illate d surface
• human p ap illoma virus (HPV)
• trauma site : finge rs, hand s, kne e s of child re n and te e ns
• p aring of surface re ve als p unctate re d -b rown sp e cks (d ilate d cap illarie s)
❏ tre atme nt
• 65-90% re solve sp ontane ously ove r se ve ral ye ars
• salicylic acid p aste (ke ratolytic)
• cryothe rap y with liq uid nitroge n (10-30 se cond s); no scar b ut
hyp op igme ntation
• light e le ctrod e siccation, cure ttage with local ane sthe sia
• se b orrhe ic ke ratosis, molluscum contagiosum
Ve rruca Plantaris (Plantar Warts )
❏ hyp e rke ratotic, shiny, sharp ly marginate d p ap ule /p laq ue
• p re ssure site s: he ad s of me tatarsal, he e ls, toe s
• p aring of surface re ve als re d -b rown sp e cks (cap illarie s),
inte rrup tion of e p id e rmal rid ge s
❏ tre atme nt
• none if asymp tomatic, d isap p e ars in 6 months
• if te nd e r on late ral p re ssure , 40% salicylic acid p laste r for 1 we e k
the n cryothe rap y
• ne e d to scrap e (“p are ”) le sions to d iffe re ntiate wart from callus and corn
• callus: p aring re ve als uniformly smooth surface with no
inte rrup tion of e p id e rmal rid ge s
• corn (cause d b y und e rlying b ony p rotub e rance ): p aring
re ve als shiny ke ratinous core , p ainful to ve rtical p re ssure
Ve rruca Plana (Flat Wart)
❏ nume rous d iscre te , skin coloure d , flat top p e d p ap ule s occurring in line ar
configuration
• face , d orsa of hand s, shins
❏ tre atme nt
• e le ctrod e siccation
• cryothe rap y
Condylomata Acuminata (Ge nital Warts ) (s e e Colour Atlas D7)
❏ skin coloure d p inhe ad p ap ule s to soft cauliflowe r like masse s in cluste rs
• young ad ults, infants, child re n
• asymp tomatic, last months to ye ars
• ge nitalia and p e rianal are as
• F: from ce rvix to lab ia and p e rine um
• M: from me atus to scrotum
• highly contagious, transmitte d se xually and non-se xually
• can sp re ad without clinically ap p are nt le sions
• this HPV is immunologically d istinct from HPV of ve rruca vulgaris
• typ e s 6 and 11 are the most common cause s
• typ e s 16, 18, 31, 33 cause ce rvical d ysp lasia, sq uamous ce ll
cance r and invasive cance r of vagina and p e nis
• child re n vaginally d e live re d to infe cte d mothe rs at risk
for anoge nital cond ylomata and re sp iratory p ap illomatosis
• ace towhite ning: sub clinical le sions se e n with 5%
ace tic acid x 5 minute s and hand le ns (tiny white p ap ule s)
• false p ositive s d ue to p soriasis, liche n p lanus

❏ tre atme nt
• p od op hyllin (contraind icate d in p re gnancy)
• liq uid nitroge n, e le ctrocaute ry
• trichloroace tic acid (80-90%), intrale sional inte rfe ron
• surge ry only ne e d e d for giant le sions
• cond ylomata lata (se cond ary syp hilitic le sion, d arkfie ld
strongly + ve )
• molluscum contagiosum
• liche n p lanus
• p e arly p e nile p ap ule s
DERMATOPHYTES
(SUPERFICIAL FUNGAL INFECTION OF SKIN)
❏ cause d b y Trichop hyton, Microsp orum, Ep id e rmop hyton
❏ live on d e ad sup e rficial skin b y d ige sting ke ratin the re fore
re sult in scaly skin, b roke n hairs and crumb ling nails
❏ d iagnose using skin scrap ings, hair, and nail clip p ings analyze d with
KOH p re p (since the se fungi live as mold s, look for hyp hae ,
and myce lia)
❏ ge ne ral p rincip le s of tre atme nt
• top icals are not first line the rap y for all d e rmatop hyte s
• top icals may b e use d as first line age nts for tine a corp oris/cruris
and tine a p e d is (inte rd igital typ e )
• main top icals are clotrimazole or te rb inafine
• othe rwise tre at orally with te rb inafine (Lamisil) or itraconazole
(Sp oranox)
• itraconazole is a P-450 inhib itor. It alte rs me tab olism
of non-se d ating antihistamine s, cisap rid e , d igoxin, and
HMG CoA re d uctase inhib itors
Tine a Capitis (s e e Colour Atlas A10)

❏ Non-scarring alop e cia with scale , cause d b y Trichop hyton tonsurans and
Microsp orum sp e cie s
• affe cts child re n (mainly b lack), immunocomp romise d ad ults
• may se e b lack-d ot b roke n off hairs, ke rion (b oggy, e le vate d ,
p urule nt, inflame d nod ule s or p laq ue s), or ye llow crust
d e p e nd ing on organism
• ve ry contagious and may b e transmitte d from b arb e r, hats,
the atre se ats, p e ts
• Wood ’s light e xamination of hair: gre e n fluore sce nce only for
microsp orum infe ction
• p soriasis, se b orrhe ic d e rmatitis, alop e cia are ata, trichotillomania
Tine a Corporis /Tine a Cruris (Ringworm) (s e e Colour Atlas F14)

❏ scaling p laq ue s with p ap ular, sharp margins, occurring in an annular
arrange me nt (with p e rip he ral e nlarge me nt and ce ntral cle aring)
• T. corporis
• trunk, limb s, face
• T. rubrum, E. floccosum, M. canis (kid s in contact with p up p ie s or kitte ns)
• T. cruris
• inte rtriginous are as, up p e r thigh, b uttock
• T. rubrum, E. floccosum
• ofte n concurre nt tinea pedis
• note : take scrap ing from ad vancing b ord e r
• cand id iasis (involve me nt of scrotum, sate llite p ustule s, no sharp
b ord e r)
• e rythrasma (coral-re d fluore sce nce with Wood ’s lamp , rod s and
filame nts, axilla and we b s of toe s)
• contact d e rmatitis (ofte n sup e rimp ose d on tine a d ue to home re me d y)
Tine a Pe dis (Athle te ’s Foot)
❏ acute : re d /white , scale s, mace ration, ve sicle s, b ullae
• inte rd igital
• he at, humid ity, occlusive footwe ar
• may p re se nt as flare -up of chronic tine a p e d is
• fre q ue ntly b e come se cond arily infe cte d b y b acte ria

❏ chronic non-p ruritic, p ink, scaling ke ratosis on sole s, and

sid e s of foot, ofte n in a “moccasin” d istrib ution
• hyp e rke ratosis
• alle rgic contact d e rmatitis (d orsum/he e l)
• e rythrasma, inte rtrigo (inte rd igital)
• p soriasis (sole s or inte rd igital)
Tine a Manuum
❏ acute : b liste rs at e d ge of re d are as
❏ chronic: single d ry scaly p atch
• p rimary fungal infe ction of the hand is actually q uite rare ; usually
associate d with tine a p e d is with one hand and two fe e t affe cte d
= “1 hand 2 fe e t” synd rome
• contact d e rmatitis, atop ic d e rmatitis, p soriasis
(all thre e commonly mistake n for fungal infe ctions)
• granuloma annulare (annular)
Tine a Unguium (Onychomycos is ) (s e e Colour Atlas A9)
❏ crumb ling, d istally d ystrop hic nails
• tre at with Te rb inafine (finge rnails 6 we e ks, toe nails 12 we e ks)
or with Itraconazole (finge rnails 2 p ulse s, toe nails 3 p ulse s)
• a p ulse = 1 we e k p e r month of 200 mg b id
• p soriasis (p itting, may have p soriasis e lse whe re )
• cand id iasis (hand s in wate r)
• hyp e rthyroid ism
YEAST
Pityrias is (tine a) Ve rs icolour (s e e Colour Atlas F7)
❏ chronic asymp tomatic sup e rficial fungal infe ction with b rown/white
scaling macule s
• e tiology: Malasse zia furfur (Pityrosp orum orb iculare )
• young ad ults
• affe cte d skin d arke r than surround ing skin in winte r, lighte r
in summe r (d oe sn’t tan)
• site s: up p e r trunk most common
se e n on face in d ark skinne d ind ivid uals
• p re d isp osing factors: summe r, te mp e rate climate s,
Cushing’s synd rome , p rolonge d corticoste roid use
• d iagnosis: d ire ct microscop ic e xam of scale s for hyp hae
and sp ore s p re p are d in KOH, Wood ’s lamp (faint ye llow-
gre e n fluore sce nce )
❏ tre atme nt
• scrub off scale s with soap and wate r
• se le nium sulfid e
• ke toconazole cre am or 200mg PO d aily for 10 d ays
Candidias is (s e e Colour Atlas F10)
❏ Cand id al p aronychia: p ainful re d swe llings of p e riungual skin
❏ Cand id al inte rtrigo: re d p atche s with p ustular b ord e rs in are as of
skin fold s
• ofte n und e r b re ast, groin, inte rd igital
• p re d isp osing factors - ob e sity, d iab e te s, syste mic antib iotics
• inte rtrigo starts as non-infe ctious mace ration from he at,
moisture and friction; e vid e nce that it has b e e n infe cte d b y
inte rtrigo is a p ustular b ord e r
• tre at b y ke e p ing are a d ry, miconazole

PARASITIC
Scabie s (s e e Colour Atlas F2)
❏ a transmissib le p arasitic skin infe ction (Sarcop te s scab ie i, a mite ),
characte rize d b y sup e rficial b urrows, inte nse p ruritus and se cond ary
infe ction
• se cond ary le sions: small urticarial cruste d p ap ule s,
e cze matous p laq ue s, e xcoriations
• site s: axillae , cub itus, wrist, sid e of p alm, we b sp ace s, groin,
b uttocks, b ack of ankle , toe s, p e nis
• se xual p romiscuity, crowd ing, p ove rty, nosocomial
• intractab le p ruritus worse at night (mite more active ; p ruritus is
also worse at night)
• ad ults: scalp , face , up p e r b ack sp are d
• infants: scalp , face , p alms/sole s involve d
• immunocomp romise d : Norwe gian Scab ie s =
Cruste d Scab ie s; all ove r b od y
• scab ie s mite re main alive 2-3 d ays on clothing/she e ts
• incub ation = 1 month, the n b e gin to itch
• re -infe ction followe d b y hyp e rse nsitivity in 24 hours
• microscop ic e xamination of root and conte nt of b urrow with KOH
for mite , e ggs, fe ce s
❏ tre atme nt
• b athe the n ap p ly Pe rme thrin 5% cre am (i.e . Nix) or Kwe llad a
from he ad (not ne ck) d own to sole s of fe e t (must b e le ft on for
8 hours)
• Nix is p re fe rre d in child re n (se izure s re p orte d with Kwe llad a)
• may re q uire se cond tre atme nt 7 d ays afte r first tre atme nt
• change und e rwe ar and line ns
• +/– antihistamine
• tre at family and contacts
• p ruritus may p e rsist for 2-3 we e ks d ue to p rolonge d
hyp e rse nsitivity re action
• d e rmatitis he rp e tiformis: se e ve sicle s, urticaria, e osinop hilia, no b urrows
• aste atotic e cze ma (“winte r itch”)
• ne urotic e xcoriation
Lice (Pe diculos is )

❏ inte nse ly p ruritic re d e xcoriations, morb illiform rash, Pediculus humanus
• scalp lice : nits on hairs
• re d e xcoriate d skin with se cond ary b acte rial
infe ction, lymp had e nop athy
• p ub ic lice : nits on hairs
• e xcoriations
• rare ly in chronic case s: “maculae ce rule ae ”= b luish
gre y, p e a-size d macule s
• b od y lice : nits and lice in se ams of clothing
• e xcoriations and se cond ary infe ction
• mainly on should e rs, b e lt-line and b uttocks
❏ tre atme nt
• Pe rme thrin 1% (Nix) cre am rinse (ovicid al)
• Kwe llad a shamp oo (kills ne wly hatche d nits)
• comb hair with fine -toothe d comb using d ilute vine gar
solution tore move nits
• re p e at in 7 d ays
• change and cle an b e d d ing, clothing and towe ls
• for b od y lice , washing clothe s is e sse ntial
• b acte rial infe ction of scalp : re sp ond s rap id ly to antib iotic
• se b orrhe ic d e rmatitis: flake s of d and ruff re ad ily d e tache d
• hair casts: p ulle d more e asily than nits, no e ggs on microscop y

PAPULOSQUAMOUS DISEASES Note s
PSORIASIS (s e e Colour Atlas A7)

❏ typ e s
• p laq ue p soriasis
• guttate p soriasis
• e rythrod e rmic p soriasis
• p ustular p soriasis
• p soriatic arthritis
❏ d iffe re ntial
• se b orrhe ic d e rmatitis
• chronic d e rmatitis
• mycosis Fungoid e s (cutane ous T-ce ll lymp homa)
PLAQUE PSORIASIS
❏ a common chronic and re curre nt d ise ase characte rize d b y d ry,
we ll-circumscrib e d , silve r scale s ove r e rythe matous p ap ule s/p laq ue s,
mostly at site s of re p e ate d trauma
• site s: scalp , e xte nsor surface s of e lb ows and kne e s, trunk, nails,
p re ssure are as
• worse in winte r (lack of sun and humid ity)
• multifactorial inhe ritance : 30% with family history and HLA marke rs
❏ p athoge ne sis: d e cre ase e p id e rmal transit time from b asal to horny
laye rs and shorte ne d ce ll cycle of p soriatic and normal skin
❏ Koe b ne r p he nome non (isomorp hic re sp onse ): ind uction of ne w le sion
b y injury
❏ Ausp itz’s sign: b le e d s from minute p oints whe n scale is re move d
❏ e xace rb ating factors: d rugs (lithium, e thanol, chloroq uine ,
b e ta-b locke rs), sunlight, stre ss, ob e sity
❏ tre atme nt
• top ical and syste mic
Table 5. Topical Tre atme nt of Ps orias is

Tre atme nt Me chanis m Comme nts
lubricants reduce fissure formation
salicylic acid 1-12% remove scales
anthralin .1%, .2%, .4% increase cell turnover stains and irritates normal skin
tar (Liquor carbonis inhibits DNA synthesis, poor longterm compliance

detergent) increase cell turnover
calcipotriol binds to skin not to be used on face or skin folds

(vit. D derivative; 1, 25-dihydroxyvitamin
Dovenex) D3 to inhibit keratinocyte
proliferation
corticosteroid ointment reduce scaling and use appropriate potency steroid

thickness in different areas and degree of psoriasis
tazarotene retinoid derivative
Goeckermann regimen: UVB 290-320 nm

UVB + tar

PAPULOSQUAMOUS DISEASES . . . CONT. Note s
Table 6. Sys te mic Tre atme nt of Ps orias is

Tre atme nt Adve rs e Effe cts
methotrexate bone marrow toxicity, hepatic cirrhosis
steroids rebound effect when withdrawn
PUVA (8 methoxy-psoralen pruritus, burning, cataracts, skin cancer

and UVA 360-440 nm)
acetretin alopecia, cheilitis, teratogenicity, epistaxis,

xerosis, hypertriglyceridemia
cyclosporine renal toxicity, hypertension, immunosuppression
GUTTATE PSORIASIS (“drop-like ”)

❏ d iscre te , scatte re d salmon-p ink scaling p ap ule s
• site s: ge ne ralize d (mainly trunk and p roximal e xtre mitie s),
sp aring p alms and sole s
• ofte n ante ce d e nt stre p tococcal p haryngitis
❏ tre atme nt
• UVB p hotothe rap y, sunlight, lub ricants
• p e nicillin V or e rythromycin if Group A b e ta-he molytic
Streptococcus on throat culture
ERYTHRODERMIC PSORIASIS
❏ ge ne ralize d e rythe ma with fine d e sq uamative scale on surface , with
island s of sp are d skin
❏ may p re se nt in p atie nt with p re vious mild p laq ue p soriasis
• aggravating factors: lithium, b e ta-b locke rs, NSAIDs, antimalarials,
p hototoxic re action, infe ction
• associate d symp toms: worse arthralgia, se ve re p ruritus
❏ tre atme nt
• hosp italization, b e d re st, IV fluid s, monitor fluid and lyte s
• tre at und e rlying aggravating cond ition
• me thotre xate
• PUVA and re tinoid s
PUSTULAR PSORIASIS
❏ sud d e n onse t of e rythe matous macule s and p ap ule s which e volve into
p ustule s rap id ly; can b e ge ne ralize d (von Zumb usch typ e ) or localize d
(acrop ustulosis or p ustulosis of p alms and sole s)
❏ uncommon
• p atie nt may have no history of p soriasis, or was re ce ntly
inap p rop riate ly withd rawn from ste roid the rap y. It also may
occur in the 3rd trime ste r of p re gnancy (imp e tigo he rp atiformis)
• associate d symp toms: fe ve r, arthralgias, d iarrhe a, 8 WBCs
❏ tre atme nt
• b e d re st, withd raw e xace rb ating me d ications, monitor lyte s
• me thotre xate and e tre tinate (start with low d ose )
• localize d PUVA for p ustulosis of p alms and sole s
PSORIATIC ARTHRITIS
❏ 5 cate gorie s
• asymme tric oligoarthrop athy
• DIP joint involve me nt is p re d ominant
• rhe umatoid p atte rn – symme tric p olyarthrop athy
• p soriatric arthritis mutilans
• p re d ominant sp ond ylitis or sacroilitis

PAPULOSQUAMOUS DISEASES . . . CONT. Note s
Table 7. Ps orias is by dis tribution

Location Signs and Symptoms Tre atme nt
s calp dry, scaling, well demarcated, reddish, • tar shampoo followed by betamethasone
lichenified plaques (no hair loss), mild valerate 0.1% lotion biweekly
to severe itching, sunlight does not • If severe (thick plaques)
cause remission remove plaque with 10% salicylic acid in mineral oil
and cover with plastic cap overnight (1-3 treatments)
• fluocinolone cream/lotion with cap overnight
• maintenance with scalp lotion (clobetasol
propionate 0.05%)
nails onycholysis, pitting, subungal hyperkeratosis, • intradermal triamcinolone acetonide 5 mg/mL

oil spots • PUVA
• methotrexate
palms and s ole s sharply demarcated dusky-red plaques with • PUVA

thick scales on pressure points; can be • retinoids
pustular • methotrexate
LICHEN PLANUS
❏ acute or chronic inflammation of mucous me mb rane s or skin
characte rize d b y violace ous, shiny, p ruritic p ap ule s top p e d with
Wickham’s striae (fine white line s); milky white p ap ule s in mouth
• site s: fle xor surface of wrists, lumb ar re gion, shins, e ye lid s, scalp ,
b uccal mucosa, tongue , lip s, nails
• scalp le sions associate d with alop e cia
• sp ntane ously re solve s in we e ks or lasts for ye ars (mouth and shin
le sions)
• mne monic “6 P’s: Purp le , Pruritic, Polygonal, Pe rip he ral, Pap ule s,
Pe nis
• p re cip itating factor: se ve re e motional stre ss
• associate d with he p atitis C
❏ tre atme nt
• top ical corticoste roid s with occlusion or intrad e rmal
ste roid inje ctions
• short course s of oral p re d nisone (rare ly)
• PUVA for ge ne ralize d or re sistant case s
• oral re tinoid s for e rosive liche n p lanus in mouth
❏ d iffe re ntial
• skin
• d rug e rup tion (chloroq uine or gold salts)
• liche noid graft vs. host d ise ase
• lup us e rythe matosus
• contact with colour film d e ve lop me nt che micals
• mucous me mb rane s
• le ukop lakia
• thrush
• HIV associate d hairy le ukop lakia
• lup us e rythe matosus
PITYRIASIS ROSEA (s e e Colour Atlas F6)

❏ acute se lf-limiting e rythe matous e rup tion characte rize d b y re d , oral
p atche s and p ap ule s with marginal collare tte of scale
• site s: trunk, p roximal asp e cts of arms and le gs
• e tiology: human he rp e s virus 7
• long axis of le sions follow line s of cle avage p rod ucing
“Christmas tre e ” p atte rn on b ack
• varie d d e gre e of p ruritus
• most start with a “he rald ” p atch which p re ce d e s othe r le sions b y
1-2 we e ks
• cle ars sp ontane ously in 6-12 we e ks
❏ tre atme nt
• no tre atme nt ne e d e d unle ss itchy
• UVB in first we e k of e rup tion (5 e xp osure s) may he lp p ruritis

VESICULOBULLOUS DISEASES Note s
PEMPHIGUS VULGARIS
❏ autoimmune b liste ring d ise ase characte rize d b y flaccid ,
non-p ruritic b ullae /ve sicle s on an e rythe matous b ase
❏ e tiology
• IgG p rod uce d against e p id e rmal d e smogle in 3 le ad ing to
acantholysis (e p id e rmal ce lls se p arate d from e ach othe r)
p rod ucing intrae p id e rmal b ullae
• associate d with thymoma, myasthe nia gravis, malignancy,
D-p e nicillamine
❏ history
• 40-60 ye ars old , p atie nts are ofte n Je wish or Me d ite rrane an
❏ p hysical
• may p re se nt with e rosions and se cond ary b acte rial infe ction
• site s: mouth (90%), scalp , face , che st, axillae , groin, umb ilicus
• Nikolsky’s sign: b ulla e xte nd s with finge r p re ssure
❏ d iagnosis
• immunofluore sce nce shows IgG and C3 d e p osite d in
e p id e rmal inte rce llular sp ace s
❏ course
• mouth le sions, months late r skin le sions; first
localize d (6-12 months) the n ge ne ralize d
• le sions he al with hyp e rp igme ntation b ut no scar
• may b e fatal unle ss tre ate d with immunosup p re ssive age nts
❏ tre atme nt
• p re d nisone 2.0-3.0 mg/kg until no ne w b liste rs, the n
1.0-1.5 mg/kg until cle ar, the n tap e r
• ste roid sp aring age nts - azathiop rine , p lasmap he re sis,
me thotre xate , gold , cyclop hosp hamid e
BULLOUS PEMPHIGOID
❏ chronic autoimmune b ullous e rup tion characte rize d b y p ruritic, te nse ,
sub e p id e rmal b ullae
❏ e tiology
• IgG p rod uce d against b ase me nt me mb rane
• associate d with malignancy in some
❏ history
• 60-80 ye ars old
❏ p hysical
• site s: fle xor asp e ct of fore arms, axillae , me d ial thighs, groin,
ab d ome n, mouth (33%)
❏ d iagnosis
• d ire ct immunofluore sce nce shows d e p osition of IgG and C3
at b ase me nt me mb rane
• anti-b ase me nt me mb rane antib od y (IgG)
❏ course
• he aling without scars if no infe ction
❏ tre atme nt
• p re d nisone 50-100 mg (to cle ar) +/– ste roid sp aring age nts
such as azathiop rine
• te tracycline 500-1 000 mg/d ay +/– nicotinamid e is e ffe ctive for some case s
• d ap sone 100-150 mg/d ay for mild e r case s
DERMATITIS HERPETIFORMIS
❏ inte nse ly p ruritic group e d p ap ule s/ve sicle s/urticarial whe als
❏ e tiology
• 90% associate d with glute n se nsitive e nte rop athy (80% are asymp tomatic),
30% have thyroid d ise ase , and some have inte stinal lymp homa
• iron or folate d e ficie ncy
❏ history
• 20-60 ye ars old , M:F = 2:1
• 90% have HLA B8, DR3, DQW2
❏ p hysical
• site s: e xte nsor surface s of e lb ows/kne e s, sacrum, b uttocks, scalp
❏ d iagnosis
• immunofluore sce nce : granular IgA and comp le me nt d e p osition
in d e rmis
❏ course
• le sions last d ays - we e ks
❏ tre atme nt
• d ap sone for p ruritus b ut multip le sid e e ffe cts
• glute n fre e d ie t

VESICULOBULLOUS DISEASES . . . CONT. Note s
Table 8. Ve s iculobullous Dis e as e s

Pe mphigus Vulgaris Bullous Pe mphigoid De rmatitis He rpe tiformis
antibody IgG IgG IgA
s ite intercellular space basement membrane dermal
infiltrate eosinophils and neutrophils eosinophils neutrophils
tre atme nt high dose steroids moderate dose steroid gluten-free diet/dapsone
cyclophosphamide cyclophosphamide
as s ociation gluten enteropathy
PORPHYRIA CUTANEA TARDA

❏ autosomal d ominant or sp orad ic skin d isord e r associate d with
the p re se nce of e xce ss he me characte rize d b y te nse ve sicle s/
b ullae in p hotoe xp ose d are as
❏ e tiology
• associate d with He p atitis C, alcohol ab use , DM, e stroge n the rap y,
HIV, 8 iron
❏ history
• 30-40 ye ars old , M>F
❏ p hysical
• facial hyp e rtrichosis, b rown hyp e rme lanosis, “he liotrop e ”
around e ye s, b ullae on e xte nsor surface s of hand s and fe e t
• site s: light-e xp ose d are as sub je cte d to trauma: d orsum of
hand s and fe e t, nose , up p e r trunk
• may comp lain of fragile skin on d orsum of hand s
❏ d iagnosis
• Wood ’s lamp of urine + 5% HCl shows orange -re d fluore sce nce
• immunofluore sce nce shows IgE at d e rmal-e p id e rmal junctions
❏ tre atme nt
• d iscontinue aggravating sub stance s (alcohol, e stroge n the rap y)
• p hle b otomy to d e cre ase b od y iron load
• hyd roxychloroq uine if p hle b otomy contraind icate d
DIFFERENTIAL OF PRIMARY BULLOUS DISORDERS
❏ Drug e rup tions
❏ EM and re late d d isord e rs
❏ Infe ctions – b ullous imp e tigo
❏ Infe stations – scab ie s (d e rmatitis he rp e tiformis)
❏ Inflammation – acute e cze ma

ERYTHEMA MULTIFORME (EM) /
STEVENS-JOHNSON SYNDROME (SJS) /
TOXIC EPIDERMAL NECROLYSIS (TEN) Note s
❏ sp e ctrum of d isord e rs with varying p re se nce of characte ristic skin
le sions, b liste ring, and mucous me mb rane involve me nt
EM (minor) EM (major) SJS TEN
Table 9. Comparis on of Erythe ma Multiforme , Ste ve ns -Johns on Syndrome and Toxic Epide rmal Ne crolys is
Erythe ma Multiforme (EM) Ste ve ns -Johns on Syndrome (SJS) Toxic Epide rmal
(s e e Colour Atlas A10) Ne colys is (TEN)
Lesion • macules/papules with central vesicles • EM with more mucous membrane • severe mucous membrane involvement
• classic bull’s-eye pattern of concentric involvement, and blistering • “atypical lesions” – 50% have no target
light and dark rings (target lesions) • “atypical lesions” - red circular lesions
• bilateral and symmetric patch with dark purple center • diffuse erythema then necrosis and
• EM minor - no mucosal involvement, • more “sick” (high fever) sheet-like epidermal detachment in >30%
bullae, or systemic symptoms • sheet-like epidermal detachment in <10%
• EM major – mucosal involvement, bullae, • Nikolsky sign
systemic symptoms, usually drug induced
• Nikolsky sign (see pemphigus vulgaris)
Sites • mucous membrane involvement (oral, • generalized with prominent face and • generalized
genital, conjunctival) trunk involvement • nails may also shed
• extremities with face > trunk • palms and soles may be spared
• involvement of palms and soles
Other organs/ • corneal ulcers, keratitis, anterior uveitis, • complications: scarring, eruptive • tubular necrosis and acute renal failure,
complications stomatitis, vulvitis, balanitis nevomelanocytic nevi, corneal scarring, epithelial erosions of trachea, bronchi, GI
• lesions in trachea, pharynx, larynx blindness, phymosis and vaginal synechiae tract
Constitutional • fever, weakness, malaise • prodrome 1-3 days prior to eruption with • high fever > 38ºC
symptoms fever and flu-like illness
Etiology • drugs – sulfonamides, NSAIDs, • 50% are drug related • 80% are definitely drug related
anticonvulsants, penicillin, allopurinol • occurs up to 1-3 weeks after drug exposure • < 5% are due to viral infection,
• infection – herpes, mycoplasma with more rapid onset upon rechallenge immunization
• idiopathic - >50%
Pathology/ • perivascular PMN infiltrate, • cytotoxic cell-mediated attack on • same as Stevens-Johnson Syndrome
Pathophysiology edema of upper dermis epidermal cells
• no dermal infiltrate
• epidermal necrosis and detatchment above
basement membrane
Differential • EM minor – urticaria, viral exanthems • scarlet fever, phototoxic eruption, GVHD, • scarlet fever, phototoxic eruption, GVHD,
diagnosis • EM major – SSSS, pemphigus vulgaris, SSSS, exfoliative dermatitis SSSS, exfoliative dermatitis
bullous pemhigoid
Course and • lesions last 2 weeks • < 5% mortality • 30% mortality due to fluid loss,
Prognosis • regrowth of epidermis by 3 weeks secondary infection
Treatment • prevention – drug avoidance • withdraw suspect drug • admit to burn unit
• symptomatic treatment • intravenous fluids
• corticosteroids in severely ill • corticosteroids – controversial
but controversial • infection prophylaxis
(SSSS = Stap hylococcal Scald e d Skin Synd rome )

ERYTHEMA NODOSUM Note s

❏ acute or chronic inflammation of ve nule s in the sub cutane ous fat
characte rize d b y round , re d , te nd e r, p oorly d e marcate d nod ule s
• 15-30 ye ars old , F:M = 3:1
• site s: asymme trically arrange d on lowe r le gs, kne e s, arms
• le sions last for d ays and sp ontane ously re solve in 6 we e ks
• associate d with arthralgia, fe ve r, malaise
❏ associations
• infe ctions: Group A Stre p tococcus, p rimary TB,
coccid ioid omycosis, histop lasmosis, Ye rsinia
• d rugs: sulfonamid e s, oral contrace p tive s (also p re gnancy)
• inflammation: sarcoid osis, Crohn’s > ulce rative colitis
• malignancy: acute le uke mia, Hod gkin’s lymp homa
• 40% are id iop athic
❏ inve stigations: che st x-ray (to rule out che st infe ction and sarcoid osis),
throat culture , ASO titre , PPD skin te st
❏ tre atme nt
• NSAIDs
• tre at und e rlying cause
• sup e rficial thromb op hle b itis, p anniculitis, e rysip e las
DRUG ERUPTIONS
EXANTHEMATOUS ERUPTIONS
(MACULOPAPULAR ERUPTIONS/
MORBILLIFORM)
❏ symme trical, wid e sp re ad , e rythe matous p atche s or p laq ue s with
or without scale s
• the “classic” ad ve rse d rug re action
• ofte n starts on trunk or on are as of sun e xp osure
• may p rogre ss to ge ne ralize d e xfoliative d e rmatitis e sp e cially if
the d rug is continue d
• p e nicillin, sulfonamid e s, p he nytoin (in ord e r of d e cre asing p rob ab ility)
• incid e nce of amp icillin e rup tion is gre ate r than 50% in
p atie nts with mononucle osis, gout or chronic lymp hocytic
le uke mia
URTICARIA (als o known as “Hive s ”)

❏ transie nt, re d , p ruritic we ll-d e marcate d whe als
• se cond most common typ e of d rug re action
• d ue to re le ase of histamine from mast ce lls in d e rmis
• lasts le ss than 24 hours
ANGIOEDEMA
❏ d e e p e r swe lling of the skin involving sub cutane ous tissue s ofte n with
swe lling of the e ye s, lip s, and tongue
❏ may or may not accomp any urticaria
❏ he re d itary Angioe d e ma - d oe s not occur with urticaria
• onse t in child hood ; 80% have p ositive family history
• re curre nt attacks; 25% d ie from laynge al e d e ma
• trigge rs: minor trauma, e motional up se t, te mp e rature change s
• d iagnosis: re d uce d C1 e ste rase inhib itor le ve l (in 85%) or function
(in 15%), d iminishe d C4 le ve l
❏ acq uire d angioe d e ma
• autoantib od ie s to C1 e ste rase inhib itor
• consump tion of comp le me nt in lymp hop rolife rative d isord e r
• d iagnosis: C1 e ste rase inhib itor d e ficie ncy, d e cre ase d C1
(uniq ue to acq uire d form), d iminishe d C4 le ve l
❏ tre atme nt: p rop hylaxIS with d anazol or stanozolol
• Ep rine p hrine p e n to te mp orize until p atie nt re ache s
hosp ital in acute attack

DRUG ERUPTIONS . . . CONT. Note s
Table 10. Clas s ification of Urticaria

Type Provocative age nts /te s ts Comme nts
acute urticaria • Food s (nuts, she llfish, e ggs, fruits) • Attack lasts <6 we e ks
• Inse ct stings • Each le sion lasts <24 hrs
• Drugs (e sp e cially asp irin, NSAID’s) • Occurs with or without angioedema
• Contacts – cosme tics, work e xp osure s
• Infe ction – viral (he p atitis, up p e r re sp iratory), b acte rial, p arasitic
• Syste mic d ise ase s – SLE, e nd ocrinop athy (TSH), ne op lasm
• Stre ss
• Id iop athic
chronic urticaria • most commonly id iop athic • Attack lasts >6 we e ks

• aggravating and causative factors may b e similar to those in • Each le sion lasts <24 hrs
acute urticaria
Choline rgic urticaria • Incre ase d core b od y te mp e rature • Tiny fle sh coloure d whe als with
• hot showe r, e xe rcise surround ing re d flare
Contact urticaria • late x rub b e r – p atch te st, alle rgy te st
Phyiscal urticarias
• Aq uage nic urticaria • e xp osure to wate r
• Ad re ne rgic urticaria • Stre ss
• Cold urticaria • ice cub e , swimming p ool • Can b e life thre ate ning
• De rmograp hism • Friction, rub b ing skin • Imme d iate and p ossib le
d e laye d typ e s
• He at urticaria • local he at
• Pre ssure urticaria • Locate d ove r p re ssure are as of b od y (should e r strap , b uttocks) • Imme d iate and d e laye d typ e s
• Solar urticaria • Cause d b y a sp e cific wave le ngth of UV rad iation
• Vib ratory urticaria • Vib ration
Vasculitic urticaria • Infe ctions – he p atitis • Painful non-p ruritic le sions

• Autoimmune d ise ase s – SLE • Le sions last > 24 hrs
• Drug hyp e rse nsitivity • Must b iop sy the se le sion
FIXED DRUG ERUPTION

❏ sharp ly d e marcate d e rythe matous oval p atche s on the skin or mucous
me mb rane s
• site s: face , ge nitalia
• with e ach e xp osure to the d rug, the p atie nt d e ve lop s
e rythe ma at the same location as b e fore (fixe d location)
• te tracycline , sulfonamid e s, b arb ituate s, p he nolp hthale in
DELAYED HYPERSENSITIVITY SYNDROME

❏ initial fe ve r, followe d b y symme trical b right re d e xanthe matous e rup tion
and may le ad to inte rnal organitis includ ing he p atitis, arthralgia,
lymp had e nop athy, and /or he matologic ab normalitie s
• classically the p atie nt has a first e xp osure to a d rug and
d e ve lop s the synd rome 10 d ays late r
• sib lings at risk
• sulfonamid e s, anticonvulsants, e tc...
PHOTOSENSITIVITY ERUPTIONS
❏ p hototoxic re action: “an e xagge rate d sunb urn” confine d to light
e xp ose d are as
❏ p hotoalle rgic re action: an e cze matous e rup tion that may sp re ad to
are as not e xp ose d to light
❏ chlorp romazine , d oxycycline , thiazid e d iure tics, p rocainamid e
DRUG ERUPTIONS . . . CONT. Note s
SERUM SICKNESS - LIKE REACTION

❏ a symme tric d rug e rup tion re sulting in fe ve r, arthralgia,
lymp had e nop athy, and skin rash
• usually ap p e ars 5-10 d ays afte r d rug
• skin manife stations: usually urticaria; can b e morb illiform
• ce faclor
COMMON SKIN LESIONS

HYPERKERATOTIC
Se borrhe ic Ke ratos is (Se nile Ke ratos is ) (s e e Colour Atlas A8)
❏ round /oval, we ll d e marcate d waxy p ap ule /p laq ue , +/– p igme nt, warty
surface , “stuck on” ap p e arance
❏ site s: face , trunk, up p e r e xtre mitie s
❏ b e nign ne op lasm of e p id e rmal ce lls
❏ usually asymp tomatic
❏ more common with incre asing age
❏ tre atme nt
• no tre atme nt usually ne e d e d
• liq uid nitroge n for cosme tic re asons
❏ d iffe re ntial
• solar le ntigo
• sp re ad ing p igme nte d actinic ke ratosis
• p igme nte d b asal ce ll carcinoma
• malignant me lanoma (le ntigo maligna, nod ular me lanoma)
Actinic Ke ratos is (Solar Ke ratos is ) (s e e Colour Atlas A19)

❏ d iscre te ye llow-b rown, scaly p atche s on a b ackground of sun d amage d
skin
• site s: (are as of sun e xp osure ) - face (fore he ad , nose , che e ks,
te mp le s), e ars, ne ck, fore arms, hand s, le gs
• mid d le age and e ld e rly (e xce p t in sunny climate s), more
common in male s and fair-skinne d p e op le
❏ tre atme nt
• 5-FU cre am
• liq uid nitroge n
❏ d iffe re ntial
• d iscoid lup us e rthe matosus
• Bowe n’s Dise ase
Ke ratoacanthoma (s e e Colour Atlas A18)

❏ re d /skin coloure d , firm, d ome -shap e d nod ule with ce ntral ke ratotic p lug
• site s: sun-e xp ose d skin of p e rsons ove r age 50
• b e nign e p ithe lial ne op lasm with atyp ical ke ratinocyte s
• asymp tomatic, attains full size in < 4 months, re gre ss in < 10 months
• rap id ly grow to ~2.5 cm in 6 we e ks
• sp ontane ously re solve with d isfiguring scar
❏ tre atme nt
• surgical e xcision
• cure ttage and e le ctrocaute ry
❏ if on lip tre at as sq uamous ce ll carcinoma
• d iffe re ntial
• sq uamous ce ll carcinoma (grows slowe r – months)
FIBROUS
De rmatofibroma
❏ firm, re d -b rown, solitary, we ll d e marcate d intra-d e rmal p ap ule s or
nod ule s with ce ntral d imp ling
❏ site : le gs
❏ unknown e tiology, ofte n with ante ce d e nt trauma or inse ct b ite s
❏ d imp le sign on p re ssure
❏ tre atme nt
• no tre atme nt usually ne e d e d (e xcise if b othe rsome )
❏ d iffe re ntial
• malignant me lanoma, ne vus
COMMON SKIN LESIONS . . . CONT. Note s
Skin Type tags

(papilloma, acrochordon, fibroe pithe lial polyp)
❏ small, soft, p e d unculate d , skin-coloure d tag
❏ site s: ne ck, axillae , and tunk
❏ mid d le -age d and e ld e rly
❏ tre atme nt
• clip p ing, caute ry
CYSTS
Epide rmal Cys ts (s e e Colour Atlas A11)
❏ round , firm ye llow/fle sh coloure d , slow growing, mob ile , e p id e rmally
line s cyst fille d with ke ratin
• site s: scalp , face , up p e r trunk, b uttocks
• may rup ture and p rod uce inflammatory re action
• e xcise comp le te ly b e fore b e come s infe cte d
Pilar Cys ts
❏ hard , p e a to grap e -size d nod ule s und e r scalp
• id iop athic, p ost-trauma (e .g. EEG)
De rmoid Cys ts
❏ rare , conge nital hamartomas
❏ arise from inclusion of e p id e rmis along e mb ryonal cle ft closure line s
❏ most common at late ral third of e ye b row and mid line und e r nose
❏ tre atme nt: e xcision
Ganglion
❏ cystic le sion originating from joint or te nd on she ath
❏ tre atme nt
• d rainage +/– ste roid inje ction if p ainful
• e xcise if b othe rsome
VASCULAR
He mangiomas
❏ b e nign p rolife ration of ve sse ls in the d e rmis
❏ tre atme nt op tions: argon lase r, tattooing, cosme tics, e xcision with skin e xp ansion
Ne vus Flamme us (Port-Wine Stain)

❏ p e rmane ntly d ilate d cap illarie s in d e rmis, p re se nt at b irth
❏ d e rmatomal d istrib ution, rare ly crosse s mid line
❏ most common site : nap e of ne ck
❏ p ap ule s/nod ule s may d e ve lop in ad ulthood , no involution
❏ se e n in Sturge We b e r synd rome
❏ tre atme nt: lase r or make -up
Cave rnous He mangioma

❏ can ulce rate
❏ 80% without scarring or d iscoloration
Angiomatous Ne vus (Strawbe rry Ne vus )

❏ conge nital
❏ ap p e ars b y age 9 months and re solve s sp ontane ously b y age 6 ye ars
❏ can e xcise if not gone b y school age
Spide r Angioma
❏ ce ntral arte riole with sle nd e r b ranche s re se mb ling le gs of a sp id e r
❏ faintly p ulsatile , b lanchab le , re d macule
❏ associate d with he p atic cirrhosis, p re gnancy, oral contrace p tive s
Che rry He mangioma
(Se nile He mangioma, Campbe ll De morgan Spot)
❏ b right re d , d ome -shap e d p ap ule s, 1-5 mm
❏ site : trunk
❏ more common with incre asing age
Me lanocytic Ne vi (Mole s )
❏ b e susp icious of ne w p igme nte d le sions in ind ivid uals ove r age 40
❏ ave rage numb e r of mole s p e r p e rson:18-40
De rmatology 26 Table 11. Me lanocytic Ne vi Clas s ification
COMMON SKIN LESIONS . . . CONT.

Ne vus Type Age of Ons e t De s cription His tology Tre atme nt
Congenital birth • sharply demarcated pigmented • excuse if suspicious, due to increased

with regular/irregular risk of developing plaque melanoma
contours +/– coarse hairs
• >1.5 cm
• R/O leptomeninges involvement
if on head/neck
Acquired • early childhood to age 40 • benign neoplasm of pigment • excisional biopsy required if
Melanocytic Nevo Cellular Nevi • involute by age 60 forming nevus cells on scalp, soles, mucous membranes,
(MNCN) • well circumscribed, round, uniformly anogenital area, or has variegated
pigmented macules/papules colours, irregular borders, pruritic,
• <1.5 cm bleeding, exposed to trauma
• can be classified according to site
of nevus cells
- Junctional NCN • flat, irregularly bordered, uniformly • melanocytes at dermal-epidermal • same as above
tan-dark brown, sharply demarcated junction above basement membrane
macule
- Compound NCN • elevated, regularly bordered, uniformly • melanocytes at dermal-epidermal junction; • same as above
(s e e Colour Atlas A22) tan-dark brown papule migration into dermis
• NOT found on palms or soles
- Dermal NCN • soft, dome-shaped, skin-coloured to • melanocytes exclusively in dermis • same as above
tan/brown papules
• sites: face, neck
MCCQE 2000 Re vie w Note s and Le cture Se rie s
Clark’s Melanocytic Nevus • variegated macule/papule with irregular • follow q 2-6 months with colour
(Dysplastic Nevus) indistinct borders and focal elevation photographs
• >6 mm • excisional biopsy if lesion changing or
• RFs: postive family history highly atypical
100% lifetime risk with 2 blood relatives
with melanoma (0.7% risk for general
population)
Halo 2-3 • dermal/compound nevus surrounded • none required

by hypomelanosis
Note s
Blue 1.5-40 • uniformly blue to blue-black • pigmented melanocytes and • remove if suddenly appears or has
macule/papule with smooth border melanophages in dermis changed
• < 6 mm
COMMON SKIN LESIONS . . . CONT. Note s
MISCELLANEOUS
Ke loid
❏ e xce ssive p rolife ration of collage n following trauma to skin, may
continue to e xp and in size for ye ars
• site s: e arlob e s, should e rs, ste rnum, scap ular are a
• p re d ile ction for Blacks and Orie ntals
❏ tre atme nt
• intrale sional ste roid inje ctions
• silicone comp re ssion
❏ d iffe re nt from a hyp e rtrop hic scar
Pyoge nic Granuloma

❏ b right re d p e d unculate d nod ule characte rize d b y p rolife ration of cap illarie s
• d e ve lop s rap id ly on finge rs, lip s, mouth, trunk, toe s
❏ tre atme nt
• e le ctrocaute ry
• lase r
• cryothe rap y
Solar Le ntigo (Aging Spots , Live r Spots )

❏ we ll d e marcate d b rown/b lack macule s with an irre gular outline
• site s: sun-e xp ose d skin e sp cially d orsum of hand s and face
• > 40 ye ars old , most common in Caucasians
• incre ase d numb e r of me lanocyte s in e p id e rmis
❏ tre atme nt
• liq uid nitroge n
❏ d iffe re ntial
• le ntigo maligna
• se b orrhe ic ke ratosis
• p igme nte d solar ke ratosis
MALIGNANT SKIN TUMOURS

BASAL CELL CARCINOMA (s e e Colour Atlas A21)
❏ usually a ce ntrally ulce rate d , transluce nt / p e arly p ap ule or nod ule with
a rolle d b ord e r and fine te langie ctasia
• 75% of all malignant skin tumours with incre ase d p re vale nce in
the e ld e rly
• usually d ue to UV light, the re fore > 80% on face
• may also b e cause d b y scar formation, trauma or arse nic e xp osure
• malignant p rolife ration of b asal ce lls of the e p id e rmis
• variants includ e sup e rficial multice ntric, scle rosing,
fib roe p ithe lium, and p igme nte d (b rown and ofte n mistake n
for ne vi)
• 95% cure rate if le sion is le ss the n 2 cm in d iame te r
• slow growing and rare ly me tastatic (< 0.1%)
❏ tre atme nt
• surgical e xcision +/– MOHS
• rad iothe rap y
• cryothe rap y
• e le ctrod e ssication and cure ttage
• carb on d ioxid e lase r
• nod ular malignant me lanoma (b iop sy)
• se b ace ous hyp e rp lasia
• e cze ma
• tine a corp oris
SQUAMOUS CELL CARCINOMA (s e e Colour Atlas A17)

❏ a malignant ne op lasm of ke ratinocyte s characte rize d b y e rythe matous,
ind urate d , scaly/ulce rate d p ap ule s
• p rimarily on sun e xp ose d skin in the e ld e rly

MALIGNANT SKIN TUMOURS . . . CONT. Note s
• p re d isp osing factors includ e UV rad iation, ionizing rad iation
e xp osure , HPV in the immunosup p re sse d , PUVA, atrop hic skin
le sions and che mical carcinoge ns such as arse nic, coal tar and
top ical nitroge n mustard s, Marjolin’s ulce rs in b urn scars
• p rognostic factors includ e : imme d iate tre atme nt, ne gative
margins, and small le sions
• ove rall control is 75% ove r 5 ye ars, 5-10% me tastasize
❏ tre atme nt
• as for b asal ce ll carcinoma
• life long follow-up
Bowe n’s Dis e as e (like a Squamous Ce ll Carcinoma in s itu)
❏ e rythe matous p laq ue with a sharp ly d e marcate d re d and scaly b ord e r
• b iop sy re q uire d for d iagnosis
• ofte n 1-3 cm in d iame te r and found on the skin and mucous
me mb rane s
• e volve s to SCC in 10-20% of cutane ous le sions and > 20% of
mucosal le sions
❏ tre atme nt
• as for b asal ce ll carcinoma
• top ical 5-fluorouracil (Efud e x) use d if e xte nsive and as a tool to
id e ntify margins of p oorly d e fine d tumours
MALIGNANT MELANOMA (s e e Colour Atlas A23)
❏ malignant ne op lasm of p igme nt forming ce lls (me lanocyte s and ne vus
ce lls)
• site s: skin, mucous me mb rane s, e ye s, CNS
• malignant characte ristics of a mole includ e (ABCD)
A - Asymme try
B - Bord e r (irre gular)
C - Colour (varie d )
D - Diame te r (incre asing or > 6 mm)
• risk factors: nume rous mole s, fair skin, re d hair, p ositive family
history, p e op le who b urn b ut d o not tan, large conge nital ne vi,
familial d ysp lastic ne vus synd rome (100%)
• most common site s: b ack (M), calve s (F)
• worse p rognosis if: male , on scalp , hand s, fe e t, late le sion
• b e tte r p rognosis if: p re -e xisting ne vus p re se nt
❏ classification of invasion - se e Plastic Surge ry Note s
• Bre slow’s Thickne ss of Invasion
• 1. <0.76 mm - me ts in 0%
• 2. 0.76-1.5 mm - me ts in 25%
• 3. 1.5-3.99 mm - me ts in 50%
• 4. >4 mm - me ts in 66%
• Clark’s Le ve ls of Cutane ous Invasion
• Le ve l I - ab ove b ase me nt me mb rane - rare me ts
• Le ve l II - in p ap illary d e rmis - me ts in 2-5%
• Le ve l III - to junction of p ap illary and re ticular d e rmis
me ts in up to 20%
• Le ve l IV - into re ticular d e rmis - me ts in 40%
• Le ve l V - into sub cutane ous tissue - me ts in 70%
Supe rficial Spre ading Me lanoma

❏ atyp ical me lanocyte s initially sp re ad late rally in the e p id e rmis
the n invad e the d e rmis
❏ irre gular, ind urate d , e nlarging p laq ue s with re d /white /b lue
d iscoloration, focal p ap ule s and nod ule s
❏ ulce rate and b le e d with growth
❏ 60-70% of all me lanomas
Nodular Me lanoma
❏ atyp ical me lanocyte s that initially grow ve rtically with little late ral
sp re ad
❏ uniform, gre y-b lack, and sharp ly d e line ate d
❏ rap id ly fatal
❏ 30% of me lanomas

MALIGNANT SKIN TUMOURS . . . CONT. Note s
Le ntigo Maligna (Pre malignant Le s ion)

❏ malignant me lanoma in situ (normal and malignant me lanocyte s
confine d to the e p id e rmis)
❏ 2-6 cm, tan/b rown/b lack p atch with irre gular b ord e rs
❏ le sion grows rad ially and p rod uce s comp le x colours
❏ site s: face , sun e xp ose d are as
❏ 1/3 e volve s into le ntigo maligna me lanoma
Le ntigo Maligna Me lanoma
❏ malignant me lanocyte s invad ing into the d e rmis
❏ similar to le ntigo maligna, b ut with raise d focal p ap ule s within the
le sion
❏ found on all skin surface s
❏ 15% of all me lanomas
Acrole ntiginous Me lanoma
❏ p almar, p lantar, sub ungual skin
❏ histologic p icture as le ntigo-maligna me lanoma
❏ me tastasize via lymp hatics and b lood ve sse ls
❏ me lanomas on mucous me mb rane s have p oor p rognosis
❏ 5% of me lanomas
Tre atme nt
❏ e xcisional b iop sy p re fe rab le , othe rwise incisional b iop sy
❏ re move full d e p th of d e rmis and e xte nd b e yond e d ge s of le sion
only afte r histologic d iagnosis
❏ lymp h nod e d isse ction shows survival ad vantage if nod e s uninvolve d
❏ che mothe rap y (cis-p latinum, BCG) for stage II (re gional) and stage
III (d istant) d ise ase
❏ rad iothe rap y curative for uve al me lanomas, p alliative b one and b rain
me tastase s
OTHERS
Le ukoplakia
❏ white p atch/p laq ue on lowe r lip , floor of mouth, b uccal mucosa, tongue
b ord e r or re tromolarly
• 40-70 ye ars old , M > F, fair-skinne d
• p re malignant le sion arising from chronic irritation or inflammation
❏ tre atme nt
• e xcision
• cryothe rap y
• liche n p lanus
• oral hairy le ukop lakia
Cutane ous T-Ce ll Lymphoma (Mycos is Fungoide s )

❏ characte rize d b y e rythe matous, p atche s/p laq ue s/nod ule s
• > 50 ye ars old
• e tiology: HTLV
• e ve ntually invad e s inte rnal organs
• Se zary’s synd rome - e rythrod e rma, lymp had e nop athy, WBC
> 20 000 with Se zary ce lls, hair loss, p ruritus
❏ tre atme nt
• PUVA
• top ical nitroge n mustard
• rad iothe rap y ––> total skin e le ction b e am rad iation
• p soriasis
• nummular d e rmatitis
• “large p laq ue ” p arap soriasis

HERITABLE DISORDERS Note s
ICHTHYOSIS VULGARIS
❏ a ge ne ralize d d isord e r of hyp e rke ratosis le ad ing to d ry skin,
associate d with atop y and ke ratosis p ilaris
• “fish-scale ” ap p e arance e sp e cially on e xtre mitie s with sp aring of
fle xural cre ase s, p alms and sole s
• “2 A.D.”: atop ic d e rmatitis and autosomal d ominant
❏ tre atme nt
• imme rsion in b ath and oils
• e mollie nt or hume ctant cre ams and ointme nts containing ure a
NEUROFIBROMATOSIS
(NF; VON RECKLINGHAUSEN’S DISEASE)
❏ characte rize d b y cafe -au-lait macule s and ne urofib romas
• d iagnostic crite ria includ e
1) more than 6 cafe -au-lait sp ots > 1.5 cm in an ad ult, and
more than 5 cafe -au-lait sp ots > 0.5 cm in a child und e r age 5
2) axillary fre ckling
3) iris hamartomas (Lisch nod ule s)
4) op tic gliomas
5) ne urofib romas, and othe rs
• autosomal d ominant d isord e r with e xce ssive and
ab normal p rolife ration of ne ural cre st e le me nts
• associate d with p he ochromocytoma, astrocytoma,
b ilate ral acoustic ne uromas, b one cysts, scoliosis,
p re cocious p ub e rty
• follow close ly for malignancy
VITILIGO (s e e Colour Atlas A13)
❏ acq uire d loss of me lanocyte s characte rize d b y sharp ly marginate d off
white macule s or p atche s
• site s: e xte nsor surface s and p e riorificial are as (mouth, e ye s,
anus, ge nitalia)
• associate d with stre aks of d e p igme nte d hair, choriore tinitis
• 30% with +ve family history
• associate d with autoimmune d ise ase e sp e cially thyroid
• d o b lood work to rule out thyroid d ysfunction, p e rnicious
ane mia, Ad d ison’s d ise ase , d iab e te s
• Wood ’s lamp to d e te ct le sions in fair-skinne d p atie nts
❏ manage me nt
• camouflage make up (se lf-tanning p re p arations)
• PUVA (p sorale ns and UVA)
• minigrafting
• “b le aching” normal p igme nte d are as (total white colour)
• d one in wid e sp re ad loss of p igme ntation
• sun p rote ction

SKIN MANIFESTATIONS OF
INTERNAL CONDITIONS Note s
`
Table 12. Skin Manife s tations of Inte rnal Conditions
Dis e as e Re late d De rmatos e s
AUTOIMMUNE DISORDERS
syste mic lup us e rythe matosus malar e rythe ma, e rythe matous p ap ule s or p laq ue s on face , hand s, and arms, he morrhagic b ullae ,
p alp ab le p urp ura, urticarial p urp ura, p atchy/d iffuse alop e cia, mucosal ulce rs (s e e Colour Atlas L1)
cutane ous lup us e rythe matosus sharp ly marginate d b right re d p ap ule s and p laq ue s with ad he re nt scale s, te langie ctasia, marke d scarring,
scarring alop e cia
scle rod e rma Raynaud 's, nonp itting e d e ma, waxy/shiny/te nse atrop hic skin (morp he a), ulce rs, cutane ous calcification,
p e riungal te langie ctasia (s e e Colour Atlas L8)
d e rmatomyositis p e riorb ital he liotrop e with e d e ma, violace ous e rythe ma, Gottron's p ap ule s (violace ous flat-top p e d
p ap ule s with atrop hy), p e riungal e rythe ma, te langie ctasia, ulce rs (s e e Colour Atlas L2 and L4)
p olyarte ritis nod osa p olyarte ritic nod ule s, p urp ura, e rythe ma, gangre ne
ulce rative colitis p yod e rma gangre nosum
rhe umatic fe ve r p e te chiae , urticaria, e rythe ma nod osum, e rythe ma multiforme , rhe umatic nod ule s
Bue rge r's d ise ase sup e rficial migraine thromb op hle b itis, p allor, cyanosis, gangre ne , ulce rations
ENDOCRINE DISORDERS
Cushing’s synd rome p urp le atrop hic striae , hyp e rp igme ntation, hyp e rtrichosis (s e e Colour Atlas B1)
hyp e rthyroid moist, warm skin with e vane sce nt e rythe ma, se b orrhe a, acne , nail atrop hy, hyp e rp igme ntation, toxic
alop e cia, localize d myxe d e ma of p re tib ial are a (s e e Colour Atlas B2 and B3)
hyp othyroid cool, d ry, scaly, thicke ne d , hyp e rp igme nte d skin; toxic alop e cia with d ull, d ry, coarse hair
Ad d ison’s d ise ase hyp e rp igme ntation on are as of friction and p re ssure
d iab e te s me llitus incre ase d incid e nce of skin infe ctions: b oils, carb uncle s, ulce rs, gangre ne , cand id iasis, tine a p e d is and
cruris, infe ctious e cze matoid d e rmatitis; othe r: p ruritus, xanthoma d iab e ticorum, ne crob iosis lip oid ica
d iab e ticorum (multicoloure d p ap ule s on ante rior shins) (s e e Colour Atlas B5)
HIV
viral HSV, HZV, HPV, molluscum contagiosum, oral hairy le ukop lakia
b acte rial imp e tigo, acne iform folliculitis, d e ntal carie s, ce llulitis, b acillary e p ithe lioid angiomatosis, syp hilis
inflammatory d e rmatose s se b orrhe a, p soriasis, p ityriasis rose a, vasculitis
malignancie s Kap osi’s Sarcoma (s e e Colour Atlas A20) , lymp homa, b asal ce ll carcinoma, sq uamous ce ll carcinoma,
malignant me lanoma
MALIGNANCY
Ad e nocarcinoma
GI Pe utz-Je ghe rs: p igme nte d macule s on lip s/oral mucosa
ce rvix/anus/re ctum Page t’s Dise ase : e rod ing scaling p laq ue s of p e rine um
Carcinoma
b re ast Page t’s Dise ase : e xze matous and crusting le sions of b re ast
GI Palmop lantar ke ratod e rma: thicke ne d skin of p alms/sole s
thyroid Sip p le ’s Synd rome : multip le mucosal ne uromas
b re ast/GU/lung/ovary De rmatomyositis: he liotrop e e rythe ma of e ye lid s and p urp lish p laq ue s ove r knuckle s
Lymp homa/Le uke mia

Hod gkin’s Ataxia Te le ge ctasia: te le nge ctasia on p inna, b ulb ar conjunctiva
Acute Le uke mia Ichthyosis: ge ne ralize d scaling e sp e cially on e xtre mitie s
Bloom’s Synd rome : b utte rfly e rythe ma on face , associate d with short stature
Multip le Mye loma Amyloid osis: large , smooth tongue with waxy p ap ule s on e ye lid s, nasolab ial fold s and lip s, as we ll as
facial p e te chiae
OTHERS
p ruritic urticaria p ap ule s and e rythe matous p ap ule s or urticarial p laq ue s in d istrib ution of striae d iste nsae , b uttocks, thighs,
p laq ue s of p re gnancy (PUPPP) up p e r inne r arms and lowe r b acks
cryoglob uline mia p alp ab le p urp ura in cold -e xp ose d are as, Raynaud 's, cold urticaria, acral he morrhagic ne crosis, b le e d ing
d isord e rs; re late d to he p atitis C infe ction

SKIN MANIFESTATIONS OF
INTERNAL CONDITIONS . . . CONT. Note s
PRURITUS
❏ care ful history is imp ortant, b e cause me d ical workup may b e ind icate d
in 20% of case s
❏ cause s
• d e rmatologic - ge ne ralize d
• winte r itch (=xe rotic e cze ma, d ry and cracke d mainly le gs,
skin
• se nile p ruritus (may not have d ry skin, any time of ye ar)
• infe stations - scab ie s, lice
• d rug e rup tions - ASA, antid e p re ssants, op iate s
• p sychoge nic state s
• d e rmatologic - local
• atop ic and contact d e rmatitis, liche n p lanus,
urticaria, inse ct b ite s, d e rmatitis he rp e tiformis
• infe ction – varice lla, cand id iasis
• ne urod e rmatitis (liche n simp le x chronicus, vicious
cycle of itching & scratching le ad s to e xcoriate d
liche nifie d p laq ue s)
• me d ical - usually ge ne ralize d
• some typ e s of chole stasis (e .g. PBC, chlorp romazine ind uce d )
• chronic re nal failure , chole static live r d ise ase of p re gnancy
• he matologic - Hod gkin’s lymp homa, multip le mye loma,
p olycythe mia ve ra, mycosis fungoid e s, he machromatosis,
Fe d e ficie ncy
• carcinoma - lung, b re ast, gastric
• e nd ocrine - carcinoid , d iab e te s, hyp othyroid /thyrotoxicosis
• infe ctious - HIV, onchoce rciasis, trichinosis, e chinococcosis
❏ tre atme nt
• tre at und e rlying cause and itch (minimize irritation and scratching)
• top ical corticoste roid and antip uritics such as me nthol, camp hor
or p he nol
• syste mic antihistamine s - H1 b locke rs are most e ffe ctive
• avoid top ical anae sthe tics which may se nsitize the skin
ALOPECIA (HAIR LOSS)

NON-SCARRING (NON-CICATRICIAL) ALOPECIA
Mne monic
T te loge n e ffluvium
O out of Fe , zinc
P p hysical - trichotillomania, “corn-row” b raid ing
H hormonal - hyp othyroid ism, and roge nic
A autoimmune - SLE, alop e cia are ata
T toxins - he avy me tals, anticoagulants, che mothe rap y, Vit. A
Phys iological
❏ male -p atte rn alop e cia
• te mp oral are as p rogre ssing to ve rte x, e ntire scalp may b e b ald
• action of te stoste rone on hair follicle s
• e arly 20’s-30’s (fe male and roge ne tic alop e cia is
d iffuse and occurs in 40’s and 50’s)
❏ tre atme nt
• minoxid il lotion to re d uce rate of loss/p artial re storation
• sp ironolactone in wome n
• hair transp lant
• finaste rid e 1 mg/d in me n
Phys ical
❏ trichotillomania: imp ulse -control d isord e r characte rize d b y comp ulsive
hair p ulling with re sultant notice ab le hair loss
❏ traumatic (e .g. tight “corn-row” b raid ing of hair)
Te loge n Effluvium
❏ 15% of hair normally in re sting p hase , ab out to she d (te loge n)
• p ost-p artum, p ost-b irth control p ill, se ve re p hysical/me ntal
stre ss can all incre ase the numb e r of hairs in te loge n
• hair may she d up to 3 months afte r stimuli
• will re grow
ALOPECIA (HAIR LOSS) . . . CONT. Note s
Alope cia Are ata (s e e Colour Atlas A12)

❏ autoimmune d isord e r characte rize d b y p atche s of comp le te hair loss
localize d to scalp , e ye lid s, che e k
• alop e cia totalis - loss of all scalp hair and e ye b rows
• alop e cia unive rsalis - all b od y hair
• associate d with d ystrop hic nail change s - fine stip p ling
• “e xclamation mark” p atte rn (hairs fracture d and have
tap e re d shafts, i.e . - !)
• may b e associate d with othe r autoimmune d ise ase i.e .
vitiligo, thyroid d ise ase
• sp ontane ously re grow (b ut worse p rognosis if young age of
onse t and e xte nsive loss)
• fre q ue nt re curre nce ofte n p re cip itate d b y e motional d istre ss
❏ tre atme nt
• ge ne rally unsatisfactory
• intrale sional triamcinolone ace tonid e can b e use d for
isolate d p atche s (e ye b rows, b e ard s)
• wigs
Me tabolic Alope cia
❏ Drugs: e .g. che mothe rap y, Danazol, Vitamin A, anticoagulants
❏ Toxins: e .g. he avy me tals
❏ End ocrine : e .g. hyp othyroid ism
SCARRING (CICATRICIAL) ALOPECIA
Phys ical
❏ x-ray, b urns
Infe ctions
❏ fungal, b acte rial, TB, le p rosy, viral
Collage n-Vas cular
❏ d iscoid lup us e rythe matosus (tre atme nt with top ical/intrale sional
ste roid or antimalarial); note that SLE can cause an alop e cia unre late d
to d iscoid lup us le sions which are non-scarring
❏ scle rod e rma - “coup d e sab re ” whe n involve s ce nte r of scalp
Clinical Pe arl
❏ Scarring alope cia ne e ds to be biops ie d vs . nons carring which doe s not
WOUNDS AND ULCERS
Table 9. Diffe re nt type s of ulce rs and manage me nt

ulce r type Symptoms and s igns Manage me nt
arte rial wound at tip of toes, cold feet 1. Doppler study

with claudication, gangrene, 2. if ankle: brachial ratio < 0.4, may consider amputation
distal hyperemia, decreased 3. if gangrenous, paint with betadine
pedal pulses 4. otherwise promote moist interactive wound healing
ve nous wound at malleolus, stasis change, 1. local wound dressing: moist interactive healing
edema, previous venous injury 2. compression: preferably 4 layer
3. after wound heals, support stocking for life
ne urotropic wound at pressure point or 1. pressure downloading by using proper shoes or seats
secondary to unknown trauma 2. promote moist interactive wound healing
vas culitic livedo reticularis, petechiae, 1. biopsy to determine vasculitis

extreme tenderness, 2. serum screening for vasculitis
delayed healing 3. treat vasculitis
4. local moist interactive wound healing

COSMETIC DERMATOLOGY Note s
CHEMICAL PEELING
(Che me xfoliation, Che mical Re s urfacing)
❏ ap p lication of caustic age nt(s) to skin to p rod uce a controlle d
d e struction of e p id e rmis or d e rmis with sub se q ue nt
re -e p ithe liazation
❏ top ical ke ratolytics are ap p lie d 2-3 we e ks p re op e rative ly
❏ 3 d iffe re nt cate gorie s of che mical p e e ling age nts use d , d e p e nd ing on
the ir d e p th of cutane ous p e ne tration re q uire d :
Table 13.
Pe ne tration Type Pe e ling Age nts Indications
Sup e rficial AHA (glycolic acid ) Fine wrinkling

10-30% trichloroace tic acid Acute actinic d amage
Je ssne r’s solution Postinflammatory p igme nt change s
Acne vulgaris/rosace a
Me d ium CO2 ice + 35% TCA Mod e rate wrinkling

Je ssne r’s + 35% TCA Chronic p hotod amage
Glycolic acid + 35% TCA Pigme nt change s
Ep id e rmal/p re malignant le sions
De e p Bake r-Gord on formula Se ve re wrinkling

Chronic p hotod amage
Sup e rficial ne op lasms
Pigme nt change s
Ep id e rmal le sions
❏ comp lications
• e rythe ma, infe ction, p ostinflammatory hyp e r/hyp op igme ntation,
hyp e rtrop hic scars
LASER THERAPY
❏ wave le ngth is inve rse ly p rop ortional to ab sorp tion and d ire ctly
p rop ortional to p e ne tration d e p th
❏ p urp ose : to re move /le sse n unwante d p igme ntation or vascular le sions
❏ he moglob in, wate r, and me lanin are the main targe ts of lase rs
❏ lase rs d e stroy unwante d skin ab normalitie s b ase d on 3 me chanisms
• he at e ne rgy – ab sorp tion of he at with 2º sp re ad to ad jace nt
tissue s
• me chanical e ne rgy – rap id the rmoe lastic e xp ansion d e stroys
targe t
• se le ctive p hotothe rmolysis – wave le ngth that is maximally
ab sorb e d b y targe t only and d oe s not sp re ad to ad jace nt tissue s
❏ comp lications
• e rythe ma, hyp e r/hyp op igme ntation, scars, infe ction

USEFUL DIFFERENTIAL DIAGNOSES Note s
Table 14. Diffe re ntial Diagnos is by Morphology

Re d Scaling Le s ions Psoriasis (elbows/knees/scalp, nail pits, Koebner’s)
(e pide rmal ce lls produce d Atop ic De rmatitis (fle xural fold s)
from e xce s s ive and Contact De rmatitis (history)
abnormal ke ratinization Discoid Lup us (d on’t se e hair follicle s)
and s he dding) Drug re action (e .g. gold , p he nolp hthale in in Ex-Lax)
Liche n Planus (flat surface , lacy line s on surface )
Mycosis Fungoid e s (gird le are a, le onine facie s)
Nummular Ecze ma (coin-like , isolate d )
Pityriasis Rose a (Christmas-tre e d istrib ution)
Se b orrhe ic De rmatitis (scalp /nasolab ial fold s/che st)
Se cond ary Syp hilis (p alms + sole s, cop p e r coloure d )
Tine a (we ll d e marcate d , raise d b ord e r)
Dis cre te Re d Papule s Acne (te e nage r, face /che st/b ack)
(e le vate d/s olid le s ion Bite s/Stings (history of outd oors, ce ntral p unctum)
< 1 cm) De rmatofib roma (“d imp le sign”)
Folliculitis (in hair follicle )
Furuncle (ve ry p ainful, ce ntral p lug)
He mangioma (b lanching)
Hive s (whitish b ord e r, p ruritic)
Inflame d Ep id e rmal Cyst (mob ile und e r skin)
Inflame d Se b orrhe ic Ke ratosis (stuck-on ap p e arance )
Liche n Planus (flat surface , lacy line s on surface )
Miliaria Rub ra (he at/ove rb und ling of child )
Psoriasis
Pyoge nic Granuloma (b le e d s e asily)
Scab ie s (b urrow, inte rd igital/groin, family me mb e rs)
Urticaria
Flat Brown Macule Actinic/Solar Le ntigo (sun-d amage d are a)
(circums rcibe d flat and Conge nital Ne vus (contain hair)
dis coloure d are a) Cafe -au-Lait (p re se nt in child hood , ve ry light b rown)
Hyp e r/hyp op igme ntation (e .g. p osttraumatic, Ad d ison’s)
Fre ckle (sun-e xp ose d are as, d isap p e ars in winte r)
Junctional Ne vus (re gular shap e )
Le ntigine s associate d with und e rlying d isord e rs (LEOPARD, LAMB, Pe utz-Je ghe r’s)
Le ntigo Maligna (irre gular, varie d p igme ntation)
Malignant Me lanoma (characte ristic atyp ia)
Pigme nte d Basal Ce ll Carcinoma
Simp le Le ntigo (non-sun e xp ose d are a, irre gular)
Stasis De rmatitis
Ve s icle s Viral
(circums cribe d colle ction • HSV (mouth, ge nitals)
of fre e fluid > 1 cm) • Zoste r (d e rmatomal,p ainful)
• Varice lla (ge ne ralize d , itchy)
• Molluscum (umb ilicate d )
• Coxsackie (p ainful, hand -foot-mouth, summe r)
Acute Contact De rmatitis (e .g. p oison ivy) (e xp osure history)
Cat-Scratch Dise ase
Dyshyd rotic Ecze ma (sid e s of finge rs/p alms/sole s)
De rmatitis He rp e tiformis (VERY itchy, glute n Hx)
Imp e tigo
Porp hyria Cutane a Tard a (hyp e rtrichosis, he liotrop e le sion around e ye s, alcohol inge stion)
Scab ie s
Bullae Bullous Imp e tigo (child re n, othe r family me mb e rs)
(circums cribe d colle ction Bullous Pe mp higoid (te nse , lowe r limb )
of fre e fluid > 1 cm) Drug e rup tion
EM/SJS/TEN (targe t le sions)
Lup us Erythe matosus
Pe mp higus Vulgaris (flaccid , e asy b le e d ing)
Pus tule s Acne (teenager, face/chest/back)
(e le vate d, contains Acne Rosace a (fortie s, te langie ctatic, no come d one s)
purvie nt fluid, Cand id a (sate llite p ustule s, are as of skin fold s)
varying in s ize ) De rmatop hyte infe ction
Dyshid rotic Ecze ma (sid e s of finge rs/p alms/sole s)
Folliculitis (in hair follicle )
Hid rad e nitis sup p urativa
Imp e tigo (hone y-crust)
Se p sis (e .g. stap h, gonococcal)
Pustular Psoriasis (p soriasis)
Rosace a
Varice lla
Ulce r Common: Arte rial, Ve nous, Ne urotrop hic, Pre ssure
(bre ak in the s kin that e xte nds Uncommon: “CHIP IN” mne monic
to the de rmis , or de e pe r) Cance r (e .g. SCC), Chromosomal (e .g. XXY)
He moglob inop athy (e .g. Sickle Ce ll)
Inflammatory (e .g. RA, SLE, Vasculitis, Raynaud ’s)
Pyod e rma Gangre nosum (e .g. ulce rative colitis, RA)
Infe ctious (syp hilis, TB, tulare mia, p lague )
Ne crob iosis Lip oid ica Diab e ticorum (DM)
Oral Ulce rs Ap hthous
Cance r (Sq uamous /Basal Ce ll Ca)
De rmatologic Dise ase s (Liche n Planus, Bullours, Pe mp higoid )
Iatroge nic (Che mo, Rad iation)
Infe ctious (HSV/HZ, Coxsackie , HIV, CMV, TB, Syp hilis, Asp e rgillosis, Cryp tococcosis)
Inflammatory (SLE, Se rone gative s, EM/SJS/TEN, alle rgic stomatitis)
Traumatic

USEFUL DIFFERENTIAL DIAGNOSES . . . CONT. Note s
Table 15. Diffe re ntial Diagnos is by Location

Location Common Le s s Common and Rare
Scalp se b orrhe ic d e rmatitis, contact d e rmatitis, p e mp higus, DH

p soriasis, folliculitis, p e d iculosis, tine a
Ears se b orrhe ic d e rmatitis, p soriasis, infe ctious fungal infe ction

e cze matoid d e rmatitis, actinic ke ratose s
Face acne , rosace a, imp e tigo, contact d e rmatitis, lup us, actinic d e rmatitis, d e rmatomyositis,
se b orrhe ic d e rmatitis, folliculitis, le ntigo maligna me lanoma
he rp e s simp le x, BCC, SCC, actinic ke ratose s,
se b ace ous hyp e rp lasia
Eye lids Contact d e rmatitis (finge rnail p olish, hairsp ray),

se b orrhe ic d e rmatitis, atop ic e cze ma
Pos te rior Ne ck ne urod e rmatitis (LSC), se b orrhe ic d e rmatitis, acne ke loid alis in b lack p atie nts
p soriasis, contact d e rmatitis
Mouth Ap hthae , he rp e s simp le x, ge ograp hic tongue , syp hilis, liche n p lanus, p e mp higus
contact d e rmatitis
Axillae Contact d e rmatitis, se b orrhe ic d e rmatitis, e rythrasma, acanthosis nigricans,

hid rad e nitis sup p urtiva inve rse p soriasis, Fox-Ford yce d ise ase
Che s t and Back Tine a ve rsicolour, p ityriasis rose a, acne , se cond ary syp hilis, Grove r’s d ise ase ,
se b orrhe ic d e rmatitis, p soriasis, He rp e s Zoste r inve rse p soriasis
Groin and Tine a, Cand id a, b acte rial inte rtrigo, scab ie s,

Crural Are as p e d iculosis, granuloma inguinale
Pe nis Contact d e rmatitis, fusosp iroche tal and p rimary and se cond ary syp hilis,
cand id al b alanitis, chancroid , he rp e s simp le x, b alanitis xe rotica ob lite rans, liche n p lanus
Cond ylomata (HPV), scab ie s
Hands Contact d e rmatitis, d yshyd rotic e cze ma, p ustular p soriasis, granuloma annulare ,
re action to fungal infe ction of the fe e t e rythe ma multiforme , se cond ary syp hilis(p alms)
(one -hand two fe e t), warts, atop ic e cze ma, and fungal infe ction
p soriasis
Cubital Fos s ae and Atop ic e cze ma, contact d e rmatitis

Poplite al Fos s ae and p rickly he at
Elbows and Kne e s Psoriasis, xanthomas atop ic e zce ma, DH
Le gs Contact d e rmatitis, stasis d e rmatitis, ulce rs, p yod e rma gangre nosum, e rythe ma nod osum,
nummular e cze ma le ukocytoclastic vasculitis, HSP and othe r vasculitid ie s
Fe e t Fungal infe ction, p rimary or se cond ary p soriasis, e rythe ma multiforme ,

b acte rial infe ction, contact d e rmatitis, se cond ary syp hilis (sole s),
atop ic e cze ma, warts acral le ntiginous me lanoma (sole s)

TOPICAL THERAPY Note s
VEHICLES
❏ for acute inflammation (e d e ma, ve siculation, oozing, crusting, infe ction)
use aq ue ous d rying p re p aration
❏ for chronic inflammation (scaling, liche nification, fissuring)
use a gre asie r, more lub ricating comp ound
Powde rs
❏ p romote d rying, incre ase skin surface are a (i.e . cooling)
• use d in inte rtriginous are as to re d uce moisture and friction
• ine rt or contain me d ication
Lotions
❏ susp e nsions of p owd e r in wate r
• cool and d ry as the y e vap orate
• le ave a uniform film of p owd e r on skin
• e asily ap p lie d to hirsute are as
Cre am
❏ se misolid e mulsions of oil in wate r
• wate r-solub le , contain e mulsifie rs and p re se rvative s
• cosme tically p le asing
Ge l
❏ transp are nt, colourle ss, se misolid e mulsion
• liq uifie s on contact with skin
• d rie s as a thin, gre ase le ss, nonocclusive , nonstaining film
• aq ue ous, ace tone , alcohol or p rop yle ne glycol b ase
Ointme nt
❏ se misolid wate r in oil e mulsions (more viscous than cre am)
• ine rt b ase s - p e trolatum
• most e ffe ctive to transp ort me d ications into skin
• re tain he at, imp e d e wate r loss, incre ase hyd ration
• occlusive , not to b e use d in oozing or infe cte d are as
TOPICAL STEROIDS
Table 16. Pote ncy Ranking of Topical Ste roids
Re lative Pote ncy Re lative Stre ngth Ge ne ric Name s Trade Name s Us age
we ak x1 hydrocortisone Emo Cort intertriginous areas,

children, face, thin skin
mode rate x3 hydrocortisone Westcort arm, leg, trunk

17-valerate
desonide Tridesilon
mometasone furorate Elocom
pote nt x6 betamethasone Betnovate body

17-valerate Celestoderm
amicinonide Cyclocort
ve ry pote nt x9 betamethasone Propaderm palms and soles

dipropionate Lidex, Topsyn gel
clucinonide
e xtre me ly pote nt x12 clobetasol propionate Dermovate palms and soles

Diprolene
Body s ite : Re lative Pe rcutane ous Abs orption

fore arm 1.0
p lantar foot 0.14
p alm 0.83
b ack 1.7
scalp 3.7
fore he ad 6.0
che e ks 13.0
scrotum 42.0
calculation of stre ngth of ste roid comp are d to hyd rocortisone on fore arm:
re lative stre ngth of ste roid x re lative p e rcutane ous ab sorp tion
TOPICAL THERAPY . . . CONT. Note s
DRY SKIN THERAPY

❏ e ncourage humid ifie r
❏ d e cre ase e xce ss e xp osure to wate r or soap
❏ use mild soap s such as Dove and b ath oils
❏ lub ricating lotions and cre ams
are occlusive and softe n the skin
❏ hume ctant age nts such as ure mol (ure a), LacHyd rin (lactic acid ) and Ne ostrata
(glycolic acid ) hold wate r to skin or affe ct d e sq uamation of stratum corne um
• top ical ste roid ointme nt for symp tomatic d ryne ss with e cze ma
SUNSCREENS AND
PREVENTATIVE THERAPY
UV Radiation
❏ UVA (320-400nm)
• p e ne trate s skin more e ffe ctive ly the n UVB or UVC
• re sp onsib le for tanning, b urning, wrinkling and
p re mature skin aging
• p e ne trate s cloud s, glass and is re fle cte d off wate r, snow and ce me nt
❏ UVB (290-320nm)
• ab sorb e d b y the oute r d e rmis
• is mainly re sp onsib le for b urning and p re mature skin aging
• p rimarily re sp onsib le for BCC, SCC and me lanomas
• d oe s not p e ne trate glass and is sub stantially ab sorb e d b y ozone
❏ UVC (200-290nm)
• is filte re d b y ozone laye r
Sunburn Pre ve ntion

❏ Sunb urn
• e rythe ma 2-6 hours p ost UV e xp osure ofte n associate d with
e d e ma, p ain and b liste ring with sub se q ue nt d e sq uamation of
the d e rmis
• UV ind e x me asure s the time to b urn for a fair skinne d ind ivid ual
• < 15 minute s = UV ind e x > 9
• ~ 20 minute s = UV ind e x 7-9
• ~ 30 minute s = UV ind e x 4-7
Suns cre e ns
❏ SPF: und e r id e al cond itions a sun p rote ction factor of 10 me ans that a
p e rson who normally b urns in 20 minute s will b urn in 200 minute s
following the ap p lication of the sunscre e n, no matte r how ofte n the
sunscre e n is sub se q ue ntly ap p lie d
❏ Top ical Che mical: re q uire s ap p lication, at le ast 15-60 minute s p rior to
e xp osure
• UVB ab sorb e rs: PABA, Salicylate s, Cinnamate s, Be nzylid e ne
camp hor d e rivative s
• UVA ab sorb e rs: Be nzop he none s, Anthranilate s,
Dib e nzoylme thane s, Be nzylid e ne camp hor d e rivative s
• Top ical Physical: re fle cts and scatte rs UV light
• Titanium d ioxid e , Zinc oxid e , Kaolin, Talc, Fe rric chlorid e and
Me lanin all are e ffe ctive against the UVA and UVB sp e ctrum
• le ss risk of se nsitization the n che mical sunscre e ns and
wate rp roof, b ut may cause folliculitis or miliaria
Sunburn Tre atme nt

❏ if significant b liste ring p re se nt, consid e r tre atme nt in hosp ital
• ap p ly cool and we t comp re sse s
• use moisturize rs for d ryne ss and p e e ling
• oral anti-inflammatory: 400 mg ib up rofe n q 6h to minimize
e rythe ma and e d e ma
• top ical corticoste roid s: soothe s and d e cre ase s e rythe ma, d oe s
not re d uce d amage
• oral ste roid s and antihistamine s have no role

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DERMAT OLOGY

APPROACH TO THE DERMATOLOGY. . . . . . . . . 2 DRUG ERUPTIONS . . . . . . . . . . . . . . . . . . . . . . 22

MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 1

palpable de e p (de rmal) nodule (e.g. dermatofibroma) tumour (e.g. lipoma)

flat le s ion macule (e.g. freckle) patch (e.g. vitiligo)

SECONDARY MORPHOLOGICAL LESIONS

OTHER MORPHOLOGICAL LESIONS

De rmatology 2 MCCQE 2000 Re vie w Note s and Le cture Se rie s

ACNE VULGARIS/COMMON ACNE

Typ e I – Inflammatory Be nzoyl Pe roxid e

Typ e II Top ical Antib iotic

Typ e III Top ical Antib iotic

Typ e IV Isotre tinoin (Accutane )

❏ othe r tre atme nts

De rmatology 4 MCCQE 2000 Re vie w Note s and Le cture Se rie s

❏ sup e rficial inflammation of the skin, characte rize d b y p ruritic

ALLERGIC CONTACT DERMATITIS

IRRITANT CONTACT DERMATITIS

Table 3. Phas e s of Atopic De rmatitis

Phas e Dis tribution

MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 5

De rmatology 6 MCCQE 2000 Re vie w Note s and Le cture Se rie s

MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 7

Erys ipe las (s e e Colour Atlas F8) Ce llulitis

upper dermis lower dermis/subcutaneous fat

Group A streptococcus GAS (most common), S. aureus (usually in

spreads through lymphatics; long term recurrent

PAINFUL (once called St. Anthony’s fire)

complications include scarlet fever, streptococcal

face and legs commonly legs

first line: Penicillin, Cloxacillin or Ancef first line: Cloxacillin or Ancef/Keflex

De rmatology 8 MCCQE 2000 Re vie w Note s and Le cture Se rie s

MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 9

❏ te rtiary syp hilis

Gonococce mia (Dis s e minate d Gonococcal Infe ction)

Diffe re ntial Diagnos is of Ge nital Ulce rations

He rpe s Zos te r (s hingle s ) (s e e Colour Atlas F9)

❏ d iffe re ntial d iagnosis

MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 11

Mollus cum Contagios um (s e e Colour Atlas F3)

De rmatology 12 MCCQE 2000 Re vie w Note s and Le cture Se rie s

Tine a Capitis (s e e Colour Atlas A10)

Tine a Corporis /Tine a Cruris (Ringworm) (s e e Colour Atlas F14)

MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 13

❏ chronic non-p ruritic, p ink, scaling ke ratosis on sole s, and

De rmatology 14 MCCQE 2000 Re vie w Note s and Le cture Se rie s

Lice (Pe diculos is )

MCCQE 2000 Re vie w Note s and Le cture Se rie s De rmatology 15

PSORIASIS (s e e Colour Atlas A7)

Table 5. Topical Tre atme nt of Ps orias is

lubricants reduce fissure formation

salicylic acid 1-12% remove scales

tar (Liquor carbonis inhibits DNA synthesis, poor longterm compliance

calcipotriol binds to skin not to be used on face or skin folds

corticosteroid ointment reduce scaling and use appropriate potency steroid

tazarotene retinoid derivative

Goeckermann regimen: UVB 290-320 nm

De rmatology 16 MCCQE 2000 Re vie w Note s and Le cture Se rie s

Table 6. Sys te mic Tre atme nt of Ps orias is

methotrexate bone marrow toxicity, hepatic cirrhosis

steroids rebound effect when withdrawn

PUVA (8 methoxy-psoralen pruritus, burning, cataracts, skin cancer

acetretin alopecia, cheilitis, teratogenicity, epistaxis,