General Practice Lecture Series 2023

07
DERMATOLOGY

JESSIE TIENG
Email: jtie0004@student.monash.edu
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SPOT DIAGNOSIS
 Atopic Dermatitis (Eczema)
Description Eczema flare
● Chronic, relapsing, intensely pruritic ● Worsening of the distribution, severity
inflammatory skin disease & irritation caused by eczema

Epidemiology ● Trigger factors:

● Predominantly a childhood disease but ○ Non adherence to treatment
can occur at any age ○ Overheating
● Most common skin disease in ○ Infections
Australian pre-school children ○ Irritants
● A/w allergic rhinitis & asthma (atopy ○ Dry skin
triad)

Good Prognosis Patchy,

● Children tend to grow out of the erythematous,
problem as the function of their oil and poorly defined,
sweat glands matures~ scaly, itchy rash
● Many are in remission by school age.
(15 % with lifelong eczema)
 Classical Distributions of AD
Infants Early Childhood Adults

Cheeks, Neck folds, Elbow & Knee Flexures More localised

Scalps, Extensor Face often clears.
surfaces of limbs
 Assessment-AD
Children with eczema have itchy skin plus 3 or more of the following:

1. Atopic history: 1st degree relative or personal history

2. Dry skin: Within the past year
3. Typical rash distribution: History of rashes involving skin creases
- antecubital fossae, popliteal fossae, neck, front of ankles, periorbital area
4. Typical age of onset: History of a recurrent rash before the age of 2 years
5. Visible eczema: red and rough skin

Severity assessment tools: SCORAD / POEM

Eczema severity + presence/ absence of infection → type & frequency of treatments
 Red Flags-AD
● Poor growth, persistent diarrhoea and/or recurrent infections [consider
immunodeficiencies- eg.Wiskott Aldrich Syndrome (WAS)]
- WAS: triad of eczema, thrombocytopenia, recurrent infections

● Signs of infected eczema (eg crusted, vesicular, satellite, pustular, erosive, tender,
scabbed or weeping lesions on eczematous skin)

Eczema bacterial infection Eczema herpeticum Eczema coxsackium

 Management -AD
The goal of treatment is disease control and not cure.
Investigations
● Clinical diagnosis
● Tests are not required.
● Skin swabs to direct
antimicrobial therapy:
○ Recurrent skin infections
○ Infection does not respond
to treatment
Treatment
● Optimal everyday management
● Treatment of eczema flares
*Educate patient & carer about
eczema cares, trigger avoidance,
recognising & responding to eczema
flares & infections.
Eczema
Management
Plan

RCH
 Optimal everyday management
● For clear skin- mild eczema flare, no infection
● Bathe daily + Apply moisturisers at least twice per day top-to-toe
● Continue even when the skin is clear.

Moisturisers
● Choose a moisturiser:
○ With sufficient greasiness
(high oil & low water content)
○ Without perfume/ alcohol
● Apply generously twice a day AND
after bathing/ hand washing
○ Immediately after bathing to
lock the absorbed moisture
Bathing
● Daily bathing - reduces bacterial
skin load & risk of infection
● Luke warm (<31°C) baths <5
minutes - avoid skin flares
● Add a capful of bath oil to bath
water.
● Use soap free skin cleansers.
● Use fresh towels with every bath to
prevent infections.
Optimal everyday management
Trigger Avoidance

RCH
 Eczema Flares Treatment
Topical Steroids
● Apply once/ twice daily until the skin is
completely clear to reduce skin
inflammation
● Apply generously underneath
moisturiser
● Facial eczema: low potency steroids
○ 1% hydrocortisone
Non steroidal alternative:
Topical Calcineurin inhibitors
● Alternatives to topical steroids on
sensitive areas such as the face
Oral antihistamine for itch at night.
Moisturisers
● Increase the frequency of moisturiser
○ Apply at least 4 times per day
● Apply the moisturiser on-top of other
topical medicines such as steroids
Wet dressings
● Return moisture, Protect from infection &
further trauma, Reduce irritation & itch
● Apply with every flare 1-4 times daily for
at least 3 days
● Patient education → correct technique
 Eczema Flares Treatment
Bleach baths
● Use daily with every flare to reduce the
bacterial skin load
● Addition of salt and oils to the bath
○ Relieve itch & Restore moisture
● The child’s face and head should be wet
during the bath
● Do not rinse after bathing.
Bacterial infections (Staph. aureus)
● Remove crusted lesions before applying
topical agents
○ Wipe gently with a cloth whilst soaking
in the bath
● Consider courses of oral antibiotics (eg
cefalexin / flucloxacillin for 7 - 10 days).
● Severe: Admission + IV abx
Viral infections
coxsackievirus, molluscum contagiosum,
herpes simplex & varicella zoster viruses
● Herpetic: Antiviral tx
● Urgent Ophthalmology review
○ infection extends periorbital
(trigeminal) distribution
SPOT DIAGNOSIS
 Psoriasis
Description
● Chronic, immune-mediated skin
disorder with a strong familial and
genetic predisposition
● Hyperproliferation of keratinocytes &
inflammation → Thickening of the skin
& Overscaling
Epidemiology
● Age of onset: Bimodal distribution
(15-25 yo & 50-60 yo)
Assessment
● Psoriasis Area & Severity Index
Etiological / Aggravating factors:
● Family history: +ve FH in at least 30%
of cases
● Strep infections:
○ May precipitate psoriasis,
particularly in children
● Trauma:
○ May localise psoriasis, also known
as the Koebner phenomenon
● Medications
○ Beta blockers
○ Hydroxychloroquine
○ Lithium
○ NSAIDS
○ Withdrawal of prednisolone
● Excess alcohol consumption
● Metabolic syndrome
● Stress (both emotional and physical)
 Psoriasis
Clinical Features Psoriatic arthritis (⅓ of cases)
● Depends on variant ● Symmetrical polyarthritis of small joints
● Typically symmetrically distributed, red (esp. PIP & DIP)
coloured plaques (palpable flat lesion ● Dactylitis; Arthritis mutilans
>1cm) with well defined white silvery
scales Nail Changes (50% of cases)
● The most common affected sites: ● Nail pitting, Ridging, Onycholysis, Oil
○ Extensor surfaces (elbows, drop sign (salmon spot)
knees)
○ Lower back Investigation
○ Scalp ● Psoriasis is usually a clinical diagnosis,
● Itching is mostly mild & not a major however a skin biopsy may show:
feature; however, may lead to
lichenification

Auspitz sign
● Small pinpoint bleeding when scales
are scraped off
 Scalp
Clinical Variants
Often 1st or only
Pustular Guttate
●
site of psoriasis
● Often on the palms & ● Acute onset of widespread,
soles teardrop lesions often on the
● No pathogens found in trunk
swabs & scrapings ● Usually occurs 2-3w following
● High correlation with Strep infection
smoking ● Resolves after several months

Palmoplantar
● Palms of hands
● Soles of feet
 Clinical Variants
Plaque Inverse/ Flexural Erythrodermic
● Most common form ● Sharp edged ● Rare derm emergency
(90%) patches found under ● Quick withdrawal from oral steroids
● Thick, well defined folds ● May result in systemic illness with
red scaly plaques ● Tend to lack the temperature dysregulation, electrolyte
● Extensor surfaces typical scaling seen imbalance and cardiac failure
● Auspitz sign in chronic plaque ● ADMIT to hospital
psoriasis
 Psoriasis-Management
Explanation of chronicity
● Psoriasis is not a curable disease →
treatment focuses on long term control
● Variable level of intervention required
(episodic/ constant)
● Any treatment of psoriasis: unlikely to see
results in <6 weeks
Lifestyle modification
● Avoid triggers
○ Stress management
○ SNAPS
○ Avoid meds that might worsen/
precipitate psoriasis
● Optimal weight control
● Daily moisturiser → maintain skin
hydration
Decide between the use of topical, phototherapy
and systemic treatment
Topicals: (Mild/ Localised psoriasis)
● Corticosteroids
● Vitamin D analogues (calcipotriol +/- steroid)
● Coal Tar solution
● Dithranol cream
● Tazarotene (topical retinoid)
UV phototherapy & photochemotherapy:
(Moderate/ Extensive psoriasis)
● Narrowband UVB
● PUVA (photochemotherapy)
Systemics: (Moderate-Severe psoriasis)
● Methotrexate
● Cyclosporin
● Retinoids
● Biologic Agents (eg: Infliximab, Ustekinumab)
 Psoriasis-Management
Address psychological issues
● Chronicity of disease → Challenge of
close relationships
● High rates of depression
Explore other preventative opportunities
● Be aware of the association with:
○ Cardiovascular diseases
○ Diabetes
○ Arthritis
○ Inflammatory bowel disease
○ Lymphoma
*good opportunity to address CVD risk factors
Indications for specialist referral
● Moderate-severe psoriasis may need
referral for
○ Phototherapy
○ Systemic meds with methotrexate
or a retinoid
○ Hospitalisation
○ One of the new Biologic agents
● Emergencies requiring urgent referral:
○ Widespread pustular psoriasis
○ Erythrodermic psoriasis
SPOT DIAGNOSIS
 Acne Vulgaris
Description
● Common skin disorder affecting the hair
follicle and sebaceous gland
Epidemiology
● Mostly affects adolescents, also found in
babies, pre-pubertal children & adults
● Typically more severe in males, but more
persistent in females
Investigation
● Clinical diagnosis
● Screen for PCOS
○ Sudden onset of severe acne with
symptoms of hyperandrogenism
4 main factors of acne development
● Abnormal follicular keratinocyte
hyperproliferation→ formation of
follicular plug
● Increased sebum production within
sebaceous follicles
● Proliferation of microorganisms (eg.
Propionibacterium acnes) in the
retained sebum
● Inflammation
* Strong genetic element in many patients
Note: The belief that acne is caused by poor hygiene,
excessive consumption of fatty foods and chocolate has
not been validated by extensive research.
 Acne Vulgaris
● Comedones (keratin filled plugs)
○ Open (blackheads)
○ Closed (whiteheads)
● Pustules:
○ Collections of neutrophils
● Cysts:
○ Follicular-lined keratin-filled structures
that dilate
● Nodules: (Further inflammation)
○ Clinically red, tender, palpable lesions
(Ruptured cysts）

Mild Moderate Mod-Severe Severe

Clinical Non Non inflammatory Numerous comedones Widespread inflammatory & noninflammatory
Features inflammatory comedones + a + papulopustular features
lesions few lesions *Numerous nodules & cysts (often painful)
(comedones)+/ papulopustular +/-
- lesions a few cysts/ nodules OR moderate acne that has not settled with at least
papules 3 months of adequate treatment
OR
non -responsive OR acne of any severity with serious psychological
mild acne impact
 Acne- Management
OSCE
Lifestyle- All severities - Address psychological
● Minimise exacerbating medications (anabolic steroids, lithium, phenytoin) issues; HEADSS screen
● Avoid squeezing/ picking lesions - Follow up in 12w as
● Use oil-free, non comedogenic make up & sunscreens & moisturisers treatment takes some time
● Avoid over washing & hot spas to work
● Avoid hot, humid and overly sunny environment

Mild (topical treatment only) Moderate Severe

Management Comedonal ADD to topical therapy: Oral isotretinoin

● Topical retinoid ● Prescribed by
Potential for photosensitivity → Night application Oral Antibiotics dermatologist
● Tetracyclines
Papulopustular (SE: photosensitivity; headache) Potent teratogen
Topical Retinoid PLUS ● Pregnancy
● Topical antiseptic (benzoyl peroxide) ● Erythromycin testing &
or Counselling
● Topical antibiotics (clindamycin, Female: prior to
erythromycin) Anti-androgenic hormonal administration
Combination reduces the risk of abx resistance treatment
● COCP (with cyproterone SE: depression
+/- salicylic acid containing cleansing agent acetate)
● Spironolactone
SPOT DIAGNOSIS
 Rosacea
Description
● Common persistent eruption of unknown aetiology that
predominantly affects the central face
● Mainly 30-50 yo
● Usually female of Celtic origin (fair skin)

Clinical Features:
● Vascular changes: central facial erythema & telangiectasia
● Inflammation: papules & pustules
● 1st sign: “Flushing & Blushing” ; sparing periorbital & perioral areas
● * Unlike acne vulgaris → no comedones

Exacerbating Factors: Vasodilation

● Topical corticosteroids ● Facial products
● Sun exposure & heat ● Alcohol consumption
● Hot spicy food ● Stress
 Management- Rosacea
Investigations:
● Clinical Diagnosis
● Skin biopsy/ Blood test TRO other causes of
facial flushing (SLE & dermatomyositis)
Conservative management:
● Avoid aggravating factors
● Sun protection
● Use gentle soap-free cleanser
Topical agents: Mild rosacea
● Metronidazole 0.75% cream
● Clindamycin 1% lotion/ cream
● Erythromycin 2% gel
● Azelaic acid 15% gel
Systemic therapy:
inadequate response to topical therapy
● Antibiotics
○ 1st line: Minocycline/ Doxycycline
(8-10 weeks)
○ 2nd choice: Erythromycin
○ Resistant: Metronidazole
Laser therapy (Refer to dermatologist)
● Telangiectasia, erythema & rhinophyma
respond to laser therapy
SPOT DIAGNOSIS
 Basal Cell Carcinoma-BCC
● Most common skin cancer (80%)
● Locally invasive non-melanocytic cancer
● Low potential to metastasize- slow growing over years
● Sites of chronic sun exposure
○ Face (mainly), neck, upper trunk, limbs Buzzword:
● Risk factors: Pearly edge; Telangiectasia;
- Age: usually >35; Male; Fair complexion; Repeated sunburn Ulcerated
- Genetic condition: Gorlin syndrome
BCC subtypes
 Common BCC subtypes
Nodular BCC Superficial BCC Morphoeic BCC
● Pearly raised edge ● Well defined red patch on ● Commonly affects
with surface trunk/ limbs (+/- scaly) mid-facial locations
telangiectasia ● Mistreated as psoriasis, ● Poorly defined;
● Most common on eczema Waxy & Scar like
the face - Be suspicious when lesion - Difficult to diagnose
● May develop central does not respond to tx ● Least common
- Stretching + Bright light → small
ulcer subtype
pearly edge
 Skin Biopsy- Non Melanoma Skin Cancer

Decision tree to guide the type of biopsy chosen in patients with

suspected basal cell and squamous cell carcinomas.
 RACGP Non melanoma skin
cancer guideline

https://www.racgp.org.au/afp/2012/july/nonmel
anoma-skin-cancers-treatment-options
 Management-BCC
● Investigations: Shave/ Punch/ Excisional skin biopsy

● Gold Standard: Simple elliptical excision

● Low risk + Superficial BCCs:

○ Photodynamic therapy
○ Cryotherapy (away from head & neck)
○ Topical Imiquimod: (not on nose/ not around eyes)

● Mohs micrographic surgery: High risk lesions

○ Large/ recurrent tumours
○ Tumours at site where maximal normal tissue needs to be preserved

● Radiotherapy:
○ Flail patients
Spectrum of Squamous Cell Carcinoma

Actinic Keratosis Bowen’s Disease Invasive SCC

(SCC in situ)
 Actinic (Solar) Keratoses
Description Management
● Erythematous, adherent, scaly ● Do not necessarily require treatment
hyperkeratotic thickenings located on unless they are unsightly,
sun-exposed areas uncomfortable or enlarging.
● NOT cancer
● May regress with good sun protection
○ Indicator of higher risk for skin
cancers ● Treatment options:
○ Relatively low potential for malignant ○ Liquid nitrogen cryotherapy
transformation) ○ Topical 3% diclofenac gel
○ 5-fluorouracil 5% cream
○ Topical imiquimod

● Biopsy TRO malignancy if lesion

○ Does not respond with treatment
○ Becomes indurated
○ Bleeds
 Bowen Disease
● Full thickness SCC in situ ● Management
○ Intraepidermal carcinoma (no ○ Shave biopsy first for diagnosis.
invasion into the dermis)
○ all layers of epidermis are Note: Biopsy a single patch of suspected psoriasis/
dysplastic dermatitis not responding to topical steroids

○ Treatment options:
Actinic Keratosis:
■ Surgical excision
partial thickness dysplasia within epidermis
■ Cryotherapy
■ Curettage and cautery
● Presents as single well-defined,
■ Topical 5-fluorouracil
erythematous and scaly plaque
■ Topical imiquimod
■ Photodynamic therapy
● Slow, progressive condition
■ Superficial radiotherapy
● 10% progress to SCC

○ Follow up: Monitor for

persistence/ recurrence
 Squamous Cell Carcinoma-SCC
Buzzword:
● Second most common skin cancer in Australia Keratotic crusted surface
Ulcers with everted edge
● Malignant tumour of epidermis
● Found on sun-exposed areas
● Tends to arise in premalignant areas such as:
○ solar keratoses, Bowen disease, burns, chronic
ulcers

BCC more common on upper lip

SCC more common on lower lip

● Initial lesion:
○ firm papule/ plaque (+/- tender)
● Advanced lesion:
○ rolled edge, ulceration, recurrent
bleeding
 Management-SCC
● Investigation: Shave/ Punch/ Excisional skin biopsy

● GOLD standard: Excision

○ Low risk : 4mm margin
○ High risk: 6mm-10mm

● Referral for specialised surgery +/- radiotherapy

○ Large/ In difficult site/ Lymphadenopathy

● SCCs of ear & lip → more malignant potential → wedged excision

● Superficial X-ray therapy

○ Surgery is not feasible

Surgery is the treatment of choice for most tumours; cryotherapy, imiquimod and curettage are not.

Murtagh
 Keratoacanthoma
Definition: Low risk variant of well differentiated SCC

Clinical Features:
● Raised crater with central keratin plug
● Rapidly growing lesion on sun-exposed skin
● Tendency to spontaneous resolution after 4-6 months
Buzzword:
Management: Central keratin core
● Surgical excision + Histological examination
○ Most patients will not tolerate a tumour for 4-6
months on an exposed area such as the face.

● Best to manage as SCC unless proven otherwise

 NMSC Prevention
● Primary preventive advice: “SUNSMART”
○ EVERYONE
○ Adopt protective measures when UV
levels≥3

● Skin examination
○ Identify skin lumps, ulcers or scaly
patches, particularly growing, scarred or
inflamed lesions

● Self examination
○ Be alert for skin lesion changes
SPOT DIAGNOSIS
 Melanoma
Description
● Malignant tumours derived from
melanocytes
Epidemiology
● Aus- Highest incidence rates of
melanoma in the world
● Most common cancer in Australians
<60 yo
● Overall 5 year survival > 90%
○ Early detection & treatment
Risk Factors: impt ques to ask in OSCE
● Hx of previous melanoma (fivefold)
● Presence of many moles (≥50),
especially atypical dysplastic naevi
● Family history (≥1member)
● History of many sunburns
● Sun sensitive skin/ fair complexion
● Patient age and sex:
○ increasing age and male
● Tanning (including solarium) treatments
 Melanoma-Clinical Features
● Radial growth phase melanomas: ABCDE
○ A: Asymmetry
○ B: Border irregularity
○ C: Colour variation
○ D: Diameter (≥6mm)
○ E: Evolution

● Vertical growth phase melanomas: EFG

○ E: Elevation
○ F: Firmness on palpation
○ G: Growing progressively for > 1 month
 Melanoma subtypes
Lentigo Maligna Superficial Nodular (20%) Acral Lentiginous
● Elderly Spreading (>70%) ● Vertical growth (3%)
● Chronically sun ● Most common phase melanoma ● Palms, Soles,
exposed areas type (EFG) Distal
● LM: in situ ● Middle aged ● Trunks & Limbs phalanges
Can remain for years ● Trunks & Limbs ● Urgent ● Dark skinned
● LMM: invasive excisional biopsy races
if not excluded ● Not due to sun
exposure
 Management-Melanoma
1. Suspicious clinical features (ABCDE)--> further investigations
2. Investigations:
a. Dermatoscope - Used in first instance to aid in diagnosis
b. Excision biopsy: GOLD standard
i. Remove lesion surgically with 2 mm margin for pathological diagnosis
ii. Avoid partial biopsies (punch, incisional, shave) -misdiagnosis → delay treatment
3. Wide local excision
a. The extent of surgical margin is guided by Breslow thickness
 Management-Melanoma
4. Sentinel Node Biopsy : if Breslow Prognosis
thickness >1mm
5. Metastatic disease Dependent on a number of factors:
a. Combination of surgery + targeted Breslow thickness, Clark level, site, age, sex
therapy/ immunotherapy
6. Follow up (based on tumour thickness)

Murtagh

Overall survival for melanoma in Australia is

around 90%.
Murtagh
 Screening of asymptomatic (low risk) people for melanoma/

Prevention non-melanocytic skin cancer (NMSC) is not recommended~

● Primary preventive advice: “SUNSMART”

○ EVERYONE
○ Adopt protective measures when
UV levels≥3
● Skin examination
○ ABCDE
○ Alternative: 7 point checklist

● Self examination
○ Identify specific skin changes that
suggest melanoma
Murtagh
Common Skin Infections
SPOT DIAGNOSIS
 Impetigo
Buzzword:
● Common, highly contagious bacterial skin infection in young Honey-Crusted Erosions
children
● Causative organisms:
○ Staph. aureus - bullous + vesiculopustular
○ Strep. pyogenes (GABHS) -vesiculopustular
● Transmitted through direct contact
● Risk factors:
○ Skin conditions (atopic dermatitis, contact dermatitis,
scabies); Skin trauma; Immunosuppression; Poor hygiene)
● Clinical features:
○ Honey coloured crusts with surrounding redness and
erosions
○ Usually itchy
 Management- Impetigo
- Stay home until lesions have crusted over/ at least 24 hrs of treatment.
- Treat underlying skin conditions.
- Use separate towels and cloths.
- Regular handwashing.

Mild (small lesions + limited area)

● Soak & remove crusts with saline/ soap & water / povidone iodine
● Topical antiseptic (povidone iodine, chlorhexidine)
● Topical antibiotics: 2% Mupirocin (Bactroban)

Extensive with systemic symptoms

● Oral antibiotics
○ Flucloxacillin / dicloxacillin
○ Cephalexin
Cellulitis & Erysipelas
Cellulitis Erysipelas

Dermis + Subcutaneous tissues Dermis (superficial form of cellulitis)

Lesions are more widespread and lack proper Lesions are more localized with well demarcated
margins boundaries.

Often caused by GABHS Almost all are caused by GABHS (Strep. pyogenes)
If surrounds a wound→ Staph. Aureus

Periorbital cellulitis in children Usually affects the face- butterfly pattern of erythema

Patient is unwell, febrile +/- lymphadenopathy

SPOT DIAGNOSIS Single oval herald patch followed by generalised rash
 Pityriasis Rosea
Buzzword:
Herald patch
Christmas tree distribution

● Self limiting rash: resolves in about 6-10 weeks

● Clinical Features:
○ Begins with a large circular/ oval “herald patch” (usually found on the chest,
abdomen, or back)
○ Followed by the development of Christmas tree distribution of smaller scaly oval
red patches (mainly on the chest & back) 1-2 weeks later
● Probably a/w HHV 6/7
SPOT DIAGNOSIS
Molluscum contagiosum (water warts)
● Common contagious DNA poxvirus infection
● Typical lesion: pearly papule with central umbilication
● Children:
○ Lesions anywhere on the body (armpits, below
waist)
○ Usually acquired during swimming/ bathing
● Adults:
○ STI: pubic region
● Treatment is not routinely recommended
○ Usually resolves spontaneously (average 8 Buzzword:
months) Pearly papule with central
● Treatment options if preferred: umbilication

○ Cryotherapy
○ Curettage
○ Tape occlusion
 Some other viral infections

Herpes simplex Herpes zoster (Shingles) Varicella zoster (chicken

● HSV 1 - oral labial ● Dermatomal pox)
lesions (mucous distribution ● Erythematous macules→
papules → vesicles→ eruption
membranes) ● Blisters → crusted papules→
● HSV 2 - genital ● Unilateral; sharp hypopigmentation of healed
lesions without scars
lesions (skin) cutoff at the midlines
SPOT DIAGNOSIS
 Tinea
● Ringworm infection caused by a dermatophyte fungi
● Investigations: MCS for surface scrapings
● Treatment:
○ Localised: topical antifungal (terbinafine)
○ Extensive/ Involving hair bearing areas: oral antifungal
■ Griseofulvin/ terbinafine

Annular eruption with an

irregular edge, central
clearing, peripheral scale
SPOT DIAGNOSIS
 Pityriasis Versicolor
● Yeast infection
○ Malassezia yeasts: normal commensals of the skin
● Predisposing factors
○ Hot conditions, Tropical climates, Occupations with physical exertion & heavy
sweating
● Clinical features:
○ Small, well defined, slightly scaly patches (either hypo/hyperpigmented)
○ Commonly asx: not itchy; not painful
○ Adults: upper trunk
○ Children: face
● Management
○ Ketoconazole/ Selenium sulfide shampoo
○ Ineffective topical therapy → oral fluconazole

Sun exposure gradually repigments hypopigmented areas if the infection had been treated
adequately
SPOT DIAGNOSIS
 Murtagh

Urticaria
● Common condition that affects the dermis
● 3 characteristics:
○ Transient erythema
○ Transient oedema
○ Transient itch (due to histamine
release)
● Acute: minutes-<6 weeks
● Chronic: >6 weeks
● Superficial dermis: Urticaria
○ Trunk & Limbs
● Deep- Subcutaneous tissue: Angioedema
○ Face, Eyelids, Hands & Feet
○ Mouth/ Airway → Airway obstruction
 Management- Acute Urticaria
Withdraw any suspected foods or drugs

● Use oral antihistamines (until resolution of rash)

○ Less sedating: during the day
■ Cetirizine, Loratadine, Fexofenadine, Desloratadine
○ Sedating: at night -aids in sleep
■ Promethazine, Trimeprazine, Cyproheptadine
● Poor response to H1 blocker → Add H2 blocker (ranitidine)
● Severe → short course of systemic corticosteroids
● Severe urticaria with hypotension & anaphylaxis → manage as per anaphylaxis
○ Reduce exposure to allergen immediately
○ ABC
○ IM adrenaline 1:1000
 Management- Chronic Urticaria
Specific precipitant is very unlikely to be found.

Investigations
Remove triggers:
● Elimination diet
● Cessation of suspected drugs

Medications:
● First line: oral antihistamine
● If 1st line is ineffective→ Referral to
immunologist → Consider certain
systemic immunosuppressants
○ Cyclosporine
○ Methotrexate
Skin Wounds
& Ulcers
QUESTIONS
Q1
An 88-year-old man presents with a mark on his face. This mark has been present for many
years and has not bothered him in the past. Recently it has become increasingly itchy and
various family members have suggested that he should get it looked at. He is otherwise in
good health. The mark is clearly visible.

Which one of the following is the most appropriate next step in management?

A. Imiquimod cream
B. Reassurance
C. Punch biopsy
D. Complete excision
E. Cryotherapy
Q1
An 88-year-old man presents with a mark on his face. This mark has been present for many
years and has not bothered him in the past. Recently it has become increasingly itchy and
various family members have suggested that he should get it looked at. He is otherwise in
good health. The mark is clearly visible.

Which one of the following is the most appropriate next step in management?

A. Imiquimod cream
B. Reassurance
C. Punch biopsy
D. Complete excision
E. Cryotherapy
 Q1
The lesion on this man's face represents a symptomatic suspicious pigmented lesion and warrants biopsy. There
are important concepts to understand around doing a biopsy of a pigmented lesion, and this case demonstrates
a good example of when alternative methods may be required. The ideal biopsy of a pigmented lesion is a
complete excision with a 2mm margin. However, based on its location and size, a complete excision would
comprise of a very large surgical procedure and would lead to significant deformity of his face. Therefore, a
punch biopsy would be appropriate in the first instance for confirmation of the diagnosis before further
treatment is considered. In cases such as this it is often appropriate to do a few (2-3) mapping punch biopsies
from different sites to ensure an accurate diagnosis is made and areas of invasive melanoma are not missed.
However, these types of biopsies must still be interpreted with great caution as the do not include the entire
lesion.

Reassurance is not appropriate as this is a pigmented lesion that is symptomatic and may represent a
melanoma.

Cryotherapy is inappropriate because a formal diagnosis cannot be made and a potential melanoma missed.

Imiquimod cream and radiation can be used for the management of less invasive forms of
melanoma/pre-cancerous lesions such as lentigo maligna, but a formal pathology diagnosis must be made before
these can be used.
Q2
An 89-year-old man attends the clinic for advice about a lesion on his face. This has been
present for about eight years and has not shown any obvious change - but the patient's son
said he should get it seen to.

Which one of the following is the most appropriate plan of management?

A. Review in six months

B. Imiquimod topical cream
C. Topical liquid nitrogen
D. Excise with a 5 mm margin
E. Excise with a 10 mm margin
Q2
An 89-year-old man attends the clinic for advice about a lesion on his face. This has been
present for about eight years and has not shown any obvious change - but the patient's son
said he should get it seen to.

Which one of the following is the most appropriate plan of management?

A. Review in six months

B. Imiquimod topical cream
C. Topical liquid nitrogen
D. Excise with a 5 mm margin
E. Excise with a 10 mm margin
 Q2
This is an example of lentigo maligna - or Hutchinson's melanotic freckle. It is characteristically found on the
faces of elderly patients who have had excessive sun exposure and will have been present for many years. It is a
subtype of melanoma-in-situ. Unlike other subtypes of melanoma, it can remain indolent for several years before
progressing into an invasive melanoma. The risk of invasive transformation is reported to range 2-5%. Hence, in
younger patients or in elderly patients who are otherwise fit and healthy, the current recommendation is to have
the lesion surgically resected with a wide margin. Recurrence rate is relatively high but this is likely secondary
to incomplete excision rather than true recurrence. Other options of treatment include the use of topical
imiquimod, but this agent can be associated with an intense local inflammatory reaction and is currently 2nd line
agent in patients where surgical resection is not feasible.

It is difficult to determine with naked eyes whether the lesion has progressed into invasive melanoma and cannot
be determined by change in size of the lesion. As this lesion has remained unchanged for many years and the
patient is elderly, it would be quite reasonable to keep it under close review - particularly as the patient does not
appear to be bothered about it. A careful discussion has to be done with the patient and his family and carefully
documented.

Provided there is no obvious change in the lesion, lentigo maligna can be kept under surveillance without any
form of active intervention.
Q3
A 35-year-old man presents with a pigmented lesion over his right scapula. He is otherwise
in good health and apart from the skin lesion, there are no other abnormal physical findings.
The lesion is excised with a 2 mm margin of normal tissue.

The histology reports that the lesion is a malignant melanoma and is 0.7 mm in Breslow
thickness. It appears to have been completely removed, with normal tissue found at all
margins of the tumour. The patient is concerned to know if he requires any further treatment.

Which one of the following is the most appropriate advice?

A. Regular observation alone

B. Further excision (1 cm margin)
C. Further excision (2 cm margin)
D. Further excision (1 cm margin) and sentinel node biopsy
E. Further excision (2 cm margin) and sentinel node biopsy
Q3
A 35-year-old man presents with a pigmented lesion over his right scapula. He is otherwise
in good health and apart from the skin lesion, there are no other abnormal physical findings.
The lesion is excised with a 2 mm margin of normal tissue.

The histology reports that the lesion is a malignant melanoma and is 0.7 mm in Breslow
thickness. It appears to have been completely removed, with normal tissue found at all
margins of the tumour. The patient is concerned to know if he requires any further treatment.

Which one of the following is the most appropriate advice?

The Breslow thickness is

A. Regular observation alone
used to determine the
B. Further excision (1 cm margin) need for further excision
C. Further excision (2 cm margin) and the need for a
D. Further excision (1 cm margin) and sentinel node biopsy sentinel lymph node
E. Further excision (2 cm margin) and sentinel node biopsy biopsy.
 Q3
Melanomas of all types have a high malignant potential and in order to minimise this wide excisional margins are
used. The key to guiding this the thickness of the lesion, using the Breslow thickness rules. Based on this, the
margins needed are:

● Melanoma in-situ: 5-10mm margin

● Thickness <1mm = 1cm margin
● Thickness 1-4mm = 1-2cm margin, increasing as thickness increases and with clinical decision
● Thickness >4mm = 2cm margin

The other consideration is a sentinel lymph node biopsy, as the this will be the first site malignant cells will lodge
following metastasis. SLN biopsy is recommended with thickness >1 mm and should be done by those with
experience. It is important to note that if draining nodes are palpable = clinically detected, then biopsy is not
needed as this is sufficient indication for complete removal.

In this patient the thickness of the melanoma is 0.7 mm and a further excision to produce a 1 cm margin is all
that is required. With this thickness (< 1 mm) the risk of metastatic spread is very low (<5%) and a SLN biopsy is
not necessary
Q4
A 14-year-old girl presents to her General Practitioner with her father. She is concerned
about the pimples on her face. She is embarrassed by this and gets teased at school by her
classmates. She is otherwise well, has no medical conditions or allergies and takes no
medications.

On examination her acne affects her forehead and chin region only. There are 3-4 small
isolated closed comedones on her forehead and five inflamed pustules on her chin. Some
have surrounding erythema and evidence of scabbing. There is no scarring.

Which one of the following is the most appropriate initial treatment?

A. Topical adapalene
B. Oral erythromycin
C. Oral doxycycline
D. Oral isotretinoin
E. Combined oral contraceptive pill
Q4
A 14-year-old girl presents to her General Practitioner with her father. She is concerned
about the pimples on her face. She is embarrassed by this and gets teased at school by her
classmates. She is otherwise well, has no medical conditions or allergies and takes no
medications.

On examination her acne affects her forehead and chin region only. There are 3-4 small
isolated closed comedones on her forehead and five inflamed pustules on her chin. Some
have surrounding erythema and evidence of scabbing. There is no scarring.

Which one of the following is the most appropriate initial treatment?

A. Topical adapalene
B. Oral erythromycin
C. Oral doxycycline
D. Oral isotretinoin
E. Combined oral contraceptive pill
 Q4
The above stem describes typical mild acne affecting an adolescent. This is extremely common and often occurs
during pre or pubertal periods. It is important to assess the psychological impact that the acne is having and also
assess the severity to determine which management option would be most appropriate.

For mild acne in adolescents topical preparations are first line. Over the counter benzoyl peroxide creams or gels
at 2.5-5% can be used. These are safe, easy for patients to access and can have a good response in many
patients. Another topical option for mild acne is a topical retinoid such as adapalene. They often take up to six
weeks for a response to be seen. Benzoyl peroxide can also be combined in a gel with topical retinoids or topical
antibiotics.

For more severe acne of if other topical methods have failed oral antibiotics such as oral doxycycline or oral
erythromycin can be trialled. Antibiotics, whether topical or oral are used for their anti-inflammatory action as
acne is not an infection. Tetracyclines are considered first line, unless they cannot be tolerated or it is a pregnant
female.

The above options can be combined in some cases such as topical benzoyl peroxide +
● a topical retinoid OR
● a topical antibiotic such as clindamycin
 Q4-cont
If these all fail, or the acne is moderate to severe oral retinoids such as isotretinoin should be considered.
Retinoids are the most effective treatment for acne, but they have side effects. They should be avoided in all
women who are planning to become pregnant, are pregnant or are breastfeeding. They are teratogenic and this
must be explained to all female patients if they are prescribed this.

Another option to avoid antibiotics and retinoids in females is starting the combined oral contraceptive pill for
moderate to severe acne. A 6 month trial is recommended to see results and also offers the benefit of
contraception if the patient is seeking an option for this as well.

In this case her acne is described as mild as suggested by the description of her acne – it is isolated to the
forehead and chin, she has <30 lesions and there is no scarring. Therefore, a topical option would be the best
first line option, such as benzoyl peroxide. If this fails other topical options can be considered at a later stage.

● Topical benzoyl peroxide or a retinoid are good first line options for mild acne.
● Retinoids are teratogenic.
● Oral antibiotics (such as doxycycline) are used to treat acne for their anti-inflammatory properties
Q5
A 65-year-old man requests an urgent appointment for a growing lesion in his right nasal
bridge (Image). He regularly attends 6-monthly for full skin examination and keratinocyte
cancer surveillance. His medical history includes multiple squamous cell carcinomas in
sun-exposed areas. This lesion appeared three weeks earlier.

Which one of the following is the most likely diagnosis?

A. Squamous cell carcinoma
B. Keratoacanthoma
C. Merkel cell carcinoma
D. Actinic keratosis
E. Seborrhoiec keratosis
Q5
A 65-year-old man requests an urgent appointment for a growing lesion in his right nasal
bridge (Image). He regularly attends 6-monthly for full skin examination and keratinocyte
cancer surveillance. His medical history includes multiple squamous cell carcinomas in
sun-exposed areas. This lesion appeared three weeks earlier.

Which one of the following is the most likely diagnosis?

A. Squamous cell carcinoma
B. Keratoacanthoma
Keratoacanthoma
C. Merkel cell carcinoma
● Central keratin plug
D. Actinic keratosis ● Rapid progression
E. Seborrhoiec keratosis
 Q5
A keratoacanthoma, which has all the morphological features of a squamous cell carcinoma,
characteristically appears over a few weeks or months. This is much more rapid growth than that
expected of a carcinoma. Most of these lesions will spontaneously resolve over a similar time
period.

Squamous cell carcinoma is an important differential for keratoacanthoma. They are both
squamoproliferative growths. It is often difficult to distinguish between the two neoplasms
clinically and often a biopsy is indicated to exclude malignant disease.

Merkel cell carcinoma is a carcinoma that rapidly grows, however more commonly appears
clinically similar to basal cell carcinomas, presenting as a solitary erythematous nodule.

Actinic keratoses are pre-malignant keratinocyte lesions appearing on sun damaged skin.

Seborrheoic keratoses are benign growths with a characteristic "stuck-on" appearance.

Q6
A 28-year-old woman presents to the clinic with a 2-week history of a non-pruritic, scaling
rash on her abdomen. On further questioning, she reports a long history of a flaky dry scalp
but no associated symptoms or past episodes of this rash. She has recently been diagnosed
with bipolar disorder and was commenced on lithium. She does not have any other past
history.

On examination, the patient appears well and her vital signs are within normal limits. She
appears to have mild pitting and onycholysis of her fingernails, there are obvious silver
plaques on her scalp, in addition to the abdominal rash.

Which one of the following is the most likely diagnosis?

A. Contact dermatitis
B. Pityriasis rosea
C. Psoriasis
D. Seborrhoeic dermatitis
E. Tinea corporis
Q6
A 28-year-old woman presents to the clinic with a 2-week history of a non-pruritic, scaling
rash on her abdomen. On further questioning, she reports a long history of a flaky dry scalp
but no associated symptoms or past episodes of this rash. She has recently been diagnosed
with bipolar disorder and was commenced on lithium. She does not have any other past
history.

On examination, the patient appears well and her vital signs are within normal limits. She
appears to have mild pitting and onycholysis of her fingernails, there are obvious silver
plaques on her scalp, in addition to the abdominal rash.

Which one of the following is the most likely diagnosis?

A. Contact dermatitis
B. Pityriasis rosea
C. Psoriasis
D. Seborrhoeic dermatitis
E. Tinea corporis
 Q6
This presentation is consistent with psoriasis. Psoriasis is a chronic inflammatory skin condition
characterised by clearly defined, scaly plaques that are typically salmon pink or silvery-white.
The aetiology of psoriasis is multi-factorial, however, exacerbations have been associated with
streptococcal throat infections, dry skin, obesity, smoking, excessive alcohol, medications such
as lithium, beta-blockers, antimalarials, NSAIDs, steroids and stress. As in this case, psoriasis
may also affect the scalp (around 80% of cases), trunk, palms/soles nails, and flexure surfaces
(genitals).

Tinea corporis is a superficial skin infection secondary to dermatophytes, also known as

ringworm. Tinea corporis presents with annular, scaly lesions that have a raised border and
often expand over several weeks. Tinea may also involve the nails and scalp but is a less
classical picture. Often the patient has a history of previous tinea infections, diabetes mellitus,
immunodeficiency, hyperhidrosis and/or household overcrowding.
 Q6
Seborrhoeic dermatitis is a common benign inflammatory condition that affects the sebaceous
gland-rich regions of the scalp, face, and trunk. This condition is more common in infants and
young adults where higher levels of sebaceous activity are present. Seborrhoeic dermatitis
usually presents with thin, pale or erythematous plaques that often have a yellow greasy crust. It
is more common on the scalp, face and sometimes the upper trunk.

Pityriasis rosea is a self-limiting rash that usually resolves in about 6-10 weeks. It is
characterised by a large ‘herald patch’ and results in areas of hypopigmentation and a trailing
scale.

Contact dermatitis is a skin disorder, caused by direct contact with a causative agent. Contact
dermatitis is commonly caused by occupational exposures. Its presentation is highly variable but
often includes redness, blisters, swelling, dryness or scaling or changes to the pigmentation of
the skin. Due to the lack of exposures identified in the patient’s history, this rash is unlikely to be
caused by contact dermatitis.
 Resources
1. Murtagh
2. RACGP
3. DermNet
4. RCH (Atopic eczema)
5. Moodle- Australian College of Dermatology
6. The New England Journal of Medicine (Ulcers)
 Thanks!
Do you have any questions?
Contact me: jtie0004@student.monash.edu
Yii Fei (GP coordinator): ylin0073@student.monash.edu
PALS: palsmum@gmail.com

pals.gp

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