Dermatology

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Scabies — Investigations
Diagnosis Is Made By Identifying The Scabietic Burrow (A Linear or Curvilinear Papule Caused By A
Burrowing Scabies Mite) In Hands, Wrist, Ankle or Genital Areas

Under A Microscope, Visualize The Mites, Ova & Scybala — Feces (Use A Needle or Dermatoscope)

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Scabies — Management
Wash All Clothings, Towels & Linens With Hot Water As Infection of Close Contacts Is Common

Apply Aqueous Solution of 5% Permethrin or Malathion 2 Times, 1 Week Apart, Overnight, Excluding The Scalp

Permethrin, Malathion & Lindane (γ-Benzene-Hexachloride — Not Given To Children < 2 Y.O. & Pregnant or
Lactating Women) Is Also Given Simultaneously To Close Contacts Even If They Asymptomatic

Single-Dose Of Systemic Ivermectin (Poor Adherence, Immunosuppression & Heavy Infestation With
Crusted-Norwegian Species)

Topical Steroids & Oral Diphenhydramine For Persistent, Generalized, Severe Pruritus (Type IV HSR)

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Acne Vulgaris — Investigations

Not Typically Required

Underlying Secondary Causes (Endocrine Disease, PCOS, Virilization) Should Be Investigated

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Acne Vulgaris — Managment

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Eczema — Investigations

Diagnostic Criteria For Atopic Eczema

Patch-Testing
If Contact Allergic Dermatitis Is Suspected

Bacterial & Viral Swabs

If Suprainfection Is Suspected (Staphylococcus Is Commonly Positive)

HSV Can Cause Eczema Herpeticum

Punched-Out Lesions Within Worsening Eczema

Suggests Secondary HSV Infection

Skin Scrapings
Rules Out Secondary Fungal Infection

Skin Biopsy
If There Is Diagnostic Doubt
Total Or Specific-IgE & Skin-Prick Tests
Only If Directed By History

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Eczema — Management

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Psoriasis — Investigations

Skin Biopsy
If There Is Diagnostic Doubt

Infection Screen (Throat Swab & Serology)

For Recent Streptococcal Infection (Guttate Psoriasis)

Assessment Of Impact On Life Using DLQI

Disease Extent Using PASI (Psoriasis Area And Severity Index)

Comorbidities & CVS Risk Factors Should Be Assessed

Due To The Association Of Psoriasis With Metabolic Syndrome

HIV-Testing
Considered In Severe Or Recalcitrant Psoriasis

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Psoriasis — Management
-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

TEN — Investigations

Obvious Diagnosis In An Adult Patient With A Culprit Drug

CBC
Decreased WBC, Hemoglobin & Hematocrit

Increased ALT & AST

Nikolsky Sign
Gentle Lateral Pressure On Stroking Of The Skin Results In Epidermal Detachment Demonstrating Skin Fragility

SCORTEN Disease Severity Score

Used To Predict Outcome

Overlap With Stevens–Johnson Syndrome

Targetoid Lesions On Palms And Soles May Be Evident

Skin-Snipping
Allow Earlier Diagnosis
Full-Thickness Skin Biopsy, Histology & Direct Immunofluorescence
If There Is Diagnostic Doubt

Exclude Immunobullous Diseases & Staphylococcal Scalded Skin Syndrome

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

TEN — Management

Identification & Cessation Of Offending Agent

Anti-Convulsants, Sulfonamides, Sulfonylureas, NSAIDs, Allopurinol & Anti-Retroviral Therapy

Supportive Management
Regular Sterile Dressings, Emollients, Fluid Balance, Infection Monitoring, Analgesics & IVIG

Acyclovir
If HSV Is Suspected

Chronic Sequelae
Uretheral & Ocular Scarring Is Problematic

Adverse Psychological Outcome

Referral
Urgent Dermatology & Ophthalmology Consultation Is Required

Patients Are Treated In The ICU Or Burn Unit Due To Risk of Sepsis & Multi-Organ Failure

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Dermatitis Herpetiformis — Investigations

Clinical Signs
Although It Is A Bullous Disease, Intact Vesicles & Blisters Are Hardly Seen

It Is So Pruritic That Excoriations Are Found On The Extensor Surfaces Of Arms, Knees, Buttocks, Shoulders &
Scalp

Skin Biopsy
Subepidermal Vesiculation In The Dermal Papillae Is Diagnostic

Neutrophil & Eosinophil-Rich Infiltrate

Direct Immunofluorescence
Granular IgA In The Papillary Dermis

Levels of Anti-Endomysial Antibodies & Tissue Transglutaminase

Intestinal (Jejunal) Biopsy

Partial Villous Atrophy (Even If They Have No GI Symptoms)

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Dermatitis Herpetiformis — Management

Gluten-Free Diet But

If Not Responsive To Dietary Modification, Dapsone Can Be Used

 If Not Responsive To Dietary Modification, Dapsone Can Be Used

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

Erythema Nodosum
Septal Panniculitis Of Subcutaneous Fat

Associated With Systemic Upset, Arthralgias & Fever

Painful, Indurated, Violaceous Nodules On The Shins & Lower Legs

Spontaneously Resolves Within A Month, Leaving Bruise-Like Marks

Any Identifiable Trigger Should Be Identified & Removed

Bed Rest, Leg Elevation & Oral NSAIDs For Symptomatic Relief

Systemic Glucocorticoids Are Effective But Should Be Avoided In Infection

Potassium Iodide, Dapsone & Hydroxychloroquine Is Used If It Becomes Resistant

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

VZV — Diagnosis

Clinical Diagnosis
Rash Recognition
 Rash Recognition

Antigen (Direct Immunofluorescence) Or DNA (PCR) Detection From Aspirated Vesicular Fluid
Confirmatory

Serology
Used To Identify Seronegative Individuals (At Risk For Infection)

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-

VZV — Management

Anti-Virals (Acyclovir, Famciclovir, Valacyclovir)

For Uncomplicated Chickenpox In Children Shortens Duration Of Rash By Only 1 Day

Helpful In Uncomplicated Chickenpox In Adults, If The Patient Presents Within 24 - 48 Hours Of Onset Of
Vesicles, In Patients With Complications, In The Immunocompromised & Pregnant Women

More Severe Disease, Particularly In Immunocompromised Hosts, Initial Parenteral Therapy

Immunocompromised Patients May Have Prolonged Viral Shedding & May Require Prolonged Treatment Until
All Lesions Crust Over

Human VZ Immunoglobulin (VZIG)

It Is Used To In Those Who Have Had Significant Contact With VZV & Are Susceptible To Infection (Have No
History Of Chickenpox Or Shingles Or Are Seronegative For VZV IgG)

It Is Also Used In Those At Risk Of Severe Disease (Immunocompromised Or Pregnant)

Ideally, VZIG Should Be Given Within 7 Days Of Exposure, But It May Attenuate Disease Even If Given Up To 10
Days Afterwards

Susceptible Contacts Who Develop Severe Chickenpox After Receiving VZIG Should Be Treated With Acyclovir

Live-Attenuated VZV Vaccine

It Is Limited To Non-Immune Healthcare Workers & Household Contacts Of Immunocompromised Individuals

Children Receive 1 Dose After 1 Year & The 2nd Dose At 4 - 6 Years

Seronegative Adults Receive 2 Doses 1 Month Apart

The Vaccine Is Also Used Prior To Iatrogenic Immunosuppression (Before Transplant)

It Is Also Used In The Elderly > 70 To Prevent Shingles

Management of Shingles
Early Therapy With Acyclovir Or Related Agents Reduces Both Early & Late-Onset Pain, Especially In Patients >
65 Years

Post-Herpetic Neuralgia Requires Aggressive Analgesia, Along With Agents Such As Amitriptyline, Gabapentin
Or Pregabalin

Capsaicin Cream May Be Helpful

Glucocorticoids Are Controversial & Have Not Been Demonstrated To Reduce Post-Herpetic Neuralgia

-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-/-