Pityriasis (tinea) versicolor

- It caused by pityrosporum orbicular.

- It is a common condition in young adults, due
to alteration of the micro- environment of
the organisms in affected individuals
encourages them to multiply and extend
onto the surface of the skin.
- It affects the trunk, neck, arm and forearm.
Clinical picture

*On a non-pigmented skin, the lesions are

brown macules with fine surface scale.
*On a pigmented skin (after sunbathing),
they are hypo-pigmented patches.
Treatment (4-8 weeks)

1- Topical antifungal:
Topical lotion or shampoos are preferred due to
large surface area
Topical shampoos are used every 3 days for 4-8
weeks
*Selenium sulfide 2% suspension or shampoo.
*Sodium hyposulphid 25%
2- Systemic antifungal
*Ketoconazol, itraconazol, or fluconazol.
- systemic antifungal for 4-8 weeks according to
severity
Candidal Infections
Candidal Infections
- It is caused by yeast-like fungus.
Candida albicans
Clinical forms:
1- Candidal paronychia
*Swollen erythematous in nail fold with
separation of the nail folds from plate giving a
space containing cheesy-like material.
*It is common in housewives and servants.
2- Oral candidal thrush
*White small patches on the mucous
membrane of the mouth and the buccal
mucosa, if they are scraped off, it give
bleeding area
3- Candidal intertrigo
*It affects the groins, axilla, and submammary
regions.
* The affected areas appear erythematous,
glazed moist with peeling edge.
4- Candidal vulvovaginitis.

5- Angular stomatitis
Treatment

-Nystatin topically
-Topical or systemic imidazoles (clotrimazole,
tioconazole…)
-Gentian violet 1-2%

N.B
most candidal infections resolve without further problems
yeast infections usually clear in 1-2 weeks. In people
with weakened immune systems, these infections can
recur and become difficult to treat.
 Parasitic Skin Diseases
Scabies
- It is caused by the female sarcoptes
scabiei.
- The disease is transmitted by close
contact within the family.
- The female invade the body forming
burrow in which it put its eggs, then, the
eggs hatch and new generation mature and
repeat the cycle.
Clinical picture

*Severe itching increase at night.

*The skin show scratch marking, papules, or
vesicles with burrows which are brown,
slightly raised, tortuous or straight track.
*The affected sites are: webs of the hand,
body flexures, around umbilicus, wrist and
around the nipple.
Commonly involved sites of rashes
of scabies
Treatment
Hot baths with hard brush and topical application -
of topical insecticidal drug for 7 days, apply to all
body areas except neck and head.
*Sulfur ppt 5-10%
*Benzyl benzoate 25% (benzanyl)
*Permethrin 2.5-5% (Octamethrin)
*Malathion 0.5%
*Gamma benzene hexachloride lotion 1% (scabine
cream®)
*Crotamiton 10% (Eurax) as antipruritic
*Ivermictin (Iverzine®) is the only accepted oral therapy
for human after common use in animal

2- Oral antihistaminic to relieve sever itching

(Fexofenadine, loratidine, chlorophenramine )
Taken once daily before sleep
Precaution:
-Infected people should be isolated
-Avoid sharing bed or underwear with others
-All families should be treated at the same
time
-Improve personal hygiene by taking shower
daily
 Pediculosis (Head lice)
-Head lice are acquired by head-to-head
contact, using caps, combs, or brushes.
- The adult female lays eggs which are
cements to the hair shafts. The eggs hatch
leaving the empty egg-case (nit).

Types:
- Pediculosis capitis
- Pediculosis corporis
- Pediculosis pubis
Clinical picture
*Itching, scratching with secondary impetigo
(non-bullous).
*Nits are grayish white cemented to hair
shafts.
Treatment
*Frequent washing and combing the hair with small
teeth space to remove nits.

*Topical application of permethrin (Ectomethrin®),

malathion 0.5% (prioderm®, quick®), benzyl benzoate
25% or gammabenzene hexachloride 1%.

*Topical lotions or shampoo should be applied on dry

hair for 3 days then washed after 10 min then
repeated again after 7days for another 3 days to avoid
resistance and toxicity.
Keep away from eye and nose as irritants
 Diseases due to disturbance of
sebaceous glands
Acne vulgaris
- Etiology:
1- Hormonal factor increase the sebum production
(Androgen hormone is the stimulus of sebaceous
glands).
2- Bacterial factor: (Propionibacterium acnes; gram-
positive anaerobes produces many enzymes including
lipases which break down sebum triglycerides to short-
chain free fatty acids which cause comedones and
result in inflammation)
3- Abnormal keratinization results in clumping of
horny cells within the pilosebaceous unit and
obstruction of the outflow of the sebum.
Pilosebaceous unit
Clinical picture
*It begins at teenagers, with peak at 17-18 and
continues up to the age of 25 years.
*It is polymorphic disorder (different types of
lesions):
1- Comedone (non inflammatory) due to obstruction of
the pilosebaceous duct by the clumping horny cells
(closed comedone; white head)
2- Papules or open comedone (blackhead its color is
attributed to melanin or oxidized lipid not dirt)
3- Pustules (the lesion fill with pus)
4- Nodules and cysts (if inflammation is severe and
deeper in the dermis with ≥ 1 cm long)
5- Scar (permanent change of skin color): occur after
* The initial lesion is the comedone(xss keratinization)
* Two types of comedones:
1- Closed comedones (white head):
They are very small papules with a central point
or elevation.
They often present on the forehead and cheeks.
There is little or no inflammation.
2- Open comedones (black head)
They consist of blocked hair follicles with black
dot.
They are inflammatory
They often present on the shoulders and chest.
Classification:
-Grade I (comedone acne): comedones
only, <10 on face only, non-inflammatory
-Grade II (papular acne): 10-25 papule on
face and trunk, inflammatory lesions <5mm
in diameter
-Grade III (pustular acne) >25 pustules, with
purulent core.
-Grade IV (sever/pustulo-cystic acne):
nodules or cysts, inflammatory lesion >
5mm in diameter.
Treatment
- In mild cases (comedone or papule < 10 in the
face only)→ topical only

- In moderate (with pustule > 20 in the trunk also)

or severe cases (with cyst) → topical and
systemic therapy
Topical Therapy (for 6 weeks)
*Benzoyl peroxide 2.5-5% cream, lotion
(Akneroxide®) (OTC):
Keratolytic and antibacterial (it decompose to release
oxygen kill P. Acnes anaerobe)
- The beneficial effects can be noticed within 2 weeks.
- Precautions: it cause severe irritation so only apply
small quantity only once daily at night

*Tretinoin (vitamin A acid) 0.5% cream or lotion

(Eudyna®, Retin-A®):
- It increases the rate of turnover (replacing) of horny
cells in the follicular canal and prevents new
comedone development)
- It is the best used for non-inflammatory acne, and
can be used in combination with antibiotics or
benzoyl peroxide for inflammatory acne.
Adapalene: topical retinoid analogue with
advanced receptor selective activity
(It is selectively binding to certain nuclear retinoic acid
receptors and not others)
- Adapalene enhances keratinocyte differentiation
without inducing epidermal hyperplasia and
severe irritation, such as is seen with retinoic acid)
- It also help reduce cell-mediated inflammation,
and decreases formation of comedones and
inflammatory and noninflammatory acne
lesions.(potent anti-inflammatory and comedolytic
properties)
*Azelaic acid 20% cream (Azelex): it’s as effective
as benzoyl peroxide or tretinoin for mild to
moderate inflammatory acne.
- It has both antibacterial and antiproliferative activity
on keratinocytes.
*Keratolytic agents (OTC) as salicylic acid or sulfur
soap (Kapritage®).
*Topical antibiotics: erythromycin (Acnebiotic®)
clindamycin (Dalacin) tetracycline (Topicyclin)
- It cause suppression of the P. Acnes so, minimize
the inflammation.
Systemic Therapy
*Antibiotics
- Tetracyclines 250-1000 mg / day
Side effects: hepatotoxicity, photosensitization
(a sun protection plan should be used), teeth
discoloration (avoid in children and pregnancy)
- Erythromycin 250 mg
- Clindamycin 300-450 mg / day (long term use
causes pseudomembranous colitis)
- Anti-inflammatory: indomethacin, ibuprofen
Severe Cases:
1- Isotretinoin (accutane) in nodulo-cystic acne
0.5-1 mg/kg for 4-5 months (teratogenic)
- It’s the most effective immunosuppressive
agent, cause atrophy of sebaceous gland with
decrease in sebum production, inhibition of
inflammation, altered pattern of keratinization
within the follicles
Monitoring: blood glucose, lipid profile, and liver
function tests
2- Antiandrogens (Cyproterone acetate) in female
with severe acne (inhibit the growth the sebaceous
glands, decrease in sebum production that cause the
sebaceous glands to become blocked, resulting in
infection, inflammation and acne spots.
(contraindication in pregnancy)
Side effects: menstrual abnormalities, breast
tenderness, fluid retention)

3- Systemic steroids (20 mg / day) for short period of

time can quickly improve acne for important events
like wedding.
Precaution:
- Gentle cleansing the skin 2 to 3 times daily
with mild facial soaps to remove excess oil.
- Avoid stress
- Avoid anabolic drugs, bromides, iodides,
androgens, progestins, lithium.
- Avoid face cosmetics (specially containing
oils)
- Remove face cosmetic at bedtime
- Avoid facial scrubbing agents
- Decrease fatty food intake (chocolate, nuts,
fried foods)
 Eczema (Dermatitis)

- The terms eczema and dermatitis are

synonymous.
- They are applied to a particular type of
inflammatory reaction in the skin which
provoked by external or internal factors.
i.e the skin protects itself from allergenic or
irritant substances.
-It can be irritating but it's not contagious.
Clinical picture
*Acute stage: erythema, edema and
vesiculation.

Chronic stage: lichenification (the epidermis

become thickened and the skin surface
markings exaggerated).
*In all stages it is pruritic and oozes.
Etiology
Exogenous
Primary irritant dermatitis
Allergic contact dermatitis

Endogenous
Atopic eczema
Solar dermatitis
Varicose eczema
Seborrheic eczema
Exogenous eczema
1-Primary irritant dermatitis
*it occurs in all persons if exposed to any
substance in high concentration for a
sufficient time.
*It occurs on the first exposure.
*Irritants are chemicals as alkali, acids,
detergents….
2-Allergic contact dermatitis
*It occurs in certain persons if exposed to
certain substances in any concentration.

*It requires previous exposure to this

substance and latent period, on re-exposure
this reaction will occur.
The common sensitizers
- Plastic, rubbers e.g watch straps, metals….
- Cements
- Nickel (cheap nickel jewellery)
- Hair dye and shampoo.
- Topical creams (creams for dry skin,
hemorrhoids, creams for insect bite….)
Endogenous eczema
1-Atopic eczema
Atopy is a genetic disorder characterized by
tendency to allergic reaction. The patient
usually gives positive family history of spring
catarrh, bronchial asthma, hay fever (allergic
rhinitis caused by pollen grains), allergic rhinitis.
- Atopic eczema is a chronic condition with
remissions and relapses.
- Psycological and climatic factors modify the
intensity of itching.
The common allergens:
*Food: eggs, milk, chocolate….
*Inhalants: pollens, house dust, animal hair, wool

2-Solar eczema (photodermatitis)

*It appears as erythema, edema, and vesiculation
on the photo-exposed parts, on exposure to sun.
3-Varicose eczema (stasis dermatitis)
*Venous stasis in lower limbs due to varicose
veins for long time leads to some sort of dermatitis
*It is in the form of scaly erythematous areas
with edema, pruritus and brownish pigmentation.
4- Seborrheic dermatitis
*It affects the face, scalp and upper back.
*It produces scaly erythema in the nasolabial
folds with itching.
Treatment (for 7 days)
1- Identify the allergen.
2-avoid perfumed or dyed soaps and detergents.
3-avoid extremes of temperature fluctuations.
4- Sunscreens should be used.
2- Systemic:
*antihistaminic for itching
*corticosteroids in severe cases (for skin inflammation)
3-Topical (depend on the stage of the eczema):
Potassium permengnate 1/10000 or zinc oxide pastes
Topical protectants (panthenol, carbamide)
Severe: cases: ointments containing corticosteroids.
* Recent medications: topical immunomodulators
(TIMs) in some cases. TIMs include tacrolimus
(Protopic) and pimecrolimus. These medications
avoid the side effects of corticosteroids.