Dermatology index 4- Various skin lesions 2: Bacterial infection 3-iral infection 4- Fungal infection 5- Parasitic infestation 6- Collagen.diseases(rheumatology chapter) 7- Papulosquamous disorders 8- Dermatitis and eczemas 9- Urticaria 10- Different types of erythemas 11- Malignant tumors 12- Acne 13-_ Skin condition in pregnancy 14- Miscellaneous topics ) PLAB 1 Course1- Various skin lesions: © Macules: flat spots (no elevation), < 1 cm large macule levated lesion solid elevated lesions Vesicles: Small blisters < 1. cm, contains clear, serous or haemorrhagic fluid ge fluid-filled blisters > 1 cm collection sm ead este em Fissure ematous, epi cadens subscribémderws gemeanrned 560@gmail. com2- Bacterial infection: a- Impetigo: > Common condition. Most often affects children (can occur at any age). 5/0: SEIERNSSEENE aureus or risk factors: Streptococcus pyogenes. # Brokertskin (Childrén-are prone to cuts and grazes) or any. + Poor hygiche and skin cohditions that lead to a break in the protective layers. Types and presentation | AeNon:bullousimpetiges | start as tiny pustules or vesicles >>> evolve rapidly into RBYEBISURER (golden-brown crust) Usually due to Streptococcus pyogenes beginsas a non-bullous impetigo >>>> | ulcerates and becomes necrotic Fluid-filled vesicles and bullae 1- 2 cm have a thin roof >>> ‘Upture >> leaving a thin flat yellow crust on the face (particularly around the mouth and nose) Found on the face, trunk, extremities, buttocks, or perineal Regions Minor trauma >> allows bacteria to invade Wewauma required likely to occur-on top of other skin disease like atopic eczema Rarely has systemic features Systemic features: fever and lymphadenopathy occur if large areas of skin affected PLA CourseManagement: v First liné — Hydrogen peroxide 1% cream (antiseptic creams) * Second line Pusidic acid’2% or mupirocin (topical antibiotics) * Flucloxacillin: thirdiline or in patichts who are systemically unwell, with bullous impetigor who have high risk of complications. ‘School exelUsion for 48/hours after'starting medicine prescribed OR When the patches dry out and crust ovér\if you don't get treatment)b- Cellulitis: » Infection of the dermis and subcutaneous tissue. > The most common causative organisms are Streptococcus or Staphylococcus spp. but they can be caused by a wide range of both aerobic and anaerobic bacteria. > Risk factor: Diabetics are more prone to infection. > Features: ‘ ¥ commonly seen6n the shins v ¥ Sometifes associated with systemic symptoms like fever v > Treatmen : © HEME! Flucioxacillin (in uncomplicated infection). In sufficient doses, this covérs both betazhaemolytic streptococci and penicillinase-resistant staphylococci. (EBERICUIMEBIEREE Clindamycith-dr doxycyclin or clarithromycin or Erythromycin (|fijSTSBRBREWORIEH) can be used ° ifewere V benzylpenicillin#flucloxacillinnecrotizing fasciitis: > a life-threatening infection which rapidly spreads It is defined as necotising infection involving any layer ofthe deep sot tissue Compartment (dermis, subcutaneous tissue, fascia or muscle). Causative organism: group A beta-haemolytic Streptococci > Risk factors ¥ Intramuscular or subcutaneous drug injection Y Diabetes Y Immidfiosuppression » Presentation : According'to days © Swelling, erytherna, pain over affected area (mimics cellulitis) * Margins of infection are poorly defined + tenderness extending beyond the apparent aréa‘of involvement + No response to antibiotic’ (unlike cellulitis) * Septic shock develops Bullae, indicating skinischaemia Skin progresses to grey Colour due to necrosis Subcutaneous tissues have @wooden-hard feel From intense pain to anaesthesia like pain due to nerves being destroyedAs necrotising infection is deep within the skin and is not visible it is often difficult to diagnose. PLA Coursed- Staphylococcal Scalded Skin Syndrome (SSSS) Ritter's disease > Characterised by red, blistered skin, resembling a scald. Caused by: Staphylococcus aureus producing epidermolytic Patients présént with fevet, generalised erythema and skin tenderness. The tender Bulla’ are (contact with the intact skin causes the upper epidermis td 'slip) and develop within 48 hours. They commonly affect ind as the name suggests, appear as Management: Y Hospital admission“is.often require Y Fluids, nutrition and analgésia, Antibiotics: Flucloxacillin x iDe- Paronychia _(whitlow) ¥ Inflammation of the Skin afOUNda irge GF teal ¥ Itcan be acute (< 6 weeks) or chronic (persisting > 6 weeks). _py Itmay be associated with felon (infection of the pulp of the are considered first line), "important" «| a >>> SE followed by packing with gauze. PLA Course 9 »scriber: darwishahmed5é60@gma3- Viral infection: a- Molluscum Contagiousm (pox virus): we + white or pink papules with an umbilicated (depressed) 6 \D\_ % They may be found anywhere on the skin. Ce They but can take around 6 to 24 “Smonths. (séif limiting condition) > rapidly become honey- coloured/ brown- coloured crusted plaques Initially Vesicles containing (clear fluid Start off as macules >> papules >> vesicles. Eventually >> they dry crust. There are always lesions at different stages (e.g. some papules, some vesicles, some crust). seen around the face, (especially mouth & nose. It can spread locally around the face (sometimes to the neck) but not as far down to the trunk. Around the mouth They can spread throughout the body (can spread to trunk). »/ Child Child Adult not commonly itchy Itchy do not spread fast Spread fast PLA Coursec- Herpetic whitlow A breakin the skin which allows the virus to enter. Vesicles are formed in the distal phalanx Se6n in dentists, nurses or children who suck their fingers >> in contact wit tips >> may shed the virus. Pen Cre Ald ed Bares a PLAB I Course 13d- Erythema infectiosum (parvovirus B19) > usually self-limiting + mainly occurs in young children. > Symptoms include : an erythematous maculopapular rash, starting on the face (slapped cheek) with mild fever. It usually @ pares the nasolabial folds and eyes. Se on the face is then followed by a lacy erythematous rash on ws extends to the trunk, lasts 2 to 4 days. The child is us ly wel. 2 siiple analgesias such as paracetamol or ibuprofen. pl o, Urgent full wo count féluding reticulocyte count is only required for patigr who reathless, dizzy, confused or lethargic. (aplasti sei ie by parvovirus in patients who tae cell ai emia, thalassaemia, or hereditary spherocytosis), G The child is no longer infe ae aaa itis © oe ms “lron xe % “Lacelike" rash ‘on extremities PLA Course subscriber: darwishahmed560@gmail com4- Fungal infect a- Tinea Capitis > Itis a fungal infection involving the hair follicles and causing hair loss (fIBBEEIS) very rapidly. > Because of the isk of scarring, treatment is with a systemic (such as oral antifungal itraconazole, or fluconazole) >>>> In children >> Griseofulvin is used. ral Terbinafine, b- Scaly ring worm: (dermatophtosi5- Parasitic infestation: Scabies Scabies is a parasitic skin infection characterized by superficial burrows and intense itch. Aetiology : ~~, Sarcoptes scabiei (transmitted by skin-to-skin contact) Clinical Findings : © Praftitus, papulesylinear tracks and burrows are commonly fouridon flexor surfaces of wrists, finger webs, elbows, axillary-folds, areola of the breast in women, and genitals of the males? ©. The mites canbe extracted from burrows using a needle which is very Satisfying althiough not required for diagnosis. Treatment: 4 © Scabies treatments with permethrin 5% which is first-line (malathion 0.5% is second-line) © Note: all household andielose physical contacts should be treated at the same time, even if asymptomatic Permethrin should be applied to the whale body, except the head. Repeat treatment with permethrin is necessary after 7 days. PLAR 1 Cou frre6- Papulosquameous disorders: 1- Lichen planus: Lichen planus is a skin disorder of unknown aetiology, most Sw probably being immune-mediated. Features “S, * Purple, pruritic, papular, polygonal rash on flexor By surfaces Oe Lacy white-pattern on the buccal mucosa “Wwinemonic: >> 4P Purple Pruritic Papular Polygonal Lichen Planus, Lacy Pattern rash >>> LP - G2- Psoriasis : Presentation: * Itchy, well-demarcated circular-to-oval bright red/pink elevated lesions (plaques) with overlying isCHbution: SAREE NII body surfaces and the scalp >>> Involve mostly elbow or knees, as these are the common areas affected in-plaque psoriasis (the most common type of psoriasis) ing, onyebalysis int bleeding - AUspitz"sign + New lesions appeaf'3t sites of injUry to the skin - ROBREESFESEHON * May have a family histoty (strong ge fatic basis) * Relapses * Vigorous scrapin®-causes pi! Management : Corticosteroids, vitamin D analogues-and tar préparations7- Dermatitis and eczema: Eczema: * Chronic, relapsing, inflammatory skin condition itchy red rash © Affects skin creases such as the folds of the elbows or behind the knees (skin flexures) Common in children >, Inet everest of eczema, The cheeks ‘Of infants aré often affected first. This is followed by a wide ARribution over jhe body. * Triggered by environmentgtirritants and allergens * Often associated with other atopic diseases such as asthma and hay fever Presentation: ¥ (IBIRPERB (dry skin, infrequent itching, small areas of redness) (BGERESLEAE (Ary skin, frequent itching, redness, may have presence of v SvereIeezeMna (dry skin,-very frequent itching, redness, excoriations, extensive skin thickening, bleeding, interferes with eating and sleeping)Management: >>>>> Elin anid topical steroies Eczema management Step 1- Step 2 - Topical steroids Step 3 - Tacrolimus, phototherapy, systemic therapies like monoclonal abs and immunosuppressants WRERBIEREEemollient.with a soap dispenser would be ideal to avoid contamination ofthe cream. (use emollients 30 mins before the use of stéfoids) > Start with the milder forms and if eczema is not controlled, we step up using a moré potent steroid. Topical steroids are divided into the following: aks Wi * Mild : Hydrocortisone acetate 0.5%, (1%, 2.5% (commonly referred to as just hydrocortisone) * Moderate : Betamethasone valerate 0.025% (Betnovate RD), Clobetasone (Eumovate) Beta LEI Soul sone B * Potent : Betamethasone 0.1% (Betnavate), Hydrocortisone butyrate 0.1% (Locoid), Mometasone (Elton) Clobetasol propionate 0.05% (Dermovate) cee Least | Hydrocortisone —— << Cobetasone (Eumovate) Betamethasone (Betnovate) i) PLAB 1 CourseAtopic eczema flare-up management ¥ Emollients routinely for moisturising, bathing and washing (first line) + Change the emollient to one with higher lipid content and advise on applying more emollient each time as well as applying it more often use emollients at least twice a day Y Topical corticosteroids for eczema itself (second line) Y Treat bacterial infection if present with oral antibiotics (Flucloxacillin as the first-line choice) are used for a week only ¥ If awake dtttight, consider a sedative antihistamine ¥ Avoid environfental irritants and stresses where possible i) PLAB 1 Course aSeborrheic Dermatitis: * Scaling rash * Affects sebaceous glands * Found on face, scalp and chest * An inflammatory reaction to a yeast « Presents as inflamed, greasy areas with fine scaling + Can present as dandruff when manifested on the scalp © Managemént : Regular antifungal medication and intermittent fopical steroids PLA Course 2 sRahrirecEczema herpeticum “isa rare life-threatening disseminated viral infection seen as clusters of EERIE or punched-out IRIS with Derusting “Seen usually in children with a history of eczema. “\# It is mostly caused by primary infection of HSV type 1 or 2. Features: “Go Fever & Malaise Ne Intense itching and pain o EES, papules and pustules ° Small punchéd'out ulcers ° oodg & calls Investigation: ¥ Bacterial swabs (eczemafherpeticum can be complicated by secondary Bacterial inféation with staphylococcus leading to impetigo) ~ Management PLA Course firmed 560Dermatitis Herpetiformis (linked to celiac disease) ¥ 2 patient with bloating, loose stools, abdominal pain, iron deficiency anemia, folate deficiency >>> Celiac disease. “CL With SENEREIMIRCHWIREER distributed over scalp, sacrum, elbows, knees >>> Dermatitis Herpetiformis. Y in Celie Disease: Tse Tansaltaminase eA, endomysial Abs 24* The typical lesion is (wheals) >> central itchy white papule or plaque, surrounded by an erythematous flare. # The lesions are variable in size and shape and may be associated with swelling of the soft tissues of the eyelids, lips and tongue ( 6 weeks Remember that urticarialrashes tendo last less than 24 hours "Here today and gone tomorrow". Urticaria >> disappear within 24 jits urticarial vasculitis >>doesn’t disappear within 24 hrs >>> Skin Biopsy Management {OfSINIMieResnanvelas BiSsnantar 1- identify and treat the cause. (Nonspecific aggravating factors should be \)- such as overheating, stress, alcohol & caffeine) 2- Antihistamines: >>> Non-sedating H1 antihistamines are the mainstay of treatment (| 3- In pregnancy chlorphenamine: 1st choice of antihistamine (sedating)¥ jhypersensitivity reaction that is most commonly triggered by infections. v It may be divided into minor and major forms. Features » Target lesions-MULTIPLE *& A vesicle surrounded by‘2n often hemorrhagic maculopapule DUSK FadIbiisteringlEenErE, with surrounding pale area % Initially seen orrthe back of the hands / feet before spreading to the torso (the trunk) + upper limbs > lower limbs affection Causes: ¥ Mycoplasma ( flu like symptorns-+ cough + fever + target lesion) v Penicillin ¥ Sarcoidosis, CT diseases, malignancy 6r idiopathicif symptoms are severe and involve blistering >>>> Think Steven Johnson Syndrome (different entity) ii vomcccsscnsanien ey sete Beer saa ee 2 Erythema Nodosum: > Tender, iene Sone > Usually over shins > May occur elsewhere e.g. forearms thigtis > Causes: ¥ ‘Sarcoidosis, 78 Y Drugs e.g. Penicillins, COCPs Y pregnancy PLA Course Hime+ Pink rings on torso or inner surface of limbs * * Barely raised and are non-itchy “+ Causes: + Reaction caused by chronic ‘exposure to infrared radiation in the form of heat * Usually an elderly w PILAR Course 2B criber: darwishahmed5 gmail.co10- = Malignant tumo: a- Malignant melanoma: A form of skin cancer developing from melanocytes. * Blue or green eyes * Multiple a . radietherapy D Diameter ‘V4 Inch Multiple Larger Than 1/4 Pa GOW Gait E Evolving ‘Smaller Than Ordinary Mole a... Changing in Colors Inch Size, Shape and + Calor OFFtManagement : * Excisional biopsy is performed on any suspicious lesion * Depending on the stage, management includes excision, chemotherapy, immunotherapy and topical imiquimod Prognosis : + BRESISWHERIERRESS is an excellent indicator of the prognosis with wordehing progrésig with an increasing depth (RE Westnet + Sentinel noes involvement of indicates poor prognosis A patient with Benign mole that does not bleed or interfere with life. What should a GP do’if the patient wants his mole removed? Refer to a PRIVATE Dermatology clinic. (Not Plastic, Nor NHS) NHS Does not usually provide Cosmetic services. i) PLAB 1 Course 30b- Basal cell carcinoma (rodent ulcer): Basal cell carcinomas (BCCs) are slow-growing, locally invasive malignant epidermal skin tumours. is ctor: ¢ predisposi * radiotherapy ‘The sun-exposed areas of thie head and neck are the most commonly but can appear at involved sites ( other places on tl raised areas with] © Indurated edge a subscriber: darwisfiblmeds<60@qmail.comc- squamous cell carcinoma: A scaly or crusty lump without pigmentation and the rolled border + can also ulcerate. “2 Ay A 6. g oe % d- Cutaneous Reta firm, round or oval non-painful nodule subscriber: aera an 2 Piceds60@gmail.com11. Acne vulgaris * acommon skin disorder which usually occurs in adolescence. *, It typically affects the + Cit is characterised by BOMEGONES) inflammation and BUSEUIES. Pathophysiology (multifactorial): Follicula¢ epidermal hyperproliferation resulting in the formation of a Keratin BIUB. This in-turn causes obstruction of the pilosebaceous follicle. % colonisation iy the ahiaerobielbacteriuim Propionibacteriurn acnes. HR acaing topi¢arbenzoyl peroxide (BPO) to the antibiotics >>> \ resistant}Propionibacterium acnes in patients with acne receiving antibiotic therapy. Astey scheme in the management of aéne.: ¥ single topical therapy (topical fetinoids "isotretinoin", benzoyl peroxide) 4292 Joly Flys ¥ Topical combination therapy (topical antibiotic, benzoyl peroxide, topical retinoid) ass as ¥ Oral antibiotic: tetracyclines: lymecycliné, oxytetracycline, doxycycline. (A single oral antibiotic shduld be used for a maximum of three months). + A topical retinoid (if not contraindicated) or benzoyl peroxide >> co-prescribed with oral antibiotics >> the risk of resistance Giila) + pill) sys alas i) PLAB 1 Course 33** Topical and oral abs should not be used in combinatior ** Tetracyclines should be avoided in pregnant or breastfeeding women and in children younger than 12 years of age. (Erythromycin may be used in pregnancy). ** Retinoids (oral and topical) are contraindicated in pregnancy. ¥ (COCPs) are an alternative to oral antibiotics in women. "They should be used ic combination with topical agents". Y Oral isotretinoin: ‘only under specialist supervision. ¥ Gram-negative folliculitis may occur as a complication of long- term antibiotic use high-dose oral trimethoprim is effective if this occurs. Stage 1 Stage(2 Stage 3 MILD MODERATE, SEVERE ian = oeeteestale Il funciona - aeagesaa’ |) Saeco onan a ‘secre Bo 3a { Pra | Pe 5 - PLA Course 34 rahe:Pregnancy W also known as pruritic urticarial papules and plaques of pregnancy <4{PUPPP) ¥ Gharacterised by an itchy urticaria-like rash, raised lumps and inflamed areas of the skin that begins on the abdomen. It has a class{o feature of Sparing the umbilicus. It usually happens in the woman's first pregnancy around the third trimester. SPA 3 Al das ds) Y Itchy rashes that develop inté blisters. ¥ Itis mistaken for PEP as both mayIdok similar during the early form. PLA Course rahe:13- Miscellaneous topics ** Rosacea Aommon chronic relapsing rash, usually occurring on the face Affects fhiddle-aged (age range 40 to 60 years old) and fair skinned ‘© Red papules and’pustules on the nose, forehead, cheeks & chin © Frequent © Red face due to persistent redness and/or prominent blood vessels — K Ageravation by sun exposure, alcohol and hot and spicy food © Fibrous thickening causing rhindphyma (Rhinophyma is an enlarged nose assOciated with rdsacea which occurs almost SSE) “> ° © Fora diagnosis to be coftfirmed the‘efythema should have been present for ° Management: ~GNhat Makes Rosacea Topical metronidazole or azelaic acid ie sek oui Oxytetracycline or tetracycline 36The main differences between acne and rosacea: Acne >>>Pustules and comedones sacea >>>Pustules, flushing , telangiectasia Mongolian blue spot al métanosis) They are a type of pigment&aFa t, congenital birthmarks commonly seen in an oriental baby although it can occur in any race. They are typically found at the vf the first year. 5 PLAB I Course subscriber: darwishahme:Bullous pemphigoid: > rare but the commonest autoimmune blistering seen in western countries. D> may be to one area or widespread on the trunk and Grima limbs. 3s are usualy (APRS of extremities andtlower trunk. > Patiénts may be site mically unwell if there is secondary fect . > It mainly affects oxoruver 60 years old. on ee a Pemphigoid Ge ‘Autoimmune cisease of elderly = rrp individu subscriber: darwistiaferids60@gmail.comXanthelasma:(Xanthelasmata = Xanthoma = Xanthelasma Palpebrum) Multiple, ctferent sited, lla So ied lags ones They occur with or without hyperlipidemia. Mariagement 's should have their fasting lipid levels checked. -> cardiovascular risk assessment + measures Various options are available including gical excision (with or without skin grafting for fatge lesions), chemical treatment, laser treatment and cryocautery. Full-thickness-skin grafting obtained via blepharoplasty is available. “<) Lipid-lowering medication and diet effect on these lesions. gvLipoma: » Lipomas are benign soft-tissue masses consisting of fatty tissue “enclosed by a fibrous capsule. They are SOfENUBBERIA The diagnosis is usually made clinically without the need for imaging. if there was doubt in thé diagnosis, ultrasound scans are usually performed: é > Typical lipomiasiare: well-defined, compressible, masses with no acoustic shadowing or flow ‘oncolour Doppler sonography. > Suspicious features for linosarcomia: heterogenous echotexture or significant colour Doppler flow, %> MRI (MRI are the modality of choice for imaging lipomas) v Removal by excision is unnecessaryunless théte is doubt of its diagnosis with imaging or if it is intérfering with’the patient's activities (e.g. difficulty sitting back against a clair). 1S5> patient presents with a typieal lipoma ( the mass is not growing at { all) >>> just FEASSUFEIBREINO InVEStigations are required | >>> patient presents with a OSSIBIEIIIBOMa Oh bekeIbIeNiposareoma # and you are unsure >>> refer for an (SURESH ! 55> ultrasound scan shows NINE refer for an I 4 scan Vice APDRO ERROR Di aaa Dito ritosencn ovaries innate i iThe oval lesions: > Starts with a Herald patch (2 to 5 cm pink plaque) >> 1-2 weeks Sr eau ‘© later >>> follows smaller groups of oval lesions with a fine scale to 1cm) over several days > ‘Many patients report recent respiratory tract infections ‘tion with the longitudinal parallel to the line of Langer subscriber: darwistiafereds60@gmail.com+ Numerous small patches (<1cm) HESEGPO, S€S1V BABUIES on the trunk and limbs (Fine, silvery scales over lesions) (Se Most cases have a history of a streptococcal infection haryngitis, tonsillitis) 2 to 3 weeks prior to rash (Persist more than 3 months Most cases resolve spontaneously * Treatment ee “A * May look like a herald wie * Lesion spreads out from cent hypopigmentation and a scaly © Itchy + May look like tinea corporis or herald patch . * Single oval plaque usually size 1to3cm © Very itchy * Scrapings >> mycology as may look like tinea corporis Course subscriber: darwishiaen ned5* Multiple oval macules * Colour of lesions can vary (e.g. pink, red brown, pale brown) sions have fine scales M@stly asymptomatic but may be mild itchy * OccurSn the upper'trunk, neck and face A * Onset Qsually cote months) and subtle (unlike guttate psoriasis whi ich-is an acute onset) A * May coexist eborthei¢ dermatitis as both conditions are st associated wi (malasse2ia) overarowth c ry. © On pcan 1 one subscriber: darwishahmed560@gmail.comActinic Keratosis (Solar Keratosis) found on sun-exposed areas (scalp, hands, forearms, face) Risk factors + Csun exposure * Immunosuppressed Presentation middle-aged or elderly fair-skinned person) * fixed erythema on the face/ Can be pink, red, or brown * Range from slightly palpable, scaly >> to very thick and hyperkeratotic (warty) lesions © 7 It is benign but a small/proportior:mhay progress to squamous cell carcinoma >>> Management >>> Advise the patient to uSe’sunblock. ‘Id treatments : + BieIBFERAEEM >> For mild lesions (palpable but not visible) «MEE >> For thin esions © + BEFUSrOUrseilNSaliovliciseld >>For moderately-thick lesions + RIGUIMEE >> For confluent lesions ; Physical treatments * Cryotherapy >> Suitable for thin lesions