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Dermatology

Minci Yazumin
Outline
• Approach to patient
• Identify skin lesions
• Skin infections
• Papulo-squamous/inflammatory rashes
• Systemic disease
• Skin tumours
• Skin failure + ER
History taking
• Time course of rash
• Distribution of lesions – flexural, extensor, acral,
symmetrical, localized, widespread, facial,
unilateral, linear, centriceptal, annular and
reticulate.
• Symptoms – itch/pain
• FH (atopy & psoriasis)
• PMH
• Provocating f(x) – sunlight & diet
• Previous skin Tx
Examination
• Look and Feel
• Concentrate on colour, moisture,
temperature, turgor, presence of
pathological efflorescence, bleeding
manifestations, and oedemas.

• Assess – Nails, Hair and Mucosal
Surfaces
• Colour • Moisture
2. Pale – whole, local 2. Enhanced – Local,
3. Red Diffuse
4. Blue – central, peri 3. Reduced
5. Yellow – jaundice,
xantosis
6. Brown – localise, diffuse
7. Grey-brown
8. Albinism
9. Addison’s disease
• Temperature • Skin efflorescence
2. Increase – • Trophic skin
reddening, oedema changes – vascular
(inflammation) & innervation
3. Decrease – pallid, disorders
cold skin 3. Bedsore(decubitus)
( ischaemia, 4. Varicose ulcer
Raynaud’s)
Skin turgor
• depends on hydration of the skin,
the epidermis and its structure.
Decreased turgor is common in older age and
is caused by decreased elasticity of epidermis.
In other cases dehydration caused by fluid loss
contributes to decreased turgor (decompensated
diabetes mellitus, diabetes insipidus, intensive
diuretic therapy) or dehydration can be caused
by insufficient intake of fluids (reduced thirst
feelings in elderly people). The combinations of
both causes are frequent, too.
• Hair • Nails
• Thin hair can be found in both
sexes in hypogonadism, • Fragile and fraying nails are
hypopituitarism, hypothyroidism, most common in thyrotoxicosis
and hepatic cirrhosis and in males and sideropenic anaemia.
treated by oestrogens.
• Spoon-shape bent nails
(koilonychia) occur in
• Stronger and denser hair thyrotoxicosis.
(hypertrichosis, hirsutism) is • Spherical nails accompany
important in women. Cushing's congenital heart disorders, chronic
syndrome. More severe forms pulmonary diseases; less
accompany androgenic tumours of frequently can be found in hepatic
the adrenal cortex and androgen cirrhosis as a part of clubbed
treatment (doping!). fingers (the shape of wrist watch
glass).
• Alopecia is diffuse or local loss of • "White" (hepatic) nails occur in
hair. It occurs in cytostatic hepatic cirrhosis (the white part of
treatment, in abdominal typhus, the nail, so called lunula occupies
and thyrotoxicosis. In some men, a significant part of the nail area).
the diffuse alopecia is a common • Nails deformed with uneven
finding. Local alopecia (alopecia surface, thick, changed in colour
areata) is rather rare to find. (particularly on toes) are affected
by mycosis (onychomycosis
• Atrophy – thinning of skin
• Bulla – large fluid-filled blister
• Crusted – Dried serum or exudate on skin
• Ecchymosis – large confluent area of purpura
(bruise)
• Erosion – denuded area of skin (partial
epidermal loss)
• Excoriation – Scratch mark
• *Perleche (lip licking) , neurotic excoriation
• Lichenification – Thickened epidermis with
prominent normal skin markings
• Macule – Flat, circumscribed, non-palpable
lesion. Generally less than 5cm with different
colour from surrounding tissue
• Papule – Small palpable, circumscribed ,
elevated lesion (< 0.5cm)
• Nodule – large papule (.0.5cm)
• Petechiae – pinpoint-sized macule of blood in
the skin
• Plaque – Large, flat-topped, palpable lesion
Purpura – large macule or papule of blood in skin
which does not blanch with pressure
• Pustule – Yellowish white pus-filled lesion
• Scaly – Visible flaking and shedding of skin
surface
• Telengiectasia – Abnormal visible dilation of
blood vessels
Ulcer – deeper denuded area of skin (full
epidermal and dermal loss)
• Vesicle – small fluid-filled blister
• Weal – Itchy raised ‘nettle rash’-like swelling due
to dermal oedema
Drug-induced rashes
• Maculopapular - penicillin
• Urticaria (Hives)
• Penicillin, aspirin
• Vasculitis
• Gold, hydralazine
• Fixed drug rash – Phenolpthalein in
laxatives, tetracyclines, paracetamol

• Pigmentation – Minocycline (black),
amiodarone (slate grey)

• Pustular - carbamazepine
• Lupus erythematosus
• Penicillamine,
isoniazid
• Photosensitivity
• Thiazides,
chlopromazine,
sulphonamides,
amiodarone.
• Erythema nodosum
• specific painful red and
violet infiltrates located on
the shanks (sarcoidosis,
idiopathic intestinal
inflammations, or
the origin may be
unclear).
• Sulphonamides, oral
contraceptive pills
• Erythema multiforme
(EM)
• acute, self-limiting,
inflammatory skin
eruption. The rash is
made of spots that are
red welts, sometimes with
purple or blistered areas
in the center. It often also
affects the mouth, eyes
and other moist surfaces.
• Barbiturates
• Acneiform
• comedones,
papulopustules, cysts,
or nodules that
resemble acne
vulgaris
• Corticosteroids
• Lichenoid
• keratinocyte
enlargement
associated with
Civatte body (colloid
body) production
• Chloroquine,
thiazides, gold
• Toxic epidermal
necrolysis
• Penicillins,
cotrimoxazole,
carbamazepine,
NSAIDs
• Pemphigus
• autoimmune disorder
that causes blistering
and raw sores on skin
and mucous
membranes
• Penicillamine, ACE
inhibitors
• Eryhtroderma
• generalized skin disorder
characterized by
reddening and scaling of
100% of the skin. It is
also known as
erythrodermatitis,
generalized exfoliative
dermatitis, and red man
syndrome. There may
also be normal areas of
skin present
• Gold, sulphonylureas,
allopurinol.
Skin Failure and ER
Dermatology
Toxic epidermal necrolysis (TEN)
• detachment of the epidermis from the dermis all over the
body.
• TEN affects mucous membranes - mouth, eyes, and
vagina.
• The severe findings of TEN are often preceded by 1 to 2
weeks of fever. These symptoms may mimic those of a
common upper respiratory tract infection.
• When the rash appears it may be over large and varied
parts of the body, and it is usually warm and appears
red. In hours, the skin becomes painful and the
epidermis can be easily peeled away from the underlying
dermis.
• The mouth becomes blistered and eroded, making
eating difficult and sometimes necessitating feeding
through a NG tube or a gastric tube. The eyes are
affected, becoming swollen, crusted, and ulcerated.
• First Line: early withdrawal of culprit drugs, early referral and
management in burn units or ICU, supportive management,
nutritional support
• Second Line: Intravenous immunoglobulin (IVIG) - Uncontrolled
trials showed promising effect of IVIG on treatment of TEN
• Third Line: cyclosporin, cyclophosphamide, plasmapheresis,
pentoxifylline, N-acetylcysteine, ulinastatin, infliximab, Granulocyte
colony-stimulating factors (if TEN associated-leukopenia)
• Systemic steroids are unlikely to offer any benefits.

Prognosis
• The mortality for toxic epidermal necrolysis is 30-40%
• Deaths are caused either by infection or by respiratory distress
which is either due to pneumonia or to the damage to airway linings.
Stevens Johnson Syndrome
• Milder form of TEN; hypersensitivity complex, rare - 1
case per million people per year.
• flu-like prodormal period of fever, sore throat, and
headache, which may also be accompanied by
photophobia and redness in the eyes, followed by the
sudden development of circular mucocutaneous lesions
that can cover the majority of the skin.
• These lesions begin as macules and can develop into
papules, vesicles, blisters, or urticaria.
• SJS is usually defined to refer to those cases where less
than 10% of body surface is involved
• Caused by infections usually following viral infections, allergic reactions to
drugs, malignancy or idiopathic factors (up to 50% of the time). SJS has
also been consistently reported as an uncommon side effect of herbal
supplements containing ginseng. SJS may also be caused by cocaine
usage.

Treatment
• Discontinue all medications, particularly those known to cause SJS
reactions.
• Treatment is initially similar to that of patients with thermal burns, and
continued care can only be supportive (e.g. IV fluids) and symptomatic (e.g.
analgesic mouth rinse for mouth ulcer); there is no specific drug treatment
• Treatment with corticosteroids is controversial since it might aggravate the
condition or increase risk of secondary infections. Other common supportive
measures include the use of topical pain anesthetics and antiseptics,
maintaining a warm environment, and intravenous analgesics.
• An ophthalmologist should be consulted immediately, as SJS frequently
causes the formation of scar tissue inside the eyelids leading to corneal
vascularization and impaired vision, as well as a host of other ocular
problems. Also, an extensive physical therapy program ensues after the
patient is discharged from the hospital
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