HOW TO DEAL WITH A

DERMATOLOGICAL CASE

By:
Dr. Ashraf Hamza
Professor of Dermatology
Alexandria University
www.alexmedonline.com
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Functions of skin:
1. Protection
2. Temperature regulation
3. Sensation
4. Excretion
5. Synthesis of vitamin D
6. Absorption
7. Psychogenic function
For diagnosis of a dermatological
disease, certain items must be
fulfilled;

1- History taking.
2- Clinical examination.
3- Investigations (if needed).
 A) History
1-Personal History:
A) Name: for patient identification.
B) Age & sex: certain diseases
occur in certain age and sex. (acne
& C.T)
C) Occupation:skin exposed to
external environment. (house wives)
D) Residence: endemic disorder such
as leprosy.
2-Present History:
A)Complaint: may be disfigurement,
itching or burning sensation.
B)Onset: acute, chronic or acute
exacerbation on top of chronic
illness.
C)Course: progressive, stationary
or regressive.
3-Past History:
Important in recurrent disorders.
4-Family History:
Important in congenital and
infestation disorders.
5-Drug History:
Drugs taken before appearance of
the disease.
 B) Clinical Examination
1- General examination:
Skin disorders associated with
systemic disorders.
2- Local examination:
I) Examination of skin:
1- Examination from distance.
2- Close-up examination.
II) Examination of skin appendages:
Mucus membrane, nails and hair.
 Examination of the skin:

A) From distance:
Shows the distribution of
lesions that may be:
1) Discrete distribution:
Multiple lesions separated
by normal skin.
2) Unilateral distribution:
Lesions involving only one
side of the body.
3) Generalized distribution:
Lesions involving more than
50% of body surface area.

4) Grouped distribution:
Lesions are restricted to
a localized area.
5) Linear distribution:
Lesions are arranged a long
a line. It may be Kobner`s
phenomenon which is
appearance of isomorphic
lesions along the site of
blunt trauma.
6) Zosteriform distribution:
Lesions are restricted to
certain dermatome.
7) Follicular distribution:
Lesions are arranged along
hair follicles.
 B)Close-up examination:
Shows the border of
lesions that may be:
1) Well defined border:
Marked separation
between the edge of
the lesion and normal
skin.
2) Ill defined border:
Difficult to identify the
separation line between
the lesion and normal
skin.
3) Circinate border:
The lesion increases in size by
peripheral extension and healing at the
centre.
 Types of Skin Lesions
Skin lesions may be:
1-Initial lesions.
2-Secondary lesions.
3-Specific lesions.
A) Initial Lesions
1) Macule:
It is discolouration
of skin less than one
cm in diameter. If
larger than one cm,
it is called patch.
2) Papule:
Solid elevation of the
skin less than one cm in
diameter. If more than
one cm, it is called
plaque.
a) Dome shaped:
Papule with smooth
convex surface.
b) Flat topped:
Papule with flat
surface. It is described
as lichenoid papule.

c) Umbilicated:
Dome shaped papule
with central notch.
d) Verrucous:
Papule with fine
mammilated surface.

3) Nodule:
Elevated solid skin
lesion with dermal
extension.
4) Vesicle:
Fluid containing
lesion less than one
cm in diameter. If
larger than one cm,
it is called bulla.
 Flacid bulla
Intraepidermal separation

Subepidermal separation Tense bulla

 B) Secondary Lesions

1) Pustule:
It is elevated
lesion containing
pus.

2) Scales:
It is dry surface
due to abnormal
keratinization.
 Types of Scales:

a) Fine branny:
Pytriasis versicolor

b) Greasy:
Seborrheic Dermatitis

c) Lamellar:
Psoriasis
 Types of Scales:

d) Fish scales:
Ichthyosis

e) Collarette:
Pityriasis rosea

f) Horny (Keratotic):
Discoid LE
3) Crust:
It is dried
exudate, either
pus or blood.

4) Erosion:
It is superficial
epidermal loss.
5) Ulcer:
It is deep dermal
loss, thus it has
characteristic edge.

6) Fissure:
It is longitudinal
discontinuity of the
skin.
7) Atrophy:
It is thinning of skin
due to thinning of
epidermis or dermis
or both.

8) Scar:
It is replacement of
the skin by fibrous
tissue.
9) Lichenification:
It is a descriptive
term of 3 criteria:
A) Thickening of skin
B) Hyperpigmentation
C) Increased skin
markings
 C) Specific Initial Lesions
1) Wheal:
It is specific to urticaria.
It is edematous
erythematous lesion which
is migratory.
2) Scutulum:
It is specific for favus.
It is concavo-convex
golden yellow cup stuck
to scalp.
3) Comedone:
It is specific to acne. It
is either:
A)Black head: papule
with central black spot.
B)White head: small pale
papule.
4) Tunnel (Burrow):
It is specific for
scabies. It is a curved
line due to burrowing of
female mite to skin.
5) Target lesion:
It is specific to erythema
multiforme. It consists of 3
zones:
A)Central zone: cyanotic.
B)Intermediate zone: pale.
C)Outer zone: erythematous.
6) Herald patch :
It is specific for P. rosea.
It has 3 concentric zones:
A)Central café au lait.
B)Peripheral erythematous.
C)Intermediate collaretic
Examination of skin appendages
A) Examination of mucus membranes

Erosion Ulceration
Examination of skin appendages
A) Examination of mucus membranes

Plaque Pigmentation
White Streaks
Examination of skin appendages
B) Examination of nails

Nail Pitting Nail Discolouration

A) Examination of nails

Nail Fold Nail Dystrophy

Swelling
Examination of skin appendages
C) Examination of hair

I) Hair loss: either

1- Diffuse hair loss.
2- Patchy or alopecia:that may be
A) Non cicatrical.
B) Cictrical.
II)Hair growth in abnormal sites.
C) Examination of hair
C) Examination of hair
 INVESTIGATIONS
There are certain investigations
specific to the skin that can help in
the diagnosis of some skin diseases.
1- Wood`s light.
2- Skin scrapping.
3- Patch testing.
4- Immunoflourescent.
5- Skin biopsy and histopathology.
1- Wood`s Light:
It is a special ultraviolet light
which if thrown to:-
- Normal skin, it reflects deep
violet colour.
- Pityriasis versicolour, it reflects
golden yellow colour.
- Erythrasma, it reflects deep red
colour.
- Tinea Capitis, it reflects brilliant
green colour.
Wood`s Light Examination

1 2
2- Skin Scrapping:
It is used for diagnosis of fungal
infection of skin.
Procedure:
Skin is scratched by scalpel. The
resulted scales are placed on glass
slide, then 10% KOH is added and
examined under the microscope.
 Skin Scrapping

Scrapping of Hyphae of
Skin by Scalpel Dermatophytes
 Hair Sample

Endothrix Ectothrix
3- Patch Testing:
It is used for diagnosis of contact
dermatitis.
Procedure:
Aluminum strip with multiple holes is
fixed on the back. The antigens are
placed each in one hole. Then, another
aluminum strip is placed over the
previous one and left for 48 hours. On
removal of the strip, we examine the
sites of different allergen for erythema
and vesicles. If present, the test is
positive.
Patch Testing Positive Result
4-Immunoflourescent Tests:
They are used for diagnosis of
autoimmune disorders. They are either:
1- Direct test:
It detects antibody in the skin. Skin
biopsy is taken and flourescent anti-
antibody is placed on it.
2- Indirect test:
It detects antibody in the serum of
patient. Flourescent anti-antibody is
added to the serum of the patient.
 1 2

Positive Immunoflourescence
5- Skin Biopsy:
It demonstrates the pathological changes
in the diseased area. It is usually
diagnostic.
Histology of skin (epidermal layers):
1- Horny layer (stratum cornium)
2- Granular cell layer (stratum granulosum)
3- Prickle cell layer (stratum spinosum)
4- Basal cell layer (stratum basale)
 Horny layer
Granular cell layer

Prickle cell layer

Basal Cell Layer

Basement Membrane

Melanocyte

Dermis

Histology of Skin
 Pathological Terms:
1-Hyperkeratosis:increased thickness
of horny layer or stratum cornium.
2-Parakeratosis: retention of nuclei
in horny layer or stratum cornium.
3-Hypergranulosis: increased
thickness of granular cell layer or
stratum granulosum.
 Pathological Terms:
4-Acanthosis: increased thickness
of prickle cell layer. Either uniform
or saw tooth acanthosis.
5- Spongiosis: edema of prickle cell
layer or stratum spinosum.
6-Acantholysis: loss of coherence
between Cells of prickle cell layer or
stratum spinosum.
Histology of Normal Skin
Hyperkeratosis, hypergranulosis & acnathosis
Parakeratosis
Hypergranulosis
Acantholysis
Hypergranulosis
 Therapy
in
Dermatology
 Therapy in Dermatology
Principles of Topical Therapy:
 Type of skin lesion: wet lesions needs
creams while dry lesions need ointments
 Never do any harm: do not use irritant
and sensitizers
 Never overtreat: this usually occurs
when a patient ask a friend and use many
medications
 Principles of Topical Therapy
 Instruct the patient adequately: it is
not important to tell a patient how to
swallow a pill but it is essential to tell
patients how to apply local medications
 Prescribe the correct amount of
medication for the area and dermatoses to
be treated
 Change the therapy as the response
indicates
 Principles of Topical Therapy
 If the prescription is expensive, explain this
fact to the patient
 Therapy plus is usually indicated, advise the
patient to continue to apply the medications for a
specific period after the dermatoses apparently
cleared. This is to prevent recurrence.
 Ask the patient to contact you if there is any
question or if the medicine appeared to irritate
the dermatoses
Effects Of Locally
Applied Drugs
 Effects of Locally Applied Drugs

 Antipruritic Agents: relieving itching in

various ways. Example Calamine lotion
 Keratoplastic Agents: increase the
thickness of horny layer. Example: Tar and
salicylic acid in 1%-2% concentration
 Keratolytic Agents: remove or soften
horny layer. Example: Salicylic acid 4%-
6%, urea 20%-40%& lactic acid 20%
Calamine Lotion
 Effects of Locally Applied Drugs

 Antieczematous: stop the secretions by

various actions. Example: corticosteroids

 Antiparasitic Agents: destroy or inhibit

living infestations. Example: permethrim 5%

 Antiseptics: destroy or inhibit bacteria,

viruses or fungi
 Effects of Locally Applied Drugs

 Antibacterial topical medications: destroy or

inhibit bacteria. Example: gentamycin, fusidic
acid, erythromycine, tetracycline, neomycin, and
chloramphenicol

 Antiviral Topical Agents: destroy of inhibit

viruses. Example: acyclovir

 Emollient Agents: soften skin surface.

Example: cold cream and vasline
Types of Local
Medications
 Types of Topical Medications
 Compresses: remove the crust. Example:
potassium permenganate 1/8000 and
saline
 Types of Topical Medications
 Drying Agents: dry oozing skin.
Example: gentian violet 1% and
microchrome 1%
 Types of Topical Medications

Creams:
They are semisolid emulsion systems
containing both oil and water. They are
water miscible, cooling and soothing, and
are well absorbed into the skin.
They are used in acute oozing skin
disorders.
Creams
Types of Topical Medications

Ointments:
They have oil or grease. They are
semisolid and anhydrous substances.
They are used in chronic, dry skin
disorders.
Ointment
 Types of Topical Medications

Gels:
They are semisolid preparations gelled with
high molecular weight polymers, such as
methylcellulose. They are non-greasy, water
miscible, easy to apply and wash off.
They are especially suitable for treating hairy
parts of the body.
Gel
 Types of Topical Medications
Paints:
They are liquid preparations, either aqueous,
or alcoholic (tinctures), which are usually
applied with a brush to the skin. They
evaporate, and are therefore cooling as well
as astringent and antiseptic.
They may also be used as protectives to seal
abrasions.
Paint
 Types of Topical Medications

Lotions:
They are combination of powder and
water
They are able to cover wide surface area of
skin due to increased evaporating surface
They are not suitable for xerosis pruritus
Example: calamine lotion.
Quantity of Creams
to Prescribe
 Quantity of Creams to prescribe

Factors affecting the quantity:

 Type of dermatoses: acute or chronic

 Base of topical medication: ointments
spread over skin more than creams
 Intelligence of the patients: educated
patients usually consume smaller amounts
 Quantity of Creams to prescribe

Surface Frequency Duration of Amount

Area of Application Needed
Application
1 Hand b.i.d. 14 days 15 grams

2 Arm b.i.d. 14 days 30 grams

3 Leg b.i.d. 14 days 60 grams

4 Entire b.i.d. 14 days 480-960

Body grams