Dermatology in general practice
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Dermatology in General Practice . Dr Lynne Rees. Description of skin lesions. Papule Macule Nodule Patch Vesicle Bulla Plaque. Papule . Small palpable circumscribed lesion <0.5cm. Macule. Flat, circumscribed non-palpable lesion. Pustule . Yellowish white pus-filled lesion. Nodule.

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Description of skin lesions
Description of skin lesions

  • Papule

  • Macule

  • Nodule

  • Patch

  • Vesicle

  • Bulla

  • Plaque


Papule
Papule

  • Small palpable circumscribed lesion

  • <0.5cm


Macule
Macule

  • Flat, circumscribed non-palpable lesion


Pustule
Pustule

  • Yellowish white pus-filled lesion


Nodule
Nodule

  • Large papule >0.5cm


Plaque
plaque

  • Large flat topped elevated palpable lesion


Patch
patch

  • Large macule


Vesicle
vesicle

  • Small fluid filled blister


Bulla
Bulla

  • A large fluid filled blister


Eczema
ECZEMA

  • Synonymous with dermatitis

  • Large proportion of skin disease in developed world

  • 10% of population at any one time

  • 40% of population at some time


Features of eczema
Features of eczema

  • Itchy

  • Erythematous

  • Dry

  • Flaky

  • Oedematous

  • Crusted

  • Vesicles

  • lichenified


Types of eczema
Types of eczema

  • Atopic

  • Discoid eczema

  • Hand eczema

  • Seborrhoeic eczema

  • Varicose eczema

  • Contact and irritant eczema

  • Lichen simplex


Atopic eczema
Atopic eczema

  • Endogenous

  • Atopic i.e asthma, hay fever

  • 5% of population

  • 10-15% of all children affected at some time


Exacerbating factors
Exacerbating factors

  • Detergents

  • Infection

  • Teething

  • Stress

  • Cat and dog fur

  • ???? House dust mite

  • ???? Food allergens

  • Theory of protection from parasite


Clinical features
Clinical features

  • Itchy erythematous scaly patches

  • Flexures of knees and elbows

  • Neck

  • Face in infants

  • Exaggerated skin markings

  • Lichenification

  • Nail – pitted ridged


Complications
complications

  • Bacterial infection

  • Viral infections – warts, molluscum, herpes

  • Keratoconjunctivitis

  • Retarded growth


Investigations
investigations

  • Clinical

  • ??IgE

  • ??RAST


Prognosis
Prognosis

  • Most grow out of it!

  • 15% may come back – often very mildly


Treatment
Treatment

  • Avoid irritants especially soap

  • Frequent emollients

  • Topical steroids

  • Sedating antihistamines – oral hydroxyzine

  • Treat infections

  • Bandages

  • Second line agents


Triple combination of therapy
Triple combination of therapy

  • Topical steroid bd as required

  • Emollient frequently

  • Bath oil and soap substitute


Principles of treatments
Principles of treatments

  • Creams

  • Ointments

  • Amounts required

  • Potential side effects

  • Soap substitutes


Creams
creams

  • Cosmetically more acceptable

  • Water based

  • Contain preservatives

  • Soap substitutes


Ointments
ointments

  • Oil based

  • Don’t contain preservative

  • Feel greasy

  • Good for hydrating


Topical steroids
Topical steroids

  • Mild – “hydrocortisone

  • Moderate – “eumovate”

  • Potent – “betnovate”

  • Very potent – “dermovate”


Amounts required
Amounts required

  • Emollients – 500g per week for total body

  • FTU – steroids

  • Bath oils – 2-3 capfuls per bath


Discoid eczema
Discoid eczema

  • Variant of eczema

  • Atopic and non atopic

  • Easily confused with psoriasis

  • Well demarcated scaly patches

  • Limbs

  • Often infective component (staph aureus)


Hand eczema
Hand eczema

  • Pompholoyx – itchy vesicles or blisters of palm and along fingers

  • Diffuse erythematous scaling and hyperkeratosis of palms

  • Scaling and peeling at finger tips


Hand eczema1
Hand eczema

  • Not unusual in atopic

  • More common in non atopics

  • Cause often uncertain

  • Irritants

  • Chemicals

  • Occupational history

  • Consider patch testing – 10% positive


Seborrhoeic eczema
Seborrhoeic eczema

  • Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur)

  • Strong cutaneous immune response

  • More common in Parkinson’s and HIV


Clinical features1
Clinical features

  • Affects body sites rich in sebacceous glands

  • Infancy – cradle cap, widespread rash, child unbothered, little pruritus

  • Young adults – erythematous scaling eyebrows, nasolabial folds, forehead scalp

  • Elderly – more extensive


Treatment1
Treatment

  • Suppressive

  • Mild steroid and antifungal combination

  • Ketoconazole shampoo

  • Emollients

  • Soap substitutes


Venous eczema
Venous eczema

  • Lower legs

  • Venous hypertension

  • Endothelial hyperplasia

  • Extravasation of red and white cells

  • Inflammation

  • Purpura

  • pigmentation


Clinical features2
Clinical features

  • Older women

  • Past history DVT

  • Haemosiderin deposition


Treatment2
treatment

  • Emollients

  • Topical moderately potent steroids

  • Soap substitutes

  • Compression – check arterial supply first

  • Leg elevation


Asteatotic eczema
Asteatotic eczema

  • Dry skin

  • Repeated soaping

  • Worse in winter

  • Hypothyroidism

  • Avoid soap

  • Emollients

  • Bath oils


Contact and irritant eczema
Contact and irritant eczema

  • Exogenous

  • Unusual

  • Worse at workplace

  • History of exacerbations


Irritant
irritant

  • Can occur in any individual

  • Repeated exposure to irritants

  • Common in housewives, hairdressers, nurses


Contact
contact

  • Occurs after repeated exposure but only in susceptible individuals

  • Allergic reaction

  • Common culprits – nickel, chromates, latex etc

  • Patch testing


Lichen simplex
Lichen simplex

  • Cutaneous response to rubbing

  • Thickened scaly hyperpigmentation

  • Emotional stress

  • May need biopsy to diagnose


Treatment3
treatment

  • Stop rubbing!

  • Very potent steroids

  • Occlusion



Psoriasis1
Psoriasis

  • Affects 2%of population

  • Well-demarcated red scaly plaques

  • Skin inflamed and hyperproliferates

  • Males and females equally

  • Two peaks of onset (16- 22) and later (55-60)

  • Usually family history


Chronic plaque
Chronic plaque

  • Extensor surfaces

  • Sacral area

  • Scalp

  • Koebners phenomenon


Guttate psoriasis
Guttate psoriasis

  • Raindrop

  • Children and young adults

  • Associated with streptococcal sore throats

  • Not all go onto get chronic plaque

  • May resolve spontaneously over 1-2 months



Flexural psoriasis
Flexural psoriasis

  • Later in life

  • Well demarcated red glazed plaques

  • Groin

  • Natal cleft

  • Sub mammary area

  • No scale


Treatment4
Treatment

  • Calcipotriol too irritant

  • Steroid


Erythrodermic and pustular psoriasis
Erythrodermic and pustular psoriasis

  • More severe

  • Need dermatologist!

  • Usually need oral therapy


Associated features
Associated features

  • Arthritis

  • Nail changes- onycholysis, pitting, discolouration, subungal hyperkeratosis


Prognosis1
prognosis

  • Chronic plaque tends to be lifelong

  • Guttate – 2/3 further attacks, or develop chronic plaque


Treatment5
treatment

  • Suit patient

  • Control rather than cure

  • Topical therapies

  • Light treatments

  • Oral therapy


Topical therapy
Topical therapy

  • Emollients

  • Vit D analogues- calcipotriol, calcitriol, tacalcitol (dovonex, silkis, curatoderm)

  • Tazarotene – (zorac)

  • Coal tar – alphosyl, exorex, cocois, polytar

  • Dithranol –dithrocream, dithranol 0.1% to 2% for short contact

  • Steroids – eumovate

  • Combinations – dovobet, alphosyl HC, etc


Light treatments
Light treatments

  • Not the same as sun beds!!!!

  • UVB

  • UVA



Cause of acne
Cause of acne

  • Common facial rash

  • Usually adolescents

  • May occur in early and mid adult life

  • Blockage of pilosebacceaous unit with surrounding inflammation

  • Androgens lead to increase sebum production

  • Increased colonisation by propionibacterium acnes


Clinical features3
Clinical features

  • Increased seborrhoea

  • Open comedones

  • Closed comedones

  • Inflammatory papules

  • Pustules

  • Nodulocystic lesions



Treatment6
Treatment

  • Consider site

  • Compliance

  • Inflammatory/non inflammatory lesions

  • Scarring

  • Fertility

  • Psychological effect


Topical treatments
Topical treatments

  • Benzoylperoxidase – OTC, PanOxyl 5 to 10%,

  • Azelaic acid – skinoren ,avoid in pregnancy

  • Antibiotics – clindamycin, erythromycin, steimycin

  • Retinoids – adapalene, tretinoin, avoid in pregnancy, avoid uv light, differin, retin-A


Combination topical treatments
Combination topical treatments

  • Antibiotics plus benzoyl peroxidase – benzamycin

  • Retinoid plus antibiotic – isotrexin

  • Antibiotic plus zinc - zineryt


Oral therapy
Oral therapy

  • Use if topical therapy ineffective or inappropriate

  • Anticomedonal topical treatment may be required in addition

  • Don’t combine topical with oral antibiotic as encourages resistance.

  • Consider side effects and interactions when starting antibiotics

  • 3 to 4 months before any improvement


Antibiotics
Antibiotics

  • Oxytetracycline 500mg bd

  • Tetracycline 500mg bd

  • Doxycycline 100mg od

  • Minocycline 100mg od

  • Erythromycin 500mg bd


Hormone treatment for acne
Hormone treatment for acne

  • Dianette - not if COCP contraindicated

    • Withdraw when acne controlled

    • VTE occurs more frequently in women taking dianette than other cocp.


Oral retinoids
Oral retinoids

  • Hospital only

  • Long list of side effects

  • Teratogenic

  • Very effective



Clinical features rosacea
Clinical features rosacea

  • Onset middle age

  • Facial flushing / erythema

  • Inflammatory papules

  • Pustules

  • No comedones

  • Telangectasia

  • Blepharitis

  • rhinophyma


Treatment7
Treatment

  • Supressive rather than curative

  • Topical metronidazole 0.075%

  • Tetracycline 500mg bd for 3 months

  • Metronidazole 400mg bd

  • Roaccutane

  • Plastic surgery and some laser therapy for rhinophyma


Coffee

COFFEE

TIME


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