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Back to the basics lmcc preparation dermatology

Back to the BasicsLMCC PreparationDermatology

Jim Walker

Assoc. Clinical Prof. Medicine



  • Ottawa U Dermatology Block Slides

  • UBC Dermatology Undergraduate Problem Based Learning Modules

  • Good Quiz site & Resource – Johns Hopkins Univ.

  • eMedicine Textbook

  • Medline

  • University of Iowa Dept of Dermatologyhttp://tray.dermatololgy/

  • Dermatology Online Atlas

  • * Please do not use images without attribution or permission!


  • Living gross pathology of skin, hair nails and visible mucosae

  • Review basic lesions, the nouns (papules, ulcers etc.)

  • Add the adjectives (size, shape, colour, texture, etc.)

  • Consider distribution, symmetry and pattern

  • Visual literacy: simple descriptions→complex interpretations (you see, but do you observe?)

  • Excellent lighting

  • Position patient

  • Look all over (skin, mucosa, hair, nails)

  • Observe and think


Pathology – high degree of clinical pathological correlation

Assess depth of lesion in skin

Bacterial skin disease
Bacterial Skin Disease

  • Barrier – dry, tough, acidic, Ig in sweat, epidermal turnover every 28 days

  • Normal Flora: Gm+, yeasts, anaerobes, Gm-

Bacterial skin diseases
Bacterial Skin Diseases

  • Impetigo

    • Bullous and non-bullous

  • Folliculitis/furuncle

  • Erysipelas/cellulitis

  • Necrotizing Fasciitis

  • Toxin diseases: SSSS, Scarlet fever, toxic shocks

  • Superantigen: Staph. aureus in atopic derm.

  • Pseudomonas: warm, moist, alkaline

Impetigenized Atopic


Staph. > strep.


-Strep. pyogenes

-Dermal infection

-Asymmetrical, sharp demarcation


-Septic patient


Oral – amoxacillin 500 QID x 14 days

IV – if severe or recurrent, or co-morbidities

Cellulitis – haemorrhagic

-usually Strep. pyogenes

-deep dermal and sub- cutaneous

Treat – as for erysipelas, but cover for Staph.

Necrotizing Fasciitis

-Pain out of proportion to apparent lesion

-Strep or multi-bacterial deep infection

-Emergency debridement and multiple IV antibiotics

Previously healthy 10 mos. child, 12 hour history of fever, decreased LOC, petechial rash progressing to current picture

Meningococcal septicaemia decreased LOC, petechial rash progressing to current picture





-blood cultures

-immediate IV antibiotics

-lumbar puncture

-support for gram negative endotoxic shock

Meningococcal disease
Meningococcal Disease decreased LOC, petechial rash progressing to current picture

  • Septicemia vs meningitis

    - 40-70% vs 10% mortality

  • Peaks: infancy to 5 years - Second peak age 15

  • Infection and Endotoxin and DIC cause damage

  • Rash subtle at first

    - Erythema→purpura →necrosis

    - Search for petechiae / purpura

    - “any febrile child with a petechial rash should be considered to have meningococcal septicemia, and treatment should be commenced without waiting for further confirmation.”

SSSS decreased LOC, petechial rash progressing to current picture

primary Staph. infection conjunctivitis

Staph. Scalded Skin Syndrome decreased LOC, petechial rash progressing to current picture

SSSS – same child, back, sterile blisters

-epidermolytic toxin mediated disease

31 yr. decreased LOC, petechial rash progressing to current picturemale admitted for biopsy of lymph node for expected lymphoma. Rash noted, dermatology consulted.Widespread papular eruption with adenopathy.

Soles of same patient. decreased LOC, petechial rash progressing to current picture

Your diagnosis?

Secondary syphilis decreased LOC, petechial rash progressing to current picture

-a systemic disease

-order STS and treponemal tests



-Benzathine penicillin 2.4 million units IM

-Herxheimer reaction

-follow STS

-report disease

-contact tracing

-check for other venereal diseases

Secondary syphilis decreased LOC, petechial rash progressing to current picture

Condylomata lata

Viral skin disease
Viral Skin Disease decreased LOC, petechial rash progressing to current picture

  • DNA – tend to proliferate on skin

  • RNA – tend to be erythemas/exanthems

  • Exanthem – epidermal/skin

  • Enanthem - mucosal

Definitions decreased LOC, petechial rash progressing to current picture

  • Exanthem(s) = Exanthema(ta), (Greek)

    • A bursting out (ex) in flowers (anthema)

    • Any dermatosis that erupts or “flowers” quickly

    • Only the erythemas are numbered

    • Includes papular, vesicular, pustular eruptions

Classic exanthems erythemas of childhood
Classic Exanthems decreased LOC, petechial rash progressing to current pictureErythemas of Childhood

1 Rubeola - Measles

2 Scarlet Fever

3 Rubella – German Measles

4 Kawasaki disease

5 Erythema Infectiosum

6 Roseola Infantum - Exanthem Subitum

Human herpes virus
Human Herpes Virus decreased LOC, petechial rash progressing to current picture

1 HSV-1

2 HSV-2




6 Roseola

7 ?

8 Kaposi’s Sarcoma

Measles – morbilliform erythema decreased LOC, petechial rash progressing to current picture

Red measles = rubeola

Koplick’s spots in oral mucosa, early

Rubella with post auricular nodes decreased LOC, petechial rash progressing to current picture

(German measles)

Erythema infectiosum syndrome

Reticulate erythema on arms

Treatment – supportive


-arthritis in adults

-hydrops fetalis


  • Toxic erythema syndrome

  • -viral

  • -scarlet fever

  • drug

  • acute collagen vascular disease

Herpes simplex, recurrent, syndrome

post pneumococcal pneumonia

HSV 2, genital syndrome

Eczema herpeticum syndrome

HSV in atopic dermatitis

Herpes virus treatment
Herpes virus, treatment syndrome

  • Acyclovir, famciclovir, valacyclovir

  • Must treat early (72 hours)

  • Front end load dose

  • Shortens course and reduces severity

  • Does not eliminate virus

Mollusca syndromeContageosain Atopic

Herald plaque - pityriasis rosea syndrome

annular, NOT fungus

Cause unclear, probably infectious (HHV7)

Pityriasis rosea syndrome


-symmetrical discrete oval salmon-coloured papules and plaques, collarette scales



-erythromycin 250 QID, early

-hydrocortisone cream if itchy

-lasts 6-12 weeks, no scars

Plantar Wart syndrome




-lateral tenderness

Plantar wart treatment summary
(Plantar) Wart, Treatment Summary syndrome

  • Respect natural history

  • First do no harm

  • Cryotherapy

  • Caustics: salicylic acid, lactic acid, cantharadine

  • Other chemicals: imiquimod, fluorouracil

  • Immunotherapy: DPCP

  • Surgery: curette only, no desiccation, no excision

  • No radiation

HIV – primary exanthem syndrome

This rash not a problem.

It’s the permissive effect of immune suppression that allows other infections and tumors to kill

Primary hiv infection
Primary HIV Infection syndrome

  • Lapins et al BJD 1996, 22 consecutive men

  • HIV Exposure

    • Acute illness 11–28 days, Seroconvert in 2–3wks

    • Fever 22, pharyngitis21, adenopathy21,

    • Exanthem day 1-5 of illness

    • Upper trunk and neck, discrete non-confluent red macules and maculopapules in 17 / 22

    • Enanthem of palatal erosions in 8 / 22

Fungal skin infections
Fungal Skin Infections syndrome

  • Superficial and Deep

  • Superficial

    • Tinea plus location

    • Tinea = dermatophyte

    • Lives on keratin (non-viable)

    • Tinea versicolour is misnomer = dimorphic yeast

    • Hair and nail infections must be treated systemically (terbinafine, griseofulvin)

Kerion – tinea capitis, syndromenot bacterial infection

Tinea faciei syndrome

Yeast infection
Yeast infection syndrome

Tinea management
Tinea - Management syndrome


  • Scrape

  • KOH

  • Fungal culture – 3 weeks


  • Topical – azoles: clotrimazole, ketoconazole cream BID x 2-3 weeks, terbinafine cream similar

  • Oral – must use for hair and nails. Terbinafine 250 mg. OD for 4-12 weeks for adult

N.A. Blastomycosis

Blastomycosis syndrome

Blastomycosis syndrome

Deep fungal infections management
Deep Fungal Infections syndromeManagement


  • Tissue culture

  • Skin biopsy with special stains


  • Amphotericin B, IV -if multi-organ infection

  • Itraconazole, po -if minimal disease in healthy patient

Break time
Break Time syndrome

Eczema syndrome

  • A morphological diagnosis based on observations of the inflammatory pattern in the skin

  • Eczema is not an etiologic diagnosis

  • Eczema is a subgroup of dermatitis

  • Etiology: exogenous vs endogenous

  • Acute signs: erythema, edema, edematous papules, vesicles, erosions, crusting, secondary pyoderma

  • Chronic signs: lichenification, scales, fissures, dyspigmentation

  • Borders usually ill-defined

Atopic dermatitis endogenous
Atopic Dermatitis syndromeendogenous

  • To make a diagnosis of atopic dermatitis (Hanifin) - must have 3 or more major features:

    1) pruritus

    2) typical morphology and distribution

    • flexural lichenification

    • facial and extensor involvement in infants and children

      3) chronic or relapsing dermatitis

      4) personal family history of atopy

  • Plus 3 or more minor features:

  • Atopic dermatitis syndrome

    Anti-cubital lichenification

    Black skin

    Exogenous impetigenization- allergic contact dermatitis, poison ivy, acute signs

    Rhus radicans impetigenization

    The rash

    The plant

    Patch testing impetigenization, to diagnose cause of allergic contact dermatitis

    Diagnosis = Scabies infant impetigenization

    Eczema caused by infestation

    Scabies Burrows, sole impetigenization

    Scabies Burrows - finger impetigenization

    Scabetic nodules in infant impetigenization

    Eczema treatment
    Eczema - Treatment impetigenization

    • Remove or treat the cause

    • General measures

      • Optimise the environment for healing

      • Compress if moist, hydrate if dry

    • Topical

      • Corticosteroids: hydrocortisone, betamethasone, clobetasol

      • BID max. frequency

      • Ointments, creams, gels, lotions

    • Systemic

      • Prednisone: define endpoint, always warn of osteonecrosis

    • Phototherapy

    Scabies treatment
    Scabies - treatment impetigenization

    • Permethrin 5% cream or lotion neck to toes overnight

    • Treat all close contacts whether itchy or not

    • Wash clothes and bed-sheets

    • Set aside gloves for 10 days

    • Nodules may persist few months

    • May use topical steroid after mites dead

    Psoriasis impetigenization

    • T-cell disease, Th1 inflammatory pattern

    • Morphology

    • Symmetry (endogenous)

      • Plaque: sharply demarcated plaque with coarse scale across whole lesion.

      • Guttate: drop-like or papular variant of plaque psoriasis

      • Pustular (sterile) and erythrodermic forms are more inflammatory and unstable

      • Erythrodermic – involves > 90% skin

    Erythemato squamous diseases differential diagnosis

    Psoriasis impetigenization

    Seborrheic dermatitis

    Pityriasis versicolour

    Pityriasis rosea


    Parapsoriasis and Mycosis fungoides

    Pityriasis rubra pilaris

    Secondary Syphilis

    Chronic Dermatitis

    Erythemato-squamous Diseasesdifferential diagnosis

    Psoriasis plaques impetigenization– symmetry, sharp demarcation, coarse scale across lesion

    psoriasis impetigenization

    normal skin

    Psoriasis – trunk impetigenization

    partially treated

    Psoriasis – annular impetigenization

    not ringworm

    Psoriasis – guttate impetigenization

    (drop-like or papular)

    Guttate Psoriasis impetigenization

    Psoriasis on black skin impetigenization

    Psoriasis - flexural impetigenization

    Psoriasis - scalp impetigenization

    Psoriasis impetigenization – toes and nails, NOT fungus, culture if in doubt

    Psoriasis treatment
    Psoriasis -Treatment disease

    • Consider exacerbating factors: stress, drugs, infection

    • Consider stability of disease (pustular and erythrodermic)

    • Koebner = isomorphic phenomenon

    • Three Pillars of therapy

      • Topical – creams, ointments, lotions, baths

      • Scalp, extensors, flexures

        • Steroids

        • Calcipotriene

        • Salicylic acid

        • Tar

      • Systemic –Pills and Injections

        • Methotrexate, Acitretin, Cyclosporin, Biologicals

      • UltravioletRadiation

        • UVB –broad and narrow band, UVA, PUVA

    Acne disease

    • Etiology: heredity, hormones, drugs, ?diet

    • Sebum – encourages growth of P. acnes

    • Propionibacterium acnes – inflammation, initiates comedones

    • Morphology

      • “Noninflammatory” – comedones, open and closed

      • Inflammatory – papule, pustule, nodule, abscess (“cyst”), scars...ulcers

      • Microcomedo is probably the primary lesion

    • Androgens disease

    • Sebum

    • Comedogenesis

    • Proprionibacterium acnes

    • Diet

    • Psychological

    • Topicals

    • Antibiotics

    • Anti-androgens

    • Isotretinoin

    • Physical

    • Exacerbating factors

    • Rosacea

    • Perioral dermatitis

    Acne – scarring disease

    Isotretinoin use

    -teratogen, not mutagen

    -depression real but rare

    -1 mg/kg/day x 4-5 months

    -beta-HCG, lipids, ALT

    -double contraception

    -record discussion

    Acne – severe disease




    -isotretinoin – low dose and increase slowly

    Acne treatment
    Acne - Treatment disease

    • Psychological impact

    • General measures: avoid picking, not due to poor hygeine

      • Mechanical –rubbing clothes and equipment

      • Chemical – oils, chlorinated hydrocarbons

      • Diet - glycemic index?, milk?

    • Drugs that flare acne

      • Lithium, anabolic steroids, catabolic steroids, dilantin, halogens, EGFRI’s

    • Topicals

      • Benzoyl peroxide 5% aq. gel, once daily, (bleach)

      • Retinoids – comedonal acne, tretinoin cream or gel nightly,

        adapalene, tazarotene are 2nd generation retinoids

      • Antibiotics – consider issue of resistance

    • Oral

      • Antibiotics: Tetra 500 BID, minocycline, erythromycin, clindamycin, trimethoprim – X 3 months

      • Hormones in females

      • Isotretinoin – (Accutane, Clarus) – only disease remitting agent

    Perioral dermatitis treatment
    Perioral Dermatitis diseaseTreatment

    • Don’t be fooled by name, it’s acne not eczema

    • Stop topical steroids

    • Metronidazole 1% topical cream or gel, or topical antibiotic (erythro, clinda)

    • Tetracycline 500 bid x 6-8 weeks

    • Sun protection

    • Reduce flare factors – fluoride in toothpaste

    Rosacea rhinophyma papules and pustule
    Rosacea disease – rhinophyma, papules and pustule

    Rosacea disease


    • Erythema and telangectasias

    • Papulopustular

    • Sebaceous hyperplastic

    • Symmetrical – usually

    • Central facial

    • Ill-defined

    • No significant scale


    -sun protect

    -reduce flare factors

    -stop topical steroids

    -Metronidazole cr. 1% nightly

    -Tetracycline 500 BID

    -surgery for rhinophyma

    -laser or IPL for telangectasia

    Pruritus itchy dermatoses
    Pruritus diseaseItchy dermatoses

    • eczematous dermatitis

    • scabies and insect bites

    • urticaria

    • dermatitis herpetiformis

    • lichen planus

    • bullous pemphigoid

    • psoriasis – sometimes

    Systemic causes of pruritus itch without rash
    Systemic causes of Pruritus disease“itch without rash”

    • chronic renal failure

    • cholestasis

    • Polycythemia

    • pregnancy

    • thyroid dysfunction

    • malignancy - Hodgkins

    • H.I.V.

    • ovarian hormones

      separate itch nerves. ,unmyelinated slow C fibres

    Mediators of pruritus
    Mediators of Pruritus disease

    • Histamine (H)-(from mast cell via various receptors)- itch mediated at H1 receptor

    • substance P, tryptase

    • opioid peptides-central or peripheral

    • cytokines-IL-2,IF….

    • Prostaglandin E, serotonin

    Drug reactions
    Drug reactions disease

    • Acute onset

    • Cephalo-caudal spread

    • Antibiotics, anticonvulsants, NSAID’s

    • Accurate history critical – graph drugs vs date

    • Treatment

      • stop offending drugs

      • supportive care

    Skin cancer
    Skin Cancer disease

    • BCCa, SCCa, Melanoma include over 98% of skin cancers you will see

    • Sunlight, UVB>UVA is major carcinogen

    Superficial Multicentric BCCa disease

    Red plaque, sharp demarcation, irregular border

    Atypical Mole disease

    Rule out melanoma



    -excise, conservative



    Melanoma-Canada 2008 (estimated) disease

    -4600 cases

    -910 deaths






    Melanoma – back, superficial spreading

    Melanoma prognosis
    Melanoma - Prognosis disease

    • Depth of invasion = Breslow thickness

      • Most important for stage 1-2 melanoma

      • Measured from granular layer of epidermis to deepest malignant cell, with ocular micrometer

        Also assess ulceration and mitotic rate of primary tumor

    • Regional Lymph-node Mets – stage 3

      • Sentinel node biopsy – high prognostic value

    • Distant Mets – stage 4

      • 10-20% 5 yr survival

    Skin cancer risk factors
    Skin Cancer – Risk Factors disease

    • Ultraviolet radiation

      • UVB – 290 - 320 nm

      • UVA – 320 – 400 nm

    • Other Controllable

      • Ionizing radiation

      • Arsenic

      • Tobacco

      • Tar

      • HPV

      • Immune-suppression (permissive)

        HIV, Drugs

    Skin cancer treatment
    Skin Cancer - Treatment disease

    • Biopsy if in doubt

      • match method to depth of lesion (shave, punch, incision, excision)

    • Curettage (BCCa, SCCa small, not Melanoma)

      • may precede with shave excision

      • electrodesiccation

    • Surgical Excision

      • Closure: fusiform, flap, graft

    • Margin Control

      • Ill-defined, critical real-estate, recurrent, aggressive

      • Mohs’, frozen section

    • Radiotherapy

    • Other: chemotherapy (imiquimod), PDT