dermatology module dr rangitha allan gp with special interest in dermatology. coventry tpct march 2007

1. DERMATOLOGY MODULE

3. Functions of the skin Protective barrier against the environment Thermo regulation Metabolism Sensation Inflammation

4. A skin problem is the fourth most common reason for consultations in primary care. 70% of consultations arise from seven conditions Acne Eczema Psoriasis Viral warts and other skin infections Tumours Vascular lesions Leg ulcers

5. Eczema Eczema is characterised by erythema and pruritis In the acute phase there are characteristically vesciles or small blisters In the chronic phase there is lichenification cracking or fissuring of the skin

6. Is it Eczema ? Tinea infections can mimic eczema Tenia pedis on the feet Tinea corporis Tinea of the hand - unilateral and in manual workers -scaling is pronounced in the palmar creases Psoriasis � atypical form Scabies can trigger an eczema reaction

7. Standard dermatological terms used in and around eczema Erythema: redness due to increased skin perfusion e.g. eczema, drug reactions

8. Vesicles a fluid-filled circumscribed elevated lesion less than 1 cm in diameter

9. Bulla a fluid-filled circumscribed elevated lesion greater than 1cm in diameter e.g. pemphigoid

10. Pustule a circumscribed collection of pus e.g. folliculitis

11. Weal (Hive) a roundish or flattish pale-red elevation that is characteristically evanescent, disappearing within hours e.g. urticaria

12. Lichenification A papular thickening of the skin associated with accentuation of the normal skin markings, hyperpig-mentation and sometimes scaling e.g. chronic eczema, lichen simplex

13. Fissure A linear defect that extends from the skin surface into the dermis e.g. dermatitis, fungal infections affecting the toes and web spaces

14. Eczema is classified into Endogenous eczema e.g. atopic eczema seborrhoeic eczema Exogenous eczema which could be divided into a) irritant contact � carried by external chemicals b) allergic contact � metal, fragrance, lanolin

15. As a general rule Endogenous eczemas are diagnosed by the distribution and morphology of the rash Allergens through patch testing Irritants by the history

16. Treatment of Eczema Avoiding irritants / allergens Triple therapies: emollients washing advice/aids topical steroids Adjunct therapies: bandaging/wet wraps antibiotics antihistamines 4. Other therapies: dietary manipulation complimentary therapies systemic therapies

17. Psoriasis Occurs in 1-3% of the population. Aetiology of psoriasis is unknown, -the focus is on immunopathogenisis Psoriasis has typical characteristic features and presentations. The most common presentation is chronic plaque psoriasis.

18. Chronic plaque psoriasis presents with Well demarcated Raised Salmon pink coloured Scaly Patches on the extensor aspects of the limbs Elbows Knees Lower back and scalp

19. Plaque

20. Scalp

21. Another common presentation is Guttate Psoriasis Presents in childhood and adolescents Usually follows a streptococcal sore throat Self limiting in 8-10 weeks

23. Flexural psoriasis Axillae Groins Inframammary grooves

25. Erythrodermic psoriasis

26. Pustular psoriasis

27. Psoriatic nail

28. Arthropathic psoriasis

29. Acne May affect up to 40% of the population at some time in their lives. Aetiology: True cause is unknown A combination of factors are responsible A high rate of sebum secretion micro-comedone formation Sebum inspissation inflammation

30. Distributions: Face Chest Shoulders Back

31. Severities Mild - comedones Papules

32. Moderate More papules Few pustules

33. Severe Pustules Cyst Scarring

34. Severity of acne � face

35. Severity of acne �back and chest

36. Psychological effect Psychosocial effect

37. Management recommendations Treat early Show empathy with positive approach Use topicals Anti comedonal e.g. adapalene Antibiotics Topical retinoids Use oral antibiotics Review therapeutic effect after 2-3 months Refer for systemic retinoids in all severe acne

38. Skin infections Viral infections Warts � human papilloma virus Herpes labialis Herpes zoster

39. Warts

40. Herpes labialis

41. Zoster

42. Bacterial Infections Superficial cutaneous infections Erythrasma � corynebacturium minutissimum Intertrigo = in opposing skin sites gp A, B streptococcus C minitissimum Pyodermas (on the epidermis) Impetigo � staph aureus Abscess, furuncle and carbuncle Caused by staph aureus

43. Erythrasma

44. Intertrigo

45. Impetigo

46. Soft tissue infections Erysipelus Gp A B � haemolytic streptococci rarely staphylococcus Cellulitis

47. Cellulitis

48. Mycobacterial infections Leprosy � lupus pernio TB � lupus vulgaris

49. Lupus Vulgaris

50. Infestations and Bites Scabies: mites transmitted by close contact itchy specially at night Diagnosis � look for burrows / mites Distrubutions Finger webs Genitals Breasts Umbilicus Axillae / groin

51. Rash

52. Mite

53. Management of Scabies Permethrin 5% cream (lyclean) Malathion 0.5% aquous lotion Treat all close contacts Wash beddings/towels/clothing at 60oC Advise regarding administration of topicals properly Inform patients that the itching will not subside for 4-6 weeks

54. Lice Body lice Head lice Diagnosis by identifying the lice/eggs Management Personal care Wet combing/bug busting Permethrin 5% Malathion carberyl 1% aquous solution

55. Head Lice

56. Bites Fleas Bed bugs Ticks Itchy, linear lesions often on legs.

57. Managment Antihistamine Antibiotics if infected Eurax cream Bite repellent sprays

58. Dermatology Reading List Core Text: 1 ABC of Dermatology 4th edition Paul K Buxton BMJ Publishing Gp Ltd. Roxburghs common skin diseases. Mark R. Arnold, A Hodder Headline Grp publications Clinical Medicines. Kumar & Clarke Differential Diagnosis in Dermatology. 3rd edition Richard Ashton & Barbara Leppard

59. Recommended Reading: Oxford Textbook of Medicine Weatherall, Ledingham & Worrell Reference: Textbook of Dermatology Rook, Wilkinson & Ebling Blackwell Science Ltd