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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
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