dermatology in general
TRANSCRIPT
Dermatology in General
Dr Belal Alrefaei
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
Large papule >0.5cm
plaque
Large flat topped elevated palpable lesion
patch
Large macule
vesicle
Small fluid filled blister
Bulla
A large fluid filled blister
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
Itchy Erythematous Dry Flaky Oedematous Crusted Vesicles lichenified
Types of eczema
Atopic Discoid eczema Hand eczema Seborrhoeic eczema Varicose eczema Contact and irritant eczema Lichen simplex
Atopic eczema
Endogenous Atopic i.e asthma, hay fever 5% of population 10-15% of all children affected at some
time
Exacerbating factors
Detergents Infection Teething Stress Cat and dog fur ???? House dust mite ???? Food allergens Theory of protection from parasite
Clinical features
Itchy erythematous scaly patches Flexures of knees and elbows Neck Face in infants Exaggerated skin markings Lichenification Nail – pitted ridged
complications
Bacterial infection Viral infections – warts, molluscum,
herpes Keratoconjunctivitis Retarded growth
investigations
Clinical ??IgE ??RAST
Prognosis
Most grow out of it! 15% may come back – often very mildly
Treatment
Avoid irritants especially soap Frequent emollients Topical steroids Sedating antihistamines – oral hydroxyzine Treat infections Bandages Second line agents
Triple combination of therapy
Topical steroid bd as required Emollient frequently Bath oil and soap substitute
Principles of treatments
Creams Ointments Amounts required Potential side effects Soap substitutes
creams
Cosmetically more acceptable Water based Contain preservatives Soap substitutes
ointments
Oil based Don’t contain preservative Feel greasy Good for hydrating
Topical steroids
Mild – “hydrocortisone Moderate – “eumovate” Potent – “betnovate” Very potent – “dermovate”
Amounts required
Emollients – 500g per week for total body
FTU – steroids Bath oils – 2-3 capfuls per bath
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
Pompholoyx – itchy vesicles or blisters of palm and along fingers
Diffuse erythematous scaling and hyperkeratosis of palms
Scaling and peeling at finger tips
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
Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur)
Strong cutaneous immune response More common in Parkinson’s and HIV
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
Treatment
Suppressive Mild steroid and antifungal combination Ketoconazole shampoo Emollients Soap substitutes
Venous eczema
Lower legs Venous hypertension Endothelial hyperplasia Extravasation of red and white cells Inflammation Purpura pigmentation
Clinical features
Older women Past history DVT Haemosiderin deposition
treatment
Emollients Topical moderately potent steroids Soap substitutes Compression – check arterial supply
first Leg elevation
Asteatotic eczema
Dry skin Repeated soaping Worse in winter Hypothyroidism Avoid soap Emollients Bath oils
Contact and irritant eczema
Exogenous Unusual Worse at workplace History of exacerbations
irritant
Can occur in any individual Repeated exposure to irritants Common in housewives, hairdressers,
nurses
contact
Occurs after repeated exposure but only in susceptible individuals
Allergic reaction Common culprits – nickel, chromates,
latex etc Patch testing
Lichen simplex
Cutaneous response to rubbing Thickened scaly hyperpigmentation Emotional stress May need biopsy to diagnose
treatment
Stop rubbing! Very potent steroids Occlusion
PSORIASIS
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
Extensor surfaces Sacral area Scalp Koebners phenomenon
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
Guttate psoriasis
Flexural psoriasis
Later in life Well demarcated red glazed plaques Groin Natal cleft Sub mammary area No scale
Treatment
Calcipotriol too irritant Steroid
Erythrodermic and pustular psoriasis More severe Need dermatologist! Usually need oral therapy
Associated features
Arthritis Nail changes- onycholysis, pitting,
discolouration, subungal hyperkeratosis
prognosis
Chronic plaque tends to be lifelong Guttate – 2/3 further attacks, or develop
chronic plaque
treatment
Suit patient Control rather than cure Topical therapies Light treatments Oral 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
Not the same as sun beds!!!! UVB UVA
ACNE VULGARIS
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 features
Increased seborrhoea Open comedones Closed comedones Inflammatory papules Pustules Nodulocystic lesions
Acne distribution
Treatment
Consider site Compliance Inflammatory/non inflammatory lesions Scarring Fertility Psychological effect
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
Antibiotics plus benzoyl peroxidase – benzamycin
Retinoid plus antibiotic – isotrexin Antibiotic plus zinc - zineryt
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
Oxytetracycline 500mg bd Tetracycline 500mg bd Doxycycline 100mg od Minocycline 100mg od Erythromycin 500mg bd
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
Hospital only Long list of side effects Teratogenic Very effective
ROSACEA
Clinical features rosacea
Onset middle age Facial flushing / erythema Inflammatory papules Pustules No comedones Telangectasia Blepharitis rhinophyma
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