Dermatology in general
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  • 1. Dermatology in General Dr Belal Alrefaei
  • 2. Description of skin lesions
    • Papule
    • Macule
    • Nodule
    • Patch
    • Vesicle
    • Bulla
    • Plaque
  • 3. Papule
    • Small palpable circumscribed lesion
    • <0.5cm
  • 4. Macule
    • Flat, circumscribed non-palpable lesion
  • 5. Pustule
    • Yellowish white pus-filled lesion
  • 6. Nodule
    • Large papule >0.5cm
  • 7. plaque
    • Large flat topped elevated palpable lesion
  • 8. patch
    • Large macule
  • 9. vesicle
    • Small fluid filled blister
  • 10. Bulla
    • A large fluid filled blister
  • 11. 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
  • 12. Features of eczema
    • Itchy
    • Erythematous
    • Dry
    • Flaky
    • Oedematous
    • Crusted
    • Vesicles
    • lichenified
  • 13. Types of eczema
    • Atopic
    • Discoid eczema
    • Hand eczema
    • Seborrhoeic eczema
    • Varicose eczema
    • Contact and irritant eczema
    • Lichen simplex
  • 14. Atopic eczema
    • Endogenous
    • Atopic i.e asthma, hay fever
    • 5% of population
    • 10-15% of all children affected at some time
  • 15. Exacerbating factors
    • Detergents
    • Infection
    • Teething
    • Stress
    • Cat and dog fur
    • ???? House dust mite
    • ???? Food allergens
    • Theory of protection from parasite
  • 16. Clinical features
    • Itchy erythematous scaly patches
    • Flexures of knees and elbows
    • Neck
    • Face in infants
    • Exaggerated skin markings
    • Lichenification
    • Nail – pitted ridged
  • 17.  
  • 18.  
  • 19.  
  • 20.  
  • 21.  
  • 22. complications
    • Bacterial infection
    • Viral infections – warts, molluscum, herpes
    • Keratoconjunctivitis
    • Retarded growth
  • 23. investigations
    • Clinical
    • ??IgE
    • ??RAST
  • 24. Prognosis
    • Most grow out of it!
    • 15% may come back – often very mildly
  • 25. Treatment
    • Avoid irritants especially soap
    • Frequent emollients
    • Topical steroids
    • Sedating antihistamines – oral hydroxyzine
    • Treat infections
    • Bandages
    • Second line agents
  • 26. Triple combination of therapy
    • Topical steroid bd as required
    • Emollient frequently
    • Bath oil and soap substitute
  • 27. Principles of treatments
    • Creams
    • Ointments
    • Amounts required
    • Potential side effects
    • Soap substitutes
  • 28. creams
    • Cosmetically more acceptable
    • Water based
    • Contain preservatives
    • Soap substitutes
  • 29. ointments
    • Oil based
    • Don’t contain preservative
    • Feel greasy
    • Good for hydrating
  • 30. Topical steroids
    • Mild – “hydrocortisone
    • Moderate – “eumovate”
    • Potent – “betnovate”
    • Very potent – “dermovate”
  • 31. Amounts required
    • Emollients – 500g per week for total body
    • FTU – steroids
    • Bath oils – 2-3 capfuls per bath
  • 32. Discoid eczema
    • Variant of eczema
    • Atopic and non atopic
    • Easily confused with psoriasis
    • Well demarcated scaly patches
    • Limbs
    • Often infective component (staph aureus)
  • 33.  
  • 34.  
  • 35. 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
  • 36.  
  • 37. Hand eczema
    • Not unusual in atopic
    • More common in non atopics
    • Cause often uncertain
    • Irritants
    • Chemicals
    • Occupational history
    • Consider patch testing – 10% positive
  • 38. Seborrhoeic eczema
    • Over growth of yeast (pityrosporum ovale, hyphal form malassezia furfur)
    • Strong cutaneous immune response
    • More common in Parkinson’s and HIV
  • 39. 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
  • 40. Treatment
    • Suppressive
    • Mild steroid and antifungal combination
    • Ketoconazole shampoo
    • Emollients
    • Soap substitutes
  • 41.  
  • 42.  
  • 43.  
  • 44. Venous eczema
    • Lower legs
    • Venous hypertension
    • Endothelial hyperplasia
    • Extravasation of red and white cells
    • Inflammation
    • Purpura
    • pigmentation
  • 45. Clinical features
    • Older women
    • Past history DVT
    • Haemosiderin deposition
  • 46. treatment
    • Emollients
    • Topical moderately potent steroids
    • Soap substitutes
    • Compression – check arterial supply first
    • Leg elevation
  • 47.  
  • 48. Asteatotic eczema
    • Dry skin
    • Repeated soaping
    • Worse in winter
    • Hypothyroidism
    • Avoid soap
    • Emollients
    • Bath oils
  • 49.  
  • 50. Contact and irritant eczema
    • Exogenous
    • Unusual
    • Worse at workplace
    • History of exacerbations
  • 51. irritant
    • Can occur in any individual
    • Repeated exposure to irritants
    • Common in housewives, hairdressers, nurses
  • 52. contact
    • Occurs after repeated exposure but only in susceptible individuals
    • Allergic reaction
    • Common culprits – nickel, chromates, latex etc
    • Patch testing
  • 53.  
  • 54.  
  • 55. Lichen simplex
    • Cutaneous response to rubbing
    • Thickened scaly hyperpigmentation
    • Emotional stress
    • May need biopsy to diagnose
  • 56.  
  • 57. treatment
    • Stop rubbing!
    • Very potent steroids
    • Occlusion
  • 58. PSORIASIS
  • 59.  
  • 60. 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
  • 61. Chronic plaque
    • Extensor surfaces
    • Sacral area
    • Scalp
    • Koebners phenomenon
  • 62.  
  • 63.  
  • 64.  
  • 65.  
  • 66. 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
  • 67.  
  • 68.  
  • 69. Guttate psoriasis
  • 70. Flexural psoriasis
    • Later in life
    • Well demarcated red glazed plaques
    • Groin
    • Natal cleft
    • Sub mammary area
    • No scale
  • 71.  
  • 72.  
  • 73. Treatment
    • Calcipotriol too irritant
    • Steroid
  • 74. Erythrodermic and pustular psoriasis
    • More severe
    • Need dermatologist!
    • Usually need oral therapy
  • 75.  
  • 76.  
  • 77.  
  • 78.  
  • 79.  
  • 80. Associated features
    • Arthritis
    • Nail changes- onycholysis, pitting, discolouration, subungal hyperkeratosis
  • 81.  
  • 82.  
  • 83. prognosis
    • Chronic plaque tends to be lifelong
    • Guttate – 2/3 further attacks, or develop chronic plaque
  • 84. treatment
    • Suit patient
    • Control rather than cure
    • Topical therapies
    • Light treatments
    • Oral therapy
  • 85. 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
  • 86. Light treatments
    • Not the same as sun beds!!!!
    • UVB
    • UVA
  • 87. ACNE VULGARIS
  • 88. 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
  • 89. Clinical features
    • Increased seborrhoea
    • Open comedones
    • Closed comedones
    • Inflammatory papules
    • Pustules
    • Nodulocystic lesions
  • 90.  
  • 91.  
  • 92.  
  • 93.  
  • 94. Acne distribution
  • 95. Treatment
    • Consider site
    • Compliance
    • Inflammatory/non inflammatory lesions
    • Scarring
    • Fertility
    • Psychological effect
  • 96. 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
  • 97. Combination topical treatments
    • Antibiotics plus benzoyl peroxidase – benzamycin
    • Retinoid plus antibiotic – isotrexin
    • Antibiotic plus zinc - zineryt
  • 98. 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
  • 99. Antibiotics
    • Oxytetracycline 500mg bd
    • Tetracycline 500mg bd
    • Doxycycline 100mg od
    • Minocycline 100mg od
    • Erythromycin 500mg bd
  • 100. Hormone treatment for acne
    • Dianette - not if COCP contraindicated
      • Withdraw when acne controlled
      • VTE occurs more frequently in women taking dianette than other cocp.
  • 101. Oral retinoids
    • Hospital only
    • Long list of side effects
    • Teratogenic
    • Very effective
  • 102. ROSACEA
  • 103. Clinical features rosacea
    • Onset middle age
    • Facial flushing / erythema
    • Inflammatory papules
    • Pustules
    • No comedones
    • Telangectasia
    • Blepharitis
    • rhinophyma
  • 104.  
  • 105.  
  • 106.  
  • 107.  
  • 108. 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