Common Skin Diseases DR . MOUSA BIN SAMHAN AL ENAZY
A 22 year old male presents with generalised pruritus of six weeks duration. Examination reveals little except for erythematous papules between the fingers. Which of the following therapies would be most appropriate for this patient?
Burrows of scabies
2 )Calamine lotion
5 )Permethrin cream
This patient has scabies, a highly contagious disease caused by the mite, Sarcoptes Scabiei . Appropriate treatment includes Permethrin cream topical Benzyl Benzoate or malathion.
In the treatment of psoriasis, which of the following statements is correct?
1 )PUVA is ineffective
2 )Retinoids are the most useful monotherapy in psoriatic patients
3 )Etanerecept is not effective in psoriatic arthritis
4 )Infliximab is associated with Tuberculosis
5 )Vitamin D analogues are associated with cutaneous atrophy
PUVA is an effective treatment for psoriasis, but has been related to increased risk of squamous cell carcinoma, and possibly malignant melanoma.
Retinoids are most effective in combination therapy, especially with UVB phototherapy and PUVA.
Part of the attraction of vitamin D analogues over steroids is that they do not cause cutaneous atrophy, whereas steroids do.
Etanercept, has demonstrated considerable beneficial effects on psoriatic arthropathy in placebo controlled, double blind studies.
Infliximab is associated with Tuberculosis, by reactivation of latent disease. Thus it is advised that patients who are to be treated with Infliximab are tuberculin tested, and if required receive chest radiography.
Which statement regarding tinea capitis is correct?
1)It is most commonly caused by the fungus microsporum canis.
2 )Its presence should suggest immunological deficiency.
3 )It often results in permanent alopecia.
4 )It causes patches that fluoresce dull green under Wood's lamp.
5 )It is effectively treated with topical Nystatin ointment.
Tinea capitus is a dermatophyte infection of the scalp most often caused by trichophyton tonsurans , and occasionally by microsporum canis .
There is initially a small papule at the base of the hair follicle which spread peripherally forming a scaly circular plaque (ringworm) within which there are brittle, broken infected hairs.
patches of alopecia develop and there may be pruritis. Sometimes a severe inflammatory response produces an elevated boggy granulomatous mass studded with sterile pustules.
There may be fever and regional lymphadenopathy, and occasionally permanent scarring and alopecia may result.
The crusted patches fluoresce dull green under Wood's light.
Microscopic examination shows tiny spores and the fungi may be grown in Sabouraud medium with antibiotics.
Oral griseofulvin for 2-3 months is required, or Ketoconazole for resistant cases.
Which of the following statements regarding Psoriasis is most true?
1)Diagnosis requires histological confirmation
2 )Guttate psoriasis often arises after staphylococcal infection
3 )T-cells play a prominent role in the pathogenesis of psoriasis
4 )Ciclosporin is ineffective in the treatment of psoriasis
5 )Twin studies have identified no genetic basis for psoriasis
Diagnosis of Psoriasis is based on clinical observation of sharply demarcated, erythematous, scaling plaques , and rarely requires biopsy.
Streptococcal infection is associated with precipitation and recurrence of guttate psoriasis.
Ciclosporin is a major inhibitor of T cell activation, and given that T cells are central to the pathogenesis of psoriasis.
Genetic studies have lead most experts to believe that psoriasis is the result of multiple genetic factors interacting with environmental stimuli..
A 24 year old female presents with vague frontal headaches and visual disturbance. She has a past history of acne for which she is receiving treatment. Examination reveals her to be obese with a blood pressure of 110/70 mmHg. There is absence of the central retinal vein pulsation on fundoscopic examination. Which of the following drugs account for these findings?
3 )Topical tetracycline
Dianette , like any oral contraceptive may be associated with Benign Intracranial Hypertension .
Topical tetracycline is not associated with BIH.
Rarely BIH has been associated with isotretinoin but usually in combination with a tetracycline.
Which of the following is a feature of hereditary haemorrhagic telangiectasia?
1)a good response to oestrogen therapy
2 )cerebral arteriovenous malformations
3 )GI haemorrhage as the usual presenting feature
4 )telangiectasia of the mucous membranes, but not the skin
5 )tendency of lesions to become less obvious with age
In hereditary haemorrhagic telangiectasia there may also be pulmonary AV malformations.
Epistaxis, not GI haemorrhage, is the usual presenting feature.
Lesions become more obvious with age and affect mucuous membranes as well as skin.
Oestrogen therapy is sometimes advocated but the effect, if any, is small.
A 23 year old obese female with known Tuberculosis presents with ulcerating nodules on the back of her legs. Which of the following is the most likely diagnosis .
2 )Erythema nodosum
3 )Erythema induratum
4 )Lupus vulgaris
5 )Lupus pernio
EI is characterized by chronic, recurrent, tender, subcutaneous, and sometimes ulcerated nodules on the lower legs that may also appear elsewhere.
Females are more frequently affected, with a female-male ratio of 7:1 and is more frequent in younger females.
It is found in association with TB.
Lupus Vulgaris is a chronic, progressive and destructive form of cutaneous tuberculosis in patient with moderate or high degree of immunity. It occurs more commonly in females than in males. The classical lesions consist of reddish-brown plaques not nodules. The lesions progress by peripheral extension and central healing, atrophy and scarring. The areas affected are head and neck (80%), followed by arms, legs, then trunk.
This rash is not the typical description of E Marginatum (finer rash) or Multiforme (Blisters, Targets). Lupus pernio occurs in association with Sarcoid.
A 17 year old boy is diagnosed with scabies. Which of the following statements regarding scabies is correct?
1)Typically affects the face.
2 )It causes itchiness in the skin even where there is no obvious lesion to be seen.
3 )It is caused by Staphylococcus aureus.
4 )Is best treated by salicylate emulsion.
5 )It can be spread by a droplet infection.
Scabies is an infestation of the skin with the microscopic mite Sarcoptes scabei. Infestation is common, found worldwide, and affects people of all races and social classes. Scabies spreads rapidly under crowded conditions where there is frequent skin-to-skin contact between people, such as in hospitals, institutions, child-care facilities, and nursing homes. Spread is by direct, prolonged, skin-to-skin contact with a person already infested with scabies. Contact must be prolonged (a quick handshake or hug will usually not spread infestation). Infestation is easily spread to sexual partners and household members. Infestation may also occur by sharing clothing, towels, and bedding. Scabies is characterised by papular-like irritations, burrows or rash of the skin, especially the webbing between the fingers ; the skin folds on the wrist, elbow, or knee; the penis, the breast, or shoulder blades. A number of treatments are available for the treatment of scabies, including permethrin ointment, benzyl benzoate, and oral ivermectin for resistant cases . Antihistamines and calamine lotion may be used for itching.
A 68-year-old woman presents with a 2 month history of a widespread pruritic rash. Examination reveals widespread erythema with several small blisters containing straw-coloured fluid and one or two larger serosanguinous blisters. What is the most likely diagnosis?
2 )Bullous pemphigoid
3 )Insect bite
5 )Urticarial vasculitis
Pemphigoid, Erythema Multiforme and Herpes are the commonest causes of a blistering rash.
The history above is a classic description of bullous pemphigoid (BP). IgG autoantibodies bind to the skin basement membrane in patients with BP. The binding of antibodies at the basement membrane activates complement and inflammatory mediators. Activation of the complement system is thought to play a critical role in attracting inflammatory cells to the basement membrane. These inflammatory cells are postulated to release proteases, which degrade hemidesmosomal proteins and lead to blister formation. Eosinophils are characteristically present in blisters as demonstrated by histopathologic analysis, although their presence is not an absolute diagnostic criteria.
A 30 year old woman presents with a skin rash. On applying pressure to an unaffected area of skin it was relatively easy to induce trauma. Increased fragility of the skin is characteristic of which of the following conditions?
1)acute intermittent porphyria
2 )epidermolysis bullosa
4 )pseudo-xanthoma elasticum
5 )tuberous sclerosis
Increased skin fragility is seen in a number of disorders and is used as a clinical test in bullous disorders ( Nikolsky's sign ).
Other causes include Pemphigus vulgaris, porphyria cutania tarda and drug reactions (especially pseudoporphyria).
Other causes of increased skin fragility (not associated with bullae) include long term corticosteroid therapy, Ehlers-Danlos syndrome and Scurvey (vitamin C deficiency).
The bullae are easily broken, and even rubbing apparently normal skin causes the superficial epidermis to slough off (Nikolsky sign).
A 38 year old female presents with red target lesions confined to the hands and is diagnosed with erythema multiforme. Which of the following could be the cause?
2 )Ureaplasma urealyticum
3 )Group B Streptococci
4 )Langerhan's cells histiocytosis
5 )Penicillin V
Potential causes of erythema multiforme include: INFECTIONS : viruses: herpes simplex 1 and 2, hepatitis B, EBV, enteroviruses. small-agents: mycoplasma pneumoniae. bacteria: Group A Streptococcus, eosinia. other: mycobacterium TB , histoplasma , coccidioides .
OTHER : aspirin, radiation therapy, etoposide, NSAIDs, sunlight, pregnancy .
Which of the following statements regarding Psoriasis is correct?
1)The prevalence in the UK is 10%
2 )Psoriasis is more common at lower geographical altitudes
3 )Guttate psoriasis is the most common form of the disease
4 )1% of patients have associated psoriatic arthropathy
5 )Psoriatic arthropathy precedes cutaneous lesions in 29% of cases
The prevalence of Psoriasis is reported as between 0.5 and 4.6%. For reasons which may be explained by the filtering of UVB light, psoriasis is more common at higher altitudes. The commonest form of psoriasis is plaque psoriasis, making up approximately 80% of cases ( guttate – 10%, erythrodermic – 3%, pustular - 3%). Studies report a 5-42%prevalence of psoriatic arthropathy in patients with cutaneous psoriasis, and arthropathy precedes cutaneous lesions in 20%; cutaneous lesions precede joint disease in 60-70%, and they occur simultaneously in 10-20%.
Which is true regarding Eczema Herpeticum?
1)Is invariably fatal if untreated.
2 )Usually has an indolent onset.
3 )Only a single crop of vesicles usually appear.
4 )Is typically associated with a high fever for over a week.
5 )Is more severe in reactivation disease.
Eczema herpeticum is the result of primary infection of eczematous skin with HSV.
The severity varies from mild to fatal.
There is usually an abrupt onset with crops appearing over 7-9 days.
Typically, the child has a high fever for 7 days, and recurrent attacks can occur.
Death can result from physiological disturbances (loss of fluid electrolytes and protein through the skin) or dissemination of the virus to brain and other organs or from secondary bacterial sepsis.
Which of the following suggests a diagnosis of molluscum contagiosum rather than chickenpox?
1)Presence of macules and papules
2 )Absence of erythema surrounding lesions
3 )Lesions disappearing within a month
4 )Presence of pruritis
5 )Positive contact history
Molluscum contagiosum is caused by a DNA pox virus. The lesions are small, skin coloured papules with central umbilication.
There is little surrounding inflammation and they may be spread following scratching to other sites. Chickenpox lesions in the early stages may be mistaken for molluscum. However, the presence of associated macules and later vesicles and pustules help to differentiate them. These lesions also affect the mucus membranes, and usually disappear within a few weeks, while molluscum can persist for up to a year.
Which of the following determines the primary mechanical properties of skin?
2 )Stratum basale
3 )Stratum corneum
4 )Stratum granulosum
5 )Subcutaneous tissue
The stratum corneum is the last layer and provides a mechanical barrier to the skin therefore determines the mechanical functions of the skin.
The hands and feet have thich stratum corneum as compared to the lips and eyelids.
The thicker the stratum corneum is the more protection there is for the skin.
The dermis also has some factor to play with its elastic fibres and fibrous tissue.
The rest of the layers are also important but the mechanical properties are primarily determined by the stratum corneum.
Exposure to sunlight aggravates:
2 )Acne vulgaris
4 )Acute Intermittent porphyria
5 )Xeroderma Elasticum
Exacerbation or localization of other dermatoses is characteristic of pellagra, Hartnup's disease, lupus erythematosus, Darier's disease, rosacea, scleroderma, actinic lichen planus, and lymphocytoma.
A 16-year-old boy presentes with erythema nodusum. Which of the following should be considered?
2 )Ulcerative colitis
3 )Cytomegalovirus infection
5 )Kawasaki Disease
Erythema nodosum is characterised by painful, indurated, shiny, red, hot, elevated nodules 1-3cm diameter particularly on the shins. There may be associated fever, malaise, and arthralgia ± hilar adenopathy. Over a period of days they become violaceous, then dull purple then fade like a large bruise without residual ulceration or scar. There may be crops over 3-6 weeks. They are uncommon under the age of 6, and are commoner in females than males. Causes include:
Which of the following concerning leg ulcers is correct?
1)Diuretics have been shown to improve ulcer healing when associated with oedema.
2 )In diabetic ulcers the dressing should be left in situ for no more than 1 week
3 )Large gravitational ulcers are always painful
4 )Treating superficial infection with antibiotics has been shown to be beneficial
5 )ulcers caused by arterial disease are typically treated by compression bandaging
Diuretics may reduce oedema but have not been demonstrated to reduce healing time. Gravitational ulcers are not usually painful. If there is no obvious features of surrounding cellulitis, antibiotic therapy is usually unnecessary and has not been shown to improve healing in superficial infection which is common in ulceration.
Common Skin Diseases
The significance of skin disease
A large proportion of the population suffers from skin diseases, which make up about 10% of all consultations in primary care in the United Kingdom.
community studies show that over 20% of the population have a medically significant skin condition and less than 25% of these consulted a doctor.
The significance of skin disease
The skin is not only the largest organ of the body, it also forms a living biological barrier .
It is therefore not surprising that there is great interest in “skin care”, with the associated vast cosmetic industry.
The impairment of the normal functions of the skin can lead to acute and chronic illness with considerable disability and sometimes a need for hospital treatment.
the term macule is used to describe changes in colour or consistency without any elevation above the surface of the surrounding skin.
There may be an increase of melanin, giving a black or blue colour depending on the depth of the pigment. Loss of melanin leads to a white macule. Vascular dilatation and inflammation produce erythema .
Papules and nodules
A papule is a circumscribed, raised lesion, conventionally less than 1 cm in diameter. It may be due to either epidermal or dermal changes 0
A nodule is similar to a papule but over 1 cm in diameter.
A vascular papule or nodule is known as an haemangioma 0
A papule surrounded by a depigmented macule
Plaque is one of those terms which conveys a clear meaning to dermatologists .
Plaques are most commonly seen in psoriasis.
Plaques in psoriasis
Vesicles and bullae
Vesicles and bullae are raised lesions that contain fluid.
A bulla is a vesicle larger than 0.5 cm. They may be superficial within the epidermis or situated in the dermis below it.
Acute reaction to insect bite— bullae
Lichenification is another term frequently used in dermatology .
Some resemblance to lichen seen on rocks and trees does occur, with hard thickening of the skin and accentuated skin markings.
It is most often seen as a result of prolonged rubbing of the skin in localized areas of eczema.
Nummular means a “coin-like” lesion.
There is no hard and fast distinction from discoid lesions, which are flat disc-like lesions of variable size.
It is most often used to describe a type of eczematous lesion .
Numular lesion as a response to a vaccination site in the arm
The term pustule is applied to lesions containing purulent material—which may be due to infection 0R sterile pustules, which are seen in pustular psoriasis.
Pustule due to infection
Atrophy refers to loss of tissue which may affect the epidermis, dermis, or subcutaneous fat.
Thinning of the epidermis is characterised by loss of the normal skin markings, and there may be fine wrinkles, loss of pigment, and a translucent appearance.
There may be other changes as well, such as sclerosis of the underlying connective tissue, telangiectasia, or evidence of diminished blood supply.
Ulceration results from the loss of the whole thickness of the epidermis and upper dermis.
Healing results in a scar.
An erosion is a superficial loss of epidermis that generally heals without scarring.
Bullous pemphigoid causing erosion
Excoriation is the partial or complete loss of epidermis as a result of scratching .
Fissures are slits through the whole thickness of the skin.
Desquamation is the peeling of superficial scales, often following acute inflammation.
Annular lesions are ring shaped lesions.
The term reticulate means “net-like”. It is most commonly seen when the pattern of subcutaneous blood vessels becomes visible .
Diagnosis of rash
• Previous episodes of the rash, particularly in childhood, suggest a constitutional condition such as atopic eczema
• Recurrences of the rash, particularly in specif situations, suggests a contact dermatitis .
Similarly a rash that only occurs in the summer months may well have a photosensitive basis.
• If other members of the family are affected, particularly without any previous history, there may well be a transmissible condition such as scabies .
Approach to diagnosis
A simplistic approach to rashes is to clarify them as being from “ inside” or “outside ”
Examples of “inside” or endogenous rashes are atopic eczema or drug rashes , whereas fungal infection or contact dermatitis are “outside” rashes .
Contact dermatitis as a response to mascara
Allergic reaction producing photosensitivity
Small vesicles of eczema
Psoriasis of both legs
Blisters occur in:
• viral diseases such as chickenpox, hand, foot and mouth disease, and herpes simplex
• bacterial infections such as impetigo
• eczema and contact dermatitis
• primary blistering disorders such as dermatitis herpetiformis,
pemphigus and pemphigoid as well as metabolic disorders such as porphyria .
A relevant history should be taken in relation to
occupational and environmental factors
• Where? Site of initial lesion(s) and subsequent distribution
• How long? Has condition been continuous or intermittent?
• Prognosis —Is it getting better or worse?
• Previous episodes—How long ago? Were they similar? Have
there been other skin conditions?
• Who else ? Are other members of the family affected? Or
colleagues at work or school?
• Other features—Is there itching, burning, scaling, or blisters?
Any association with drugs or other illnesses?
• Treatment —By prescription or over the counter? Have
prescribed treatments actually been used?
The following points are helpful when examining
• This may give the essential clue, so a full examination is
necessary. For example, there are many possible causes for
dry thickened skin on the palms, and finding typical psoriasis
on the elbows, knees, and soles may give the diagnosis
• Are the lesions dermal or epidermal? Macular (flat) or
forming papules? Indurated or forming plaques? With a well
defined edge? Forming crusts, scabs, or vesicles?
• This is the overall clinical picture of both morphology and
distribution. For example, an indeterminate rash may be
revealed as pityriasis rosea when the “herald patch” is found
What is psoriasis?
Psoriasis is a chronic skin condition characterized by inflamed, red, raised areas that often develop as silvery scales on the scalp, elbows, knees, and lower back. Psoriasis affects nearly 6 million people in the USA.
Psoriasis of both legs
What causes psoriasis?
The cause of psoriasis is unknown, however, it is thought to be caused by abnormally fast-growing and shedding skin cells.
The skin cells multiply so quickly, causing the skin to shed every three to four days. Though not contagious, the condition is hereditary. Psoriasis is often recurrent and occurs in varying severities.
What are the symptoms of psoriasis?
The following are the most common symptoms of psoriasis. However, each individual may experience symptoms differently, as psoriasis comes in several forms and severities. Symptoms may include:
Also called plaque psoriasis , this type of psoriasis is the most common. Symptoms may include patches of red, raised skin on the trunk, arms, legs, knees, elbows, genitals, and scalp. Nails may also thicken, become pitted, and separate from the nail beds.
Pitting of the nail
This type of psoriasis affects mostly children. Symptoms may include many small patches of red, raised skin. A sore throat usually proceeds the onset of this type of psoriasis.
Symptoms may include small pustules (pus-containing blisters) all over the body or just on the palms, soles, and other small areas.
Pustules on the foot
Widespread pustular psoriasis
The typical patient
Psoriasis usually occurs in early adult life, but the onset can be
at any time from infancy to old age, when the appearance is often atypical.
The following factors in the history may help in making a
• There may be a family history—if one parent has psoriasis
16% of the children will have it, if both parents, the figure
• The onset can occur after any type of stress, including
infection, trauma, or childbirth.
• The lesions may first appear at sites of minor trauma—
• The lesions usually clear on exposure to the sun.
• Typically, psoriasis does not itch .
• There may be associated arthropathy —affecting either the
fingers and toes or a single large joint.
Koebner’s phenomenon: psoriasis in surgical scar
Psoriasis of the nail
Psoriasis of the hand
Erythrodermic psoriasis is a serious, even life threatening, condition with erythema affecting nearly the whole of the skin.
Diagnosis may not be easy as the characteristic scaling of psoriasis is absent, although this usually precedes the erythroderma.
Less commonly the erythema develops suddenly without preceding lesions.
There is a considerable increase in cutaneous blood flow, heat loss, metabolism, and water loss.
It is important to distinguish between the stable , chronic, plaque type of psoriasis, which is unlikely to develop exacerbations and responds to tar, dithranol, and ultraviolet treatment, and the more acute erythematous type, which is unstable and likely to spread rapidly.
The use of tar, dithranol, or ultraviolet light can irritate the skin and will make it more widespread and inflamed .
Joint disease in psoriasis
Patients with seronegative arthropathy of the non-rheumatoid
type show double the normal (2%) incidence of psoriasis.
Psoriatic arthropathy commonly affects the distal
interphalangeal joints, sparing the metacarpophalangeal joints,
and is usually asymmetrical.
Radiological changes includea destructive arthropathy with deformity.
Rheumatoid nodules are absent.
The sex ratio is equal but a few patients develop a “rheumatoid-like” arthropathy, which is more common in women than in men.
A third rare group have arthritic changes in the larger joints, where there is considerable resorption of bone. Other members of the families of those with psoriatic arthropathy are affected in 40% of cases
Acute arthropathy— X ray signs
Treatment for psoriasis:
The goal of treatment is to reduce inflammation and slow down the rapid growth and shedding of skin cells. At the present time, there is no cure for psoriasis. Treatment may include:
ointments and creams (to moisturize the skin)
sunlight or ultraviolet light exposure (under a physician''s supervision)
steroids (such as cortisone creams)
vitamin D cream
creams containing salicylic acid or coal tar
Anthralin - a drug that treats the thicker, hard-to-treat patches of psoriasis.
methotrexate - an anti-cancer drug that interrupts the growth of skin cells.
oral or topical retinoids
immunosuppressive medications (such as Cyclosporine)
Treatment of psoriasis
Type of psoriasis Treatment
Stable plaque psoriasis Tar preparations & Calcipotriol & topical steroids
Tacalcitol &Ultraviolet B (TL 01) 0R Short contact dithranol
Extensive stable plaques As above. If not responding: Ultraviolet B (TL01) psoralen with ultravioletA + etretinate
Widespread small plaque Ultraviolet B 0R Tar
Guttate psoriasis Emollients then ultraviolet B &Weak tar preparations
Facial psoriasis 1% hydrocortisone ointment
Flexural psoriasis Local mild to moderate strength Steroids & antifungal
Pustular psoriasis of hands and feet Moderate to potent strength topical steroids 0R Acitretin
Acute erythrodermic, unstable, or general pustular psoriasis Inpatient treatment Methotrexate
Short term local steroids for acutely inflamed lesions
Ciclosporin or other immunosuppressants
Psoriasis suitable for short contact dithranol treatment
Guttate psoriasis suitable for ultraviolet B treatment
Ultraviolet B cabinet
Before phototherapy & After phototherapy
Erythematous psoriasis suitable for methotrexate treatment, having failed to respond to phototherapy
Psoriasis of the scalp This condition can be very difficult to clear, particularly if there are thick scales • 3% salicylic acid in a suitable base and left on for four to six hours or overnight and then washed out with a tar shampoo • Dithranol preparations are effective but will tint blonde or red hair purple • Steroid preparations can be used to control itching
Updated Guidelines of ACNE (2007)
Acne, including :
Comedonic acne (a. comedonicus)
Common acne (a. vulgaris) or pustular acne
Cystic acne (a. cystica)
Classification of Acne
Plenty of open or obstructed comedos, but scant inflammatory changes
Common acne (a. vulgaris) or pustular acne
Pustules and comedos
Cystic acne (a. Cystica,)
Cystic foci of infection that result in scars
Multilobular inflammatory cysts containing volatile pus
Therapy-resistant, scar forming
Acne cysts and scars
Hypertrophic scars (from acne)
An uncommon variant of acne in young men characterized by systemic symptoms (fever, arthralgia, skeletal foci of inflammation)
Systemic corticosteroids , not antibiotics, are the drugs of choice.
Refer patients with suspected acne fulminans to a dermatologist without delay. The painful disease is not well known, and is often left untreated for a long time.
Local treatment is usually sufficient for comedonic acne and mild common acne .
Wash the skin with soap or antibacterial detergents.
Benzoyl peroxide (3 to 10%)] (Purdy, 2005) [A] cream or gel
All above drugs can be irritating at first. Use a low concentration of the active drug initially, and advise the patient to wash the drug away after a few hours. The tolerance of the skin increases with time.
Common acne can be treated with
Local antibiotics (e.g., clindamycin solution) (Purdy, 2005) [A]
Combination gel containing benzoyl peroxide and clindamycin
Ultraviolet light therapy (as a course of 15 treatments added to other treatment) for widespread disease
Consider systemic treatment if the effect of local treatment is unsatisfactory 2 to 3 months from the onset of treatment.
Tetracycline (Garner et al., 2003) [B] and erythromycin (Purdy, 2005) [A] are equally effective. The usual dose is 250 to 500 mg/day for a few months. Six months' treatment with tetracycline or erythromycin 1 g/day is more effective than a shorter treatment with a smaller dose. Do not use tetracyclines in children below 12 years of age.
Local treatment and light therapy can be used simultaneously with systemic treatment.
Local treatment is not sufficient in cystic acne and conglobate acne. Use systemic antibiotics or consider referral to a dermatologist. Pus-containing cysts can be drained by incising them with a large-caliber injection needle or narrow-tipped scalpel.
Hormonal treatment for women
Cyproterone acetate (an anti-androgen) + oestrogen for 6 months reduce the excretion of sebaceous glands and alleviate acne.
Consider treatment of scars by skin abrasion or laser therapy (Jordan, Cummins, & Burls, 1998; Health Technology Assessment Database [HTA]-998502, 2001) [D] only after the activity of the disease has totally subsided.
Scars can be treated either by a dermatologist or a plastic surgeon.
Indications for Specialist Consultation
Severe forms of acne (a. cystica, conglobata, fulminans)
If ordinary treatment fails, the dermatologist can consider isotretinoin. However, it has considerable teratogenicity . A program called iPLEDGE has been set up to make sure that pregnant women do not take isotretinoin and that women do not become pregnant while taking isotretinoin:
There is not enough data to evaluate the effectiveness of spironolactone as treatment of acne (Farquhar et al., 2003) [C].
Other Evidence Summaries
Azelaic acid may be effective in reducing inflammatory lesions and comedones in patients with acne vulgaris (Purdy, 2005) [C].
Topical erythromycin appears to be effective in reducing inflammatory lesions in patients with acne vulgaris (Purdy, 2005) [A].
Topical tetracycline appears to be effective in reducing acne severity, but it causes skin discolouration (Purdy, 2005) [B].
Oral doxycycline is as effective as oral minocycline and oral erythromycin in reducing lesions in patients with acne vulgaris (Purdy, 2005) [A].
Retinoic acid cream or solution , adapalen gel , and benzoyl peroxide (3 to 10%) can be irritating at first. The tolerance of the skin increases with time.
Isotretinoin has considerable teratogenicity
Tetracyclines should not be used in children below 12 years of age.
Isotretinoin is contraindicated in pregnancy.
Rosacea is a persistent eruption occurring on the forehead and cheeks.
It is more common in women than men.
There is erythema with prominent blood vessel
Pustules,papules, and oedema occur.
Rhinophyma , with thickened erythematous skin of the nose and enlarged follicles, is avariant. Conjunctivitis and blepharitis may be associated. It is usually made worse by sunlight.
The treatment of rosacea is with long term courses of
oxytetracycline, which may need to be repeated.
Topical treatment along the lines of that for acne is also helpful.
Topical steroids should not be used as they have minimal effect and cause a severe rebound erythema, which is difficult to clear. Avoiding hot and spicy foods may help.
Recent reports indicate that synthetic retinoids are also effective.
Eczema and dermatitis
Eczema is an inflammatory condition of the skin characterised by groups of vesicular lesions with a variable degree of exudate
In some cases dryness and scaling predominate, with little inflammation.
In more acute cases there may be considerable inflammation and vesicle formation,
. Sometimes the main feature may be blisters that become very larg
Eczema commonly itches and the clinical appearance may be modified by scratching, which with time may produce
lichenification (thickening of the skin with increased skin markings). Also as a result of scratching the skin surface may be
broken and have excoriations, exudate, and secondary infection.
Classification of eczema
Nummular or discoid
Types of eczema Atopic eczema affects mainly the flexor surfaces of the elbows and knees as well as the face and neck. To a variable degree it can affect the trunk as well. Atopic eczema is common, affecting 3% of all infants, and runs a chronic course with variable remissions.
Nummular eczema Nummular eczema appears as coin shaped lesions on legs and trunk.
Stasis eczema occurs around the ankles, where there is impaired venous return.
Pompholyx is itching vesicles on the fingers, with lesions on the palms and soles in some patients.
• Haematological—polycythaemia, iron deficiency anaemia
• Malignancy—lymphoma, reticulosis,carcinomatosis
• Psychological—anxiety, parasitophobia
• Tropical infection—filariasis, hookworm
Treatment of eczema
• Treat the patient, not just the rash
• Complete cure may not be possible
• Be realistic about the problems of applying treatments at home
• Make sure the patient understands how to carry out the treatment
• Advise using emollients and minimal soap
• Provide detailed guidance on using steroids
Treatment of eczema
Dry skin tends to be itchy, so advise minimal use of soap.
Emollients are used to soften the skin, and the simpler the
Emulsifying ointment BP is cheap and effective but
rather thick. By mixing two tablespoons in a kitchen blender
with a pint of water, the result is a creamy mixture that can
easily be used in the bath.
A useful preparation is equal parts of
white soft paraffin and liquid paraffin.
Various proprietary bath oils are available and can be applied directly to wet skin.
There are many proprietary emollients .
Treatment of eczema
Wet weeping lesions should generally be treated with creams rather than ointments (which remain on the surface).
Steroid ointments are effective in relieving inflammation and
itching but are not always used effectively.
Advise patients to
use a strong steroid (such as betamethasone or fluocinolone
acetonide) frequently for a few days to bring the condition
under control; then change to a weaker steroid (dilute
betamethasone, fluocinolone, clobetasone, hydrocortisone) less
Strong steroids should not be continued for long
periods, and, as a rule, do not prescribe any steroid stronger
than hydrocortisone for the face. Strong steroids can cause
atrophy of the skin
Treatment of eczema
Immunosuppressants are a valuable adjunct in severe cases not
responding to topical treatment and antibiotics. Ciclosporin is
usually given on an intermittent basis, with careful monitoring for side effects.
Azathioprine is also used, provided the
thiopurine methyl transferase (TPMT) level is normal.
Tacrolimus is an immunosuppressant that has recently
Fungal and yeast infections
Fungal and yeast infections Tricophyton rubrum infection of the neck
Fungal infection of nail
Tinea corporis presents with erythema and itching and a well defined scaling edge. In the groin, tinea cruris , the infection may spread to the adjacent skin on the thighs and abdomen. Intense erythema and satellite lesions suggest a candida infection
In the axillae erythrasma due to Corynebacterium minutissimum is more likely.
It does not respond to antifungal treatment but clears with tetracycline by mouth
affects the trunk, usually of fair skinned individuals exposed to the sun. It affects mainly the upper back, chest, and arms. Well defined macular lesions with fine scales develop, which tend to be white in suntanned areas and brown on pale skin. It may be confused with seborrhoeic dermatitis,
pityriasis rosea, and vitiligo. In skin scrapings the causative organisms, Malassezia spp ., normally found in hair follicles, can be readily seen.
The most commonly used treatments are the imidazole
preparations, such as clotrimazole and miconazole (two to four weeks) and also topical terbinafine (one to two weeks).
The polyenes, nystatin, and amphotericin B are also effective against yeast infection.
For damp macerated skin dusting powders may be helpful.
In toe web infections a mixture of micro-organisms including dermatophytes and Gram negative bacteria may be present and both require treatment
It is important to confirm the diagnosis from skin scrapings before starting treatment.
Terbinafine is a very effective fungicidal drug.
It is taken in a dosage of 250 mg once daily for
two to six weeks for skin infections, six weeks for finger nail or three months for toe nail infections
Griseofulvin is mainly used for tinea capitis.
The duration of treatment is six to eight weeks for infections of the scalp.
The dose is 10–20 mg/kg for children, taken with food.
Contraindications to griseofulvin are severe liver disease
Triazole preparations such as itraconazole are effective in
both dermatophyte and yeast infections
Viral infections Herpes simplex The herpes simplex virus consists of two viral subtypes. Type I is associated with lesions on the face and fingers and sometimes genital lesions. Type II is associated almost entirely with genital infections
Herpes simplex—points to note
• The initial vesicular stage may not be seen in genital lesions,
which present as painful ulcers or erosions
• There is usually a history of preceding itching and tenderness
• The most rapid methods of detecting virus from scrapings
from the base of the ulcer are electronmicroscopy, immunofluorescence, or PCR
• Genital herpes in a pregnant woman carries a great risk of ophthalmic infection of the infant. Caesarean section may be
• “ Eczema herpeticum ” or “Kaposi’s varicelliform eruption” are
terms applied to severe cutaneous and, less commonly,
systemic, infection with herpes virus in patients with atopic
eczema and some other skin conditions. Treatment is with
oral or parenteral aciclovir
What is shingles?
Shingles, or herpes zoster , is a common viral infection of the nerves, which results in a painful rash of small blisters on an area of skin anywhere on the body. Even after the rash is gone, the pain can continue for months, even years.
Shingles is caused by the reactivation of the varicella-zoster virus, which causes chickenpox. After a person has had chickenpox, the virus lies dormant in certain nerves for many years. Herpes zoster is more common in persons with a depressed immune system, and in persons over the age of 50.
What is the cause of his rash?
What are the symptoms of shingles?
The following are the most common symptoms of shingles.
skin sensitivity and/or pain in the area of the skin before the rash appears
rash, which appears after five days and initially looks like small, red spots that turn into blisters (usually takes about two to three days)
blisters turn yellow and dry, often leaving small, pitted scars
Other early symptoms of shingles may include:
Herpes zoster—points to note
• Trigeminal zoster may affect:
the ophthalmic nerve (causing severe conjunctivitis)
the maxillary nerve (causing vesicles on the uvula or
the mandibular nerve (causing vesicles on the floor of the
mouth and on the tongue)
• Disseminated zoster is a severe illness presenting with
widespread lesions. Visceral lesions may present with pleuritic
or abdominal pain
• Extensive and haemorrhagic vesicles may develop in patients
Treatment usually focuses on pain relief. Treatment may include painkillers to help alleviate some of the pain, and antiviral drugs to help lessen some of the symptoms and minimize nerve damage. Other treatments may include:
bed rest , especially during the early phase of shingles, if fever is present
calamine lotion or other topical agents
cool compresses applied to affected skin areas
antiviral medications (such as acyclovir, valacyclovir, and famcyclovir)
Localised lesions of herpes simplex have been treated with a variety of medications from zinc sulphate to iodoxuridine .
Topical acyclovir is useful in primary infection
Severe, recurrent, herpes simplex, or herpes zoster can be treated with oral or intravenous aciclovir as early in the course
of the illness as possible
Ganciclovir is an alternative
Steroids (prednisolone 40–60 mg/day) given during the
acute stage of herpes zoster may diminish pain and
Rest and analgesics are recommended treatment for extensive herpes simplex or herpes zoster infections
The commonest skin infection due to a pox virus is molluscum contagiosum, a skin infection seen particularly in children.
Despite its name it is not very contagious, but can occur in families.
The white, umbilicated papules of molluscum contagiosum are characteristic
. Treatment with liquid nitrogen is probably the simplest treatment.
Other methods include superficial curettage and carefully rotating sharpened orange stick moistened with phenol in the centre of each lesion.
What are warts?
Warts are non-cancerous skin growths caused by the papilloma virus. Warts are more common in children than adults, although they can develop at any age. Warts can spread to other parts of the body and to other persons. There are many different types of warts, due to many different papilloma virus types (more than 60). Warts are not painful, except when located on the feet. Most warts go away, without treatment, over an extended period of time.
Treatment for warts:
Warts often disappear without treatment.
Treatment of warts depends on several factors, including the following:
length of time on the skin
Treatment for warts:
application of salicylic and lactic acid (to soften the infected area)
freezing with liquid nitrogen
electrodesiccation (to destroy the wart with an electrical current)
Treatment of warts with liquid nitrogen
Bacterial Skin Infections
Cardinal signs of infection
• Swelling and oedema
• Heat or warmth
• Pain and discomfort
The woman shown in the photographs had acute erysipelas
due to streptococcal infection, and all four features of inflammation were present. She was referred to the clinic with a diagnosis of an acute allergic response,. However, malaise and fever were also present and the lesions were warm and tender. The condition responded well to antibiotic treatment.
is a superficial infection of the skin of which there are two forms. In the non-bullous form the affected skin is covered with crusts. Both staphylococci and streptococci are responsible. However the bullous form which presents with blisters is due to staphylococci. Folliculitis, an inflammation of the hair follicle, is commonly caused by Staph. aureus .
which is most common on the leg, is due to bacterial infection penetrating through the epidermis to the dermis causing a necrotic lesion with a superficial crust and surrounding inflammation. Both streptococci and staphylococci are responsible.
The clinical presentation of infections due to mycobacteria, a specific group of organisms that includes the causes of tuberculosis and leprosy, reflects the success of the host’s response in eradicating organisms. There are clear differences, for instance, between disseminated miliary tuberculosis and
Skin Pigment Disorders
What are skin pigment disorders?
Skin color is determined by a pigment (melanin) made by specialized cells in the skin (melanocytes).
The amount and type of melanin determines a person''s skin color.
Acanthosis Nigricans Benigna
What is a blister?
A blister is a bump on the skin containing fluid. Blisters are usually circular in shape. The fluid that forms underneath the skin can be bloody or clear.
What causes a blister?
Blisters are caused by injury, allergic reactions, or infections, which may include the following:
friction (from a shoe, for example)
eczema (also known as atopic dermatitis)
impetigo - a contagious infection of the skin.
pemphigus - a rare, blistering skin disease often occurring in middle-aged and elderly adults.
pemphigoid - a blistering autoimmune disorder.
dermatitis herpetiformis - a blistering autoimmune disorder.
viral infections (including chickenpox and herpes zoster)
Blisters often heal spontaneously. Treatment will vary, depending on the cause. Some general guidelines for first-aid may include:
Wash the area with soap and water .
A cold or ice pack may help reduce swelling and discomfort.
Keep the area clean and dry - do not burst or puncture the blister.
If the blister bursts, place an adhesive bandage or dressing on the area to keep it clean.
Observe the area for signs of infection such as increased warmth, swelling, redness, drainage, pus formation, or pain
Treatment for blisters :
A blister will usually heal on its own. Treatment may include :
keeping the area clean
antibiotics (to treat infections)
dressings on burst blisters
What is the diagnosis?
What is the cause of his rash?
What is the likely diagnosis?
What is the likely diagnosis?
What is the likely diagnosis?
Scabies are tiny mites that commonly infest the skin. They are highly contagious. Children are the most vulnerable, but anyone can get them. Whenever a child develops intense itching, especially at night , the possibility of scabies should be considered
Most cases of scabies are completely eradicated with a single overnight application of 5% permethrin cream (Elimite cream), available by prescription. It is the preferred agent to treat scabies all the way down to 2 months of age (more than 30% of scabies are now resistant to Eurax lotion, an earlier treatment).