1. Dermatolgy
Dr Alistair Brown

2. 
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Descriptive terms in dermatology
Common skin conditions
Skin cancer
Emergency Dermatology
Infections
MCQs

3. What are you describing?
Pruritus
 Lesion – altered area of skin
 Rash – eruption
 Naevus – localised malformation of tissue
structure.
 Comedone – plug in a sebaceous follicle
containing sebum – may be open (blackhead) or
closed (whitehead).
“The patient has a rash…”


4. Where is it?
Generalised – all over body
 Widespread – extensive
 Localised – one area of skin
 Flexural – body fold eg groin, axilla
 Extensor – eg knees, shins
 Pressure areas – sacrum, buttocks, ankles, heels.
 Dermatome – skin supplied by single nerve
 Photosensitive areas – sun exposed.
“The patient has a widespread rash affecting their torso”
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5. What colour is it?
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Erythema – redness (due to inflammation and
vasodilation) blanches on pressure.
Purpura – red or purple colour (due to bleeding into
the skin or mucous membranes) does not blanch to
pressure. Petechiae (small pinpoint macules) and
ecchymoses (larger bruise like patches)
Hypopigmentation (pityriasis vesicolor)
De-pigmentation (vitiligo)
Hyperpigmentation (melasma)

6. Configuration
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Discrete
Confluent – lesions merge together
Linear
Target
Annular
Discoid

7. What shape is it?
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Macule – flat area of altered colour
Patch – larger area of altered colour
Papule – solid raised lesion <0.5cm in diameter
Nodule – Solid raised lesion >0.5cm diameter
Plaque – palpable raised lesion >0.5cm
Vesicle – raised clear fluid filled lesion <0.5cm
diameter.
Bulla – raised clear fluid filled lesion >0.5cm diameter.

8. Test Yourself
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Macule
Patch
Papule
Nodule
Plaque
Vesicle
Bulla

9. http://www.dermnetnz.org/dermatit
is/atopic.html

10. Atopic Excema
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Itchy papules and vesicles on an erythematous base.
Affects face and extensor in infants, flexor aspect
children and adults.
Occurs in early childhood, usually resolves.
Risk factors: fhx of atopy, assoc asthma, allergic rhinitis
etc)
Exacerbating factors: infections, allergens (chemical,
food, dust, pets), sweating, heat, stress.
Complications: secondary bacterial/viral infection

11. Management
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Avoid exacerbating agents
Frequent emolients
Topical steroids for flares
Antihistamine for symptomatic relief

12. http://www.dermnetnz.org/scaly/p
soriasis-general.html

13. Psoriasis
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A chronic inflammatory disease hyperproliferation of
keratinocytes and inflammatory cell infiltration.
Chronic plaque – most common
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(Other types: guttate, seborrhoiec, flexural, pustular, erythrodermic)
2% of population
Precipitants: trauma, stress, infection, drugs, alcohol
Signs and symptoms:
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Well demarcated lesions with erythematous base, and silver scaly plaques
Affecting extensor surfaces and scalp
Auspitz sign
50% nail changes (pitting, onycholysis)
5-8% associated arthropathy (symmetric polyarthritis, asymmetrical
oligomonoarthritis, distal interphalangeal disease, spondyloarthropathy,
athritis mutilans.)

14. Management
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Avoid precipitants.
Topical therapy – vit d analogues, topical
corticosteroids, coal tar preparations, dithranol,
topical retinoids, salicylic acids.
Phototherapy (extensive disease)
Systemic – methotrexate, oral retinoids,
ciclosporin, mycophenolate mofetil, biologics
(adalimumab, etanercept, infliximab and
ustekinumab)

15. http://www.dermnetnz.org/acne/ac
ne-vulgaris.html

16. Acne Vulgaris
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Inflammation of pilosebaceous follicle – face, chest,
upper back.
Hormonal – increased sebum productiomn, abnormal
follicular keratinisation, p. acnes colonisation and
inflammation.
Non inflammatory lesions - open and closed
comedones, inflammatory lesions – papules, pustules,
nodules, cysts.
Complications – post inflammatory hyperpigmentation,
scarring, deformity, psychosocial impact.

17. Management
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Topical – benzoyl peroxide, topical antibitics,
topical retinoids.
Oral
oral antibiotics eg tetracycline’s
 Females – OCP – dianette
 Oral retinoids – isotretinoin, severe acne


18. http://www.dermnetnz.org/lesions/
basal-cell-carcinoma.html

19. Basal cell carcinoma
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Locally invasive tumour of epidermal keratinocytes
“pearly papule” with surface telangectasia and rolled edges,
may have ulcerated centre.
Risk factors
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uv exposure
Sunburn as a child
Skin type 1
Male
Immunosuppresion
Previous hx of skin cancer
Genetic predisposition
Management
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Surgical
Radiotherapy
Other: cryotherapy, curretage and cautery, topical photodynamic therapy,
imiquimod cream.

20. http://www.dermnetnz.org/lesions/bo
wen.html

21. Squamous cell carcinoma
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Invasive malignant tumour of epidermal kertinocytes or
appendages with potential to metastasise.
Risk factors: sun exposure, pre-malignant skin
condistions eg. Actinic keratoses, chronic inflammation
(leg ulcers), immunosuppression, genetic predisposition,
smoking.
Treatment:
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Surgical excision
Moh’s micrographic surgery
Radiotherapy
Chemotherapy – metastatic disease

22. http://www.dermnetnz.org/lesio
ns/melanoma.html

23. Malignant melanoma
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Invasive malignant tumour of epidermal melanocytes with metastatic
potential.
ABCDE approach
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Asymettry
Border
Colour
Diameter
Evolution
Symptoms – bleeding, itch
Risk factors:
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Atypical moles
Large numbers of moles
Skin type 1&2
Severe sun burn <14
Fhx
Sun exposure
Previous melanoma
immunosuppression

24. Management
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Surgical excision
Excision biopsy
 WLE +/- sentinel node biopsy
 If node positive – axillary clearance
 If further nodes positive – staging
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Intensive followup
Palliative options – aim to reduce macroscopic
disease burden.

25. Emergencies
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http://www.dermnetnz.org/reactions/angioede
ma.html

26. Urticaria, Angioedema, Anaphylaxis
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Causes – food, drugs, insect bites, contact eg
latex, autoimmune, hereditary (angiodema), etc
Urticaria – swelling superficial dermis – raises
epidermis causing itch wheals.
Angiodema – deeper swelling involving dermis
and subcutaneous tissue – tongue and lips.
Anaphylaxis – bronchospasm, facial and
laryngeal oedema, hypotension, can start with
angiodema and urticaria.

27. Management
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ABC approach – call for help if concerned.
Urticaria only – antihistamines
Angioedema and severe urticaria –
corticosteroids and antihistamines.
Anaphylaxis – get help!
Adrenaline 0.5 mg IM = 0.5 mL of 1:1000
 Antihistamine – chlorphenamine
 Corticosteroids


28. q=stevens+johnson+syndrome+der
m+nz&oq=steven&aqs=chrome.1.69
i57j69i59l2j0l3.3052j0j4&sourceid=chr
ome&espv=210&es_sm=122&ie=UT
F-8

29. Stevens-johnson syndrome and
Toxic epidermal necrolysis
•Primarily
a drug reaction: sulfonamides (eg cotrimoxazole), NSAIDs, Carbamazepine,
Phenytoin, Phenobarbital, Valproic acid, Lamotrigine.
•Can also be caused by infections: HSV, mycoplasma.
•Prodromal illness – fever, cough, sore throat, general malaise followed by abrupt
onset macular or purpuric blistering rash.
•Prominent mucosal involvement, at least 2 of:
•Eyes (conjunctivitis) – red, sore, sticky
•Lips/mouth (cheilitis, stomatitis) – red crusted lips, mouth ulcers
•Oesophagus – causing difficulty eating
•Upper respiratory tract (trachea and bronchi) – causing cough and
respiratory distress
•Genital area and urinary tract – ulcers
•Gastrointestinal tract – causing diarrhoea.
•SJS <10%BSA TEN>30% BSA
•Mortality 5-12% SJS, >30%TEN
•Management – stop drug cause, supportive – preferably burns unit

30. http://www.dermnetnz.org/reactions
/erythroderma.html

31. Erythroderma
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Exfoliative dermatitis involving >90% of skin
surface. 20-40% mortality.
Treat cause – eg. atopic dermatitis, psoriasis,
blistering diseases (pemphigus and bullous
pemphigoid), cutaneous T-cell lymphoma
Supportive management – fluid loss, elctrolyte
imbalance, hypothermia, high output cardiac
failure, capillary leak, prevention of secondary
infection.
Prognosis depends on cause, mortality 20-40%

32. http://www.dermnetnz.org/bacteria
l/necrotising-fasciitis.html

33. Necrotising fasiitis
•
Rapidly spreading infection of the deep fascia with secondary
tissue necrosis
•
Group A haemolytic strep or mixed anaerobic and aerobic
bacteria.
•
Risk factors – abdominal surgery, diabetes, immunosuppression,
age, malignancy
•
BUT 50% occur in previously healthy individuals
•
Pain disproportionate to signs, erythematous blistering necrotic
skin, systemically unwell with fever and tachycardia, subcutanceos
emphysema (crepitus).
•
Urgent surgical debridement and antibiotics

34. http://www.dermnetnz.org/viral
/eczema-herpeticum.html

35. Excema Herpeticum
•
Caused by HSV infection superimposed on a skin
condition most commonly atopic eczema.
•
Extensive papules and erosions with systemic fever
and malaise
•
Management – antivirals (aciclovir) +/- abx for
secondary bacterial infection
•
Complications – Encephalitis, DIC, opthalmic
involvement, rarely death

36. http://www.dermnetnz.org/bact
erial/impetigo.html

37. Impetigo
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Streptococcus pyogenes and/or Staphylococcus aureus
Enlarging pustules and round, oozing patches +/- golden
yellow crusts.
Exposed areas such as the hands and face, or in skin folds
particularly the armpits.
Management:
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Antiseptic or antibiotic ointment eg. Fusidic acid
Oral antibiotics
Avoid spread
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Avoid close contact with others.
Affected children must stay away from school until crusts have dried
out.
Use separate towels and flannels.
Change and launder clothes and linen daily.

38. http://www.dermnetnz.org/arthr
opods/scabies.html

39. Scabies
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Itchy rash on trunk and limbs, finger webspaces,
wrist, spares the scalp
Burrow tracts can be seen
Diagnosis on microscopic examination of tracts.
Treatment (all contacts simultaneously!)
25% Benzyl benzoate lotion, applied daily for 3 days
 5% Permethrin cream, left on for 8-10 hours
 0.5% Aqueous malathion lotion, left on for 24 hours


40. MCQs
Atopic Eczema True or False
A. a family history of atopy
B. If occurs early and defined has bad
prognosis
C. In children it is common on cheeks
D. In adults more common on flexor area
E. Pruritis is absent

41. MCQ 2
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What skin condition
is this likely to be?
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Atopic dermatitis
Tinea corporis
Psoriasis
Vitiligo
Scabies
What else should
you examine?

42. MCQ 3
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True or False which of the following are known
risk factors for melanoma?
Sun bed use
 Xeroderma pigmentosum
 Smoking
 Ciclosporin
 Living in the South West
 Obesity
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43. MCQ4
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How would you manage this
patient?
Imiquimod cream
 Watch and wait
 Punch biopsy of the lesion for
histology
 Take a picture and review in
3months to see if it has grown
 Surgically remove with a 2mm
margin for histology
 WLE with a 2-3cm margin
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44. MCQ 5
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A 60 year old woman presents with raised, erythematous
lesions on the limbs and blistering in the mouth and
eyes. She had been taking a number of drugs prescribed
by her GP. Which may be responsible for her
presentation?
nifedipine
paracetamol
paroxetine
prednisolone
Sulphasalazine
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What is the most important first management?
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45. MCQ 6
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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?
astemizole
calamine lotion
chlorpromazine
ciprofloxacin
permethrin cream

46. MCQ 7
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Which of the following is a recognised
feature of psoriasis?
angular stomatitis
iridocyclitis
Koebner Phenomenon
loss of hair
response to chloroquine