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Dermatology approach

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Dermatology approach

  1. 1. Dermatology Approach Fayza Rayes MBBCh. Msc. MRCGP (UK) Consultant Family PhysicianJoint Program of Family & Community Medicine – Jeddah www.fayzarayes.com fayzarayes@yahoo.com
  2. 2. Prepared by dr. Fayza RayesDermatology Approach: 1. Skin Rash 2. Skin pruritus 3. Mouth Condition 4. Palm & Sole Lesions 5. Nail Diseases 6. Nappy rash 7. Acne 8. Skin Pigmentations
  3. 3. Site and/or Distribution of The Lesions Generalized -- Viral exanthema & drugs Extensor -- Psoriasis, SLE, -- Soles keratosis, ichthyosis Flexor -- Atopic dermatitis Lower extremities -- Erythema nodosum -- Stasis dermatitis Sites of pressure -- Urticaria Site of trauma -- Psoriasis -- Lichen planus, -- Molluscum, Warts.
  4. 4. DD. Of Generalized Skin Rash Drug eruption Ampicillin rash Viral exanthema Measles
  5. 5. DD. Of Rash at Site of TraumaMolluscum contaguasum PsoriasisLichen Warts.planus
  6. 6. DD. Of Truncal Lesions RashTinea versicolor Pityreasis rosea
  7. 7. Palms & Soles Conditions Secondary syphilis
  8. 8. Dermatology Arrangement of lesions Arrangement Examples• Isolated • Melanoma, Keratoacanthoma• Scattered • Molluscam contagiosum, common warts• Grouped • Lichen planer, insect bites• Grouped of • Herpes simplex, herpes zoster vesicles (Dermatomal )• Annular (ring) • Tinea corporis, erythema multiform, drug eruptions. Lupus erythomatosus, 2ry syphilis, pityriasis rosea.• Linear • Contact dermatitis, linear scleroderma, keposi sarcoma
  9. 9. 1Approach to Patient with skin Rash
  10. 10. Diffuse Erythema Differential DiagnosisInfectious :  Streptococcal infection (Scarlet fever)  Staphylococcal infection (Toxic syndrome)  Enteroviral infectionNon-infectious Causes: – Allergy -- Vasodilatation – Eczema -- Psoriasis – Pityrosis rubra -- Lymphoma
  11. 11. Scarlet fever
  12. 12. Scarlet fever Incubation period: 2 - 4 days Days of illness Complications: Otitis media Cervical adenitisRash RhinitisSore throat Sinusitis Rare: Rheumatic fever Acute nephritis
  13. 13. Maculo-papular Rash with Fever Differential DiagnosisInfection :-- Measles -- Interoviral infection-- Chickenpox -- Mononucleosis-- Rubella -- Typhoid fever-- Rubeola (Red measles) -- Secondary syphilis-- Erythema infectious (5th) -- HIV (Primary)-- Adenoviral exanthema -- Early meningitisNon-infectious Causes :-- Allergy -- Erythema multiform-- SLE -- Erythema margenatum-- Dermatomyositis -- Serum sickness-- Drug rash
  14. 14. DD of Maculo-papular Rash with Fever Chickenpox Measles Mononucleosis
  15. 15. Common Exanthematous Diseases Measles Maculopapular (5 days) IP (10-14 days) Koplik’s spots, Prodromal illness, complications are common. Rubella Macular --> maculopapular (3 ds) IP (14-21 days) Malaise, little or no fever Chickenpox Maculer --> Papules --> Viscles --> IP (1-14 days) Crust (7ds) No other symptoms apart from rash & low grade fever
  16. 16. Measles
  17. 17. ChickenpoxIncubation period: 1-14 days :Complications Secondary infection :Rare Encephalomyelitis
  18. 18. German measles Incubation period: 14-21 days Days of illness Progression over 4 days Maculopapular ComplicationsRashIng. Nodes Rare:Malaise ArthritisURTI Encephalitis Purpura
  19. 19. DD. Of Generalized Skin Rash This 32-year-old extravenous drug abuser complained of headaches and arthralgia & maculopapular rash This may occur shortly before seroconversion in HIV-infected individuals
  20. 20. DD of Maculo-papular Rash with Fever Typhoid fever
  21. 21. Typhoid feverDistribution of rose-spot rash: The typical rash oftyphoid fever may appear towards the end of the first weekbut it has been recorded as late as the 20th day. It is presentin about half the adults with typhoid but is less common inchildren. Rose spots are difficult to detect on dark skins.
  22. 22. DD of Maculo-papular Rash with Fever Secondary syphilisErythemainfectious(5th)Earlymeningitis
  23. 23. Early rash of meningitis:Fleeting macular or papular rash.This may occur alone or proceedinghemorrhagic eruption by few hours
  24. 24. Suspected Meningococcal Infection Immediate Treatment  Adult and children older that 10 years 1200 mg Benzyl penicillin. IM  Children aged 1-9 years 600 mg Benzyl penicillin. IM  Infants aged less than 1 year 300 mg Benzyl penicillin. IM
  25. 25. Secondary Syphilis-rashThe rash may be papules or pustules and crusts
  26. 26. DD of Papulosquamous Exanthems Secondary syphilis
  27. 27. DD of Papulosquamous Exanthems * Figure 5. Drug eruption * Figure 6. Erythrodermic drug eruption 5 6 * Figure 7. Psoriasis * Figure 8. Lichen planus 7 8
  28. 28. DD of Papulosquamous1 2 Exanthems * Figure 1,2,3 & 4 Secondary syphilis3 4 * Figure 5. Drug eruption * Figure 6.5 6 Erythrodermic drug eruption * Figure 7. Psoriasis * Figure 8. Lichen planus7 8
  29. 29. DD of Non-infectious Causes of Maculo-papular Rash SLE Erythema margenatum
  30. 30. DD of Non-infectious Causes of Maculo-papular Rash Steven-Johnson Syndrome
  31. 31. Erythema Multiforme with “bulls eyes” target lesions
  32. 32. Classification of Pustular LesionsLocal Infections :• Bacterial : impetigo, folliculitis• Viral : herpes simplex, herpes zoster,• Fungal : dermatophyte infection, candidaSystemic Infections :• Bacterial• Meningococcaemia, Gonococcaemia & Staphylococcaemia• Viral : varicella, enteroviral infection, HIVNon-infective conditions : Generalized pustular psoriasis or localized pustular psoriasis. Acne vulgaris and rosacea, Eczema, Pemphigus, Porphyria, Erythema multiform, Erythema bullosum.
  33. 33. DD of Pustular Lesions - Local Infections Herpes simplexImpetigo herpes zoster
  34. 34. DD of Pustular Lesions Non-infective ConditionsGeneralized pustular psoriasis Erythema multiforme
  35. 35. DD of Pustular Lesions Non-infective ConditionsLarge, tense blisters in bullous pemphigoid
  36. 36. Pemphigus vulgaris demonstrating Bullous pemphigoid with flaccid bullae which are easily tense vesicles and bullae ruptured, resulting in multiple on an erythematous, erosions and crusted plaques. urticarial base.
  37. 37. DD of Pustular LesionsNon-infective Conditions Linear blistering lesions in primula dermatitis Bullae occurring as a reaction to flea bites on the ankle
  38. 38. BlistersVasculobullous lesions on Phototoxic bullaethe palm, Characteristic associated with of pompholyx nalidixic acid
  39. 39. DD of Pustular Lesions Infective ConditionsSepticemia, probably gonococcal.
  40. 40. Purpuric or Petechial Rash Differential Diagnosis Infections :  Bacteremia (with or without DIC) o Infectious endocarditis o Meningococcemia o Gonococcemia or other pathogenic bacteria  Enteroviral infection  Dengue fever  Hepatitis  Rubella  Infectious Mononucleosis
  41. 41. DD of Purpuric or Petechial Rash Rash of meningitis
  42. 42. Purpuric or Petechial Rash Differential Diagnosis Non-infectious causes :  Allergy  Low platelets of any cause  Scurvy  Henoch-Schonlain purpura  Vasculitis  Acute rheumatic fever  Hyperglobulinemia
  43. 43. Purpuric Rash Bruises (ecehymoses) in a patient with coagulation meningococcal defects due toHenoch- septicemia - often acute hepaticSchonlein disease sparse and need to be necrosis looked for carefully
  44. 44. Purpuric Rash Vasculitis. Palpable purpuric papules on the lower legs are seen in this patient with coetaneous small vessel vasculitis.
  45. 45. Patient with rash Warning Presentation Associated symptoms suggestive of serious illness. Purpuric or petechial rash Generalized pustular rash Infection in dangerous area E.g.. eyes, dangerous area of the face. Very toxic patient
  46. 46. 2Approach to Patient with skin Pruritus
  47. 47. Pruritus History Duration, localization & character of the itch. Provocating factors Diurnal variation Sleep disturbance Occupational history Itchy contact
  48. 48. PruritusExamination & warning presentation Examination :  Patient general condition  Characteristic of the skin lesion e.g. o Burrows of scabies o Lichenification of eczema o Skin discoloration o Scaly lesion Warning presentation :  No overt skin disease  Ill elderly patient (cancer)
  49. 49. Systemic Causes of Pruritus1. Cholestasis : -- Primarily biliary cirrhosis -- Pregnancy -- Extrahepatic obstruction -- Drugs e.g. Contracep.2. Endocrine : -- Thyrotoxiosis -- Myxoedema -- Hyperparathyroidism -- DM3. Hematological / Myeloproliferative : -- Iron deficiency -- Polycythemia -- Hodgkin’s disease -- Multiple myeloma4. Chronic Renal Failure :5. Malignancy / Miscellaneous : -- Gout -- Psychological -- Old age.
  50. 50. Some common dermatological conditions associated with itching Severe Moderate Infestation : Scabies, lice  Psoriasis Insect bites  Fungal infections Eczema  Pityriasis rosea Articaria  Pemphigiod Dermatitis herpetiformis  Xerosis (dry skin) Lichen planus Localized Itching Lichen simplex  Pruritus ani Drug reactions  Pruritus vulvae
  51. 51. Some common dermatologicalconditions associated with itching Severe  Infestation : Scabies, lice  Insect bites  Eczema  Urticaria  Dermatitis herpetiformis  Lichen planus  Lichen simplex  Drug reactions
  52. 52. The head louse: Head lice need relativelyPhysical evidence of prolonged head-to-beadliving lice is required contact. Estimates suggest itbefore treatment takes of least 30 seconds forbegins, but they con lice to move from one besidebe difficult to detect to another
  53. 53. Dermatological conditions associated with severe itchingChildhood atopic eczema. Facial atopic eczema.
  54. 54. Dermatological conditions associated with severe itching Eczema Hyperkeratotic hand Vesicular hand dermatitis eczema. (pompholyx). Infected hand eczema (Ring) dermatitis
  55. 55. Dermatological conditions associated with severe itching Urticaria
  56. 56. Dermatological conditions associated with severe itching Urticaria showing charac- teristic discrete and confluent, edematous, erythematous papules and plaques.
  57. 57. Dermatological conditions associated with severe itching ScabiesWidespread pruritis rash of scabies. Characteristic burrow ofscabies..
  58. 58. Dermatological conditions associated with severe itching Dermatitis herpetiformisHerpes simplex infection associated with atopic dermatitisIt was misdiagnosed as pyoderma and treated withantibiotics for more than 2 weeks
  59. 59. Dermatological conditions associated with severe itchingDermatitis herpetiformis manifested bypruritic, grouped vesicles in a typical location.The vesicles are often excoriated and may occuron knees, buttocks, and posterior scalp.
  60. 60. Dermatological conditions associated with severe itching lichen planus Flat-topped violaceous Wickhams striae papules of lichen planus. (lichen planus).
  61. 61. Dermatological conditions associated with severe itching Lichen planus showing multiple flat-topped, violaceous papules and plaques. Nail dystrophy as seen in this patients thumbnail may also he a feature.
  62. 62. Dermatological conditions associated with severe itching Lichen simplexlichen simplex Lichen simper of Lichenificationchronicus scrotum from constant rubbing
  63. 63. Dermatological conditions associated with severe itching Angio-edema Most drugs have the potential to cause angio-edema, urticaria, pruritus and maculopopular rash
  64. 64. Dermatological conditions associated with severe itching Widespread urticaria Severe angio-oedema
  65. 65. Some common dermatologicalconditions associated with itching Moderate:  Psoriasis  Fungal infections  Pityriasis rosea  Pemphigiod  Xerosis (dry skin)
  66. 66. Some common dermatological conditions associated with moderate itching Pityriasis rosea Psoriasis
  67. 67. Common Cause of Local Itching Pruritus ani - perianai dermatitis.
  68. 68. Herpes simplex of the anus.
  69. 69. 3Mouth Conditions
  70. 70. Month Ulcers Differential Diagnosis Trauma (dentures)  Erythema multiform (from drugs) Aphthous ulcers  Pemphigus Candida infection  Lichen planus Herpes simplex  Carcinoma
  71. 71. DD. Of OralConditionsErythema multiform Aphthous ulcers Lichen planus
  72. 72. Erythema multiformeBullous erythemamultiforme lesions of palm. Typical target lesionsErythema multiforme:mucosal involvement
  73. 73. Aphthus UlcerAphthous ulcers: Small ulcers, 1 – 4 mm in diameter mayoccur on healthy persons as a recurrent, painful, self-limiting problem lasting five to six days, aetiology unknown.An aphthous-like ulcer may occur on the pharynx ininfectious mononucleosis
  74. 74. DD. Of OralConditionsAphthus UlcerPemphigus
  75. 75. Oral thrush Leukoplakia
  76. 76. lichen planus on the tongue, resembling leukoplakia
  77. 77. Iron deficiency anemiaSmooth tongue Angular stomatitis
  78. 78. 1 2 Differential Diagnosis of Mucous Membrane Lesions Figure 1. Secondary syphilis3 4 Figure 2. Lichen planus Figure 3. Scrotal tongue Figure 4. Geographic tongue5 6 Figure 5. Aphthus ulcer Figure 6. Black hairy tongue7 8 Figure 7. Pyogenic granuloma Figure 8. Median rhomboid glossitis
  79. 79. 1 3 2 4 51) Angular stomatitis 3) Carcinoma of lip 5) Peutz-Jeghers2) Herpes labialis 4) Hereditary syndrome hemorrhagic telangiectasia
  80. 80. 4Palm & Sole Lesions
  81. 81. DD. Of Acral Tinea pedis Lesionsplantar warts dyshydrotic dermatitis
  82. 82. DD. Of Palm & Sole Lesions Tinia pedis Unilateral scaling of the palm(tinea manuum). Dermatophyte infection spreading out from the toes
  83. 83. DD. Of Palm & Sole LesionsPustular psoriasis on sole of footPsoriasis nail with ridging and pitting
  84. 84. 5Nail Diseases
  85. 85. Differential Diagnosis1 2 of Nail Diseases * Figure 1. Fungal infection * Figure 2. Paronychia.3 4 * Figure 3. Posttraumatic hematoma * Figure 4. Ingrown toenail5 6 * Figure 5. Onychogryposis * Figure 6. Lichen planus * Figure 7& 8. Psoriasis7 8
  86. 86. Splinter hemorrhages of the nails
  87. 87. Tinea Infection
  88. 88. Longitudinal section of distal phalanx to shownail.Brittle nails may be a sign of peripheral vascularinsufficiency, anemia or hypothyroidism
  89. 89. 6Nappy Rash
  90. 90. Nappy Rash Differential Diagnosis & Management Contact dermatitis -- Emollient, frequent changing & cleaning. -- Zincoxide paste + Topical steroids Atopic dermatitis -- Emollient, Local steroids, Systemic antihistamine for pruritus antibiotics. Seborrhoeic dermatitis -- Local steroids / Antiseptic. Cleaning cream. Candiasis -- Topical antifungal e.g.. Nystatin & Unidazole or Hydrocortisone / Unidazole combination.
  91. 91. Napkin rashNapkin dermatitis CandidiasisErythema and ulcers on expose Bright red area (involving flexures) surfaces (sparing flexures) spread from prenial area
  92. 92. Napkin EruptionsSebarrhoeic dermatitis of infantsAmmoniacal napkin rash
  93. 93. Napkin Eruptions Granuloma PsoriasiformCandidal intertrigo gluteale napkin rash infantum (candida).
  94. 94. 7Acne
  95. 95. Acne - Lesions / Stages Primary comedones Mildly inflammatory : Comedones and papules Moderate or severe Inflammatory : Many papules , pustules & some cysts Conglobate abscesses (large cysts) & severe scarring
  96. 96. Acne
  97. 97. Acne
  98. 98. AcneGray discoloration in the numerous old acnescar of the face as side effect of Minocycline
  99. 99. Rosacea is easily confused with acne, acnevulgaris tends to occur in a younger age groupand comedones are usually present. Comedonesare not seen in rosacea
  100. 100. Typical case of rosacea: small papules andpustules on an erythematous, telangiectaticbackground. The most common sites are thecentral cheeks, forehead, tip of the nose and chin
  101. 101. Acne rosacea. Commoner in Rhinophyma. Enlargement ofwomen, esp. those with Celtic the nose due to hypertrophy ofskin. Cruciate distribution sebaceous glands.
  102. 102. Acne Therapy Guide Lesion / Stage Therapy• Primary comedones • Retinoic acid cream / gel• Mildly inflammatory : • Topical antibiotic or benzoyl Comedones and peroxide lotion or gel papules (sometimes retinoic acid) • Benzoyl peroxide & oral or• Moderate or severe Inflammatory : topical antibiotic (sometimes retinoic acid) Many papules & pustules, some cysts • Referral of treatment failures• Conglobate abscesses, • Referral severe scarring
  103. 103. 8 SkinPigmentation
  104. 104. Differential Diagnosis of Pigmented Skin Lesions * Figure 1. Pigmented basal cell carcinoma * Figure 2.1 2 Blue nevus * Figure 3. Lentigo maligna * Figure 4. Superficial3 4 spreading melanoma
  105. 105. Differential Diagnosis of Pigmented Skin Lesions * Figure 5. Nodular melanoma5 6 * Figure 6. Seborrhoeic keratosis * Figure 7. Dermatofibroma * Figure 8. Angiokeratoma7 8
  106. 106. Differential Diagnosis of Pigmented Skin Lesions1 •Figure 1. Pigmented basal cell 2 carcinoma •Figure 2. Blue nevus •Figure 3. Lentigo maligna3 4 •Figure 4. Superficial spreading melanoma5 6 * Figure 5. Nodular melanoma * Figure 6. Seborrhoeic keratosis * Figure 7. Dermatofibroma7 8 * Figure 8. Angiokeratoma
  107. 107. Oral Kaposi’s SarcomaCoetaneous Kaposi’sSarcoma in a homosexualman
  108. 108. Skin Manifestation of Internal Malignancy Fig. 1 Acanthosis nigricans1 2 in a patient with underlying malignancy. Fig. 2 Acanthosis nigricans (benign type). Fig. 3 Acquired ichthyosis with underlying lymphoma. Fig. 4 Migratory thrombophlebitis.3 4

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