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Dermatology
                   Approach

                   Fayza Rayes
              MBBCh. Msc. MRCGP (UK)
              Consultant Family Physician
Joint Program of Family & Community Medicine – Jeddah

                www.fayzarayes.com
               fayzarayes@yahoo.com
Prepared by dr. Fayza Rayes

Dermatology 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
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.
DD. Of Generalized Skin Rash


              Drug eruption
              Ampicillin rash




              Viral exanthema
              Measles
DD. Of Rash at Site of Trauma
Molluscum contaguasum
                        Psoriasis




Lichen
                        Warts.
planus
DD. Of Truncal Lesions Rash
Tinea versicolor   Pityreasis rosea
Palms & Soles Conditions
     Secondary syphilis
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
1
Approach to Patient
  with skin Rash
Diffuse Erythema
      Differential Diagnosis
Infectious :
    Streptococcal infection (Scarlet fever)
    Staphylococcal infection (Toxic syndrome)
    Enteroviral infection

Non-infectious Causes:
   – Allergy             -- Vasodilatation
   – Eczema              -- Psoriasis
   – Pityrosis rubra     -- Lymphoma
Scarlet fever
Scarlet fever
   Incubation period: 2 - 4 days
              Days of illness

                                   Complications:

                                   Otitis media
                                   Cervical adenitis
Rash                               Rhinitis
Sore throat                        Sinusitis

                                   Rare:
                                   Rheumatic fever
                                   Acute nephritis
Maculo-papular Rash with Fever
    Differential Diagnosis
Infection :
-- Measles                     -- Interoviral infection
-- Chickenpox                  -- Mononucleosis
-- Rubella                     -- Typhoid fever
-- Rubeola (Red measles)       -- Secondary syphilis
-- Erythema infectious (5th)   -- HIV (Primary)
-- Adenoviral exanthema        -- Early meningitis
Non-infectious Causes :
-- Allergy                     -- Erythema multiform
-- SLE                         -- Erythema margenatum
-- Dermatomyositis             -- Serum sickness
-- Drug rash
DD of Maculo-papular Rash with Fever
                      Chickenpox




      Measles




     Mononucleosis
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
Measles
Chickenpox
Incubation period: 1-14 days



                               :Complications
                               Secondary infection

                               :Rare
                               Encephalomyelitis
German measles
 Incubation period: 14-21 days
             Days of illness
                                 Progression over 4 days
                                 Maculopapular


                                 Complications
Rash
Ing. Nodes                       Rare:
Malaise                          Arthritis
URTI                             Encephalitis
                                 Purpura
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
DD of Maculo-papular Rash with Fever

         Typhoid fever
Typhoid fever




Distribution of rose-spot rash: The typical rash of
typhoid fever may appear towards the end of the first week
but it has been recorded as late as the 20th day. It is present
in about half the adults with typhoid but is less common in
children. Rose spots are difficult to detect on dark skins.
DD of Maculo-papular Rash with Fever
                        Secondary syphilis

Erythema
infectious
(5th)




Early
meningitis
Early rash of meningitis:
Fleeting macular or papular rash.
This may occur alone or proceeding
hemorrhagic eruption by few hours
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
Secondary Syphilis-rash




The rash may be papules
 or pustules and crusts
DD of Papulosquamous Exanthems
        Secondary syphilis
DD of Papulosquamous Exanthems

                         * Figure 5.
                         Drug eruption
                         * Figure 6.
                         Erythrodermic
                         drug eruption
            5        6


                         * Figure 7.
                         Psoriasis
                         * Figure 8.
                         Lichen planus
        7            8
DD of Papulosquamous
1   2
             Exanthems
        * Figure 1,2,3 & 4
         Secondary syphilis
3   4
        * Figure 5.
         Drug eruption
        * Figure 6.
5   6
         Erythrodermic drug eruption
        * Figure 7. Psoriasis
        * Figure 8. Lichen planus
7   8
DD of Non-infectious Causes of
    Maculo-papular Rash




   SLE          Erythema margenatum
DD of Non-infectious Causes of
    Maculo-papular Rash




               Steven-Johnson
                  Syndrome
Erythema Multiforme with
 “bulls eyes” target lesions
Classification of Pustular Lesions
Local Infections :
• Bacterial :    impetigo, folliculitis
• Viral :        herpes simplex, herpes zoster,
• Fungal :       dermatophyte infection, candida

Systemic Infections :
• Bacterial
• Meningococcaemia, Gonococcaemia & Staphylococcaemia
• Viral : varicella, enteroviral infection, HIV

Non-infective conditions :
   Generalized pustular psoriasis or localized pustular psoriasis. Acne
   vulgaris and rosacea, Eczema, Pemphigus, Porphyria, Erythema
   multiform, Erythema bullosum.
DD of Pustular Lesions - Local Infections
                       Herpes simplex


Impetigo



  herpes
  zoster
DD of Pustular Lesions
            Non-infective Conditions
Generalized pustular psoriasis

                                 Erythema multiforme
DD of Pustular Lesions
      Non-infective Conditions




Large, tense blisters in bullous pemphigoid
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.
DD of Pustular Lesions
Non-infective Conditions




        Linear blistering lesions in
        primula dermatitis


  Bullae occurring as
  a reaction to flea
  bites on the ankle
Blisters




Vasculobullous lesions on   Phototoxic bullae
the palm, Characteristic     associated with
     of pompholyx             nalidixic acid
DD of Pustular Lesions
     Infective Conditions




Septicemia, probably gonococcal.
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
DD of Purpuric or Petechial Rash




       Rash of meningitis
Purpuric or Petechial Rash
     Differential Diagnosis

     Non-infectious causes :
      Allergy
      Low platelets of any cause
      Scurvy
      Henoch-Schonlain purpura
      Vasculitis
      Acute rheumatic fever
      Hyperglobulinemia
Purpuric Rash



                                            Bruises
                                            (ecehymoses) in
                                            a patient with
                                            coagulation
                    meningococcal           defects due to
Henoch-             septicemia - often      acute hepatic
Schonlein disease   sparse and need to be   necrosis
                    looked for carefully
Purpuric Rash


        Vasculitis. Palpable
        purpuric papules on
        the lower legs are
        seen in this patient
        with coetaneous small
        vessel vasculitis.
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
2
Approach to Patient
 with skin Pruritus
Pruritus
                   History

 Duration, localization & character of the itch.
 Provocating factors
 Diurnal variation
 Sleep disturbance
 Occupational history
 Itchy contact
Pruritus
Examination & 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)
Systemic Causes of Pruritus

1. Cholestasis :
  --   Primarily biliary cirrhosis           -- Pregnancy
  --   Extrahepatic obstruction      -- Drugs e.g. Contracep.
2. Endocrine :
  --   Thyrotoxiosis                 -- Myxoedema
  --   Hyperparathyroidism           -- DM
3. Hematological / Myeloproliferative :
  -- Iron deficiency                 -- Polycythemia
  -- Hodgkin’s disease               -- Multiple myeloma
4. Chronic Renal Failure :
5. Malignancy / Miscellaneous :
  -- Gout       -- Psychological             -- Old age.
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
Some common dermatological
conditions associated with itching

                   Severe
      Infestation : Scabies, lice
      Insect bites
      Eczema
      Urticaria
      Dermatitis herpetiformis
      Lichen planus
      Lichen simplex
      Drug reactions
The head louse:           Head lice need relatively
Physical evidence of      prolonged head-to-bead
living lice is required   contact. Estimates suggest it
before treatment          takes of least 30 seconds for
begins, but they con      lice to move from one beside
be difficult to detect    to another
Dermatological conditions associated with severe itching




Childhood atopic eczema. Facial atopic eczema.
Dermatological conditions associated with severe itching
                   Eczema



 Hyperkeratotic hand        Vesicular hand dermatitis
 eczema.                    (pompholyx).




  Infected hand eczema         (Ring) dermatitis
Dermatological conditions associated with severe itching

                  Urticaria
Dermatological conditions associated with severe itching




                         Urticaria showing charac-
                         teristic discrete and confluent,
                         edematous, erythematous
                         papules and plaques.
Dermatological conditions associated with severe itching


                       Scabies



Widespread pruritis rash of scabies. Characteristic burrow of
scabies..
Dermatological conditions associated with severe itching
          Dermatitis herpetiformis




Herpes simplex infection associated with atopic dermatitis
It was misdiagnosed as pyoderma and treated with
antibiotics for more than 2 weeks
Dermatological conditions associated with severe itching




Dermatitis herpetiformis            manifested by
pruritic, grouped vesicles in a typical location.
The vesicles are often excoriated and may occur
on knees, buttocks, and posterior scalp.
Dermatological conditions associated with severe itching

              lichen planus




    Flat-topped violaceous   Wickham's striae
    papules of lichen
    planus.                  (lichen planus).
Dermatological conditions associated with severe itching




        Lichen planus showing multiple
        flat-topped, violaceous papules and
        plaques. Nail dystrophy as seen in
        this patient's thumbnail may also he a
        feature.
Dermatological conditions associated with severe itching

                 Lichen simplex




lichen simplex      Lichen simper of     Lichenification
chronicus           scrotum              from constant
                                         rubbing
Dermatological conditions associated with severe itching



                                Angio-edema
                                Most drugs have the
                                potential to cause
                                angio-edema,
                                urticaria, pruritus
                                and maculopopular
                                rash
Dermatological conditions associated with severe itching




 Widespread urticaria         Severe angio-oedema
Some common dermatological
conditions associated with itching


        Moderate:
         Psoriasis
         Fungal infections
         Pityriasis rosea
         Pemphigiod
         Xerosis (dry skin)
Some common dermatological conditions associated
              with moderate itching

                                Pityriasis rosea
       Psoriasis
Common Cause of
  Local Itching




                  Pruritus ani - perianai
                       dermatitis.
Herpes simplex of the anus.
3
Mouth Conditions
Month Ulcers
          Differential Diagnosis

 Trauma (dentures)    Erythema multiform
                        (from drugs)
 Aphthous ulcers
                       Pemphigus
 Candida infection
                       Lichen planus
 Herpes simplex       Carcinoma
DD. Of Oral
Conditions
Erythema multiform
                     Aphthous ulcers




                     Lichen planus
Erythema
 multiforme
Bullous erythema
multiforme lesions of palm.

                              Typical target lesions

Erythema multiforme:
mucosal involvement
Aphthus Ulcer




Aphthous ulcers: Small ulcers, 1 – 4 mm in diameter may
occur 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 in
infectious mononucleosis
DD. Of Oral
Conditions

Aphthus Ulcer



Pemphigus
Oral thrush   Leukoplakia
lichen planus on the
 tongue, resembling
    leukoplakia
Iron deficiency anemia
Smooth tongue




                Angular stomatitis
1   2
        Differential Diagnosis of
        Mucous Membrane Lesions
        Figure 1. Secondary syphilis
3   4
        Figure 2. Lichen planus
        Figure 3. Scrotal tongue
        Figure 4. Geographic tongue
5   6
        Figure 5. Aphthus ulcer
        Figure 6. Black hairy tongue

7   8   Figure 7. Pyogenic granuloma
        Figure 8. Median rhomboid
        glossitis
1                   3




                 2                     4                 5

1) Angular stomatitis 3) Carcinoma of lip   5) Peutz-Jeghers
2) Herpes labialis    4) Hereditary         syndrome
                      hemorrhagic
                      telangiectasia
4
Palm & Sole
  Lesions
DD. Of Acral       Tinea pedis
  Lesions
plantar warts




                dyshydrotic dermatitis
DD. Of Palm
  & Sole
  Lesions
                        Tinia pedis   Unilateral scaling of the
                                      palm(tinea manuum).

  Dermatophyte
  infection spreading
  out from the toes
DD. Of Palm
                  & Sole
                  Lesions
Pustular psoriasis on sole of foot




Psoriasis nail with ridging and pitting
5
Nail Diseases
Differential Diagnosis
1    2      of Nail Diseases
         * Figure 1. Fungal infection

         * Figure 2. Paronychia.
3   4
         * Figure 3. Posttraumatic
         hematoma
         * Figure 4. Ingrown toenail
5   6
         * Figure 5. Onychogryposis
         * Figure 6. Lichen planus
         * Figure 7& 8. Psoriasis
7   8
Splinter hemorrhages of the nails
Tinea Infection
Longitudinal section of distal phalanx to show
nail.Brittle nails may be a sign of peripheral vascular
insufficiency, anemia or hypothyroidism
6
Nappy Rash
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.
Napkin rash
Napkin dermatitis                         Candidiasis




Erythema and ulcers on expose   Bright red area (involving flexures)
  surfaces (sparing flexures)        spread from prenial area
Napkin Eruptions

Sebarrhoeic dermatitis of infants




Ammoniacal napkin rash
Napkin Eruptions




                      Granuloma    Psoriasiform
Candidal intertrigo   gluteale     napkin rash
                      infantum
                      (candida).
7
Acne
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
Acne
Acne
Acne



Gray discoloration in the numerous old acne
scar of the face as side effect of Minocycline
Rosacea is easily confused with acne, acne
vulgaris tends to occur in a younger age group
and comedones are usually present. Comedones
are not seen in rosacea
Typical case of rosacea: small papules and
pustules on an erythematous, telangiectatic
background. The most common sites are the
central cheeks, forehead, tip of the nose and chin
Acne rosacea. Commoner in       Rhinophyma. Enlargement of
women, esp. those with Celtic   the nose due to hypertrophy of
skin. Cruciate distribution     sebaceous glands.
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
8
   Skin
Pigmentation
Differential Diagnosis of Pigmented Skin Lesions


                                         * Figure 1.
                                         Pigmented
                                         basal cell
                                         carcinoma
                                         * Figure 2.
1                                    2   Blue nevus
                                         * Figure 3.
                                         Lentigo
                                         maligna
                                         * Figure 4.
                                         Superficial
3                                    4   spreading
                                         melanoma
Differential Diagnosis of Pigmented Skin Lesions



                                          * Figure 5.
                                          Nodular
                                          melanoma
5                                     6 * Figure 6.
                                        Seborrhoeic
                                        keratosis
                                          * Figure 7.
                                          Dermatofibroma
                                          * Figure 8.
                                          Angiokeratoma
7                                     8
Differential Diagnosis of
          Pigmented Skin Lesions

1       •Figure 1. Pigmented basal cell
    2
                  carcinoma
        •Figure 2. Blue nevus
        •Figure 3. Lentigo maligna
3   4
        •Figure 4. Superficial spreading
                  melanoma

5   6   * Figure 5. Nodular melanoma
        * Figure 6. Seborrhoeic keratosis
        * Figure 7. Dermatofibroma
7   8   * Figure 8. Angiokeratoma
Oral Kaposi’s Sarcoma

Coetaneous Kaposi’s
Sarcoma in a homosexual
man
Skin Manifestation of
         Internal Malignancy

        Fig. 1 Acanthosis nigricans
1   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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Dermatology approach

  • 1. Dermatology Approach Fayza Rayes MBBCh. Msc. MRCGP (UK) Consultant Family Physician Joint Program of Family & Community Medicine – Jeddah www.fayzarayes.com fayzarayes@yahoo.com
  • 2. Prepared by dr. Fayza Rayes Dermatology 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. 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. DD. Of Generalized Skin Rash Drug eruption Ampicillin rash Viral exanthema Measles
  • 5. DD. Of Rash at Site of Trauma Molluscum contaguasum Psoriasis Lichen Warts. planus
  • 6. DD. Of Truncal Lesions Rash Tinea versicolor Pityreasis rosea
  • 7. Palms & Soles Conditions Secondary syphilis
  • 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. 1 Approach to Patient with skin Rash
  • 10. Diffuse Erythema Differential Diagnosis Infectious :  Streptococcal infection (Scarlet fever)  Staphylococcal infection (Toxic syndrome)  Enteroviral infection Non-infectious Causes: – Allergy -- Vasodilatation – Eczema -- Psoriasis – Pityrosis rubra -- Lymphoma
  • 12. Scarlet fever Incubation period: 2 - 4 days Days of illness Complications: Otitis media Cervical adenitis Rash Rhinitis Sore throat Sinusitis Rare: Rheumatic fever Acute nephritis
  • 13. Maculo-papular Rash with Fever Differential Diagnosis Infection : -- Measles -- Interoviral infection -- Chickenpox -- Mononucleosis -- Rubella -- Typhoid fever -- Rubeola (Red measles) -- Secondary syphilis -- Erythema infectious (5th) -- HIV (Primary) -- Adenoviral exanthema -- Early meningitis Non-infectious Causes : -- Allergy -- Erythema multiform -- SLE -- Erythema margenatum -- Dermatomyositis -- Serum sickness -- Drug rash
  • 14. DD of Maculo-papular Rash with Fever Chickenpox Measles Mononucleosis
  • 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
  • 17. Chickenpox Incubation period: 1-14 days :Complications Secondary infection :Rare Encephalomyelitis
  • 18. German measles Incubation period: 14-21 days Days of illness Progression over 4 days Maculopapular Complications Rash Ing. Nodes Rare: Malaise Arthritis URTI Encephalitis Purpura
  • 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. DD of Maculo-papular Rash with Fever Typhoid fever
  • 21. Typhoid fever Distribution of rose-spot rash: The typical rash of typhoid fever may appear towards the end of the first week but it has been recorded as late as the 20th day. It is present in about half the adults with typhoid but is less common in children. Rose spots are difficult to detect on dark skins.
  • 22. DD of Maculo-papular Rash with Fever Secondary syphilis Erythema infectious (5th) Early meningitis
  • 23. Early rash of meningitis: Fleeting macular or papular rash. This may occur alone or proceeding hemorrhagic eruption by few hours
  • 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. Secondary Syphilis-rash The rash may be papules or pustules and crusts
  • 26. DD of Papulosquamous Exanthems Secondary syphilis
  • 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. DD of Papulosquamous 1 2 Exanthems * Figure 1,2,3 & 4 Secondary syphilis 3 4 * Figure 5. Drug eruption * Figure 6. 5 6 Erythrodermic drug eruption * Figure 7. Psoriasis * Figure 8. Lichen planus 7 8
  • 29. DD of Non-infectious Causes of Maculo-papular Rash SLE Erythema margenatum
  • 30. DD of Non-infectious Causes of Maculo-papular Rash Steven-Johnson Syndrome
  • 31. Erythema Multiforme with “bulls eyes” target lesions
  • 32. Classification of Pustular Lesions Local Infections : • Bacterial : impetigo, folliculitis • Viral : herpes simplex, herpes zoster, • Fungal : dermatophyte infection, candida Systemic Infections : • Bacterial • Meningococcaemia, Gonococcaemia & Staphylococcaemia • Viral : varicella, enteroviral infection, HIV Non-infective conditions : Generalized pustular psoriasis or localized pustular psoriasis. Acne vulgaris and rosacea, Eczema, Pemphigus, Porphyria, Erythema multiform, Erythema bullosum.
  • 33. DD of Pustular Lesions - Local Infections Herpes simplex Impetigo herpes zoster
  • 34. DD of Pustular Lesions Non-infective Conditions Generalized pustular psoriasis Erythema multiforme
  • 35. DD of Pustular Lesions Non-infective Conditions Large, tense blisters in bullous pemphigoid
  • 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. DD of Pustular Lesions Non-infective Conditions Linear blistering lesions in primula dermatitis Bullae occurring as a reaction to flea bites on the ankle
  • 38. Blisters Vasculobullous lesions on Phototoxic bullae the palm, Characteristic associated with of pompholyx nalidixic acid
  • 39. DD of Pustular Lesions Infective Conditions Septicemia, probably gonococcal.
  • 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. DD of Purpuric or Petechial Rash Rash of meningitis
  • 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. Purpuric Rash Bruises (ecehymoses) in a patient with coagulation meningococcal defects due to Henoch- septicemia - often acute hepatic Schonlein disease sparse and need to be necrosis looked for carefully
  • 44. Purpuric Rash Vasculitis. Palpable purpuric papules on the lower legs are seen in this patient with coetaneous small vessel vasculitis.
  • 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. 2 Approach to Patient with skin Pruritus
  • 47. Pruritus History  Duration, localization & character of the itch.  Provocating factors  Diurnal variation  Sleep disturbance  Occupational history  Itchy contact
  • 48. Pruritus Examination & 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. Systemic Causes of Pruritus 1. Cholestasis : -- Primarily biliary cirrhosis -- Pregnancy -- Extrahepatic obstruction -- Drugs e.g. Contracep. 2. Endocrine : -- Thyrotoxiosis -- Myxoedema -- Hyperparathyroidism -- DM 3. Hematological / Myeloproliferative : -- Iron deficiency -- Polycythemia -- Hodgkin’s disease -- Multiple myeloma 4. Chronic Renal Failure : 5. Malignancy / Miscellaneous : -- Gout -- Psychological -- Old age.
  • 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. Some common dermatological conditions associated with itching Severe  Infestation : Scabies, lice  Insect bites  Eczema  Urticaria  Dermatitis herpetiformis  Lichen planus  Lichen simplex  Drug reactions
  • 52. The head louse: Head lice need relatively Physical evidence of prolonged head-to-bead living lice is required contact. Estimates suggest it before treatment takes of least 30 seconds for begins, but they con lice to move from one beside be difficult to detect to another
  • 53. Dermatological conditions associated with severe itching Childhood atopic eczema. Facial atopic eczema.
  • 54. Dermatological conditions associated with severe itching Eczema Hyperkeratotic hand Vesicular hand dermatitis eczema. (pompholyx). Infected hand eczema (Ring) dermatitis
  • 55. Dermatological conditions associated with severe itching Urticaria
  • 56. Dermatological conditions associated with severe itching Urticaria showing charac- teristic discrete and confluent, edematous, erythematous papules and plaques.
  • 57. Dermatological conditions associated with severe itching Scabies Widespread pruritis rash of scabies. Characteristic burrow of scabies..
  • 58. Dermatological conditions associated with severe itching Dermatitis herpetiformis Herpes simplex infection associated with atopic dermatitis It was misdiagnosed as pyoderma and treated with antibiotics for more than 2 weeks
  • 59. Dermatological conditions associated with severe itching Dermatitis herpetiformis manifested by pruritic, grouped vesicles in a typical location. The vesicles are often excoriated and may occur on knees, buttocks, and posterior scalp.
  • 60. Dermatological conditions associated with severe itching lichen planus Flat-topped violaceous Wickham's striae papules of lichen planus. (lichen planus).
  • 61. Dermatological conditions associated with severe itching Lichen planus showing multiple flat-topped, violaceous papules and plaques. Nail dystrophy as seen in this patient's thumbnail may also he a feature.
  • 62. Dermatological conditions associated with severe itching Lichen simplex lichen simplex Lichen simper of Lichenification chronicus scrotum from constant rubbing
  • 63. Dermatological conditions associated with severe itching Angio-edema Most drugs have the potential to cause angio-edema, urticaria, pruritus and maculopopular rash
  • 64. Dermatological conditions associated with severe itching Widespread urticaria Severe angio-oedema
  • 65. Some common dermatological conditions associated with itching Moderate:  Psoriasis  Fungal infections  Pityriasis rosea  Pemphigiod  Xerosis (dry skin)
  • 66. Some common dermatological conditions associated with moderate itching Pityriasis rosea Psoriasis
  • 67. Common Cause of Local Itching Pruritus ani - perianai dermatitis.
  • 68. Herpes simplex of the anus.
  • 70. Month Ulcers Differential Diagnosis  Trauma (dentures)  Erythema multiform (from drugs)  Aphthous ulcers  Pemphigus  Candida infection  Lichen planus  Herpes simplex  Carcinoma
  • 71. DD. Of Oral Conditions Erythema multiform Aphthous ulcers Lichen planus
  • 72. Erythema multiforme Bullous erythema multiforme lesions of palm. Typical target lesions Erythema multiforme: mucosal involvement
  • 73. Aphthus Ulcer Aphthous ulcers: Small ulcers, 1 – 4 mm in diameter may occur 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 in infectious mononucleosis
  • 75. Oral thrush Leukoplakia
  • 76. lichen planus on the tongue, resembling leukoplakia
  • 77. Iron deficiency anemia Smooth tongue Angular stomatitis
  • 78. 1 2 Differential Diagnosis of Mucous Membrane Lesions Figure 1. Secondary syphilis 3 4 Figure 2. Lichen planus Figure 3. Scrotal tongue Figure 4. Geographic tongue 5 6 Figure 5. Aphthus ulcer Figure 6. Black hairy tongue 7 8 Figure 7. Pyogenic granuloma Figure 8. Median rhomboid glossitis
  • 79. 1 3 2 4 5 1) Angular stomatitis 3) Carcinoma of lip 5) Peutz-Jeghers 2) Herpes labialis 4) Hereditary syndrome hemorrhagic telangiectasia
  • 80. 4 Palm & Sole Lesions
  • 81. DD. Of Acral Tinea pedis Lesions plantar warts dyshydrotic dermatitis
  • 82. DD. Of Palm & Sole Lesions Tinia pedis Unilateral scaling of the palm(tinea manuum). Dermatophyte infection spreading out from the toes
  • 83. DD. Of Palm & Sole Lesions Pustular psoriasis on sole of foot Psoriasis nail with ridging and pitting
  • 85. Differential Diagnosis 1 2 of Nail Diseases * Figure 1. Fungal infection * Figure 2. Paronychia. 3 4 * Figure 3. Posttraumatic hematoma * Figure 4. Ingrown toenail 5 6 * Figure 5. Onychogryposis * Figure 6. Lichen planus * Figure 7& 8. Psoriasis 7 8
  • 88. Longitudinal section of distal phalanx to show nail.Brittle nails may be a sign of peripheral vascular insufficiency, anemia or hypothyroidism
  • 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. Napkin rash Napkin dermatitis Candidiasis Erythema and ulcers on expose Bright red area (involving flexures) surfaces (sparing flexures) spread from prenial area
  • 92. Napkin Eruptions Sebarrhoeic dermatitis of infants Ammoniacal napkin rash
  • 93. Napkin Eruptions Granuloma Psoriasiform Candidal intertrigo gluteale napkin rash infantum (candida).
  • 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. Acne
  • 97. Acne
  • 98. Acne Gray discoloration in the numerous old acne scar of the face as side effect of Minocycline
  • 99. Rosacea is easily confused with acne, acne vulgaris tends to occur in a younger age group and comedones are usually present. Comedones are not seen in rosacea
  • 100. Typical case of rosacea: small papules and pustules on an erythematous, telangiectatic background. The most common sites are the central cheeks, forehead, tip of the nose and chin
  • 101. Acne rosacea. Commoner in Rhinophyma. Enlargement of women, esp. those with Celtic the nose due to hypertrophy of skin. Cruciate distribution sebaceous glands.
  • 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. 8 Skin Pigmentation
  • 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. Superficial 3 4 spreading melanoma
  • 105. Differential Diagnosis of Pigmented Skin Lesions * Figure 5. Nodular melanoma 5 6 * Figure 6. Seborrhoeic keratosis * Figure 7. Dermatofibroma * Figure 8. Angiokeratoma 7 8
  • 106. Differential Diagnosis of Pigmented Skin Lesions 1 •Figure 1. Pigmented basal cell 2 carcinoma •Figure 2. Blue nevus •Figure 3. Lentigo maligna 3 4 •Figure 4. Superficial spreading melanoma 5 6 * Figure 5. Nodular melanoma * Figure 6. Seborrhoeic keratosis * Figure 7. Dermatofibroma 7 8 * Figure 8. Angiokeratoma
  • 107. Oral Kaposi’s Sarcoma Coetaneous Kaposi’s Sarcoma in a homosexual man
  • 108. Skin Manifestation of Internal Malignancy Fig. 1 Acanthosis nigricans 1 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