Dermatology Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 10)

Dermatology Review
(A Free Booklet Series by Dr. Aryan)

Preface:
• This is the study material designed by Dr. Aryan with creation and compilation of the best
of the best and the most finest slides on the subject. I would like to offer a billion heartily
thanks for everyone who contributed directly or indirectly to the creation of the material
through creation and dissemination of the scientific information.
• Covering everything in one study material is next to impossible. Hence, refer to gold
standard textbooks for building solid concepts or in case of any doubt. Textbooks are
acknowledged at the end of the presentation. If any source has been missed to
acknowledge, it doesn’t lessen their impact and contribution in any way.
• Don’t keep searching for pattern between the consecutive slides. You won’t find many.
Rather to boost your recall and review, I have constructed many slides and are deliberately
placed with no much relation between the preceding and the succeeding ones.
• The main rule of a review material is that it must make you recall or learn maximum
amount of information in minimum amount of time and space.
• Motivational quotes and articles are included within the slides. Always remember that
every good idea, nice piece of information and everything else is literally and absolutely
worthless unless you execute.
• If you know everything in the slides in much detail, you probably wouldn’t need this
material.
Best of luck WORK & SUCCESS! Dr. Aryan
(Anish Dhakal)

+ve in Pemphigus vulgaris, Staphylococcal Scalded Skin Syndrome & Toxic Epidermal Necrolysis

Bed side test for Psoriasis vulgairs
(Chronic Plaque Psoriasis)
• Grattage test
• Auspitz sign

Psoriasis:
• Well-defined, erythematous papules and plaques
• Surmounted by large, loose, silvery scales.
• It is a chronic dermatosis
• Characterized by an unpredictable course of remission and relapses at
typical sites.
Dr. Aryan (Anish Dhakal)

Variants of CPP
Small plaque psoriasis
Rupioid psoriasis
Flexural psoriasis
Scalp psoriasis
Penile psoriasis
Psoriasis of palms and soles

Nail involvement in Psoriasis
• Occurs in 10-50% of cases
• Nail matrix psoriasis (pitting): also occurs in alopecia areata and
dermatitis
• Nail bed psoriasis:
Nail plate thickening
Subungual hyperkeratosis
Discolouration and dystrophy of nail plate
Onycholysis
Oil spot

Pustular psoriasis
• Exaggeration of one particular
component of the disease
1. Palmoplantar pustulosis
2. Generalized pustular psoriasis
(Von Zumbusch disease)

Histogenesis of Psoriasis:
Epidermal Changes:
Increased epidermal cell proliferation
i. Increased growth fraction (30-100%)
ii. Shortened epidermal turnover time
Parakeratosis
Loss of granular layer
Regular acanthosis
Suprapapillary thinning
Collection of polymorphs in the epidermis to form spongiform pustule of Kogoj and Munros’s
microabcesses
Dermal Changes:
Dilated and tortuous capillary loops
Proliferation of fibroblasts

Classification of Topical Steroids

US classification has 7 levels: 1 is superpotent and 7 is least potent

Burrows in Scabies:
 Linear/thread like/serpentine markings in the skin due to the movement of the mite
invading stratum corneum.

Crusted/ Norwegian Scabies
• Crusted scabies (hyperkeratotic scabies)
• Seen in pt with inadequate host immunity
• Presents with thick, scaly, white-gray plaques with no or minimal pruritus
• Very high mite load (millions) as protective itching function disabled in
debilitating patients or due to absence of itching. Ordinary scabies contains
7-8 mites.

Scabicidal Agents (Sarcoptes scabiei var. hominis)
(Lindane)
30g

Pathophysiology of Acne
1. Occlusion of pilosebaceous orifice
2. Increased sebum secretion
3. Microbial colonization
• Propionibacterium spp. especially P. acnes
• Malassezia furfur
• Staph epidermidis
• Trigger a type IV inflammatory response
• Produce extracellular enzymes, which attract inflammatory
cells
4. Release of inflammatory mediators
• Distended follicle rupture, ductal epithelium or microbes.

Condylomata acuminata: Cauliflower like, Bulky & Dry (contrast to lata
which are smooth, flat & moist
Differentials of condylomata acuminata (anogenital warts) also include molluscum contagiosum, pearly
penile papules & neoplastic lesions.

Treatment: Molluscum contagiosum

Long term complications of Gonorrhea in males: Stricture, Infertility
Long term complications of Gonorrhea in females: Ectopic pregnancy, Tubal infertility

Classification: Eczema
Etiology Pattern Duration
Endogenous Discoid Acute
Exogenous Hyperkeratotic Chronic
Combined Lichenified
Seborrheic
Endogenous Exogenous Combined
Seborrheic
dermatitis
Irritant dermatitis Atopic dermatitis
Discoid dermatitis Allergic dermatitis Pompholyx
Lichen simplex
chronicus
Photodermatitis
Pityriasis alba Radiation
dermatitis
Stasis dermatitis Infective dermatitis

LayersofSkin

Darier’s disease is a skin condition characterized by wart-like blemishes on the body. The
blemishes are usually yellowish in color, hard to the touch, mildly greasy, and can emit a
strong odor.

Steroid Indications in Leprosy:
Erythema nodosum leprosum
Impending nerve damage
Iridocyclitis
Orchitis
Dapsone/Sulfone syndrome

• Melanin at the stratum corneum absorbs all light and appears black,
no scattering. Melanin at the dermoepidermal junction still absorbs
all light but some light is reflected back by particles in the epidermis
so it appears brown (near-black).
• Melanin in the superficial dermis still absorbs all light reaching it but
light scattered back by collagen causes a minor Tyndall effect so there
is a slight shift to blue; it appears grey. Melanin in the deep dermis
still absorbs all light reaching it but light scattered back by collagen
causes a major Tyndall effect, so it appears blue/violet.

Drugs implicated in Toxic Epidermal Necrolysis:

• Folliculitis: Infection & inflammation of one or more hair follicles
• Furuncle: deep seated follicular & perifollicular infection
• Carbuncle: deep infection of contiguous hair follicles, seen mostly in
diabetes and patients on steroids (basically a cluster of furuncles)

Vitiligo:
Morphology: Chalky or milky white macules with scalloped margin: Trichome vitiligo,
leucotrichia and koebner phenomenon
Treatment: Steroid (topical/oral), PUVA (topical/sol.), NBUVB

Side effects of systemic retinoids:

Causes of urethral discharge in male:
• Gonorrhoea,
• Trichomoniasis,
• Candidiasis
• Chlamydial infection,
• Non-gonococcal urethritis,
• Intraurethral herpes/wart
Treatment: Tab Cefixime 400 mg stat along with Tab Azithromycian 1 gm stat OR Inj
Ceftriaxone 250 mg IM single dose with Azithromycin 1 g, partner tracing and treatment of
partner.

Trichomoniasis in a Nutshell
• Trichomonas vaginalis: Motile, anaerobic protozoan
• MOT: Sexual contact/hygiene
• Female: Thin greenish yellow frothy offensive discharge/Strawberry
vagina
• Male: Less profuse discharge/dysuria
• Saline wet mount; Culture (gold standard)
• Metronidazole/Tinidazole 2g single dose vs. 500mg BD*7
days

LGV in a Nutshell
Caused by Chlamydia trachomatis serovars L1, L2, and L3
Inguinal bubo, Groove sign, Esthiomene (elephantiasis and
chronic ulceration in female), Saxophone deformity in male
Diagnosis: Direct Smear, Culture (Specimen: Lesion swab,
Bubo Aspirate), Nucleic Acid Amplification Test
 Treatment:
Doxycycline, 100 mg twice a day for 3 weeks
Alternative: Erythromycin, 500 mg, 4 times a day for 3
weeks

Granuloma Inguinale (Donovanosis) in a Nutshell
• Painless, no lymphadenopathy, autoinoculation
• Beefy red granulation tissue
• Closed safety pin appearing bodies
• Complications include esthiomene, ureteral stricture, phimosis, pelvic
abscess, SCC
•Azithromycin, 1 gm stat followed by
500 mg as a single oral dose daily
OR,
• Doxycycline
• 100 mg orally twice a day
Until all the lesions heal (minimum of 3 weeks)

Alopecia areata (Exclamation mark hair):
From scalp skin to outside: proximal more thinner, distal more thicker

Hair Growth Stages:

Cicatricial alopecia:

Variants
1. Ophiasis (Band or wave like pattern at pheriphery of scalp
2. Sisiaphio (involving the central scalp and sparing the periphery)
3. Alopecia totalis (lose hair from whole scalp)
4. Alopecia universalis (lose hair from whole body)

• Kerion definition:
A scalp condition that occurs in
severe cases of scalp ringworm
(tinea capitis), appearing as an
inflamed, thickened, pus-filled
area & it is sometimes
accompanied by a fever is called
kerion.
.

CHANCROID or SOFT CHANCRE
Haemophilus ducreyi
• ‘school of fish’ or ‘rail road track’ appearance
• Treatment with Azithromycin 1 gm single dose. Alternative include
Ceftriaxone 250 mg im single dose
• Reexamine after 3-7 days. If h/o sexual contact within 10 days
preceding onset of symptoms, treat sex partner as well
• Differentials of chancroid: Chancre of syphilis, Donovanosis, HSV (due
to presence of ulcer), LGV (due to bubo formation)

Tinea incognito
• Dermatophytic infection of skin modified by steroid therapy
• Atypical lesions usually asymptomatic, poorly defined edge with minimal scales
and papulovesicles

Differential diagnosis of Onychomycosis
• Psoriasis
• Lichen planus
• Paronychia
Psoriasis Onychomychosis
Symmetry Symmetrical Asymmetrical
Site Begins proximally Usually distally
Pitting Frequent Not seen
Nail plate Thickened and
discolored
Thickened ,discolored and
tunneled
Subungal debris Firm Friable

Treatment: Superficial Superficial Fungal Infection
Topical: Miconazole 2% cream, Clotrimazole 1% cream/ lotion/
powder, Ketoconazole 2% shampoo, Terbinafine 1% cream
Systemic antifungals:
Terbinafine 250 mg daily
Itraconazole/Ketoconazole 200 mg daily
Fluconazole 150 mg daily
Griseofulvin 10 mg/kg daily

Duration of Treatment: Superficial Fungal Infection
Tinea corporis 4 weeks topical for localized
2 weeks oral Terbinafine for extensive
Tinea cruris 4 weeks topical for short duration
4-6 weeks oral Terbinafine for chronic
Tinea capitis 8 weeks oral Griseofulvin or Terbinafine
Tinea unguinum 6 weeks for finger nails oral Terbinafine
12 weeks for toe nails oral Terbinafine
Pulse therapy with oral Itraconazole ( 2 pulse i.e. 1 week/ month for
finger nails & 3 pulses for toe nails)
Pityriasis versicolor Ketoconazole topical for 4 weeks
Ketoconazole for 3 consecutive days
Itraconazole for 7 days
Fluconazole 400 mg single dose

Differential diagnosis:
psoriasis vulgaris, eczematous
dermatitis, pitted keratolysis
Moccasin type:
Well demarcated erythema with minute
papules on margin, fine white scaling and
hyperkeratosis

Mycetoma/Madura foot
• Chronic suppurative infection originating in dermis and subcutis,
extending to contaguous tissues (fascia, bone)
• Causative agents:
• Actinomycetoma: caused by filamentous bacteria (Norcardia brasiliensis,
Streptomyces somaliensis)
• Eumycetoma: caused by true fungi (Madurella mycetomatis, M. grisea)
Chromoblastomycosis:
• Causative agent: Fonsecaea pedrosoi (common)

Chromoblastomycoses
• F. compacta, Phialophora verrucosa, Cladosporium carrionii, Rhinocladiella
aquaspersa, Botryomyces caespitosus
• Male > Female; 20-60 years
• Transmission:
• Cutaneous inoculation
• Risk groups:
• Agriculture workers
• Miners

LeprosyTypes

TypesofLeprareaction

Management of Leprosy
WHO recommended regimen for adults:
Pauci-bacillary Multi-bacillary
Definition 5 or < lesions > 5 lesions
Duration of therapy 6 months (can be
completed in 9 months)
12 months (can be
completed in 18 months)
Drugs Rifampicin, 600mg
Supervised (monthly)
Dapsone, 100mg
Not Supervised (daily)
Rifampicin, 600mg and
Clofazimine, 300mg
Dapsone, 100mg and
Clofazimine, 50mg

Child PB Pack
Child MB Pack

Psoriasis Lichen Planus
Erythematous papules & plaques Violaceous papules with Wickham’s
striae
Slivery scales removed by Grattage Thin, transparent & adherent scale
Koebner phenomenon present in both
Auspitz’s sign present Auspitz’s sign absent

Topical Steroids Adverse Effects Profile:

Treatment for Gonorrhoea:
Uncomplicated: Cefixime 400mg SOD
Or Ceftriaxone 125mg IM,SD
Complicated: Ceftriaxone 1g IM OD for 7 days
Or Cefixime 400mg BD for 7days

Pathogenesis of Syphilis:

Specific treatment for Syphilis:
Treatment of choice
• Benzathine penicillin, 2.4 mega units intramuscular
-Two equally divided doses (early syphilis) single time dose
• Weekly for 3 consecutive weeks (late syphilis viz. late latent &
tertiary syphillis)
In penicillin-sensitive patients:
• Doxycycline, 100 mg twice daily (not in pregnancy)
• Erythromycin stearate 2 g daily (in four divided doses)
-14 days(early syphilis)
- 28 days(late syphilis)

Treatment
Neurosyphilis:
• Crystalline penicillin* 3–4 million units, four-hourly intravenous ×
14 days
Congenital syphilis
• Procaine penicillin*, 50,000 units/kg intramuscular, daily × 14 days.
Penicillin G: standard for syphilis in pregnancy. If allergic conduct penicillin desensitization (challenge
until tolerance). The patient must be off beta blocker in case anaphylaxis occur for adrenaline to
work on adrenergic beta receptors.

• Retinoic acid actions:
1. Reverse blockage of pilosebaceous system
2. Keratolytic action
3. Decrease sebum production & inflammatory mediators
Whitfield’s Ointment:
Benzoic acid (fungistatic) + Salicylic acid (keratolytic)

due to evanescent edema
of dermis (& sometimes of
subcutis)
If edema involves subcutaneous or submucosal layers, the term angioedema is used.
Angioedema mostly in distensible tissues such as the eyelids, lips, lobes of the ears and external
genitalia or the mucous membranes of the mouth tongue or larynx

Types of UrticariaPhysical
 cold
 solar
 heat
 cholinergic
 dermographism (immediate pressure urticaria)
 delayed pressure
 adrenergic
Hypersensitivity
Autoimmune
Pharmacological
Contact

Also, Chlorpheniramine 20 mg & Hydrocortisone 100 mg both iv

Bullous Impetigo Impetigo Congtagiosa
Aetiology Staph. Aureus Staph aureus or strep.
Pyogens or both
Prevalence Sporadic Frequent, often epidemic
Age Usually infant Children
Morphology of bulla Bullae thick-walled,
persistent and may
become large
Thin-walled and
transient. So rarely seen
Crusts Thin, Varnish like Thick, honey coloured
Erythematous halo Absent Present
Lymphadenopathy Rare Frequent
Central clearing Present, so annular
lesions seen
Absent/incomplete.
Lesions coalesce to form
polycyclic plaques
Mucous membranes May be involved Involvement rare
Sites of predilection Face and other parts Periorificial

Acyclovir Dosing:
Herpes simplex: First episode: Acyclovir 200 mg 5 times/day * 7days
For recurrent Herpes genitalis: episodic treatment
same 200 mg 5 times a day as above for 5 days
If > 6 episodes per year, suppressive treatment: Acyclovir 400 mg BD
*12 months
For varicella: Acyclovir 800 mg 5 times/day * 7-10 days

Intially herald patch is present in pityriasis rosea. Also present are: collarette of scaling. Hypothesized
to represent a reaction to viral infection with HHV 7 & 6

Topical podophyllin 25% or podophylotoxin 0.5% is contraindicated in pregnancy. Use
tricholoroacetic acid or cryotherapy with liquid nitrogen at -195 degrees

Tinea (Dermatophytes) Prototype lesion:
• Annular or arcuate lesion that spreads
centrifugally
• The margin is active showing
papulovesiculation, pustulation &
scaling (scales from edges for KOH
mount)
• Center is relatively clear though in
chronic lesions there may be nodules,
hyperpigmentation & even
lichenification in the center

Bacilli at any one site in silt smear test: Multibacillary

Smear in Leprosy:
Ear lobes
Medial eyebrows
Knuckle
Nose
Lesion
Normal Skin
M. tuberculosis is strongly acid fast, a 3% v/v acid alcohol is used to decolorize the smear, where as M.
leprae is only weakly acid fast. 0.5-1% v/v decolorizing solution is therefore used for M. leprae smears.

Topical Steroids in a Nutshell:
Uses? Side effects? Where not to be
used?
Eczema Atrophy Face
Psoriasis Erythema Thin skin
Vitiligo Telangiectasia Children
Acneiform eruption Intertriginous areas (where two
skin areas may touch or rub
together like axilla of the arm, the
anogenital region, skin folds of the
breasts and between digits)
Hypertrichosis
Delayed wound healing &
Secondary bacterial infection

• Silt skin smear
materials: Carbol
fuschin, Hydrochloric
acid/Sulphuric acid,
Methylene blue, tap
water, wire rack, Bunsen
burner/hot plate
• Skin biopsy materials:
Local anaesthesia,
syringe, Punch,
disinfectant, suture,
cotton, gauze Remember Leonine facies in LL & Thalidomide
DOC for ENL (lepra reaction Type 2 in LL)

ADRs of Leprosy Medications:
Rifampicin Dapsone Clofazimine
Reddening of body secretions Hemolytic anemia Ichthyosis
Hepatotoxicity Wooly headed Reddish brown discoloration
Skin rash Methemoglobinemia Abdominal cramps
Dapsone/Sulphone
hypersensitivity syndrome
Hepatotoxicity

Melasma (Chloasma) Causes:
•OCP
•Pregnancy
•Thyroid disorders
•UV exposure

Chicken pox complications:
• Secondary bacterial infection
• Herpes zoster
• Varicella pneumonitis
• Orchitis
• Encephalitis
• Cerebellar ataxia
• Fetal varicella syndrome
• Varicella scars

Non cicatricial alopecia causes:
• Alopecia areata
• Non inflammatory tinea
• Trichotillomania
• Traction alopecia
• Androgenic alopecia
• Telogen/anagen effluvium

Painful genital ulcers differentials:
oHerpes genitalis
oChancroid
oBechet’s disease
oSJS
oPemphigus vulgaris
oLichen planus
Behçet disease is a rare vasculitic disorder that is characterized by a triple-symptom complex of
recurrent oral aphthous ulcers, genital ulcers, and uveitis.

Few systemic disease causing nail changes:
Iron deficiency anemia
Chronic liver failure
SLE
DM
Scleroderma
Thyroid disease
Liver disease
Congestive cardiac failure

5 Cs of STI ?

Acknowledgements:
Best of the best slides, pictures and information on the web. Special
thanks to all those brilliant minds for their act of creation and
compilation of scientific material without which this work would not
have been possible
Illustrated Synopsis of Dermatology and STDs, Neena Khanna
Clinical Dermatology, Lange
Clinical Dermatology, John Hunter et al.
Rook’s Textbook of Dermatology

How to get over fear of accidents while travelling?
https://medium.com/@anishdhakal718/how-to-get-over-fear-of-
accidents-while-travelling-fa49cd430dff

Dermatology Review Booklet by Dr. Aryan (Medical Booklet Series by Dr. Aryan Part 10)

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