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(Atopic, Irritant, Seborrhoeic, varicose)

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Atopic DermatitisPresentation itchy condition.

If no itching then it’s not eczema.

Infants Itchy vesicular eczema on face ± hands. May cause

sleep disturbance.

Children >18mo Involves antecubital and popliteal fossae, neck, wrists, and ankles.

Lichenification, excoriation, and dry skin.

Adults Most commonly hand dermatitis in a person with past history of atopic eczema. A

few continue to have generalized atopic eczema. Exacerbated by stress.

Associated with

other atopic

conditions, e.g.

asthma, hay fever.

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Diagnosis Itchy skin plus ≥3 of:

• Itching in skin creases

• History of asthma or hay fever

• Generally dry skin

• Visible flexural eczema

• Onset in the first 2y of life

Assessment Ask about:

• Family and personal history

• distribution of the disease

• Aggravating factors (pets, irritants, e.g. soaps/detergents, allergens)

• Impact on quality of life (school work, career, social life)

Complications

• Skin thickening and scaling

• Bacterial infection Secondary infection (usually with Staph. aureus)

• Viral infection, e.g. viral warts, molluscum. Eczema herpeticum

• Cataracts Rarely occur in young adults with very severe eczema

• Growth retardation Children with severe eczema, cause unknown.

A growth chart should be kept for children with chronic severe eczema

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Non Pharmalogical Management

• Advise—loose cotton clothing; avoid wool (exacerbates eczema);

avoid excessive heat; keep nails short; gloves in bed

• If a specific irritant is identified (e.g. house dust mite, pets) then avoid

Pharmalogical Management

• Emollients Topical creams/ointments and bath emollients—use

as soap substitutes, even if skin is clear. May Ideally apply 3–4x/d

• Topical steroids least potent strength that is effective.

Use od or bd. Ointments are preferable on dry, scaly eczema; creams

on wet, exudative eczema.

• Antibiotics For infected eczema—topical (alone or in combination

with steroid, e.g. Fucidin) or oral (e.g. flucloxacillin or erythromycin

qds for 2wk). Swab if antibiotic treatment is ineffective

• Oral steroids Rescue therapy

•Sedative antihistamines

• Bandages Excoriated or lichenified eczema—zinc and

calamine. Bandages can be applied at night on top of steroid ointment.

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Contact Dermatitis• Irritant (water, abrasives, chemicals, detergent), or

• Allergic (nickel; chrome; rubber)

site and knowledge of occupation, hobbies, sports, help find the

cause.

• Acute itchy erythema and skin oedema, papules, vesicles, or

blisters

• Chronic lichenification, scaling, and fissuring

Management

• Identification of the allergen or irritant Consider referral for patch

testing

• Exclusion of the offending allergen or irritant from the environment

Although this may be impossible. There is some evidence that nickel

avoidance diets can help patients with nickel sensitivityG.

• Hand care

• Emollients

• Topical steroids

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Seborrhoeic DermatitisScalp and facial involvement Most common in young men. Excessivedandruff, itchy scaly erythematous eruption affecting sides of the nose,eyes, ears, hairline.

Petaloid Dry,

scaly eczema

over the pre-

sternal area

Pityrosporum

folliculitis

Erythematous

follicular eruption

with

papules/pustules

over the back

Flexural Most

common in the elderly. Axillae, groins, and

submammary areas. Moist intertrigo. Associated with s candidainfection

Infantile

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Varicose Dermatitis

• Associated with underlying varicose viens

• haemosiderin deposition around the

ankles over prominent veins >>Later signs Eczema ±

fibrosis of the dermis and subcutaneous tissue ±

ulceration

• Management

Emollients ± mild or moderate steroid ointment (avoid

long-term use) .

Treat venous disease

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• ASSOCIATIONS:

• CAUSE

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Erthrodermic psoriasis >> Admit as

an emergency

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Plantopalmar pustulosis

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Management

Frequent emollients ±

• Salicylic acid decrease surface scale.

• Coal tar Anti-inflammatory + anti-scaling. The thicker the patch the

stronger the preparation needed.

• Vitamin D analogue (e.g. calcipotriol, tacalcitol).

• Dithranol Plaque psoriasis—apply to lesion only.

• Topical retinoids Mild/moderate plaque psoriasis

• Topical steroids Can be used on localized plaques.

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(Impetigo, erysipelas, cellulitis, folliculitis, carbuncle)

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Impetigo

Erysipelas

Cellulitis

Folliculitis

Furuncle

Carbuncle

Dermis

Epidermis

Hair29

Caused by Staph A.

Very common in children

Caused by Staph A. and

Strept.

Common in all ages

Bullous Non-Bullous

Management:Non pharmalogical: Avoid spreading to other children—no sharing of towels, face flannels. Reassure that non-scarring

Pharmalogical:

Localized Treat with topical antibiotics (e.g. fusidic acid cream)

Widespread Treat with oral flucloxacillin or clarithromycin

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• cellulitis involves the deeper dermis

and subcutaneous fat >> lesions will

not raise

• Systemic symptoms after few days

• involves the upper dermis and

superficial lymphatics >>> lesions are

raised above the level of surrounding

skin, and there is a clear line of

demarcation between involved and

uninvolved tissue

• Acute systemic symptoms

They infect the dermis and manifest as areas of skin erythema, edema, and

warmth

ERYPSIPELASCELLULITIS

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• SEVERE INFECTION ADMIT FOR IV ANTIBIOTICS

• IF SYSTEMICALLY WELL MARK THE AREA BEFORE STARTING FLUCLOXACILLIN OR

CLARITHROMYCIN FOR 7–14D. ADVISE TO SEEK HELP IF INFECTION IS SPREADING OR

BECOMING SYSTEMICALLY UNWELL

• FACIAL INFECTION TREAT WITH PENICILLIN V QDS OR CLARITHROMYCIN BD

• RECURRENT INFECTIONS (>2 EPISODES AT ONE SITE) MAY NEED PROPHYLACTIC LONG-TERM

PENICILLIN WITH ATTENTION TO SKIN CARE

Management:

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• Occurs when a group of

hair follicles become deeply

infected with Staph. aureus.

• May be associated with

fever ± malaise

• Swollen, painful area

discharging pus from

several points.

• Acute infection of a hair

follicle with Staph. aureus.

Occasionally associated with

fever ± malaise

• A hard, tender, red nodule

surrounding a hair follicle

becomes larger and fluctuant

after several days.. Later may

discharge pus and a central

‘core’ before healing; may

leave a scar.

CARBUNUCLEFURUNCLE

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Management:

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(Candidiasis, Tinea)

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Mouth lesions Remove tongue deposits with a toothbrush by brushing

2x/d. Treat with oral suspensions or gels (e.g. nystatin, miconazole).

Genital lesions Imidazole cream or pessaries

• Nail infections amorolfine Avoid nail varnish/articifial nails during treatment

• Skin lesions Imidazole cream, spray, or powder; terbinafine cream

Management of Fungal infections:

• TINEA VERSICOLOR

• PINKISH BROWN

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(Warts, HSV)

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Viral Warts

Genital wartsPresentation in women asymptomatic but may be associatedwith itching or vaginal discharge. Warts enlarge during pregnancy.Presentation in men Warts are usually found on the penis or perianally.

Common WartsDome-shaped

papules with

papilliferous surface.

Usually

>1. Most common

on hands but may

affect other areas.

Plantar wartsOn soles of feet.

Pressure

makes them grow into

the dermis, painful.

Characterized by dark

punctate spots on the

surface

Plane wartsSmooth, flat-topped

papules often slightly

brown in colour.

Most common on

face/backs of hands

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transmitted by direct contact with lesions.

Lesions appear on around the mouth and on the lips, conjunctiva, cornea, and genitalia. Diagnosis is usually

clinical.

Primary HSV stomatitis After a prodromal period (<6h) of tingling,

discomfort, or itching, small tense vesicles appear on an erythematous

base. These burst to form multiple, small, painful mouth ulcers. Can be accompanied by systemic symptoms, e.g.

fever, malaise, and tender

lymph nodes..

Management

Give symptomatic relief—analgesic mouthwashes, If seen <48h

after onset give oral antivirals, e.g. aciclovir 5x/d for 5d

Recurrent infection (cold sores) HSV remains dormant in the nerve ganglia so Recurrent eruptions can occur

HSV Infection

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Herpetic whitlow Swollen, painful, and erythematous lesion of the distal phalanx, results

from inoculation of HSV through a skin break or abrasion and is most common in health

workers.

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(Scabies, Pediculosis)

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ScabiesExtremely contagious. The scabies mite (Sarcoptes scabei) is spread by direct physical contact

Presentation Symptoms of intense itching appear 4–6wk after infection.

Examination reveals burrows (irregular, tortuous, <1cm long) on the sides of fingers, wrists, ankles, and

nipples.

Management

Pharmalogical:

Treat with. permethrin 5% or malathion lotion. All close contacts need treatment simultaneously. Apply to

whole body including scalp, neck, face, and ears. Ensure finger/toe webs are covered, and brush lotion

under the ends of finger/toenails.

Non Pharmalogical

Advise patients to launder all worn clothing and bedding after application. Itching may persist for

some time after elimination of infection

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Pediculosis

Symptoms/signs asymptomatic.

Detected by contact tracing of other cases or routine inspection at home or school. Occasionally

present as itchy scalp. Presence of ‘nits’ (eggshells—white dots attached

to hair), a moving louse must be found to confirm active infection.

Management Treat all household contacts simultaneously.

• Dimeticone Lotion or spray. Coats lice and interferes with their

water balance by preventing the excretion of water. Advise to rub

into dry hair and scalp in the evening, allow to dry naturally, then

shampoo off the next morning. Repeat after 7d

• Insecticides. 4 types: malathion, phenothrin, permethrin, and carbaryl (prescription only).

Malathion and phenothrin/permethrin are used as first-/second-line;

carbaryl is reserved for third-line.

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(Flushing, Nodusum, Multiforme, Rosacea, Lyme)

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Cause:• Physiological: exertion, heat

• Emotion: anger, anxiety, embarrassment

• Foods: spices, chillies, alcohol

• Endocrine: menopause, Cushing’s syndrome

• Drugs: opioids, tamoxifen, danazol, GnRH analogues, nitrates, calcium channel blockers

• Inflammatory SLE; dermatomyositis

• Infection: slapped cheek syndrome (Fifth disease); cellulitis/erysipelas

• Tumour :Pancreatic tumours, medullary thyroid cancer, carcinoid, phaeochromocytoma

Management : Treat cause if possible (e.g. avoid alcohol, HRT). Embarrassing flushing may be helped

with propranolol or clonidine

If severe > refer

Flushing

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Erythema nodosum

Tender erythematous nodules on extensor surfaces of limbs—especially shins ± fever.

Resolves in <8wk, non-scarring.

No treatment only analgesia

Associations:

• Streptococcal infection

• Drugs, e.g. oral contraceptives, sulfonamides

• Acute sarcoidosis

• Inflammatory bowel disease— UC, Crohn’s

• Malignancy

• TB

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Erythema Multiforme

Immune-mediated disease characterized by

target lesions on hands and feet

Causes:

• Idiopathic (50%)

• Infective Streptococcal, HSV, hepatitis B, mycoplasma

• Drugs Penicillin, sulfonamide, barbiturate

• Other SLE, pregnancy, malignancy

Presentation Target lesions on hands and feet. Frequently oral, conjunctival,

and genital mucosa is affected—if severe termed Stevens–Johnson syndrome.

Management Identification and removal of the underlying cause. Mild

cases resolve spontaneously and require symptomatic measures only.

Admit if extensive involvement.

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RosaceaRelapsing-remitting chronic inflammatory facial dermatosis

characterized by erythema and pustules

No cure.

Cause: unknown

Presentation Earliest symptom is flushing. Erythema, telangiectasia,

papules, pustules affect cheeks, nose, forehead, and chin

Aggravating factors Sun exposure; emotional stress ; hot

weather ; alcohol; spicy foods ; exercise; cold

weather or wind; hot baths; hot drinks; cosmetics/

skin care products.

Complications Rhinophyma ; eye involvement—blepharitis, dry eye, and conjunctivitis.

Management

• Avoid triggers

• Antibiotics

• Refer to dermatology if rhinophyma, ocular complications, or failure to

respond to treatment.

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Lyme Disease

Cause: Borrelia burgdorferi. Spread: transmitted by ticks—usually from deer or sheep.

Presentenation:

• Erythema migrans: a red macule/papule on the upper arm, leg, or trunk 7–10d after a tick bite, which

expands over days/weeks to form a ring with central clearing;

• Flu-like illness

• Lymphadenopathy ± splenomegaly

• Arthralgia

Symptoms are typically intermittent and changing.

Complications:

neurological abnormalities, aseptic meningitis, myocarditis, and arthritis.

Management:

Confirm diagnosis with serology. Treatment is usually with 2–3wk course of64

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(MM, SCC, BCC)

Superficial

spreadingsite: lower leg ; back

Macular lesion with

variable

pigmentation

Nodular ontrunk. Pigmented

nodule grows

rapidly and

ulcerate

Lentigo malignaarises in sun

damaged skin

usually on the face—

and melanoma

develops many years

after

Acral

lentiginousmelanoma in black-

skinned populations.

Affects palms, soles,

and nail beds. Often

detected late. Poor

prognosis

Malignant Melanoma

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Risk factors Sun exposure; genetic;

multiple benign moles (>50 of >2mm diameter); congenital naevus;

previous malignant melanoma; immunosuppression; fair skin type (red hair,

blue eyes); severe sunburn in childhood/adolescence.

Check the ABCDEF criteria:

• Asymmetry of outline

• Border irregularity

• Colour variation

• Diameter

• Evolution—changes in size, shape, colour, and/or elevation

• Funny-looking’ mole—‘ugly duckling’ moles that stand out from the

others are very discriminatory for nodular melanoma

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Management:

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• common >55y

• Usually develops in sun-exposed sites, e.g. face, neck, hands.

• May start within an solar keratosis or de novo as a nodule which progresses to ulcerate

and crust

• Causes Chronic sun damage, X-ray exposure, chronic ulceration and

scarring (aggressive SCC may develop at the edge of chronic ulcers),

smoking pipes and cigars , industrial carcinogens (tars, oils),

wart virus, immunosuppression, genetic.

Squamous cell carcinoma (SCC)

• Management : Refer 70

• Most common form of skin cancer—accounts for >75% of skin cancer.

• Locally invasive, locally aggressive, locally destructive

• multiple and appears mainly on light-exposed areas—most commonly the face.

Basal cell carcinoma (rodent ulcer, BCC)

Nodular Most

common. Starts as small

pearly nodule. May

necrose centrally leaving a

small crusted ulcer with

pearly, rolled edge

Cystic

MulticentricPlaque like, large

superficial+/- central

depression

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Urticaria (hives or nettle rash)

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Superficial, itchy swellings of the skin or weals

come and go in an attack giving the appearance of a shifting rash.

Management of acute urticaria• antihistamines for itch—non-sedating for daytime ± sedative if

interferes with sleep (e.g. chlorphenamine, hydroxyzine).

• Topical menthol 1% cream is an alternative/adjunct to antihistamines

• If severe, consider short-course steroids (e.g. prednisolon).

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angio-oedema

Deeper longer-lasting swellings; painful rather than itchy.

affect eyes, lips, genitalia, hands, and/or feet.

May affect bowel (abdominal pain, nausea, vomiting, diarrhoea) or airway (tongue swelling,

shortness of breath, wheeze). If airway compromise, consider

Management of angio-oedema

• If anaphylaxis is suspected, give adrenaline

and admit

• If any airway compromise, admit—even if

anaphylaxis is not suspected

• Otherwise treat as for acute urticaria; monitor

for airway compromise

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