common skin problems

Common Skin Problems

Dr. Sanjeeva Hulangamuwa

Consultant Dermatologist

GH Chilaw

ECZEMA

Acute eczema

Dry Eczema

Infantile Eczema

Chronic Lichenified Eczema

Contact Dermatitis to rubber slippers

Acute Contact Dermatitis to Vicks

Venous Eczema

Eczema herpeticum

Eczema Symptoms and Signs

• Itchy skin patches

• Oozing ( weeping ) – acute stage

• Pigmentary changes

• Dry thick patches in chronic stages

• Recurrent attacks

• Can associated with asthma and allergic rhinitis

• Family members may have atopy

• Common sites –

face and flexures – infants and children

legs – adults

• Worsen with exposure to certain chemicals, dust, cement, fur,etc

Eczema (cont.)

Management

• Weepy areas - Condys ( potassium permangenate ) wash or compression

• Steroid creams – hydrocortisone, betamethasone, clobetasol

• Moisturizers – aquous cream, emulsifying ointment

• Oral antibiotics for acute infective eczemas

• Antihistamines for itching – chlorpheniramine, cetirizine, loratidine

• Avoid frequent washing and soaps

• Severe and resistant cases – prednisolone, azathioprine, methotrexate, ciclosporin

• Rule out immunodeficiency syndromes in severe eczemas in infants

Photodermatitis

Chronic folliculitis

Seborrhoeic dermatitis

Chronic plaque psoriasis

Flexural Psoriasis in a baby

Erythrodermic Psoriasis

Psoriasis

• Thick scaly erythematous plaques

• Common sites - elbows, knees, umbilicus, scalp

In some pts. whole body is involved

• Scalp – scaling as in dandruff but severe

• Nail changes and arthritis occur in some patients

• Itching may or may not present

• Family history may be positive

• Rare presentations – pustular psoriasis and erythrodermic psoriasis

• Diagnosis - clinically

Psoriasis • Topical application –

steroid creams – hydrocortisone, betamethasone, clobetasol

coal tar

dithranol

moisturizers – aquous cream, emulsifying ointment, liquid paraffin

• Light therapy

PUVA ( Psoralen tablets + ultraviolet A )

Ultraviolet B

Solar PUVA – Expose to early morning sunlight 2h after taking the psoralen tablet

Psoriasis

• Systemic treatment

methotrexate, acitretin, ciclosporin,etc

• Newer therapies

Biological agents ( expensive )

INFECTIONS

Bacterial infections

Secondary bacterial infection of chicken pox scars

Staphylococcal scalded skin syndrome

Staphylococcal scalded skin syndrome

• Common below 4y of age

• Irritable

• Refuse feeds

• Febrile

• Erythema and scaling around mouth, genital region and flexures

• Skin is tender

• Treatment

flucloxacillin

cloxacillin

Furuncles

Furuncles

• Common in preschool children

• Painful pustules and papules

• Some rupture and discharge pus

• Fever may occur

• Common on face and scalp

• Can be recurrent

• Treatment

oral – cloxacillin, erythromycin

topical – soframycin ( framycetin ), fucidic acid, mupirocin

Impetigo

Bullous impetigo

Impetigo

• Common in children

• Honey colored crusted plaques

• Sometimes blisters may occur ( bullous impetigo )

• Commonly occur peri-orificial ( around mouth, nose )

• Painful

• Appears suddenly in a few days

• Treatment Oral – cloxacillin

Topical – soframycin, fusidic acid, mupirocin creams

Other bacterial infections

• Eg; gram negative bacterial infections ( eg; pseudomonas )

anaerobic infections

MRSA ( methicillin resistant staphylococcus aureas )

secondary bacterial infection of skin lesions

( eg; chicken pox scars, eczema, scabies )

VIRAL INFECTIONS

Herpes simplex infection

Herpes simplex infection

• Common in immuno – compromised patients

Eg; AIDS, Diabetes, malnourished, etc

• Common sites – lips, genital area

• Presents with sudden eruption of painful grouped vesicles

• Genital herpes is a sexually transmitted disease

• Can be recurrent in some patients

Treatment • Aciclovir

• Topical or oral antibiotics to prevent secondary infections

Chicken pox

Chicken pox • Fever

• Body aches and pains

• Vesicular skin eruption

• Starts from head and gradually spreads to trunk and limbs

• Crusting occurs in 7-10 days

Complications • Common in adults and in immuno suppressed individuals

eg; pneumonia, secondary bacterial infection, myocarditis, thrombocytopenia, encephalitis, osteomyelitis, hepatitis

Treatment

• Aciclovir

• Antibiotics if needed

Chicken pox

• Chicken pox in pregnancy ( 1st trimester ) may lead to foetal abnormalities

Prevention varicella vaccine

Herpes zoster

Herpes Zoster

• Treatment

aciclovir

antibiotics if necessary for the secondary bacterial infection

Molluscum contagiosum

• Treatment

spontaneously resolves sometimes

larger lesions – prick with a sterile needle and extrude the

contents

trichloroacetic acid

electro cautery

Viral warts

Plantar warts

Plane warts

Treatment

• Cryotherapy

• Electrocautery – in a few occasions

• 5% imiquimod – genital warts

• Wart implantation

• Hypnotherapy

Hand foot mouth disease

FUNGAL INFECTIONS

Tinea corporis

Tinea incognito

Tinea capitis

Kerion - due to zoophilic fungal infection

Tinea infections

• Reddish or skin colored patches

• Common sites – groins, buttocks, submammary areas, etc

• Annular or polycyclic

• Elevated edge

• Can be itchy

Treatment • Topical antifungals – miconazole, clotrimazole, terbinafine

• Oral antifungals – griseofulvin, terbinafine

Pityriasis versicolor

Treatment

• Ketoconazole – oral and topical

• Itraconazole – oral

• Fluconazole - oral

Candidiasis

Candidiasis • Common sites Oral mucosa, genital mucosa, flexural areas ( neck, groins ),

periungual ( around the nails )

• Precipitating conditions Diabetes mellitus, AIDS, other immuno suppressed pts,

Patients on prednisolone and broad spectrum antibiotics

Treatment

miconazole oral paste

2% ketoconazole cream

oral fluconazole, itraconazole

Chromoblastomycosis

Madura foot

Fungal infections

• There are so many other different fungal infections

• Some are deep fungal infections

• Needs skin biopsy and fungal cultures to diagnose them

• Needs prolong oral antifungal treatment

Parasitic infections

Scabies

Crusted scabies

Scabies • Very itchy skin condition

• Papular eruption

• Common sites are finger webs, genital region, abdomen and thighs

• Can lead to crusted scabies in neglected patients

Investigation Skin scrapings – will reveal the parasite – Sarcoptes scabei

• Treatment

5% Permethrin

Sulphar ointment

Benzyl benzoate

Should treat the family members at the same time

LEPROSY

• Caused by Mycobacterium Leprae

• Very slow growing bacterium

• Has a long incubation period before the onset of the clinical disease

• Common in over crowded places with poor ventilation

Tuberculoid Leprosy

Borderline tuberculoid leprosy

Tuberculoid Leprosy • Presents with

Hypopigmented patches

Sensory impairment

Enlarged superficial nerves

Treatment • Multi drug treatment ( MDT – PB ) for 6months

( pauci bacillary )

Rifampicin

Dapsone

• However MDT ( MB ) for 12 months needed for some patients

Lepromatous Leprosy

Lepromatous Leprosy • Can be infective to others

• Clinical Features

skin colored and erythematous nodules

Some have leonine facies

Infiltration of the ears

Peripheral neuropathy

Trophic ulcers

Certain internal organs could be involved

• Treatment

Multi drug treatment ( MDT – MB ) for 12months

( multi bacillary )

Rifampicin

Clofazimine

Dapsone

Ulnar claw hand

Trophic ulcers

Type 1 reaction

ENL (type 2) reaction

Treatment – Lepra reactions

prednisolone

azathioprine

clofazimine

thalidomide

Cutaneous Tuberculosis (Skin TB) • Long standing non healing skin patches

• Various morphological patterns present

Investigations • Skin biopsy

• Mantoux test

• Chest Xray

• PCR studies

• T spot test

Treatment • Anti TB therapy

Verrucous TB

Scrofuloderma

Lupus vulgaris

Cutaneous Leishmaniasis

Cutaneous Leishmaniasis

• Non healing volcano like skin lesions

• Occur on exposed areas of the body

• Common in certain parts of the country

North central province, southern province

Investigations Skin smears to identify the parasite

Skin biopsy for histology

Treatment Liquid nitrogen

Sodium stibo gluconate injection ( local / IM )

NUTRITIONAL

DEFICIENCIES

Zn deficiency

Zinc deficiency

• Common below 2 years

• Adults – in alcoholic pts.

• Eczema like skin eruptions

• Red, dry and scaly skin patches over the genital area, face and flexures

• Child is irritable

• Refuse feeds

Investigations

Serum Zn level, alkaline phosphatase

Treatment

Zinc replacement

Other nutritional deficiencies

• There are many other nutritional deficiencies which cause skin manifestations

Eg; Iron deficiency

Protein energy malnutrition

Biotin deficiency

Essential fatty acid deficiency

B12 deficiency

DRUG ERUPTIONS

Drug Eruptions

• Drug eruptions can present with various patterns

• Proper drug history is important in diagnosis

• Some are mild and some can be life threatening

• Internal organs can be affected in some drug reactions

Morbiliform type eruption

Urticaria

Fixed drug eruption

Striae due to prolong application of topical steroids

Stevens johnson syndrome

Toxic epidermal necrolysis

Drug hypersensitivity syndrome

Stevens johnson syndrome and toxic epidermal necrolysis

Can be life threatening Management stop the offending drug immediately monitor the vital functions investigate to detect the internal organ involvement (liver and kidney) skin care oral care eye care – urgent eye referral if eyes are involved increase hydration and fluid balance chart antibiotics to prevent secondary infection prednisolone and IV immunoglobulins sometimes antiepileptics

EXFOLIATIVE DERMATITIS

EXFOLIATIVE DERMATITIS

• More than 90% of the skin is involved

• Itching

• Erythema ( redness )

• Scaling

• Dehydration

• Low urine out put

• Aetiology

Common causes

Eczema, Psoriasis, Drugs, Lymphomas, etc

Treatment

Moisturizers – aquous cream, emulsifying ointment

liquid paraffin

Increase oral fluids and to maintain a fluid balance chart

High protein diet

Antibiotics if there are signs of infection

Antihistamines ( eg; chlorpheniramine ) for itching

skin biopsy

Need to find the aetiology and treat the cause

Needs regular follow up

Hidradenitis suppurativa

Punch out & Ice pick Scars

Acne

• Very common skin problem

• Starts around puberty

• Chronic inflammation of the pilosebaceous units

• Clinical features

comedones, papules, pustules, cysts and scars

face, chest and upper back are usually involved

• Need to treat early to prevent unsighty scars

Treatment Depends on the sex, age, severity and extent of the disease

• Topical

benzoyl peroxide

antibiotic creams and lotions – erythromycin, clindamycin

retinoid creams and gels

• Oral

antibiotics – erythromycin, doxycyclines

hormonal – cyproterone acetate with ethynyl estradiol

isotretinoin ( most effective )

• Chemical peeling

salicylic acid and trichloroacetic acid

vasculitis

Vasculitis

• Inflammation of blood vessels

• Hall mark is the ‘palpable purpura’

• Erythematous papules and patches on dependent parts of the body

• Fever, arthralgia, abdominal pain, malaise, etc

Approach to the patient

Suspect vasculitis

Exclude non-vasculitic disorders that mimic vasculitis

Investigate to

establish vasculitis

evaluate the extent of the systemic involvement

look for underlying disorders

Sweets syndrome

Erythema nodosum

SKIN CANCERS

Skin cancers

• Common in white skin individuals

• Rare in Asians

• Eg;

Basal cell carcinoma, Squamous cell carcinoma, Melanoma, etc

Risk factors

high sun exposure

white skin

family history

immunosupression

chronic ulcers and scarring

arsenic ingestion

Basal cell carcinoma

Squamous cell carcinoma

Malignant melanoma

Management

complete excision

radiotherapy

look for metastases ( local and distal spreading )

BLISTERING DISEASES

Causes of blisters

• Frictional

• Cold and Thermal injury

• Bullous Impetigo

• Diabetes

• Insect bites

• Drug reaction

• Herpes Simplex infection

• Chicken Pox, Herpes Zoster

• Epidermolysis Bullosa

• Autoimmune

Eg; Pemphigus, Pemphigoid

• There are many causes for blisters

• We must find the cause and treat

• Some conditions such as auto immune blistering disorders need special treatment and regular follow up

Pemphigus Vulgaris

Pemphigus Vulgaris • Flaccid blisters

• Easily ruptured and left with erosions

• Mouth, genital area and eyes can be involved

• Can be life threatening

• Common in Asians

Treatment

• Depends on the severity of the disease

• Mainstay of treatment is steroids

• IV dexamethasone and cyclophosphamide pulse therapy

• Antibiotics for the secondary infection

• Sometimes IV Immunoglobulins and plasmapharesis

Bullous Pemphigoid • Tense blisters

• Oral lesions are very rare

• Common in old age

• Incidence is high in west

• Less severe than Pemphigus

Treatment • Prednisolone

• Azathioprine

• Dapsone

• Tetracycline

• Topical steroids

Epidermolysis Bullosa

Epidermolysis Bullosa

• Blisters appear on frictional sites

• These are mechanical blisters

• Exacerbates with sweating, hot and humid climates

Treatment • Prevention of repeated trauma

• Loose clothes

• Keep the skin dry and clean

• Minimal handling

Linear IgA disease

( chronic bullous dermatosis of childhood )

Linear IgA disease

( chronic bullous dermatosis of childhood ) • Tense blisters

• Mainly peri-orificial

( around mouth and genitalia )

• Oral mucosa can be involved

Treatment

• Dapsone

• prednisolone

DIABETES

SKIN MANIFESTATIONS

• Various systemic diseases including Diabetes Mellitus have skin manifestations

• Therefore skin features are important to detect underlying illnesses

Carbuncle on the nape of a diabetic man. This is a

staphylococcal infection of several contiguous hair follicles.

Carbuncle

Diabetic Bulla

Older lesions of necrobiosis lipoidica are often pigmented as

well as obviously atrophic, but often lose the more inflamed

appearance of more recent lesions.

Necrobiosis Lipoidica

Melasma

Pityriasis rosea

Pyogenic granuloma

Dermatitis artefacta by proxy

Urticaria

Miliaria

Vitiligo

Lichen planus

Granuloma annulare

common skin problems

Health & Medicine